salivary gland tumors ppt by Dr Gulzar A Bhat

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SALIVARY GLAND NEOPLASMS:

SALIVARY GLAND NEOPLASMS Presenter: Dr Gulzar Ahmad Bhat Moderator: Dr M. Inam Zaroo Associate Profesor Plastic Surgery

ANATOMY:

ANATOMY

PAROTID :

PAROTID Major salivary gland Ectodermal origon Irregular in shape extend from zygoma superiorly to oblique line of sternomastoid inferiorly and to mid point of massetor muscle Superficial & deep lobes Processes ( glenoid , pterygoid ,facial ) parotid duct (Stensen’s duct) & accessory gland

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Covered by investing fascia of the neck & contain lymph node mainly in superficial lobe Structures within the gland: Facial nerve Retromandibular vein External carotid artery Parotid L.N

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STRUCTURES WITHIN GLAND

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Deep lobe lie in parapharyngeal space Anterior: Infratemporal fossa Posterior: Carotid sheath & styloid process Medial: Superior constrictor muscle of pharynx which is separating the gland from oropharynx & tonsils

RELATIONS:

RELATIONS

BLOOD SUPPLY :

BLOOD SUPPLY Superficial temporal & maxillary arteries Retromandibular vein LYMPH DRAINAGE Parotid & deep cervical L.N

NERVE SUPPLY :

NERVE SUPPLY PARASYMPATHETIC Inf. Salivary nucleus CN IX L esser petrosal Nerve Otic ganglion Auriculoteporal N. (CN V3) Parotid gland

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SYMPATHETIC: Sympathetic trunk Sup.cervical ganglion Ext.carotid artrey plexus Parotid gland

THE SUBAMANDIBULAR SALIVARY GLAND:

THE SUBAMANDIBULAR SALIVARY GLAND It is wedged between the mandible & the floor of the mouth (upper part deep to the mandible) It has large superficial part & small deep part Its duct opens in the floor of the mouth at the tip of the sublingual papilla

THE SUBLIGUAL SALIVARY GLAND:

THE SUBLIGUAL SALIVARY GLAND A small gland which lies between the mandible & tongue It raises the floor of the mouth forming sublingual papilla It opens by many ducts directly to the floor of the mouth & into the submandibular duct

NERVE SUPPLY OF THE SUBMANDIBULAR & SUBLINGUAL SALIVARY GLANDS:

NERVE SUPPLY OF THE SUBMANDIBULAR & SUBLINGUAL SALIVARY GLANDS Parasympathetic: Facial (7 th ) nerve through the chorda tympani (fibers relay in the submandibular ganglion) Sympathetic: Superior cervical symp . Ganglion Sensory: The lingual nerve

PHYSIOLOGY:

PHYSIOLOGY 25% of total salivary volume secreted by parotid Organic & inorganic compounds Serous type ( mucin , enzymes) Produced & stored in the Acinus & modified in the ductal cells Parasympathatic increases the secreation Several reflexes (sight,smell,taste…etc) augment the secretion rate

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Saliva has several important functions: Lubricant to aid in swallowing food Digestion by an emulgation of food and enzymatic cleavage 3. Mechanical cleaning 4. Immunologic defense 5. Mediation of taste sensations 6.Excretion of endogenous and exogenous materials, for example, antibodies, blood group–reactive substances, iodine, and viruse 7. Buffering effect

NEOPLASMS:

NEOPLASMS

CLASSIFICATION:

CLASSIFICATION Mainly classified into four groups Adenomas Carcinomas Miscellaneous Tumor -like lesions

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Benign/malignant Tumour type Clinical site Clinical feature Benign Pleomorphic adenoma Parotid commonest Painless, slow-growing firm mass Oncocytic tumour (Warthin’s tumour) Parotid gland Soft to firm, occasionally bilateral, mass Malignant Mucoepidermoid carcinoma Parotid commonest Slow-growing firm mass Adenoid cystic Minor salivary glands commonest Slow-growing submucosal nodule in the upper aerodigestic tract Acinic cell tumour Parotid gland Slow-growing nodule Adenocarcinoma Minor salivary gland Submucosal lump

CLASSIFICATION:

CLASSIFICATION ADENOMAS Pleomorphic adenoma Myoepithelioma ( myoepithelial adenoma) Basal cell adenoma Warthin’s tumor (adenolymphoma) Oncocytoma (Oncocytic adenoma) Canalicular adenoma Sebaceous adenoma

CLASSIFICATION (Cont’d):

CLASSIFICATION (Cont’d) 8 Ductal Papilloma Inverted ductal papilloma Intraductal papilloma Sialadenoma papilliferum 9 Cystadenoma Papillary cystadenoma Mucinous cystadenoma

CLASSIFICATION (Cont’d):

CLASSIFICATION (Cont’d) Carcinomas 1 Acinic cell carcinoma 2 Mucoepidermoid carcinoma 3 Adenoid cystic carcinoma 4 Polymorphous low-grade adenocarcinoma 5 Epithelial- myoepithelial carcinoma 6 Basal cell adenocarcinoma 7 Sebaceous carcinoma 8 Papillary cystadenocarcinoma 9 Mucinous adenocarcinoma 10 Oncocytic carcinoma

CLASSIFICATION (Cont’d):

CLASSIFICATION (Cont’d) 11 ) Salivary duct carcinoma 12 ) Adenocarcinoma 13 ) Malignant myoepithelioma 14 ) Squamous cell carcinoma 15 ) Small cell carcinoma 16 ) Undifferentiated carcinoma 1

CLASSIFICATION (Cont’d):

CLASSIFICATION (Cont’d) 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

INCIDENCE:

INCIDENCE Salivary gland tumors >>> 3-4% of all head & neck neoplasm 70% originate in parotid gland > 70% of them are Benign 70% of them  P lemorphic adenoma 10% of parotid tumors  M ucoepidermoid carcinoma

PATHOGENESIS:

PATHOGENESIS

I. MULTI-CELLULAR THEORY:

I. MULTI-CELLULAR THEORY 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

II. BICELLULAR THEORY:

II. BICELLULAR THEORY The basal cell of excretory & intercalated duct 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

ETIOLOGY:

ETIOLOGY

I. RADIATION:

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

II. EPSTEIN-BARR VIRUS:

II. EPSTEIN-BARR VIRUS The consistent association of EBV with lymphoepithelial carcinoma of the salivary gland suggest the virus probably plays causal role Similar pathogenesis of nasopharyngeal carcinoma No evidence of a causal role of EBV in other primary tumors of the salivary gland

III. GENETIC FACTORS:

III. GENETIC FACTORS Many genetic alternation may be responsible for increased likelihood of developing salivary gland neoplasm as Allelic loss Structural rearrangement Monosomy & polysomy

IV. OTHER FACTORS:

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

DIAGNOSIS:

DIAGNOSIS

I. CLINICAL FEATURES:

I. CLINICAL FEATURES 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. CLINICAL FEATURES:

I. CLINICAL FEATURES History of malignant skin lesion should be clarified as case of metastatic disease to the parotid Need full examination especially. The mass itself Skin of face or scalp Oropharynx C N S Cervical lymph node

II. FINE NEEDLE ASPIRATION BIOPSY:

II. FINE NEEDLE ASPIRATION BIOPSY Efficacy is well established Accuracy = 84-97% Sensitivity = 54-95% Specificity = 86-100% Safe, well tolerated

FINE NEEDLE ASPIRATION BIOPSY:

FINE NEEDLE ASPIRATION BIOPSY PROPONENT Important to distinguish benign vs. Malignant nature of neoplasm Preoperative patient counseling Surgical planning Differentiate between neoplastic and non- neoplastic processes Avoid surgery in large number of patients

FINE NEEDLE ASPIRATION BIOPSY:

FINE NEEDLE ASPIRATION BIOPSY OPPONENTS Doesn’t change management Surgery regardless of reported diagnosis Obscuring final pathologic diagnosis Frequency of “inadequate” sampling, requires multiple biopsies, prolongs course until definitive treatment Increases cost

III. RADIOLOGY:

III. RADIOLOGY Conventional radiography & sialography are rarely used 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 But most of the time can’t differentiate between benign & malignant entities

PowerPoint Presentation:

Nuclear imaging using Technetium 99m pertechnetate is rarely obtained because FNAB may provide better information OTHER IMAGING STUDIES Ultrasonography Color doppler sonography

US: PLEOMORPHIC ADENOMA:

US: PLEOMORPHIC ADENOMA

US : BENIGN PAROTID TUMOR:

US : BENIGN PAROTID TUMOR

IV: BIOPSIES :

IV: BIOPSIES The proper approach to parotid neoplasm is parotidectomy which is diagnostic & curative Incisional intraoral biopsy of parapharyngeal tumor should not be performed Open biopsy done rarely & in the patient who are not surgical candidates & for whom FNAC is not diagnostic

BENIGN TUMORS:

BENIGN TUMORS

PLEOMORPHIC ADENOMA:

PLEOMORPHIC ADENOMA Most common of all salivary gland neoplasms 80-90% of parotid tumors 4th-6th decades M:F = 1:3-4 Slow-growing, painless,firm mass Rarely progresive

PLEOMORPHIC ADENOMA:

PLEOMORPHIC ADENOMA

WARTHIN’S TUMOR:

WARTHIN’S 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

ONCOCYTOMA:

ONCOCYTOMA < 1%of salivary gand tumors Parotid is the most frequent site Slow-growing , painless mass 6th decade M:F = 1:1

MONOMORPHIC ADENOMAS:

MONOMORPHIC ADENOMAS < 5% of salivary gland tumors Only one morphologic cell type Subclassified into: Basal Cell Adenoma Canalicular Adenoma Myoepithelioma Clear cell adenoma Glycogen-rich adenoma Sebaceous adenoma

BASAL CELL ADENOMA:

BASAL CELL ADENOMA Basal cell is the most common (mono- morphic adenoma) 1.8% of benign epithelial salivary gland neoplasms 6th decade M:F = approximately 1:1 Caucasian > African American

BASAL CELL ADENOMA:

BASAL CELL ADENOMA Most common in parotid Histological types: Solid Trabecular Tubular Membranous Must be differentiated from: Adenoid cystic carcinoma Basal cell adenocarcinoma Ameloblastoma

HEMANGIOMA:

HEMANGIOMA Benign of endothelial origin < 5% of salivary gland tumors > 90% of parotid tumors in children < 1year Present at birth Unilateral, painless, rapid-growth F > M CT & MRI are dignostic Spontanouus regression , surgery if needed

MALIGNANT TUMORS:

MALIGNANT TUMORS

MUCOEPIDERMOID CARCINOMA:

MUCOEPIDERMOID CARCINOMA Most common salivary gland malignancy 5-9% of salivary neoplasms Parotid 80% - 90% of cases 3rd-8th decades, peak in 5th decade F>M Caucasian > African American Most common salivary gland tumor in children

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It contain two major elements: mucin producing cells & epithelial cells of epidermoid variety & according to that classified into Low grade High grade Intermediate Presentation Low-grade: slow growing, painless mass High-grade: rapidly enlarging, +/- pain

ADENOID CYSTIC CARCINOMA :

ADENOID CYSTIC CARCINOMA Overall 2nd most common malignancy Most common in submandibular, sublingual and minor salivary glands M = F 5th decade Presentation Asymptomatic enlarging mass Pain, paresthesias, facial weakness/paralysis

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Perineural involvement is characteristic of adenoid cystic carcinoma & occur in 20-80% Lymphatic spread uncommon ~ 15% Distant metastasis common in lung (90%)

ACINIC CELL CARCINOMA :

ACINIC CELL CARCINOMA 3% of all salivary gland neoplasm 80-90% in parotid 15% of all parotid tumors Mean age is 40-50 years 2/3 Occur in female 3% Shows bilateral involvement Second most common salivary gland tumor in children Well circumscribed tumor with fibrosis tissue macroscopically

ACINIC CELL CARCINOMA:

ACINIC CELL CARCINOMA

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Four histological patterns identified Solid Microcystic papillary cystic Follicular But the type of pattern do not correlate with biologic behavior or prognosis It is generally regarded as relatively low grade malignancy & has more favorable prognosis They seldom metastasize but they have high tendency to recur locally

MALIGNANT MIXED TUMOR :

MALIGNANT MIXED TUMOR Epithelial & mesenchymal elements 3-12% of salivary gland tumor ¾ in parotid

CARCINOMA EX-PLEOMORPHIC ADENOMA :

CARCINOMA EX-PLEOMORPHIC ADENOMA Incidence increase by duration & recurrence of pleomorphic adenoma Microscopic foci of necrosis, hemorrhage, calcification or excessive hyalinization 2 Subgroups Invasive non-invasive Degree of the invasion determine the prognosis <8-mm 5-year survival rate is 100% > 8-mm show <50% Invasive type show 25% regional & 33% distant metastasis

CARCINOMA EX-PLEOMORPHIC ADENOMA:

CARCINOMA EX-PLEOMORPHIC ADENOMA

POLYMORPHOUS LOW GRADE ADENOCARCINOMA:

POLYMORPHOUS LOW GRADE ADENOCARCINOMA Known also as terminal duct or lobular carcinoma Majority in oral cavity (palate or bucal mucosa) Slow growing Common in female 2:1 Lymph node metastasis 9% Local recurrence 17% No distant metastasis

SALIVARY DUCT CARCINOMA :

SALIVARY DUCT CARCINOMA High grade aggressive tumor from excretory duct cells in major salivary gland mainly Microscopic feature remarkably similar to mammary intraductal carcinoma 35% recurrence 62% distant metastasis Approx. 80% die of the disease

EPITHELIAL-MYOEPITHELIAL CARCINOMA :

EPITHELIAL-MYOEPITHELIAL CARCINOMA 1% of salivary gland neoplasm Ductal cell population Mostly involve the parotid at age 50-80 female Solid, tubular & cribriform subtypes High incidence of local recurrence 50% especially with solid type Distant metastasis 25% 40% of patient die by their disease

ADENOCARCINOMA:

ADENOCARCINOMA Ranging from low grade well differentiated to high grade invasive lesions Common in major gland Originate from excretory or striated ducts Cystic or solid, may be papillary or non-papillary in growth pattern Prognosis depend on grade

SQUAMOUS CELL CARCINOMA:

SQUAMOUS CELL CARCINOMA Rare to be primary & common to be secondary from intraparotid lymph node or direct involvement Should be differentiated from mucoepidermoid carcinoma by presence of mucin on electronmicroscope with stain or immunohistochemical test Incidence 0.3% -1.5% in major gland 50% nodal metastasis M:F = 2:1 7th-8th decades TR: Surgery + Neck dissection + Postop. RT

UNDIFFERENTIATED CARCINOMA:

UNDIFFERENTIATED CARCINOMA Lack of histological characteristics High incidence in china Indistinguishable histologically from undifferentiated carcinoma of nasopharynx Linked to E B virus

LYMPHOMA:

LYMPHOMA 5% of all extranodal lymphoma affect salivary gland 90% occur in parotid 85% are N H L Nodal or extranodal in the salivary gland Primary or disseminated Its risk in Sjogren’s syndrome is 44 fold higher & has bad prognosis

SECONDARY TUMORS:

SECONDARY TUMORS The majority of metastasis are caused by lymphatic spread from cutaneous malignancy of the head & neck Hematogenous metastasis are rare & majority from lung, kidney & breast Contiguous extension of facial sarcomas 10% of malignant parotid gland tumors 40% are SCC, & 40% are melanoma Melanoma correlate with thickness of primary tumor

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MANAGEMENT

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STAGING

STAGING SYSTEM:

STAGING SYSTEM T N M: T0 no clinical evidence of primary tumour T1 0.1 – 2.0 cms diameter without significant local extension T2 2.1 – 4 cms without local extension T3 4.1 – 6.0 cms without local extension T4 a >6 cms without local extension b tumour of any size with significant extension

STAGING SYSTEM:

STAGING SYSTEM T N M : NX: Lymph nodes (LN) not evaluated N0: Without lymph nodes affection 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

TNM STAGING:

TN M STAGING M0 no distant mets M1 distant mets eg., bone, lung

STAGING:

STAGING Stage I T1N0M0 Stage II T2N0M0 Stage III T3N0M0 or T1-3N1M0 Stage IVA T4aN0-1M0 or T1-4aN2M0 Stage IVB T4bNxM0 or TxN2-3M0 Stage IVC TxNxM1

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The principal treatment of salivary gland tumors is surgical resection with safe margins Used either as single modality or conjunction with adjuvant radiotherapy

SURGERY:

SURGERY Parotid 90% confined to superficial lobe – perform superficial parotidectomy If adjacent to deep lobe - total parotidectomy If invades adjacent soft tissue – radical parotidectomy Never perform piecemeal excision in an attempt to preserve facial nerve Nerve grafting can be performed and RT can start 3-4 wk post op without adverse affects

SURGERY:

SURGERY Submandibular Small tumor – gland excision ECE –En bloc resection with extended supra- omohyoid neck dissection Small and localized tumour can be resected without submandibular gland Generally requires resection of submandibular gland as well

SURGERY:

SURGERY Minor Salivary Glands Benign : Upper lip: Excision  pry closure of defect Palate : <1cm  excision--- healing by sec intention >1cm incisional Bx-definetive Rx Malignant : Palate: Wide excision(low-level or total maxillectomy) Defect Rx by Prosthesis Microvescular flaps (radial, fibular, RA, LD, iliac crest graft)

COMPLICATION OF PAROTIDECTOMY :

COMPLICATION OF PAROTIDECTOMY Frey’s syndrome (Gustatory sweating): Symptoms vary in severity ?Incidence 35-60% Due to cross re- innervation between the postganglionic secretomotor parasympathetic fibers to the parotid gland & the postganglionic sympathetic fibers supplying the sweat glands of the skin

PowerPoint Presentation:

Diagnosis depend largely on the patient’s symptoms but can be confirm by Minor’s starch & iodine test If the symptoms are bothersome we can use Antiperspirant Glycopyrrolate lotion Tympanic neurectomy Muscle flap or sheet of facia between the skin and the parotid bed

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Salivary fistula Uncommon & self limited Clear sialorrhea or fluid collections Treated by wound care pressure dressing repeated aspiration of fluid collections oral anticholinergics

Facial nerve paresis or paralysis:

Facial nerve paresis or paralysis

II: NECK DISSECTION :

II: NECK DISSECTION If there is metastatic cervical L.A.P. the patient need comprehensive cervical lymphadenectomy 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 dissection should be considered In low-grade malignancy the elective neck dissection not recommended

Lymph Node Groups of the Neck:

Lymph Node Groups of the Neck Level Lymph Node Group I Submental and submandibular nodes II Upper jugular nodes III Middle jugular nodes IV Lower jugular nodes V Posterior triangle nodes VI Anterior compartment lymph nodes

RADIOTHERAPY :

RADIOTHERAPY Adjuvant radiotherapy is superior to surgery alone & effective to improve locoregional control & highly recommended in patient with poor prognosis In inoperable tumor the neutron irradiation alone is the therapy of choice & superior to conventional proton or electron therapy & even superior to debulking surgical procedure

RADIATION :

RADIATION Surgically unresectable tumors external beam radiation therapy with photon and or electrons with conventional or altered fractionation Brachytherapy ± EBRT Neutron therapy

Radiation – Surgically unresectable tumors :

Radiation – Surgically unresectable tumors EBRT Equivalent control rates as for equivalent head and neck squamous cell cancers Early stage 71-100% control rates Late and Recurrent 50-70% Hyperfractionation Wang and Goodman reported on 14 patients using 1.6 Gy bid to 65-70 Gy 5 yr LCR 82%

Radiation – Surgically unresectable tumors :

Radiation – Surgically unresectable tumors Brachytherapy Used frequently with recurrent or advanced disease 5 yr LCR 60% Neutron therapy Biologic effect of neutrons less effected by hypoxia Lethal effects less dependent on cell cycle Repair of sublethal damage in malignant cells is less Severe late effect greater 17% versus 7% Improved local control but no diff. in overall survival

POSTOPERATIVE RADIATION :

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

RADIATION:

RADIATION 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

SIDE EFFECTS:

SIDE EFFECTS Salivary fxn Loss of salivary fxn complete >35 Gy Dose limit to spare salivary function is 26 Gy Trismus TMJ and masseter muscle < 50Gy Physiotherapy during and after treatment

CHEMOTHERAPY :

CHEMOTHERAPY Although the salivary gland malignancy show some response to various chemotherapeutic agents, these response have not resulted in significant improvement in long survival rate

POSTOPERATIVE DETAILS:

POSTOPERATIVE DETAILS Evaluate postoperative facial, hypoglossal, and lingual nerve function Occasionally, transient facial nerve paresis occurs It usually resolves within 3-12 weeks after surgery

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PROGNOSIS

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I. Stage: The most important factor The incidence of local recurrence & regional metastasis are lowest in patient with stage I

II. HISTOLOGY & GRADE::

II. HISTOLOGY & GRADE: The biologic behavior depend largely on the histologic type of malignancy Squamous cell carcinoma, malignant mixed tumors, undifferentiated carcinoma & salivary duct carcinoma are considered high-grade tumors while acinic cell carcinoma & polymorphous low grade adenocarcinoma are considered low-grade tumor Adenoid cystic carcinoma considered a high grade malignancy although histologic pattern have different biologic behavior Mucoepidermoid carcinoma highly correlated with tumor grade

III. SITE: :

III. SITE: The prognosis & also the local recurrence after treatment have a definite correlations with primary site of origin which is better in major salivary glands than minor salivary glands mainly due to: Present at more advance stage High incidence of extension & fixation Bone involvement

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IV. Nodal metastasis: Considered as predictor of poor prognosis Adenoid cyst carcinoma 10 & 20 years survival rate drop from 62 & 50% to 38 & 8% with nodal metastasis V. Surgical margins: Some consider it as the most important factor Microscopic positive margin need radiotherapy to achieve good prognosis .

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VI. Perineural spread In squamous cell carcinoma the perineural spread show poor prognosis The effect of perineural spread in the prognosis of adenoid cystic carcinoma still controversial But any how the perineural spread in major nerve indicate adverse prognostic factor

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VII. Facial Nerve paralysis: Although facial nerve paralysis may not be associated with 100% mortality rate, it is an indicator of poor prognosis VIII. Pain: Patients with pain appear to have a less favorable outcome Its presence increase likelihood of local invasion of bone or sensory nerves

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IX. Distant metastasis: 20% of parotid malignancy Most frequently in adenoid cystic carcinoma & undifferentiated carcinoma Lung, bone & brain X. Gender: Men have poorer outcome

REFRENCES:

REFRENCES Bailey & Loves Short Practice of surgery Schwartz’s Principles of Surgery Sabiston : Text book of surgery Mathews Internet

THANK U:

THANK U

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