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salivary gland neoplasm

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salivary gland neoplasm

  1. 1. Parotid tumors and parotidectomy Dr Sumer Yadav MBBS, MS, MCh Plastic and reconstructive surgery sumeryadav2004@gmail.com
  2. 2. sumeryadav2004@gmail.com
  3. 3. sumeryadav2004@gmail.com
  4. 4. sumeryadav2004@gmail.com
  5. 5. sumeryadav2004@gmail.com
  6. 6. sumeryadav2004@gmail.com
  7. 7. sumeryadav2004@gmail.com
  8. 8. 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). sumeryadav2004@gmail.com
  9. 9. 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. sumeryadav2004@gmail.com
  10. 10. 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
  11. 11. 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 sumeryadav2004@gmail.com
  12. 12. 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 sumeryadav2004@gmail.com
  13. 13. 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
  14. 14. 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
  15. 15. 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 sumeryadav2004@gmail.com
  16. 16. 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 sumeryadav2004@gmail.com
  17. 17. 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 sumeryadav2004@gmail.com
  18. 18. 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. sumeryadav2004@gmail.com
  19. 19. 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. sumeryadav2004@gmail.com
  20. 20. 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
  21. 21. 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 sumeryadav2004@gmail.com
  22. 22. Open biopsy Contraindicated Justified only in minor gland trs Ulcerated lesions sumeryadav2004@gmail.com
  23. 23. Benign tumors Painless Slow growing No facial palsy sumeryadav2004@gmail.com
  24. 24. Pleomorphic Adenoma commonest benign tumor Pseudocapsule Pseudopodal extensions Not multicentric sumeryadav2004@gmail.com
  25. 25. Pleomorphic Adenoma Mixed tumor Consists of cartilage besides epithelial cells Cartilage not of mesodermal origin Derived from mucin secreted by epithelial cells sumeryadav2004@gmail.com
  26. 26. Microscopy Epithelial and myoepithelial components Abundant matrix mucoid,myxoid or chondroid supporting tissue sumeryadav2004@gmail.com
  27. 27. Diagnosis Lobulated , painless swelling Long duration Neither adherent to skin/ masseter muscle Generally firm / variable consistency sumeryadav2004@gmail.com
  28. 28. Malignant transformation 3–5%of cases Pain Rapid growth Hard sumeryadav2004@gmail.com
  29. 29. Treatment Superficial parotidectmy Total parotidectomy sumeryadav2004@gmail.com
  30. 30. Adenolymphoma/Warthins tumor Papillary cystadenoma lymphamatosum 5–15%of parotid tumors Always at the lower pole of the parotid Overlies the angle of mandible sumeryadav2004@gmail.com
  31. 31. Warthins tumor More in white races Not seen in negroes Encapsulated lesions No malignant transformation sumeryadav2004@gmail.com
  32. 32. Warthins tumor Only salivary neoplasm more in males Elderly males Slow growing painless sumeryadav2004@gmail.com
  33. 33. Warthins tumor Surface is smooth Well defined Distinct margins Soft in consistency with fluctuation Not tansilluminant sumeryadav2004@gmail.com
  34. 34. Investigations FNAC Tc99 scan – hot spot sumeryadav2004@gmail.com
  35. 35. Microscopy Cystic / glandular spaces Lined by columnar epithelium Within abundant lymphoid tissue with germinal centres sumeryadav2004@gmail.com
  36. 36. Treatment Superficial parotidectmy Enuclation sumeryadav2004@gmail.com
  37. 37. Mucoepidermoid carcinoma MC- epithelial malignancy of gland Parotid &minor glands Hard in consistency Infiltrate local tissue Slow growing tumor Recurs locally sumeryadav2004@gmail.com
  38. 38. Mucoepidermoid carcinoma LN mets in 30% Lung, bone, brain -15% Graded based on cellular content sumeryadav2004@gmail.com
  39. 39. 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
  40. 40. 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. sumeryadav2004@gmail.com
  41. 41. 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. sumeryadav2004@gmail.com
  42. 42. 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. sumeryadav2004@gmail.com
  43. 43. 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) sumeryadav2004@gmail.com
  44. 44. 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. sumeryadav2004@gmail.com
  45. 45. During an operation on the parotid, where do you find the facial nerve? sumeryadav2004@gmail.com
  46. 46. 1. Tragal cartilage (pointer) – always point to the facial nerve. The facial nerve is 1 cm. inferior and 1 cm. medial to the pointer. sumeryadav2004@gmail.com
  47. 47. 2. Tympanomastoid fissure – FN is 4 mm inferior to the tympano mastoid fissure as it exit from the stylo mastoid foramen. sumeryadav2004@gmail.com
  48. 48. 3. Posterior belly of digastric muscle. The facial nerve is superior to the upper border of the belly of the digastric muscle. sumeryadav2004@gmail.com
  49. 49. 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. sumeryadav2004@gmail.com
  50. 50. 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 sumeryadav2004@gmail.com
  51. 51. Does the grading make difference in management of the parotid malignancy? sumeryadav2004@gmail.com
  52. 52. 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. sumeryadav2004@gmail.com
  53. 53. 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. sumeryadav2004@gmail.com
  54. 54. 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. sumeryadav2004@gmail.com
  55. 55. 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 sumeryadav2004@gmail.com
  56. 56. 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
  57. 57. 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 sumeryadav2004@gmail.com
  58. 58. 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. sumeryadav2004@gmail.com
  59. 59. 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 sumeryadav2004@gmail.com
  60. 60. •Thanks sumeryadav2004@gmail.com
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