Salivary gland tumours

'fT^^B^D: Tumours arising in either the major (parotid, submandibular, sublingual) or minor salivary glands, characterised by a diversity of histological subtypes.

Unknown. 80% arise in the parotid (20% malignant); 15% in the submandibu-

Olar (30-50% malignant); and 15% in the minor salivary glands (> 60% malignant). Sublingual gland tumours are rare (0.3%, but nearly all malignant).

H|a/R: Warthin's tumour is associated with smoking (8x " risk), others with radiation exposure.

Q^IE Relatively rare, most occur in adults (most common in children is haeman-gioma). Pleomorphic adenoma: mean age 42 years, Warthin's tumour: mean

Zage 60 years (male>female), acinic cell carcinoma: affects women in fifties, squamous carcinomas: men in seventies.

^IH A swelling, usually slow-growing and painless. Pain is more likely if the tumour is malignant.

In locally advanced cases, induration or ulceration of overlying skin or mucosa.

_E The swelling should be examined with attention to evidence of fixation.

Inspection of the oral cavity should be performed as deep lobe parotid tumours may enlarge into the parapharangeal space, visualised as a mass lateral to the tonsil that may displace it medially or the palate downwards.

The submandibular gland should be palpated bimanually.

Facial nerve function in parotid lesions (weakness should raise suspicion of malignancy) and evidence of regional lymphadenopathy.

P: Benign tumours:

Pleomorphic adenoma: 80-85% of parotid gland tumours. Epithelial or myoepithelial cells without a true capsule; hence propensity to recur after removal. Warthin's tumour (papillary cystadenoma lymphomatosum previously known as adenolymphoma): Only parotid, 15% of neoplasms, 10% bilateral or multicentric with glandular and cystic elements with eosinophilic epithelium. Malignant carcinomas:

Acinic cell carcinoma: Most commonly in parotid. Wide histological spectrum with lymphocytic infiltrates.

Mucoepidermoid carcinoma: Most common malignant tumour of the parotid gland, of variable malignancy, i.e. low grade to aggressive. Adenoid cystic carcinoma (6% most common malignant carcinoma of the sub-mandibular): Aggressive with perineural spread into the brain and potential for late metastases.

Adenocarcinoma, squamous and undifferentiated carcinomas: All aggressive. Nonepithelial tumours (e.g. haemangiomas, lymphomas): All rare.

Imaging: Ultrasound, CT or MRI scanning are useful in delineating the mass and its relationship to surrounding structures, but cannot tell if malignant. Tissue biopsy: FNA can be used, but cannot absolutely be relied on for histological diagnosis. Incisional or excisional biopsy of masses in major glands should be avoided because of the risk of tumour spillage. CXR: For staging if malignancy is suspected.

Surgical: Excision is used for both benign and malignant tumours. Parotid: Superficial (for benign or low-grade malignancies) or total parotidectomy (for higher-grade malignancies) with careful preservation of the facial nerve and its branches that run between the deep and surperficial lobes. If the nerve is involved, sacrifice and immediate reconstruction with a nerve graft can be performed.

Submandibular: Tumours are approached by an incision in the submandibular triangle. Malignant tumours may involve the lingual or hypoglossal nerves and resection may be necessary. This results in partial loss of sensation, and

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