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Head and Neck > Salivary Gland Pathology > Flashcards

Salivary Gland Pathology Flashcards

1
Q

List the different types of salivary glands, the type of fluid they produce and associated ducts

A

MAJOR:
1. Parotid
- Predominantly Serous fluid (serous acini)
- Stenson’s duct
- Retromandibular vein divides superficial and deep lobes (Radiographically)
- 20% people have accessory lobe superficial to masseter
- 10-20 Lymph nodes within the glands

  1. Submandibular gland
    - Mixed serous/mucinous fluid
    - Wharton’s duct
  2. Sublingual gland
    - Mucinous (Viscous) fluid
    - Ducts of Rivinus (~10)

MINOR:
- 500-1000 minor salivary glands throughout oral/nasal cavity/pharynx
- Mucinous (viscous) predominant
- Unencapsulated glands –> easy spread of disease

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2
Q

Describe the anatomy of the salivary gland

A

SECRETORY UNIT = TUBULOACINAR UNIT
- Arborized tiissue with terminal acini leading to common excretory ducts.
- Composed of multiple parts (as below)
- Epithelial cells are acinar and ductal cells
- Parenchymal tissue are the secretory tissues, which are divided into many lobules by stromal (supportive) connective tissue

  1. Acinus/Acinar cells
    - Serous, mucinous, seromucinous cells
    - Fluid generation (isotonic)
    - 85% protein generation
  2. Myoepithelial cells
    - Supporting/contracting cells
  3. Secretory Ducts
    - a) Intercalated Ducts = Secrete potassium, absorb sodium
    - b) Striated ducts = Secrete HCO3, absorb Chlorine
  4. Collecting/Excretory Ducts
    - Fluid carriers

Central control of salivary function = MEDULLA

Photo: Vancouver notes Pg 102

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3
Q

Describe two theories on how neoplasms are formed from the salivary glands?

A
  1. Multicellular Theory: Each neoplasm originates from a distinct cell type within the salivary gland unit (e.g. oncocytic tumors from striated ducts)
  2. Bicellular Theory: All neoplastic cells differentiate from basal (reserve) cells of either excretory (e.g. mucoepidermoid, SCC), undifferentiated, or intercalated (pleomorphic, all others) ducts
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4
Q

What are Ebner glands? What do they secrete and what are they innervated by?

A

Serous minor sublingual glands on the posterior tongue along the sulcus terminalis.
- Secrete lipase (begins lipid hydrolysis in mouth)
- IX innervation

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5
Q

What are Weber glands?

A

Minor salivary glands at superior tonsillar pole.
Infection of these suspected to be responsible for peritonsillar abscesses

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6
Q

What are Fordyce granules?

A

Sebaceous cells in the oral mucosa of normal individuals

https://www.pcds.org.uk/imager/gallery/clinical/fordyce-spots-syn-fordyces-granules/12420/FS_buccal_fee391183f15cb4d62773032fe0be92d.jpg

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7
Q

What proportion of salivary gland masses are malignant?

A
  • 80% salivary masses occur in parotid
  • 20 % masses occur in minor salivary glands (~15% submandibular, 5% sublingual)

Malignancy relationship is reverse
- 20% parotid masses are malignant
- 50% submandibualr malignant
- 80% minor salivary/sublingual masses are malignant

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8
Q

List the differential diagnosis for parotid mass/enlargement

A

A. CONGENITAL
1. Hemangioma
2. Branchial cleft cyst (1st)

B. INFECTIOUS
1. Acute sialadenitis
2. Mumps
3. DILS - Diffuse infiltrative lymphocytosis syndrome (HIV)
4. Granulomatous (TB, atypical mycobacteria, actinomyces, toxoplasmosis)

C. INFLAMMATORY
1. Chronic sialadenitis
2. Sialolithiasis
3. Sjogren’s
4. SLE
5. Sarcoidosis (Uveoparotid fever)
6. HIV-related salivary gland disease

D. NEOPLASTIC: BENIGN
1. Pleomorphic adenoma
2. Warthin’s tumor
3. BLEL - Benign lymphoepithelial lesions (HIV/Sjogren’s)
4. Oncocytoma
5. Monomorphic adenoma
6. Clear cell adenoma

E. NEOPLASTIC: MALIGNANT
1. Mucoepidermoid cancer
2. Adenocarcinoma
3. Adenoid cystic carcinoma
4. Acinic cell carcinoma
5. Carcinoma ex-PA
6. Lymphoma
7. Rhabdomyosarcoma
8. Fibrosarcoma

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9
Q

Which tumors derive from each of the different components of the salivary unit?

A

ACINAR CELLS:
1. Acinic cell carcinoma

MYOEPITHELIAL:
1. Monomorphic adenoma
2. Pleomorphic adenoma
3. Adenoid cystic carcinoma

INTERCALATED DUCTS:
1. Polymorphous low-grade adenocarcinoma
2. Pleomorphic adenoma

STRIATED DUCTS:
1. Warthin’s tumor
2. Oncocytoma

EXCRETORY DUCTS
1. Mucoepidermoid carcinoma
2. Squamous cell carcinoma

“Epithelial cells” are considered acinar cells and ductal cells

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10
Q

What is the differential diagnosis of benign salivary gland neoplasms in adults? 7

A
  1. Pleomorphic adenoma
  2. Warthin’s tumor
  3. Oncocytoma
  4. Monomorphic adenoma, including:
    - Basal cell adenoma
    - Clear cell adenoma
    - Glycogen rich adenoma
    - Myoepithelioma
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11
Q

What are 11 risk factors for salivary gland malignancy?

A
  1. Radiotherapy (low dose)
  2. Full mouth dental x-rays
  3. EBV (lymphoma)
  4. Overlying skin malignancy
  5. Smoking (only Warthin’s)
  6. Rubber industry
  7. Nickel
  8. Silica dust
  9. Hair dye
  10. Kerosene cooking fuel
  11. Vegetables preserved in salt
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12
Q

What are 3 mutations that are commonly seen in salivary lesions?

A
  1. p53
  2. Bcl-2
  3. RAS
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13
Q

Describe the Milan Classification for Salivary FNA biopsy, their risk of malignancy, and typical management

A

Similar to the Bethesda classification for thyroid nodules; categories:

A. NON-DIAGNOSTIC
- Risk: 25%
- Mx: Clinical and radiologic correlation/repeat FNA

B. NON-NEOPLASTIC
- Risk: 10%
- Mx: Clinical follow up and radiologic correlation

C. ATYPIA OF UNDETERMINED SIGNIFICANCE (AUS)
- Risk: 20%
- Mx: Repeat FNA or surgery

D. NEOPLASM: BENIGN
- Risk: < 5%
- Mx: Conservative surgery or clinical follow-up

E. NEOPLASM: SALIVARY GLAND NEOPLASM OF UNCERTAIN MALIGNANT POTENTIAL (SUMP)
- Risk: 35%
- Mx: Conservative surgery

F. SUSPICIOUS FOR MALIGNANCY
- Risk: 60%
- Mx: Surgery

G. MALIGNANT
- Risk: > 90%
- Mx: Surgery (extent dependent on type and grade of malignancy)

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14
Q

List the differential diagnosis for a salivary FNA with a “basaloid neoplasm” 6

A
  1. Pleomorphic adenoma
  2. Basal cell adenoma
  3. Myoepithelial carcinoma
  4. Adenoid cystic carcinoma
  5. Adenocarcinoma
  6. Metastasis

Has an A in the name of

Power Boss MA’AM

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15
Q

Regarding pleomorphic adenoma, discuss:
1. Where are the top 4 pleomorphic adenoma locations?
2. What is the typical appearance of these tumors?
3. Describe the histology
4. What is the treatment?

A

LOCATIONS:
1. Parotid
2. Hard palate (minor salivary gland)
3. Submandibular gland
4. Minor salivary glands (e.g. upper lip)
90% superficial to FN, 10% deep to stylomandibular ligament

APPEARANCE:
- If tumor extends from parotid to PPS through stylomandibular tunnel = dumbbell appearance
- If tumor entirely deep to ligament = rounded appearance

HISTOLOGY:
- Gross: Well encapsulated, smooth, rubbery
- Microscopic: Incomplete encapsulation, pseudopod extensions
- Mixture of epithelium, myoepithelium, and mesenchymal stroma
- Epithelial growth patterns: Cystic, papillary, small nests, solid sheets, ductal structures, anastomosing trabeculae
- Myoepithelial cells: Spindle shaped, hyperchromatic nuclei, may be multiple cell layers thick
- Mesenchymal stroma morphologies: Fibroid, myxoid, mucoid, chondroid, osteoid

TREATMENT:
1. Excision with a small cuff of normal tissue
2. Recurrent: difficult dissection with facial nerve at risk
3. If asymptomatic, widespread, slowly progressing and no malignant transformation - consider observation
4. Radiotherapy does not work

Pseudopods: https://www.pathologyoutlines.com/imgau/salivaryglandspleomorphicadenomaxu06new.jpg
Spindle Myoepithelial cells: https://www.pathologyoutlines.com/imgau/salivaryglandspleomorphicadenomaxu11new.jpg
Chondroid stroma: https://www.pathologyoutlines.com/imgau/salivaryglandspleomorphicadenomacow40403new.jpg

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16
Q

Regarding Monomorphic adenoma, discuss:
1. What is the histology?
2. What are the subtypes (in order of how common they are)? 6

A

HISTOLOGY:
- Similar to pleomorphic adenoma, except no mesenchymal stromal component
- Predominantly epithelial component
- Gross: Well circumscribed and encapsulated
- Microscopic: Basal cell, rows of peripheral palisading cells

TYPES:
1. Basal cell adenoma (most common, occur in parotid and upper lip)
2. Clear cell adenoma (second most common - need to rule out metastatic renal cell carcinoma)
3. Glycogen rich adenoma (third most common)
4. Myoepithelioma
5. Canalicular (upper lip)
6. Membranous

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17
Q

What are the histologic subtypes of myoepithelioma? 3

A

HISTOLOGIC SUBTYPES OF MYOEPITHELIOMA:
1. Spindle pattern
2. Plasmacytoid
3. Combination

SPC

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18
Q

Describe the differences between Malignant Mixed salivary tumor and Carcinoma Ex-Pleomorphic adenoma

A

Malignant Mixed Tumors:
- Display malignant transofmration in both epithelial (carcinoma) and stromal (sarcoma) components
- Can look like adenocarcinoma, ductal or undifferentiated carcinomas

Carcinoma ex-pleomorphic adenoma:
- Only displays malignant transformation in its epithelial component
- There should be evidence of underlying benign PA here

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19
Q

What is the rate of malignant transformation of pleomorphic adenoma?

A

1.5% in the first 5 years

Increase to 10% in > 15 years

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20
Q

What is the full name of a Warthin’s tumor?

A

Papillary Cystadenoma Lymphomatosum

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21
Q

What is the epidemiology of a Warthin’s tumor?
Where is it more common with respect to ethnicity, age, gender, risk factors, and salivary gland location.
What is its rate of transformation?

A

= Papillary Cystadenoma Lymphomatosum

Epidemiology:
1. Whites
2. Male:Female 5>1
3. 5-6th decades
4. Radiation and smoking influence
5. 10% of all parotid tumors, 10% bilateral, 10% multicentric
6. Almost exclusive to parotid gland
7. Extremely rate transformation to malignancy (< 1%)

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22
Q

What is the histology of Warthin’s tumor?

A

= Papillary Cystadenoma Lymphomatosum

  • High density of mitochondria on extracellular matrix
  • Gross: Smooth with well-defined capsule
  • Microscopic: Biphasic, epithelial cells forming papillary projections into cystic spaces with a background of lymphoid stroma
  • Epithelium: Double cell layer of oncocytic cells with nuclei of the cystic side (columnar luminal cells) toward cystic space and nuclei of basement membrane (cuboidal basal cells) side toward basement membrane (ie. nuclei face away from each other)
  • Lymphoid stroma: Lymphocytes with follicles and germinal centres

Oncocytes are epithelial cells with abundant, granular, eosinophilic cytoplasm due to presence of numerous large mitochondria of varied sizes.

Epithelium: https://www.pathologyoutlines.com/imgau/salivaryglandswarthinBalgobind04new.jpg
Papillary structures lined by bilayered oncocytic epithelial cells and surrounded by a lymphoid stroma: https://www.pathologyoutlines.com/imgau/salivaryglandswarthinBalgobind03new.jpg

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23
Q

What are the features of Warthin’s tumor on imaging? 3

A
  1. CT: Solid and cystic components, nodular border
  2. MR: Bright on T2 (cystic)
  3. Tc-99 enhancing - many mitochondria (oncocytic double layer)

Kevan Question #115

24
Q

What is the risk of malignant transformation of a Warthin’s tumor?

A

< 1% risk of malignant transformation, but will continue to grow

Treatment: Observation vs. Excision

25
Q

Regarding Oncocytoma, discuss:
1. Histology
2. Location
3. Treatment

A

Histology:
- Cell of origin is an oncocyte (= large epithelial cells with granular eosinophilic cytoplasm from mitochondrial hyperplasia)
- Gross: Slow growing, circumscribed but encapsulated
- Microscopic: Brown, plump, granular eosinophilic cells with small indented nuclei & high mitochondrial density (no lymphoid component as seen in Warthin’s)
- Electron microscopy = Mitochondrial hyperplasia
- Mitochondria enhance with Technetium99

Location:
1. Almost exclusive parotid (80%)

Treatment:
1. Surgery

This is what an oncocyte looks like (not oncocytoma); note very granular pink cytoplasm: https://pathorama.ch/pathopic/003036/show

26
Q

Regarding Mucoepidermoid carcinoma, discuss:
1. Epidemiology and Most common locations
2. Risk factors
3. Histology
4. Grading
5. Stains
6. Treatment

A

MOST COMMON salivary gland malignancy

LOCATION:
1. Parotid
2. Minor salivary glands (palate)
3. Submandibular gland

RISK FACTORS:
1. Radiation to head/neck

HISTOLOGY:
1. Stain positive for PAS and mucin
2. Three cell types: Mucous (glandular) cells, intermediate cells, epidermoid cells
3. Ratio of high epidermoid cell content and low mucous cells –> lead to increasing grade

GRADING SYSTEMS:
1. AFIP grading system (most common)
2. Modified Healey system
3. Brandwein system (most common)
Which one to use is controversial, some classify low as high and vice versa, some also have intermediate

In general:
1. Low grade
- High mucous cells, low epidermoid (solid) cells
- Prominent cysts and mature cellular elements
- Behave like benign neoplasm but capable of local invasion and metastasis
- Rare metastasis/recurrence, EXCEPT for submandibular gland more aggressive

  1. Intermediate grade:
    - Mucous cells and epidermoid cells roughly similar in number
    - Fewer and smaller cysts
    - Increasing pleomorphism and mitotic figures
  2. High grade: (could be mistaken for SCC)
    - Solid (< 30% mucous component)
    - Poor differentiation
    - High Epidermoid cells, low Mucous cells
    - Perineural and/or vascular invasion
    - Necrosis
    - Increased mitotic figures
    - Requires IHC staining for MUCIN to differentiate from SCC

STAINS:
1. Mucicarmine
2. Mucin
3. Alcian Blue
4. PAS

TREATMENT:
- Low grade = Wide local excision, no elective neck dissection
- High grade = Radical excision, elective neck dissection and post op XRT

https://www.pathologyoutlines.com/topic/salivaryglandsMEC.html

27
Q

Regarding Adenoid cystic carcinoma, discuss:
1. Common locations
2. Features? What is the most common route of spread? When do they tend to recur?
3. Histology
4. Histologic subtypes
4. Grading system
5. Treatment
6. Survival 5 and 20 year survival

A

LOCATIONS:
1. Submandibular
2. Sublingual
3. Minor salivary glands
Second most common salivary gland malignancy

Most common malignancy in the SMG, SLG, and MSGs.

FEATURES:
- Slow, progressive growth
- Perineural spread with skip lesions is the most common route of spread
- Late recurrences common > 10 years
- ALL types are considered HIGH GRADE tumors
- Appears Violaceous

HISTOLOGY:
- Gross: Monolobular, either no capsule or partially encapsulated; infiltrates surrounding tissue
- Micro: Basaloid epithelium arranged in cylindric formations, eosinophilic hyaline strome (blue goo)
- Perineural invasion is a common feature

HISTOLOGIC SUBTYPES: “STC”
1. Solid (worst prognosis)
2. Tubular (best prognosis)
3. Cribriform (most common, intermediate prognosis)

GRADE:
- All considered high grade
- Overall grade depends on percentage of solid elements
- Grade 1: Tubular ± Cribriform WITHOUT ANY solid areas (0% solid)
- Grade 2: Cribriform with < 30% solid (typically has minimal tubular component)
- Grade 3: Any combination of types with > 30% solid

TREATMENT:
1. Surgery with post-op XRT (proton beam), neck dissection only if N+

SURVIVAL:
1. 5 year: 75%
2. 20 year: 13%

Blue Goo: https://www.pathologyoutlines.com/topic/salivaryglandsadenoidcystic.html
See Vancouver notes pg 105 and Kevan HNQ123 for images of types

28
Q

Regarding Acinic Cell Carcinoma, discuss:
1. Location. What % are bilateral?
2. Features
3. Histology
4. Configuations 4
5. Treatment
6. Survival at 5 and 20 years?

A

LOCATION:
Derived from serous acinar cells, thus for location:
1. Parotid (95%)
2. Submandibular
3. Rare in minor salivary glands
4. 3% bilateral

FEATURES:
1. Second most common salivary gland cancer in children
2. All considered low grade, better prognosis (63-87% 10 year survival)

HISTOLOGY:
1. Basophilic cytoplasm of acinar cells contains purple zymogen granules (tumor cells are purple and granular)
2. Granules are PAS stain positive (pink)
3. “Pushing borders” (not infiltrative)
4. Dense lymphoid infiltrate
5. Amyloid

CONFIGURATIONS:
1. Solid
2. Microcystic
3. Follicular (thyroid follicle like spaces)
4. Papillary-cystic

TREATMENT:
1. Surgery (no neck dissection as low grade) with post-op RT if residual disease

SURVIVAL:
1. 5-year 80%
2. 20-year 50%
3. Size and invasion determines survival, not grade

Vancouver notes page 106
Kevan HNQ124

29
Q

Regarding salivary adenocarcinoma, discuss:
1. Common locations
2. Clinical features
3. Subtypes
4. Histology
5. Histologic classification
6. Treatment

A

LOCATIONS:
1. Minor salivary glands (most common)
2. Parotid

FEATURES:
1. Aggressive tumors, likely to recur & metastasize
2. Generally HIGH grade

SUBTYPES:
1. Adenocarcinoma NOS
2. Polymorphous low-grade adenocarcinoma
3. Acinic cell adenocarcinoma

HISTOLOGY:
1. Gross: firm/hard, attached to surrounding tissue
2. Micro: Cyclindric cells of variable height, form papillae, acini, solid masses; mucin producing
3. Negative for keratin
4. Negative for Glial Fibrillary Acidic protein (GFAP) stain - compared to pleomorphic adenoma
4. Perineural invasion, infiltration common

HISTOLOGIC CLASSIFICATION:
1. Depends on degree of glandular structure cellular differentiation
2. Grade I: Well-formed ductal structures
3. Grade III: Solid growth pattern with few glandular characteristics

TREATMENT:
1. Aggressive surgical resection with post op RT
2. Elective ND if extensive local disease or high-grade lesions

30
Q

What are 3 things that must be ruled out in parotid Squamous cell carcinoma? 3

A
  1. Rule out high grade Mucoepidermoic carcinoma - stain positive for mucin/mucus and PAS
  2. Metastatic SCC to intraglandular nodes (e.g. skin cancer, other mucosal SCC)
  3. Direction extension of cutaneous SCC to parotid
31
Q

What is the management of SCC of the parotid? What is the 5 year prognosis?

A

Surgical resection with neck dissection, with post-op RT

25% 5 year OS

32
Q

Regarding Carcinoma ex-Pleomorphic adenoma, discuss:
1. What is it
2. Clinical presentation
3. Transformation rate
4. Prognosis

A

Carcinoma Ex-PA:
- Focal carcinoma within any portion of the PA (very heterogenous group)

CLINICAL PRESENTATION:
- Sudden, rapid growth in a long-standing salivary mass

TRASNFORMATION RATE from PA to Ca-ExPA:
1.5% in first 5 years
2.10% > 15 year

PROGNOSIS:
- Generally high grade, aggressive
- Variable prognosis, depending on cell type and invasion

33
Q

Regarding polymorphous low-grade adenocarcinoma (PLGA), discuss:
1. Location
2. Grade
3. Histology
4. Treatment

A

LOCATION:
- Second most common cancer of the minor salivary glands (does not occur in major SG)
- Seen on palate (junction of hard and soft palate)
- Buccal mucosa
- Upper lip

GRADE:
- Overall low grade
- Good prognosis, rarely results in death

HISTOLOGY:
1. Gross: Firm, painless, mucosalized mass
2. Histology: Concentric whorling of the nests around each other in a single file arrangement, “eye of the storm” or “Indian filling” Pattern
3. Most have perineural invasion

TREATMENT:
1. Surgical excision
2. No neck dissection unless N+

Histology Vancouver notes Page 107
Kevan HNQ127

34
Q

Regarding Mammary Analogue Secretory Carcinoma (MASC) of the salivary glands, discuss:
1. What is it?
2. Genetic associations?
3. Location?
4. Clinical presentation and Epidemiology?
5. Grade?
6. Treatment?

A

MASC:
- Rare tumor, described in 2010
- Looks like acinic cell carcinoma, but relates morphologically and genetically to a arare breast secretory carcinoma
- Low grade

GENETICS:
- Genetic translocation unique to this cancer resulting in an ETV6-NTRK3 fusion gene (can be tested for)

LOCATION:
- Parotid 70%

CLINICAL PRESENTATION:
- Young males, but can occur in wide range of patients
- Slow growing, painless tumor
- Infrequent local recurrence
- Rare metastases
- Considered to be a low-grade malignancy, but aggressive clinical behaviour has been described

TREATMENT:
1. Treat as Low grade cancer - Surgery without prophylactic neck dissection, adjuvant rads only if found to have aggressive features on pathology

35
Q

Regarding salivary duct carcinoma, discuss:
1. What is it?
2. Location
3. Epidemiology
4. Clinical presentation
5. Histology
6. Prognosis
7. Treatment

A

WHAT IS IT?
- Aggressive adenocarcinoma (high grade)
- Resembles high grade ductal carcinoma of the breast

LOCATION:
1. > 90% major salivary glands (ie. parotid)

EPIDEMIOLOGY:
- 9% of malignant salivary tumors
- Adults > 50 years common
- 4:1 male

CLINICAL PRESENTATION:
1. Rapidly growing mass
2. Ulceration
3. Facial nerve involvement

HISTOLOGY:
- High grade
- Common malignant component of carcinoma ex-PA
- Large duct component
- Large cribiform ducts with “roman bridging” and central comedonecrosis
- 30-40% Neu/HER2 positive

TREATMENT:
1. Radical excision with elective neck dissection and adjuvant radiation
2. 30-40% of salivary duct carcinomas are Neu/HER2 positive (associated with poor prognosis) - if positive can treat with chemo that targets HER2 pathway

PROGNOSIS:
1. 30% local recurrence
2. 60% local regional LN metastasis
3. 50% distal spread
4. 65% mortality (often within months of diagnosis)

Pathology Vancouver Notes Page 107 - duct replaced by tumor with central necrosis

36
Q

What is undifferentiated salivary carcinoma? What are the risk factors 2 and how are they treated?

A
  • High grade neoplasm with distant metastasis being common
  • ~3%, very poor prognosis
  • Risk factors: Eskoimo or EBV+
  • Treatment is similar to all other high grade neoplasms
37
Q

Where are common locations for primary salivary gland lymphoma? What are the risk factors?

A

Locations:
1. Parotid gland
2. Submandibular gland

Risk factors:
1. Sjogren’s

38
Q

List the low grade salivary gland malignancies (5)

A
  1. Acinic cell carcinoma
  2. Low grade Mucoep
  3. Polymorphous low grade adenocarcinoma
  4. Low grade Adenoid cystic carcinoma (tubular)
  5. Mammary analogue secretory carcinoma
39
Q

List the high grade salivary gland malignancies (7)

A
  1. Adenoid cystic carcinoma (solid)
  2. High grade Mucoep
  3. Undifferentiated carcinoma / lymphoepithelioma
  4. Adenocarcinoma NOS
  5. Carcinoma ex-PA
  6. Salivary duct carcinoma
  7. Squamous cell carcinoma (1%, rare)

beCAUSS, HA!

40
Q

Which salivary lesions show increased uptake on Technetium-99 scans? Why? 4
(“Hot lesions” on Tc-99)

A
  1. Warthin’s Tumors
  2. Hemangioendothelioma
  3. Oncocytoma
  4. Acinic cell

“WHOA”

Why? High mitochondrial content (striated duct)

41
Q

What is the role of salivary Tc-99 scintigraphy?

A
  1. Evaluate salivary function (e.g. flow rate)
  2. Can help diagnose certain benign salivary gland tumors
42
Q

What are the most common bilateral salivary gland lesions?

A
  1. Warthin’s (10%)
  2. Acinic cell (3%)
  3. Oncocytoma

“Bilateral lesions are WAcO”

43
Q

What are seven signs or symptoms which would support a malignant diagnosis for parotid mass?

A
  1. Facial nerve paralysis/paresis
  2. Fixation to overlying/underlying structures
  3. Overlying skin ulceration/infection
  4. Localized pain or trismus
  5. Cervical adenopathy
  6. Metastatic disease
  7. Large size >4cm
44
Q

What are 3 reasons for surgical excision of a benign salivary gland lesion diagnosed on FNA biopsy?

A
  1. Impact on cosmesis and continued growth of lesion
  2. Definitive diagnosis (FNA can be wrong)
  3. Chance of malignant transformation over time
45
Q

List 9 complications of parotidectomy

A
  1. Bleeding
  2. Earlobe numbness (GAN sacrifice)
  3. Hematoma
  4. Seroma
  5. Sialocele
  6. Skin flap necrosis
  7. Facial nerve paresis/paralysis
  8. Frey’s syndrome
  9. First bite syndrome: rare pain syndrome of pain with commencement of eating (resolves with further bites) - due to ?aberrant reinnervation?
46
Q

What are five methods used to identify the facial nerve during parotidectomy?

A
  1. Tragal pointer (1cm deep, anterior and deep)
  2. Tympanomastoid suture (follow it)
  3. Retrograde dissection from a distal branch
  4. Identification within mastoid bone (mastoidectomy)
  5. Digastric muscle attachment to the digastric groove - follow posterior belly of digastric to digastric groove

Use a nerve stimulator

47
Q

What are 4 indications for a total parotidectomy?

A
  1. High grade disease
  2. LN metastasis present
  3. Deep lobe involved
  4. Facial nerve involvement
48
Q

What are 3 indications for elective neck dissections in salivary gland malignancies?

A
  1. T3 & T4: Extension to extraglandular tissues or size ≥ 4cm
  2. High grade tumors (SCC< adenocarcinoma, undifferentiated, high grade muco epi)
  3. Submandibular gland carcinoma primary (21% chance of node positive)
  4. Positive nodal disease or ENE+
49
Q

What neck levels should be addressed for salivary gland malignancy with a N0 neck?

A
  1. Parotid: I-IV, some debate about V
  2. Submandibular: I-III
  3. In N+ disease - Modified radical neck dissection - ipsilateral only
50
Q

What are 8 indications for radiotherapy in salivary gland malignancies?

A
  1. High grade tumors (SCC, Adenocarcinoma, undifferentiated, high grade mucoep, malignant mixed
  2. Positive margins (unresectable or incomplete resection)
  3. Extraparotid spread - T3/T4
  4. Lymph node metastasis
  5. Extracapsular spread
  6. Facial nerve dysfunction caused by cancer (perineural spread)
  7. Recurrent tumor
  8. All malignant tumors EXCEPT T1N0 or T2N0 (< 4cm) disease with low grade histology (low grade mucoep, acinic cell) and negative resection margins
51
Q

What type of radiation should be used for treatment of adenoid cystic carcinoma?

A

Proton beam for primary site

52
Q

What is the radiotherapy protocol for salivary gland neoplasms in general?

A

STAGE 1/2 - Surgery ± Adjuvant Radiotherapy
- High grade
- Positive margins
- +ENE
- Nodal positive

STAGE 3/4 - Multomodality therapy
- Primary RT: Unresectable disease, particularly adenoid cystic
- No adjuvant systemic therapy used at this time
- Cetuximab (EGFR inhibitor) and Imatinib (tyrosine kinase inhibitor) in clinical trials

53
Q

Regarding Frey’s Syndrome, discuss:
1. What is it
2. Pathophysiology
3. Diagnosis

A

FREY’S SYNDROME:
- Gustatory sweating, secondary to postganglionic PNS reinnervation to sweat gland receptors - results in cheek redness, warmth, sweating with chewing
- Reinnervation affects ALL (or some resources say 50%) parotidectomy patients, but only 10% clinically significant

PATHOPHYSIOLOGY:
- Post-ganglionic parasympathetic nerves normally supply parotid via auriculotemporal nerve, but reinnervated to the sweat glands of the face
- Inferior salivatory nucleus (medulla) –> Glossopharyngeal nerve CNIX exits the skull through jugular foramen –> Jacobsen’s nerve (branch from IX) and ascends through inferior tympanic canaliculus into middle ear –> In middle ear Jacobsen’s nerve forms a tympanic plexus on the promontory –> Lesser superficial petrosal nerve (LSPN) arises from tympanic plexus –> LSPN leaves middle ear through the hiatus of LSPN –> LSPN travels on the surface of petrous apex (middle cranial fossa) –> LSPN exits middle cranial fossa through foramen ovale –> Fibers synapse in the otic ganglion and travel with the auriculotemporal nerve to innervate parotid (or sweat glands of skin in Frey’s syndrome)

DIAGNOSIS:
1. Minor’s Starch Iodine test
- Face painted with iodine and allowed to dry
- Dry corn staff is applied to the face
- Patient starts chewing to stimulate response
- Starch turns blue of exposure to iodine in the presence of sweat

54
Q

What is the prevention strategies for Frey’s? List 3

A

PREVENTION:
1. Interpose muscle flap
2. Interpose fascia graft
3. Thick skin flap

55
Q

What are the treatment options for Freys? 9

A

TREATMENT:
A. Medical Management
1. Antiperspirant
2. Topical anticholinergic (Scopolamine cream, glycopyrrolate, or atropine)
3. Systemic anticholinergics
4. Botox injections to skin

B. Surgical
1. Tympanic neurectomy (controversial)
2. Fascial graft
3. SCM flap/temporal-parietal flap (muscle flap interposition)
4. Free flap

C. Radiation therapy (last resort)

56
Q

What is First bite syndrome? What are the treatment options?

A
  • Consequence of deep lobe parotid surgery (into PPS/ITF)
  • Damage to SNS system results in unopposed PNS to parotid
  • Causes cramping/pain of facial muscles with first bite
  • Diminishes with subsequent bites (as neurotransmitters gets used up)

Experimental treatment:
1. Botox

Head and Neck (15 decks)

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