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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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