pr. nicolas fakhry, md, phd marseille, france · •minority of parotid tumours require imaging...
TRANSCRIPT
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Salivary glands tumors
Pr. Nicolas Fakhry, MD, PhD
Marseille, France
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What kind of tumor and what kind of surgery?
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Is it a salivary gland tumor?
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Is it benign or malignant?
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Initial work-up
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Sonography
Location into salivary gland vs lymphnode or other
FNAC guidance
Only superficial parotid analysis
Poor diagnosis accuracy
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CT scan
Cancer staging
Bone invasion
Lymph nodes
Distant metastases
Poor diagnosis accuracy
Poor anatomical definition
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MRI
Best anatomical definition
Best diagnosis accuracy
Accessibility
Cost
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25 Gauges
FNAC
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WHO classification 2017
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Objectives of preoperative evaluation
• To avoid unnecessary surgery (infective or non-neoplastic masses, lymphoma, unresectable tumour
• To do appropriate surgery
• To avoid embarking on surgery that is beyond the scope of a surgeon e.g. deep lobe tumour, tumourextending to parapharyngeal space, tumour requiringneck dissection, or tumour requiring facial nerve reconstruction
https://developingworldheadandneckcancerguidelines.com/afhns-guidelines
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Imaging in poorly resourced settings?
• Minority of parotid tumours require imaging
– Only required if it might change management
– Infrequently indicated for clinically benign, mobile parotidtumours as it rarely alters surgical management
• Indications
– Deep lobe / extension to parapharyngeal space
– Fixed tumor, invasion of local structures
– Neurological deficits
– Cancer staging
https://developingworldheadandneckcancerguidelines.com/afhns-guidelines
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Parapharyngeal space extension
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Local spread / recurrence
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Perineural spread: adenoid cysticcarcinoma
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Surgery
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Frozen section
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Surgical margins
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Clear margins?
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Pleiomorphic adenoma (parotidgland)
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Pleiomorphic adenoma (parotidgland)
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T2T1 Gado FatSat
Pleiomorphic adenoma (parotidgland)
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Pleiomorphic adenoma(submandibular gland)
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Parapharyngeal space tumors
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Cancer
Preoperative cancer work-up !
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Cancer (parotid gland)Total parotidectomy
Radical or not (facial nerve preservation whenpossible)
Lymph node dissection
T2
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Cancer (submandibular gland)
Submandibular gland excision
Lymph node dissection
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Nerves management (cancer)
Facial nerve preservation whenever possible, neuromonitoring
Nerve graft must be anticipated
Patient information++
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Beware of perineural spread!
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Radical surgery + reconstruction
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Radical surgery + reconstruction
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Lymph node dissection (cancer)
cN0 : levels (I)-II - III
cN+ : levels I - V
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Postoperative radiotherapy (PORT)
• High grade tumors
• T3-T4 stages
• Positive lymph nodes
• Positive margins or close margins
• Recurrence (if no previous RT)
• Chemotherapy?
http://refcor.org/
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Surgical approach (parotidgland)
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Skin incision
Lazy-S ++
Face lift
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Skin incision
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SMAS flap
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SMAS flap?
Yes No No
T1 T1 T1
Pleiomorphic adenoma Pleiomorphic adenoma Cancer
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Facial nerve dissection
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Facial nerve trunk
Stylomastoid foramen
Landmarks
Posterior belly of the digastric muscle
Cartilage pointer
Tympanomastoid suture line
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Prograde dissection
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Retrograde dissection
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Key points
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Salivary glands tumors
2/3 of cancers have a benign clinical presentation
Preoperative work-up if possible
Imaging
FNAC
Frozen section
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Surgery
Parotid gland
Partial parotidectomy: Benign tumors (Warthin and smallpleiomorphic adenomas) …SMAS flap, face lift incison
Total parotidectomy: Malignant and large pleiomorphicadenomas
Submandibular gland
Submandibular gland excision
+/- systematic level I removal
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SurgeryIf no previous work-up and no frozen section:
Systematic total parotidectomy?
Management of lymph nodes?
If no access to Postoperative radiotherapy?
Radical surgery ?
Consider resecting nerves adherent to a malignant tumour?
Consider who not to offer surgery for advanced tumours when outcomes without PORT will be poor
Discussion is open !
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Facial nerve dissection