Department of Otorhinolaryngology
Head & Neck Surgery
Neoplastic Diseases of the Salivary
Glands
Maria Monique Theresita M. Soliven, MD
2nd year resident
Department of ORL-HNS
Zamboanga City Medical Center
July 14, 2020
Department of Otorhinolaryngology
Head & Neck Surgery
Outline
1. Introduction
2. Approach to Evaluation for Salivary Gland Disorders
3. Classification of Salivary Gland Disorders
4. Imaging Studies
5. Diagnosis of Salivary Gland Neoplasms
6. Management of Salivary Gland Neoplasms
7. Current Trends and Updates on the Management of Salivary Gland
Neoplasms
8. References
Department of Otorhinolaryngology
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Introduction
HISTOGENESIS
BICELLULAR STEM CELL THEORY
(Reserve Cell Theory) MULTICELLULAR THEORY
• Neoplasms arise from two populations • Differentiated cells are capable of cell
of undifferentiated stem cells – division
excretory duct or the intercalated duct
Department of Otorhinolaryngology
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Introduction
ASSOCIATED FACTORS
GENETIC FACTORS OTHER
RADIATION ENVIRONMENTAL
PLAG1 – Pleomorphic adenoma gene
Increasing evidence suggests that
FACTORS
I
exposure to ionizing radiation
HER2 – salivary duct CA Cigarette smoking, and
may increase the risk of developing
CTTNB1 mutation and 16q12-13 the risk decreases after smoking
tumors of the salivary glands
deletion in basal cell adenomas cessation
Department of Otorhinolaryngology
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Introduction
INCIDENCE
Department of Otorhinolaryngology
Head & Neck Surgery
Approach to Salivary Gland
Disorders
C L A S S I F I C AT I O N O F S A L I VA RY G L A N D D I S O R D E R S
NON-NEOPLASTIC NEOPLASTIC
INFLAMMATORY NON-INFLAMMATORY BENIGN MALIGNANT
Acute Chronic Acute Chronic Pleomorphic adenoma Malignant mixed tumor.
Sialolithiasis Obstructive Trauma Aging
Mucoid epidermoid tumor.
Papillary cyst adenoma
Necrotizing (Warthin tumor) Adenoid cystic carcinoma.
Viral Granulomatous Sialadenosis
sialometaplasia
Bacterial Autoimmune -Endocrine Monomorphic adenoma Acinous cell carcinoma.
Pneumoparotitis
-Nutritional
Radiation-
-Behavioral
-Medications Oncocytoma Adenocarcinoma.
induced HIV-associated
cystic sialedenitis Amyloidosis Oncocytic carcinoma.
Idiopathic Clear cell carcinoma.
Squamous cell carcinoma.
Department of Otorhinolaryngology
Head & Neck Surgery
Approach to Salivary Gland
Disorders
PHYSICAL EXAMINATION
i. Vital signs (systemic signs of disease)
ii. Complete head and neck examination
a. Unilateral/one gland versus bilateral/multiglandular
b. Careful examination of salivary ducts and orifices
c. Careful examination of eyes and lacrimal glands and ducts
d. Cranial nerve examination
e. Neck examination or lymphadenopathy (unilateral vs.
bilateral)
iii. Comprehensive body examination (lung, cardiovascular, skin
changes/rashes/lesions, musculoskeletal/joints)
Department of Otorhinolaryngology
Head & Neck Surgery
Approach to Salivary Gland
Disorders
DIAGNOSTICS
IMAGING LABORATORY STUDIES SIALENDOSCOPY BIOPSY
Chest Xray CBC FNAB
Sialography Calcium, ACE Tissue Biopsy
Ultrasound Autoantibodies – RF, ANA,
anti-SSA & anti-SSB
CT-Scan
TSH
MRI
Complete metabolic panel
HIV
Nutritional/ vitamin deficiencies
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B e n i g n S a l i v a r y G l a n d Tu m o r s
C L I N I C A L F E AT U R E S
• painless, slow-growing masses on the face for parotid
tumors or at the angle of the jaw for submandibular
tumors
• Minor salivary gland tumors - most commonly occur
on the palatal mucosa but can also occur within other
areas of the oral cavity, the parapharyngeal space, the
paranasal sinuses, the nasal cavity, the larynx, or the
lacrimal gland
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B e n i g n S a l i v a r y G l a n d Tu m o r s
F I N E - N E E D L E A S P I R AT I O N B I O P S Y
• The overall sensitivity ranges from 85.5% to 99%, and
the overall specificity ranges from 96.3% to 100%
• depends greatly on the experience of the
cytopathologist and the overall volume of salivary
neoplasms evaluated at a particular institution
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B e n i g n S a l i v a r y G l a n d Tu m o r s
IMAGING
MRI
-Superior than CT to view internal architecture of
salivary gland tumors CT
- bone marrow involvement is better demonstrated
-MRI signal characteristic of salivary gland masses,
may be suggestive of certain diagnoses:
-Warthin tumor: bilateral, do not enhance
- Bone destruction of the mandible or skull base is
-Pleomorphic adenoma: unilateral, with best visualized on CT
postcontrast enhancement, high T2 signal, does
- can adequately evaluate the neck for metastatic
not invade surrounding tissue planes adenopathy, although CT has the advantage of
- Malignant mass (ACC or MEC): being less expensive and more available
intermediate to low T2 signal mass with or
without invasion of surrounding tissue planes
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B e n i g n S a l i v a r y G l a n d Tu m o r s
IMAGING
PET Scan
ULTRASOUND
-inexpensive, noninvasive, and simple to perform. It can
be used to differentiate solid from cystic masses in the
salivary glands. -unreliable in tumor detection and in distinguishing
Ultrasound guidance may also enhance the accuracy of benign from malignant salivary tumors
FNAB in nonpalpable tumors and in masses with a
heterogeneous architecture - a possible role for combined PET-CT in detection of
recurrences and distant metastasis
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B e n i g n S a l i v a r y G l a n d Tu m o r s
BENIGN MIXED TUMOR (PLEOMORPHIC ADENOMA)
• Most common salivary gland neoplasm in adults and
children.
• About 85% present in the parotid
• Can extend into the prestyloid parapharyngeal space,
presenting as an oropharyngeal mass
• Ultrasound is inexpensive imaging technique. MRI is
superior to CT.
• FNA accurate in diagnosis
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B e n i g n S a l i v a r y G l a n d Tu m o r s
BENIGN MIXED TUMOR (PLEOMORPHIC ADENOMA)
Hypercellular (epithelial rich) tumors are usually present at an
earlier stage; hypocellular myxoid tumors are more generally at
an advanced stage and more prone to rupture.
Informed consent should include transient and permanent facial
nerve dysfunction, ear numbness, gustatory sweating (Frey
syndrome), sialocele, hematoma, and recurrence.
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B e n i g n S a l i v a r y G l a n d Tu m o r s
BENIGN MIXED TUMOR (PLEOMORPHIC ADENOMA)
Facial nerve dysfunction and Frey syndrome less frequent or
partial superficial parotidectomy with nerve dissection compared
to complete superficial or total parotidectomy. No higher
recurrence.
Extracapsular dissection is an alternative technique that does
not dissect the facial nerve; only or select tumors in expert
hands.
Enucleation results in unacceptably high recurrence rate.
Recurrence with facial nerve dissection procedures is 1% to 4%.
Definitive treatment or recurrence involves resection o all gross
tumor and postoperative radiation therapy.
Surgery or recurrent mixed tumors: high rate of temporary facial
nerve injury.
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B e n i g n S a l i v a r y G l a n d Tu m o r s
P a p i l l a r y C y s t a d e n o m a Ly m p h o m a t o s u m ( Wa r t h i n t u m o r )
Almost exclusively in the parotid.
Second most common benign neoplasm o the parotid.
Slow growing mass, occasionally can become inflamed and
painful.
Up to 20% are multifocal, 5% are bilateral.
Associated with smoking, but no clonal population by PCR, so
not considered a true neoplasm.
Technetium C-99m pertechnetate uptake is due to oncocytic cell
component.
Histology—oncocytic epithelium, papillary architecture,
lymphoid stroma, and cystic spaces.
Treatment—complete resection or observation
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B e n i g n S a l i v a r y G l a n d Tu m o r s
BASAL CELL ADENOMA
About 5% occur in the parotid, 2% to 5% o salivary
gland tumors.
Can mimic solid subtype adenoid cystic carcinoma.
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O N C O C Y TO M A
About 1% of salivary gland neoplasms.
Oncocytes—epithelial cells with accumulations o mitochondria.
Oncocytic metaplasia—transformation o acinar and ductal cells
to oncocytes— associated with aging.
Oncocytosis—proliferation o oncocytes in salivary glands.
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MUCOEPIDERMOID CARCINOMA
Most common malignant tumor o the salivary glands in adults
and children.
Low-grade histology—glandular and microcystic structures,
associated with translocation mutation t(11;19).
Intermediate-grade histology—more epidermoid cells.
High-grade histology—solid sheets tumor, +Ki-67, Her2/neu-
poor prognosis.
Adenopathy associated with increasing histologic grade.
Surgical Rx: Complete surgical resection.
Radiotherapy: High-grade tumor, positive margins, positive
cervical adenopathy
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ADENOID CYSTIC CARCINOMA
Solid pattern—high-grade tumor.
Delayed local and distant spread—survival does not stabilize at
5 years.
Rx: Complete surgical resection and postoperative radiation
therapy or almost all.
Most common mode of failure is distant metastasis.
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ACINIC CELL CARCINOMA
Most common in the parotid, occasionally bilateral, most low-
grade tumors; plus proliferation marker Ki-67-high grade
Multiple subtypes do not have prognostic significance
Treatment: complete surgical resection
Recurrence more likely local than regional
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M a l i g n a n t S a l i v a r y G l a n d Tu m o r s
S A L I VA RY D U C T C A R C I N O M A
High-grade tumor with resemblance to mammary ductal
carcinoma
Can present de novo or in setting o carcinoma ex-pleomorphic
adenoma
Early regional metastasis
Rx: complete resection, postoperative radiation therapy
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P O LY M O R P H O U S L O W- G R A D E C A R C I N O M A
Second most common salivary malignant tumor in oral cavity
(usually hard palate).
Rarely in parotid.
Overall good prognosis; rarely metastasizes to the neck.
Can have perineural spread.
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M a l i g n a n t S a l i v a r y G l a n d Tu m o r s
CARCINOMA EX-PLEOMORPHIC ADENOMA
Most common malignant mixed tumor.
Up to 10% o salivary gland malignancies.
Arises rom long-standing mixed tumor.
Presents as a rapid growth o tumor in a long-standing salivary
mass.
Comprised o epithelial-derived carcinoma arising with mixed
tumor.
Rx: complete resection, postoperative radiation therapy.
Poor long-term survival.
Carcinoma sarcoma—metastasis must display both malignant
epithelial and malignant mesenchymal components— fulminant
natural history.
Metastasizing pleomorphic adenoma—rare entity—behaves
with unequivocally malignant features but with benign
histologic features.
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LY M P H O M A
Parotid is most common salivary gland involved. Sjögren patients are at higher risk.
Extranodal (primary lymphoma) arises rom lymphocytes within the parotid.
Most common extranodal lymphoma is MAL lymphoma.
MALT lymphomas are marginal zone B-cell lymphomas.
The central feature o MAL lymphoma is the lymphoepithelial lesion.
MALT lymphomas often localized disease- favorable prognosis.
Localized Rx or MAL lymphoma includes resection and/or radiation.
Nodal or secondary lymphoma is occasionally seen with systemic non-Hodgkin lymphoma.
Rx or secondary lymphoma is systemic
Department of Otorhinolaryngology
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Metastasis to Major Salivary
Glands
SQUAMOUS CELL CARCINOMA
• Can occur by direct invasion; lymphatic metastasis rom a nonsalivary gland primary; and
hematogenous spread rom a distant primary.
• Cutaneous SCC - About 5% o cutaneous squamous cell carcinomas metastasize to the
parotid or neck.
• Usually within 1 year of the index cancer.
• Histologic actors will not distinguish between the rare primary salivary gland squamous
cell carcinoma.
• Risk factors: Diameter > 2 cm, thickness > 4 mm, local recurrence, perineural invasion,
preauricular skin, or external ear index lesion.
• Superfcial parotidectomy should be considered in the treatment of selected preauricular
squamous cell cancers.
• Parotid metastasis rom skin primary is associated with 25% rate o clinical neck metastasis
and 35% rate o occult neck metastasis.
• Metastasis rom a cutaneous primary posterior to the external auditory canal is unlikely to
involve the parotid.
• Radiation therapy is used with surgery or metastasis to the parotid.
• Neck and parotid metastasis has worse prognosis than parotid metastasis
Department of Otorhinolaryngology
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Metastasis to Major Salivary
Glands
MELANOMA
• Most parotid melanoma arises rom a head and neck cutaneous primary.
• Regional metastatic rates correlate with tumor thickness:
< 5% in tumors < 1 mm, 20% from tumors between 1 and 4 mm, and up to 50% or
tumors > 4 mm.
• Sentinel node biopsy appropriate or 2, 3, 4, and N0; use lymphoscintigraphy and
handheld gamma probe, blue dye injected intradermally.
• Melanoma with unexpected drainage patterns.
• A high rate o patients with parotid metastasis will have neck metastasis.
• Metastasis to the parotid poor prognosis.
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