SALIVARY GLAND TUMORS

3. Dr Samreen Younas
PGR (FCPS) OMFS
Mayo Hospital, Lahore

4. OUTLINE
 What is a tumor
 Types of salivary glands
 Classification of salivary gland tumors
 Incidence
 Clinical features
 Histopathological features
 Treatment plan for benign and malignant
tumors one by one.
 Take home messege

5. Abnormal growth of tissue resulting from
uncontrolled, progressive multiplication of
cells, serving no physiological function.
Tumor can be benign or malignant..

6. 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).

7. Mainly classified into four groups
 Adenomas
 Carcinomas
 Miscellaneous
 Tumor-like lesions

8. ADENOMAS
1. Pleomorphic adenoma
2. Myoepithelioma (myoepithelial adenoma)
3. Basal cell adenoma
4. Warthin’s tumor (adenolymphoma)
5. Oncocytoma (Oncocytic adenoma)
6. Canalicular adenoma

9. 7 Ductal Papilloma
a). Inverted ductal papilloma
b). Intraductal papilloma
c). Sialadenoma papilliferum
8 Cystadenoma
a) Papillary cystadenoma
b) Mucinous cystadenoma

10. 1) Mucoepidermoid carcinoma
2) Adenoid cystic carcinoma
3) Acinic cell carcinoma
4 Polymorphous low-grade
adenocarcinoma
5 Epithelial-myoepithelial carcinoma
6 Basal cell adenocarcinoma
8 Papillary cystadenocarcinoma
9 Mucinous adenocarcinoma
10 Oncocytic carcinoma

11. 11 ) Salivary duct carcinoma
12 ) Adenocarcinoma
13 ) Malignant myoepithelioma
14 ) Squamous cell carcinoma
15 ) Small cell carcinoma
16 ) Undifferentiated carcinoma

12. Miscellaneous
1) Nonepithelial tumors
2 ) Malignant lymphomas
3 ) Secondary tumors
4 ) Unclassified tumors
Tumour-like lesions
1 ) Siladenosis
2 ) Oncocytosis
3 ) Necrotizing sialometaplasia (salivary gland Infarction.
4 ) Benign lymphoepithelial lesion
5 ) Salivary gland cysts
6 ) Chronic sclerosing sialedenitis of submandibular gland
(Kuttner tumor)
7 ) Cystic lymphoid hyperplasia in patients with acquired
immunodeficiency syndrome

13. Gland Frequency % Malignant %
Parotid 65 25
Submandibular 10 40
Sublingual <1 90
Minor Glands 25 50
Incidence

14.  Pleomorphic adenoma is most common
benign tumor in all major and minor
salivary glands.
 Most common malignancy in Parotid is
Mucoepidermoid CA while in
Submandibular It’s Adenoid Cystic CA.

15. Group Palate Lips Buccal and
Labial
Mucosa
Frequency % 42-54 21-25 11-15
Malignant % 30-58 Uper lip5-25
Lower lip 50-
90
30-58
Minor Salivary Glands

16.  Upto 91% of retromolar tumors are
malignant.
 Most tumors of floor of mouth and
tongue are malignant…

19.  Salivary gland tumor arise from the adult differentiated
counter part of salivary gland unit:
• Acinar cell : acinous tumor
• Striated duct cell: oncocytic tumor
• Intercalated duct cell: mixed tumor
• Excretory duct cells: mucoepidermoid carcinoma & squamous
cell carcinoma

20.  The basal cells of excretory & intercalated
ducts act as stem cells
 Intercalated duct stem cell: acinous cell
carcinoma, adenoid cystic carcinoma, mixed
tumor & oncocytic tumors
 Excretory duct stem cell: squamous cell
carcinoma & mucoepidermoid carcinoma

22.  Several studies
implicate radiation as an
etiological factor
 Dose-response pattern
 Mostly parotid
 Commonly
mucoepidermoid
carcinoma

23. The consistent association of EBV with
lymphoepithelial carcinoma of the salivary gland
suggest the virus probably plays causal role.
No evidence of a causal role of EBV in other
primary tumors of the salivary gland

24. Many genetic alternation may be responsible
for increased likelihood of developing salivary
gland neoplasm as
Allelic loss
Structural rearrangement
Monosomy & polysomy

25.  Silica dust or wood dust
 Using Kerosene as cooking fuel
 Warthin’s tumor is strongly associated with
cigarette smoking

27. Usually present as slowly growing painless swelling.
A sudden increase in size:
 Infection
 cystic degeneration
 hemorrhage inside the mass
 malignant transformation
MALIGNANT INDICATORS ARE:
 Facial nerve paresis or paralysis.
 Weakness or numbness of the tongue or in distribution of
branches of trigeminal nerve
 Pain
 Fixation
 Cervical adenopathy
I)HISTORY CLINICAL EXAMINATION

28. V).INCISIONAL BIOPSY
C T & M R I give better understanding
 Location & extent of the tumor
 Its relation to major neurovascular structure
 Perineural spread
 Skull base invasion
 Intracranial extension
II.ULTRASOUND OF THE TUMOR
IV.FINE NEEDLE ASPIRATION CYTOLOGY
III.RADIOLOGY

30. Is derived from a mixture of ductal and
myoepithelial elements…
 Painless, slow growing,
 Peak age 30-60
 Slight female predilection
 In parotid gland most commonly
involves superficial lobe, 90%
 In case of minor salivary gland palate is
most common site

32.  Well circumscribed, encapsulated
incomplete infilterations
 Is composed of glandular
epithelium and
myoepithelial cells with a
mesenchyme like
background.

33.  Best treated with surgical excision
 SUPERFICIAL LOBE; Superficial
parotidectomy saving facial nerve.
 DEEP LOBE; Total parotidectomy.
 SUBMANDIBULAR; Total removal.
 HARD PALATE; Excised down to
periosteum with mucosa.
 95% cure rate.
 5% malignant transformation.

34. Occurs almost exclusively in Parotid and
is second most common benign parotid
tumor.
1) Traditional hypothesis suggest that they
arise from heterotropic salivary gland
tissue found within parotid lymph nodes.
2) Proliferation of ductal epithelium that is
associated with 2ndry formation of
lymphoid tissue.

35.  Slowly growing, painless, nodular mass
 Firm or fluctuant
 Tail of parotid
 Unique feature is tendency to occur
bilaterally 5-7%
 Peak prevalence is in 6th and 7th decade

36.  Composed of a mixture of ductal epithelium
and lymphoid tissue . The epithelium is
oncocytic and cells are arranged in 2 layers.
 Inner layer have papillary infoldings that
protrude into cystic spaces.

37. Lymphocyte
infilterate
Bilayer epithelium

38.  Surgical removal is treatment of choice.
 6-12% recurrence
 Malignant Warthin tumors have been
reported but are rare..

39. Is composed of large epithelial cells known as
oncocytes. ONCOCYTES have swollen
granular cytoplasm excessive
accumulation of mitochondria.
CLINICAL FEATURES:
 Firm, slow growing, painless mass
 8th decade
 Slight female predilection
 Occur primarily in major salivary glands
 Rarely exceeds 4cm

40. ONCOCYTOMA

41. MONOMORPHIC
ADENOMA
Canalicular adenoma Basal cell adenoma
 Almost exclusively in
minor glands
 Primarily tumor of parotid
 Peak incidence 7th decade  same
 Female predilection  Female predilection
 Slowly growing painless
mass
 Slowly growing painless
mass mostly < 3cm

42. CANALICULAR
ADENOMA
 Single layered cords of
columnar and cuboidal
epithelial cells.
 Large cystic spaces
often are created, with
epithelial papillary
projections.
 Capsule often surrounds
but stellate islands
observed in 22-24%
cases.

44. TREATMENT
CANALICULAR
ADENOMA
 Complete surgical
excision.
BSAL CELL
ADENOMA
 Surgical excision
 There are rare
examples of
malignant degen -
eration to Basal cell
adenocarcinoma.

46. Is most common salivary malignancy.
 Is most common in parotid gland usually
appears as asymptomatic swelling.
 Pain/ facial nerve palsy occurs with Hi grade
tumor.
 In minor Palate Asymptomatic
blue/ red color, can be mistaken for mucocele.
 Peak age 2-7th decade
 Most common salivary malignancy in children

47.  – Well-circumscribed to
partially encapsulated
to unencapsulated
 – Solid tumor with cystic
spaces

48. 1. Mucous
2. Squamous
3. Intermediate cells
1. Relative numbers of mucous,
squamous and intermediate cells
2. Amount of cyst formation
3. Degree of cytologic atypia

50. – Mucus = epidermoid
– Fewer and smaller
cysts
– Increasing
pleomorphism
and mitotic figures

51. – Epidermoid > mucus
– Solid islands of
squamous
and intermediate cells
- inc. pleomorphism
and mitotic activity
– Mistaken for SCCA

52. Influenced by location, Grade and stage of
tumor.
PAROTID; Early stage subtotal
parotidectomy, saving facial nerve
Advanced tumors total parotidectomy,
sacrificing facial nerve
SUBMANDIBULAR; total gland removal
In low grade lesions only modest margin of
normal tissue needs to be removed in Hi grade
wider resection is needed.

53.  Neck disection is indicated for patients
with clinical evidence of metastatic
disease or Hi grade tumors.
 Post-op radiation may also be used for
more aggressive tumors.

54.  Slow growing mass
 Pain is common and important finding
 In parotid tumors facial nerve paralysis may
develop
 Palatal tumors can be smooth surfaced or
ulcerated
 Minor salivary gland 50-60%
 Parotid 2-3%
 Submandibular 12-17%
 Middle aged adults

55. – Well-circumscribed
– Solid, rarely with
cystic spaces
– infiltrative

56. – Most common
– “swiss cheese”
appearance

57. TUBULAR PATTEREN
 Layered cells
forming duct like
structures
 Basophiclic
mucinous substance
SOLID PATTEREN
Solid nests of cells
without cystic spaces

58. A highly characteristic feature of ACC is to
show
finding of pain
TUMOR CELLS
NERVE

59.  ACC is prone to local recurrence and
eventual distance metastasis.
is treatment of choice
may
improve survival in some cases.
 Metastasis to regional lymph nodes is
uncommon, typically is
not indicated.

60. is poorest for tumors arising
in maxillary sinus and submandibular gland
and for tumors with solid histopathologic
patteren.
occurs in aprox.35% cases
most frequently to lungs and bones.
42%

61.  Occurs almost exclusively in minor salivary
glands
 65% cases occur in hard and soft palate
 Older adults , more common in females
 Slow growing, painless mass
 Can erode or infilterate bone

62.  – Isomorphic cells,
indistinct borders,
uniform nuclei
 -Cells may grow in Solid,
cribriform,
ductular, tubular, trabecular,
cystic pattern
 Perineural invasion is also
evidentt

63.  Best treated with wide surgical excision
 Metastasis to regional lymph nodes 10%
cases
 Reported recurrence is 9-17%

64. Is a salivary gland malignancy with cells
that show serous acinar differentiation.
 85% occur in parotid
 9% occur in oral minor salivary glands
 Occurs over a broad age range from 2nd-
7th decade
 Females> males

65. Cells show features of serous acinar cells
and are fairly uniform in appearance,
showing different growth patterns
1. Solid
2. Microcystic
3. Papillary-cystic
4. follicular

67. ; no clinical evidence of primary tumour
; 0.1 – 2.0 cms diameter without significant
local extension
; 2 – 4 cms without local extension
; 4– 6.0 cms without local extension
;
a) >6 cms without local extension
b) tumour of any size with significant extension

68.  NX: Lymph nodes (LN) not evaluated
 N0: no nodal invovment
 N1: metastasis in only one LN ipsilateral
to the tumor with up to 3 cm
 N2a: LN of 3 to 6 cm, ipsilateral
 N2b: multiple ipsilateral LNs
 N2c: bilateral or contralateral LN’s
 N3: LN’s larger than 6 cm

69. TNM STAGING
 M0 no distant mets
 M1 distant mets eg., bone, lung

70. STAGING
 Stage I T1NoMo
 Stage II T2NoMo
 Stage III T3NoMo or
T1-3,N1Mo
 Stage IVA T4aNo-1M0 or
T1-4aN2M0
 Stage IVB T4bNxM0 or
TxN2-3M0
 Stage IVC TxNxM1

71.  If there is metastatic cervical L.A.P.
 But there is controversy about
management of clinically negative neck
nodes
 In high-grade or large tumor. The
incidence of occult regional disease is
relatively high, so the elective neck
dissection or selective (supraomohyoid)
neck disection should be considered
 In low-grade malignancy the elective
neck disection not recommended

72.  Microscopically positive margin
 High grade including adenoid cystic
 Involvement of skin, bone, nerve
 LN spread
 Large tumors requiring radical resection
 Tumor spillage
 Recurrence

73.  Salivary gland tumors have diverse
pathology.
 Principal treatment of salivary gland
tumors is surgical resection with safe
margins.
 Used either as a single modality or in
conjuction with adjuvant radiotherapy.