Transcript Folie 1 - جمعية ألأنف والاذن

Salivary Glands Tumors
A short overview
Dr. Med. Ibrahim K. Lada‘a
ENT-specialist
2009
Ramallah
Salivary Glands Tumors

benigne




about 70%
predominantly in the
parotid glands
Swelling without
symptoms
Surgery is the standard
therapy

malignant





Very low Incidence
Predominantly in the
small salivary glands
swelling with Malignant
symptoms
modified surgical therapy
radiation therapy
Salivary glands tumors


2% of all Tumors
Gl. Parotidea:





10%
50% Benigne
40% Malignant
small salivary glands(600):


70% Benigne
30% Malignant
Gl. Submandibularis:

80%
5%
70% Malignant
Gl. Sublingualis:
1%
Salivary glands tumors
Benigne
Malignant
Epithelial
Epithelial



Pleomorphic Adenoma
45%
Cystadenoma (Warthin tumor)
15%
monomorph Adenomas
5%
(Basalcell, Onkocytoma, Canalicular)





Mesenchymal





Hemangioma/Lymphangioma
Lipoma
others (Neurofibrom)
2%
2%
1%
5%
5%
3%
3%
3%
2-3%
2%
Non-epithelial


% to all Salivary glands tumors
Mucoepidermoid carcinomas
Carc. ex pleiomorphic adenoma
Cystadeno carcinoma
Adenocarcinoma
Undifferenciated carcinoma
Acinuscell carcinoma
Squamousepithelium carcinom

Lymphomas
Sarkoma
others
1-2 %
< 1%
< 1%
Pleomorphic Adenoma


Synonym: benign salivary gland mixed tumor
Microscopy:

epithelial elements in a mixed matrix





epithelial
Mucoid
Chondromatös
Hyalin
Macroscopy


capsulated
Even borderd o. lobbed
Pleomorphic Adenoma
clinic and epidemiology

Most frequent Adenoma of the Salivary glands









Gl. Parotidea
Gl. Submandibularis
Gl. Sublingualis & small Salaivary glands
W>M
50-60 age
Malignant Transformation 3-5% (rises in case of
recurrent tumor or size of tumor)
grows very slow
painless
Mostly unileteral
85%
5%
10%
Pleomorphic Adenoma
Diagnostic


Medical history
Inspection
(special case: Eisbergtumor)

Palpation



mobile
Firm, elastic
Facial nerve control
Pleomorphic Adenoma
Diagnostic

B- Mode Sonography:
 even o. lobed borders
 cystical parts
 low echo
 Low perfusion

Fine needle puncture


Different opinions
Frozen section
Pleomorphic Adenoma
Diagnostics


CT or MRI
T2
T1
>>>>>
Kontrast
Pleomorphic Adenoma
Therapy

always Surgical




laterofacial parotidectomy (in sano resection)
keep tumor capsula intact!!!!
keep facial nerv alive (Facial nerve Monitoring)
If necessary total parotidectomy
Pleomorphic Adenoma
Therapy
Pleomorphic Adenoma
Prognosis
good
 excision with intact Capsula = no Residual
 Capsula damage!: multilocal metastasis,
surgical resektion very difficult with higher risk of
facial nerv palsy
 Don‘t wait too long




Malignant transformation risk
Surgical difficulty rises
Evtl. facial nerve palsy
Zystadenolymphoma




Synonym: Warthin Tumor
Possibility of viral Association
Epidemiology:
 Second common Tumor of Gl. Parotis
 5:1 (M/W)
 10% bilateral, 10% multifokal
 Age of 60 and up
Clinic:
 Indolent Swelling at Parotisunderpole (Arcus mandibulae)
 No malignant symptoms
Cystadenolymphoma
Diagnostic







medical history (months)
Inspection
Palpation
Sono: one or more Cystic
structures
FNB: Hilft i.d.R. nicht weiter
CT/MRI
DD:
1) Lymphoma
2) Lymphoepithelialecysts
Cystadenolymphoma

Therapy



pericapsular excison
Capsula close preparation
very Slow growth

Prognosis


barely malignant
transformation
barely recurrent
Benign Parotid Tumors
-Hemangiomas: short overview




Made up of blood vessels
sometimes with intramural
calcification
rare < 2 %
mainly at Kids and teenagers
Blaufärbung unter der Haut,
die durch Wegstreichen
zunächst verschwindet, um
kurz danach wieder
aufzutauchen
Therapy: surgical extirpation
cm 1 2
3 4
5 6
WHO-Classification
Salivary gland carcinomas
Salivary gland carcinomas
Epidemiology


Incidence < 1: 100.000
Percentage of malignant salivary gland tumors under all
neoplasia





small SG:
Gl. SL
Gl. SM
Gl. Parotis
70-80%
50%
35-50%
20-30%
50-60 age
Clinical-Epidemiological Data of Pat. with Salivary gland carcinomas from TRM (tumor register Munich)
1978-2003
Salivary gland carcinomas
atiologie & Risik factors





Almost unknown
Radiation exposition (25 years latency)
Genetic Aberrations (spez.)
Genetic Predispositoin (Breast & skin cancer)
Alcohol, cigarettes, nicel, Chrom, Asbest????
Salivary gland carcinomas
Malignancy criteria



Skin infiltration
Lymph node Metastasis
Facial palsy
46/378 malignant
 0/1750 benigne
(Enroth et. al)


fast growing

Only at 8% (malignant tumors)
2% at benigne tumors

Painless swelling is the most common Leading symptom 56%



pain
classical symptoms of Malignancy are not representativ. because
65-80% of the malignant tumors are clinically manifested as a
singular node without Symptoms
Salivary gland carcinomas

challenging Diagnostic and Therapy




various histological Varietys
Different clinical history
anatomically close to the Facial nerve
low Incidence
Salivary gland carcinomas
Diagnostics
Obligatory:
clinical history
 Inspection und palpation


solid, painless vs. painfull, fixed
clinical Function of N. facialis
 Ultrasound of the parotid region and neck




Topography ( up to 100% Sensitivity)
Almost no differentiation
Postsurgical control
Salivary gland carcinomas
Diagnostics

In some cases is CT or MRI usefull:

CT or MRI



CT:


Exclusion of bone infiltration
MRI:




medial Parotid lobe
Parapharyngeal space
Exclusion of soft tissue infiltration (N. Facialis)
Local recurrence
Carcinoma Differentiation (Gadolinium with T1 sequences)
PET: (Glucosestoffwechsel)

Differntiating between Scar tissue & Recurrence (very expensive)
Salivary gland carcinomas
surgical therapy



Complete tumor excision
Eventually
neckdissection from
Level I-V
Maintainance of the N.
Facialis/ Reconstruction
in same session
When to perform ND
Salivary Gland Cancer
N+ Neck
N0 Neck
High Grade Carcinoma T1 - T4
Low Grade Carcinoma T1
Low Grade Carcinoma T2 - T4
Neck Dissection Level I - V
Neck Dissection Level I - III
Neck Dissection Not
Required
Radiotherapy

Compatible for all histological entitys
exepct for:



High differntiated Mucoepidermoid carcinomas
Azinus cell carcinoma
Primary Radiotherapy:

inoperable Tumors

Recurrence tumors with palliativ case
When to perform Postsurgical
radiation ?







Recurrence
R1- or R2- excision
Infiltration of neighboring structures
N+
T3, T4-Malignomen generell,
High-grade Malignomas
Adenoidcystic carcinoma
5 year survival
after combined therapy

combination of surgery & radiotherapy can
improve the 5-year survival significantly!
combined versus surgery alone

Stage T3,T4:

N+:

High-grade Malignomas:
51% vs. 10%
49% vs. 19%
57% vs. 28%
Adenoidcystic carcinoma
short overview









Synonyma: cylindroma
8% of all salivary gland carcinomas
mainly in small salaivary glands (palate)
boneinfiltration
Perineural + Perivascular invasion
Metastasis: Hematogenic 40-60%, Lymphogen 8%
Slow growth –(some cases fulminant growth)
Radiotherapy resistance
5-year survival: 75%
carcinoma ex pleomorphic Adenoma




7% of all salivary gland carcinoma
8% of pleomorph adenoma degenerate to
carcinoma
mainly Gl. Parotis
Risk factors:
Local recurrence of pleomorphic adenomas
 Waiting over 10 years for excision

Take Home Message

In general
 The smaller the gland the higher the
chance of a carcinoma
 Diagnosis and Therapy very simillar in
all cases
 Mainly elderly >50
(Exception: Hämangioma(teenagers) and
Mucoepidermoid carcinomas <50)
Take Home Message

Benign Tumors
 Pleomorphic Adenoma
Can degenerate to malignant
carcinoma
Complete tumor excision with intact
capsula
Take Home Message

Malignant Tumors
 Mucoepidermoid carcinoma : chest X-ray
 Adenocystic carcinoma: radiotherapy resistant
 Malignant Symptoms (facial palsy,pain, skin
infiltration, metastasis,fast growing) are not
obligatory since 65-80% have no malignant
symptoms
 comb.
of Surgery + Raditherapy improves 5year survival significantly
Saliva is not only associated with food
In fact some unusual uses of saliva are to preserve social status among lamas
However what is spat by the lama is not actually saliva, but rather a digestive
acid, that is both green and has a foul odor.
Rest assured though, that it is easily washable, just in case you have an
unfriendly encounter with a lama