Case PresentationCase Presentation

A 58 year old female from Metro Manila A 58 year old female from Metro Manila was admitted due to right lateral facial mass. History was admitted due to right lateral facial mass. History of an enlarging right pre and infra auricular mass of an enlarging right pre and infra auricular mass which progressively enlarged within 12 months. She which progressively enlarged within 12 months. She denies of any pain however she complained of denies of any pain however she complained of difficulty of moving her right side of the face. difficulty of moving her right side of the face. Pertinent examination revealed an 8 x 10 hard , Pertinent examination revealed an 8 x 10 hard , fixed, non tender , non erythematous mass on the fixed, non tender , non erythematous mass on the right pre-auricular extending to the right infra-right pre-auricular extending to the right infra-auricular and upper neck. No palpable auricular and upper neck. No palpable lymphadenopathy was noted. Positive right lymphadenopathy was noted. Positive right peripheral facial paresis. Oral and oropharyngeal peripheral facial paresis. Oral and oropharyngeal examination are unremarkable.examination are unremarkable.

Panorexxray and CXR done- Negative.Panorexxray and CXR done- Negative.

1). What is your diagnosis including differentials ?2). What tests and ancillary procedures should be done to confirm your diagnosis ?3) What is your treatment plan?

DiagnosticsDiagnostics

CT scanCT scan Excellent delineation Excellent delineation

of the ductal systemof the ductal system Limited parenchymal Limited parenchymal

informationinformation May require contrast May require contrast

media to obtain media to obtain further information further information about the nature and about the nature and extent of the tumorextent of the tumor

DiagnosticsDiagnostics

MRIMRI Good Good

parenchymal parenchymal definitiondefinition

DiagnosticsDiagnostics

FNABFNAB Accuracy rates of 80-Accuracy rates of 80-

98%98% means of establishing means of establishing

a definite diagnosisa definite diagnosis dictating subsequent dictating subsequent

managementmanagement Salivary gland – high Salivary gland – high

vulnerability to vulnerability to misdiagnosismisdiagnosis

Alphs et al. Curr Opin Otolaryngol Head Neck Surg.2006;14:62–66

Benign Diseases of Salivary Benign Diseases of Salivary GlandsGlands

InflammatoryInflammatory TBTB ActinomycosisActinomycosis SarcoidosisSarcoidosis

Only 6% of cases involve the salivary gland Only 6% of cases involve the salivary gland clinically but pathologically, 30%clinically but pathologically, 30%

Heerfordt’s syndrome : involves the triad of Heerfordt’s syndrome : involves the triad of uveitis, parotid enlargement and CN VII uveitis, parotid enlargement and CN VII paralysis paralysis

Treatment is symptomaticTreatment is symptomatic

Benign Diseases of Salivary Benign Diseases of Salivary GlandsGlands

Sjogren’s syndromeSjogren’s syndrome chronic, slowly chronic, slowly

progressive, relatively progressive, relatively benign autoimmune benign autoimmune disease characterized by disease characterized by lymphocyte-mediated lymphocyte-mediated destruction of the destruction of the exocrine glands resulting exocrine glands resulting in keratoconjunctivitis in keratoconjunctivitis sicca and xerostomiasicca and xerostomia

Diagnosis is by biopsy of Diagnosis is by biopsy of labial minor salivary labial minor salivary glandsglands

Treatment is Treatment is symptomaticsymptomatic

Benign Diseases of Salivary Benign Diseases of Salivary GlandsGlands

Non-inflammatoryNon-inflammatory SialolithiasisSialolithiasis

80% usu affect the 80% usu affect the submandibular gland & duct submandibular gland & duct bec the submandibular saliva is bec the submandibular saliva is more alkaline with higher more alkaline with higher concentrations of calcium, concentrations of calcium, phosphate, and mucus; phosphate, and mucus; Wharton’s duct is longer and Wharton’s duct is longer and located at the FOM located at the FOM

90% of submandibular calculi 90% of submandibular calculi are radioopaque while 90% of are radioopaque while 90% of parotid calculi are radioluscentparotid calculi are radioluscent

Sialography in non-acute Sialography in non-acute settingsetting

Benign Diseases of Salivary Benign Diseases of Salivary GlandsGlands

Non-inflammatoryNon-inflammatory Sialodenosis : nonneoplastic, Sialodenosis : nonneoplastic,

noninflammatory enlargement of the salivary noninflammatory enlargement of the salivary gland associated with systemic disordersgland associated with systemic disorders

asymptomaticasymptomatic Obesity, malnutrition, alcoholic cirrhosisObesity, malnutrition, alcoholic cirrhosis

Diseases of Salivary Diseases of Salivary GlandsGlands

Salivary Salivary GlandGland

BenignBenign MalignantMalignant

ParotidParotid 75%75% 25%25%

SubmandibulaSubmandibularr

57%57% 43%43%

SublingualSublingual 18%18% 82%82%

Benign Diseases of the Benign Diseases of the Salivary GlandsSalivary Glands

Pleomorphic adenoma or Pleomorphic adenoma or benign mixed tumorsbenign mixed tumors

Most common histologyMost common histologySlow-growing, painless, Slow-growing, painless,

firm mass w/o facial firm mass w/o facial paralysisparalysis

PseudocapsulePseudocapsulePseudopodsPseudopodsContains epithelial and Contains epithelial and

stromal components such stromal components such as myxoid, chondroid, as myxoid, chondroid, osteoid and fibrous osteoid and fibrous elementselements

Benign Diseases of the Benign Diseases of the Salivary GlandsSalivary Glands

Warthin’s tumors or papillary Warthin’s tumors or papillary cystadenoma cystadenoma lymphomatosumlymphomatosum

Bilateral in 10% of cases Bilateral in 10% of cases Male:female ratio 5:1Male:female ratio 5:1 44thth-6-6thth decade decade Usually painless and slow Usually painless and slow

growinggrowing have papillary projections have papillary projections

into cystic spaces, into cystic spaces, surrounded by lymphoid surrounded by lymphoid stroma stroma

Benign Diseases of the Benign Diseases of the Salivary GlandsSalivary Glands

OncocytomaOncocytoma

Basal cell adenomaBasal cell adenoma

MyoepitheliomaMyoepithelioma

Sebaceous adenomaSebaceous adenoma

Malignant NeoplasmsMalignant Neoplasms Mucoepidemoid Mucoepidemoid

carcinomacarcinoma Most common salivary Most common salivary

gland malignancy gland malignancy adult and pediatricadult and pediatric

Proportion of mucus Proportion of mucus cells & epidermoid cells & epidermoid cells determine the cells determine the gradegrade

Malignant NeoplasmsMalignant NeoplasmsAdenoid cystic Adenoid cystic

carcinomacarcinoma second most common second most common

salivary gland salivary gland malignancy overall, but malignancy overall, but is the most common in is the most common in the submandibular, the submandibular, sublingual and minor sublingual and minor salivary glandssalivary glands

Can present with pain Can present with pain and facial nerve and facial nerve paralysis because of paralysis because of high propensity for high propensity for perineural invasionperineural invasion

High recurrence rates High recurrence rates as much as 42%as much as 42%

Malignant NeoplasmsMalignant Neoplasms Acinic cell carcinomaAcinic cell carcinoma

AdenocarcinomaAdenocarcinoma

Malignant mixed tumorsMalignant mixed tumors

Clear cell carcinomaClear cell carcinoma

Basal cell adenocarcinomaBasal cell adenocarcinoma

Sebaceous carcinomaSebaceous carcinoma

Oncocytic carcinomaOncocytic carcinoma

Malignant lymphomaMalignant lymphoma

American Joint Committee on American Joint Committee on Cancer 2002Cancer 2002

Primary Tumor (T)Primary Tumor (T)

TX - Primary tumor cannot be TX - Primary tumor cannot be assessedassessed

T0 - No evidence of primary tumorT0 - No evidence of primary tumor

T1 - Tumor 2 cm or less in greatest T1 - Tumor 2 cm or less in greatest dimension without extraparenchymal dimension without extraparenchymal extension*extension*

T2 - Tumor more than 2 cm but not T2 - Tumor more than 2 cm but not more than 4 cm in greatest dimension more than 4 cm in greatest dimension without extraparenchymal extension*without extraparenchymal extension*

* Extraparenchymal extension is clinical or macroscopic evidence of invasion of soft tissues. Microscopic evidence alone does not constitute extraparenchymal extension for classification purposes.

American Joint Committee on American Joint Committee on Cancer 2002Cancer 2002

Primary Tumor (T)Primary Tumor (T)

T3 - Tumor more than 4 cm and/or tumor T3 - Tumor more than 4 cm and/or tumor having extraparenchymal extension*having extraparenchymal extension*

T4a - Tumor invades skin, mandible, ear T4a - Tumor invades skin, mandible, ear canal, and/or facial nervecanal, and/or facial nerve

T4b - Tumor invades skull base and/or T4b - Tumor invades skull base and/or pterygoid plates and/or encases carotid pterygoid plates and/or encases carotid arteryartery

American Joint Committee on American Joint Committee on Cancer 2002Cancer 2002

Nodal categories (N)Nodal categories (N)Nx - regional LN can’t be assessedNx - regional LN can’t be assessedN0 - no regional LNN0 - no regional LNN1 - metastasis in a single LN < 3cmN1 - metastasis in a single LN < 3cmN2a - metastasis in a single LN > 3cm but < N2a - metastasis in a single LN > 3cm but <

6cm6cmN2b – metastasis in multiple ipsilateral LN < N2b – metastasis in multiple ipsilateral LN <

6cm6cmN2c – metastasis in bilateral or contralateral N2c – metastasis in bilateral or contralateral

LN < 6cmLN < 6cmN3 – LN metastasis > 6cmN3 – LN metastasis > 6cm

American Joint Committee on American Joint Committee on Cancer 2002Cancer 2002

M categoriesM categories Mx - distant metastasis can’t be assessedMx - distant metastasis can’t be assessed M0 - no distant metastasisM0 - no distant metastasis M1 – with distant metastasisM1 – with distant metastasis

American Joint Committee American Joint Committee on Cancer 2002on Cancer 2002

Stage IStage I T1T1 N0N0 M0M0

Stage IIStage II T2T2 N0N0 M0M0

Stage IIIStage III T3T3 N1N1 M0M0

Stage IVa (advanced Stage IVa (advanced resectable)resectable)

T4aT4a N2N2 M0M0

Stage IVb (advanced Stage IVb (advanced unresectable)unresectable)

T4bT4b N3N3 M0M0

Stage IVc (distant Stage IVc (distant metastasis)metastasis)

Any TAny T Any NAny N M1M1

Thank You!Thank You!