The significance of lymph nodes in the treatment concept of malignant

tumors of the salivary glands

Jochen A. Werner

Marburg, Department of Otolaryngology, University of Marburg, UKGM

Frankfurt, 02.02.2008

• Lymphatic drainage is mainly drained into the deep and superficial parotid lymph nodes, and rarely from the lower parts to the submandibular lymph nodes of the posterior part in the accessory chain.

• Efferent lymph collectors of the profound and superficial parotid lymph nodes drainage to Level II nodes.

Lymphatic drainage of the parotid gland

• The lymph fluid of the anterior and upper part of the submandibular gland is drained into the submandibular lymph nodes.

• 1-2 lymph collectors run with facial artery from the posterior part of the submandibular gland to the subdigastric and principal lymph nodes.

Lymphatic drainage of the submandibular gland

The significance of submandibular lymph nodes

• Rouviere (1938) described the 6 existing lymph node groups that are found around the submandibular gland.

• Carcinomas of the oral cavity metastasize most frequently into the prevascular submandibular lymph nodes, located superfically to the submandibular gland in direct neighbourhood to the facial vein or located between the submandibular gland and the submandibular branch of the facial nerve.

• Less prevalent but also significant is the metastatic spread into the preglandular and deep submandibular lymph nodes.

General information

• Frequency of regional lymph node metatases amounts to 20%-72% while the incidence depends directly to the histological type of salivary neoplasm.

• The difference must be made between- real metastatic dissemination - continuous tumor growth

• This is especially true for adenoid cystic carcinoma where often an infiltration of the lymph nodes by the tumor can be observed. Real lymphogenic metastasis occurs more rarely.

Adenoid cystic carcinoma (parotid gland) 10%

Polymorphic low-grade adeno carcinoma 10%

Basal cell adeo carcinoma 10%

Indication for neck dissection?

=> No elective treatment of the lymphatic drainage

Acinus cell carcinoma 8-19%

Myoepithelial carcinoma 10-20%

Epithelial-myoepithelial carcinoma 17-25%

Indication for neck dissection?

=> Ultrasound control in short intervals, neck dissection in cases of clinical suspicion of lymph node metastases

Squamous cell carcinoma 20-58%Carcinoma within cyst adeno lymphoma 30%Papillary cyst adeno carcinoma 30%Adenoid cystic carcinoma (submandibular gl.) 34%Undifferentiated carcinoma 40-50%Carcinoma within pleomorphic adenoma 55%Oncocytar carcinoma 40-60%Muco-epidermoid carcinoma (low differntiation) 60%Carcinoma of the salivary duct 60-80%

Indication for neck dissection?

=> Elective treatment of the lymphatic drainage

• High-grade tumor

Indications for neck dissection

Bell RB et al. (2005) J Oral Maxillofac Surg 63: 917-928 Medina JE (1998) Otolaryngol Clin North Am 31: 815-822

• T3 and T4 tumors

• Tumor size > 3 cm

• Facial nerve palsy

• Patient‘s age >54 years

• Extraglandular extension

• Perilymphatic (non-perineural) invasion