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Salivary Gland Tumors

Salivary Gland Tumors. Professor Ravi Kant MS, FRCS (Edin), FRCS (Glasg), FRCS (Ireland), DNB, FACS, FICS, FAIS, FAMS. Objectives. Setting : CME Audience : PG Time duration : 20 minutes Evidence based. Objectives. Why How to diagnose The Natural Course of disease

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Salivary Gland Tumors

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  1. Salivary Gland Tumors Professor Ravi Kant MS, FRCS (Edin), FRCS (Glasg), FRCS (Ireland), DNB, FACS, FICS, FAIS, FAMS

  2. Objectives • Setting : CME • Audience : PG • Time duration : 20 minutes • Evidence based

  3. Objectives • Why • How to diagnose • The Natural Course of disease • What treatment to offer • Prognosis • Limitations

  4. Etiology-1 Epstein - Barr Virus Childhood Irradiation Nutritional deficiencies UV Exposure Genetic

  5. Etiology-2 Wood & silica dust exposure Kerosene users HIV-BLL Benign Lymphoepithelial lesion HIV-NHL, Kaposi’s, Ad Cy, Protection: dark yellow vegetables & liver

  6.  Familial occurrence of acinic cell carcinoma of the parotid gland. 13: Arch Pathol Lab Med 1999Nov;123(11):1118-20 Depowski PL, USA.

  7. Epstein-Barr virus infection in salivary gland tumors in children and young adults.  Cancer 2000Jul 15;89(2):463-6  Venkateswaran L, Department of Hematology-Oncology, St. Jude Children's Research Hospital,Memphis, Tennessee, USA.

  8. Signs of malignancy-1 • Painless mass • Nerve involvement • Dysphagia • Skin ulceration • Sudden increase in size

  9. Signs of malignancy-2 • Symptoms of surrounding structure involvement • Mild intermittent pain • Numbness- mucosal, tongue, 7 n, • 9,10,11,12 cranial nerve

  10. DD-deep lobe • Oral neoplasm (+/- fat plane on CT or MR) • Parapharyngeal neoplasm • Lymphoma • Neurogenic tumor • Paraganglioma

  11. Investigations • FNAC >90% specificity, sensitivity • MR =ideal for deep lobe • MR Angio • CT-3D sialography • 99 m Tc scan for Warthin’s, Oncocytoma, Acinic, Adeno

  12. Investigations • SPECT / FDG PET for No Neck • ICA + balloon occlusion test+XeCT • Frozen section biopsy 95%√ • Perineural invasion • LN mets • Surgical margins • Type of CA or benign 67%√

  13. MR>CT • Tumor-salivary gland interface • Benign Vs malignant • 7 n or Perineural evaluation • Intracranial extension of tumor • DD; Parapharyngeal tumors • DD; Neurogenic tumors

  14. MR>CT : Perineural spread • Replacement of normal perineural fat with tumor • Enhancement with gadolinium • Increased size of nerve • Bony erosion • Sclerotic margins • Widening of crania base channels

  15. CT>MR for bone erosion • CE-CT is better than non CE • Base of skull involvement • Mandible erosion

  16. New strategy for the diagnosis of parotid gland lesions utilizing 3D sialography. Comput Aided Surg 2000;5(1):42-5   Kosaka M, Kamiishi H, Japan.

  17. 3D sialography:advantages-1 (1) The structure of the acinar surface is visualized in detail. (2) The 3D structure of the entire parotid system from Stensen's duct to the gland is shown in one image.

  18. 3D sialography:advantages-2 (3)The parotid gland can be assessed in the context of the bony architecture of facial bones. (4) The surface structure of the parotid gland can be understood very easily, like a scanning electron micrograph.

  19. BLL • Sjogren’s • Mikulicz • HIV asso. Malignancy = K,NHL,AC • Observe as benign • Low dose RT • Parotidectomy as assoc malignancy

  20. Warthin’s = Papillary cyst Adenolymphoma • Benign • Kerala coast • Favour tail of parotid • 10% bilateral • Hot on isotope scan • Older man, bilateral, left alone

  21. Pleomorphic – components • Myxoid • Mucoid • Chondroid • Epithelial • Other

  22. Proliferative activity in recurrent pleomorphic adenoma MIB1 antibody against the cell proliferation associated nuclear antigen (Ki-67 antigen). The proliferation index (MIB1 positive cells per 100 cells)

  23. Proliferative activity in recurrent pleomorphic adenoma Epithelial differentiation as a possible origin for recurrence. Bankamp DG : Laryngorhinootologie 1999 Feb;78(2):77-80 

  24. Proliferative activity in recurrent pleomorphic adenoma • Tongue like projections, • Pseudocapsule • 7 n palsy • Skull base involvement • Locally invasive • Recurrence even multiple

  25. Pleomorphic adenoma • Malignant transformation • Locally dangerous No enucleation, only Wide margin of tissue = Superficial parotidectomy

  26. Pleomorphic adenoma & Adjuvant RT • Spill • Residual • Recurrent, • Nerve encasing • Deep lobe involvement Rx→Postoperative Radiotherapy

  27. T • T1 <2 cm • T2 >2-4 cm • T3 >4-6 cm • T4 >6 cm

  28. N • No • N1 <3 cm,ipsilateral single • N2 A >3-6 cm,ipsilateral single B <6cm,ipsilateral multiple C <6cm, bilateral • N3 >6 cm

  29. LN • Preauricular- Squamous Melanoma Not parotid Intraparotid

  30. M • Mo -distant mets • M1 +distant mets

  31. M • Lung • 40% Adenoid Cystic • 30% Malignant Mixed • Also with Acinic cell • SM:P::2:1 • Lung mets In AdCy can live up to 20 years

  32. Mode of Spread • Expansion • Local infiltration • Lymphatics • Perineural infiltration • Seedling in the tumor and skin

  33. Probability of cancer

  34. HP & Site : %

  35. HP & Site : %

  36. Acinic-1 • 16% of Parotid • of all acinic; 81% in Parotid • 3% of all salivary • 5th decade • Bilateral • More in Females

  37. Acinic-2 • Types- four types 1. Solid, 2. Microcytic, 3. Papillary-cystic, & 4. follicular • Papillary cystic 100% mortality • Solid has equally worse prognosis • Node +, Nerve+, Margin +,T3-T4 = poor prognosis

  38. Acinic-3 • 5,10,15 yr survival in %= 100,87,65 • Local recurrence 15% • Distant Mets 10% • Facial palsy 0-8% • Regional N0-16% • Adjuvant RT in T3,T4, N+ • Improper Rx = recurrence rate 75%, N+ 25%

  39. Adenoid Cystic-1 • Billroth 1854 Cylindroma • Minor 31%, Submand 41% • Perineural invasion in 80%,↑ if >1cm • Types: Tubular, Cribriform and Solid • Solid has worst prognosis, • High grade or low grade • 10 yr survival in high grade is 0%

  40. Adenoid Cystic-2 • Prognosis- T, Bone invasion, Nerve+, Grade,DNA ploidy, best with tubular • LN+ is rare <8%, lethal 6% @10 yr • No role of elective neck dissection • Site 10 yr survival = 29% parotid, 7% paranasal

  41. Adenoid Cystic-3 • Adj RT for local control as recurrence 37% • No solution to distal mets 40%, up to 20 years • Mets to lung 63%, Bone & liver • Survival @ 5y =69%, @ 20y=22% even in favorable grade • 1/3 free,1/3 dead,1/3 recurrence

  42. Muco epidermoid • Gr 1 Well differentiated • Gr 2 Moderate • Gr 3 Poorly • Grade Low or High • Death in 5y LGME 6%, HGME 65% • Agnor count ά prognosis

  43. Malignant mixed-1 • 4% = CA Ex pleomorphic =epithelial • Risk 1.5% <5y long, 9.5% after 15 y • Risk 7% with recurrent Pleomorphic • Risk if 20y long, >2cm, age, deep lobe, solitary nodule, previous surg • de-novo = carcinosarcoma, 5y =0% S

  44. Malignant mixed-2 • < 8mm invasion, 5y survival = 100% • > 8mm invasion, 5y survival =<50% • Survival 5y=40%,10y=24,15y=19% • Regional mets 25%;Distant mets 33% • Types:1. CA ex pleo;2. CASA, 3.Metastasizing mixed, 4. Non-invasive

  45. Large Tumors: General Principle: • Failure at distant site • Role of Postoperative RT • Avoid Marked mutilation & Physiological compromise • Lung mets not preclude rx of primary

  46. Rx • Superficial / Total parotidectomy • Save 7th Nerve, • if not directly involved ? • 56% recurrence even if nerve excised • Submandibular triangle resection

  47. LN %

  48. LN % in Clinical No

  49. LN %in Clinical No

  50. LN % in Clinical No

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