salivary gland neoplasia Flashcards
what could cause a source of swelling in the region of major salivery glands?
- Skin/subcutaneous
– Blood vessels
– Nerves
– Muscles
– Lymph nodes (most common)
– Salivary tissue
what could cause a source of swelling in the region of minor salivery glands?
> Mucosa/submucosa – Blood vessels
> Nerves
> Muscles
> Bone
> (Nose/sinuses)
> (Skin, etc)
> Salivary tissue
what are swelling of the salivary gland classified as?
> Reactive
> Neoplastic
what are Reactive salivary gland swellings classified into?
> Developmental
- Hamartoma, heterotopia
> Traumatic
- Mucous extravasation cyst
> Infective
- Viral, bacterial,…
> Obstructive
- Calculus, duct stricture
> Autoimmune
- Sjögren’s syndrome
> Metabolic
- Sialosis
what are neoplastic salivary gland swellings classified into?
> Primary =
- Benign = Epithelial or Mesenchymal
- Malignant = Epithelial or Mesenchymal or Lymphoid
> Secondary =
- Nodal metastasis
- Haematogenous metastasis
- Nodal lymphoma
what are the more general 3 categories of salivary gland neoplasms?
> Completely benign = Warthin’s, Oncocytoma
> Potentialforlocalrecurrence±nodalmets. = PA, Mucoepidermoid Ca, PLGA, Acinic
> High grade malignant = Ca ex-PA, Salivary Duct Ca
(adenoid cystic carcinoma in a category of its own due to its severity)
what is the incidence of neoplasm in major glands compared to minor?
> 10 times more common in major glands
what is the site and behaviour (B:M) of salivary gland neoplasms?
> 60-70% occur in the parotid gland (4:1)
> 10-15% occur in the sub mandibular gland (1:1)
> 20-25% occur in the minor salivary glands (1:1)
- upper lip (3:1)
- cheek/ palate (1:1)
- lower lip (1:2)
- tongue/ FOM/ RMP (1:6-8)
> <1% occur in the sub lingual gland (1:5)
what is the most common salviery gland tumour?
> pleomorphic adenoma
> 60%+
> in both major and minor glands
what age does pleomorphic adenoma usually affect?
> occurs at all ages
> peak 20 - 40 years
what does pleomorphic describe?
> describes the architectural diversity NOT the cytology
> forms ducts, sheets and strands of my-epithelium
> forms a Myxoid matrix – may resemble cartilage
> Thin incomplete capsule formed
what type of tumour is a pleomorphic adenoma?
> Benign tumour but local recurrence common
– Especially if ruptures
> Malignancy can occur in longstanding and/or recurrent lesions
– Carcinoma ex-PA
> Very rarely benign PAs may metastasise – Usually post-op, major glands
is warthins tumour common?
yes, 2nd most common?
where is a warthins tumour found?
> only In the parotid near the tail
> can present as a neck swelling
what is the typical age range of a warthins tumour
> wide age range
> usually older patients (50-60)
> never in children
what is the frequency in males and females?
> 3M: 2F
what is a common risk factor for warthins tumour?
> smokers
> 8 times more likely
how does a warthins tumour present as ?
> completely benign…
> May be multiple and/or bilateral…
> Probably hyperplastic/neoplastic salivary elements in a lymph node…
- May be affected by other malignancies, e.g., metastatic CAs, NHL
what is warthins tumour also known as ?
> Also known as adenoid lymphoma
> histo = Cysts with papillary projections of bland epithelium and lymphoid background++
where is a muceopidermoid carcinoma common?
> common in minor salivary glands and the parotid gland
where is a muceopidermoid carcinoma common?
> common in minor salivary glands and the parotid gland
> if removed to margin of normal tissue they do not recur if low grade, however high grade behaves badly
what is the typical age range for mucoepidermoid carcinoma?
> occurs at all age ranges
> peak at 40-50 years
> most common salivary tumour in childhood and adolescents
how does a mucoepidermoid carcinoma usually present?
> Malignant tumour but usually low-grade – Less than - 10% metastasise (cured with surgery)
> May be solid, cystic or both
> Circumscribed but unencapsulated
> histo = Mucous cells, epidermoid cells and intermediate cells
> Generally cytologically bland but it is malignant
how do high grade mucoepidermoid carcinomas usually present?
> High-grade lesions look like adenocarcinoma NOS or even SCC
> Solid rather than cystic
> Cytologically malignant-looking cells
> infiltrative edge
where are adenoid cystic carcinoma common?
> common in minor glands and the parotid gland
> most feared
> top 4 most common
what is the common age ranges of adenoid cystic carcinoma?
> occurs at all ages, not defined
> peak at 40- 50 years
how does an adenoid cystic carcinoma usually present?
> usually very subtle, often missed
> Soft, unencapsulated, discoloured mucosa
> May have nerve-related symptoms
> histo Classical “Swiss cheese” pattern (cribuform), Deceptively bland cytology
is an adenoid cystic carcinoma benign or malignant?
> Malignant tumour but usually low-grade
does the adenoid cystic carcinoma invade?
> yes, there is widespread local invasion seen beyond the borders of the mass
> rarely excised completely
> the tumour cells don’t cause a virus reaction to the host cells so they just keep invading
what is the adenoid cystic carcinoma famed for?
> perineurial invasion
> seen in around 50%
why is it hard to diagnose the adenoid cystic carcinoma?
> the absence of an advert desnoplastic reaction, it does not feel hard or like a malignant tumour by palpation
> accounts for the difficulty of finding the true extents of the tumour
how long do patients tend to live for with adenoid cystic carcinoma?
> patients live for 10 years but rarely cured
> doesn’t respond well to radiotherapy
what type of matastisis common in adenoid cystic carcinoma?
> haematogenous metastasis common to brain, liver and lungs
> not regional lymphnoids
what does a carcinoma ex PA usually affect?
> usually effects major glands
when is the peak incidence of a carcinoma ex PA?
> Peak incidence about 10 years after PA
how does a carcinoma ex PA usually present?
> classically rapid enlargement of lump
what does the prognosis of a caricinoma ex PA usually depend on?
> Degree of invasion beyond capsule of the PA
> precise subtype(s)
what is the management of salivary gland tumours?
> Establish the diagnosis
> Determine the treatment need – Usually to get rid of the tumour
> Rationalise treatment options
– Surgery
– Radiotherapy
– Both
– Neither
what investigation can you carry out to aid treatment and diagnosis of salivary gland tumours?
> Ultrasound (USS)
> Computerised Tomography (CT)
> Magnetic Resonance Imaging (MRI)
> Fine Needle Aspiration (FNA)
> Open biopsy
– Incisional
– Excisional
what does imaging investigations show you?
USS/ CT/ MRI
> Location
> Size and shape
> Consistency
– Solid or cystic
> Interface with adjacent tissues… – …up to a point
what are the advantages of FNA cytology?
> Cellular populations to be visualised
> highly Accurate = Exclude metastasis
> Quick and easy… Painless (if pain when withdrawn = ACC)
what are the disadvantages of FNA cytology?
> Sampling error common
> Guidance often required
> Not always correct = Benign-malignant inversions common
> Usually doesn’t change the treatment
what are the advantage of an incisional biopsy?
> more accurate than other biopsy
> allows more precise treatment planning
what are th disadvantages of an incisional biopsy?
> risks in PG, SMG = salivary fistula, causing injury, seeding tumour along the tract
> Not always correct = minor element missed
> usually doesn’t change the treatment
what are the advantages excisional biopsys?
> very accurate
> may be the treatment
> usually the preferred option
what are the disadvantages of excisional biopsys?
> May need a major op
> Risk to vital structures VII, Gr Aur. N
> Facial asymmetry PG, SMG
> Mucosal defect
> Further Rx may be required…radiotherapy
is radiotherapy efffective?
> no
> CAs mostly recapitulate ductal differentiation and the ducts are mostly radiation-resistant
> it is used when you have to make sure a tumour doesn’t continue to grow E.g., high-grade tumours with positive/close margins +/- LN mets…
what chemotherapy drug is used to target salivary Gland tumour?
> Formalin
what is the go to treatment for slavery gland tumours?
> surgery (eg excisional biopsy)
a salivary gland tumour is likely to be malignant if…
> It’s low in the mouth
> There’s a history of pain/tenderness
> There’s VIIth nerve dysfunction
> There’s involvement of skin, fixation or ulceration
