AKBAR FAUZI

Introduction
There are three major salivary glands in human body,

parotid gland, submandibular gland and sublingual gland and the largest is parotid gland Salivary gland neoplasms represent 57% of all head and neck tumors. Among salivary gland neoplasms, 80% arise in the parotid gland, from which 80% is benign. Pleomorphic adenoma is the most common tumor of parotid gland and represents 60% of all parotid neoplasm Submandibular: 15% overall; 50% benign Sublingual/Minor: 5% overall; 40% benign

Definition
Parotid tumors are relatively rare neoplasms that

present as an enlarging mass beneath the skin of the cheek

Anatomi
The parotid gland is the largest of the major salivary

glands. It arises as an epithelial proliferation from the lining of the oral cavity at 5 weeks postovulation The facial nerve (cranial nerve VII) divides the gland into the larger superficial and smaller deep component. Though these are commonly referred to as the superficial and deep lobes, they are not true lobes

Incidence and etiology

benign tumors of the parotid gland are more likely to

occur in women than in men The median age for occurrence of these tumors is in the fifth decade of life Parotid tumors occur most commonly in Caucasians

Etiology
unknown

Classification
Tumor Parotid

BENIGN MALIGNA Pleomorfic adenona - Basal cell carsinoma Warthin Tumor - Mucoepidermoid carcinoma Oncocytoma - Adenoid cystic carsinoma Myoepithelioma - Adenocarsinoma Monomorphic adenoma - Carsinosarcoma Basal cell adenoma - Acistic cell carsinoma Canalicular adenoma - Squamous Cell carsinoma - Clear cell carsinoma - Epithelial-myoepithelial carsinoma

Pleomorfic adenoma

American Join Committee On Cancer TMN Clinical Classification Of Major Salivary Gland Tumors
Tx : Primary tumor cannot be assessed T0 : No evidence of primary Tumor T1 : Tumor 2 cm in greatest dimension without extraparenchymal extension T2 : Tumor > 2 cm but 4 cm in greatest dimension without extraparencymal extension T3 : Tumor having Extraparenchymal extension without seventh nerve inolement and?or > 4 cm but 6 cm in greatest dimension T4 : Tumor invades base of skull, seventh nerve and/or > 6 cm in greatest dimension

Primary Tumor (T)

Regional Lymph Nodes (N)

Nx : Regional lymph nodes cant be assessed N0 : No regional lymph node metastasis N1 : Metastasis in a single ipsilateral lymph node, 3 cm in greatest dimension N2 : Metastasis in a single ipsilateral lymph node, > 3 cm but 6 cm in greatest dimension ; or in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension ; or in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension N2a : Metastasis in a single ipsilateral lymph node > 3 cm but 6 cm in greatest dimension N2b : Metastasiss in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension N2c : Metastasis in bilateral or contralaeral lymph nodes, none > 6 cm in greatest dimension N3 : Metastasis in lymph node > 6 cm in greatest dimension

Distant Metastasis

Mx : Distant metastasis cant be assessed M0 : No distant metastasis M1 : Distant Metastasis

American Joint Committee On Cancer Staging System For Major Salivary Gland Tumors
Stage
Stage 1 Stage II

T
T1, T2 T3

N
N0 N0

M
M0 M0

Stage III
Stage IV

T1, T2
T4 T3, T4 Any T Any T

N1
N0 N1 N2, N3 Any N

M0
M0 M0 M0 M1

CLINICAL EVALUATION
BENIGN MALIGNA

grow slowly and without pain

Facial or jaw pain, facial twitching or weakness, pain with chewing (trismus), or spread to lymph nodes in the neck or to other

Deep-lobe parotid tumors may grow silently deep to the lower jaw (mandible)

regions (lung, liver, brain)

INVESTIGATIONS
Radiologic
CT-Scan MRI

Fine needle aspiration biopsy

BENIGN PAROTID TUMOR pleomorfic adenoma

Most common of all salivary gland neoplasms

70% of parotid tumors 50% of submandibular tumors 45% of minor salivary gland tumors 6% of sublingual tumors 4th-6thdecades F:M = 3-4:1

Gross pathology Smooth - Well-demarcated Solid Cystic changes Myxoid stroma

Histology Mixture of epithelial, myopeithelial and stromal components Epithelial cells: nests, sheets, ducts, trabeculae Stroma: myxoid, chrondroid, fibroid, osteoid No true capsule Tumor pseudopods

 Treatment:

complete surgical excision Parotidectomy with facial nerve preservation - Avoid enucleation and tumor spill

Warthins Tumor
papillary cystadenoma lymphomatosum 6-10% of parotid neoplasms Older, Caucasian, males 10% bilateral or multicentric 3% with associated neoplasms Presentation: slow-growing, painless mass

Histology Papillary projections into cystic spaces surrounded by lymphoid stroma Epithelium: double cell layer Luminal cells Basal cells Stroma: mature lymphoid follicles with germinal centers

Oncocytoma
Rare: 2.3% of benign salivary tumors
6th decade M:F = 1:1

Parotid : 78%

Maligna

Mucoepidermoid Carcinoma
Most common salivary gland malignancy
5-9% of salivary neoplasms Parotid 45-70% of cases

3rd-8th decades, peak in 5th decade

F>M Caucasian > African American

Mucoepidermoid Carcinoma
Presentation Low-grade: slow growing, painless mass High-grade: rapidly enlarging, +/- pain

Mucoepidermoid Carcinoma
Gross pathology
Well-circumscribed to

partially encapsulated to unencapsulated Solid tumor with cystic spaces

Mucoepidermoid Carcinoma
HistologyLow-grade
Mucus cell >

epidermoid cells Prominent cysts Mature cellular elements

Mucoepidermoid Carcinoma
Histology Intermediate- grade
Mucus = epidermoid Fewer and smaller cysts Increasing pleomorphism

and mitotic figures

Mucoepidermoid Carcinoma
HistologyHigh-grade
Epidermoid > mucus Solid tumor cell

proliferation Mistaken for SCCA

Mucin staining

Mucoepidermoid Carcinoma
Treatment Influenced by site, stage, grade Stage I & II

Wide local excision Radical excision +/- neck dissection +/- postoperative radiation therapy

Stage III & IV

Acinic Cell Carcinoma

2nd most common parotid and pediatric malignancy
5th decade F>M

Bilateral parotid disease in 3%

Presentation Solitary, slow-growing, often painless mass

Acinic Cell Carcinoma

Gross pathology
Well-demarcated Most often

homogeneous

Acinic Cell Carcinoma

Histology
Solid and microcystic

patterns

Most common Solid sheets Numerous small cysts

Polyhedral cells Small, dark, eccentric

nuclei Basophilic granular cytoplasm

Acinic Cell Carcinoma

Treatment Complete local excision Prognosis 5-year survival: 82% 10-year survival: 68% 25-year survival: 50%

Adenocarcinoma
Rare
5th to 8th decades F>M

Parotid and minor salivary glands

Presentation: Enlarging mass 25% with pain or facial weakness

Adenocarcinoma
Histology
Heterogeneity Presence of glandular

structures and absence of epidermoid component Grade I Grade II Grade III

Adenocarcinoma
Treatment
Complete local excision
Neck dissection Postoperative XRT

Prognosis
Local recurrence: 51% Regional metastasis: 27% Distant metastasis: 26%

15-year cure rate:

Stage I = 67% Stage II = 35% Stage III = 8%

HATUR NUHUN