Salivary Gland Tumours--Analysis of 162 Cases ASHOK VERMA, SATISH MEHTA, Y. N. MEHRA, S.B.S. MANN & B. D. RADOTRA

The c l in ical records of 162 cases o f sa l ivary g land t u m o u r s were studied. Parot id g land w a s the c o m m o n e s t s i te for or ig in o f t u m o u r (110 cases.) C o m m o n e s t b e n i g n t u m o u r w a s p l e o m o r p h i c a d e n o m a (42 cases) a nd the c o m m o n e s t m a l i g n a n t t u m o u r w a s m u c o e p i d e r m o i d c a r c i n o m a (26 out o f 162 cases) . The next c o m m o n t u m o u r s were adeno idcys t i c and undi f ferent ia ted c a r c i n o m a w h i c h cons t i tu ted 23 and 20 cases respect ive ly . Surgery or surgery wi th rad io therapy were the m a i n modaHties o f t r e a t m e n t for the p r i m a r y t u m o u r s . T w e n t y pat ients h a d recurrence w i t h i n three years after the treatment . These pa t i en t s were t reated w i t h e i ther rev is ion surgery or external radiat ions . C h e m o t h e r a p y was given to one pat ient o f soft t i s s u e s a r c o m a . Twenty n ine pat ients had post -operat ive c o mp l i c a t i o ns l ike facial para lys i s , paro- t id f istula, sk in necros i s and Frey's syndrome .

Salivary gland tumours constitute 5% of all the benign and malignant turnouts (Frazell 1954). The only etiological factor which has so far been blamed is the radiat ion expo- sure, (Belsky, J . L. 1972, Takechi, N. 1976). Pr ior to the work of Thackery and Sobin (1972), these turnouts were not classified into benign and malignant variety, with the result most of the benign tnmours used to be radically t reated and the malignant ones were not looked after properly. Thackery and Sobln (1972) classified these tumours accor- ding to the cell of origin, which changed their management drama- tically. We present a series of 162 cases of salivary gland tumours, who were t reated at Nehru Hospital, Postgraduate Inst i tute of Medical Educat ion and Research, Chandi- garh dur ing the period t981 to 1986.

Age and Sex D i s t r i b u t i o n Majori ty of these patients presen-

ted in the age group of 50 - 60 years. Only 25 patients were below the age of 20 years (Table I). Males were affected more commonly than fe- males (Table I I ) .

Site o f O r i g i n

Parot id gland was the commo- nest site of origin of these turnouts

(110 out of 162 cases). Th e second common gland to be invoiced by these tumours was submandibular (Table I I I ) .

TABLE I

Shows the preva lence , o f th e se t u m o u r s in the vataous age groups .

No. Age in Years of

Cases

0~I0 06

11--20 19

21m30 26

31 40 15

41--50 23

51---60 38

61m70 24

71 and above I1

Tota l 162

TABLE II

Shows the sex inc idence o f tu- rnouts o f sa l ivary g land. Aahok Verma : Senior Resident

Satish Mehta : Senior Resident Y. N. Mehra : Professor & Head S. B. S. Mann : Associate Professor, No. Deptt. o£ Otolaryngology. Of B. D. Radotra : Lecturer, Deptt. of Patho- log,/. Sex cases Postgraduate Institute of Medical Education and Research, Clhandigarh-160 012.

Male 106 Reprints request to : Dr. S. B. S. Mann, F e m a l e 56 Associate Professor, Deptt. of Otolaryngology, Postgraduate Institute of Medical Education Total 162 & Research, Chandigarh-160 012.

TABLE ELI

Di s t r ibut ion o f sa l ivary g land t u m o u r s accord ing to the s i te o f or ig in .

No. of

Site of Origin cases %age

Parotid gland 110 67.9

Submandibular gland 28 17.3

Minor Salivary gland 24 14.8

To ta l 162 100

H i s t o p a t h o l o g y o f T u m o u r s

Th e most common benign tumour was pleomorphic adenoma (Fig I) (42 cases). Among the mali- gnant tumours, mucoepidermoid carcinoma (Fig I I ) was the com- monest (26 cases) followed by ade- noidcystic carcinoma (Fig I I I ) (23 cases) and undifferentiated car- cinoma (20 cases). O the r turnouts like acirdc celt carcinoma (7 cases), adenocarcinoma (8 cases), epider- mold carcinoma (12 cases) and Warthin 's turnout (5 cases) were also seen.

Twelve cases of pleomorphic adenoma of parotid gland had mali- gnant change (Table IV).

Therapeut ic Moda l i t i e s

Surgery was the pr imary thera- peutic modali ty in all of our patients. 35 patients were subjected to super- ficial parotidectomy. 25 pat ient un- derwent total conservative paro- t idectomy whereas radical paro-

Indian Journal of Otolaryngology, Volume 40, No. 4, December, 1988 139

Salivary Gland Tumours-Analysis of 162 Gases--Verma et al

TABLE IV

Histopathology o f 162 cases o f sal ivary gland tumours

Fig. I. Pleomorphlc adenoma, Epithelial nests in myxoid background. H & l~ X 140.

Histopathology of the Parotid Sub- Minor Total tumour gland mahdi- salivary

bular gland gland

~/o age

Pleomorphic Adenoma 37 03 02 42 26.0 Warthin's tumour 05 00 00 05 3 Muco-epidermoid

Carcinoma 16 07 03 26 16.1 Adenoid cystic Carcinoma 03 08 12 23 14.2 Epidermoid Carcinoma 08 01 03 12 7.4 Undifferentiated Carcinoma 16 00 04 20 12.4 Carcinoma in Pleomorphic

adenoma 12 00 00 12 7.4 Adenocarcinoma 06 02 00 08 4.9 Acinic cell carcinoma 05 02 00 07 4.3 Misc. (including

metastasis 02 05 00 07 4.3

Total 110 28 24 162 100

Fig. II. Perineural spread in muco-epider- mold carcinoma. H & E X 140.

. . . . . . . . 5:!

Fig. III. Adenoid cystic carcinoma showing cribriform pattern H & E X 55.

tidectomy was done in 18 patients. In cases where there was no evidence of facial nerve paralysis preopera- tively, the facial nerve was not sacrificed. In 21 patients of sub- mandibular and minor salivary gland tumours, only excision of the tumour was done while in 17 patiens who had the cervical neck node metas- tasis radical neck dissection

was combined with the primary ex- cision of growth. A large number of cases (33 patients) were inoperable either due to extensive local disease or fixed lymph glands in the neck or distant metastasis or very poor

general conditions. 13 patients re- fused surgery and were treated with radiotherapy alone (Table V).

TABLE V

Treatment modal i t ies given in these patients.

Treatment given No. of

patients

Superficial parotidectomy 35

Total conservative parotidectomy 25

Radical parofidectomy 18

Excision of submandibular & minor Salivary gland turnouts 21

Excision o£ primary turnout with radical neck dissection 17

Palliative radiation (Ino- perable cases) 33

Refused surgery 13

Total 162

33 patients who were inoperable clinically were given palliative radio- therapy.

Adjuvant radiotherapy was given to 43 patients. 5 patients had pre- operative radiations (tumour resis- tant dose) and 38 had post operative radiotherapy either elective or sal- vage for recurrence (Table VI).

TABLE VI

N u m b e r o f pat ients w h o received radiotherapy

Treatment given

No. of

patients

l. Radiotherapy alone 13

2. Preoperative radiations (tumour resistant dose) 05

3. Postoperative radiations elective 32

4. Salvage for recurrence 06

5. Palliative radiotherapy 33

Total number of patients 89

Compl icat ions o f Surgery

Twenty nine patients had posto- perative complications. II patients

140 Indian Journal of Otolaryngology, Volume 40, No. 4, December, 1988

Salivary Gland Tumours-Analysis of 162 Cases--Verma et al

had complete facial nerve paralysis, 7 had par t ia l weakness of face due to injury to one of the twigs of facial nerve, 3 patients developed parotid fistula and one pat ient had necrosis of the skin.

7 patien.ts developed Frey's syndrome following superficial paro- t idectomy (Table V I I I ) .

TABLE VII

N u m b e r o f p a t i e n t s w h o had pos topera t ive c o m p l i c a t i o n s

Complications

No. of

patients

1. Facial paa'alysis 11

2. Facial paresis 07

3. Parotid fistula 03

4. Skin necrosis 01

5. Frey's syndrome 07

Total 29

Fol low up

All these patients were followed till date and it was noted that 20 patients had recurrence of tumours. The most common tumour which recurred was pleomorphic adenoma (10 cases), next was mucoepidermoid and adenoid cystic carcinoma (3 cases each) (Table V I I I ) .

TABLE VII I

N u m b e r o f p a t i e n t s w h o had recurrence o f t u m o u r s after surgery.

Type of tumour recurred

No. of

patients

1. Pleomorphic adenoma 10 2. Mucoepidermoid carcinoma 03 3. Adertoid cystic carcinoma 03 4. Carcinoma in Pleomorpkic

adenoma 02 5. Ader~ocarcinoma 01 6. Soft tissue sarcoma 01

Tota l 20

M a n a g e m e n t o f Recurrence

14 out of 20 patients with re- currence were treated with surgery alone, one pat ient required surgery along with radiotherapy. 4 patients were treated with external radio- therapy alone and one patient of soft tissue sarcoma was supplemented with vincristine, adr iamycin and cyclophosphamide (Table IX).

TABLE IX

Show M a n a g e m e n t o f recurrence

Modality of t reatment No. of

patients

t. Revision surgery alone 14

2. Surgery with radiotherapy 01

3. External radiotherapy alone 04

4. External radiations with chemotherapy 01

Total 20

D i s c u s s i o n

In our series of 162 cases of salivary gland tumours, parotid gland was involved in 110 cases (67.9%). Submandibular in 28 cases (17.3%) and minor salivary glands in 24 cases (14.8%).

Majori ty of authors (quoted in Scott-Brown 1979) reported that pleomorphic adenoma constitute 69.7% of all the tumours occurring in the major and minor salivary glands, mucoepidermoid 5.2%, adenoid cys- tic 6.1%, other carcinoma 14% and miscellaneous 5%. In our series pleomorphic adenoma constituted 42 out of 162 cases (26.0%). muco- epiderlnoid 26 cases (16.1%) adenoid cystic 23 cases (14.19%) other carcinoma 59 cases (36.4%) and miscellaneous 7 cases (4.3%).

In our series pleomorphic adeno- ma was the commonest type of tu- mour in parotid gland constituting 37 out of 42 cases (88.9%) whereas mucoepidermoid and adenoid cystic carcinoma constituted only 16 (14.

5%) and 3 (2.7%) out of 110 cases respectively.

According to Foote and Frazell, (1954) 90% of all the tumours of parotid gland are pleomorphic ade- noma whereas mucoepidermoid and adenoid cystic carcinoma constitutes 5% and 1.2% respectively.

Another sigrfificant observation noted in the present study was a high incidence of mucoepidermoid car- cinoma(23 out of 26 cases i.e. 88.9%) and adenoid cystic carcinoma (11 out of 23 cases i.e. 48%) in the major salivary glands.

Surgew. was the pr imary mode of t reatment an our patients. 43 patien- ts were given radiotherapy along with surgery either as elective or salvage treatment. 13 patients who refused surgery were giver~ radio- therapy alone. 5 patients were subjected to preoperative radio- therapy ( tumour resistant dose) because of poor general condition at the time of presentation.

We were conservative as far as facial nerve resection was concerned. Facial nerve resection was done only in those cases where clinically facial nerve was seen to be involved preoperatively.

The main complication after surgery was facial nerve palsy or paresis. Th e commonest branches of facial nerve injured were marginal mandibular and buccal. 11 patients had complete facial nerve palsy as in these cases turnout was very invasive thus distorting the normal anato- mical configuration.

We encountered recurrence in 20 cases and the most common turnout which recurred was pleomo- rphic adenoma (I0 out of 20 cases). Revision surgery was the main t rea tment given for recurrence (14 out of 20 cases). Surgery with ex- ternal radiation, radiotherapy alone and radiotherapy with chemotherapy was given to other six patients.

C o n c l u s i o n s

From the present study we ar- rived at the following conclusions that :

Indian Journal of Otolaryngology, Volume 40, No. 4, December, 1988 14l

Salivary Gland Turnouts-Analysis o f 162 Cases--Verma et al

1. T h e r e was art increased inc idence of m u c o e p i d e r m o i d and adeno id cystic c a r c i n o m a irt the ma jo r sa l ivary g lands in our series.

2. T h e t r e a t m e n t of these tumours is surgical excision.

3. T h e r ecu r rence is more c o m m o n i n the pa ro t i d g l and a n d most suspected cause of r ecu r r ence is e i ther i n a d e q u a t e surgical r emova l or r up tu r e of t u m o u r capsule whi le dissection.

4. Fac ia l nerve should n9 t be re- sected unless it is involved pre- operat ively .

5. A d j u v a n t r a d i o t h e r a p y should be g iven to al l t he m a l i g n a n t t umours where the surgical ex- cision is no t r ad ica l as there are chances of m a c r o or micro metas- tasis at the local site after surgery.

6. I n b e n i g n t u m o u r s r a d i o t h e r a p y has no role to p lay .

R e f e r e n c e s

1. Belsky, J.L., Tachikawa, K ; Cihak R.W. and Yamamolo, T. (1972) : Salivary gland turnouts in atomic bomb survivors Hiroshima-Nagasaki, t957 to 1970. 07. Amer med Ass. 219 : 864.

2. Eneroth, G.M., Hjertman, L. and Mob- 10. erger, G. (1967) : 'Malignant turnouts of the submandibular glands', Acta Oto- laryngologiea Stockholm, 64 : 514-536.

3.

4.

5.

6.

7.

8.

9.

Farr, H.W. (1967) : 'Tumours of the parotid gland', i n : Proceedings of the In. ternational Workshop on Cancer of the Head and .Neck (F,d.J. Cordey), pp : 542-549 ; B,a tterworths, London and Boston.

Foote, F.W. and Frazell, E.L. (1954) : 'Tumours of the major salivary glands', in: Atlas o f Turnout Pathology (Sect. IV ; Fast, i l ) ; Armed Forces Insti- tute of Pathology, Washington DC.

Frazell, E.L. (1954) : Clinical aspects of tumours of the major salivary glands. Cancer, I : 637.

Linell, F. (I948) : 'Mucus-secreting and cystic epidermoid carcinomas of mucous and salivary glands', Acta pathology and Microbiology Scandinavia, 25 : 801-828.

Morrlson, R. (1966) : 'Tumours of the parotid gland'. Proceedings of the Royal Society of Medicine 59 : 429-437.

Naunton Morgan, M. and Mackenzie, D.H. (1968) : 'Tumours of salivary glands. A review of 204 cases with 5-year follow-up', British 07ouraal of Surgery, 55 : 284-288.

Patey, D.H. and Thackray, A.G. (1955) : 'Salivary gland tumours', Annual Report of the British Enpiriral cancer Campaign, 31 ; 74-75.

11.

12.

13.

I4.

15.

16.

17.

Patey, D.H. and Thackray, A.G. (1957) : 'The pathological anatomy and treat- meat of parotid tumours with retro- ph ,a~geal extension (dumb-bell tumo- urs) , British Journal of Surgery 44 : 352- 358.

Patcy, D.H. and Thackray, A.C. and Keeling, D.H. (1965) : 'Malignant disease of the Parotid'. British Journal of Cancer, 19 : 712-737.

Ranger, D., Thackray, A.C. and Lucas, R.B. (1956) : 'Mucous gland tumours', British ffournal of Cancer, 10 : 1-16.

Douglas Ranger (1979) : Diseases of the salivary glands. Scott-Brown's disease of the Ear, Nose and Throat. Fourth Edition, Vol. 4, 54.

Stewart, F.W., Foote, F.W. and Becket, W.F. (1945) : 'Mucoepidermoid tumo- urs of salivary glands', Annals of Surgoy, 122 : 820-844.

Thackray, A.G. (1961) : 'Mucous gland turnours ; Clinical Radiology 12 : 241-245.

Thackray, A.G. and Lucas, R.B. (1974) : Turnouts of the Major Salivary Glands ; Armed. Forces Imtitute of Pathology Washington DG.

Thackray, A.C. and Sobin, L.H. (1972) : Histological Typing of Salivary Gland Tttmours, Series of the International Histological Classification of Turnouts, No. 7 ; World Health Organ;sation Geneva.

142 Indian Journal of Otolaryngology, Volume 40, No. 4, December, 1988