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  Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 55  |  Issue : 1  |  Page : 33-36
 

Surgical morbidities and outcomes of major salivary gland neoplasms treated at a tertiary cancer center


Department of Head and Neck Surgery, Tata Memorial Centre, Mumbai, Maharashtra, India

Date of Web Publication23-Aug-2018

Correspondence Address:
Dr. Shivakumar Thiagarajan
Department of Head and Neck Surgery, Tata Memorial Centre, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_466_17

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 » Abstract 


Background and Objectives: Salivary gland neoplasms are relatively uncommon. They have a wide variety of histopathological types with diverse biological behavior. It involves all the major and minor salivary glands in the head and neck. This article focuses on the various types of major salivary gland tumors treated at a tertiary cancer center along with their surgical morbidities and outcomes. Materials and Methods: Data of all the salivary gland neoplasms operated in the head and neck services between January 2012 and December 2013 were retrieved from a prospectively collected database. The clinical, demographic data and types of surgeries along with the morbidities were collated from the database and the details regarding the follow-up were collected from the electronic medical record. Results: Out of 235. cases registered, 107. patients were treated at our institute. The parotid gland was most commonly involved; majority were malignant lesions. Sixty-two patients were treatment naive at presentation. Majority presented with advanced disease. Superficial parotidectomy was the most common surgery performed and neck dissection was done in 27. patients. Facial nerve palsy was the most common complication following surgery. (16%). Sixty patients received adjuvant treatment. All patients on follow-up were alive at their last visit, with 10. patients having recurrence. Factors influencing the disease-free survival were extracapsular spread, tumor grade, and perineural invasion. Conclusion: The postoperative morbidities and outcomes for major salivary gland neoplasms in our series were acceptable and comparable to the results available in the literature. Appropriate treatment of the salivary gland neoplasm will yield good outcomes with acceptable morbidity.


Keywords: Major salivary gland, morbidity, neoplasm, outcomes, surgical


How to cite this article:
Thiagarajan S, Fathehi K, Nair D, Deshmukh A, Pantvaidya G, Chaukar DA, D'Cruz AK. Surgical morbidities and outcomes of major salivary gland neoplasms treated at a tertiary cancer center. Indian J Cancer 2018;55:33-6

How to cite this URL:
Thiagarajan S, Fathehi K, Nair D, Deshmukh A, Pantvaidya G, Chaukar DA, D'Cruz AK. Surgical morbidities and outcomes of major salivary gland neoplasms treated at a tertiary cancer center. Indian J Cancer [serial online] 2018 [cited 2018 Dec 11];55:33-6. Available from: http://www.indianjcancer.com/text.asp?2018/55/1/33/239593





 » Introduction Top


Salivary gland neoplasms are relatively uncommon and constitute only about 0.5% of all cancers. Around the world, the annual incidence of all salivary gland tumor is 0.4–13.5 cases per 100,000 and 0.4–2.6 per 100,000 for malignant tumor.[1] There are a wide variety of histopathological types with a range of clinical and biological behavior. Hence, making the correct diagnosis and delivering appropriate treatment becomes a challenge. Most salivary gland neoplasms are benign and often involve the parotid gland. Surgery remains the mainstay of treatment with or without adjuvant therapy. The 5-year relative survival of salivary gland cancer (all stages) in adults is 65% at 5 years.[2],[3] Survival decreases with increasing age.[4]


 » Materials and Methods Top


This retrospective study was conducted for major salivary gland neoplasms treated at our institute with a focus on the clinical presentation, 30-day morbidity, and outcomes after treatment. All patients with histopathologically proven lesion treated with surgery (with or without adjuvant therapy) between January 2012 and December 2013 were included. The data regarding this were retrieved from the prospectively maintained database in the head and neck services. Details regarding patient demography, clinical details, surgeries performed, and 30-day morbidity were retrieved from this database. Further details regarding final histopathology, adjuvant treatment, recurrences, and status at last follow-up were obtained from the electronic medical record.

Statistical analysis was done using SPSS 24, IBM New york. The univariate analysis was done using Log rank test. The variables were selected based on their clinical relevance. All significant (P < 0.05) variables were subsequently tested by multivariate analysis using cox regression analysis with forward stepwise selection. The disease-free survival (DFS) was calculated using the Kaplan–Meier method for the malignant lesions.


 » Results Top


Among the 235 cases of major salivary gland tumors registered in the years 2012 and 2013, 107 cases were treated at our institute. The median age of the patients in the cohort was 43 years (range: 12–87 years). Majority of the patients were males (n = 61, 56.5%). Most patients had no comorbidities at presentation (n = 76, 71%). Parotid gland was the most common major salivary gland involved (n = 96, 90%), majority being malignant lesions [Table 1]. There were no sublingual gland tumors in this series. Majority of the patients were treatment naïve (n = 62, 58%), the remaining had received treatment outside (n = 45, 42%), mostly in the form of surgery, before registering with us [Table 1]. All patients who had received treatment outside had their slide and/or blocks reviewed by the institute pathologist. Fine needle aspiration cytology (FNAC) was done for 60 patients (56%), of which definitive diagnosis of benign (n = 28) and malignant (n = 20) was possible in 48 patients. The remaining four had nondiagnostic aspirate and eight had inconclusive reports. Two patients did not have any FNAC done on them. Majority of the patients had malignant salivary gland tumor, and they presented with advanced disease (n = 36, 49%). For 11 patients, the stage could not be assessed due to their prior treatment [Table 1]. None of the patients had distant metastasis at presentation. All the patients in the series underwent surgery. The most common surgery performed was superficial parotidectomy (n = 49, 45%), followed by facial nerve preserving total parotidectomy (n = 15, 14%) [Table 2]. Neck dissection was performed on 27 patients. Reconstruction with a flap was needed in eight patients [Table 2]. Following surgery, the most common (30-day) morbidity noted was facial nerve palsy (n = 24). Among these, three patients had preoperative facial nerve palsy, and in four patients, the nerve was sacrificed intraoperatively due to involvement by disease, which was immediately repaired with a nerve graft. The incidence of facial nerve palsy in this series was 16%. Surgical-site infection (SSI) and seroma were the other two common postoperative complications [Table 2].
Table 1: Demographics and clinical details

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Table 2: Treatment given

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Overall, as expected, malignant tumors were common (n = 73, 68%) in this series. Mucoepidermoid carcinoma was the most common neoplasms followed by pleomorphic adenoma [Table 3]. This pattern remained the same for parotid gland neoplasms, whereas adenoid cystic carcinoma was the most common neoplasm involving the submandibular gland. Perineural invasion (PNI) was seen in 17 patients (16%). It was associated with both adenoid cystic carcinoma (n = 6) and salivary duct carcinoma (n = 7). Thirteen patients had node positivity, and 11 among them had extracapsular spread (ECS). Most patients received adjuvant treatment (n = 60, 56%) [Table 3]. The median follow-up of the cohort was 30 months (range: 0-62 months months). Follow-up details were available for 89 patients (81%) [Table 4]. None of the patients died of disease or other causes, in view of which, only the DFS was analyzed. Ten patients developed recurrence, nine of which were for malignant lesions and one for a benign lesion (pleomorphic adenoma).
Table 3: Histopathology details

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Table 4: Follow-up details

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For malignant lesions, grade of the tumor (P = 0.004), tumor histopathology (P < 0.001), pN stage (P = 0.01), presence of ECS (P = 0.006), and PNI (P = 0.004), influenced DFS on univariate analysis. On multivariate analysis, ECS (P ≤ 0.001) was the most significant factor influencing DFS. This was followed by grade of tumor (P = 0.002) and PNI (P = 0.002). The DFS at a median time of 30 months was 73.6% in our cohort.


 » Discussion Top


Surgery remains the mainstay of treatment for salivary gland tumors. Surgery may be followed by adjuvant therapy for malignant tumors when indicated and rarely for recurrent benign tumors. Salivary gland tumors are seen in all age groups, but the highest incidence is observed in the third and fourth decades of life with a slight female preponderance.[2],[3] Parotid gland is the most common (major) salivary gland involved (80%) followed by submandibular gland (11%) and rarely the sublingual gland (<1%).[3],[5] Benign tumors are more frequent (54%–79%) than malignant (21%–46%).[3] This percentage changes with the gland involved. In general, pleomorphic adenoma is the most common benign tumor, and mucoepidermoid carcinoma, the most common malignant tumor of the salivary glands.[1],[5],[6],[7] In this series, the median age of the patients was 43 years, with a slight male preponderance (M:F = 1.3:1). Patients with benign tumors were younger by 5 years (median age) in comparison those with malignant tumors. The distributions of benign and malignant tumors between the two genders were uniform. Malignant tumors were much more common than benign tumors. This is likely due to the bias in the referral pattern to a tertiary cancer center.

Most patients were investigated with FNA and computed tomography (CT)/magnetic resonance imaging (MRI) in our series. FNA is a very important investigation to establish a diagnosis of salivary gland swelling. It provides a diagnosis to the clinician with which counseling of the patients can be done regarding the treatment plan, complications (especially, the VII nerve palsy), and prognosis. The risk of seeding along the needle route has been demonstrated to be negligible. The sensitivity and specificity of the FNA to differentiate between benign and malignant lesion are 80% and 97%, respectively.[8] CT scan and/or MRI are recommended in the presence of malignant disease or when the deep lobe of the parotid is involved. MRI is particularly recommended in demonstrating the interface of tumor and surrounding tissues, especially facial nerve.[9]

In this series, surgery for the primary was performed on 102 patients, and five patients needed only a neck dissection, after the initial surgery for the primary from outside. The most common surgery performed for the primary was a superficial parotidectomy followed by facial nerve preserving total parotidectomy [Table 2]. Neck dissection was done in 27 patients. The most common type of neck dissection performed was a modified neck dissection followed by selective neck dissection. Level II sampling (clearance of fibro fatty tissue within the boundaries of level II) was performed predominantly in low- and intermediate-grade malignant tumors, to decide on the need for further nodal clearance in the presence of positive nodal disease on frozen section.[10]

The most common complications encountered in the postoperative period following surgery for the major salivary gland are facial nerve palsy, hypesthesia of greater auricular nerve, hemorrhage/hematoma, infection, skin flap necrosis, parotid fistula, chyle leak, and seroma. In literature, incidence of temporary palsy ranges between 30% and 65% and that of permanent facial nerve palsy from 3%–6%.[11] Temporary facial nerve palsy usually recovers within 6–18 months.[12],[13],[14] The incidence of facial nerve palsy (temporary) in our series was 16%. The incidence of facial nerve palsy was higher with total parotidectomy. The marginal mandibular nerve was at highest risk. The other morbidities encountered were seroma and Surgical Site Infection (SSI). Seroma was treated conservatively with aspiration and pressure dressing and SSI was treated with appropriate antibiotics. There were two cases of salivary fistula (2%), which was treated conservatively. Salivary fistula rate following parotidectomy described in literature is between 4% and 14%.[15],[16]

Sixty patients were advised adjuvant therapy. All were for malignant tumors except for one, in whom it was indicated for a recurrent pleomorphic adenoma. Fifty-five received radiotherapy alone and five received chemoradiotherapy.

The 5-year relative survival rate for salivary gland cancer quoted in literature is 65% (all stages inclusive).[2],[3] In our series, the estimated 5- year survival was 78%. There is a positive correlation between the grade/type of tumor and the stage of disease.[3] The factors influencing the DFS were ECS followed by tumor grade and presence of PNI.


 » Conclusion Top


Although salivary gland tumors are relatively rare, they comprise a sizeable number of patients being treated at our institute. Malignant tumors (mucoepidermoid carcinoma) of the parotid gland was most common. All patients underwent surgery and, when indicated, adjuvant therapy. Facial nerve palsy was seen in 16% of cases. Factor influencing DFS the most was ECS followed by tumor grade and presence of PNI. Major salivary gland tumors when treated appropriately do well with acceptable morbidity and survival.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Ellis GL, Auclair PL, Gnepp DR. Surgical Pathology of the Salivary Glands. Philadelphia: W.B. Saunders; 1991.  Back to cited text no. 1
    
2.
Parkin DM, Whelan SL, Ferlay J, Teppo L, Thomas DB. Cancer Incidence in Five Continents. IARC Scientific Publications No. 55. Vol. 8. Lyon: IARC Press; 2002.  Back to cited text no. 2
    
3.
Barnes L, Eveson JW, Reichart P, Sidransky D. editors. WHO Classification of Tumours. Pathology and Genetics of Head & Neck Tumour. Lyon: IARC Press; 2005. p. 209-15.  Back to cited text no. 3
    
4.
Berrino F, De Angelis R, Sant M, Rosso S, Bielska-Lasota M, Coebergh JW, et al. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995-99: Results of the EUROCARE-4 study. Lancet Oncol 2007;8:773-83.  Back to cited text no. 4
    
5.
Subhashraj K. Salivary gland tumors: A single institution experience in India. Br J Oral Maxillofac Surg 2008;46:635-8.  Back to cited text no. 5
    
6.
Eveson JW, Cawson RA. Salivary gland tumours. A review of 2410 cases with particular reference to histological types, site, age and sex distribution. J Pathol 1985;146:51-8.  Back to cited text no. 6
    
7.
Spiro RH. Salivary neoplasms: Overview of a 35-year experience with 2,807 patients. Head Neck Surg 1986;8:177-84.  Back to cited text no. 7
    
8.
Schmidt RL, Hall BJ, Wilson AR, Layfield LJ. A systematic review and meta-analysis of the diagnostic accuracy of fine-needle aspiration cytology for parotid gland lesions. Am J Clin Pathol 2011;136:45-59.  Back to cited text no. 8
    
9.
Weber AL. Imaging of the salivary glands. Curr Opin Radiol 1992;4:117-22.  Back to cited text no. 9
    
10.
Medina JE. Neck dissection in the treatment of cancer of major salivary glands. Otolaryngol Clin North Am 1998;34:932-7.  Back to cited text no. 10
    
11.
Zhang SS, Ma DQ, Guo CB, Huang MX, Peng X, Yu GY, et al. Conservation of salivary secretion and facial nerve function in partial superficial parotidectomy. Int J Oral Maxillofac Surg 2013;42:868-73.  Back to cited text no. 11
    
12.
Laccourreye O, Akl E, Gutierrez-Fonseca R, Garcia D, Brasnu D, Bonan B, et al. Recurrent gustatory sweating (Frey syndrome) after intracutaneous injection of botulinum toxin type A: Incidence, management, and outcome. Arch Otolaryngol Head Neck Surg 1999;125:283-6.  Back to cited text no. 12
    
13.
Laccourreye H, Laccourreye O, Cauchois R, Jouffre V, Ménard M, Brasnu D, et al. Total conservative parotidectomy for primary benign pleomorphic adenoma of the parotid gland: A 25-year experience with 229 patients. Laryngoscope 1994;104:1487-94.  Back to cited text no. 13
    
14.
Reilly J, Myssiorek D. Facial nerve stimulation and postparotidectomy facial paresis. Otolaryngol Head Neck Surg 2003;128:530-3.  Back to cited text no. 14
    
15.
Wax M, Tarshis L. Post-parotidectomy fistula. J Otolaryngol 1991;20:10-3.  Back to cited text no. 15
    
16.
Laskawi R, Drobik C, Schönebeck C. Up-to-date report of botulinum toxin type A treatment in patients with gustatory sweating (Frey's syndrome). Laryngoscope 1998;108:381-4.  Back to cited text no. 16
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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