11.7 mixed tumor of the left submandibular. Surgeries for salivary gland tumors

Benign tumors account for 60% of all neoplasms salivary glands (SJ) and in 90% of cases develop in the parotid gland. There are epithelial tumors (adenomas) and tumors of connective tissue origin.

Adenomas develop mainly in the parotid gland, less often in the submandibular gland and extremely rarely in the sublingual salivary gland. Meet benign neoplasms in the small fluid spaces of the oral cavity, oropharynx, nasopharynx, paranasal sinuses, larynx, trachea. The ratio of benign and malignant neoplasms for the parotid gland is 6:1, for the submandibular salivary gland - 3.3:1, for small glands - 1:3.5. Age composition patients vary: from newborns to individuals old age; middle age patients are 30-50 years old.

Non-epithelial tumors of the gastrointestinal tract account for no more than 2% of all neoplasms salivary gland and are predominantly benign. Tumor-like processes occur in SG much more often than is reflected in hospital statistics from oncology clinics.

Pleomorphic adenoma

Pleomorphic adenoma ( mixed tumor) occupies a leading place among all GS tumors. It is localized mainly in the large salivary glands, but is found in small salivary glands, as well as in the lacrimal gland. According to the State Institute of Russian Cancer Research Center named after. N.N. Blokhin Russian Academy of Medical Sciences, the number of patients with pleomorphic adenoma of the salivary gland is 85.3% (719 out of 843 patients with benign tumors of the salivary gland), table. 6.1.

Table 6.1. Distribution of pleomorphic adenomas by location

Tumor localization	Number of patients	Primary tumor	Recurrent tumor
Parotid gland	619 (86,1%)	533 (86,0%)	86 (14,0%)
Submandibular gland	43 (6,0%)	39 (90,7%)	4 (9,3%)
Sublingual gland	1 (0,1 %)	1
Total...	663 (100%)	572 (86,4%)	90 (13,6%)
Hard palate	17	13	4
Soft palate	12	11	1
Lateral wall of the oropharynx	11	10	1
Cheek	8	7	1
Upper and lower lip	2	2
Root of tongue	3	3
Alveolar process upper jaw	1	1
Nasal cavity	1	1
Lacrimal gland	1	1
Total...	56 (7,8%)	49 (87,5%)	7 (12,5%)
Total...	719 (100%)	626 (87%)	93 (13%)

In the parotid gland, pleomorphic adenomas were found in 86.1% of cases, in the submandibular gland - in 6%, in the minor salivary glands of the oral cavity, oropharyngeal region, nasal cavity and lacrimal gland - in 7.8% of cases. In the sublingual SG we observed one pleomorphic adenoma - 0.1%.

Pleomorphic adenoma of the parotid gland

61% of patients are women, the ratio of women to men is 1.6:1.0, the average age of patients is 40 years. The most common pleomorphic adenomas occur in age groups 20-29, 30-39 and 40-49 years old. The youngest patient was 9 years old, the oldest was 88 years old. There are known cases of tumors in newborns. According to our observations, the left parotid gland is affected by the tumor somewhat more often than the right one. The ratio of men and women in this group is approximately equal. The right parotid salivary gland in women is affected by a tumor 3 times more often than in men, the ratio is 3:1.

The duration of the medical history from the onset of the first symptoms to the start of treatment varies in different groups patients from 6 months. up to 50 years old. The duration of the medical history up to 1 year was noted in 30.8% of patients. 2 years after the onset of the tumor, 10% of patients turned up, after 3 years - 16.8%, after 4 years - 9.5%, after 5 years - 13.3%, after 6-9 years - 5.6%, after 10-25 years - 13.6%, after 50 years - 0.4% of patients. Thus, 80.4% of patients applied within 5 years from the onset of the tumor. Among the patients who came to early dates, the majority were young people.

Let's look at a few observations.

Observation 1

A 13-year-old patient discovered a dense, painless tumor in the left retromaxillary region, which was regarded by the surgeon at the district clinic as banal lymphadenitis. Anti-inflammatory and physiotherapeutic treatment was ineffective. The tumor was slowly growing. A year later, the patient contacted the Oncology science center. X-ray and morphological examination revealed the presence of pleomorphic adenoma of the gastrointestinal tract. A tuberous tumor measuring 3.5 x 3.0 x 2.5 cm occupied the retromaxillary area, raising the left lobe auricle. There were no signs of paresis of facial muscles. Resection of the lower pole of the parotid SG was performed. The cartilaginous density tumor in the capsule was located below the main trunk facial nerve, the mandibular branch of the facial nerve was fused to the tumor capsule. Judging by the size of the tumor, its growth in the teenage girl began at an earlier age.

Observation 2

A 52-year-old patient had a slow-growing tumor that had existed for 25 years. She refused surgical treatment that was repeatedly offered. She came to the Oncology Research Center for cosmetic reasons (the tumor caused deformation of the facial contour). The left parotid-masticatory and retromaxillary region was occupied by a large-tuberous tumor measuring 8 x 6 x 4.5 cm, limited displacement, painless. The skin over the tumor easily gathered into a fold, there was no paresis of the facial muscles. A parotidectomy was performed preserving the facial nerve. The tumor in a thin capsule pushed the facial nerve anteriorly, was located under the main trunk of the facial nerve and between the branches of the nerve, and spread into the superficial part of the parotid salivary gland.

The above observations indicate a progressive course of the tumor and an increase in its mass with increasing observation period.

The literature discusses the connection between childhood experiences mumps with the development of a tumor process in the parotid gland. We found no such connection. Only 1.2% of patients suffered mumps in childhood. Here is one of our observations.

A sixteen-year-old patient at the age of 12 suffered from mumps, after which two neoplasms measuring 0.8 and 1 cm, located in front of the auricle and behind the corner, were detected in the left parotid gland. lower jaw, in the lower pole of the gland. Due to suspected lymphadenitis, the patient underwent anti-inflammatory and physiotherapeutic treatment for four years, which had no effect. Cytological examination was not carried out. The patient contacted the Oncology Research Center.

One tumor node was located in front of the auricle in the form of a dense, non-displaceable neoplasm measuring 5 x 4 cm, the other - dense, painless, non-displaceable, with a coarsely tuberous surface, occupied the retromandibular fossa and went under the base of the skull. The external dimensions of the tumor were 6.5 x 4.5 x 5 cm. There were no signs of paresis of facial muscles. A parotidectomy was performed, preserving the branches of the facial nerve. The salivary gland is completely replaced by tumor masses. In all likelihood, tumor nodes existed in the parotid salivary gland even before the onset of mumps. Enough rapid growth The tumor was promoted by infection and inadequate treatment using physiotherapeutic procedures.

Rice. 6.1. Double localization of a pleomorphic adenoma of the left parotid salivary gland and the minor salivary glands of the soft palate on the right: Front view of the patient: a - external component of a pleomorphic adenoma from the minor salivary glands of the soft palate on the right. A tumor of dense elastic consistency occupies the retromaxillary region, the upper third of the neck. Tumor of the left parotid salivary gland; b - parapharyngeal component of pleomorphic adenoma of the soft palate on the right. Exophytic tumor with clear contours. The integrity of the mucous membrane is preserved; c - profile view of a pleomorphic adenoma of the left parotid salivary gland

The combination of pleomorphic adenoma of the parotid gland with tumors of other locations was present in 4% of patients. These tumors were: breast fibroadenoma, uterine fibroid, cutaneous angiofibroma, laryngeal fibroma, adenoma prostate gland, breast cancer, ovarian cancer, cancer thyroid gland, sarcoma of the leg.

Rice. 6.2. Pleomorphic adenoma arising from the middle part of the parotid salivary gland

Pleomorphic adenoma usually occurs monolaterally, in one of the SGs. Rarely, the tumor develops bilaterally, i.e. in both parotid salivary glands. We observed 2 patients with bilateral pleomorphic adenoma. In one of them, a pleomorphic adenoma was located in the right and left parotid gland. In another case, the tumor originated from the small glands of the soft palate on the right, spreading parapharyngeally. A pleomorphic adenoma was also localized in the left parotid salivary gland (Fig. 6.1). Most often, the tumor occurs in the superficial part of the parotid gland, and in its middle (Fig. 6.2) and lower (Fig. 6.3) sections. In the deep part of the gland, a tumor was diagnosed in 7.1% of patients (Fig. 6.4).

Rice. 6.3. Pleomorphic adenoma localized in the lower pole of the parotid salivary gland

Typically, a tumor in the parotid or retromaxillary region is discovered by the patient himself when its size reaches 1.5-3 cm (Fig. 6.5). Sometimes the patient notes the presence of a tumor up to 6 mm (the size of a “pea”) with childhood. The tumor does not cause pain and slowly (possibly over decades) increases in size. Previously, patients came to the clinic with huge tumors.

Rice. 6.4. Pleomorphic adenoma arising from the deep part of the parotid salivary gland: a - frontal view; b - profile view

Currently, the maximum tumor size during treatment on average ranges from 5-8 cm in diameter.

Clinical picture

The typical clinical picture is a displaced or limitedly displaced tumor with a smooth or coarsely lumpy surface, clearly defined edges, and a dense, sometimes elastic consistency. The skin is not changed, it moves over the tumor upon palpation. The function of the facial muscles is not impaired, which indicates that the facial nerve is not involved in the tumor process, even with large tumor sizes. Regional lymph nodes not enlarged (Fig. 6.6).

Rice. 6.5. Pleomorphic adenoma of the left parotid gland is not large sizes emanating from the posterior edge of the gland

With prolonged existence, as a result of an increase in mass and poor circulation, necrotic areas appear in the tumor, the skin over the tumor stretches and becomes thinner, but its integrity is not compromised (see Fig. 6.6). Whatever the size of the tumor, tumor cells do not germinate into the facial nerve, and paralysis of the facial muscles does not develop.

Rice. 6.6. Pleomorphic adenoma of the left parotid salivary gland. A large, lumpy, painless tumor arising from the superficial part of the gland. The function of the facial nerve is not impaired. View of the patient: a - full face; b - in profile

Rice. 6.7. Typical clinical picture of a pleomorphic adenoma localized in the pharyngeal part of the gland: a - slight tissue swelling upper third neck; b - view of the tumor from the side of the oropharynx, deformation of the right lateral wall of the oropharynx is visible

The clinical picture and symptoms of pleomorphic adenoma, localized in the pharyngeal process of the parotid gland, are manifested by awkwardness and difficulty swallowing. When examined in the parotid region, some asymmetry may be determined, and in the oropharynx, deformation of the lateral wall is detected due to bulging of the tumor (Fig. 6.7).

The mucous membrane of the oropharynx is not changed. The degree of deformation of the pharynx is determined by the size of the tumor. We have never observed a violation of the integrity of the mucous membrane over the tumor.

The accessory lobe of the parotid gland is also a site of tumor development, but such observations are rare. Among our patients, pleomorphic adenoma of the accessory lobe of the parotid gland was diagnosed in 1.2% of patients. The clinical picture is quite poor. Swelling of the cheek has been noted for many years (in our patients - 5-10 years). Palpation in the thickness of the cheek, along the border with the parotid-masticatory region, reveals a tumor 1-3 cm in size with clear contours, elastic consistency, displaceable or limited displacement depending on size, painless. The skin over the tumor is unchanged. If the tumor is large, it can spread under the zygomatic arch.

A.I. Paches, T.D. Tabolinovskaya

Salivary gland adenoma is a benign formation that develops in the glandular epithelium.

The most common tumors are on the parotid gland. The formation occurs in single quantities, but sometimes several tumors appear at once. They occur in men and women, but the latter are more susceptible to the disease.

The tumor mainly forms in people over 50 years of age, but after 70 years of age the disease is less common.

A benign neoplasm has clear boundaries and a capsule. The thickness of the latter may vary. More often the tumor is correct round shape or oval. The adenoma is dense, its shade may vary. Large lesions are accompanied by hemorrhages or tissue necrosis. Tumors rarely appear on both sides.

Causes of salivary gland adenoma

The causes of tumors have not been clarified to this day. Scientists say that there is a connection with previous injuries or inflammatory processes. But these factors are not always present in the medical history.

Prerequisites for the occurrence of the disease may be congenital dystopias and oncogenic viruses. As in other cases, salivary gland adenoma can occur due to gene mutations, failures in hormonal sphere, unfavorable factors external environment, .

There are also reports that the risk of developing a benign tumor is higher in people who do not receive sufficient quantity vitamins, eat foods with high content cholesterol.

Classification

There are several forms:

polymorphic (pleomorphic),
basal cell,
greasy,
canalicular,
adenolymphoma,
monoform.

The photo shows a pleomorphic adenoma of the right parotid salivary gland

Pleomorphic The tumor grows slowly, but can reach large sizes. More often it has a lumpy structure. Occurs in the parotid gland. In the later stages, the risk of tumor malignancy increases.
Basal cell can be multiple. It is a small knot. It has a dense but uniform structure. This form usually does not recur and is sometimes prone to malignant transformation.
Canalicular. Contains prismatic epithelial cells that are collected in thin bunches, resembling beads. Usually occurs in people aged 60-65 years. Amazes upper lip, inner side cheeks. There are no symptoms of the disease.
Sebaceous adenoma. Can be of any shapes and sizes. The tumor appears in the parotid, cheek area, and submandibular zone. Development proceeds painlessly. Adenoma does not lead to relapses after treatment.
Adenolimforma. Lymph is contained inside. She grows slowly. More often found in older men. At first the growth is unnoticeable. The formation is clear, has an elastic or dense structure.
Monoform. Similar to the previous version, but does not contain mesenchymal tissue. Consists of large cells. Usually has a light shade.
Adenocacinoma. These malignant tumors arise in the large and small salivary glands. The prognosis for this form is unfavorable.

Symptoms of education

The most popular is a polymorphic tumor. It grows for several years, but does not cause pain or lead to paresis of the facial nerve.

If the adenoma affects the facial nerve, paralysis occurs. Over time, the entire nerve may become involved in the inflammatory process. Paralysis is followed by pain, which can have varying intensity. These symptoms mainly appear if the cells begin to change into cancerous ones.

In certain localizations, patients complain of:

difficulty swallowing,
speech disorder,
pain in the ear, neck,
swelling.

Diagnostics

The diagnosis is made using a complex of clinical and instrumental studies. At the first appointment, data is collected. Particular attention is paid to the location, consistency, size and contours of the tumor.

In order to identify the nature of the tumor, the following is carried out:

radiography of the skull,
sialography,
Ultrasound of the salivary glands.

A puncture allows you to determine the nature of the formation. If the adenoma develops into cancer, then the salivary glands and a study of the lymphatic system are prescribed.

Additionally, CT and MRI can be used. Long-term results depend on the degree of cancer.

About 85% of salivary gland tumors affect the parotid glands, less commonly the submandibular and minor salivary glands, and about 1% of tumors occur in the sublingual glands. About 75-80% of tumors are benign, slow growing, mobile, painless, usually dense nodes are detected under the skin or mucosa. With a cystic structure, the nodes can be soft, but most often have a hard consistency.

Benign tumors. The most frequent type A benign tumor is a pleomorphic adenoma. It is possible for the tumor to become malignant, leading to the formation of carcinoma, but this is rare and can occur after 15-20 years. Once malignancy occurs, there is very little chance of cure, despite adequate surgical treatment and adjuvant therapy.

Other benign tumors include monomorphic adenoma, oncocytoma, and lymphomatous papillary cystadenoma.

Malignant tumors of the salivary glands have a hard consistency, nodular structure and can attach to underlying tissues. Often accompanied painful sensations and neurological symptoms. Over time, the overlying skin or mucosa may ulcerate, and the tumor may grow into the underlying soft tissue.

The most common salivary gland cancer is mucoepidermoid carcinoma, which most often affects people between 20 and 50 years of age. It can manifest in any salivary gland, often in the minor salivary glands of the palate, and can also occur deep in the bone tissue, for example a dental cyst.

From malignant tumors Glandular cystic carcinoma is the most common carcinoma of the salivary glands. It is a slow-growing malignant transformation of the more common cylindroma. The peak incidence occurs at the age of 40-60 years, manifests itself in the form of severe pain and often paresis of the facial nerve. This tumor has a predisposition to perineural invasion with spread pathological process many centimeters from the primary focus. Lymphogenic spread is not typical for this type of tumor, so selective removal of lymph nodes is rarely used. Although the mortality rate after 5-10 years is quite low, after 15-20 years the mortality rate is quite high, since most patients develop distant metastases. Metastases often form in the lungs, but patients can live with them for quite a long time.

Mixed tumor carcinoma is adenocarcinoma arising from existing benign carcinoma in a mixed tumor.

Symptoms and signs of salivary gland tumors

A significant number of tumors manifest as painless formations. However, growing into nerves, they cause local pain, numbness, paresthesia, causalgia or loss of motor function.

Diagnosis of salivary gland tumors

Biopsy.
CT and MRI for a common process.

A biopsy can determine the cell type. Before starting treatment, it is necessary to screen the body for distant metastases.

Treatment of salivary gland tumors

Treatment of mucoepidermoid carcinoma consists of wide excision and postoperative radiation therapy. The 5-year survival rate is 95% in the first stages of cancer, mainly affecting mucosal cells, and in the last stages the survival rate is 50%, and epidermoid cells are affected. Wide excision is also indicated for glandular cystic carcinoma, but local recurrences are common. The prognosis of acinar carcinoma is favorable after high-quality surgical treatment; with most surgical interventions, dissection of the facial nerve is inevitable.

Tumors of the salivary glands account for 0.5% of all neoplasms, but the tendency to frequent local relapses, malignancy and metastasis determines the interest that is shown in them.

There is still no consensus on the origin of mixed tumors, which account for 90% total number neoplasms of the salivary glands.

The morphology of salivary gland tumors is highly diverse. There are no clear boundaries between benign and malignant neoplasms; moreover, there are transitional forms that can be classified into one or another group. Therefore, it is no coincidence that numerous, often contradictory classifications have been proposed.

Classification

The classification of salivary gland tumors proposed by Albom is as follows.

Mixed tumors (fibroepithelpomas, fibromyxoepitheliomas and fibromyxochondroepitheliomas).
Adenomas.
Capillary cystadenomas.
Basaliomas.
Malignant mixed tumors (fibroepitheliomas, fibromyxoepitheliomas, fibromyxochondroepitheliomas, fibromyxosarcomatous tumors).
Adenocarcinoma.
Cystopapilloma.
Basal cell carcinoma with cylindromatous and solid areas.
Squamous cell carcinoma with cystic areas and solid.
Poorly differentiated tumors are epithelial.
Tumors are poorly differentiated without epithelial structures.

Epithelial neoplasms are most common, connective tissue (sarcoma, angioma) and malignant neoplasms are less common, and neurogenic neoplasms are extremely rare.

All mixed tumors in the semi-malignant group. Semi-malignant tumors are characterized by infiltrative and destructive growth, as well as a pronounced tendency to local relapses without metastases to distant organs. Tumors of the salivary glands such as cylindromas, papillary cystoadenolymphomas, adenolymphomas, mucoepidermoid tumors are usually classified as epithelial in the classifications of various authors.

Adenomas are classified into a group of benign epithelial tumors. Attempts to classify epithelial tumors of the salivary glands according to morphological characteristics, according to the malignancy index, are justified from the standpoint of determining rational therapy. The most acceptable is the Panikarsky classification, which divides all epithelial tumors of the salivary glands according to the degree of malignancy into 5 groups:

adenomas;
papillary cystadenolymphomas;
mixed tumors;
cylindromas;
mucoepidermoid tumors.

Then comes a group of malignant neoplasms - adenocarcinomas.

Mixed tumors of the salivary glands usually occur between the ages of 30 and 40 years.

Symptoms

Malignant tumors account for 13% of all neoplasms of the salivary glands (cancer, sarcoma,).

Cancerous tumors V early stages They look like a small painless dense nodule. Usually during this period, cancer is mistaken for an inflammatory process of the salivary gland.

Foci of decay create the elastic consistency of the neoplasm.

The tumor is usually smooth or lumpy, ranging in size from 1 to 10 or more centimeters, but never reaches the same size as benign tumors. Due to the growth of the tumor and infiltration of the surrounding tissue, the mobility of the neoplasm becomes less, to the point of complete immobility (with germination of the muscle and underlying bone).

Metastases predominantly spread to the lymph nodes of one side and occur frequently and early. The frequency of clinically detectable metastases is 20–50%.

Pain is the most common occurrence in salivary gland cancer, its intensity depends on the stage of the process.

Relapses, as a rule, occur after non-radical surgery and appear in the first months after.

The cause of death of patients is exhaustion, intoxication, malnutrition due to limited mouth opening, ulceration, sepsis, pneumonia, bleeding.

Approximately equally often, neoplasms are located both on the right and on the left. Bilateral damage to the salivary glands is extremely rare. The favorite site for localization of salivary gland tumors is the parotid salivary glands.

Mixed tumors characterized by slow growth and for a long time do not cause any distress to the patient. Their consistency can be dense and elastic; according to the nature of the surface, they can be smooth, knotty, large and finely lumpy. In terms of size, the most common neoplasms are from 2 to 8 cm in diameter, but can reach the size of a newborn’s head.

The mobility of mixed tumors can be complete, limited, weak and immobile. Limited mobility and immobile neoplasms are more common in cases of malignancy. Mixed tumors can become malignant at any period of growth (from 1.4 to 30% of cases). Acceleration of cancer growth is stimulated by non-radical surgery and physical therapy.

As a rule, damage to the main trunk and branches of the facial nerve is not observed in tumors of the salivary glands. Pain is relatively rare. Mixed tumors of the salivary glands are prone to frequent repeated and multiple relapses. The causes of relapses are considered to be the non-radical nature of the operation, cell implantation when the integrity of the tumor is damaged, and the primary multiplicity of tumor buds.

Cylinders in initial period development is no different from mixed tumors, however, cylindromas are prone to more frequent relapses, infiltrative growth and metastasis. Metastases affect the lungs, pelvic bones, abdominal cavity, sometimes eyes and other organs. It is very difficult to distinguish a mixed tumor from a cylindroma, even with examination. The prognosis is less favorable than with mixed tumors.

Mucoepidermoid tumors otherwise called mucus-forming adenocysts. They represent a group of borderline neoplasms with a high potential for malignant growth. Observed in middle-aged and elderly people. They are localized mainly in the area of the parotid salivary glands.

New growths develop slowly, usually not reaching large sizes. Clinical course is similar to mixed tumors. Tumors are often not encapsulated and often recur.

In addition to epithelial ones, there are benign tumors of the salivary glands of connective tissue origin: myxomas, adenomas, lipomas, angiomas.

Myxomas are accompanied by diffuse swelling in the area of the parotid gland, which has a smooth surface, painless, mobile, the skin over it is not changed. The diagnosis is usually made by removing the specimen.

Adenomas have a fibrous capsule. The clinical course is no different from other benign neoplasms.

Lipomas are rare benign formations- originate from the interlobular adipose tissue of the salivary glands. A small lipoma usually does not cause any inconvenience to the patient, except for its localization in the area of the pharyngeal process of the salivary gland. For large lipomas, in rare cases, paralysis of the facial nerve and difficulty in chewing are observed.

Differential diagnosis

Due to the difficulty differential diagnosis in the initial stages of the disease, the percentage of errors in recognizing salivary gland tumors ranges from 17 to 18.

These neoplasms need to be able to be distinguished from inflammatory processes, stones, tuberculosis, syphilis, actinomycosis, cysts, chronic lymphadenitis, Mikulicz's disease.

At chronic mumps swelling of the gland is determined, there is no fusion with the muscles and lower jaw, the skin is not involved in the process. Swelling is especially visible when opening the mouth; regional lymph nodes are not enlarged.

Salivary gland stones are more common in men, are located in the ducts and cause chronic inflammation glands. The course of the disease is long, paroxysmal pain when eating with enlarged glands, indicate the presence of salivary stones.

Tuberculous lymphadenitis in the area of the salivary glands, it more often affects the glands on both sides, with a characteristic course for them, which is expressed in alternating swelling and reduction, and not in the constancy of size and steady growth inherent in true tumors. The diagnosis can be clarified using specific reactions.

Syphilis of the parotid glands- extremely rare disease, differentiates with mixed neoplasms, usually in the tertiary stage, when, due to the gummy process, the gland becomes lumpy and dense.

The duration of the process, the painlessness of the neoplasm, simultaneous syphilitic damage to other organs, as well as serological reactions allow the diagnosis to be made correctly.

Actinomycosis rarely primarily affects the salivary glands, most often in the neck and lower jaw. The gland increases in size, becomes dense, the compaction spreads to the surrounding tissues, fistulas appear, from which specific pus is released. The presence of a dense infiltrate, adherent to the underlying tissues and skin, makes it possible to suspect malignant mixed tumors, however, preservation of the function of the facial nerve, the absence of metastasis, and the release of characteristic pus (drusen are detected under a microscope) make it possible to distinguish this disease from mixed tumors.

Salivary gland cysts it is difficult to distinguish from cancer only when they are deeply located. A puncture biopsy helps resolve diagnostic difficulties. For the success of the salivary glands great value acquires histological examination during the operation.

Treatment

Tumors of the salivary glands have long been treated by surgical removal in combination with.

Best results are achieved after surgery in combination with the introduction of radioactive drugs into the wound, which provides relapse-free treatment in most patients, however, this method is also not without some disadvantages.

The main advantages of radium therapy are the favorable distribution of absorbed energy in tissues and the proximity of the radiation source to the irradiated surface, which creates a steep dose decline with depth.

However, correct distribution of drugs presents technical difficulties, and dosage calculations are usually imprecise.

Taking into account the identity of the biological effects of X-rays and radium, as well as the fact that the effectiveness of radiotherapy is determined by physical and technical conditions, we decided to reproduce these conditions when treating with X-rays by close-focus irradiation using the Monopan, TUR-60 devices.

The method of combined surgical and x-ray treatment of salivary tumors consists of radical removal of cancer within healthy tissues, followed by simultaneous contact irradiation of the tumor bed at the time of surgery from one or several fields so as to irradiate the entire tumor bed.

Close-focus suboperative radiotherapy is performed using the Monopan and TUR-60 apparatus. A set of localizers of the above X-ray units reliably delimits areas various shapes and squares. For correct distribution radiation in a given volume requires precise selection of localizers. During irradiation, fields inevitably overlap, but no complications are observed.

According to the proposed method, treatment is carried out as follows.

Adenomas are subject to purely surgical treatment.

Papillary cystoadenolymphomas are subject to surgical removal in combination with contact irradiation during surgery (dose 1200 rad per field). The number of fields depends on the area of the tumor bed.

For mixed tumors, after surgical removal of the tumor, suboperative contact irradiation is performed (dose - 2000-2500 rad per field).

For cylindromas, after surgical removal of the tumor, the tumor bed is irradiated (dose - 2500-2800 rad per field).

Mucoepidermoid tumors are removed surgically, followed by contact irradiation of the bed (dose - 3000 rad per field), in the postoperative period (after 3-4 weeks) an additional course of radiotherapy is carried out on the area of the postoperative scar (dose - up to 4000 rad).

If the cancer is located in the area of the pharyngeal process for any form of tumor, treatment is supplemented with a postoperative course of intraoral close-focus irradiation. For mucoepidermoid neoplasms, the total dose of intraoral irradiation is 5500 rad, for cylindromas - 4000 rad, for mixed tumors - 3000 rad, for papillary cystadenolymphomas - 2000 rad. The physical and technical conditions are described above.

In cases of malignancy of mixed tumors, treatment begins with a preoperative course of radiation therapy (total dose up to 2000 rad), after 3-4 weeks the tumor is surgically removed, followed by contact irradiation during surgery (dose -2500 rad per field). In the postoperative period (after 3-4 weeks), a course of radiotherapy (dose - 2500 rad) is given to the area postoperative scar.

For malignant mixed tumors and malignant neoplasms Stage 4 is treated for palliative purposes. A palliative course of treatment is permissible only in cases where there remains hope of stopping the growth of the tumor for at least 4-6 months.

For radiation therapy, remote gamma therapy is used, as well as radiotherapy at a voltage of 180 - 200 kV. The radiation field depends on the extent of the cancer and its metastases. Along with radiation treatment it is necessary to prescribe general strengthening agents.

For cancer relapses, tumor removal and contact irradiation at the time of surgery are used (dose - 2800 rad per field). IN postoperative period after 2-3 weeks, radiotherapy is performed on the area of the postoperative scar (dose - 3000 rad).

For inoperable metastases, external external irradiation is used, which has palliative purposes. If, after irradiation, metastatic tumors are rendered operable, they are removed.

Extensive metastases are subject to telegammatherapy or remote radiotherapy.

Cancer relapses, according to the literature, in the vast majority of cases appear during the first year. The most effective method turned out to be the X-ray surgical method, that is, the use of close-focus X-ray therapy on the bed during surgery after tumor removal, even if the principles of ablastics are not observed (pieces of the tumor are allowed so as not to damage the facial nerve).

The article was prepared and edited by: surgeon

The surgical method is the leading one, since all benign and most malignant tumors are resistant to radiation.

Benign neoplasms of the salivary glands (except for “mixed” tumors of the parotid gland) in principle require the same treatment - enucleation without damaging the capsule. Sometimes vascular tumors The parotid salivary gland decreases under the influence of irradiation and becomes more displaceable, apparently due to atrophy of the gland.

So far for unknown reasons There is an opinion that benign, including mixed, tumors do not need to be removed and that a wait-and-see approach should be followed. Experience shows that such “tactics” lead to tumor enlargement, facial disfigurement and other complications. In addition, the true nature of the salivary gland tumor can only be determined by histological examination.

To carry out surgical treatment of polymorphic adenomas of the parotid salivary gland, one must proceed from the following fundamental principles:

1. It is necessary to operate under anesthesia in order to freely manipulate the branches of the facial nerve in unchanged tissues. Local anesthesia does not create the calm conditions that are essential for surgical intervention, and significantly complicates orientation in tissues flooded with novocaine.
2. Considering that the capsule of a mixed tumor is not always solid and the neoplasm tissue is adjacent directly to the parenchyma of the salivary gland, it is necessary to remove the tumor along with the surrounding healthy gland tissue.
3. Our randomized studies have shown that mixed tumors are not sensitive to radiation therapy. In this regard, our studies do not confirm the opinion of S. L. Daryalova (1972) about the radiosensitivity of a mixed tumor.
4. The operation should begin with exposure of the main trunk of the facial nerve at the mastoid process and should be isolated in the direction of the main branches. Exposing a mixed tumor is very dangerous due to the possibility of crossing the branches of the facial nerve and seeding the wound with tumor cells.
5. Depending on the location and size of the mixed tumor, a differentiated approach to the choice of surgical intervention should be taken. To carry out these operations, you need to clearly understand the anatomy of the facial nerve and its relationship with surrounding tissues. Many options for dividing the facial nerve have been described, for example, R. A. Davis offers six division options (Fig. 169). A. E. Vaccato - four, L. J. MacCormack et al. - eight. It seems that each person has his own unique version of the structure of the facial nerve.

Resection of the parotid salivary gland is indicated for tumors up to 2 cm in size located at the poles or posterior edge of the gland. Offered various options skin incisions (Fig. 170). We use a modified Redon skin incision (Fig. 171).

The skin incision must satisfy two basic requirements:

1) it must expose the entire outer surface of the parotid salivary gland and thereby ensure freedom of inspection and manipulation of the gland;
2) it should be such that if a diagnosis of a malignant tumor is made, the skin incision could be extended to excise the cervical tissue.

After mobilization of the skin flaps and exposure outer surface of the parotid salivary gland, the parotid fascia of the lower pole and posterior edge of the gland is cut and the posterior edge of the gland is mobilized (Fig. 172). The anterior edge of the sternocleidomastoid muscle and mastoid process are exposed. At the mastoid process, the main trunk of the facial nerve is exposed approximately 1 cm from its apex. Then one of the branches of the facial nerve is isolated, above which the mixed tumor is located. Under visual control, moving aside the selected branch of the facial nerve, the parotid salivary gland is resected along with the tumor (Fig. 173). After resection, catgut sutures are placed on the parotid fascia.

Subtotal resection of the gland in the plane of the location of the branches of the facial nerve is performed when the mixed tumor is located in the thickness of the gland or occupies a significant proportion of the superficial part of the gland. This operation begins in the same way as the previous one, however, after isolating the trunk of the facial nerve, the branches of the facial nerve are sequentially isolated one after another and the gland tissue along with the tumor is excised in the plane of their location (Fig. 174). When isolating the branches of the facial nerve, one should strive to disrupt their blood supply as little as possible. If a mixed tumor is located in the area where the main trunk of the facial nerve is located, then in order to prevent damage to the nerve or its trauma, the operation should begin from the periphery of the branches of the facial nerve.

Parotidectomy with preservation of the branches of the facial nerve is indicated for large mixed tumors, relapses, including multinodular ones, as well as mixed tumors of the pharyngeal process of the salivary gland. First, a subtotal resection of the gland is performed in the plane of the exposed nerve branches after preliminary ligation of the external carotid artery. The branches of the facial nerve are raised and under them the deep part of the parotid salivary gland is isolated and excised in a single block with the tumor (Fig. 175).

Resection of the pharyngeal process of the parotid salivary gland is performed when the mixed tumor is located in the pharyngeal process and bulges into the pharynx (Fig. 176).

A skin incision is made in the submandibular region, 2 cm away from the lower edge of the lower jaw and parallel to the latter from the chin region to the mastoid process (Fig. 177).

The external carotid artery is ligated. For wide access to a mixed tumor located parapharyngeal, it is necessary to cut off the submandibular salivary gland (Fig. 178). The lower surface of the tumor, the deep lobe of the parotid salivary gland, is exposed. The tumor is bluntly separated from the wall of the pharynx, base of the skull and other surrounding tissues. The tumor is dislocated into the wound and the pharyngeal process of the parotid gland is resected.

Recurrences of mixed tumors of the parotid salivary gland are also subject to surgical treatment. An indispensable condition for the radicality of the operation should be excision in a single block of the parotid salivary gland and the recurrent tumor with the surrounding tissues and skin, where the surgeon had previously manipulated (Fig. 179). Parotidectomy is performed while preserving the branches of the facial nerve.

It should be specially emphasized that differentiated approach the choice of surgery depending on the size and location of the mixed tumor of the parotid gland avoids damage to the facial nerve. We do not warn patients about the possibility of crossing the facial nerve, but we are talking about the development of temporary paresis of facial muscles. In the surgery of mixed tumors of the parotid salivary gland, including many malignant ones, great importance must be attached to the detection, isolation and protection of the facial nerve.

Surgeries for mixed tumors of the salivary glands usually proceed without complications. In the postoperative period or after a few months, some complications are observed.

1. Sometimes temporary paresis of the facial muscles develops, which is associated with impaired blood circulation and the development of nerve ischemia. The degree of severity and duration of paresis depends on the type of division of the facial nerve and its development (caliber of the trunk and branches), the relationship of the tumor and the branches of the facial nerve, previous treatment and the condition of the gland tissue, the volume of surgical intervention and the age of the patients. Paresis of facial muscles, observed in approximately 5% of cases after primary operations, is much more common - in 28% - observed after repeated operations. Usually, within a period of 2 weeks to 2 months, the functions of the branches of the facial nerve are restored. In some patients, paresis of the facial muscles lasts up to 6 months. In these cases, it is necessary to carry out therapy with B vitamins, massage, and facial exercises.
2. Formation of a punctate salivary fistula. It usually closes on its own when bandaged tightly.
3. 3-4 months after surgery, some patients (2%) experience the appearance of drops of sweat and hyperemia in the area of the parotid salivary gland during meals. In the literature, this is described as “auriculotemporal nerve syndrome”, “peritemporal hyperhidrosis”, “Frey’s syndrome”. After eating, these symptoms disappear. S. Hanowell, D. Ericlees, T. Macnamara (1979) believe that Frey’s syndrome develops as a result of damage during surgery to the branches of the auriculotemporal nerve, impaired regeneration of parasympathetic fibers and transmission of excitation to sympathetic fibers. It is recommended to lubricate the skin of the parotid area with 3% scopolamine ointment. The symptoms of hyperhidrosis disappear within 2-3 weeks.

The reader will find more detailed information about the surgical treatment of mixed tumors of the parotid salivary gland in the methodological recommendations published by us in 1977.

Treatment of acinar cell tumor, characterized by locally destructive growth and a long-term benign pre-treatment course, is mainly surgical. Parotidectomy with preservation of the facial nerve is indicated when small tumors- subtotal resection of the parotid gland in the plane of the branches of the facial nerve.

It is advisable to treat mucoepidermoid tumors (poorly differentiated type of structure) and adenoid cystic carcinomas (cylindromas) using a combined method. Long-distance gamma therapy is carried out in preoperative period. In case of a benign course, treatment is completed with parotidectomy with preservation of the branches of the facial nerve; in case of a malignant course, treatment is carried out according to the method described below (for adenocarcinomas). Moderately and well differentiated mucoepidermoid tumors, due to their radioresistance, can only be treated surgically.

Adenocarcinoma, epidermoid and undifferentiated carcinoma, and cancer from a “mixed” tumor are also subject to the combined treatment method. It is better to start treatment with preoperative long-distance gamma therapy using the GUT-Co-60-400-1 device or more powerful units. Gamma therapy should be carried out with a focal total absorbed dose of 5000-6000 rad (50-60 Gy). It is necessary to irradiate regional lymph nodes if metastases are present or suspected. Radiation often causes the tumor to shrink significantly.

After the end of the irradiation, surgery is performed (about 3 weeks later). Surgery can be considered radical if the parotid gland affected by the tumor is removed in a single block with regional lymph nodes, taking into account the characteristics of lymph circulation in the neck. For these cases, different skin incisions are offered (Fig. 180). There is no need for postoperative radiation after radical surgery.

In case of stage I-II parotid salivary gland cancer, when metastases on the neck are not palpable or there are single, small and displaceable metastases, it is necessary to perform a complete parotidectomy (without preserving the facial nerve) in a single block with tissues carried away. In these cases, in addition to the block of tissue that is usually removed during fascial-case excision of cervical tissue, the area of tissue removed includes the external jugular vein with its surrounding tissue, superficial lymph nodes and vessels. For parotid cancer Stage III(including with multiple and poorly displaced metastases on the neck), the parotid gland is removed as a single block (1-2 cm from its edges) along with the facial nerve and soft tissues of the neck using the Crail method. The tissue of the neck is excised within the boundaries of the lower edge of the lower jaw, the midline of the neck, the clavicle and the anterior edge of the trapezius muscle (Fig. 181). The subcutaneous muscle of the neck, sternocleidomastoid muscle, submandibular salivary gland, internal and external jugular veins, external carotid artery, posterior belly of the digastric muscle, stylohyoid and omohyoid muscles. The technique of this operation, based on numerous anatomical studies, has remained the subject of our study for many years and has been repeatedly described in journals and books.

In Fig. 182-186 depict the main stages of radical surgery for cancer of the parotid salivary gland. After excision of these tissues, it is necessary, if possible, to perform plastic surgery of the facial nerve, for example, by transplanting one of the nerves of the neck.

Polymorphic adenomas of the submandibular salivary gland are usually treated surgically. The operations are not difficult, since the submandibular fascial sheath is excised along with the submandibular salivary gland. Mixed tumors of the sublingual and minor salivary glands of the oral cavity are removed while maintaining the integrity of the capsule.

Malignant neoplasms of the submandibular salivary gland are subject to combined treatment. In the absence of metastases in the regional lymph nodes, long-distance gamma therapy is performed on the primary lesion, and then fascial-sheath excision of the cervical tissue along with the tumor is performed. For metastases in the cervical lymph nodes, the irradiation zone should include the corresponding half of the neck and long-distance gamma therapy should be carried out in several fields. The total dose is determined by the size of the tumor and the number of irradiation fields. We carry out surgical interventions 3 weeks after the end of irradiation. When malignant tumors of the submandibular gland recur, it is often necessary to increase the volume of excised tissue, often resorting to resection of the lower jaw or floor of the mouth.

Malignant tumors of the minor salivary glands of the oral cavity and maxillary sinus should be treated according to the same principles as cancer of the oral and nasal mucosa with paranasal sinuses. However, it must be taken into account that with malignant tumors of the minor salivary glands, metastasis to regional lymph nodes is observed much less frequently than with squamous cell carcinoma of the oral mucosa. Therefore, in these cases we perform excision of the cervical tissue in the presence of metastases or suspicion of them.

The postoperative period in most patients after radical surgery for malignant tumors of the salivary glands proceeds smoothly. However, resection of the internal jugular vein and traumatization vagus nerve should be taken into account during and after surgery in terms of preventing shock and lowering intracranial pressure.

In advanced forms of malignant tumors of the salivary glands, according to indications, radiation therapy can be used to reduce the pain associated with inflammatory processes and tumor activity. We observed patients in whom such tumors became operable under the influence of “palliative” radiation therapy.

Drug, hormonal and chemosurgical methods for the treatment of malignant tumors of the salivary glands have not yet been used and continue to be studied. In our practice, only methotrexate caused significant tumor regression in some patients with cancer of the major salivary glands. Similar antitumor effect can often be achieved with regional use of sarcolysin. L.P. Malchikova strongly recommends introducing into practice the method of regional carotid perfusion with sarcolysin in combination with radical surgery, believing that this technique significantly reduces regional and distant metastasis.

Long-term results of treatment for benign tumors of the salivary glands, including mixed ones, are generally favorable. Almost all patients return to their previous activities. Often, paresis of individual facial muscles, which persists in the first weeks after surgery, decreases and disappears after 4-7 months. Relapses after treatment of mixed tumors of the parotid salivary gland are observed, according to various authors, in 1.5-35% of cases (in large specialized clinics in the USA - in 5%) and occur more often during the first 2 years. We observed relapses only after surgical treatment of recurrent mixed tumors - in 3%. According to American surgeons, repeated relapses after surgery to remove recurrent tumors should be expected in 25%. This figure indicates the high responsibility of the surgeon performing the first operation.

Long-term results of treatment of malignant tumors of the salivary glands are generally unfavorable. For mucoepidermoid tumors prognostic value We have not established the duration of the pre-treatment period. The prognosis depends on the structural variant of the mucoepidermoid tumor. Local relapses are observed in approximately 40% of all structural variants. This is due to the fact that these tumors are often diagnosed as mixed tumors and, of course, are not treated radically. Metastases to the lymph nodes of the neck are less often observed with a well-differentiated variant of the tumor structure (9%), more often with a moderately differentiated one (37%), and even more often with a poorly differentiated one (50%). Accordingly, the number of deaths is 10.27, 60%. It has also been established that the prognosis is worse for mucoepidermoid tumors that contain “free” mucus and do not have lymphoid-plasmacytic infiltration.

In adenoid cystic carcinomas (cylindromas), local relapses occurred in 40%, metastases to regional lymph nodes in 6.6%, metastases in the lungs and bones in 44%, and 25.5% of patients died. However, the forecast largely depends on the option histological structure cylindromas (Fig. 187). For example, with the cribriform variant, distant metastases are observed in 34.2%, deaths- in 29%, with a solid option - 100% and 90%, respectively.

The prognosis for adenocarcinoma and other types of salivary gland carcinomas, including malignant mixed tumors, is approximately the same. Cure is observed in 20-25% (based on materials from various authors). The ability to work in a number of patients is restored after a few months, but in many it is reduced due to paralysis of the facial muscles and swelling of the face. The treatment results improved somewhat after the combined treatment method and modern combined radical operations. Relapses are observed in 40-44%, metastases to regional lymph nodes - in 47-50%. The results of treatment of malignant tumors of the submandibular salivary gland are worse compared to the parotid gland.