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

Diagnostics CT scan CT scan Excellent delineation of the ductal system Excellent delineation of the ductal system Limited parenchymal information Limited parenchymal information May require contrast media to obtain further information about the nature and extent of the tumor May require contrast media to obtain further information about the nature and extent of the tumor

Diagnostics MRI MRI Good parenchymal definition Good parenchymal definition

Diagnostics FNAB FNAB Accuracy rates of 80-98% Accuracy rates of 80-98% means of establishing a definite diagnosis means of establishing a definite diagnosis dictating subsequent management dictating subsequent management Salivary gland – high vulnerability to misdiagnosis Salivary gland – high vulnerability to misdiagnosis Alphs et al. Curr Opin Otolaryngol Head Neck Surg.2006;14:62–66

Benign Diseases of Salivary Glands Inflammatory Inflammatory TB TB Actinomycosis Actinomycosis Sarcoidosis Sarcoidosis Only 6% of cases involve the salivary gland clinically but pathologically, 30% Only 6% of cases involve the salivary gland clinically but pathologically, 30% Heerfordt’s syndrome : involves the triad of uveitis, parotid enlargement and CN VII paralysis Heerfordt’s syndrome : involves the triad of uveitis, parotid enlargement and CN VII paralysis Treatment is symptomatic Treatment is symptomatic

Benign Diseases of Salivary Glands Sjogren’s syndrome Sjogren’s syndrome chronic, slowly progressive, relatively benign autoimmune disease characterized by lymphocyte-mediated destruction of the exocrine glands resulting in keratoconjunctivitis sicca and xerostomia chronic, slowly progressive, relatively benign autoimmune disease characterized by lymphocyte-mediated destruction of the exocrine glands resulting in keratoconjunctivitis sicca and xerostomia Diagnosis is by biopsy of labial minor salivary glands Diagnosis is by biopsy of labial minor salivary glands Treatment is symptomatic Treatment is symptomatic

Benign Diseases of Salivary Glands Non-inflammatory Non-inflammatory Sialolithiasis Sialolithiasis 80% usu affect the submandibular gland & duct bec the submandibular saliva is more alkaline with higher concentrations of calcium, phosphate, and mucus; Wharton’s duct is longer and located at the FOM 80% usu affect the submandibular gland & duct bec the submandibular saliva is more alkaline with higher concentrations of calcium, phosphate, and mucus; Wharton’s duct is longer and located at the FOM 90% of submandibular calculi are radioopaque while 90% of parotid calculi are radioluscent 90% of submandibular calculi are radioopaque while 90% of parotid calculi are radioluscent Sialography in non-acute setting Sialography in non-acute setting

Benign Diseases of Salivary Glands Non-inflammatory Non-inflammatory Sialodenosis : nonneoplastic, noninflammatory enlargement of the salivary gland associated with systemic disorders Sialodenosis : nonneoplastic, noninflammatory enlargement of the salivary gland associated with systemic disorders asymptomatic asymptomatic Obesity, malnutrition, alcoholic cirrhosis Obesity, malnutrition, alcoholic cirrhosis

Diseases of Salivary Glands Salivary Gland BenignMalignant Parotid75%25% Submandibular57%43% Sublingual18%82%

Benign Diseases of the Salivary Glands Pleomorphic adenoma or benign mixed tumors Pleomorphic adenoma or benign mixed tumors Most common histology Most common histology Slow-growing, painless, firm mass w/o facial paralysis Slow-growing, painless, firm mass w/o facial paralysis Pseudocapsule Pseudocapsule Pseudopods Pseudopods Contains epithelial and stromal components such as myxoid, chondroid, osteoid and fibrous elements Contains epithelial and stromal components such as myxoid, chondroid, osteoid and fibrous elements

Benign Diseases of the Salivary Glands Warthin’s tumors or papillary cystadenoma lymphomatosum Warthin’s tumors or papillary cystadenoma lymphomatosum Bilateral in 10% of cases Bilateral in 10% of cases Male:female ratio 5:1 Male:female ratio 5:1 4 th -6 th decade 4 th -6 th decade Usually painless and slow growing Usually painless and slow growing have papillary projections into cystic spaces, surrounded by lymphoid stroma have papillary projections into cystic spaces, surrounded by lymphoid stroma

Benign Diseases of the Salivary Glands Oncocytoma Oncocytoma Basal cell adenoma Basal cell adenoma Myoepithelioma Myoepithelioma Sebaceous adenoma Sebaceous adenoma

Malignant Neoplasms Mucoepidemoid carcinoma Mucoepidemoid carcinoma Most common salivary gland malignancy adult and pediatric Most common salivary gland malignancy adult and pediatric Proportion of mucus cells & epidermoid cells determine the grade Proportion of mucus cells & epidermoid cells determine the grade

Malignant Neoplasms Adenoid cystic carcinoma Adenoid cystic carcinoma second most common salivary gland malignancy overall, but is the most common in the submandibular, sublingual and minor salivary glands second most common salivary gland malignancy overall, but is the most common in the submandibular, sublingual and minor salivary glands Can present with pain and facial nerve paralysis because of high propensity for perineural invasion Can present with pain and facial nerve paralysis because of high propensity for perineural invasion High recurrence rates as much as 42% High recurrence rates as much as 42%

Malignant Neoplasms Acinic cell carcinoma Acinic cell carcinoma Adenocarcinoma Adenocarcinoma Malignant mixed tumors Malignant mixed tumors Clear cell carcinoma Clear cell carcinoma Basal cell adenocarcinoma Basal cell adenocarcinoma Sebaceous carcinoma Sebaceous carcinoma Oncocytic carcinoma Oncocytic carcinoma Malignant lymphoma Malignant lymphoma

American Joint Committee on Cancer 2002 Primary Tumor (T) TX - Primary tumor cannot be assessed TX - Primary tumor cannot be assessed T0 - No evidence of primary tumor T0 - No evidence of primary tumor T1 - Tumor 2 cm or less in greatest dimension without extraparenchymal extension* T1 - Tumor 2 cm or less in greatest dimension without extraparenchymal extension* T2 - Tumor more than 2 cm but not more than 4 cm in greatest dimension without extraparenchymal extension* T2 - Tumor more than 2 cm but not more than 4 cm in greatest dimension 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 Cancer 2002 Primary Tumor (T) T3 - Tumor more than 4 cm and/or tumor having extraparenchymal extension* T3 - Tumor more than 4 cm and/or tumor having extraparenchymal extension* T4a - Tumor invades skin, mandible, ear canal, and/or facial nerve T4a - Tumor invades skin, mandible, ear canal, and/or facial nerve T4b - Tumor invades skull base and/or pterygoid plates and/or encases carotid artery T4b - Tumor invades skull base and/or pterygoid plates and/or encases carotid artery

American Joint Committee on Cancer 2002 Nodal categories (N) Nodal categories (N) Nx - regional LN can’t be assessed N0 - no regional LN N1 - metastasis in a single LN < 3cm N2a - metastasis in a single LN > 3cm but 3cm but < 6cm N2b – metastasis in multiple ipsilateral LN < 6cm N2c – metastasis in bilateral or contralateral LN < 6cm N3 – LN metastasis > 6cm

American Joint Committee on Cancer 2002 M categories M categories Mx - distant metastasis can’t be assessed Mx - distant metastasis can’t be assessed M0 - no distant metastasis M0 - no distant metastasis M1 – with distant metastasis M1 – with distant metastasis

American Joint Committee on Cancer 2002 Stage I T1N0M0 Stage II T2N0M0 Stage III T3N1M0 Stage IVa (advanced resectable) T4aN2M0 Stage IVb (advanced unresectable) T4bN3M0 Stage IVc (distant metastasis) Any T Any N M1

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