CASE PRESENTATION

SUBMANDIBULAR TUMOR

Compiled by:
Azizah Fitriayu Andyra
(1102014055)

Advisory Lecturer:
dr. Herry Setya Yudha Utama, Sp.B, M.H.Kes, FInaCS

Clinical Rotation in Department of Surgery

Arjawinangun Regional General Hospital
Faculty of Medicine YARSI University
2019
 CASE PRESENTATION

I. IDENTITY
Date of Hospital Entry: February 4th 2019
Name : Mr. S
Age : 38 years old
Gender : Male
Occupation : Labore
Address : Kaliwedi
Religion : Moslem
Marital Status : Single

II. ANAMNESIS
Main Complaint
Lumps on the right neck since ± 1 month before admitted to the hospital

Current Medical History

Mr. S, 38 years old, came to Arjawinangun Regional Public Hospital to
complained about lumps on the right neck that arose and began to swell since 1
month before admitted to the hospital. There is only one lumps initially, but then it
multiplied and now there are two. The lumps getting bigger as time goes by and
became the size of a pebble. Lumps also accompanied by pain and interfered with
swallowing which disturbed the process of eating and drinking. Patient admit that
the lumps cause difficulty in speaking and salivating more than usual. Patient deny
the presence of redness, swollen and warm sensation. Patient has lose some weight,
had fever, and sweating especially in the night. Patient had surgery on 6th February
2019. At this time, patient felt a slight pain due to a surgical suture.

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 Past Medical History
Patient deny of having these symptoms in the past. Patient has consume treatment
for lung disease for a month.

Family Medical History

There is no family member with the same condition or complaint as patient

III. `PHYSICAL EXAMINATION

a. Generalized Status
General Condition : Mild pain
Awareness : Composmentis
Blood Pressure : 110/70 mmHg
Pulse : 78 x/minute, reguler
Respiratory : 20 x/minute
Temperature : 37,40C

Head
Form : Normocephale
Hair : Black, hairfall (-)
Eyes : Anemic conjunctiva (-/-), icteric sclera (-/-), light
reflexes (+/+), isochore pupil right = left
Ears : Normal form, cerumen (-), tympanic membrane
intact
Nose : Normal form, septum deviation (-), epistaxis (-/-)
Mouth : Normal

Neck
Trachea in the middle

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Pulmonary
Inspection : The chest is symmetrical both left and right
Palpation : Vocal and tactile fremitus are symmetrical, crepitation (-),
tenderness (-), rebound tenderness (-)
Percussion : Resonant sound in both lung fields

Auscultation : Vesicular and bronchial sound in the entire lung field,

rhonchi (+/+), wheezing (-/-)

Cor
Inspection : Ictus cordis is not appear
Palpation : Ictus cordis is palpable on the 5th intercostal space, left
midclavicular line
Percussion : Right border of the heart is on the 4th intercostal space,
right parasternal line
Left border of the heart is on the 5th intercostal space, left
midclavicular line
Top left border of the heart is on the 2nd intercostal space,
left parasternal line
Auscultation : Regular S1 and S2 , murmur (-), gallop (-)

Abdomen
Inspection : Flat, symmetrical, mass (-)
Auscultation : Intestine sound (+)
Palpation : Tenderness (-), rebound tenderness (-)
Percussion : Tympani sound in four quadrants of abdomen

Upper extremities
Muscle tone : Normal
Movement : Active / active

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 Mass :-/-
Strength : 5555 / 5555
Oedema :-/-

Lower extremities
Muscle tone : Normal
Movement : Active / active
Mass :-/-
Strength : 5555 / 5555
Oedema :-/-

b. Localized Status
Regio : Neck
Inspection : The surgical scar is covered by wound dressings

IV. LABORATORY EXAMINATION

Date : 4th February 2019
Reference
Test Result Unit
Value
HEMATOLOGY
Haemoglobin 10.9 (L) g/dL 13.2-17.3
Leukocyte 16.0 (H) 10^3μL 3.8-10.6
Trombocyte 471 (H) 10^3μL 150-440
Hematocrite 33.4 (L) % 40-52
Erithrocyte 3.87 (L) 10^6μL 4.4-5.9
MCV 86.3 fL 80-100
MCH 28.2 Pg 26-34
MCHC 32.6 d/dL 32-36
RDW 13.7 % 11.5-14.5
MPV 5.9 (L) fL 7.0-11.0

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 BLOOD COUNT (DIFF)
Segment 28.0-78.0
Limphocyte 94.3 (H) % 25-40
Monocyte 3.4 (L) % 2-8
Eosinophil 1.9 (L) % 2-4
Basophil 0.3 % 0-1
Luc 0 % 3-6
COAGULATION
Clotting Time 3’ minutes 2–6
Bleeding Time 1’30” minutes 1–3
CLINICAL CHEMISTRY
Random blood glucose 109 mg/dL 75 – 140
IMMUNOLOGY
Quantitative HBsAg 0.01 S/CO Negative < 0.13
Anti HIV Non reactive Non reactive

Chest X-Ray
Date : 11th December 2018
Semiopaque infiltrate at dextra superior lobe, air bronchogram (+)
Tapered costophrenicus angle
Cor: CTR <0.5
Diaphragms has smooth rounded contour
Bone structures are intact
Impression: Superior dextra lobar pneumonia dd/lung mass

V. DIAGNOSIS
Submandibular tumor

VI. DIFFERENTIAL DIAGNOSIS

Tuberculous lymphadenitis
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VII. TREATMENT
Kabiven intravenous fluid 25 drops/minute
Parenteral Cefazolin 3x1
Parenteral Ketorolac 2x1
Parenteral Ranitidine 3x1
Oral TB regimen
Chemotherapy

VIII. PROGNOSIS
Quo ad vitam : dubia ad bonam
Quo ad sanationam : dubia ad bonam
Quo ad fungsionam : dubia ad bonam

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 LITERATURE REVIEW

A. SALIVARY GLANDS ANATOMY

Salivary glands serve to produce saliva, a fluid found in the mouth and
throat. Saliva contains enzymes that serve to help digest food. Saliva also serves to
block the occurence of infection in the mouth and throat. There are two kinds of
salivary glands, namely the major salivary glands and minor salivary glands.

Major Salivary Glands

Parotid gland is the largest salivary gland with the size of 5.8 x 3.4 cm. 80%
of these glands are located above m. Masseter and mandible, another 20% in
retromandibula. The parrot tail is located at the top ¼ m. Sternocleidomastoideus
and extends to the mastoid process. The parotid gland is connected to the oral cavity
through the Stensoni ducts and empties into the buccal mucosa as high as the upper
two molars. The cranial nerve VII (facial nerve) that functions motorically for the
facial muscles, enters the parotid gland and divided into 2 surgical zones
(superficial and deep lobes).
This facial nerve in the parotid gland branches into 5, namely: the temporal
branch to the frontal muscle; branch of zygoma to muscle orbicularis oculi; buccal

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branches to the facial muscles and upper lip; mandibular branches to the muscles
of the lower lip and chin; the cervical branch to the platisma muscle. The
auriculotemporal nerve, which is a branch of the mandibular nerve, runs parallel to
the superficial temporal artert and vein. This nerve carries parasympathetic fibers
to the parotid if the injury will result in Frey’s syndrome. This nerve also causes the
spread of malignant parotid tumors to the cranial and intracranial bases through its
perineural sheath (Suyatno and Emir TP, 2010).
The arteries adjacent to this gland are the external carotid artery, the internal
maxillary and the superficial temporalis. The drainage is through the deeply located
retromandibular vein of the facial nerve. While the lymphatic drainage through the
lymph nodes located within the parotid and paraparotid (Tjakra, 2010).

The submandibular glands weigh half of the parotid gland. Located within
the submandibular triangle formed by m.anterior and posterior digly of the belly
and the inferior edges of the mandibular ramus. The facial nerve of the mandibular
marginal branch runs superficially from these and inner glands of m. Platisma. The
submandibular duct (Wharton’s duct) exits the medial surface of this gland and runs
between the m. Milohioid (lateral) and hioglossus and to m. Genioglossus. This
duct enters the lateral oral cavity of the lingual frenulum. The lingual nerve feels

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around Wharton’s, while the parallel hypoglossal nerve with the ducts, runs
inferiorly from the ducts (Suyatno and Emir TP, 2010).

The artery that enters the submandibular gland is the submental branch of
the facial artery (the branch of the external carotid artery). The drainage is through
a facial vein, which passes through the lateral surface of this gland. Lymphatic
drainage runs to the deep cervical lymph nodes and jugular chain (Suyatno and Emir
TP, 2010).
The sublingual gland, the most minor salivary gland. Located below the
basic mucosa of the mouth between the mandible and m. Genioglossus. The inferior
part is m. Mylohioid. The Wharton’s duct and the lingual nerve pass through the
sublingualis and m. Genioglossus. This gland lacks a capsule, unlike the parotid
gland and the submandibular gland. This glans also lacks the dominant duct, its
drainage through approximately 10 small ducts (Rivinus duct) and empties into the
sublingual creases at the floor of the mouth (John and Harri, 2007).
The artery supplying this gland is the sublingual branch of the lingual artery
and the submental branch of the facial artery. Lymphatic drainage leading to the
submandibular lymph nodes (Suyatno and Emir TP, 2010).

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 Minor Salivary Glands
The minor salivary gland is a gland different from the major salivary glands,
i.e. has no duct. The minor salivary glands are concentrated in the buccal, labial,
palatal and lingual regions. Minor salivary glands may also be found in the upper
pool of tonsils (Weber’s gland), tongue base (von Ebner’s gland), paranasal sinuses,
larynx, trachea and bronchi. Most of these glands are present in palate, upper lip
and cheeks. Most minor salivary glands receive innervation from the lingual nerve,
except for glands in the palate that receive the innervation of the palatine nerve
(Kuppersmith, 1995).

B. EPIDEMIOLOGY
The salivary gland neoplasm is a benign or malignant neoplasm derived
from the salivary gland epithelium, either the major or minor salivary gland.salivary
gland cancer is 5-7% of all malignancy heads and in the United States there are
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 2000 to 2500 new sufferers per year, whereas in Indonesia the incidence rate is
unknown. 85% of salivary gland tumor are present in the parotif gland (the largest
salivary gland) and 75% are benign tumors which are mostly pleiomorphic
adenomas (benign mixed tumors) and with a smaller incidence of a monomorphic
adenoma (Wartin’s tumor). While the other major salivary glands such as the
submandibularis salivarius gland are 50% incidents as malignant/cancerous tumors
and in subllingual sublosts almost all are malignant/cancerous (Tjakra, 2010).
It was said to be the etiology of salivary gland cancer is exposure to radiation
especially the type of mucoepidermoid carcinoma. While adenocarcinoma which
occurs in the nasal cavity or sinus paranasales (especially sinus ethmoidalis) is
associated with exposure to wood dust and is often found in wood industry workers
(Tjakra, 2010). The incidence of salivary gland cancer continues to increase with
age and the incidence of this cancer in patients <16 years is 2% (Futran et al, 2009).
The likelihood of exposure to male salivary glands is equal to female. It is
rare in children but the frequency of malignacy is more common in children.
Approximately 35% of salivary gland tumors in children are mallignant, the most
common type is mucoepidermoid carcinoma. Tumor or cancer of the salivary gland
is often correlated with gender, which results from no predilection of sexual data
except in monomorphic adenoma (Warthin’s tumor) found five times in men
(Tjakra, 2010).

C. CLASSIFICATION OF TUMOR
Clinical stage determination was established on the basis of TNM (Tumor,
Nodule, Metastase) from AJCC (American Joint Committee on Cancer) in 2002,
with revisions that have been made several times. This is due to new technology in
the diagnosis and staging of cancer, the presence of new painting techniques with
monoclonal antibody and molecular biology technique (PCR/RT-PCR). The
proposed TNM classification is in tumor/malignancy of the parotid salivary gland,
which can also be used in other salivary gland malignancy.

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Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor ≤2 cm in greatest dimension without extraparenchymal extension*
T2 Tumor >2 cm but not more than 4 cm in greatest dimension without
extraparenchymal extension*
T3 Tumor >4 cm and/or tumor having extraparenchymal extension*
T4 Moderately advanced or very advanced disease
T4a Moderately advanced disease
Tumor invades the skin, mandible, ear canal, and/or facial nerve
T4b Very advanced disease
Tumor invades skull base and/or pterygoid plates and/or encases carotid artery
*Extraparenchymal extension is clinical or macroscopic evidence of invasion of soft
tissues. Microscopic evidence alone does not constitute extraparenchymal extension for
classification purposes.

Nodes (N)
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node ≤ 3 cm in greatest dimension and
ENE (-)
N2 Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in
greatest dimension and ENE (-);
or metastases in multiple ipsilateral lymph nodes, none > 6 cm in greatest
dimension and ENE (-);
or in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension and
ENE (-)
N2a Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in
greatest dimension and ENE (-)
N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension
and ENE (-)
N2c Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest
dimension and ENE (-)
N3 Metastasis in a lymph node > 6 cm in greatest dimension and ENE (-); or
metastasis in any node(s) with clinically overt ENE (+)
N3a Metastasis in a lymph node > 6 cm in greatest dimension and ENE (-)
N3b Metastasis in any node(s) with clinically overt ENE (+)
Pathological N (pN)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node ≤ 3 cm in greatest dimension and no
extranodal extension (ENE [-])
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 N2 Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension
and ENE (+);
or a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest
dimension and ENE (-);
or metastases in multiple ipsilateral lymph nodes, none > 6 cm in greatest
dimension and ENE (-);
or in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension and
ENE (-)
N2a Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension
and ENE (+);
or a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest
dimension and ENE (-)
N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension
and ENE (-)
N2c Metastasis in bilateral or contralateral lymph node(s), none > 6 cm in greatest
dimension and ENE (-)
N3 Metastasis in a lymph node > 6 cm in greatest dimension and ENE (-);
or in a single ipsilateral node > 3 cm in greatest dimension and ENE (+);
or multiple ipsilateral, contralateral, or bilateral nodes, any with ENE (+);
or a single contralateral node of any size and ENE (+)
N3a Metastasis in a lymph node > 6 cm in greatest dimension and ENE (-)
N3b Metastasis in a single ipsilateral node > 3 cm in greatest dimension and ENE (+);
or multiple ipsilateral, contralateral, or bilateral nodes, any with ENE (+);
or a single contralateral node of any size and ENE (+)

Distant Metastasis (M)

cM0 No distant metastasis
cM1 Distant metastasis
pM1 Distant metastasis, microscopically confirmed

Prognostic Stage Groups

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T0–T3 N1 M0
IVA T4a N0–N1 M0
T0–T4a N2 M0
IVB T Any N3 M0
T4b N Any M0
IVC T Any N Any M1

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 Stadium histopathology WHO (Tjakra, 2010)
Benign
1. Pleomorphic adenoma (Benign Mixed Tumor)
2. Monomorphic adenoma
3. Papillary cyst-adenoma lymphomatous (Warthin’s Tumor)
Malign
1. Mucoepidermoid carcinoma
2. Acinic cell carcinoma
3. Adenoid cystic carcinoma
4. Adenocarcinoma
5. Epidermoid carcinoma
6. Small cell carcinoma
7. Lymphoma
8. Malignant mixed tumor
9. Carcinoma ex pleomorphic adenoma

D. RISK FACTORS
Patient diagnosed with this disease is usually between the age of 50 and 60
years old. Radiation exposure also affect the possibility to increase the risk of
salivary gland tumors especially in patients undergoing treatment with radiation in
the head or neck area. Those who are working in places where there is radiation
exposure also increased the risk of salivary gland tumors. In patients with previous
family history has a higher risk for salivary gland tumors (John and Harri, 2007)

E. DIAGNOSIS
Anamnesis
1. Lumps of the parotid, submandibular and oral mucosal glands (palate,
sublingual)

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2. A lump in the parotid gland is usually located pre-auricular, causing the ears to
rise, pain or not (associated with N. Trigeminal), the presence or absence of bell’s
palsy associated with parotid malignancy
3. Paralysis n. Fascialis is present in approximately 2-3% of parotid malignancies
4. Dysphagia, throat pain and hearing loss are associated with malignant profundus
lobes with extension to the oropharynx
5. Paralysis n. Glossopharyngeus, n. Vagus, n. Hypoglossus, n. Accesories, truncus
sympathicus (Horner’s Syndrome) associated with parotid malignancy with
extension on the nerve
6. The presence of lymph nodes of the neck enlargement, especially at levels I, II,
and III are usually associated with malignant metastases derived from salivary
glands
7. Progression of disease, the rate of growth associated with malignant grading and
tumor size (cancer cells doubling time)
8. Risk factors, exposure to radiation and exposure to radiation and exposure to
leather plant waste or sawdust

Physical Examination
1. Generalist status (examination from head to foot and vital signs)
2. General state (anemia, icterus, cough/shortness of breath, paresus of the
extremities)
3. Performance status (Karnofsky Score)
4. Metastatic signs of lymph nodes, lungs, liver, bone or vertebrae
5. Local status
1. Inspection: the location of the tumor, the shape of the tumor, surrounding
organs and the condition of the skin or mucosa above the tumor. On the
neck, lifted ear lobules/lobules, lymph nodes enlargement. Intra oral such
as blockage of the Stensen’s duct (stone, stricture), mucosal bulge in the
parapharyngeal area or tonsil/uvula cramps

15
 2. Palpation: bimanual palpation is performed to assess the consistency,
surface, mobility, size, limit and tenderness. Also the function of n. VII,
VIII, IX, X, XI, XII
6. Regional status, palpation of lymph nodes neck at all levels, especially at all
levels especially upper level (level I, II, III), both ipsilateral and contralateral. If
there is an enlargement determine the location level, the largest size of lymph
nodes, the number and mobility.

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Investigations
Radiological Examination
- Plain jaw image to determine whether or not the jaw bone (mandibular/maxilla)
is involved in the malignant process of this salivary gland
- To perform a differential diagnosis of jaw bone cyst, jaw bone malignancy
(Ewing Sarcoma, osteosarcoma) and salivary gland tumors (parotid and
submandibular)
- Sialography, made when there is a differential diagnosis of parotid cyst or
submandibular cyst. This examination is needed to see the image of the Stenson’s
duct and its branches. With sialography can be seen there is narrowing or
blockage of the duct, the shadow of the narrowed and fibrotic. Can also be seen
whether the duct structure is pushed or not by a tumor mass.
Radiological examination for staging
- Chest X-ray to see pulmonary metastases
- Abdominal ultrasound
CT-Scan/MRI
- Especially for large salivary gland tumors with limited mobility
- Important for surgical and operability approaches e.g. in parotid tumors of the
profundus lobes and extension into the oropharynx
- Metastases on neck lymph nodes, extension, sometimes to see extracapsular
extension
Biopsy
- FNAB, not yet a standard check, its accuracy varies (60-90%).
- Frozen cut, on operative specimens for operable tumors. In parotid tumors,
frozen cuts are performed from superficial parotidectomy specimens,
submandibular tumors and minor salivary glands from excision specimens
- Excisional biopsy, recommended for sublingual tumors and small salivary gland
tumors, is performed in the form of definitive surgery (wide excision). When an
17
 inoperable tumor is performed and incisional biopsy. An incisional biopsy
should be avoided in an operable tumor to prevent tumor spillage, tumor damage
and facial nerve injury.

F. MANAGEMENT
For benign tumors, excision of the submandibular gland is for diagnosis and
curative purpose and of course with frozen cut to confirm. If the frozen benign
operation is completed and the malignancy is still continuing, the submandibular
dissection (excision of lymphatic level I structure) and frozen are necessary. If the
lymph nodes contain metastases, then it should be followed with radical neck
dissection. The sequence of actions is performed when there is no clinical neck
lymph node enlargement (N0). If no bone is involved with N0 extended
supraomohyoid dissection includes removal of the glandular bed, muscles and
nerves around it. If clinical lymph nodes are palpable, neck dissection is modified
(Albar, et al, 2003).
Neck dissection is performed when there is enlarged clinically naive (n-
positive) lymph nodes. If there is mandibular infiltration, composite resection
(mandibulectomy and one sided neck dissection) is performed. As with parotid
tumors, removal of the hypoglossal nerve and lingual nerve is only done if the
macroscopic has infiltrated the tumor and local extension to the surrounding tissue
(e.g. the base of the mouth, tongue) requires a more radical excision (Suyatni and
Emir TP, 2010).

Radiation
Radiation as primary therapy is indicted in cases of inoperable salivary
gland cancer and as post-operative adjuvant in high grading cancer or recurrence
cases. Adenoid cystic carcinoma, high grade mucoepidermoid carcinoma, high
grade adenocarcinoma, squamous cell carcinoma and lymph node metastases are
the spesific cases requiring adjuvant radiation. Adjuvant radiation is also indicated
in the tumors attached to the nerves (facialis, lingualis, hypoglossus and assesorius),

18
 residual carcinoma, macroscopic or microscopic tumor residue and T3 or T4 stage
cancer. In cases of recurrent or macroscopic pleomorphic adenomas, tumor
spoillagr may be given post-operative radiation. As adjuvant radiation can decrease
local recurrence and increase survival rate, local recurrence decreases from 54% to
14%. The dose of radiation on the primary tumor and covering the incision site is
50-70 Gy (Tjakra, 2010).
Adjuvant radiation on post neck dissection is indicated in all high grade
malignancy, T3 or T4 cancer stage, lymph node containing more than 1 metastase,
and growth of capsule or lymph node with diameter over 3 cm.

Chemotherapy
Chemotherapy cannot be used as a primary therapy for curative purposes in
salivary gland salivary gland cancer. Data and research on the role of chemotherapy
in cancer is still limited. Chemotherapy may be given as an adjuvant or palliative
in metastatic cases. Response to chemotherapy generally ranges from 10-30%.
Doxorubicin and 5-fluorouracil were inferred in response to a retrospective study
(in adenoid cystic carcinoma) but were not proven prospectively. Cisplastin,
paclitaxel, vinorelbin, epirubicin and mitoantrone averaged a response of 10-20%
in prospective studies with metastatic or recurrent cancer samples. The combination
of chemotherapy of chemotherapy containing cisplatin or anthracycline
(cyclophospamide/doxorubicin/cisplatin/vinorelbin, cisplatin/5-FU) will increase
the average response to 20-30% with tolerable toxicity (Tjakra,2010).

G. PROGNOSIS AND FOLLOW UP

Prognosis
In salivary gland cancer, overall 5 years survival is 70-90% at low grading
and 20-30% in high grading tumors. Total recurrence and distant metastases vary
from 15% to 20% and commonly occur in the perineural invasive carcinoma
(adenoid cystic carcinoma). Survival 5 years on beingn tumors reaches 100%, high
risk for recurrence in patients who get adequate surgery.

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 Byers, et al, reported the results of selective rafiation therapy on malignant
submandibula tumors, the mean local control was 64% and the survival rate was
50%. Spiro in another research reported the results of surgery of 129 submandibular
gland cancers with observations of at least 10 years of obtaining a 40% locoregional
and the cause-specific cure rate for 5 and 10 years were 31% and 22%. The benign
submandibular benign tumor operated in operated 106 patients and only 2 cases
were recurrent (Albar, 2003)

Follow Up
It is recommended every 3 months in the first 3 years after the therapy is
completed, then every 6 months for 5 years and continued once a year for life. At
the patient’s annual follow up, things that should be examined completly are:
physical, chest X-ray, abdominal ultrasound and bone scan to determine cancer-
free patients or not. Information to look for at the examination is the length of life
(in years and months), duration of tumor-free intervals, patient complaints,
performance status, disease status (cancer free, residual, metastatic, cancer or new
disease) and therapy including for its complication. In the adenoid cystic carcinoma
that has the pitential to spread along the nerve and metastasize deep into the lungs,
a careful imaging examination (MRI and thoracic photos) should be performed
(Suyatno and Emir TP, 2010).

REFERENCES

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Alber, Z., Tjindarbumi, D., et al. (2003). Protokol PERABOI. Bandung.

American Society of Clinical Oncology. (2011). Salivary Gland Cancer. Retrieved

from: www.cancer.net/cancer-types/salivary-gland-cancer/risk-factor at 8
February 2019

Futran, N., Parvathaneni, U., et al. (2009). Malignant Salivary Gland Tumor, Head
and Neck Cancer:; A Multidisciplinary Approach 3rd Ed. Philadephia:
Lippincott William & Wilkins

John, M. & Harri, P. (2007). Salivary Gland Neoplasm. Emory University Hospital:
eMedicine

Kuppersmith, R. (1995). Minor salivary gland tumor. Department of

Otolaryngology of Baylor College of Medicine

Stevenson, M. (2011). Major Salivary Glands Cancer Staging. Retrieved from:

emedicine.medscpae.com/article2047666-overview at 8 February 2019

Suyatno & Emir, T. (2010). Bedah Onkologi: Diagnosisi dan Terapi. Jakarta: CV
Sagung Seto

Tjakra, W. (2010). Panduan Penalatalaksanaan Kanker Solid PERABOI 2010.

Jakarta: CV Sagung Seto

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