Malinant Salivary Gland Tumours Dr.Shaji Thomas Additional Professor,Regional Cancer Centre Trivandrum

MALIGNANT SALIVARY GLAND TUMOURS
DR. SHAJI THOMAS MS,MCh
Additional Professor
Division of Surgical Oncology
REGIONAL CANCER CENTRE, TRIVANDRUM
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Introduction
• Tumours of the salivary glands account for only 5% of
H&N cancers and 0.3% of all cancers
• Diverse histopathology
• Proportion of malignant and benign varies with the gland of
origin.
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Malignant Neoplasms-subtypes
Mucoepidermoid Carcinoma
Adenoid Cystic Carcinoma
Carcinoma ex-pleomorphic adenoma
Acinic Cell Carcinoma
Adenocarcinoma
Squamous Cell Carcinoma
Undifferentiated Carcinoma
Sarcoma
Lymphoma
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• Most common type
• 80-90% occur in the parotid gland
• More common in females
• Highest prevalence in 5th decade of life
• Characterized histologically by a mixed population of cells, mucin-producing
cells, epithelial cells, and intermediate cells.
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• Mucoepidermoid cancer is histologically classified into low and high
grade. A higher grade correlates with a poorer outcome
• Low-grade tumors have a higher percentage of mucinous cells
• Epithelial cells predominate in high-grade.
• The presence of four or more mitotic figures per 10 high-power fields,
neural invasion, necrosis, intracystic component <20%, and cellular
anaplasia indicate high-grade behavior.
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• Adenoid cystic carcinoma is the most common malignancy of the
Submandibular gland
• Adenoid cystic carcinoma is characterized by slow growth,
neurotropism, local recurrence, and distant metastasis.
• Exhibits a predilection for neurotropic spread, often leading to
recurrences at the skull base after surgical and radiation treatment
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• Three distinct histologic patterns, cribriform, tubular, or solid,
although the histologic patterns may coexist in the same tumor
• The cribiform pattern has a glandular architecture and is reported to
have the best prognosis.
• The solid pattern is more epithelial in nature and is associated with a
poorer prognosis.
• The tubular pattern has a clinical prognosis of intermediate nature
between the other two patterns.
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Acinic Cell Carcinoma
• This tumor has a low-grade behavior and has the best survival rate of
any salivary malignancy
• Parotid gland was the most common site of origin
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Carcinoma ex-Pleomorphic Adenoma
• Malignant degeneration can occur in 3% to 7% of pleomorphic
adenomas.The risk of malignant degeneration is estimated at 1.5% in
the first 5 years and 9.5% after 15 years.
• Histologic findings include those of benign pleomorphic adenoma with
carcinomatous degeneration.
• A typical clinical history includes a longstanding salivary mass that
begins to rapidly enlarge, often to substantial size, although many
patients have no history of a prior
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Low Grade Rare Subtypes
Polymorphous low-grade adenocarcinoma
Epithelial-myoepithelial carcinoma
Basal cell adenocarcinoma
Papillary cystadenocarcinoma
Myoepithelial carcinoma
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High Grade Rare Subtypes
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Squamous cell carcinoma
Small cell carcinoma
Sebaceous carcinoma
Mucinous adenocarcinoma
Oncocytic carcinoma
Adenocarcinoma
Salivary duct carcinoma

Diagnosis
• Malignant salivary neoplasms present as a painless mass in
approximately 75% of patients. Rarely,patients are initially seen with
pain or facial nerve palsy.
• A palpable mass arising in a salivary gland, associated with pain,
and/or nerve paralysis is more likely to be malignant than benign.
• It is believed that episodic pain suggests continued obstruction,
whereas constant pain is more suggestive of malignancy.
• Trismus, cervical adenopathy, fixation, numbness, loose dentition, or
bleeding also suggest the presence of malignancy.
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TNM
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor 2 cm or less in greatest dimension without gross
extraparenchymal extension
T2 Tumor more than 2 cm but not more than 4 cm in greatest
dimension without gross extraparenchymal extension
T3 Tumor more than 4 cm and/or tumor having gross
extraparenchymal extension
T4a Tumor invades skin, mandible, ear canal, and/or facial nerve
T4b Tumor invades skull base and/or pterygoid plates and/or encases
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carotid artery

TNM
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in
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greatest dimension
N2a Metastasis in a single ipsilateral lymph node, more than 3 cm but
not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6
cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more
than 6 cm in greatest dimension
N3 Metastasis in a lymph node more than 6 cm in greatest dimension

Stage Grouping
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVB T4b Any N M0
Any T N3 M0
Stage IVC Any T Any N M1
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Diagnostic Studies
• CT (with contrast)
• Requires contrast and radiation
• Excellent detail of the tumor volume
• Useful in evaluating the parapharyngeal
space
• Relation of tumor to vascular and bony
structures helpful in surgical planning
• Lymphatic survey
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Diagnostic Studies
• MRI
• Does not require iodination or
radiation
• Excellent soft tissue detail
• Superior in defining the tumor
boundaries
• Useful to determine if nerve
involvement present
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T1, low signal
intensity
T2, high signal
intensity

Diagnostic Studies
• PET Scan
• Useful in staging and follow-up
• Rule out distant and regional metastases
• Predicted the nature of the neoplasm in 69%
• Demonstrated 100% sensitivity for malignancy
• False-positive rate of 30%
• Role not yet well defined
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PET
Increased FDG uptake
• Inflammatory lesions,
• warthin’s and
• pleomorphic adenomas
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Fine-Needle Aspiration Biopsy
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• Opponents argument:
• Doesn’t change management
• Often surgery regardless of reported diagnosis
• Obscuring final pathologic diagnosis
• Frequency of “inadequate” sampling, requires multiple biopsies,
prolongs course until definitive treatment, increases cost

Fine-Needle Aspiration Biopsy
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• Proponent’s argument:
• Important to distinguish benign vs. malignant nature of
neoplasm
• Preoperative patient counseling
• Surgical planning
• Differentiate between neoplastic and non-neoplastic
processes
• Avoid surgery in a number of patients

Value of the cytological diagnosis in
the treatment of parotid tumors.
Jafari et. al.
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• Concluded:
• In the majority of parotid tumors, there was a good correlation
between the FNA cytological diagnosis and the histopathological
results
• FNA provides an adjuvant tool in the strategic and surgical
approach of a parotid tumor:
• wider resection of parotid gland
• cervical neck dissection

Treatment – The Primary
• What surgery should I perform on the primary tumor?
• Does this patient need postoperative radiation?
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Surgeries for parotid
If not for the facial nerve
parotid surgery would just be a
lipoma excision
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Surgeries for parotid
• Superficial Parotidectomy
• Adequate Parotidectomy
• Total conservative Parotidectomy
• Total radical Parotidectomy
• Extended radical Parotidectomy
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• Superficial parotidectomy has been touted as the minimal surgery of
the parotid gland
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• Use of lesser procedures
• A higher risk of facial nerve injury and
• The potential for intraoperative seeding of tumor resulting in
recurrence.
• The safety of parotidectomy has been well established, and the
complication rate remains low.

• Total parotidectomy may be necessary for tumor extension into the
deep parotid lobe or when the tumor primarily arises in the deep
lobe. This can be performed with preservation of the facial nerve
• Occasionally, patients may require extended parotidectomy, which
includes resection of the masseter muscle or the ascending portion
of the mandible.
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• Facial nerve sacrifice is not routinely advocated.
• Nerve preservation in primary salivary malignancy is recommended if
the nerve is functioning normally before surgery.
• Every attempt to dissect the tumor from the individual branches
should be undertaken.
• If tumor is completely encasing the nerve branches, neural sacrifice
is limited to the involved branches.
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• Concluded:
• Selective sacrifice when nerve impaired or where tumor margins
compromised seems to improve local control and survival.
• QOL significantly affected.
• Pre-op FNA and CT extremely useful in counseling patients.
• Patients managed with XRT better local control.

Adequate parotidectomy
• Jesus Medina of Oklahoma University
• Procedure less than a classical superficial parotidectomy
• For low grade parotid tumours in tail of parotid or accessary parotid –
away from facialN
• Warthins tumour
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Revision Parotid Surgeries
• Inadequate and incomplete primary surgery
• Difficult to perform when facial N in scar tissue
• Always perform a proper and complete surgery in the first chance
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itself
• High incidence of nerve damage and neuro praxia

• Chen, in 2007, 207 patients who, over 5 decades, received surgery
without XRT as primary modality
• He identified patients who were at high risk of locoregional
recurrence with surgery alone
• Based on these observations, he recommended postoperative XRT
for patients with T3-T4 disease, positive surgical margins, high grade
tumor histology, or regional nodal metastasis
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Concluded
• Recommended postop XRT for:
• High-grade histology
• Recurrent disease
• Inadequate surgical margins
• Perineural invasion
• Extension of disease beyond the gland
• Nodal disease
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• In general, tumors of the submandibular gland require
complete excision of the gland.
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Malignant lesions –SM gland
• Simple excision of the submandibular gland sufficient in cases where
the tumor is confined within the capsule of the gland
• Given the high incidence of adenoid cystic carcinoma at this site, a
more extensive regional resection is often required(adjacent muscles,
the lingual or hypoglossal nerves,part of mandible, or the floor of the
mouth)
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Malignant Lesions: Minor Salivary Glands
• Surgical treatment will vary depending on the site of origin.
• In general, these lesions are resected in a manner similar to that
utilized for squamous carcinoma arising at the same primary site.
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Management of nodal mets
• Incidence of regional metastases is relatively low for most types of
salivary cancer
• Appropriately treating the neck in salivary malignancy is important for
patient outcomes
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Treatment – The Neck
• How should I treat the neck in my patient?
• Observation, elective neck dissection, or elective neck irradiation?
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• Palpable nodal metastases - comprehensive neck dissection
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indicated
• Elective neck dissection reserved for those with a high incidence of
nodal involvement (high grade mucoepidermoid carcinoma or
primary squamous carcinoma),locally advanced disease

Role of Chemotherapy
• Adjuvant chemotherapy is currently indicated only for palliation.
• Doxorubicin(induce apoptosis) and platinum-based agents(promote
cell arrest) are most commonly used.
• Platinum-based agents, in combination with mitoxantrone or
vinorelbine, are effective in controlling recurrent salivary gland
malignancy..
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Conclusions
• Malignancies of the major salivary glands represent a rare and
diverse group of cancers
• Knowledge about tumor staging and histologic grading is necessary
for prognostic predictions, patient counseling, and treatment planning
• Surgical treatment should be the primary therapy with removal of all
gross disease as the surgical goal
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Conclusions
• Patients should receive postoperative radiation to the primary site if
the tumor is stage III or IV, or if the pathology shows positive
margins or perineural invasion
• Careful consideration must be given to treatment of the neck, with
clinical disease as definite indication for neck dissection and/or neck
XRT
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Malinant Salivary Gland Tumours Dr.Shaji Thomas Additional Professor,Regional Cancer Centre Trivandrum

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