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Part 2 Site-Specifi c Indications and Techniques
Case
Study
13-8
neck dissection, and histologic examination revealed an
ACC in the submandibular gland measuring 2.5 × 2 × 2
with perineural invasion. One of the eight nodes (a subdigastric node) in the specimen contained metastatic disease.
e lingual and hypoglossal nerves were free of gross
tumor invasion. Postoperative radiotherapy was delivered through a le lateral appositional eld (Fig. 13.8)
encompassing the tumor bed, the proximal extension of
the nerves at risk, and the upper neck. A combination of
20-MeV electrons and 6-MV photons was used weighted
4 to 1. Adose of 50 Gy in 25 fractions was delivered, a er
which the eld was reduced to administer an additional
10 Gy in ve fractions boost to the tumor bed. e mid
and lower neck nodes were treated with a matching 9-MeV
electron eld to a dose of 50 Gy in 25 fractions.
An 82-year-old man noted an asymptomatic
mass in the le submandibular area and sought
medical attention immediately. Examination
revealed a 3-cm le submandibular mass. is
tumor was resected along with a le modi ed
Figure 13.8
Case
Study
13-9
nodes (levels I and II) were involved. Because of the intention to irradiate the neural pathways to foramen ovale, she
was treated with postoperative IMRT.
A 68-year-old woman presented with right
lower facial numbness and a submandibular
mass. She underwent resection of the mass,
which revealed ACC. e lingual nerve was
involved and encased by the tumor and ve
Figure 13.9 shows axial isodose distributions at the
level of the removed gland and upper neck (Fig. 13.9A),
superior oral cavity, including the lingual nerve pathway along the ascending ramus, and high jugular region
(Fig.13.9B) and the skull base (Fig. 13.9C).
A
Figure 13.9A,B
B
C
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Figure 13.9C
Chapter 13 Salivary Glands
235
Case
Study
13-10
nation revealed ACC, cribriform type, with perineural invasion. Tumor was within 1mm of the inked margin. Restaging
imaging revealed no residual tumor so it was elected to treat
her with adjuvant radiation. Radiation consisted of IMRT
to the submandibular bed and perineural pathways, covering the lingual nerve to the mandibular nerve up to foramen
ovale. CTVHD (60 Gy, orange colorwash) covered subman-
A 41-year-old woman presented with a le
upper neck mass. Fine-needle aspiration did not
establish a conclusive diagnosis. She underwent
surgical excision, which showed a 3-cm tumor of
the le submandibular gland. Histologic exami-
dibular bed, CTVID (57 Gy, aqua colorwash) encompassed an
addition 1 cm on CTVHD and the remainder of the operative
bed within the upper neck, and CTVED (54 Gy, yellow color-
wash) delineated the nerve pathway to foramen ovale. As the
margin was essentially positive (<1 mm), a small higher risk
volume was prescribed 66Gy (teal colorwash).
Figures 13.10A-E show axial contours and isodose
distributions at the levels of the submandibular bed
(Fig.13.10A–C), the lingual nerve (Fig. 13.10D), and foramen ovale (Fig.13.10E), and a coronal view with contours
and isodose distribution (Fig. 13.10F). e patient remains
without disease 5years later.
A
Figure 13.10A,B
B
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Part 2 Site-Specifi c Indications and Techniques
C
E
Figure 13.10C-F
D
F
• CTV
delineates volumes to receive an intermediate dose,
ID
which typically encompasses the remaining operative bed
not included in CTV
• CTVED delineates volumes to receive an elective dose for
subclinical disease. Perineural spread from submandibular gland tumors a ects branches of V3 (particularly the
lingual nerve) and the hypoglossal nerve. e mandibular
nerve exits foramen ovale. e lingual nerve branches o
anterior to the lateral pterygoid muscle and lies medial to
the inferior alveolar nerve (also a branch of V3). While
the inferior alveolar nerve enters its canal in the mandible,
HD.
thelingual nerve continues between the pterygoid muscle
and the ramus of the mandible and crosses the submandibular duct (the usual origin point of perineural spread)
before branching o in the tongue. In patients with highgrade cancers without clinical evidence of nodal involvement, CTVED covers ipsilateral nodal levels II to IV. In
patients with nodal involvement, CTVED encompasses
ipsilateral nodal levels not included in higher dose CTVs.
e isocenter is placed in the center of the treatment volume
when the submandibular bed alone is treated. If the entire
Chapter 13 Salivary Glands
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237
neck is to be treated, a half-beam matching technique might be
preferable. e isocenter is placed above the level of the arytenoids. Ipsilateral levels III and IV are included in a matching anterior (or parallel anterior and posterior) photon portal.
Appropriate eld reduction is made to deliver boost dose.
Dose
For high-grade tumors and those with lymph node metastases, the commonly prescribed dose is 60 Gy in 30 fractions
Background Data
Table 13.6
Type of Tumors No. of Patients
Benign
Pleomorphic adenoma
Other
Malignant
Adenoid cystic
Tubular
Cribriform
Solid
Mucoepidermoid
High grade
Intermediate grade
Low grade
Not specifi ed
Adenocarcinoma
Carcinoma ex-mixed tumor
Squamous carcinoma
Undifferentiated
Other
Total 110
a
Oncocytoma (1), sebaceous adenoma (1), and benign lymphoepithelial lesion (1).
b
Acinic cell (1), lymphoepithelioma (1), unclassifi ed (2), and carcinoma exmonomorphic adenoma (1).
From Weber RS, Byers RM, Petit B, et al. Submandibular gland tumors. Adverse
histologic factors and therapeutic implications. Arch Otolaryngol Head Neck Surg
1990;116:1055, with permission.
Histologic Findings of Submandibular Gland
Tumors
a
b
a er complete resection or 64 to 66 Gy in 32 to 33 fractions
in the presence of positive margin or ECE. Field reduction is
made a er 50 to 54 Gy. For elective neck irradiation, a dose
of 50 Gy in 25 fractions is prescribed.
With IMRT, doses prescribed to CTVHD, CTVID, and
CTVED are 60, 57, and 54 Gy, respectively, and treatment is
given in 30 fractions. High-risk volume (e.g., positive margin) can receive a total dose of 66 Gy in 30 fractions (2.2 Gy
per fraction).
21
3
37
5
17
15
15
5
3
6
1
9
8
8
4
5
Table 13.7
Effect of Therapy on Failure Site for Patients with Malignant Lesions Extending into Periglandular
Soft Tissue
Treatment Modality No. of Patients No Evidence of Disease
Surgery 23 9 12
Surgery and radiotherapy 22 13 4
a
P <0.034. Includes four patients from group 2 with previous excisional biopsy and soft-tissue extension treated with radiotherapy after referral.
From Weber RS, Byers RM, Petit B, et al. Submandibular gland tumors. Adverse histologic factors and therapeutic implications. Arch Otolaryngol Head Neck
Surg 1990;116:1055, with permission.
Local–Regional
Relapse Distant Metastases
a
a
2
5
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Part 2 Site-Specifi c Indications and Techniques
Table 13.8
Variable No. of Patients Control (%)
Adenocarcinoma 10 41
Adenoid cystic
carcinoma
High grade 23 69
Positive resection
margin
Perineural
invasion
Named nerve
involvement
Positive nodes 21 78
Extraglandular
extension
All patients 83 88
Data from the M.D. Anderson Cancer Center.
Modifi ed from Storey MR, Garden AS, Morrison WH, et al. Postoperative
radiotherapy for malignant tumors of the submandibular gland. Int J Radiat
Oncol Biol Phys 2001;51:952.
Submandibular Gland Neoplasms: 5-Yr
Local–Regional Control Rates (Stratifi ed
by Risk Variables) of Surgery and
Postoperative Irradiation
50 98
19 79
54 94
17 88
58 85
with frontline radiation. Indications for postoperative
radiotherapy are listed in the “Parotid” section.
Postoperative Radiotherapy
Target Volume
Initial Target Volume
• Low-grade tumors without lymph node involvement: sur-
gical bed.
• High-grade tumors or lymph node involvement: surgical
bed and neck nodes. e extent of elective neck treatment
varies with histology and the anatomical site of the primary lesion.
ACC or presence of perineural invasion: more generous
coverage of the neural track (see Case Studies 13-11 to
13-14).
e boost volume encompasses the tumor bed and
involved nodal bed.
Setup and Field Arrangement
Varies with the site of the primary lesion (see respective
sites). Knowledge of the nerves at risk and their speci c
proximal pathways to the respective foramina in the base of
skull is essential for planning IMRT.
MINOR SALIVARY GLAND TUMORS
Treatment Strategy
Surgery is the preferred treatment for operable patients if the
cosmetic and functional repercussions are not too severe.
Occasional patients with small tumors may be treated
Case
Study
13-11
perineural invasion and positive margins. Examination was
suspicious for a residual mass, so a wide reexcision using a
transpalatal approach was performed. e pathologic studies on the reexcision were negative, but because of the original ndings and tumor location, postoperative radiation was
recommended. Radiation was delivered through a pair of
parallel–opposed beams (Fig. 13.11). e initial elds encompassed the primary tumor and operative bed. e generous
margin superiorly allowed for coverage of the perineural
pathways. e elds were reduced o the spinal cord at 42 Gy,
and reduced further at 50 Gy to boost the tumor bed to 60 Gy.
e patient remains free of disease 10 years from his therapy.
A 59-year-old man presented with obstructive right ear symptoms. A mass was found in
the posterior wall of the right nasopharynx.
A transoral piecemeal excision was performed
and histologic examination revealed ACC with
Dose
See “Parotid” section
Figure 13.11
Chapter 13 Salivary Glands
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239
Case
Study
13-12
maxillary nerve. Tumor was present at the proximal section
margin of the nerve, where clips were placed. He received
A 51-year-old man presented with an asymptomatic hard palate mass. Tumor biopsy
revealed ACC, cribriform and tubular type. He
underwent resection, which included an infrastructure maxillectomy and drill-out of the
AB
Figure 13.12A,B
postoperative IMRT. e region of positive margin and V2
through foramen rotundum received 66 Gy and a more
generous margin including the operative bed received
60Gy in 30 fractions.
Figure 13.12 shows isodose distributions through
the clipped margin on axial (Fig. 13.12A) and coronal
(Fig.13.12B) views.
Case
Study
13-13
A biopsy showed ACC. She underwent a resection of the
mass with bilateral selective neck dissections. Histologic
examination revealed ACC, 3.5 cm in size with perineural
invasion. Adjuvant IMRT was started 1 month a er surgery
and delivered in 30 fractions. CTVHD (green colorwash),
CTVID (orange colorwash), and CTVED (aqua colorwash)
A 71-year-old woman presented with an
asymptomatic mass in the oor of mouth.
Figure 13.13 shows representative axial
(Fig.13.13A) and coronal (Fig. 13.13B) MRI
images revealing the tumor (green arrows).
were de ned and prescribed 60, 57, and 54 Gy, respectively.
While the epicenter of the tumor was in the right oor of
mouth, CTVHD covered nearly the entire oor of mouth
due to the operative ndings and in ltrative nature of the
disease crossing midline. CTVID encompassed margin on
CTVHD, and the operated necks that did not harbor disease.
CTVED covered V3 bilaterally from the inferior aspects of
the le and right foramen ovale and its branches superior
and posterior to the operative bed. Figures 13.13C–F show
representative axial contours and isodose distributions. e
patient was without disease on last follow-up visit.
A B
Figure 13.13A,B
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Part 2 Site-Specifi c Indications and Techniques
C
E F
D
Figure 13.13C-F
Chapter 13 Salivary Glands
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241
Case
Study
13-14
nation revealed ACC.
Figure 13-14 shows a representative coronal image of
staging MRI. A large right maxillary sinus mass can be seen
(green arrows).
A right maxillectomy was performed with orbital
preservation. e orbital oor was resected and reconstructed with a titanium mesh, and the remaining defect
repaired with an anterolateral thigh ap. Histologic
examination revealed a 4-cm ACC. ere was perineural
invasion, but the infraorbital nerve specimen was negative. However, the bone decalci cation revealed disease
in the maxilla with a positive bony margin. Postoperative IMRT started 5 weeks a er surgery and was delivered
in 30 fractions. Four target volumes were delineated as
A 61-year-old man presented with right facial
pain following extractions of maxillary molars.
He eventually developed a right facial mass
and sought medical attention. An intranasal
biopsy was performed and histologic exami-
illustrated in Figure 13.14. CTVHD (60 Gy, orange colorwash) covered the vGTV with 1-cm margins, CTVID (57
Gy, lavender colorwash) encompassed the remaining
operative bed, and CTVED (54 Gy, yellow–green colorwash) delineated V2 on the intracranial side of the base of
skull and the sphenoid sinus. Because of concern for the
positive margin, a small volume (teal colorwash) at the
medial edge of the remaining palate was delineated and
prescribed 65 Gy. Isodose distributions are shown in coronal views through the orbits (Fig. 13.14B) and the cavernous sinus (Fig. 13.14C), and in axial views through the
mid orbits (Fig. 13.14D), the orbital oor (Fig. 13.14E),
where the titanium mesh is visible, the level of the inferior maxillary sinus (Fig. 13.14F), and through the hard
palate (Fig.13.14G,H). e patient remained without disease 4 years later. He underwent repair of a right-sided
ectropion and later also a dacryocystorhinostomy with
placement of a silicone tube. He had no epiphora but
experienced a progressive cataract in the right eye.
A B
C
Figure 13.14A-D
D
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Part 2 Site-Specifi c Indications and Techniques
FE
G
Figure 13.14E-H
H
Background Data
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Chapter 13 Salivary Glands
243
Table 13.9
Distribution by No. of Patients
By histologic fi ndings
Adenoid cystic 174 1 13 10 24 (14%)
Mucoepidermoid 76 — 12 11 23 (30%)
Solid duct
Adenocarcinoma 106 — 19 11 30 (28%)
Variants of duct
Adenocarcinoma 37 1 4 4 9 (24%)
Malignant mixed 13 1 3 1 5 (38%)
Acinic cell 2 — — — —
Oat cell 14 — 5 2 7 (50%)
Colonic type 12 — 1 — 1 (8%)
Anatomic site
Palate 140 — 10 12 22 (16%)
Sinuses or nasal 127 1 9 9 19 (15%)
Tongue 52 1 15 6 22 (42%)
Cheek or lips 40 — 4 2 6 (15%)
Gingivae 29 — 2 4 6 (21%)
Floor of the mouth 17 — 5 2 7 (41%)
Larynx 15 1 5 4 10 (67%)
Tonsil 11 — 7 — 7 (65%)
Pharynx 3 — — — —
Total 434 3 57 39 99 (23%)
Modifi ed from Spiro RH, Koss LG, Hajdu SI, et al. Tumors of minor salivary origin. A clinicopathologic study of 492 cases. Cancer 1973;31:117.
Cervical Node Metastases in 434 Patients with Malignant Tumors of Minor Salivary Gland Origin
Metastases Previously
Excised
Present on
Admission Appeared Later
Total with
Metastases
Table 13.10
First Author, Year Patient Number Adenoid Cystic Carcinoma (%) 10-yr Local Control Rate (%)
Garden, 1994 160 71 86
Le, 1999 54 59 88
Cianchetti, 2009 76 58 86
Local Control of Minor Salivary Gland Carcinomas Treated with Postoperative Radiation
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