1. SALIVARY TUMORS AND CALCULI Prof. Yasser Hamza Professor of Surgery Faculty of Medicine, University of Alexandria

2. Anatomical Considerations Two submandibular Two Parotid Two sublingual > 400 minor salivary glands

3. Ducts

4. Minor salivary glands just under mucosa. lips, cheeks, palate, floor of mouth retro-molar area. upper aerodigestive tract 10% of total salivary volume.

5. Clinical History History of swellings / change over time Trismus Pain Variation with meals Bilateral Dry mouth. dry eyes Recent exposure to mumps Radiation history Current medications

6. Diagnostic approach Clinical examination Extra-Oral examination: Palpate cervical lymph nodes Palpate the gland Check motor function of facial nerve

7. Diagnostic approach Clinical examination. Intra-Oral examination: Gland orifice Teeth problems Oral hyegene Lemon test Bi-digital palpaption

8. 1. ??Plain-film radiography 2. ??Sialography 3. Ultrasonography 4. CT 5. MRI Diagnostic approach Imging

9. Allows complete exploration of the ductal system, direct visualization of duct pathology Success rate of >95% Technically challenging Complications: trauma could result in stenosis, perforation

10. Obstructive Salivary Gland Disorders Sialolithiasis Mucous retention/extravasation

11. Sialolithiasis ( salivary stones= calculi) “One or more round or oval calcified structures in the duct of the major or minor salivary glands”

12. Salivary calculi Submandibular Most common Pain subsides before swelling. Recurrent painful swelling at mealtime Acute & subacute infection Persistent obstruction leads to permanent damages to the gland.

13. Obstructive SG Disorders: Sialolithiasis results in a mechanical obstuction of the salivary duct Is the major cause of unilateral diffuse parotid or submandibular gland swelling

14. Sialolithiasis exact pathogenesis unknown. organic nidus that progressively grows by deposition of layers of inorganic and organic substances.

15. Etiology Water hardness Hypercalcemia Xerostomia Tobacco smoking Gout.

16. Sialolithiasis Acute ductal obstruction may occur at meal time when saliva producing is at its maximum, the resultant swelling is sudden and can be painful.

17. Stone Composition Organic; often predominate in the center Glycoproteins Mucopolysaccarides Bacteria! Cellular debris Inorganic; often in the periphery Calcium carbonates & calcium phosphates in the form of hydroxyapatite

18. Reasons sialolithiasis may occur more often in the submandibular gland Saliva more alkaline Higher concentration of calcium and phosphate in the saliva Higher mucus content Longer duct Anti-gravity flow

19. Obstructive Salivary Gland Disorders Sialolithiasis Mucous retention/extravasation

20. Mucocele Extravasation is the leakage of fluid from the ducts or acini into the surrounding tissue. Retention: narrowed ductal opening that cannot adequately accommodate the exit of saliva produced, leading to ductal dilation and surface swelling. Less common phenomenon

21. Ranula Is a term used for mucoceles that occur in the floor of the mouth. The name is derived form the word rana, because the swelling may resemble the translucent underbelly of the frog.

22. Ranula Although the source is usually the sublingual gland, may also arise from the submandibular duct or possibly the minor salivary glands in the floor of the mouth.

23. Ranula blue dome shaped swelling in the floor of mouth larger than mucoceles & can fill the FOM & elevate tongue. lateral to the midline.

24. Plunging or Cervical Ranula Occurs when spilled mucin dissects through the mylohyoid muscle and produces swelling in the neck. Concomitant FOM swelling may or may not be visible.

25. Ranula Treatment Marsupialization has fallen into disfavor due to the excessive recurrence rate of 60-90% Sublingual gland removal via intraoral approach

26. Salivary Gland Tumors Frequency (%)Malignant (%) Parotid glands 6525 Submandibular gl. 1040 Sublingual gl. < 1 90 Minor Salivary gl. 2550

27. Benign tumors 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

28. Malignant neoplasm of the parotid gland 1. Mucoepidermoid carcinoma 40% 2. Adenoid cystic carcinoma 10% 3. Acinic cell carcinoma 10 – 15 % 4. Malignant mixed tumor 7% 5. Polymorphous low grade adenocarcinoma 10% 6. Adeno carcinoma 10% 7. Squamous cell carcinoma 4%

29. Malignant neoplasm of the parotid gland 1. Mucoepidermoid carcinoma – 40% Can be: high, intermediate, and low-grade based on the clinical behavior and the tumor differentiation which is related to the percentage of mucinous to epidermoid cell.

30. Malignant neoplasm of the parotid gland 2. Adenoid cystic carcinoma – 10% unique indolent preneural spread skip lesions. The disease thus specific survival continuous to declined for more than 20 years after initial treatment.

31. 3. Acinic cell carcinoma – 10 – 15 % a low-grade tumor. 4. Malignant mixed tumor - 7% a high-grade malignancy. 5. Polymorphous low grade adenocarcinoma – 10% a low-grade variant of adenocarcinoma. 6. Adeno carcinoma – 10% high-grade with poor prognosis. 7. Squamous cell carcinoma – 4% It is high-grade more common in elderly patients can confused with high-grade mucoepidermoid carcinoma.

32. 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

33. 2. Intermediate grade - intermediate grade mucoepidermoid carcinoma - intermediate grade adenocarcinoma - oncocytic carcinoma The malignant parotid tumor can be classified into:

34. 3. Low-grade malignancy - low grade mucoepidermoid carcinoma - pholymorphous low grade adenocarcinoma - acinic cell carcinoma - low grade adenocarcinoma - basal cell carcinoma The malignant parotid tumor can be classified into:

35. Normal Histology

36. Pleomorphic Adenoma

37. pleomorphic adenoma contains both epithelial (E) and stromal (S) components.

38. Warthin's Tumor Warthin's tumor (benign papillary cystadenoma lymphomatosum) Bilateral in 10% of the cases may contain mucoid brown fluid in FNA

39. Warthin’s Tumor Mid Power Thought to arise from salivary gland inclusions within lymph nodes.

40. Warthin’s Tumor Epithelial Component Consists of papillary fronds which demonstrate 2 layers of oncocytic epitheilal cells Cytoplasm stains deep pink and shows granularity b/c of an abundance of mitochondria Occasionally undergoes squamous metaplasia (may mistakenly diagnose SCCa on FNA)

41. Warthin’s Tumor Lymphoid Component An abundance of this is present Occasional germinal centres will be seen Lymphoid tissue forms the core or papillary structures Both lymphoid and oncocytic epithelial elements must be present to diagnose Warthin’s

42. Warthin’s Tumor High Power Lymphocytc infilterates. Bilayer of epithilium.

43. Mucoepidermoid Carcinoma

44. Adenoid Cystic Carcinoma Adenoid cystic carcinoma with Swiss cheese pattern. It is the second-most common malignant tumor of the salivary glands. ACC is the most common malignant tumor found in the submandibular, sublingual, and minor salivary glands.

45. Acinic Cell Carcinoma mainly in the parotid gland, also known as blue dot tumor. Classic multicystic pattern. Stained by PAS. Cells heavily stained.

46. Treatment Surgery – Total conservative – Total – Extended – +/- RND

47. Parotidectomy

51. Treatment Postoperative Radiation – Indications Close surgical margins (deep lobe parotid tumors, facial nerve sparing) Microscopically positive margin High grade including adenoid cystic Involvement of skin, bone, nerve (gross or extensive perineural invasion), tumor extension beyond capsule with periglandular and soft tissue invasion LN spread Large tumors requiring radical resection Tumor spillage Recurrence

52. Postoperative Radiation versus Surgery for Salivary Gland Tumors: Results from the literature Series # PTs FUP length (y) Prognastic factors LC 5y S S/R Surv 5y S S/R MSKCC92 S 10.5 S/R 5.8 Stage I/II Stage III/IV Positive nodes High-Grade 79 91 17 51 40 69 44 63 96 82 9.5 51 19 49 28 57 JH87 All patients 58 92 59 75 MDACC1557.5 All patients 58 86 50-56 66-72 PMH27110 All patients - - 29 68 (RFS)

53. Treatment Radiation – Surgically unresectable tumors EBRT with photon and or electrons with conventional or altered fractionation Brachytherapy ± EBRT Neutron therapy

54. Treatment Dosage – Primary treatment Accelerated fractionation with a delayed concomitant boost Phase I 1.8Gy daily to 36 Gy Phase II 1.8 Gy as in phase I in AM x 10 fractions to 54Gy and > 6hrs 1.6 Gy to GTVx 10 fractions to 16 Gy Spinal cord dose < 45 Gy. IMRT to 70 Gy for GTV 63 Gy CTV 1 and 56 Gy CTV2

55. Treatment Dosage – Post op treatment Administered within 6 weeks of surgery High Risk 2.0 Gy/fx to 60Gy and 1.8Gy/fx to 63Gy. Small volume known microscopic disease 66 Gy. Elective at risk 50 Gy (2.0Gy/fx) 54 Gy(1.8Gy/fx) Gross residual 70Gy.

56. Side effects Salivary fxn 80% of saliva produced by major salivary glands Loss of salivary fxn complete >35 Gy Dose limit to spare salivary function is 26 Gy. Trismus TMJ and masseter muscle < 50Gy. PT during and after treatment

57. 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%

58. LOCALIZATION OF THE FACIAL NERVE

59. 1. Tragal cartilage (pointer) – always point to the facial nerve. The facial nerve is 1 cm. inferior and 1 cm. medial to the pointer.

60. 2. Tympanomastoid fissure – FN is 4 mm inferior to the tympano mastoid fissure as it exit from the stylo mastoid foramen.

61. 3. Posterior belly of digastric muscle. The facial nerve is superior to the upper border of the belly of the digastric muscle.

62. 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.

63. 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

65. CT scan

67. operation

68. Postoperative 01/02/2016Yasser Hamza 68

69. Complications of parotid surgery

70. Submadibular sialadenectomy

75. New techniques Lithtrypsy Sialoscopy Min invasive …

76. Surgical Endoscopy, May 2009