salivary gland neoplasm

Parotid tumors and
parotidectomy
Dr Sumer Yadav
MBBS, MS, MCh
Plastic and reconstructive surgery
sumeryadav2004@gmail.com

Salivary gland neoplasm
1. Major salivary gland
a. Parotid gland
b. Submandibular gland
c. Sublingual gland
2. Minor salivary gland
600 – 1,000 minor salivary gland distributed throughout
the mucosa of the upper aerodigestive tract (more
common in the soft and hard palate).

80% of salivary gland tumor occur in the parotid.
10 – 15% in the minor salivary gland.
5 – 10% in the submandibular gland.
80% of the parotid tumor are benign.
The most common is pleomorphic adenoma.
50% of the submandibular gland tumor are benign.
30% of the minor salivary gland are benign.

Malignant disease of the parotid
Pathogenesis:
1. Reserve cell theory
(currently the favored
theory) of salivary gland
neoplasia states that salivary
neoplasms arise from
reserved (stem cells) of the
salivary duct system e.g.
adenoid cystic carcinoma
and acinic cell carcinoma
arising from intercalated
duct reserve cell. The
mucoepidermoid carcinoma,
squamous cell carcinoma,
and salivary duct carcinoma
arise from excretory reserve
cell.
Salivary gland unitsumeryadav2004@gmail.com

2. Multicellular theory of
salivary gland neoplasia
states that salivary
neoplasm arise from
already differentiated
cells along the salivary
gland unit. For example,
squamous cell carcinoma
arises from the excretory
duct epithelium and
acinic cell carcinoma
arise from the acinar
cells.
Salivary gland unit

What are the most common benign
tumor of the parotid?
1. Pleomorphic adenoma (benign mixed tumor).
2. Warthin’s tumor (papillary cyst adenoma
lypmhomatosum).
3. Monomorphic adenoma
a. Basal cell adenoma
b. Canalicular adenomas
c. Oncocytoma
d. Myoepitheliomas
4. Granular cell tumor
5. Hemangioma

What are the most common malignant neoplasm of
the parotid gland?
1. Mucoepidermoid carcinoma – 40%
It can high, intermediate, and low-grade base on the
clinical behavior and the tumor differentiation which is
related to the percentage of mucinous to epidermoid cell.
2. Adenoid cystic carcinoma – 10%
Adenoid cystic carcinoma are unique among the salivary
gland tumors because of their indolent and protracted
clinical course.
Characterized by perineural spread including skip lesions.
The disease thus specific survival continuous to declined
for more than 20 years after initial treatment.sumeryadav2004@gmail.com

3. Acinic cell carcinoma – 10 – 15 % of
It is considered a low-grade tumor.
4. Malignant mixed tumor - 7%
It is considered a high-grade malignancy.
5. Polymorphous low grade adenocarcinoma – 10%
It is a low-grade variant of adenocarcinoma.
6. Adeno carcinoma – 10%
It is a high-grade with poor prognosis.
7. Squamous cell carcinoma – 4%
It is high-grade, more common in elderly patients, and
can confused with high-grade mucoepidermoid
carcinoma. sumeryadav2004@gmail.com

The malignant parotid tumor can be classified
into:
1. High-grade: aggressive behavior, local invasion, and
lymph node metastasis.
- high grade mucoepidermoid carcinoma
- adenoid cystic carcinoma
- carcinoma ex phelomorphic adenoma
- adenocarcinoma
- aquamous cell carcinoma
- undifferentiated carcinoma

2. Low-grade malignancy
- low grade mucoepidermoid carcinoma
- pholymorphous low grade adenocarcinoma
- acinic cell carcinoma
- low grade adenocarcinoma
- basal cell carcinoma
3. Intermediate grade
- intermediate grade mucoepidermoid carcinoma
- intermediate grade adenocarcinoma
- oncocytic carcinoma

Evaluation of patients with a parotid mass
1. History
Important points in the history:
- Parotid mass (duration, rate of the growth,
presence of pain)
- Facial paralysis
- Cervical lymphadenopathies
- Eyes and joints symptoms
- History of exposure to radiation

2. Examination
- Size of the mass
- Skin fixation
- Cervical adenopathies
- Facial nerve functions
- Raised ear lobule and retromandibular groove
obliteration
3. Investigation
C.T. and MRI are both effective modalities for imaging
the size, the local, and the regional extension of the
primary tumor and the neck metastasis.
C.T. saliography – it replaced now by high-resolution
contrasted C.T. and MRI.

4. FNAB
- The accuracy is around 90% depend on the
techniques of aspirate and the
cytopathologist.
5. Superficial parotidectomy is considered as a
diagnostic and therapeutic for most benign
tumors.

Treatment
Surgery -Parotid
90%confined to superficial lobe - 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
syndrome – (gustatory sweating) due to redirection of
parasympathetic and sympathetic nerve fibers to the
dermal sweat glands sumeryadav2004@gmail.com

Indications of malignancy
Facial nerve involvement
Indurations / ulceration of skin , mucous membrane
Change in consistency
Fixity to muscles/ mandible
Lymph node metastasis
Rapid tumor growth

Open biopsy
Contraindicated
Justified only in minor gland trs
Ulcerated lesions

Benign tumors
Painless
Slow growing
No facial palsy

Pleomorphic Adenoma
commonest benign tumor
Pseudocapsule
Pseudopodal extensions
Not multicentric

Pleomorphic Adenoma
Mixed tumor
Consists of cartilage besides epithelial cells
Cartilage not of mesodermal origin
Derived from mucin secreted by epithelial cells

Microscopy
Epithelial and myoepithelial components
Abundant matrix mucoid,myxoid or
chondroid supporting tissue

Diagnosis
Lobulated , painless swelling
Long duration
Neither adherent to skin/ masseter muscle
Generally firm / variable consistency

Malignant transformation
3–5%of cases
Pain
Rapid growth
Hard

Treatment
Superficial parotidectmy
Total parotidectomy

Adenolymphoma/Warthins tumor
Papillary cystadenoma lymphamatosum
5–15%of parotid tumors
Always at the lower pole of the parotid
Overlies the angle of mandible

Warthins tumor
More in white races
Not seen in negroes
Encapsulated lesions
No malignant transformation

Warthins tumor
Only salivary neoplasm more in males
Elderly males
Slow growing
painless

Warthins tumor
Surface is smooth
Well defined
Distinct margins
Soft in consistency with fluctuation
Not tansilluminant

Investigations
FNAC
Tc99 scan – hot spot

Microscopy
Cystic / glandular spaces
Lined by columnar epithelium
Within abundant lymphoid tissue with
germinal centres

Treatment
Superficial parotidectmy
Enuclation

Mucoepidermoid carcinoma
MC- epithelial malignancy of gland
Parotid &minor glands
Hard in consistency
Infiltrate local tissue
Slow growing tumor
Recurs locally

Mucoepidermoid carcinoma
LN mets in 30%
Lung, bone, brain -15%
Graded based on cellular content

The post-operative complications:
1. Skin flap necrosis
2. Hematoma
3. Salivary fistula and sialoseles – it presents as an
opening in the suture line below the lobule of the
ear.
4. Facial nerve paralysis – which could be:
a. Temporarily: 5 – 10% of the patients.
b. Permanent: less than 2% of the cases.
5. Numbness of the ear due to injury of great auricular
nerve. sumeryadav2004@gmail.com

6. Xerostomia not common in the superficial
parotidectomy (30% of salivary producing tissue).
5. Frey’s syndrome (Gustatory sweating syndrome)
Incidence in 50% of the patients.
Etiology: post-operative growth of the interrupted
preganglionic parasympathetic nerve branches to
the parotid into the more superficial sweat glands.
The diagnosis is usually made from the history but
can be confirmed by the starch-iodine test.

What is starch-iodine test?
Paint the affected skin with iodine, dust the
skin with the starch, feed the patient. The
appearance of bluish discoloration of the
overlying skin due to reaction of starch
and iodine in the presence of moisture
(sweat.

How do you treat Frey’s syndrome?
Although frey’s syndrome is usually a minor problem, it
may require treatment which include:
1. Parasymphatholytic creams such as glycopyrrolate
lotion may also be applied to the skin or scopolamine
cream 3%.
2. Apply anti-perspirant to avoid sweating.
3. Jacobsen’s neurectomy via tympanotomy approach.
4. Elevating skin flap and placing tissue such as fascia,
dermis, or creating SCM muscle flap and if there is a
big defect you can use regional flap as a PMMF.

Facial nerve paralysis
In parotid malignancy
a. Patient with clinically pre-op facial
nerve paralysis. What to do?
Intra-operative resection of the involved
part of the facial nerve and primary
grafting using greater auricular nerve or
sural nerve.
Post-operative radiotherapy (high-grade)

b. Patient with a normal facial function
but intra-operative involvement of the
facial nerve. What to do?
Careful dissection of the tumor of the
facial nerve without sacrifying the facial
nerve and followed-up with radiotherapy
treatment.

During an operation on the
parotid, where do you find
the facial nerve?

1. Tragal cartilage
(pointer) – always
point to the facial
nerve.
The facial nerve is
1 cm. inferior and
1 cm. medial to
the pointer.

2. Tympanomastoid
fissure – FN is 4
mm inferior to
the tympano
mastoid fissure as
it exit from the
stylo mastoid
foramen.

3. Posterior belly of
digastric muscle. The
facial nerve is superior
to the upper border of
the belly of the digastric
muscle.

4. Retrograde inferior
approach to the
facial nerve.
The lower branch of
the facial nerve
invariably can be
found immediately
external to the
posterior facial
vein as it exits the
lower pole of the
parotid gland.

5. Retrograde anterior
approach.
The parotid duct is
constant imposition
as it goes
horizontally across
the border of
masseter muscle.
It’s always
accompanied by a
branch of buccal or
zygomatic branch
within 1 cm. of the
duct.
Angle of
mandible
Parotid
duct

Does the grading make
difference in management
of the parotid malignancy?

Stage T N M
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1-3 N1 M0
IVA T1-3 N2 M0
T4a N0-2 M0
IVB T4b Any N M0
Any T N3 M0
IVC Any T Any N M1
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor < 2 cm, no extraparenchymal extension
T2 Tumor > 2 cm, < 4 cm, no extraparenchymal
extension
T3 Tumor > 4 cm or extraparenchymal extension
(or both)
T4aTumor invades skin, mandible, ear canal, facial
nerve, or any of these structures
NX Regional lymph nodes cannot be assessed
N0 No cervical nodes metastasis
N1 Single ipsilateral lymph node < 3 cm
N2a Single ipsilateral lymph node < 3 cm and <
6 cm
N2b Multiple ipsilateral lymph node
metastases, each < 6 cm
N2c Bilateral or contralateral lymph node
metastases, each < 6 cm
N3 Single or multiple lymph node metastases
< 6 cm
MX Distant metastases cannot be assessed
M0 No distant metastases
M1 Distant metastases present
Modified, with permission, from Greene FL,
Page DL, Fleming ID et al
(eds.):American Joint Committee on
Cancer: AJCC Cancer Staging Manual, 6th
ed. New York, Berlin, Heidelberg:
Springer-Verlag, 2002.

Group 1: T1 and T2NO low-grade malignancy
Treatment is excision of the tumor with cuff of a
normal tissue.
Facial nerve is preserved.
Regional lymph node evaluated at the time of
surgery.
No post-op radio therapy unless the resection
margin is not clear.

Group 2: T1 and T2NO high-grade malignancy
Treatment is total parotidectomy with excision of digastric
and submandibular nodes.
Facial nerve involvement:
a. patient with facial paralysis pre-operatively.
Resection of the facial nerve with primary grafting.
b. patient with normal facial function pre-op.
Resect the tumor of the facial and post-operative
wide field radiation.

Group 3: T3NO or any N+ high-grade or
recurrent cancer.
Treatment is total parotidectomy
Modified radical neck dissection
Post-operative wide field radiotherapy
Facial nerve as in group 2

Group 4: include all T4 tumor
Treatment is radical parotidectomy with modified
radical neck dissection and resection of
masseter muscle, part of the mandible or
mastoid or ear canal as required.
Resection of the facial nerve with the tumor and
primary grafting.
Followed by wide field post-operative
radiotheray. sumeryadav2004@gmail.com

Points to remember in parotid surgery:
1. Pre-op evaluation: general condition of the patient,
CBC, LFT and RFT, X RAYS , VIRAL
MARKERS, ECG
2. Consenting patients for possible facial weakness.
3. Operating in bloodless field by:
a. hypotensive technique
b. elevation of the head of the bed
c. delicate tissue handling
d. proper hemostasis

4. Using facial nerve monitoring during
operation and at the end of operation.
5. Exposure of the eye and the operative side of
the face.
6. Lazy S incision.
7. Landmark for the facial nerve.
8. Fasciovenus pane of patey.- facial nerve and
retromandibular vein forms it b/w superficial
and deep lobe.

Indications of post-operative
radiotherapy
1. High-grade tumor
2. Gross or microscopic residual disease
3. Tumor involving or close to the facial nerve
4. Recurrent disease
5. Documented lymph node metastasis
6. Extraparotid extension
7. Deep lobe cancers
8. All T3 and T4 cancers

•Thanks

salivary gland neoplasm

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