The document discusses the management of salivary gland tumours, including an overview of the different salivary glands and tumours that can occur in each, the workup, staging, treatment options of surgery, radiation therapy and chemotherapy, with a focus on the evidence for use of adjuvant radiation therapy to improve local control based on several studies. Adjuvant radiation therapy significantly increases local control for high-risk features like advanced T and N stage, close or positive margins, nerve involvement and perineural invasion. Elective nodal radiation is also recommended for high-grade tumours but not for adenoid cystic or ac
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Management of salivary gland tumor
1. Management of Salivary gland
Tumours
Presenter
Dr. Shashank bansal
JR-2,MD Radiation Oncology
BBCI
Moderator
Dr. Rubu Sunku
Asst professor
Department of Radiation Oncology
BBCI
2. Introduction
• Salivary glands :
• Major salivary glands(3)
Parotid
Submandibular
Sublingual
• Minor salivary glands
Located throughout the aerodigestive tract (lips, tongue,BM,palate)
• Lymphatic drainage
• Parotid gland : preauricular, Intraparotid nodes , level II,III
• Submandibular: Submandibular LN
• Sublingual : Submandibular LN
3.
4.
5. • Annual global mean incidence 1.2/lakh(0.4-2.6)
• Most commonly Tumour occur in parotid (70%)>
minor glands (25%)> submandibular glands .
• Proportion of malignant tumours , parotid (25%),
submandibular (43%), minor (65%).
• Equal gender preponderance
• Mean age of presentation 54yrs.
• Most common salivary gland tumour Pleomorphic
adenoma
• Most common malignant tumour Mucoepidermoid
cancer.
• Risk Factors :
• Diet deficient in VitA and vit C
• Radiation exposure
• Women employed in saloons
6. Workup
• History and physical examination
• USG with FNAC
• CT scan
• MRI (MRI>CT)
• FDG PET (unpredictable and low sensitivity)
• Minor salivary glands : biopsy is definitive diagnostic procedure (FNAC
impractical)
15. T3, T4a T4b
Surgical Evaluation
Resectable Unresectable
Definitive
RT
Or
Chemo/RT
Untreated Resectable
Surgery
Complete
Resection
Follow
up
Adenoid
cystic
Adverse
features
Adj. RT
Gross residual disease
16. Surgery
• Superficial Parotidectomy : remove gland
superficial to the plane of facial nerve
• Treatment of choice for tumours in the superficial lobe
which are not involving facial nerve
• Adequate Parotidectomy : implies removal of
tumour completely taking care to avoid capsular
rupture or nerve damage with approx. 0.5 to 1cm
tumour free margin
• Should be done only in benign tumours located to
superficial gland
17. • Total conservative Parotidectomy: implies
excision of entire parotid gland (superficial
and deep lobe), while preserving the facial
nerve.
• Done in tumours involving deep lobe with intact facial
nerve
• High grade tumours with high risk of metastasis
• Parotid malignancy with nodal mets.
• Positive margin after superficial Parotidectomy
18. • Radical Parotidectomy: implies excision of structures
other than facial nerve
– Done in case of involvement of
• Skin
• Infratemporal fossa
• Mandible
• TM joint
• Petrous bone
• Complications of Parotid surgery
Acute Late
Facial nerve palsy Sensory deficit
Bleeding or hematoma Cosmetic deformity
Seroma Frey’s syndrome
Salivary fistula
19. Neck dissection
Resectable T3,T4 tumors
Parotid Others
N0 N+ N0 N+
Parotidectomy
+ END if high
risk
Parotidectomy
+ ND
complete
resection
Complete
Resection + ND
20. Adjuvant Radiotherapy
• Indications
• T3/T4 cancers
• Close or positive margins
• Lymph node metastasis
• Adenoid cystic carcinoma
• High or intermediate grade tumours
• Deep lobe cancers
• Perineural involvement
• Recurrent tumours
21. • Elective nodal RT
• T3-T4/N0, high grade tumours .
• Benign tumours
• Inoperable or unresectable tumour
• Facial nerve involvement
• Recurrent tumour
• Subtotal excision
• Radical RT
• Role of radical RT is restricted to unresectable tumours. This
form of treatment is usually palliative in intent.
• Fast neutron beam therapy has been shown to be beneficial
than standard photon therapy in a RCT however its use is
limited by the extremely scarce availability of fast neutron
RT units.
22. Evidence for Adjuvant RT
Dutch Head and neck oncology cooperative group (NHNOCG)
Trial 2005 538 cases
– Parotid gland in 59 %, submandibular gland in 14%, oral cavity in 23%
and elsewhere in 5%.
– All with surgery and 78% (386) with post op RT
– Mean RT dose 62 Gy.
– Adjuvant RT significantly increased local control in T3-T4 tumours,
close surgical margins, incomplete resection, bone invasion and
perineural infiltrations
– PORT improved 10 yr. local control significantly
• in T3-T4 tumours (84% vs. 18%)
• in patient with close(95% vs. 55%)
• incomplete resection (85 % vs. 60%)
• in bone invasion (86% vs. 54%)
• perineural invasion (88% vs. 60%)
• N+ neck (86% vs. 62%) for surgery alone
23. Elective nodal RT
University of California and San Francisco Trial (2007)
• 251 cases with N0 malignant salivary gland tumours was analysed
retrospectively. [Surgery(120) vs. Surgery + ENI(131)]
• Adenocystic 33% ,Mucoepidermoid 24%, Adenocarcinoma 23%.
• Gross total resection R0 44%, R1 56%.
• Adjuvant RT, Median primary RT dose 63 Gy (45-72 Gy), Median Neck RT
dose 50Gy (40-66 Gy).
– Elective neck RT: Ipsilateral 69%, bilateral 31%
– Crude rate of nodal relapse without ENI: squamous 67%,undifferentiated 50%,
adenocarcinoma 34%, mucoepidermoid carcinoma 26%.
– Nodal relapse : 10 yr. actuarial rate of nodal relapse T1 7%,T2 5%,T3 12%, T4 16%.
– Elective nodal RT: 10 yr. nodal relapse risk decreased from 26% to 0% (p value 0.0001)
– Whether or not elective nodal RT was given, no nodal relapse was observed in adenocystic
(0/84) and acinic cell(0/21)tumors .
• Conclusion : Elective nodal RT is required for high grade tumours, but not for
adenoid cystic and acinic cell tumours.
24. Definitive RT
USCF 2006
• Retrospective analysis of 45 patients with malignant salivary
gland tumours treated with RT alone done.
– Median primary dose 66Gy (57-74 Gy).
– Distribution of T-stage was: 24% T1, 18% T2, 31% T3, and 27% T4.
– Histology: Mucoepidermoid (31%), Adenocarcinoma (22%), Adenoid cystic
(18%), Undifferentiated (9%), Acinic (9%), Malignant mixed (4%), Squamous
(4%), and Salivary duct carcinoma (2%).
– No patient has clinical or pathological evidence of clinical disease.
– 5 year local control with RT: 70%
– 10 year local control with RT: 57%
– Local recurrences are frequent in T3-T4 tumours (p value 0.004) and for
RT doses <66 Gy (p value 0.001).
• Conclusion :
• Radiotherapy alone is a reasonable alternative for surgery in the
definitive management of Salivary gland tumours resulting in
significant long term survival.
• Radiation doses in excess of 66 Gy is recommended
27. Proton therapy
Stephen R. et al (2015):
• Retrospective analysis of 24 paediatric patient treated with adjuvant
RT, 13 received proton therapy and 11 received photon/electron
therapy.
– Mean prescribed dose in each cohort: 60Gy
– Follow up 49 months
– Grade 3 mucositis and dermatitis 18% and 27% vs. 0%
– No disease recurrence or deaths were observed in each cohort.
– Reduced doses to OARs. In proton arm
• Conclusion: Proton therapy significantly reduced doses to multiple
normal tissues. Moreover, clinically, no grade 3 toxicities were
observed in the proton group vs. 45% in the photon/electron cohort.
stephenR. Grant BS. Et al (P086) proton vs Photon/electron based therapy in the treatment of paediatric salivary gland tumours : A comparison of
dosimetric Data and Acute Toxicities
29. General consideration
• Parotid gland contains several intraparotid lymph nodes-
tumour cells can spread via the intraparotid nodes to the
subparotid nodes in the retrostyloid space and hence to
the retropharyngeal nodes, or directly to level II nodes
• Tumours of the submandibular salivary gland can invade
locally or perineurally in
– The marginal branch of the facial nerve
– Lingual nerve ,nerve to mylohyoid and hypoglossal nerve
RT planning
30. • Target volume (longitudinally covers gland from 1 cm above the
zygomatic arch to 1 cm below the angle of mandible, medially cover the
Para pharyngeal space, and laterally cover operation scar/ palpable tissue) )
Superior : lower
orbital margin
Inferior : lower part
of gland and upper
deep cervical nodes.
Anterior : cover the
masseter muscle
Posterior : passes
through mastoid
process.
31. • Conventional planning :
– Positioning: patient lies in supine cast, head should be extended
as much as possible, operation scar and any palpable disease should be
marked with the wire. And AP and lateral films are taken.
– Field Arrangements:
• Single field technique
• anterior and posterior wedge fields technique : used to obtain a homogenous
distribution and avoid the opposite parotid gland. The gantry angle of the posterior
fields lies along the petrous bone to minimise dose to the brain stem and spinal cord.
32.
33. • When entire ipsilateral neck is to be irradiated then an anterior
field covering the lower neck is matched with the oblique
fields, taking care that junction does not overlie palpable
disease.
• in case of named perineural involvement cranial nerve
pathways from parotid to base of the skull is covered
34. • CTV 60
– Particular attention is given to the deep excision
margin which is likely to be close or involved if
the facial nerve has been preserved
– As a minimum, the medial extent of the CTV60
should be to the lateral surface of the internal
jugular vein but if the deep lobe of the parotid is
thought to contain tumour the parapharyngeal
space and infratemporal fossa should be included
– In adenoid cystic carcinoma the CTV 60 should
include the course of the facial nerve up to the
stylomastoid foramen at the skull base.
35. • If neck dissection is done then the levels to be treated are
included in the CTV60
• Retropharyngeal LN to be included for deep lobe tumours of
parotid
• For prophylactic neck radiotherapy the ipsilateral level Ib, II
and III nodes should be included in the treatment volume
• A separate CTV 44 can be defined to give these sites
prophylactic dose
• sites where resection margins are involved, or where there
was extracapsular nodal extension should be defined in a CTV
66
• CTV is expanded isotropically to form the PTV by a margin
defined by institute protocol.
36. • Electron portal margins should be 1 cm larger than those for
photons because of the constriction of the electron isodose
curves at depth.
• The energy of the electron has to be chosen depends on the
anatomic distance from the skin of the ipsilateral cheek to the
oral mucosa and generally ranges from 12-16MeV.
• When a combination of electrons and photons are used either
modality can start first.
• By mixing the two different beams one can decrease the
irradiation of the contralateral parotid gland, acute radiation
skin reaction, and mucositis.
37.
38. Submandibular glands
• Single field is enough
• Possible regions that should be included in portal:
submandibular angle , neighbouring oral cavity,
pterygomaxillary fossa, cranial base, ipsilateral neck
• Superior border : hard palate
• Inferior border: hyoid bone
• Anterior border: anterior to mentum
• Posterior border: posterior to mandibular angle.
39. Sublingual gland
• General portal margins that encompass the planning
target volume are :
– superior: 1cm above the upper border of the tongue
– Inferior: hyoid bone- thyroid notch interspace
– Anterior : anterior aspect of the mental symphysis
– Posterior: posterior aspect of the ascending mandibular
ramus
– Lateral: 2cm form ipsilateral mandible
– Medial: 2cm past midline
• Right and left opposed lateral portals are needed to
completely encompass this treatment volume,
particularly when the regional lymph nodes are
included
40. Chemotherapy
• Chemotherapy has role only in palliative settings in patient
with recurrent un-resectable disease or distant metastases.
• May have palliative benefit for a small proportion of patients
with recurrent/metastatic adenoid cystic carcinomas after due
considerations of other therapies (palliative radiation,
metastaectomy of solitary lesions)
41. 2 Groups
Adeno Ca like tumors i.e.
Adenoid cystic Ca, Acinic Cell
Ca, Ca ex polymorphic Ca
Adriyamycin
Cisplatin
5-FU
Epidermoid like tumor i.e.
Sq.cell Ca,
Mucoepidermoid Ca
Methotreaxate
Cisplatin
42. Follow up
• H&P exam (including a complete head and neck
exam; mirror and fiberoptic examination as
clinically indicated)
• Year 1 : every 1-3 months
• Year2 : every 2-6 months
• Year 3-5: every 4-8 months
• > 5years : every 12 months
• Routine annual imaging in areas difficult to
visualise on exam.
• Routine TSH every 6-12 months if neck
irradiated.
43. Recurrence
Loco regional recurrence without
RT
Resectable Unresectable
Surgery
Complete
resection
RT or Chemo
Adverse featuresAdj. RT
Loco regional recurrence or
second primary with prior RT
Resectable Unresectable
Surgery*
Or
reRT+Chemo
reRT+Chemo
Or
Chemo
45. Conclusion
• Surgery after proper imaging (MRI or CT scan) is the
main stay of treatment for salivary gland tumours
• Best effort should be made to preserve the facial nerve
whenever it is not infiltrated
• Adjuvant external radiation should be considered in
tumours with high-risk features or whenever indicated.
• For inoperable cancer, Radical RT is a valuable option.
• Protons or Neutron are promising but access to them is
limited for usual treatment.
