06- Salivary Glands Tumors (1)

Salivary Glands Tumors

Presented by :

• Asma’ Al-Husamia

• Rawnaq Al-Masa’eed

Supervised by prof. Fua’d Ammari

Salivary GlandsThe salivary glands are exocrine glands, glands with ducts, that produce saliva.

There is 3 pairs of major glands: Parotid, submandibular, sublingual.

Other minors (approximately 450) that are distributed in the mucosa of the lips, cheeks, palate, floor of the mouth and retromolar area. A few are also found in the nasopharynx , paranasal sinuses, larynx, trachea, bronchi & lacrimal glands.

-lying mainly below the external acoustic meatus between mandible and sternomastoid.

Structures within Parotid Gland

– Branches of the facial nerve.– The terminal branch of the

external carotid artery that divides into the maxillary artery and the superficial temporal artery.

– The retromandibular vein.(((temporomaxillary vein), formed by the union of the superficial temporal and maxillary veins)

– Intraparotid lymph nodes.

Parotid gland

Large superficial and small deeper part continuous with each other around the post. Border of mylohyoid

• .

Submandibular gland:

• Impo. anatomical relationship of the gland – Anterior facial vein. (running

over the surface of the gland)

– Facial artery.– Lingual nerve.– Hypoglossal nerve.(The deep part of the gland lies on the hyoglossus muscle closely related to the lingual nerve and inferior to the hypoglossal nerve.)– Marginal mandibular branch

of the facial nerve

Sublingual

• Lies beneath the oral mucosa

Histology• Compound Tubuloalveolar glands

• Salivary glands are made up of secretory acini (acini - means a rounded secretory unit) and ducts.

• There are two types of secretions - serous and mucous. The acini can either be serous, mucous, or a mixture of serous and mucous.

We have Three Types of Cells , Tow secretory (serous and mucus ) and myoepithelial cells.

SECRETORY CELLS : 1-Serous : proteins in an isotonic watery

fluid. 2-Mucus :Mucin (lubrication )

MYOEPITHELIAL CELLS:Surround each secretory portion and are

able to contract . • Parotid glands have mainly serous acini. • Sublingual glands have mainly mucous

acini. • Submandibular glands have a mixture of

mucous and serous acini.(some mucous alveoli capped by serous cresents – ’Demilunes’)

Function of Salivary Glands

About 1500ml of saliva is produced each day– It facilitates swallowing– It keeps the mouth moist & aids speech– It serves as a solvent for molecules which

stimulates the taste buds– It cleans the mouth, gum, & teeth.– It contains ptyalin, an enzyme which breaks-down

starch into dextrin and maltose.

Physiology

Salivary Glands- Diseases• Inflammatory

– Acute parotitis– TB– Mumps– Actinomycosis– Cat scratch disease

• Obstructive– Sialolithiasis– Sjögren syndrome– Strictures

• Tumors Epithelial ( adenoms , Mucoepidermoid , Carcinoma ) Non Epithelial ( Fibromas )

Salivary Glands- Tumors

• BENIGN I. Pleomorphic adenoma “mixed tumor”II.Adenolymphoma “warthin’s tumor”

• MALIGNANTI. Mucoepidermoid tumorII. Carcinomas

• Parotid gl. 75% of all salivary t., 80% are benign and 80% of the benign are pleo-morphic ad.

• Sub mand. gl. 15% of all salivary t., 60% are benign and 95% of the benign are pleomorphic ad.

• Minor salivary gl. 10% of all salivary t., only 40% are benign pleomorhic ad.

Salivary Glands- Benign Tumors

I. PLEOMORPHIC ADENOMA “MIXED TUMOR”

II.ADENOLYMPHOMA “WARTHIN’S TUMOR”

Pleomorphic adenoma

Pleomorphic Adenoma

• is the most common salivary gland tumor • accounts for about 60% of all salivary

neoplasms.epidemiology• Appears in early and middle adult life • occurs more often in males than in females.

• The tumor is usually solitary and Slowly growing benign tumor but strands or lobules of the tumor tends to penetrate the thin capsule and extend beyond the main limits of the mass (enucleation is inadequate).

• Pleomorphic adenoma shows a remarkable degree of morphological diversity.

• The essential components are the capsule, epithelial and myoepithelial cells, and mesenchymal or stromal elements.

Histopathology:• Epit.cells proliferate in strands or duct like• Myoepith. cells proliferate in sheets with the production

of a mucoid material which separate the cells producing a myxomatous appearance cartilage like.

Cystic areas may appear due to excessive mucoid accumulation.

• After many years(10-30), few tumors may exhibit malignancy(carcinoma in pleomorphic adenoma).

• Treatment of benign tumor is by superficial parotidectomy.(NOT by simple enucleation )

• Clinical presentation: – The patient complains of a painless swelling on the side of their

face which has been present for months or years and which is slowly growing.

– Lump may be more prominent when the mouth is open or when eating.

• Examination:– Position :The majority of parotid adenoma are found just

anterior and superior to the angle of the jaw.– When found in the parotid tail, it may present as an eversion of

the ear lobe.– Color and temp. of overlaying skin are normal.– Tenderness :Not tender– Shape mostly Spherical , but as they grow they become flat on

their deep surface and slightly pointed superficially .

• Size :Vary from pea-sized nodules to large masses 20 cm across.• Surface :Smooth • Edge : distinct and easy to feel • Composition :rubbery , hard consistence ,dull to percussion ;

not fluctuant or translucent and not compressible.• Relation: Overlying skin and ear are freely movable .(not

attached to the lump .• It is usually mobile unless found in the palate• Lymph drainage: Cervical LNs should not be enlarged.• Local tissue: The facial nerve should function normally .

Paralysis of any facial muscles indicates infiltration of the nerve , which means that the lump is a carcinoma , not a benign adenoma.

Adenolymphoma Warthin’s Tumor

Adenolymphoma- Warthin’s Tumor

etiologyis unknown, but there is a strong association with cigarette smoking. Smokers are at 8 times greater risk of developing Warthin's tumor than the general population.Epidemiology • Warthin's tumor primarily affects in middle aged or

elderly males (age 60–70 years).• recent studies show slight female predilection

( possibly due to the tumor's association with cigarette smoking and the growing use of cigarettes by women.)

Histopathology :• It is formed of a double layered epithelium with

spaces of cysts “papillary-like appearance”.• The stroma contains lymphoid tissues and follicles.

• Purely benign.( does not turn into malignancy)• Can be multiple and bilateral.

• It forms a hot spot in a 99mTc-pertechnetate

Treated by superficial parotidectomy.

• Clinical presentation: – The patient complains of a slow-growing , painless

swelling over the angle of the a jaw (tail of the parotid gland). The swelling may be bilateral.

(10% of parotid tumors )

• Examination:– Position :Usually develop in lower part of the parotid

gland , slightly lower than common site of origin of the pleomorphic adenoma.

– Color and temp. of overlaying skin looks and feels normal.– Tenderness :Not tender– Shape Spherical .

• Size : 1 – 3 cm in diameter • Surface : smooth and well defined. • Edge : distinct and sometimes seem separate from parotid .• Composition :Soft consistence , dull on percussion and not

translucent but they often fluctuate. • Relation: the lump can be moved a little in all directions

and is not attached to the skin .• Lymph drainage: Cervical LNs should not be enlarged.• Local tissue: the adjacent tissues are all normal.The site and consistence of the lesion are the features which make one suspect that a parotid swelling is an adenolymphoma.

The tumor, at the right of the image, is well-demarcated from the adjacent parotid tissue

Salivary Glands- Malignant Tumors

I. Mucoepidermoid tumor

II. Carcinomas

Mucoepidermoid tumor

Mucoepidermoid tumor• is the most common type of malignant salivary gland in adults. • Mucoepidermoid carcinoma can also be found in other organs, as

bronchi, lacrimal sac and thyroid.EpidemiologyOccurs in adults, with peak incidence from 20–40 years of age. A causal link with cytomegalovirus has been strongly implicated in a 2011 research.

HistologyThis tumor is not encapsulated and is characterized by squamous cells, mucus-secreting cells, and intermediate cells.It is composed of sheets and masses of epidermoid cells and cystic spaces lined by mucus secreting cells (no cartilage like appearance)

Clinical FeaturesPresents as painless, slow-growing hard mass. Most appear clinically as mixed tumors.• harder than mixed tumor, yet become fixed when large.• Mostly they do not cause facial paralysis.

• They are of varying speed of growth and degree of differentiation.• Mostly they are slow-growing and invade local tissues to a limited

degree. • Only occasionally grow rapidly and metastasize to lymph nodes,

lungs or skin.

• FNA is necessary for diagnosis.

Management :• Superficial parotidectomy if the tumor is of the benign

variety, but if it’s of the malignant variety, we have to remove the whole parotid gland.

• radiotherapy may be advisable.

prognosis• Generally, there is a good prognosis for low-grade tumors, and

a poor prognosis for high-grade tumors.

Carcinomas

• Carcinoma of the parotid gland is uncommon , but not very rare.• It can arise de novo , or in a long-standing pleomorphic adenoma.• The patient is usually over the age of 50.• Men and women are equally affected.• Tend to produce obvious clinical signs of malignancy at an early stage.• They are hard , rapidly-growing , and may infiltrate the surrounding tissues.• FNA is necessary for diagnosis. CT scan is used to see the involved LNs.• In these conditions radical excision , block dissection of the neck , and radiotherapy

may be necessary.

Carcinomas Clinical presentation• The common complaint is of a rapidly enlarging swelling on the side

of the face.• The swelling is persistently painful , especially during movements of

the jaw. The pain may radiate to the ear and over the side of the face.

• The patient may give a history of a preceding painless lump that has been present for many years.

• The patient may also complain of asymmetry of the mouth and difficulty in closing the eyes.

Carcinomas Examination• The tumor is basically a flattened hemisphere but , as it spreads in

different directions , its shape becomes irregular.• Its size increases inexorably , the surface is smooth but irregular ,

and the edge is often indistinct.• The mass is not very tender , hyperaemic and hot. If the underlying

skin is infiltrated it may be reddish-blue.• The cervical LNs are likely to be enlarged and hard.• If the facial nerve is infiltrated , the patient will be unable to use the

muscles of facial expression.• There may be evidence of disseminated blood-borne metastases.

Carcinomas• The physical features of the pleomorphic adenoma and carcinoma

in the submandibular gland are identical to those of these tumors when they occur in the parotid gland , apart from the site.

• Numbness of the anterior two-thirds of the tongue indicates infiltration of the lingual nerve , and is diagnostic of carcinoma of the submandibular gland.

Carcinomas

Complications of Salivary gland excision

• Submandibular gland:– Haematoma.– Wound infection.– Marginal mandibular

nerve injury.– Lingual nerve injury.– Hypoglossal nerve injury.– Transection of the nerve

to the mylohyoid muscle producing submental skin anaesthesia.

• Parotid gland:– Haematoma formation.– Infection.– Temporary facial nerve

weakness.– Transection of the facial nerve

and permanent facial weakness.– Sialocele.– Facial numbness.– Permanent numbness of the ear

lobe associated with great auricular nerve transection.

– Frey’s syndrome.

Sialocele

Frey’sSyndrome

Clinical features of malignant salivary tumours

• Facial nerve weakness.• Rapid enlargement of the swelling.• Induration and/or ulceration of the overlying

skin.• Cervical node enlargement.

Investigation• Computerised tomography (CT) and MRI scanning are the most helpful

techniques for imaging tumors arising in the major salivary glands. The tumor is intrinsic to the gland, and its border can be imaged to highlight whether it is circumscribed and probably benign or diffuse, invasive and probably malignant. The scan will highlight the relationship of the tumor to other anatomical structures, which is helpful in planning surgery.

• Open surgical biopsy is contraindicated as this may seed the tumor into surrounding tissues, making it impossible to eradicate microscopic deposits of tumor cells (unless malignancy is suspected).

• Fine-needle aspiration biopsy is a safe alternative to open biopsy. There is evidence to suggest that, provided the needle gauge does not exceed 18G, there is no risk of seeding viable tumor cells. The role of fine-needle aspiration biopsy is, however, controversial as it rarely alters surgical management.

Sialolithiasis

• Submandibular gland is the most common site of salivary calculi. • A salivary gland calculus is composed of cellular debris , bacteria ,

mucous , and calcium and magnesium phosphates.• Easily demonstrated by X-ray.• Most occur in middle-aged adults.• Men and women are equally affected.• The main symptoms are pain and swelling beneath the jaw , caused

by obstruction of Wharton’s duct.• Both symptoms appear , or worsen , before and during eating. • Pain goes away before the swelling.• Very rarely , the patient may notice discomfort and a swelling in the

floor of the mouth.

Sialolithiasis

• Pressure on the gland may give foul tasting saliva (purulent saliva).

• Acute & subacute infection may be the first indication of a stone.• Persistent obstruction damages the gland making it harder and

tender.• When the gland gets infected , it gives the features of cellulitis.• Calculi are radio-opaque , can be seen on plain X-ray.• Sialography is necessary to demonstrate the lumen of the ducts

for stone , tumor , or stricture.• Calculi within the duct may be removed through the floor of the

mouth. On the other hand , calculi within the gland need excision of the submandibular gland.

Sialolithiasis