Salivary+Gland

**Malignancies of the parotid glands account for between 80% and 90% of salivary gland malignancies. 44% of the time, the nodes will be involved upon diagnosis. [2] High grade tumors have a significantly higher rate of lymph node metastasis compared to low grade tumors. Less advanced tumors in the larger glands have the best prognosis**. || **There are several histologic classifications of malignant salivary gland tumors. They are as follows: **
 * //**SALIVARY GLANDS**// || =[[image:wiki_head-and-neck-glands.jpg]]= ||
 * Epidemiology: || **Annually, in North America, salivary gland malignancies account for less than 3% of all cancers and less than 7% of head and neck cancers diagnosed. [1] 4 out of 100,000 people are diagnosed with salivary gland cancer in the entire population. Men and women are at equal risk of being diagnosed with salivary gland cancer, with ages between 53-55 being the most common upon diagnosis. A higher incidence of salivary gland cancer has been seen in: **
 * **Arctic Inuits with a low intake of vitamins A and C **
 * **In people previously irradiated for benign conditions such as acne **
 * **Caucasians with the Epstein-Barr Virus **
 * **Survivors in Hiroshima and Nagasaki who were exposed to radiation from the atomic bombs **
 * Etiology: || **Although the actual causes of salivary gland cancer are unknown, several things have been associated with it, including:**
 * **Nutritional Deficiencies**
 * **Exposure to both ionizing and ultraviolet radiation**
 * **Genetics**
 * **History of other cancers**
 * **Viral Infection**
 * **Alcohol use** ||
 * Signs & Symptoms: || **The most common symptom of salivary gland cancer is a painless, palpable mass that persistently grows. Even though only 10% of patients complain of facial pain, 25% of new diagnoses have facial nerve involvement. [2]** ||
 * Diagnostic Procedures: || **The diagnostic workup for salivary gland cancer includes:**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**History and physical with much importance placed on the palpation of the head and neck**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**Computed Tomography scans can reveal the extent of the disease**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**Magnetic resonance is used to help distinguish between tissues**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**Salivary gland malignancies, which have been known to be very heterogeneous, are biopsied with an open technique, and upon confirmation are surgically removed. [2]** ||
 * Histology: ||  || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">According to Gunderson & Tepper the origin of most salivary cancers is thought to be the excretory and intercalated ducts.Histologic subtype predicts the behavior of salivary tumors. Low-grade tumors simulate benign conditions and high-grade tumors present with pain, are hard & fixed and are very aggressive. High-grade tumors often metastasize and require aggressive treatment.6 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Carcinoma ex pleomorphic adenoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Mixed tumors arise from existing benign tumors, which can be aggressive and present with regional lymph node metastasis. 6 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Adenoid cystic carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Solid-type/high-grade tumors often have perineural invasion in 50% of cases. 6 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Mucoepidermoid carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Typically arise within the minor salivary glands and present with lymph node metastasis. **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Low-grade tumors are slow growing and rarely invade regional or local structures. **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">High-grade tumors are locally aggressive which commonly metastasize to regional lymph nodes. 6 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Adenocarcinoma (NOS) **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">High-grade often with lymph node metastasis, lung metastasis and bone metastasis. **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Low-grade tumors behave less aggressively and often arise from the minor salivary glands. **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Most common ex pleomorphic adenoma. 6 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Acinic cell carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Typically low-grade slow growing tumors that arise from the parotid gland. These tumors may invade bone, blood vessels, nerves and the skin. 6 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Undifferentiated Acinic cell carcinomas are widely invasive and metastasize early, as they are highly malignant. 6 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Squamous cell carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">High-grade aggressive tumors, which present with deep fixation and facial nerve palsy. 6 **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Myoepithelial carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Cystadenocarcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Small cell carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Polymorphous low-grade Adenocarcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Epithelial Myoepithelial carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Clear cell carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Basel cell Adenocarcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Salivary duct carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Carcino-sarcoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Metastasizing pleomorphic adenoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Large cell undifferentiated carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Lymphoepithelial carcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Rare histologic subtypes **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Malignant sebaceous tumors **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Mucinous Adenocarcinoma **
 * **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Oncocytic carcinoma ** ||
 * <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Sialoblastoma6 **
 * Lymph Node Drainage: ||  ||  **__<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Major Lymph Node Chains of Head7 __**  ||
 * Lymph Node Drainage: ||  ||  **__<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Major Lymph Node Chains of Head7 __**  ||





** The parotid gland lymphatic’s include: the subparotid, paraparotid, tail of parotid, Submandibular, upper jugular, subdigastric, middle & lower jugular and posterior triangle lymph nodes. 6 ** ||
 * ||  || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Salivary Glands Lymph Node Chains: **
 * ** Submandibular **
 * ** Submaxillary **
 * ** Submental **
 * ** Deep cervical **
 * ** Cervical **
 * ** Cervical **
 * <span style="color: #7030a0; font-family: 'Calibri','sans-serif'; font-size: 15px; line-height: 115%;">The lymphatic’s of the mandibular gland include: the Submandibular, subdigastric, and high and middle jugular lymph nodes. 6 **
 * Metastatic Spread: || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Gunderson & Tepper state that metastasis occurs more often hematogenously than lymph node metastasis for both major and minor salivary glands. Distant metastasis is common later in the history of the disease. Common sites of involvement include the lungs, bone and liver. Acinic cell carcinomas often metastasize to the lungs, mucoepidermoid to regional lymph nodes, mixed tumors to the lungs and regional lymph nodes, adenoid cystic systemically and undifferentiated and primary squamous cell carcinomas metastasize to regional lymph nodes. 6 ** ||  ||
 * Metastatic Spread: || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Gunderson & Tepper state that metastasis occurs more often hematogenously than lymph node metastasis for both major and minor salivary glands. Distant metastasis is common later in the history of the disease. Common sites of involvement include the lungs, bone and liver. Acinic cell carcinomas often metastasize to the lungs, mucoepidermoid to regional lymph nodes, mixed tumors to the lungs and regional lymph nodes, adenoid cystic systemically and undifferentiated and primary squamous cell carcinomas metastasize to regional lymph nodes. 6 ** ||  ||

**__<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">AJC Staging System: __<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">5 ** **//<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Primary tumor (T) //** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">TX Primary tumor cannot be assessed ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">T0 No evidence of primary tumor ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">T1 Tumor ≤2cm in greatest dimension without extraparenchymal extension ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">T2 Tumor >2cm but not >4cm in greatest dimension without ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">extraparenchymal extension ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">T3 Tumor having extraparenchymal extension without seventh nerve ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">involvement and/or >4cm but not >6cm in greatest dimension ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">T4 Tumor invades base of skull, seventh nerve, and/or exceeds 6 cm in ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">greatest dimension ** **//<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Regional lymph nodes (N) //** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">NX Regional lymph nodes cannot be assessed ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">N0 No regional lymph node metastasis ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">N1 Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">N2 Metastasis in a single ipsilateral lymph node, >3 cm but not >6 cm in ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">greatest dimension, or in bilateral or contralateral lymph nodes, none ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">>6 cm in greatest dimension ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">N2a Metastasis in a single ipsilateral lymph node >3 cm but not >6cm in ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">greatest dimension ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">N2b Metastasis in multiple ipsilateral lymph nodes, none >6 cm in greatest ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">dimension ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">N2c Metastasis in bilateral or contralateral lymph nodes, none >6 cm in ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">greatest dimension ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">N3 Metastasis in a lymph node, >6 cm in greatest dimension ** **//<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Distant metastases (M) //** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">MX Presence of distant metastases cannot be assessed ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">M0 No distant metastases ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">M1 Distant metastases ** **//<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Stage Grouping //** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Stage I T1 N0 M0 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">T2 N0 M0 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Stage II T3 N0 M0 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Stage III T1 N1 M0 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">T2 N1 M0 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Stage IV T4 N0 M0 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">T3 N1 M0 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">T4 N1 M0 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Any T N2 or N3 M0 ** **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Any T Any N M1 ** ||<  ||   ||
 * Grading: || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">The histologic grade is a significant predictor of outcome in salivary gland carcinomas. Because of the many varieties and rarity of these tumors, many grading systems are in use. Most of these grading schemes use general cytomorphologic features (pleomorphism, mitoses, necrosis) and are highly individualized depending on the intuitiveness of the pathologist.4 Two carcinoma types, adenoid cystic and mucoepidermoid, have common grading schemes: ** ||<  ||   ||
 * <span style="color: #002060; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Histologic Grade** || <span style="color: #002060; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Criteria** ||
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Low ** || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Well formed glandular structures or microcysts lined by a single layer of mucus-secreting columnar cellsMay have papillary infoldings ** ||
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Intermediate ** || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Solid areas of epidermoid cells or squamous cells with intermediate basaloid cellsPapillary cystic infoldings of epidermoid or basaloid cells ** ||
 * **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">High ** || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">Majority of cells present as solid nests and cords of intermediate basaloid cells and epidermoid cellsProminent nuclear pleomorphismCystic component usually <20%Rare glands although occasionally the glandular component may predominateMore mitotic figures (usually >4/10hpf), necrosis, and perineural invasion ** ||<  ||
 * Staging: || **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px;">The American Joint Committee on Cancer (AJCC) staging system for major salivary glands is based on size, extension, and nodal involvement. No major staging system has been developed for minor salivary glands, but like the major glands, the degree of local extension and/or metastasis to lymph nodes has a great bearing on the prognosis of the disease.3 **


 * Radiation Side Effects: ||  || **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Xerostomia **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Trismus **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Otitis media **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Hair loss **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Skin erythema & desquamation **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">dental problems **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">taste loss **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">hypothyroidism **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">mucositis **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">oral candidiasis **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">esophagitis **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">CN palsy **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">2nd malignancy6,7 ** ||

<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 0px; overflow: hidden;"> ||< **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Figure 1. Typical lateral field setup for parotid tumor treatment.11 ** ||
 * Prognosis: ||  || **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Survival is influenced by tumor grade, postsurgical residual disease, tumor size (larger is worse), facial nerve invasion, and presence of +cervical nodes.8 Patterns of failure are related to high rates of distant metastases.2 **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Patients with mucoepidermoid well-differentiated carcinomas and acinar cell carcinomas have the best prognosis, while patients with squamous cell carcinoma and adenocarcinoma have the worst. 2 ** ||  ||
 * Treatments: ||  ||< **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Surgical excision is the number one treatment choice; followed by postop RT.8 Complications include facial nerve dysfunction and Frey's Syndrome.2 Low-grade parotid tumors are treated with a superficial parotidectomy unless the lesion begins in the deep lobe. **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Low-grade tumors do not warrant a neck dissection. Patients who have clinically +nodes or high-grade, advanced stage disease qualify for neck dissection. A nerve-sparing surgery is done if the facial nerve is uninvolved with the tumor; if the facial nerve is involved with the tumor the facial nerve is reconstructed during surgery to decrease the chance of postop facial palsy.8 **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">No adjuvant chemotherapy2 **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Postop RT is indicated for microscopic or macroscopic residual disease, recurrent cancer, and high-grade, advanced stage cancer. **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Parotid cancer local control is 87% with postop RT2 **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">RT alone is used for cases that are inoperable & unresectable **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Utilizing neutron therapy, 67% local control for major salivary gland & 50% local control for minor salivary gland8 **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Resectable T1-2 N0, superficial: observation if low-grade. **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Surgery alone; or postop RT if adenoid cystic or high-grade **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Resectable T3-4 N+: surgery with neck dissection for +LN or high-grade **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">postop RT for close and/or +margins **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 0px; overflow: hidden;">﻿ **




 * **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Figure 2. A typical lateral field for a parotid tumor treatment.10 ** ||

<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;"> <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">
 * [[image:Scan0002.jpg width="800" height="483"]] || **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Figure 3. Isodose distribution from 4 MV photon (50%) and a 14 MV electron (50%) beams to treat a parotid tumor. Solid lines represent dose from photon beam and hatched lines the electron beam.10 **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Figure 4. Isodose distribution from anterior and posterior oblique fields with 45 **** ˚ ****<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;"> wedges to treat a parotid tumor with 6 MV photons. A = tranverse plane. B = coronal plane. C---lateral field added to reduce the anterior and posterior dose with fields equally weighted.10 ** ||


 * TD5/5: ||  || **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Malignant Tumors of Parotid: Factors Affecting 5-YR Absolute Cure Rate (288 patients)9 **
 * __<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Factor Patients No Evidence of Disease@5 YR in % __**
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">facial nerve intact 212 66% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">nerve palsy 43 14% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">tumor spill 32 58% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">no tumor spill 256 50% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">(-) neck (N0) 157 74% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">(+) neck (N+) 57 9% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">(+) neck delayed 18 17% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">no local recurrence 194 79% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">local recurrence 71 21% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">note; Memorial-Sloan Kettering date; patients treated 1939-1968 **
 * __<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Parotid Cancer Absolute 5 YR Survival (120 patients)9 __**
 * __<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Histologic Type Patients 5YR Survival (%) __**
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">acinic cell 12 92% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">mucoepidermoid (low-grade) 28 76% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">adenocarcinoma 12 66% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">malignant mixed 27 50% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">squamous cell 6 50% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">mucoepidermoid (high-grade) 13 46% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">undifferentiated 12 33% **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">note: M.D. Anderson Hospital data; patients treated 1944-1965 **
 * __<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Adenoid Cystic Carcinoma __**
 * __<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Initial Tx Patients No evidence of disease @ 5 years9 __**
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">surgery 19 6 patients **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">surgery & RT 35 23 patients **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">RT alone 8 0 patients **
 * <span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Note: Princess Margaret Hospital data, Toronto; major salivary glands=50 patients, minor salivary glands=12 patients. ** ||

__**REFERENCES:**__


 * # **<span style="color: #31849b; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Gunderson L, Tepper J. Clinical Radiation Oncology. Churchill Livingstone. Philadelphia PA. 2000: 518-534. **
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 * 2) **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Mucoepidermoid Carcinoma. The Doctor’s Doctor Web site. ****<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%; text-decoration: none;">http://www.thedoctorsdoctor. com/ diseases/mucoepidermoid_ca.htm#gross ****<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">. Accessed June 1, 2011. **
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