NEOPLASIAS DE GLNDULAS SALIVARES-estudo clinicopatolgico e

indicadores de prognstico.

Resumo

Os tumores de glndulas salivares (TGS) ainda que incomuns, compreendem uma importante rea da Patologia. A ampla variedade de comportamento biolgico e a grande diversidade morfolgica que estes tumores apresentam, suscitam, muitas vezes, dificuldades de diagnstico, classificao e tratamento ( Speight, 2007). As neoplasias de glndulas salivares correspondem a 2 a 6,5% dos tumores da regio de cabea e pescoo, sendo a maioria de origem epitelial, podendo apresentar variadas caractersticas clnicas e histopatolgicas. Dentro do espectro de neoplasias malignas epiteliais originadas em glndula salivar, segundo a OMS (Barnes et al. 2005) so reconhecidos os seguintes tipos histolgicos:Carcinoma mucoepidermide, Carcinoma adenoide cstico, adenocarcinoma polimorfo de baixo grau, carcinoma epitelial-mioepitelial, carcinoma de clulas claras, carcinoma mioepitelial, adenocarcinoma de clulas basais, cistoadenocarcinoma, carcinoma oncoctico,adenocarcinoma mucinoso,carcinoma do ducto salivar, carcinoma exadenoma pleomrfico,adenoma pleomrfico mestatizante e carcinossarcoma, Por sua vez, embora o adenoma pleomrfico seja uma neoplasia benigna, merece destaque o seu estudo uma vez que a mesma pode apresentar comportamento biolgico agressivo representado pelo o alto ndice de recidiva e capacidade de transformao maligna razo pela qual tambm ser includo no presente estudo. Dentre as diversas neoplasias malignas que acometem as glndulas salivares, merece destaque o carcinoma mucoepidermide por ser o mais frequente, ocorrendo tanto em adultos quanto em crianas, caracterizado pela presena de clulas mucosas, intermedirias e epidermides.Ele o mais frequente tanto nas glandulas salivares maiores como menores ( Whitt, Schafer, Callihan, 2008). A maioria dos casos ocorre em glndulas salivares maiores, nesta ordem decrescente de acometimento: partida, submandibular e sublingual; alguns casos tem sido documentados em glndulas salivares menores preferencialmente as do palato, mucosa jugal, lbios, regio retromolar e lingua (GonzlezArriagada et al., 2011). A etiologia ainda no est bem esclarecida mas, fatores genticos, exposio a radiao e fumo so citados como importantes (Florian et al., 2008; Liu et al., 2009). O tratamento do carcinoma mucoepidermide determinado pela localizao, grau histopatolgico e estgio clinico do tumor, embora de forma geral seja preconizada cirurgia.

Quando as leses esto em estgio inicial e localizadas em glndula partida, o tratamento realizado pela parotidectomia subtotal e preservao do nervo facial. Nos estgios avanados, se faz necessrio a remoo total da glndula partida, com a remoo do nervo facial. Os tumores de glndula submandibular so tratados pela remoo cirrgica da glndula envolvida e quando em glndulas salivares menores, so usualmente tratados pela exciso cirrgica (Neville et al., 2009). Com relao ao prognstico deste tipo de neoplasia, muitos pacientes tm prognstico desfavorvel, sendo descrito que 8% destes morrem decorrentes desta neoplasia, sendo 11% em glndulas salivares maiores e 5% em glndulas salivares menores. Segundo ainda a literatura, morte decorrente do carcinoma mucoepidermide de alto grau histopatolgico ocorre quando em tumores de glndula salivar menor e partida, mas no quando a glndula envolvida a submandibular (Barnes et al.,2005). O carcinoma adenide cstico um dos mais comuns tumores malignos de glndula salivar compreendendo cerca de 20% de todas as neoplasias malignas desta localizao. O tumor merece destaque devido ao seu aspecto microscpico, comportamento biolgico, ndice de recidiva e disseminao sistmica (Bianchi et al., 2008) acometendo principalmente pacientes na quinta e sexta dcadas de vida e raramente crianas e adolescentes so afetados (da Cruz Perez et al., 2006). Para alguns autores no h predileo de ocorrncia em relao ao sexo enquanto que para outros o tumor mais comum em homens (da Cruz Perez et al., 2006). Alguns autores encontraram uma alta prevalncia no sexo feminino para os casos localizados na glndula submandibular (Barnes et al.,2005). A leso ocorre em glndulas salivares especialmente no palato, partida, submandibular e sublingual (da Cruz Perez et al., 2006), bem como, em outros locais como as glndulas lacrimais, esfago e rvore traqueobrnquica (Rapidis et al., 2005). O tratamento de escolha para o carcinoma adenoide cstico a resseco total e o valor de outras modalidades de terapias adjuvantes permanece controverso. O tipo de tratamento varia de acordo com o estgio do tumor, sendo a cirurgia e radioterapia pscirrgica os mtodos mais frequentemente utilizados seguido de apenas cirurgia. O adenoma pleomrfico a neoplasia mais frequente das glndulas salivares maiores e menores. Segundo Pires et al. (2007), estes tumores correspondem a 33% de todas as neoplasias benignas e malignas, 30% das neoplasias em partidas e 33% de todas as neoplasias de glndulas salivares menores. De acordo com Eveson et al. (2005), este tumor representa em torno de 60% de todas as neoplasias de glndula salivar, sendo relatada uma incidncia anual de 2,4-3,05 por 100.000 pessoas.

A neoplasia ocorre geralmente entre a quarta e a sexta dcadas de vida, em indivduos com idade mdia de 46 anos, tendo uma leve predileo pelo sexo feminino, apresentando-se tipicamente como uma massa firme de crescimento lento e indolor. A maioria dos casos ocorre na glndula partida e quando acomete as glndulas salivares menores, o palato a localizao mais freqente, seguido pelo lbio superior e mucosa jugal (Pires et al., 2007).

O adenoma pleomrfico composto de clulas epiteliais e mioepiteliais que se arranjam em ninhos, cordes, lenis celulares e estruturas ductiformes que se organizam em diversos padres conferindo ao tumor uma ampla diversidade citomorfolgica e arquitetural (Dardick, 1996; Eveson et al., 2005). O componente epitelial do adenoma pleomrfico demonstra uma variedade de tipos celulares incluindo clulas cuboidais, basalides, escamosas, fusiformes, plasmocitides e clulas claras. Raramente clulas mucosas e sebceas so evidenciadas. Este componente forma ninhos, estruturas tipo ductos e reas hipercelularizadas que podem compor o maior volume tumoral (Eveson et al., 2005). Normalmente, o adenoma pleomrfico circunscrito e encapsulado. No entanto, essa cpsula pode ser incompleta ou mostrar infiltrao pelas clulas tumorais, principalmente nos TGS menor (Eveson et al., 2005). A presena de extenses focais do tumor para a cpsula muito comum nos adenomas pleomrficos, sendo um dos seus critrios diagnsticos (Dardick 1996; Eveson et al., 2005).
O risco de transformao maligna nos adenomas pleomrficos foi relacionado aos casos com longo tempo de evoluo e/ou aqueles submetidos a vrias cirurgias e com histria de recorrncias (Lewis et al., 2001). A taxa total de transformao maligna do adenoma pleomrfico foi estimada em cerca de 6 a 13% dos casos ). De acordo com a literatura, quando ocorre a transformao maligna do adenoma pleomrfico, o carcinoma ex-adenoma pleomrfico a sua contraparte maligna mais frequentemente encontrada. O tumor apresenta um comportamento agressivo, que geralmente est associado a metstases regionais e a distncia em pulmes, ossos e vsceras que podem levar a um desfecho fatal ( Eveson et al., 2005). O tratamento indicado para os adenomas pleomrficos a exciso cirrgica, porm na glndula partida, essa remoo complicada devido presena do nervo facial. Assim, nos tumores do lobo superficial recomenda-se a parotidectomia superficial com preservao do nervo facial, enquanto que no lobo profundo, se faz necessria a exciso total da glndula junto com o tumor (Eveson et al., 2005).

OBJETIVOS Frente a diversidade de aspectos morfolgicos que os tumores de glndula salivar apresentam e ao comportamento biolgico variado dos mesmos, dificultando muitas vezes o tratamento e, consequentemente, o prognstico dos pacientes portadores deste tipo de tumor, procuraremos na presente pesquisa realizar um levantamento de todos os casos de neoplasias malignas de glndula salivar diagnosticadas no servio de patologia da Liga Norteriograndense Contra Cncer, avaliando os seus achados clnicos e tipos histolgicos, o tratamento institudo em cada caso e a evoluo /acompanhamento durante no mnimo 3 anos aps concludo o tratamento com a finalidade de estabelecer parmetros de comparao entre tipo histolgico X tratamento institudo e prognstico destas leses. No mesmo estudo, analisaremos tambm os casos de Adenoma Pleomrfico, que embora sendo uma neoplasia benigna pode apresentar comportamento diferente pela capacidade de recidiva e sofrer transformao maligna.

MATERIAL E MTODOS
Para este estudo, sero utilizados os casos de neoplasias de glndula salivar, diagnosticados no Servio de Anatomia Patolgica da Liga Norteriograndense Contra Cncer, diagnosticados no perodo de janeiro de 1970 a dezembro de 2009. A partir das fichas de requisio de bipsias, sero coletados os dados clnicos referentes idade e gnero dos pacientes e localizao anatmica das neoplasias de glndulas salivares. Dos pronturios mdicos sero coletadas as informaes referentes ao tipo histolgico das leses, o tratamento institudo para o caso e o prognstico avaliado atravs da avaliao da evoluo do caso e sobrevida ou no do paciente. Para o estudo histopatolgico, sero utilizadas lminas contendo cortes com 5m de espessura, coradas pela tcnica de rotina da hematoxilina e eosina, mantidas em arquivo. Todos os casos sero avaliados sob microscopia de luz, sendo classificados de acordo com os critrios propostos pela Organizao Mundial da Sade (OMS), em sua recente publicao. (Barnes et al. 2005).

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