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Salivary Gland Tumors

Salivary Gland Tumors. Marka Crittenden M.D. Ph.D. Anatomy. Major Glands Parotid, submandibular and sublingual glands Minor Glands Hundreds residing in the oral cavity, pharynx and paranasal sinuses. Major Salivary Glands. ?. ?. ?. ?. ?. Parotid Gland. Borders

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Salivary Gland Tumors

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  1. Salivary Gland Tumors Marka Crittenden M.D. Ph.D.

  2. Anatomy • Major Glands • Parotid, submandibular and sublingual glands • Minor Glands • Hundreds residing in the oral cavity, pharynx and paranasal sinuses.

  3. Major Salivary Glands ? ? ? ? ?

  4. Parotid Gland • Borders • Superior – zygomatic arch. • Posterior – angle of mandible under earlobe toward the mastoid tip. • Inferior – extends to the inferior aspect of the angle of mandible toward hyoid bone. • Medial – borders of the parapharyngeal-base of skull. • Lateral – below the skin of the preauricular cheek-upper neck. • Anterior – wraps around ascending ramus of mandible • Facial nerve divides the gland into the superficial (80 %) and deep lobe (20%) • Parotid duct (Stensons) is 5 cm long and opens opposite the second molar. • Lymphatic drainage – periparotid/intraparotid – lvl I – lvl II- lvl III. • Accessory parotid lobe – Present in 20% of patients.

  5. Submandibular Gland • Borders • Lateral – proximal half of the mandible. • Posterior – anterior to but near the low anterior margin of the parotid gland. • Inferior – approaches the level of the hyoid bone. • Majority of gland lies over the external surface of the mylohyoid muscle. • Lateral to and abuts the lingual and hypoglossal nerve and is medial to the marginal mandibular and cervical branch of the facial nerve. • Drains through Wharton’s duct in anterior floor of the mouth • Lymphatic Drainage Lvl I – Lvl II- Lvl III

  6. Sublingual Gland • 10% size of parotid gland • Located anterior floor of the mouth • Borders • Lateral –medial aspect of mandible • Inferior –mylohyoid muscle • Lingual nerve courses adjacent to sublingual gland • Drain into the floor of the mouth through Rivinus ducts • Lymphatic drainage – Lvl I- Lvl II- Lvl III

  7. Epidemiology • Salivary tumors 7% of head and neck tumors • Parotid tumors 10x more common then submandibular and 100x more common then lingual • Parotid 80% benign (pleomorphic adenoma) • Submandibular 50% malignant • Sublingual majority (65-88%) are malignant • Equal incidence between sexes • Risk Factors: nutritional deficiency, exposure to ionizing radiation, UV exposure, genetic predisposition, EBV

  8. Pathology • Benign Tumors • Pleomorphic Adenomas • Malignant tumors • Parotid – mucopidermoid most common – low grade, slow growing cured by surgery alone • Submandibular and minor salivary – adenoid cystic most common.

  9. Adenoid Cystic • Cribiform pattern – differentiated • Cribiform/solid pattern – moderately differentiated • Solid Features – undifferentiated • Natural history ranges from months to greater then 20 years. • Lymph Node spread <5%

  10. Adenoid Cystic • Perineural spread common and can track along the cranial nerves back to the base of skull • 40% develop pulmonary mets but survival of 10-20 years can occur with pulmonary mets so primary must be managed

  11. Metastatic Disease involving Parotid • Mechanism • Lymphatic spread – most common from skin • Hematogenous spread - lung • Direct extension – skin or osseous sarcomas

  12. Staging • T1 ≤ 2cm and no extraparenchymal extension • T2 > 2cm but not >4cm without extraparenchymal extension • T3 >4cm and or extraparenchymal extension • T4a invades skin, mandible, ear canal and/or facial nerve • T4b invades skull base and or pterygoid plates and or encases carotid artery

  13. Parotid Tumors • Clinical presentation • Asymptomatic mass • Cranial nerve palsey – inability to move one side of face, one shoulder, one side of tongue. • Evaluation • Trismus – to evaluate pterygoid involvement • CT/MRI • FNA in parotid tumors 90% sensitive and >95% specific • Never perform incisional or excisional biopsy

  14. Parotid Tumors • Lymph Nodes • Rare in adenoid cystic • 12% positive in clinically negative tumors. • Size and grade are risk factors • >4 cm 20% occult metsvs 4% in smaller tumor • High grade 49% risk regardless of histologic type vs 7% for low or intermediate • Distant Spread • Lung • 25-35% risk for mucoepidermoid, adenoid cystic and malignant mixed tumors. • Routine CXR

  15. Postoperative Radiation versus Surgery for Salivary Gland Tumors: Results from the literature

  16. Submandibular tumor • Clinical presentation • Asymptomatic mass • Painful mass as enlarges • Cranial nerve palsey –decrease sensation in ipsilateral lower teeth, lip and gums, inability to move ipsilateral oral tongue or inbality to move part of face. • Evaluation • CT/MRI – help to distinguish a pseudomass • FNA in submandibular tumors useful only if reveals a malignancy. • All lesions approached with a submandibular triangle dissection • Almost never perform incisional or excisional biopsy.

  17. Submandibular Tumors • Lymph Nodes • 28% risk in submandibular tumors • Lvl I, II and III most common sites • Distant Spread • Lung >bone and liver

  18. Sublingual Tumors • Clinical presentation • Asymptomatic swelling in floor of mouth • Cranial nerve palsey – ipsilateral loss of sensation of one side of tongue. • Evaluation • CT/MRI • Most tumors are malignant so FNA only useful if maligant • Always resect with a formal cancer surgery

  19. Sublingual Tumors • Lymph Nodes • Higher risk of LN spread then parotid tumors • Lvl I is first site of drainage • Distant Spread • Lung > bones and liver

  20. Treatment • Surgery -Parotid • 90% confined to superficial lobe – perform superficial parotidectomy • If adjacent to deep lobe - total parotidectomy • If invades adjacent soft tissue – radical parotidectomy • Never perform piecemeal excision in an attempt to preserve facial nerve • Nerve grafting can be performed and RT can start3-4 wk post op without adverse affects • Frey’s syndrome – (gustatory sweating) due to redirection of parasympathetic and sympathetic nerve fibers to the dermal sweat glands

  21. Treatment • Surgery - Submandibular • Small tumor – gland excision • ECE –En bloc resection with extended supraomohyoid neck dissection • Surgery – Sublingual • Small and localized can resect without submandibular gland • Generally requires resection of submandibular gland as well.

  22. Treatment • Radiation – Surgically unresectable tumors • EBRT with photon and or electrons with conventional or altered fractionation • Brachytherapy ± EBRT • Neutron therapy

  23. Treatment • Radiation – Surgically unresectable tumors • EBRT • Equivalent control rates as for equivalent head and neck squamous cell cancers • Early stage 71-100% control rates • Late and Recurrent 50-70% • Hyperfractionation • Wang and Goodman reported on 14 patients using 1.6 Gy bid to 65-70 Gy. • 5 yr LCR 82%

  24. Treatment • Radiation – Surgically unresectable tumors • Brachytherapy • Used frequently with recurrent or advanced disease • 5 yr LCR 60% • Neutron therapy • Biologic effect of neutrons less effected by hypoxia • Lethal effects less dependent on cell cycle • Repair of sublethal damage in malignant cells is less • RBE > 2.6 • Severe late effect greater 17% versus 7% • Improved local control but no diff in overall survival

  25. Treatment • Postoperative Radiation • Indications • Close surgical margins (deep lobe parotid tumors, facial nerve sparing) • Microscopically positive margin • High grade including adenoid cystic • Involvement of skin, bone, nerve (gross or extensive perineural invasion), tumor extension beyond capsule with periglandular and soft tissue invasion • LN spread • Large tumors requiring radical resection • Tumor spillage • Recurrence

  26. Treatment • Postoperative Radiation • LCR with surgery and post op RT • T1 100% T2 83% T3 80% T4 43% • Technique • Parotid • Electrons – lateral en face • Mixed beam – 50-80% electron weighting lateral en face or wedge pair. • Photons - wedge pair or IMRT

  27. Treatment • Technique • Portal margins – Parotid • Superior – top of zygomatic bone • Inferior – hyoid bone – thyroid notch • Anterior - 2cm ant to upper second molar • Posterior – posterior to mastoid tip. • Lateral - 2 cm flash on cheek • Medial – 2 cm medial from ipsilateral oropharyngeal area. • Electron portal margins are 1 cm greater • Usually 12 MeV- 16 MeV energy used

  28. Treatment • Technique • Portal margins – Submandibular • Superior – 1cm above upper border of tongue • Inferior – Hyoid bone-thyroid notch interspace • Anterior – anterior aspect of mental symphysis • Posterior – BOT- jugulodigastric nodal area • Lateral – 2 cm flash of ipsilateral mandible • Medial – midline of tongue

  29. Treatment • Technique • Portal margins – Sublingual • Superior – 1cm above upper border of tongue • Inferior – Hyoid bone-thyroid notch interspace • Anterior – anterior aspect of mental symphysis • Posterior – posterior aspect of the ascending mandibular ramus • Lateral – 2 cm flash of ipsilateral mandible • Medial – 2cm past midline

  30. Treatment • Dosage – Primary treatment • Accelerated fractionation with a delayed concomitant boost • Phase I 1.8Gy daily to 36 Gy • Phase II 1.8 Gy as in phase I in AM x 10 fractions to 54Gy and > 6hrs 1.6 Gy to GTVx 10 fractions to 16 Gy • Spinal cord dose < 45 Gy. • IMRT to 70 Gy for GTV 63 Gy CTV 1 and 56 Gy CTV2

  31. Treatment • Dosage – Post op treatment • Administered within 6 weeks of surgery • High Risk 2.0 Gy/fx to 60Gy and 1.8Gy/fx to 63Gy. • Small volume known microscopic disease 66 Gy. • Elective at risk 50 Gy (2.0Gy/fx) 54 Gy(1.8Gy/fx) • Gross residual 70Gy.

  32. Side effects • Salivary fxn • 80% of saliva produced by major salivary glands • Loss of salivary fxn complete >35 Gy • Dose limit to spare salivary function is 26 Gy. • Trismus • TMJ and masseter muscle < 50Gy. PT during and after treatment

  33. Adenoid Cystic Carcinoma • Post op RT always recommended • Post op RT of entire pathway of adjacent cranial nerve to base of skull always recommended • Regional LN spread is 15% and elective nodal irradiation is not standard • Surgery alone LCR 25-40% +RT 75%-80%

  34. Pleomorphic Adenoma • Benign tumor – 75% of all parotid epithelial tumors. • Surgery is treament of choice • Multiply recurrent tumors can be treated with RT • >3 local recurrences • Large lesion with surgically inadequite margin • Microscopically positive surgical margins • Macroscopic residual disease • Malignant transformation • 50-60 Gy dose

  35. Minor Salivary Tumors • Highest concentrations of the glands in the oral cavity, palate, nasal cavity and paranasal sinus • 500-700 Glands • No glands located in the gingiva or anterior half of the hard palate • 50% malignant • Adenoid cystic is most common malignant histology seen.

  36. Quiz • What is the most common tumor of minor salivary glands • A. Pleiomorphic Adenoma • B. Adenoid cystic carcinoma • C. Mucoepidermoid carcinoma • D. Squamous cell carcinoma

  37. QuizWhat are the borders of the parotid gland? • Superior • Inferior • Anterior • Posterior • Zyogomatic arch • Hyoid bone • Ascending ramus of mandible • Mastoid process

  38. Quiz • The most common parotid tumor is • A. Pleomorphic adenoma • B. Mucoepidermoid carcinoma • C. Adenoid cystic carcinoma • D. Detroit tigers

  39. Quiz • Most parotid tumors are ___________ • A. Benign 60% • B. Benign 80% • C. Malignant 60% • D. Malignant 80%

  40. Quiz • All of the following are true regarding adenoid cystic carcinoma except? • A. It rarely spreads to Lymph nodes • B. It is a common minor salivary tumor • C. It typically does not involve nerves • D. 40% develop pulmonary metastasis

  41. Quiz • Adenoid cystic of parotid s/p parotidectomy with perineural invasion, what is treatment field? • A. Post op bed • B. Post op bed and BOS • C. Post op bed and BOS and ipsilateral neck • D. Post op bed and BOS and bilat neck

  42. Quiz • What is treatment of choice for cystic pleomorphic adenoma? After rupture or residual? • Superficial parotidectomy. If intraop cystic rupture, add post op RT

  43. QuizHow are parotid tumors staged? • T1 • T2 • T3 • T4 • ≤ 2cm • 2-4 cm • Extraparenchymal, No VII involvement ± 4-6cm • >6cm, BOS, CN VII

  44. Quiz • All of the following are indication for RT in pleiomorphic adenoma except? • A. Deep lobe involvement • B. Large >5cm • C. Recurrent tumor • D. Positive margin

  45. Quiz • What seperates the superficial parotid from the deep lobe? • Facial Nerve

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