Submandibular Gland Transfer Research Articles

A retrospective evaluation of submandibular gland involvement in oral cavity cancers: a case for gland preservation

The key factor mitigating against prognosis in head and neck cancer is nodal metastasis and its management. Neck dissection has been known to play an integral part in this type of cancer management. Submandibular gland preservation during neck dissection and post radiotherapy, have been known to improve subjective symptoms of xerostomia. The authors retrospectively surveyed the involvement of submandibular gland involvement in oral cancer with a view to confirm oncologic safety of submandibular gland preservation, as a first step in a quest to manage radiation induced xerostomia by submandibular gland transfer. The medical and pathological records of oral cancer patients who underwent surgical treatment at the authors’ centre were reviewed retrospectively. 194 patients were included in the study. 229 submandibular glands were excised from the same number of neck dissections. 3 (1.3%) submandibular glands were involved with malignancies microscopically. The mode of involvement was by direct infiltration. In conclusion, no metastasis to submandibular gland was observed. This may suggest the oncologic safety of submandibular gland preservation and transfer.

A Phase II Study of Submandibular Gland Transfer Prior to Radiation for Prevention of Radiation-induced Xerostomia in Head-and-Neck Cancer (RTOG 0244)

We report the results of a phase II study to determine the reproducibility of a submandibular salivary gland transfer (SGT) surgical technique for prevention of radiation (XRT)-induced xerostomia in a multi-institutional setting and to assess severity of xerostomia. Eligible patients had surgery for primary, neck dissection, and SGT, followed by XRT, during which the transferred salivary gland was shielded. Intensity modulated radiation therapy, amifostine, and pilocarpine were not allowed, but postoperative chemotherapy was allowed. Each operation was reviewed by 2 reviewers and radiation by 1 reviewer. If 13 or more (of 43) were "not per protocol," then the technique would be considered not reproducible as per study design. The secondary endpoint was the rate of acute xerostomia, grade 2 or higher, and a rate of ≤ 51% was acceptable. Forty-four of the total 49 patients were analyzable: male (81.8%), oropharynx (63.6%), stage IV (61.4%), median age 56.5 years. SGT was "per protocol" or within acceptable variation in 34 patients (77.3%) and XRT in 79.5%. Nine patients (20.9%) developed grade 2 acute xerostomia; 2 had grade 0-1 xerostomia (4.7%) but started on amifostine/pilocarpine. Treatment for these 11 patients (25.6%) was considered a failure for the xerostomia endpoint. Thirteen patients died; median follow-up for 31 surviving patients was 2.9 years. Two-year overall and disease-free survival rates were 76.4% and 71.7%, respectively. The technique of submandibular SGT is reproducible in a multicenter setting. Seventy-four percent of patients were prevented from XRT-induced acute xerostomia.

Prevention of radiation‐induced xerostomia by submandibular gland transfer

This study was carried out for the purpose of evaluating the efficacy of submandibular gland transfer to prevent radiation-induced xerostomia. Thirty-eight patients with oropharyngeal carcinoma were recruited. Twenty-six submandibular glands were transferred into the submental space to elude radiotherapy in 24 patients (transfer group); the submandibular gland was not disturbed in the control group (n = 14). The salivary flow rate, xerostomia, and quality of life (QOL) were assessed preoperatively, postoperatively, and after radiotherapy. The swallowing function was then evaluated after radiotherapy. All the transferred glands survived and functioned after radiotherapy. The submandibular salivary flow rate recovered by 6 months after radiotherapy in the transfer group, whereas the flow rate declined drastically after radiotherapy and remained at a low level in the longer term in the control group. Two years after radiotherapy, 92.3% of patients in the transfer group had no or minimal xerostomia. QOL in the transfer group was better than that in the control group from 3 months after radiotherapy. Histologically, the majority of the transferred glands had normal glandular acini and ducts. There was no significant difference in dysphagia between the groups. The submandibular gland can be successfully transferred to the submental space, thus preserving salivary function and preventing radiation-induced xerostomia. The transfer of the submandibular gland can improve the QOL by alleviating xerostomia, although it did not relieve dysphagia in this study.

Establishment of a Rabbit Model for Keratoconjunctivitis Sicca

To establish a rabbit model for keratoconjunctivitis sicca (KCS) to study autologous submandibular gland transfer for treating severe KCS. In 2 groups of 10 rabbits, left eyes were operated and right eyes were controls. In the trichloroacetic acid-treated group, the lacrimal and harderian glands and nictitating membrane were removed surgically; the palpebral and bulbar conjunctiva were swabbed with 50% trichloroacetic acid. In the non-trichloroacetic acid-treated group, the lacrimal and harderian glands and nictitating membrane were surgically removed. The Schirmer test was performed preoperatively and 1, 2, 3, and 4 months postoperatively. Corneal densities of rose bengal and fluorescein staining were scored every month postoperatively. At 4 months, the cornea and bulbar conjunctiva were removed from operated and control eyes for histopathology. The upper bulbar conjunctiva was used to determine goblet cell density. Compared with preoperative conditions, tear secretion of operated eyes significantly decreased in both groups postoperatively, then gradually increased. Scores for corneal rose bengal and fluorescein staining were higher and conjunctival goblet cell density was lower in the operated eyes than in control right eyes in both groups, but no significant difference was found between the operated eyes of the two groups. Inflammatory histopathologic changes of the cornea and conjunctiva were not found in either of the eyes in the two groups. A new rabbit model for KCS could be created by either of these methods. Experimental KCS with reduction of tear production was possible with surgical ablation of the lacrimal and harderian glands and nictitating membrane. It is unnecessary to apply trichloroacetic acid to burn the conjunctiva. Our modified incision better exposed the surgical field.

Functional outcomes related to the prevention of radiation‐induced xerostomia: Oral pilocarpine versus submandibular salivary gland transfer

Xerostomia has a devastating impact on oral function and quality of life in patients who receive radiation treatment for head and neck cancer. The purpose of this study was to examine functional outcomes related to 2 saliva-sparing treatments: (1) oral pilocarpine during radiotherapy; or (2) the submandibular salivary gland transfer (SGT) before radiotherapy. Sixty-nine patients were recruited (SGT = 36; pilocarpine = 33). Speech intelligibility, swallowing outcomes, and quality of life were assessed at 4 points in time (pretreatment, and 1 month, 6 months, and 12 months after the pretreatment assessment). There were no differences between groups in speech outcomes; however, significant between-group differences existed in swallowing and quality of life outcomes. In all cases, patients who received the SGT procedure had better swallowing outcomes and quality of life scores than the patients who received oral pilocarpine. The SGT should be the treatment of choice between the 2 treatments offered to prevent xerostomia in the present study.

Submandibular salivary gland transfer for the prevention of radiation‐induced xerostomia in patients with nasopharyngeal carcinoma: 5‐Year outcomes

Our aim in this study was to investigate the value of the submandibular salivary gland transfer procedure in prevention of radiation-induced xerostomia in patients with nasopharyngeal carcinoma (NPC). In all, there were 70 patients, consisting of a test group (36 patients) and a control group (34 patients) in a nonrandomized fashion. In the test group, the submandibular salivary gland was transferred to submental space before radiotherapy (XRT) and shielded. Salivary gland functions were evaluated by the amount of saliva and a quality of life questionnaire before and after XRT and 3 and 60 months after XRT. At 5 years, the trapping and excretion functions of salivary gland were significantly better in the test group (p = .000 and p = .000). The mean weight of saliva after XRT was heavier (1.65 g vs 0.73 g, p = .000), and the incidence of xerostomia was lower in the test group, with no difference in 5-year survival and neck nodal recurrence between the 2 groups. Salivary gland transfer procedure prevents XRT-induced xerostomia and improves quality of life of patients with NPC.

A Phase II Study of Submandibular Salivary Gland Transfer to the Submental Space Prior to Start of Radiation Treatment for Prevention of Radiation-induced Xerostomia in Head and Neck Cancer Patients: Initial Report of RTOG – 0244

To determine reproducibility of surgical technique of submandibular salivary gland transfer (SGT) for prevention of radiation (XRT) induced xerostomia in a multi-institutional setting and to assess severity of xerostomia.

Microanatomic Study of the Vascular and Duct System of the Submandibular Gland

Autologous microvascular submandibular gland (SMG) transfer is an effective treatment for severe keratoconjunctivitis sicca (KCS). However, epiphora (excessive tear secretion) may occur after the successful transfer of whole submandibular gland because tear secretion level is closely related to the size of the transferred gland. The aim of this study was to investigate the microanatomy of SMG to explore the possibility of partial SMG transfer to prevent postoperative epiphora. Sixty intact and histologically normal human SMGs from patients with benign tumor of the mandible who underwent vascularized mandibular reconstruction and removal of the SMG for anastomosis of the blood vessels were included in the study. SMGs were perfused with methacrylate to form resin casts of blood vessels and ducts. The length and diameter of the blood vessels and ducts in the casts were measured using a sliding caliper. The numbers of lobules, distribution of arteries, veins, and ducts, as well as the relationship among them, were analyzed. The resin cast of the gland showed a treelike structure, with the vessels gradually dividing into multiple branches. The arteries, veins, and ducts run in parallel and were roughly divided into 3 levels: from the stem extending into the main branches (level I), into the narrower secondary branches (level II), and then the secondary branches subsequently divided into terminal branches (level III). The structures of the blood vessels and ducts were similar at each level in the lobules. In the vein casts, communicating vessels were found between the anterior facial vein and the concomitant vein of the facial artery. The characteristic treelike structure of the SMG vascular and ductal system may provide useful information for partial gland transfers.

Establishing the guideline to improve the success rate of autologous submandibular gland transfer

角结膜干燥症是眼科常见病,我国该病患病率为2.7%,有近三千万程度不同的角结膜干燥症患者[1];该病在65岁以上人群中的患病率为23.6%[2].国外报告65岁以上人群患病率为15.0%～28.7%[3-6]。

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: management strategies and economic impact

This systematic review aimed to assess the literature for management strategies and economic impact of salivary gland hypofunction and xerostomia induced by cancer therapies and to determine the quality of evidence-based management recommendations. The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. For each article, two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results, and conclusions. Seventy-two interventional studies met the inclusion criteria. In addition, 49 intensity-modulated radiation therapy (IMRT) studies were included as a management strategy aiming for less salivary gland damage. Management guideline recommendations were drawn up for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer. There is evidence that salivary gland hypofunction and xerostomia induced by cancer therapies can be prevented or symptoms be minimized to some degree, depending on the type of cancer treatment. Management guideline recommendations are provided for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer. Fields of sparse literature identified included effects of gustatory and masticatory stimulation, specific oral mucosal lubricant formulas, submandibular gland transfer, acupuncture, hyperbaric oxygen treatment, management strategies in pediatric cancer populations, and the economic consequences of salivary gland hypofunction and xerostomia.

Reliability of venae comitant of facial artery as the donor vein in microvascular autologous submandibular gland transfer

To analyse the reliability of concomitant venae of facial artery as the donor vein in microvascular autologous submandibular gland transfer. One hundred and seventeen cases with severe keratoconjunctivitis sicca treated by microvascular transfer of autogenous submandibular gland transfer from August of 1999 to November of 2007 were reviewed. The cases were divided into three groups according to their different donor veins, with group A using facial veins, group B using concomitant venae of facial artery, and group C using a vein near the duct. Group A and B were compared in terms of venous thrombosis rate and failure rate related to venous thrombosis. Among 117 cases, there were 122 sides of submandibular gland transfers, with 93 in group A, 27 in group B, and 2 in group C. Postoperative venous thromboses rate was 15% in group A and 7% in group B, with significant difference (P < 0.01). The failure rate of transferred gland related to venous thrombosis was 8% in group A, and 7% in group B, with no significant difference (P > 0.05). Concomitant venae of facial artery can be used as reliable donor vein in microvascular autologous submandibular gland transfer.

Submandibular Gland Transfer for Xerostomia Prevention in Patients Undergoing Chemotherapy and Radiation Therapy

Submandibular Gland Transfer for Xerostomia Prevention in Patients Undergoing Chemotherapy and Radiation Therapy

Phase III randomized study: Oral pilocarpine versus submandibular salivary gland transfer protocol for the management of radiation‐induced xerostomia

Xerostomia is a serious morbidity of radiation treatment in head and neck cancer. We conducted a prospective phase III multicenter randomized study comparing submandibular salivary gland transfer (SGT) procedure with pilocarpine during and for 3 months after XRT. Salivary flow (baseline, stimulated) and University of Washington Quality of Life Questionnaire (U of W QOL) scores were measured. RESULTS.: An interim intent to treat analysis (120 patients) at 6 months shows superior results in SGT arm: median baseline salivary flow for SGT (0.04 mL/minute) versus pilocarpine (0.01 mL/minute), p = .001; median stimulated salivary flow (0.18 mL/minute) for SGT versus (0.05 mL/minute) for pilocarpine, p = .003. Scores (U of W QOL) for amount (p = .017) and consistency of saliva (p = .005) in favor of SGT leading to premature closure of study. Submandibular SGT procedure is superior to pilocarpine in management of radiation-induced xerostomia.

Transplantation of a reverse facial artery pedicled submandibular gland in a dog

This study was performed to evaluate the possibility of using reverse facial artery pedicled submandibular gland transfer for treating keratoconjunctivitis sicca. A reverse facial artery pedicled submandibular gland, including the duct, from a beagle dog was transplanted into the temporal region in the same animal. 99mTc pertechnetate scintigraphy was used to monitor graft viability, and the grafted glands were examined histologically 12 weeks after transplantation. Postoperative 99mTc pertechnetate scintigraphy demonstrated viable salivary gland tissue in the transplanted region. Histologically, some of the acinar cells in the graft had atrophied. The transplantation of a reverse facial artery pedicled submandibular gland was successful and may be a simple, reliable treatment for patients with keratoconjunctivitis sicca.

Long-term results of autologous submandibular gland transfer for the surgical treatment of severe keratoconjunctivitis sicca

The aim of this study was to assess the long-term results of autologous submandibular gland transfer for surgical correction of severe keratoconjunctivitis sicca. A survey was undertaken of 32 patients who had undergone submandibular gland transfer (42 glands) and by following up 11 patients (15 glands) for 5-10 years. Subjective benefit was evaluated as well as clinical findings at the ocular surface. The biochemical consistency of the secreted "saliva-tear" was analysed and compared with natural submandibular saliva of a matched control-group. The vitality and function of the transplants was tested by means of sialoscintigraphy. Immunohistochemical investigations were carried out in specimens of submandibular tissue, gained during reduction procedures of the transplants to correct secretory excess. Patient evaluation and clinical assessment revealed a long-lasting subjective benefit in 2/3 of the patients and a stabilisation at the ocular surface in all cases. The secretion remained as highly concentrated submandibular saliva. Glandular vitality and function was shown scintgraphically. Immunohistochemical investigations revealed no progressive atrophy after transplantation, the ability of cell division remained intact and there was still neuronal tissue in all transplants, even several years after transfer. As all transplants responded well to parasympathomimetic drugs, this might be an indication of re-innervation of the gland.

Submandibular Gland Transfer for Severe Xerophthalmia

To report early clinical experience with a new microvascular reconstructive procedure for patients with severe xerophthalmia. Retrospective clinical series. Patients with severe xerophthalmia were referred for treatment after having exhausted all conventional means of treatment. The ipsilateral submandibular gland was transferred to the temporal fossa, as described by Macleod et al., and revascularized using the superficial temporal artery and appropriate vein(s). The submandibular duct was directed to the superolateral fornix so that the saliva produced moistened the eye. Results and complications were reviewed. Seven microvascular submandibular gland transfer procedures were performed in five patients, ages 6 to 54. The etiology of severe xerophthalmia was Stevens-Johnson syndrome in four and chemical burn in one. Follow-up time was 4 to 20 months. Successful transfer with revascularization was achieved in six of seven (86%) cases. Schirmer's test scores improved from 1.3 pretransfer to 8.1 posttransfer (P = .005). Patients experienced symptomatic relief within 1 month, and the microenvironment of the eye surface improved enough to make them candidates for visual restorative eye surgery. There were no major complications. Microvascular submandibular gland transfer is an effective approach for correcting severe xerophthalmia. The procedure should be within the skills of any reconstructive microsurgeon. This procedure offers a unique opportunity for otolaryngologist-head and neck reconstructive surgeons to help restore vision to this unfortunate group of patients.

2411: Sparing Both Parotids and Submandibular Gland by Combining Submandibular Gland Transfer Procedure and Helical Tomotherapy in Head and Neck Cancer Patients Undergoing Post-Operative Radiation

2411: Sparing Both Parotids and Submandibular Gland by Combining Submandibular Gland Transfer Procedure and Helical Tomotherapy in Head and Neck Cancer Patients Undergoing Post-Operative Radiation

O.287 Microsurgical submandibular gland transfer for severe keratoconjunctivitis sicca – Final assessment

We describe and review the most recent techniques of male genital reconstruction, identifying relevant material with an unstructured PubMed-based search of previous reports, using the keywords ‘reconstruction’, ‘glans’, ‘shaft’, ‘lymphoedema’, ‘skin graft’, ‘scrotoplasty’, ‘urethroplasty’, and ‘penile prosthesis’. This search produced 22 reports that were analysed in this review. Split-thickness skin grafts are ideal for glans reconstruction, while full-thickness skin grafts should be used to cover defects on the shaft penis, as they tend to heal with less contracture. The radial artery-based free-flap phalloplasty is the technique of total phallic reconstruction associated with the highest satisfaction rates. Further research is required to identify an ideal reconstructive technique that would guarantee superior cosmetic and functional results, minimising donor site morbidity.

9 Complete salivary sparing by combining submandibular gland transfer procedure and helical tomotherapy in head and neck cancer patients undergoing post-operative radiation

9 Complete salivary sparing by combining submandibular gland transfer procedure and helical tomotherapy in head and neck cancer patients undergoing post-operative radiation

The role of submandibular salivary gland transfer in preventing xerostomia in the chemoradiotherapy patient

Xerostomia is a significant morbidity of radiation therapy in the management of head and neck cancers. The hypothesis is that the surgical transfer of 1 submandibular salivary gland to the submental space outside of the proposed radiation field, before starting radiation treatment would prevent xerostomia. To evaluate the potential role of submandibular salivary gland transfer in reducing or preventing xerostomia in head and neck patients receiving chemoradiotherapy. We conducted a prospective clinical trial in which the submandibular gland was transferred to the submental space as an independent surgical procedure, followed by chemoradiotherapy. The patients were followed clinically, with salivary flow studies, nuclear medicine salivary gland scans, and the University of Washington quality of life questionnaire. We report the results of 8 patients who have undergone this procedure. All of the transferred salivary glands were positioned outside of the proposed radiation fields; were partially shielded from radiation and were functional. All of the patients completed their treatment. Four patients did not have xerostomia-related complaints, and 3 patients had only minor symptoms on subjective assessment. There were no surgical complications. Surgical transfer of a submandibular salivary gland to the submental space (outside the radiation field) preserves its function and minimizes the development of radiation-induced xerostomia.