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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 apresentarvariadas 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 ex-

adenoma 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 (Gonzlez-

Arriagada 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, grauhistopatolgico e estgio clinico do tumor, embora de forma geral seja preconizada cirurgia.


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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 ps-cirrgica 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.


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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 soevidenciadas. 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 adistncia 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).


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OBJETIVOS

Frente a diversidade de aspectos morfolgicos que os tumores de glndula salivar

apresentam e ao comportamento biolgico variado dos mesmos, dificultando muitasvezes 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 oscritrios propostos pela Organizao Mundial da Sade (OMS), em sua recente publicao .

(Barnes et al. 2005).


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