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Surgical Management of Minor Salivary Gland Neoplasms of the Palate

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Surgical Management of Minor Salivary Gland Neoplasms of the Palate The Ochsner Journal 8:172–180, 2008 f Academic Division of Ochsner Clinic Foundation Surgical Management of Minor Salivary Gland Neoplasms of the Palate Brian A. Moore, MD,* Brian B. Burkey, MD,{ James L. Netterville, MD,{ R. Brent Butcher II, MD,{ Ronald G. Amedee, MD{ *Department of Otolaryngology—Head and Neck Surgery, Eglin Regional Hospital, Eglin AFB, FL {Department of Otolaryngology—Head and Neck Surgery, Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences, Nashville, TN {Department of Otolaryngology—Head and Neck Surgery, Ochsner Clinic Foundation, New Orleans, LA Conclusions: Neoplasms of the minor salivary glands in the ABSTRACT palate may be excised, with limits dictated by tumor Objective: Minor salivary gland tumors are uncommon, histopathology and perineural invasion. Improved functional accounting for up to 15% of salivary gland neoplasms. We results may be achieved by immediately reconstructing the describe our experience with both benign and malignant tumors defects with rotational flaps, reserving free flaps for more of the palatal minor salivary glands, focusing on the extent of extensive defects of the maxilla and infratemporal fossa. resection and options for defect reconstruction. Study Design: Retrospective review of medical records. Results: From 1994 to 2002, 37 patients with primary neoplasms originating in the palatal minor salivary glands were INTRODUCTION treated at a single institution. Patients ranged in age from the Although 450 to 750 minor salivary glands are present in the head and neck, minor salivary gland second to the seventh decades, with a female preponderance. 1 Twenty-four percent of the lesions were benign. The most tumors remain relatively uncommon neoplasms. common malignant tumor encountered was low grade polymor- Because the highest concentration of these glands phous adenocarcinoma, followed by mucoepidermoid carcino- has been described as on the palate, particularly the ma, and adenoid cystic carcinoma. The extent of surgical junction of the hard and soft palates, it is not surprising that most minor salivary gland tumors resection was dictated by tumor pathology and evidence of 2,3 perineural spread, and defects were reconstructed with a variety occur at this site. In all, 8% to 15% of salivary gland tumors arise in the palate, and these tumors are of techniques. Postoperative complications included velopha- 1,3–5 ryngeal insufficiency, flap fistulization or loss, and trismus. After malignant in 40% to 82% of cases. The incidence 1 month to 8 years of follow-up, 1 patient has died with regional of malignancy in minor salivary gland tumors appears and systemic metastases. to follow the general principle that tumors in smaller salivary glands are more likely to be malignant than their counterparts in the major or paired glands. Address correspondence to: Given the propensity for malignant histology in R. Brent Butcher II, MD minor salivary gland tumors, the management of Department of Otolaryngology—Head and Neck Surgery these lesions is predicated upon adequate surgical Ochsner Clinic Foundation resection to maximize the ultimate oncologic result. 1514 Jefferson Hwy. However, the surgical zeal for wide margins must be New Orleans, LA 70121 tempered by the realization that tumor aggressive- Tel: (504)842-3640 ness varies with histologic subtype, as well as an Fax: (504)842-3979 appreciation of the cosmetic and functional sequellae Email: [email protected] of palate defects. Traditionally, reconstruction of defects resulting from the extirpation of these lesions Presented at The Southern Section of the Triological Society, has received little attention, as local flaps and Naples, FL, January 10–12, 2003. obturators have been the prime modalities of defect management.5 Advances in reconstructive tech- The views expressed in this article are those of the author(s) niques, including free tissue transfer and pedicled and do not reflect the official policy or position of the United flaps, have expanded the head and neck surgeon’s States Air Force, Department of Defense, or United States armamentarium. By reviewing our experience with Government. these lesions, we seek to identify the factors that suggest more aggressive histology to aid in preoper- Key Words: Palate, salivary gland neoplasms ative planning. We then advocate an aggressive 172 The Ochsner Journal Moore, BA surgical approach that is tailored not only to the tumor Table 1. Tumor Histopathology type but also to the likelihood of local or perineural spread, usually followed by primary reconstruction Number of Patients (%) performed to maximize the ultimate functional result. Diagnosis (n = 37) Benign 9 (24) MATERIALS AND METHODS Pleomorphic adenoma 8 (22) After gaining approval from the Vanderbilt Institu- Monomorphic adenoma 1 (3) tional Review Board, the medical records of all Malignant 28 (76) patients who underwent resection of palate lesions Low grade polymorphous 10 (27) and reconstruction of palate defects from 1994 to adenocarcinoma 2002 were retrospectively reviewed. Patients with Mucoepidermoid carcinoma 8 (22) epithelial or metastatic lesions were excluded, leaving Low grade 3 a total of 37 patients for analysis. Hospital and clinic Intermediate grade 5 records were then studied, focusing on patient Adenoid cystic carcinoma 7 (19) demographics, comorbidities, and the duration and Adenocarcinoma 2 (5) nature of presenting symptoms. Carcinoma ex pleomorphic 1 (3) The precise anatomic location and appearance of the lesions were noted, as was the gross extension into surrounding structures. Specimens were re- Tumor histopathology for our patients is summa- viewed to determine histopathologic type and the rized in Table 1. The majority (76%) of tumors was status of margins, including nerve margins. The extent malignant, and low grade polymorphous adenocarci- of surgical resection was recorded, along with any noma comprised the most frequently encountered concomitant procedures, and the reconstructive tissue diagnosis, followed by mucoepidermoid carci- method was noted. We then documented the length noma and adenoid cystic carcinoma. Among the of stay, time to initiation of an oral diet, a subjective benign tumors, pleomorphic adenoma was the most assessment of speech and swallowing function by the common, accounting for 89% of all benign lesions. patient, and the incidence of complications in the Nineteen tumors (51%) were detected by the postoperative period. The length of patient follow-up, patient as an asymmetric swelling of the palate documented recurrences, and last known disease (Figure 1). Surprisingly, 13 tumors (35%) were com- status were also gathered for each patient. Data were pletely asymptomatic and were detected only on tabulated and analyzed using Excel 97 (Microsoft routine dental examination. Other symptoms encoun- Corporation, Redmond, Wash.), with statistical anal- tered included pain, ulceration, and dysesthesias. ysis using Fischer’s exact test performed with Presenting symptoms are depicted in Table 2. Al- GraphPad Prism version 3.00 for Windows (GraphPad though most tumors were symptomatic at the time of Software, San Diego, Calif.). diagnosis, the symptoms (or at least knowledge of its presence from detection on a dental examination) RESULTS Since 1994, 37 patients have undergone surgical management of minor salivary gland tumors arising from the palate. The patients ranged in age from 15 to 81 years, with a mean of 48.1. There were 20 women included in the study, compared to 17 men. Postop- eratively, patients were followed from 1 to 96 months, with an average of 22.2 months of documented clinical follow-up. The majority of patients (57%) were otherwise healthy non-tobacco users, but numerous patients exhibited other comorbidities, such as hypertension, hypercholesterolemia, hypothyroidism, and gastroesophageal reflux disease. A history of ongoing tobacco use was found in 10 patients, comprising the most common potential risk factor. However, there was no statistically significant asso- Figure 1. Submucosal mass on the right hard palate, near ciation between tobacco use and malignant histology the junction of the hard and soft palates. A painless in our cohort. No patient had a history of prior swelling of the palate is the most common presenting radiation exposure to the head and neck. symptom for tumors of the palatal minor salivary glands. Volume 8, Number 4, Winter 2008 173 Surgical Management of Salivary Gland Neoplasms Table 2. Presenting Symptoms and Corresponding Pathology Symptoms Histopathology Swelling/Mass Pain/Dysesthesia Ulceration Asymptomatic Low grade polymorphous adenocarcinoma 7 0 1 2 Mucoepidermoid carcinoma 3 0 0 5 Adenoid cystic carcinoma 3 4 0 2 Adenocarcinoma 1 1 0 0 Carcinoma ex pleomorphic 1 0 0 0 Pleomorphic adenoma 4 1 0 3 Monomorphic adenoma 0 0 0 1 were present from 1 month to 40 years, with an Nineteen patients (51%) required partial palatec- average of 32.1 months, prior to evaluation by a head tomy for extirpation of both benign and malignant and neck surgeon. Both pain alone (P 5 .0374) and disease, with resection of the soft tissues and either neural complaints including pain and dysesthesias (P resection or exenteration of the underlying bone with 5 .0068) exhibited a statistically significant associa- a drill. Meanwhile, 10 patients with malignant tumors, tion with a histopathologic diagnosis of adenoid cystic evenly distributed between adenoid cystic carcinoma, carcinoma. No other symptoms or symptom duration mucoepidermoid
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