oncology

1. Salivary Gland Tumors
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2. ANATOMY AND LYMPHATIC
DRAINAGE

3. Salivary Glands
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The Major Salivary Glands
1. Parotid
2. Submandibular
3. Sublingual
The Minor Salivary Glands

4. Applied Anatomy – Parotid Gland
 There is no true anatomic separation, the parotid gland is arbitrarily divided
into “superficial” and “deep” lobes by the plane of the facial nerve.
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5. Extensive lymphatic capillary plexus
Numerous intraglandular LN in the superficial lobe
Lymphatics drain from – Lateral areas on the face & Frontal region of the scalp.
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• Associated with the gland are parotid nodes, drain downward along the retromandibular
vein to empty into – Superficial lymphatics , Nodes along the sternocleidomastoid
muscle & Upper nodes of the deep cervical chain.

6. • There are numerous lymph nodes located within, and adjacent
to, the capsule of the parotid gland that serve as the first
echelon of nodal drainage for the temporal scalp, portions of
the cheek, the pinna, and the external auditory canal.
 For this reason, the parotid gland may harbor metastatic
cutaneous malignancy from these sites
• Efferent lymphatics from the gland communicate with lymph
nodes of the upper and middle deep jugular chain.
Lymphatics Drainage
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7. Positive neck nodes (percent) at first presentation according to site and level (I–V).
Lymphnodal spread
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8. WHO CLASSIFICATIONS OF SGTs
Adenomas
Pleomorphic adenoma
Warthin’s tumor
(adenolymphoma)
Myoepithelioma
(myoepithelial
adenoma)
Basal cell adenoma
Oncocytoma (Oncocytic
adenoma)
Canalicular adenoma
Sebaceous adenoma
Ductal Papilloma
• Inverted ductal papilloma
• Intraductal papilloma
• Sialadenoma papilliferum
Cystadenoma
• Papillary cystadenoma
• Mucinous cystadenoma
Carcinomas
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Acinic cell carcinoma
Polymorphous low-grade
adenocarcinoma
Epithelial-myoepithelial
carcinoma
Basal cell adenocarcinoma
Sebaceous carcinoma
Papillary
cystadenocarcinoma
Mucinous adenocarcinoma
Oncocytic carcinoma
Salivary duct carcinoma
Adenocarcinoma
Malignant myoepithelioma
Squamous cell carcinoma
Small cell carcinoma
Undifferentiated carcinoma
Miscellaneous
Nonepithelial tumors
Malignant lymphomas
Secondary tumors
Unclassified tumors
Tumor-like lesions
• Sialadenosis
• Oncocytosis
• Necrotizing
sialometaplasia
(salivary gland
infarction)
• Benign lymphoepithelial
lesion
• Salivary gland cysts
• Chronic sclerosing
sialedenitis of
submandibular gland
(Kuttner tumor)
• Cystic lymphoid
hyperplasia in patients
with acquired
immunodeficiency
syndrome

9. Carcinomas - Histologic Types
Mucoepidermoid Carcinoma 34%
Adenoid Cystic Carcinoma 22%
Adenocarcinoma 18%
Carcinoma ex pleomorphic adenoma 13%
Acinic cell carcinoma 7%
Squamous cell carcinoma 4%

11. Mucoepidermoid Carcinoma
• Most common salivary gland malignancy
• 5-9% of salivary neoplasms
• Parotid 70-80% of cases (most common in parotid)
• 3rd- 8th decades, peak in 5th decade
• F>M
• Caucasian > African American
• Presentation
– Low-grade: slow growing, painless mass
– High-grade: rapidly enlarging, +/- pain
– Stained +ve by muscarmine.
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12. • Gross pathology
– Well-circumscribed to
partially encapsulated
to unencapsulated
– Solid tumor with cystic
spaces
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Mucoepidermoid Carcinoma

13. • MECs contain two major
elements:
• Epidermoid and Mucinous
components
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Mucoepidermoid Carcinoma

14. Adenoid Cystic Carcinoma
• Overall 2nd most common malignancy
• Most common in submandibular, sublingual and
minor salivary glands
• M = F
• 5th decade
• Presentation
– Asymptomatic enlarging mass
– Pain, paresthesias, facial weakness/paralysis
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15. • Gross pathology
– Well-circumscribed
– Solid, rarely with cystic spaces
– Infiltrative
Unique features
 Locally aggressive, with local
recurrences often after many years.
 Perineural infiltration
 Asymptomatic large pulmonary mets
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Adenoid Cystic Carcinoma

16. • 3 basic growth patterns :
 Tubular – grade 1
 Cribriform – grade 2
 Solid – grade 3
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Adenoid Cystic Carcinoma

17. CLINICAL FEATURES

18. SGTs - Clinical Presentation
LOCAL
• “Painless, rapidly enlarging mass (present for years) before a sudden
change in its growth pattern”
• Painless submucosal mass – Minor salivary gland tumour
• Pain (10% to 20%) - malignant disease.
REGIONAL
• Pain - involvement of deeper structures (masseter, temporal, and pterygoid
ms).
• Mucosal ulceration in the palate , lips, or buccal mucosa
• Malignant tumours - median duration of clinical symptoms is shorter (3 to
6 months) in comparison to benign (10 years)
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19. SGTs - Clinical Presentation
• Tumours of parotid may involve the base of skull and cause
intractable pain and paralysis of various cranial nerves.
• 1/3rd of parotid cancers may have facial nerve involvement
• Deep lobe parotid – tonsillar and palatal bulge
• Sublingual – ulcerated mass in floor of mouth
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20. Minor Salivary Gland tumours
• S/S associated with tumours of minor salivary glands vary because of their
diverse locations.
• Most are intraoral, and a painless lump is the most common presenting
symptom.
• Tumours of nasal cavity or sinuses, facial pain is most common presenting
symptom , followed by nasal obstruction.
• Laryngeal primary tumours most frequently cause hoarseness or voice
change.
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SGTs - Clinical Presentation

21. • Malignant salivary gland tumour
• Rapid growth rate
• Pain
• Facial nerve palsy
• Childhood occurrence
• Skin involvement and
• Cervical adenopathy
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SGTs - Clinical Presentation

22. DIAGNOSTIC WORK-UP

23. Diagnostic Work-Up
Major Salivary Glands
• History
• Physical examination with particular to signs of local fixation or regional
adenopathy.
• Laboratory Investigation
• Radiology for locoregional assessment
• CT scans - evaluating the extent of lesions involving the parotid gland.
- Temporal bone or mandibular bone invasion/destruction
• MRI - superior to other modalities
• Metastatic workup – CXR ,USG abdomen, Bone scan , ?PET scan
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24. Diagnostic Work-Up
Major Salivary Glands
MRI
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25. 25

26. Histopathological Diagnosis
FNAC
• A reliable procedure.
• The sensitivity for malignancy varies between 80% - 90%; the specificity is > 90%.
• False-negative findings may be seen as result of lack of representative material or a
cyst(Ultrasound fine-needle aspiration is advised)
• Negative predictive value for malignancy 70% to 75%
• Low negative predictive value of FNAC will be improved if MRI and fine-needle
aspiration are combined.
Other options – Trucut biopsy (metastatic ds with inconclusive FNAC)
Superficial/Total Parotidectomy (Grand biopsy)
submandibular gland excision
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27. Minor Salivary gland tumour
• MRI/CT – none has been validated
• FNAC – no role
– Especially if malignancy is suspected
– Polymorphism is most pronounced with malignant tumours
• Biopsy – Ideal tissue proof
– Unplanned incisional biopsy avoided
– Excisional biopsy/trucut

28. STAGING

29. TREATMENT MODALITIES
Surgery
Radiotherapy
Chemotherapy
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30. Treatment Outline
• Benign & Low grade tumours –
 Typically treated with surgery alone
• High-grade carcinomas and those with positive margins or other
high-risk features -
– Usually treated with surgery and adjuvant radiation therapy (RT)
• Unresectable tumors
– May be treated with RT alone or RT in combination with
chemotherapy

31. Surgery
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• Surgical resection is the principal form of treatment for both
benign and malignant salivary tumors
• Complete surgical resection is the cornerstone of treatment when
this can be achieved with negative surgical margins
Aggressive surgery does not improve disease-free survival.
Facial nerve grafting with the greater auricular or sural nerve graft
decreases the incidence of facial palsy postoperatively, especially if
branches and not the main trunk are involved
Adjuvant postoperative radiotherapy has no negative effect on
facial nerve function

32. Surgical Options In Parotid Surgery
1. Local Excision vs. Enucleation
2. Superficial Conservative parotidectomy
3. Superficial parotidectomy (VII sacrificed)
4. Total parotidectomy
5. Extended parotidectomy
- Mandible, masseter, T-bone, etc.,
6. Neck dissection

33. Options In Parotid Surgery
Local Excision vs. Enucleation
 Enucleation, has no role in surgical management of salivary neoplasms
 Pleomorphic adenoma has a pseudocapsule, so there is almost certainly
residual tumor after simple excision, resulting in frequent relapses
 It is important to avoid enucleation and excision biopsy because it greatly
increases the likelihood of recurrence (up to 80%) and nerve damage

34. Options In Parotid Surgery
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Superficial Conservative Parotidectomy
• It is the “treatment of choice” for tumors in the superficial lobe,
which are not involving the facial nerve.
• Implies complete removal of the parotid gland superficial to the plane
of the facial nerve
• It is the minimum standard surgical procedure.
• Less extensive than a superficial parotidectomy
• Does not fully dissect the facial nerve

35. Options In Parotid Surgery
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Total Conservative Parotidectomy (Facial N sparing)
• Implies excision of entire parotid gland (superficial and deep lobes), while
preserving the facial nerve
• Done for tumors involving the deep lobe with
– Intact facial nerve functions,
– High-grade malignant tumors with a high risk for metastasis,
– Any parotid malignancy with an indication of metastasis to intraglandular or
cervical lymph nodes,
– Any primary malignancy originating within the deep lobe itself,
– Positive margin (base) after superficial parotidectomy

36. Total Parotidectomy with the Excision of Facial nerve
• Indications as above, when the nerve is involved by the tumor
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Options In Parotid Surgery

37. Radical/Extended Parotidectomy
• When tumour is extending beyond the parotid gland
• Implies excision of structures in addition to parotid gland and facial nerve.
• Done when tumor involves:
– Skin, Infra-temporal fossa, Masseter, Mandible, TM joint or Petrous bone
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Options In Parotid Surgery

38. How to address nodes (extent of LND) ?
For parotid : Ipsi Level Ib, II, III, IV and Va
For SM gland : Ipsi Level I, II and III
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39. Surgery for Submandibular gland
• Excision of the Submandibular gland + SOND
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40. Surgery For Minor Salivary Glands
• Depends on site of origin,grade & extent of disease
• Localized low grade tumor- Wide local excision
• Larger & high grade lesions-
– Marginal/segmental mandibulectomy
– Partial/ total resection of hard or soft palate
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41. Benign tumors
• Superficial Parotidectomy
– is recommended for most benign tumors
confined to the superficial lobe, including
pleomorphic adenomas

42. Role Of Radiation Therapy
In Salivary Gland Tumours
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43. • No level I or level II evidence to support use of adjuvant
RT
• Large number of prospective and retrospective studies
are the guidelines for use of PORT
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Evidence for Adjuvant RT ???

44. Adjuvant malignant salivary gland tumor RT
Supporting clinical evidence
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45. 45
Adjuvant malignant salivary gland tumor RT
Supporting clinical evidence

46. Post op RT – Indications –
Pleomorphic adenoma
1. Recurrent tumour
2. Positive margin despite re-resection
3. Deep seated tumours not amenable to complete resection
4. Surgery will sacrifice facial nerve
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47. Post op RT – Indications - Malignant
1. pT3–4 tumors
2. High-grade tumours
a. Mucoepidermoid carcinoma
b. Malignant mixed tumours
c. Adenocarcinoma
d. Squamous cell carcinoma
3. Close (<5mm) or Positive surgical margins
4. Tumour adherence to or invasion of Facial nerve
5. PNI
6. Bone and/or connective tissue involvement
7. LN positive (particularly if ECE +ve)
8. After resection of recurrent disease even with negative margin
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48. Other Indications Of Radiotherapy
• PRIMARY
1. Large unresectable tumors
2. Medically/ surgically inoperable tumors
• PALLIATIVE
1. Large , fungating masses
2. To achieve haemostasis in bleeding tumors
3. Recurrent tumors with exhausted available treatment
modalities.
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49. PORT – NECK Radiation
• ENI – cN0/pN0
– Advanced T stage
– High grade histology
– Facial Nerve dysfunction
– Recurrence
– Intraparotid tumour, II, III
– Recommendation – Ib to IV - 46 – 50 Gy
• cN+/pN+
– Level I to V 60 to 66Gy

50. EBRT Techniques
• Conventional
• Three-dimensional conformal radiation therapy
(3DCRT)
• Intensity-modulated radiation therapy (IMRT)
• Neutron Beam Radiotherapy
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51. 51

52. Conventional Technique
• unilateral anterior and
posterior wedged pair fields
using 60Co or 4- to 6-MV
photons
• homolateral fields with 12- to
16-MeV electrons in
combination with photons (4:1
weightage)
• wedged anteroposterior and
posteroanterior and lateral
technique with 6-MV photons

53. Unilateral field
With Photon

54. En-face Unilateral field
With Electron
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55. En-face Unilateral field
Photon & Electron combination

56. • Homolateral fields with 12- to 16-MeV
electrons in combination with
photons
• 80% of the dose is delivered with
electrons and 20% with 6-MV
photons to spare the opposite
salivary gland, reduce mucositis,
and decrease the skin reaction
produced by electrons
• If deep lobe tumor  parallel
opposed photon portals
weighted to side of lesion in the
initial phase 56
Unilateral field
Photon & Electron combination

57. Oblique Anterior–Posterior Wedge Technique
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58. 3 field photon technique
Anterior (wedged), Posterior (wedge) and Lateral field
Technique
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59. Conformal Technique
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60. 60

61. Post op RT in 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%
• In a PNI + disease, PORT decreases LRR from 15% TO
5%

62. 62
Case scenario
Example of intensity-modulated radiotherapy plan for 46-year-old woman diagnosed with Stage T2N0, left, parotid,
low-grade mucoepidermoid carcinoma. No perineural invasion was found, but the tumor was within 1 mm of the
surgical margin, and two major divisions of the facial nerve were splayed by the mass, requiring dissection of all its major
branches. Given these pathologic and intraoperative findings, the patient was treated with adjuvant radiotherapy to the parotid
bed. Contours were developed using preoperative imaging findings and in situ contralateral parotid as a guide to
contour a dummy structure representing the removed parotid gland and tumor. This structure was expanded by 1–1.5
cm into the surrounding soft tissue to create the clinical target volume (CTV). The expansion was reduced at the
natural barriers to tumor extension (e.g., bone) and expanded in areas at greater risk of residual disease (e.g.,
medially, neardeep lobe). Planning target volume (PTV) was created by uniformly expanding the CTV by 5 mm. The
PTV was prescribed to 60 Gy in 30 fractions. Avoidance structures included the oral cavity (mean dose, 26.8 Gy),
contralateral parotid and submandibular glands (mean doses, 6.4 and 3.6 Gy, respectively), cochlea (mean and maximal dose,
20.6 and 30.5 Gy, respectively), and spinal cord (maximal dose, 14 Gy). The maximal hot spot was 105.3%, which was within
the PTV. (A) Example axial slice representing method for contouring target and avoidance structures. Representative (B) axial,
(C) coronal, and (D) sagittal slices with dose distributions

63. Submandibular Gland tumours
• Surgical excision
• Post op RT (similar indications)
• Elective nodal irradiation (similar indications)
• Technical considerations are similar
• Bilateral fields may be required for tumor extension toward the midline
• Dose : 50 Gy in 5 weeks for microscopic disease
: 60 to 66 Gy in 6 to 6.5 weeks If perineural invasion
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64. Minor Salivary Glands
• Varies with location
• Surgical excision
• Palate, tongue, floor of the mouth, oral cavity, or oropharynx  Resection
• Posterior nasal cavity, nasopharynx, or sphenoid regioninaccessible and are
mostly treated with radiation therapy
• Elective neck treatment is usually not indicated except for tumors of the floor of mouth,
oral tongue, pharynx, and larynx. PROGNOSTIC FACTOR – (male sex, stage T3,T4,
pharyngeal location and high grade). These factors are used in prognostic index. Each
factor is scored 1; a prognostic index of more than equal to 2 will require neck
management
• Irradiation : surgically inaccessible sites, aggressive tumor (positive margins,
perineural spread, or bone invasion) or incomplete resection
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65. Neutron Therapy
• Slow rate of regression of advanced salivary gland tumors
• RTOG-MRC randomized phase III clinical trial inoperable primary
or recurrent major or minor salivary glands
• The 10-year locoregional control probability was 17% after photon
therapy, and 56% after neutron therapy
• Late morbidity was somewhat higher for neutron therapy.
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66. Fast neutron radiotherapy is an effective treatment for
locally advanced ACC of the head and neck region with
acceptable toxicity.
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67. THANK YOU