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Malignant neoplasm of salivary gland — Clinical Guidelines

Overview

Malignant neoplasms of salivary glands encompass a variety of aggressive tumors with distinct histological features and clinical behaviors, differing significantly from benign lesions like pleomorphic adenomas. Accurate diagnosis and management are crucial due to their potential for metastasis and poor prognosis.

Diagnosis

MRI: Recommended for initial imaging to assess tumor extent and regional lymph nodes 1.

Fine Needle Aspiration Cytology (FNAC): Particularly useful for tumors difficult to characterize by imaging 1.

Frozen Section Biopsy: Essential for confirming diagnosis and guiding surgical approach intraoperatively 1.

Histologic Follow-Up: Important for neoplasms of uncertain malignant potential (NUMP) to assess risk of malignancy 2 4.

Interobserver Variability: High in pattern-based risk stratification systems; multidisciplinary review recommended 3.

Immunohistochemistry: Useful for differentiating tumor types, particularly in acinic cell carcinomas and mixed tumors 9.

Management

Complete Resection: En bloc resection recommended for parotid pleomorphic adenomas, respecting facial nerve preservation 1.

Surgical Approach: En bloc resection advised for accessory and submandibular gland neoplasms 1.

Surgical Margins: Ensuring clear margins is critical, especially in malignant transformations 1 5.

Risk Stratification: Application of systems like the Milan System for reporting salivary gland lesions aids in preoperative risk assessment 4.

Follow-Up: Regular monitoring essential for early detection of recurrence or malignant transformation 2 4.

Special Populations

Pediatrics: Specific surgical approaches for pediatric cases may vary; expert opinion suggests tailored management 6.

Elderly: Considerations for comorbidities and functional status are crucial in surgical planning 5.

Key Recommendations

Perform MRI with head and neck lymph node assessment in clinically suspected salivary gland neoplasms (Evidence: Strong 1).

Utilize frozen section biopsy intraoperatively to confirm diagnosis and guide surgical extent (Evidence: Strong 1).

Employ complete en bloc resection for parotid pleomorphic adenomas, prioritizing facial nerve preservation (Evidence: Strong 1).

Apply risk stratification systems like the Milan System for preoperative risk assessment in salivary gland neoplasms (Evidence: Moderate 4).

Regular histologic follow-up is necessary for neoplasms of uncertain malignant potential to monitor for malignant transformation (Evidence: Moderate 2 4).

Tailor surgical management in pediatric patients considering their unique anatomical and physiological differences (Evidence: Expert opinion 6).

References

1 Vergez S, Fakhry N, Cartier C, Kennel T, Courtade-Saidi M, Uro-Coste E et al.. Guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL), part I: Primary treatment of pleomorphic adenoma. European annals of otorhinolaryngology, head and neck diseases 2021. link 2 Liu H, Ljungren C, Lin F, Zarka MA, Chen L. Analysis of histologic follow-up and risk of malignancy for salivary gland neoplasm of uncertain malignant potential proposed by the Milan System for Reporting Salivary Gland Cytopathology. Cancer cytopathology 2018. link 3 Griffith CC, Schmitt AC, Pantanowitz L, Monaco SE. A pattern-based risk-stratification scheme for salivary gland cytology: A multi-institutional, interobserver variability study to determine applicability. Cancer cytopathology 2017. link 4 Rohilla M, Singh P, Rajwanshi A, Gupta N, Srinivasan R, Dey P et al.. Three-year cytohistological correlation of salivary gland FNA cytology at a tertiary center with the application of the Milan system for risk stratification. Cancer cytopathology 2017. link 5 Turk AT, Wenig BM. Pitfalls in the biopsy diagnosis of intraoral minor salivary gland neoplasms: diagnostic considerations and recommended approach. Advances in anatomic pathology 2014. link 6 Tarakji B, Nassani MZ. Survey of opinions on the management of pleomorphic adenoma among United Kingdom oral and maxillofacial surgeons. Kulak burun bogaz ihtisas dergisi : KBB = Journal of ear, nose, and throat 2010. link 7 Hughes JH, Volk EE, Wilbur DC. Pitfalls in salivary gland fine-needle aspiration cytology: lessons from the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology. Archives of pathology & laboratory medicine 2005. link 8 Murase N, Kobayashi K, Mitani H, Mori M. Immunohistochemical localization of alpha 1-antitrypsin and alpha 1-antichymotrypsin in salivary pleomorphic adenomas. Virchows Archiv. A, Pathological anatomy and histopathology 1985. link 9 Warner TF, Seo IS, Azen EA, Hafez GR, Zarling TA. Immunocytochemistry of acinic cell carcinomas and mixed tumors of salivary glands. Cancer 1985. link56:9<2221::aid-cncr2820560915>3.0.co;2-j) 10 Caselitz J, Lunau U, Hamper K, Walther B, Schmiegelow P. The pleomorphic adenoma of salivary glands transplanted on athmymic mice. A lightmicroscopical and immunohistochemical investigation. Virchows Archiv. A, Pathological anatomy and histopathology 1985. link

Malignant neoplasm of salivary gland