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Management of

Salivary Gland Malignancies

Daniel G. Deschler, MDDirector: Division of Head and Neck Surgery

Massachusetts Eye & Ear Infirmary

Massachusetts General Hospital

Professor

Harvard Medical School

No Disclosures

or

Conflicts of Interest

Anatomy

• Major Salivary Glands

– Parotid (Serous)

– Submandibular (Mixed)

– Sublingual (Mucinous)

• Minor Salivary Glands

– 500-1000 throughout aerodigestive tract

• Sinus, base of tongue, laryngeal

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Histology

• Multiple cell types– Acinar, intercalated, myoepithelial,

Reserve cells

• Tumorogenesis– Tumors traceable to specific cell types

– Tumor arise from abnl proliferation of progenitor cell

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Epidemiology

• Salivary Gland Malignancies

– 2-5% of head and neck cancers

• Multiple cell types

– Divided into high and low grade

• Importance of site of tumor

– Parotid -15-20% malignant

– Submand - 35-50 % malignant

– Sublingual / Minor - 50-85% malignancy

Staging - AJCC 7th Ed.T X Primary cannot be assessed

T0 No evidence of tumor

T1 <2cm w/out extraparenchymal extension

T2 2-4cm w/out extraparenchymal extension

T3 >4cm or with parenchyma extension and no facial nerve involvement

T4a Invades skin, mandible, ear canal, and/or facial nerve (Moderately Advanced)

T4b invades skull base, pterygoid plates, encases carotid artery (Very Advanced)

N0, N1, N2(a,b,c) , N3 - Per classic H&N Staging

Staging - AJCC 7th Ed.

T1 T2 T3 T4a T4b

N0 I II III IVa IVb

N1 III III III IVa IVb

N2 IVa IVa IVa IVa IVb

N3 IVa IVa IVa IVa IVb

Any T, Any M, M1 – Stage IVc

Staging - AJCC 7th Ed.

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Tumor Grade

• High Grade– High Grade

mucoepidermoid Ca

– High Grade AdenoCa

– Adenoid Cystic Ca

– Carcinoma Ex Pleomorphic adenoma

– Primary SCCa

• Low Grade

– Low Grade Mucoepidermoid Ca

– Low grade AdenoCa

– Acinic Cell Ca

Evaluation

• History

– Rate of growth, pain

• Physical Exam

– Fixation, Cranial Nerve involvement

• Imaging

• Tissue Diagnosis

Imaging

• CT

– Excellent initial evaluation

• Easily tolerated

• Easily obtained

– Bone Excellent, Soft tissue adequate

• MRI

– Excellent soft tissue evaluation

– Assess perineural spread

Imaging - Utility

• Parotid– 85% accuracy in defining benign parotid

tumor

– Assess extent (depth)

– Assess Nodes

• Other sites– Sinonasal, oropharyngeal

• Perineural spread

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Fine Needle Aspiration

• High Accuracy Rate

– 90-95% in numerous studies

• Minimal risk of tumor spread w/ Fine needle

– 23-25 gauge

• Utility of tissue diagnosis

– Pre-operative planning

• Extent of procedure

• Patient understanding of procedure

• Level of vigilance in surgical approach

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FNA - Which Lesions• Parotid - Yes

• Pain, VII weakness

• Submandibular - Yes• High rate of malignancy, Pain

• Sublingual - Yes• Usually done transorally

• Oral / Oropharyngeal - Usually No• Mucosa part of resection, Unless mobile in buccal region

• Derm Punch

• Parapharyngeal space - Usually No• Does not change approach

• Transoral or CT guidance

Treatment

• Surgery traditionally has been the

mainstay of treatment

• Over the last 30 years there has been

an evolution validating the efficacy of

adjuvant radiation therapy for many

lesions

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Treatment

• Arch Head Neck Surg 1990

– 46 matched pairs treated at Memorial Sloan Kettering Cancer Center

Overall Survival

Surg Surg/XRT

I,II 96% 82% (NS)

III,IV 10% 51% (p=0.015)

Treatment

• Appropriate extent of surgery

• Parotid Tumors

– Parotidectomy approach

– Identification and attempted preservation of facial nerve

– Clearance of tumor with cuff of normal tissue

– Goal is to clear surgical margins

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Treatment

• Facial Nerve – Unaffected pre-op

– Dissect and preserve nerve

– If nerve close and tumor malignant –preserve

– If nerve frankly involved, verify path (frozen section), sacrifice and reconstruct involved branches

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Treatment

• Facial nerve - affected pre-op

– If all branches, prepare for total nerve sacrifice

• Clear nerve margins (main trunk)

• May require mastoid procedure

– If affected in selective distribution, potential exists for selective sacrifice

• Clear distal and proximal margins

Treatment

• Reconstruction

– Primary nerve grafting

• Greater auricular

• Ansa cervicalis

• Sural

• Medial antebrachial cutaneous

• Other

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Treatment

• Rehabilitation

– Eye

– Oral Commissure

– Forehead

– XII -> VII Grafts

– Crossfacial grafting

– Free tissue transfer

Eye Rehabilitation - Lid Tightening

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Eye Rehabilitation – Gold Weight

Treatment

• Surgery can be extensive

– Temporal bone

– Auricle

– External carotid

– Condyle

– Mandible

• “Closest margin is the closest Margin”

– Reasonable restraint

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Treatment

• Submandibular gland

– Similar approach as Parotid

– Attention to clear margins

– Attention to Nerves

• Marginal Mandibular Branch of VII

• Hypoglossal (XII)

• Lingual (V)

• Sacrifice as needed, reconstruct as possible

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Treatment

• Neck Dissection

– N + Disease – MRND / SLN

– N0 Disease

• No Dissection for low grade lesions

– (Adenoid cystic ca)

• Selective neck dissection for High Grade lesions

– High grade mucoepidermoid

– High grade adenoCa

– SCCa

Treatment

Neck Metastasis by Histologic Subtype 47/ 407 Occult LN (Cancer: 615-9. 1992)

• Tumor type % LN +• Epidermoid 42%• AdenoCa 18%• MucoEp 14%• Acinic 4%• Adenoid Cystic 4%• Malignant Mixed 0%

Treatment

• Minor Salivary Gland

– Surgery

– “en bloc” resection can be challenging by site

• Sinonasal, BOT, Larynx, Pharynx

– Risk of perineural spread

– Adjuvant XRT often included because of potential close margins

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Treatment

• Adjuvant XRT

– Conventional

– IMRT

– Fast Neutrons (ACC)

– Proton (ACC)

– Intraoperative Radiation Therapy (IORT)

• Use in salvage setting of previous XRT

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Treatment

• Chemotherapy

– Largely reserved for recurrent unresectable disease

– Taxol – Head Neck 2006

• 26% response in mucoep and adenoca

• 0% response in ACC

– Use of SCCa regimens for high grade mucoepidermoid

– Small Series demonstrating better outcome with post-op concurrent Chemo-Rad

Treatment

Grade / Margins

• Low Grade / Clear Margins

– Surgery

• Low Grade / Positive-Close Margins

– Surgery - XRT

• High Grade / Clear Margins

– Surgery - XRT

• High Grade / Positive Margins

– Surgery - XRT

Treatment

Grade / Stage

• Low Grade / Early Stage

– Surgery

• Low Grade / Advanced Stage

– Surgery - XRT

• High Grade / Early Stage

– Surgery - XRT

• High Grade / Advanced Stage

– Surgery - XRT

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