ORIGINAL ARTICLE

SUBLINGUAL GLAND TUMORS: CLINICAL, PATHOLOGIC,

AND THERAPEUTIC ANALYSIS OF 13 PATIENTS TREATED
IN A SINGLE INSTITUTION
Rafael Zdanowski, MD,1 Fernando Luiz Dias, MD,2 Mauro Marques Barbosa, MD,1
Roberto Araújo Lima, MD,1 Paulo Antônio Faria, MD,3 Adriano Mota Loyola, DDS,4
Kellen Christine Nascimento Souza, DDS4
1
Department of Surgery, Head and Neck Surgery Service, Brazilian National Cancer Institute, Rio de Janeiro, Brazil.
E-mail: rzdan.cp@gmail.com
2
Department of Surgery, Head and Neck Surgery Service, Chief, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
3
Department of Surgical Pathology, Brazilian National Cancer Institute, Rio de Janeiro, Brazil
4
Department of Oral Pathology, Federal University of Uberlandia, Minas Gerais, Brazil

Accepted 31 March 2010

Published online 19 July 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hed.21469

gland. From 1930 to 1981, only 59 cases of malignant

Abstract: Background. Sublingual gland tumors are rare,
although frequently malignant. This study describes the clinico-
pathologic features and treatment results and reviews the
literature.
Methods. Thirteen cases treated between 1996 and 2007
were reviewed with interest on clinical, pathologic, and thera-
peutic information. Survival data were calculated by the
Kaplan–Meier method.
Results. Malignancies represented 92.3% of cases. Adenoid
cystic carcinoma was the most common malignant type (66.7%).
Most patients (83.3%) presented in advanced pathologic TNM
stages (III or IV). All cases underwent surgical treatment. Neck
dissection was performed in 69.2% with no metastases detected.
Ten patients (83.3%) had adjuvant radiotherapy. Distant metasta-
ses occurred in 3 patients (25%). The 5-year overall and disease-
free survival rates were 78.7% and 87.5%, respectively.
Conclusions. Tumors of the sublingual gland are rare and
are usually malignant. Radical surgery and adjuvant radiother-
apy seems to offer adequate local and regional control. Unlike
distant failure, local recurrence and regional metastases are
not common. V C 2010 Wiley Periodicals, Inc. Head Neck 33:
476–481, 2011
Keywords: sublingual gland; major salivary glands; malignant
tumors; adenoid cystic carcinoma; head and neck tumors
Salivary gland tumors (SGTs) are uncommon, repre-
senting 3.5% to 10% of all tumors arising in the head
and neck area.1 Neoplasms of the sublingual glands
are very rare, constituting between 0.3% and 5.2% of
all epithelial SGTs and approximately 1.5% of all car-
cinomas of major salivary glands.1–4
Brunschwig5 published the first description of a
sublingual gland tumor in 1930: a 60-year-old woman
with a malignant mixed tumor on the right sublingual
Correspondence to: R. Zdanowski
V
C 2010 Wiley Periodicals, Inc.
sublingual gland tumors were described in the litera-
ture.3 Adenoid cystic carcinoma (ACC) or mucoepider-
moid carcinoma (MEC) were the most common
histopathologic types found according to some recent
literature reviews.6–8 Benign tumors, such as pleo-
morphic adenoma or basal cell adenoma, although
extremely rare, have also been reported.1,9,10
Clinically, these tumors present as an asymptom-
atic mass located in the floor of the mouth, usually in
patients during the fifth and sixth decades of life,
with no sex predilection.3,6 Sometimes they are diffi-
cult to distinguish from other epithelial neoplasms
such as minor salivary gland or primary floor of
mouth tumors.1,6,11 Correlations between clinical,
radiologic, and pathologic findings are very important
for the correct diagnosis.
Although treatment of choice is surgical resection,
the procedure extension varies, depending on the size
and histopathologic type of tumors.1–3,6 On the other
hand, the role of elective neck dissection for sublin-
gual malignant tumors is still controversial. Adjuvant
radiation therapy is generally recommended for clini-
cally advanced disease, high-grade tumors, or inad-
equate surgical margins.6,11
The objective of this study was to analyze treat-
ment results describing clinicopathologic features of
13 sublingual gland tumors treated in a single
institution.
MATERIALS AND METHODS
From 1996 to 2007, 854 patients with histologically
confirmed salivary gland neoplasms were treated at
the Brazilian National Cancer Institute (INCA-MS-
RJ). Thirteen of these cases (1.5%) were sublingual
gland tumors and they were reviewed, with the focus
on epidemiologic features, initial symptoms, head and

476 Sublingual Gland Tumors HEAD & NECK—DOI 10.1002/hed April 2011
 RESULTS
Nine patients (69.2%) were men and 4 were women.
The mean age was 52.8 years (range, 37–68 years).
Asymptomatic swelling in the floor of mouth was the
most frequent primary clinical presentation and
occurred in 69.2% of cases (see Figure 1). Pain was
associated with swelling in another 4 patients. In 4
patients (30.7%) a submandibular cervical mass could
be palpable, and in 1 patient (7.7%) tongue numbness
was present. Mean tumor size was 3.9 cm (range,
1.6–7 cm).
Twelve patients (92.3%) had malignant tumors,
whereas 1 patient presented with a pleomorphic ade-
noma (see Table 1). The most frequent histopathologic
FIGURE 1. Mass in the floor of the mouth. A case of adenoid type was ACC, meaning 66.7% of malignancies. The
cystic carcinoma of the sublingual gland. [Color figure can other types were salivary duct carcinoma (SDC) in 2
be viewed in the online issue, which is available at patients (16.7%), high-grade MEC in 1 (8.3%), and poly-
wileyonlinelibrary.com.]
morphous low-grade adenocarcinoma in 1 (Table 1).
Six patients (50%) were classified as stage II, 2
neck examination findings, radiologic signs, surgical patients (16.7%) as stage III, and 4 patients (33.3%) as
and radiotherapy treatments, and outcome. stage IV on clinical TNM classification. Two patients
Disease was retrospectively staged using the were restaged after previous treatment in other institu-
Union Internationale Contre le Cancer (UICC)–TNM tions: 1 after surgery and another after surgery plus
2002 Classification of Malignant Tumors in accord radiotherapy, as shown in Table 2. One patient with
with available clinical and radiologic data on stage IV ACC (case 13) had multiple lung metastases
admission.12 at the time of initial diagnosis confirmed by CT scan.
Sublingual gland tumors diagnosis was based on After definitive pathologic examination, 5 cases (41.7%)
careful chart review, including: history and physical were upstaged (cases 4, 5, 8, 10, and 12) as the result
exam of a growing tumor initially arising at the sub- of neural or bone infiltration and 1 (8.3%) was down-
lingual gland topography, without any evidence of tu- staged (case 3). Two patients were finally confirmed as
mor in the floor of mouth mucosa or in the stage II, 6 as stage III, and 4 as stage IV (Table 2).
submandibular space at the initial presentation; CT No cervical metastasis was found after surgical
or MRI findings, suggesting tumors arising in the specimens’ pathologic examination. Cervical palpable
sublingual gland over the mylohyoid muscle and masses were in fact primary tumors spreading to the
under the mucosa line; surgical finding of a tumor submandibular triangle. Two patients (16.7%) had
occupying the sublingual gland topography, taking tumors infiltrating mandible bone, and in 7 patients
the place of the entire or part of the gland; and a his- (58.3%) microscopic perineural invasion was present,
topathologic exam providing evidence of a tumor aris- 1 of them spreading macroscopically through the
ing inside or replacing the parenchyma of the
sublingual gland. Patients treated for minor salivary
gland (without any evidence of tumor arising from
the sublingual gland) or squamous cell tumors involv- Table 1. Age, sex, tumor size, and histopathology of patients in this
ing the floor of mouth were excluded. Frozen sections study.
were used to confirm the diagnosis and to check sur-
Patient Tumor
gical margins. The same pathologist (PAF) reviewed Case age, y/sex size, cm Histopathology
all histologic slides stained with hematoxylin and eo-
1 52/Male 5.5 Pleomorphic Ad
sin, periodic acid–Schiff, and mucicarmine.
2 51/Female 3.0 Cribriform ACC
All patients underwent radical surgical treatment 3 60/Female 7.0 Cribriform ACC
with or without neck dissection. The surgical plan was 4 68/Female 4.5 Cribriform ACC
based on primary tumor TNM classification, histopa- 5 50/Male 2.5 Cribriform ACC
thologic type, and intraoperative findings. Adjuvant 6 58/Male 7.0 Cribriform ACC
7 58/Male 4.0 Tubular þ cribriform ACC
external beam radiation therapy in accord with stand- 8 37/Male 2.7 Tubular ACC
ard techniques, varying in dose from 5100 to 7000 cGy, 9 59/Male 3.3 Salivary duct Ca
was indicated for patients with advanced-stage disease 10 54/Male 1.6 Salivary duct Ca
(stages III or IV), high-grade tumors, neural invasion, 11 43/Female 2.5 High-grade MEC
12 48/Male 4.5 Polym low-grade AdenoCa
or extraglandular extension.
13 49/Male 3.1 ACC (not classified)
All patients’ survival and local or regional control
data were calculated by the Kaplan–Meier method. Abbreviations: Ad, adenoma; ACC, adenoid cystic carcinoma; Ca, carcinoma;
MEC, mucoepidermoid carcinoma; Polym, polymorphous; AdenoCa,
Follow-up data were obtained until July 2009. adenocarcinoma.

Sublingual Gland Tumors HEAD & NECK—DOI 10.1002/hed April 2011 477
 Table 2. TNM classifications and patterns of tumor invasion.

Case cTNM pTNM ExGld spread Stage Perineural Vascular

1 — — — — — —
2 T2N0M0 T2N0M0 — II þ

3 T2N2M0 T3N0M0 — III þ

4 T3N0M0 T4N0M0 Lingual nerve IVa þ

5 T2N0M0 T3N0M0 Soft tissue III


6 T3N0M0 T3N0M0 Soft tissue III þ

7 rT4N0M0 T4N0M0 Bone IVa


8 T2N0M0 T3N0M0 Soft tissue III þ

9 rT4N1M0 T4N0M0 Bone IVa þ þ
10 T2N0M0 T3N0M0 Soft tissue III


11 T2N0M0 T2N0M0 — II


12 T2N0M0 T3N0M0 — III


13 T2N0M1 T2N0M1 — IV þ

Abbreviations: ExGld spread, extraglandular spread; (
) absent; (þ) present.

lingual nerve. Only in 1 patient (8.3%) was a vascular
invasion found at the final histopathology.
Radical surgery was the treatment of choice for
all malignant tumors patients: 2 patients by per-oral
resections, 4 patients by transcervical approaches, 1
patient by visor flap access, 1 patient by a pull-trough
resection, and 4 patients by composite procedures.
Nine patients underwent selective neck dissection in
association with the primary tumor resection. Ten
patients had complementary external beam radiation
therapy. Indications for adjuvant radiotherapy
included positive margins, advanced local disease, or
high-grade histology. The patient with pleomorphic
adenoma underwent sublingual gland resection
through oral approach and had no evidence of recur-
rence after a 42-month follow-up. Surgical treatment
options are shown in Table 3.
The mean follow-up time was 47.8 months (range,
7–82 months). Eleven patients (69.2%) were alive, 9
of them without any evidence of disease (including
the benign tumor). One patient (case 13) was alive at
the last follow-up, but with asymptomatic and stable
lung metastasis checked with sequential CT scans (6-
month interval).
The overall survival rate was 78.7% and the dis-
ease-free survival rate was 87.5%. No local or regional
failures were observed in the studied cases. Two
patients (16.7%) died during the study time, 1 from dis-
tant metastases (lung) and 1 from other causes (cardiac
failure). Among 12 malignant tumor cases, metastatic
disease developed after surgery in 2 patients (16.7%): 1
with a cribriform ACC who developed bilateral lung
metastases 25 months after surgery and adjuvant radi-
ation therapy, undergoing surgical resection (left

Table 3. Treatment and outcome by histopathologic type.

Case Histopathology Surgical treatment RT Outcome, mo

1 Pleomorphic Ad Peroral resection of sublingual gland
NED (42)

2 Cribriform ACC Transcervical: resection of sublingual gland and þ NED (73)
submandibulectomy
3 Cribriform ACC Composite procedure: FOM resection with segmental þ NED (65)
mandibulectomy and SOHND (L I–III)
4 Cribriform ACC Transcervical: resection of sublingual gland and SOHND þ NED (65)
5 Cribriform ACC Pull-through: partial glossectomy and FOM resection þ Alive, lung met (34)
with marginal manibulectomy and SOHND
6 Cribriform ACC Peroral FOM resection with marginal mandibulectomy þ NED (21)
7 Tubular þ Cribriform ACC Visor flap: partial glossectomy and FOM resection with þ NED (77)
segmental mandibulectomy
8 Tubular ACC Transcervical: resection of sublingual gland and SOHND þ NED (66)
9 Salivary duct Ca Composite procedure: partial glossectomy and FOM þ (preop) DOC (7†)
resection with segmental mandibulectomy (hemi) and
ND (L I–II)
10 Salivary duct Ca Composite procedure: partial glossectomy and FOM þ NED (46)
resection with segmental mandibulectomy and
SOHND
11 High-grade MEC Peroral resection of sublingual gland þ NED (82)
12 Polym low-grade AdenoCa Transcervical: FOM resection with segmental mandibu-
DOD (22†)
lectomy and submandibulectomy
13 ACC Composite procedure: FOM resection with segmental þ Alive, lung met (13)
mandibulectomy and SOHND (L I–III)
Abbreviations: RT, radiation therapy; Ad, adenoma; Ca, carcinoma; ACC, adenoid cystic carcinoma; MEC, mucoepidermoid Ca; FOM, floor of mouth; SOHND, supraomohyoid
neck dissection; ND, neck dissection; L, level; NED, no evidence of disease;
†
, dead; DOC, died of other causes; DOD, died of disease; met, metastasis; (
) without radiotherapy; (þ) with radiotherapy.

478 Sublingual Gland Tumors HEAD & NECK—DOI 10.1002/hed April 2011

Table 4. Sublingual  total salivary gland tumors.
Sublingual/Total
salivary gland
Reference tumors
14
Foote and Frazel (1953) 4/877
Nagler and Laufer (1997)17 2/245
Ma’aita et al (1999)16 1/221
Satko et al (2000)27 33/1021
Das et al (2004)28 2/343
Luukkaa et al (2005)29 1/237
BNCI, 2009 13/854
Abbreviation: BNCI, Brazilian National Cancer Institute.
inferior lobectomy and multiple nodulectomies), and 1
with a stage III low-grade polymorphous adenocarci-
noma, diagnosed 17 months after surgical treatment
(not submitted to adjuvant radiotherapy) who died 3
months later from the metastatic disease.
DISCUSSION
The sublingual glands are located on the sublingual
sulcus in each side of the posterior face of the mandi-
ble, close to the symphysis, over the mylohyoid muscle.
They are in close proximity to the submandibular sali-
vary duct, the lingual vessels and nerve, the hypoglos-
sal nerve, and the mucosa of the floor of the mouth.2
Tumors arising in the sublingual gland are very rare,
although they are frequently malignant. In 1939 Smith13
described 11 cases of sublingual gland tumors, with 7 of
them malignant (63.6%). In 1953 Foote and Frazell14
encountered 4 malignant sublingual gland tumors
(0.5%) in their review of 877 major salivary neoplasms
treated at the Memorial Sloan–Kettering Cancer Center
(MSKCC) from 1930 to 1949. Sixteen years later, Ran-
kow and Mignogna11 presented 46 cases of primary
tumors of the sublingual gland, 37 of which were malig-
nant (80.4%), the same proportion Batsakis15 had esti-
mated in a pathologic consultation in the early 1990s.
However, some authors did not find any benign tumor in
FIGURE 2. CT and MRI of 2 patients with adenoid cystic carcinoma. The tumor filled the sublingual gland space (white arrows) on the
mylohyoid muscle (black arrows). (A) Coronal section CT image after intravenous contrast injection. (B) and (C) Coronal and sagittal
T2-weighted MR images of another patient.
Sublingual Gland Tumors
their series.1,3,4,16,17 Spiro6 found only 18 sublingual
gland tumor cases (0.5%) in 4000 salivary gland tumors
treated in 55 years at the MSKCC and all of them were
malignant. We had an incidence of 1.5% of sublingual
Incidence, %
glands among all salivary gland tumors, which is in
0.5 agreement with other series findings (Table 4). Mean-
0.8 while, large series of salivary gland tumors, without a
0.5
3.2
single case occurring in the sublingual gland, can be
0.6 found in the literature.18,19
0.4 Sublingual salivary gland tumors most frequently
1.5 occur in patients during the fifth and sixth decades of
life, without sex prevalence.1,6,20 Besides being rare,
they are also a diagnostic challenge for surgeons. Clini-
cally, these tumors present as an asymptomatic sub-
mucous mass located in the floor of mouth, which can
be easily confused with a squamous cell carcinoma of
the floor of mouth, a submandibular gland tumor, a
minor salivary gland tumor, or other nonneoplastic
lesions, such as rannula or inflammatory conditions.
Because of their poor symptoms they are frequently
diagnosed in advanced clinical stage.2,6,11 We found
83.3% of the malignant tumors in stages III or IV.
Spiro6 had already reported that it is often quite
impossible to identify the gland of origin when tumor
presents as an extensive mass at the floor of the mouth,
but the initial presentation history, imaging, and surgi-
cal specimens may help to define the correct site. In eval-
uation of patients with tumors of the sublingual gland,
both CT or MRI scans may provide accurate information
about suspected diagnosis and guide the best surgical
approach, showing the extent of tumor and its relation to
neurovascular structures and bone invasion. High-reso-
lution imaging may help to distinguish the sublingual
gland tumors from others lesions mentioned earlier (see
Figure 2), showing features such as tumor epicenter
occupying the sublingual space upon the mylohyoid mus-
cle, under the mucosa line.
Histopathologic findings in our study showed that
the most common malignant type was ACC (66.7%),
followed by salivary duct carcinoma, high-grade
HEAD & NECK—DOI 10.1002/hed April 2011 479
MEC, and polymorphous low-grade adenocarcinoma.
This distribution is similar to those presented in the
literature, sometimes with mucoepidermoid carci-
noma (MEC) showing a more elevated incidence. Be-
nign tumors, such as pleomorphic adenoma, are
rarely described in the sublingual gland.1,3,6,8,20
ACC is a frequent malignancy encountered in
major salivary glands representing 26% to 29% of
submandibular and more than half of all sublingual
malignant tumors.8,21,22 Cervical metastases are
rarely found, occurring in only 8% to 13% of patients
with ACC of major salivary glands. On the other
hand, distant metastases may occur in up to 50% of
patients, with lung and bones as the most common
sites.8,23–25 Interestingly, in our group of patients,
any metastatic node was diagnosed at the time of sur-
gery and not during the follow-up period. This result
is of particular importance because, although 83.3%
of our patients were in advanced clinical stages, the
most frequent tumor was ACC, which characteristi-
cally has a low incidence of cervical metastasis.
ACC has an indolent course with locally aggres-
sive behavior and a high rate of local recurrence,
especially when perineural invasion is present, which
can occur late in disease progression.22 A review of
184 patients with ACC in head and neck sites clearly
identified tumor stage as the single most important
factor that defines poor prognosis.26 We believe that
tumor behavior for sublingual ACC should be the
same as described for other sites (parotid or subman-
dibular glands), and perineural invasion must also
have an important impact on survival.30
The treatment of choice for sublingual gland tumors
is surgery and the technique may differ, depending on
the primary tumor extension.1–3,6,17,20 Spiro6 suggested
that for small malignancies, <2 cm and confined to the
floor of mouth, an adequate wide excision, including the
submandibular gland and primary repair of the defect,
may be sufficient. For larger tumors, a more aggressive
resection such as a pull-through or a composite resection
is recommended, especially considering the high inci-
dence of ACC and MEC. To ensure safe margins, some-
times, when adenoid cystic carcinoma is suspected and
tumor is in close contact with the nerve, sacrifice of the
lingual nerve and proximal extremity frozen section ex-
amination should be necessary.
The literature states that tumors in close proximity
or involving the mandible’s periosteum will need, at
least, a marginal mandibulectomy to achieve safe mar-
gins, whereas segmental mandibulectomy is indicated
when cortical bone involvement is evident. Most of our
patients (61.5%) were submitted to resections, including
mandibulectomy, in contrast to others series in which
marginal or segmental mandible resections were neces-
sary in only 11% to 33% of patients.1,6 Spiro6 presented
only 1 patient (5.5%) with segmental mandibulectomy,
whereas 6 of our patients (50%) had mandible segmen-
tal resection. As suggested in the literature, we estab-
lished clinical assessment and preoperative imaging to
480 Sublingual Gland Tumors
adequately determine mandible infiltration.1,20,31 More-
over, perioperative evaluation, detecting tumor growth
or fixation of the mass to the inner surface of the man-
dible, must guide surgeons in deciding when to choose
a segmental mandibulectomy or not.
Local recurrence may occur in 16.7% to 30%, caus-
ing death in almost all cases described in the litera-
ture.1,6,20 We did not have any case of local recurrence
during follow-up periods, which may represent the
agressive surgical treatment submitted in most
patients, with a high rate of segmental mandibular
resection, despite the low rate of cancer in the bone
specimen (15.4%). Perhaps segmental mandibulectomy
should be required only if the sublingual tumor has
wrapped around the inner cortex and, thus, a marginal
mandibular resection could be sufficient to treat most
of our patients, reaching a similar local control rate.
Neck dissection is well defined for tumors arising in
the major salivary gland with clinically positive neck me-
tastases. In the N0 neck, the odds for occult nodal metas-
tasis presentation are increased in advanced clinical
stages, high-grade tumors, neural invasion, and extra-
glandular tumor extension.22,30,32 The low incidence of
nodal disease in ACC, which corresponds to approxi-
mately more than half of sublingual gland tumors, can-
not be discredited, although despite the small risk for
nodal metastasis (0% to 5%), a supraomohyoid neck dis-
section (levels I, II, and III) may still be indicated and,
occasionally, may prove to be useful by the same criteria
seen for parotid gland tumors.6 There is no evidence in
the literature that would contraindicate this strategy.
Clinically detectable nodal involvement will require a
modified or classic radical neck dissection.1,3,6,20
The incidence of regional recurrences is difficult
to analyze because there are few data for related out-
come in the literature. One patient with adenocarci-
noma reported by Nishijima,3 initially positive in the
neck, developed contralateral neck disease 3 months
after initial radical surgery and subsequent pulmo-
nary metastasis, dying 8 months after surgery. Spiro6
confirmed nodal involvement in only 1 of 18 patients
(5%) included in his study. A case report showed a
papillary cystadenocarcinoma of the sublingual gland
with submental and submandibular nodal recurrence
after primary tumor treatment.33 Other series showed
no cervical lymphatic spread in patients with malig-
nant sublingual gland tumors.1 Even though most of
our patients were initially in advanced clinical stages,
we found no regional metastasis or local recurrences.
Pulmonary metastasis appears to be the most fre-
quent site for distant spread, especially in ACC, vary-
ing from 5.5% to 33.3% and always leading to
patients’ death.1,6,20 Interestingly, in this study the
only death caused by metastatic disease occurred in a
patient with a low-grade tumor, but with advanced
clinical disease (stage III), who did not undergo adju-
vant radiotherapy. Two other patients with ACC had
pulmonary metastatic disease and were alive and
asymptomatic at the last clinical evaluation.
HEAD & NECK—DOI 10.1002/hed April 2011
 Adjuvant radiation therapy is suggested in the lit-
erature for selected patients presenting with high
clinical stage, high-grade tumors, neural invasion,
and close surgical margins, as it should be for other
malignant SGTs.1–3,6,20
In summary, our series confirmed the rarity of
these tumors as well as the very high frequency of
malignancies. Adenoid cystic carcinoma was the most
common malignant histopathologic type found
(66.7%). Radical surgical treatment, with or without
adjuvant radiotherapy when indicated, seems to offer
adequate locoregional control. The absence of nodal
metastasis in our group of patients questions the
need for elective treatment of the neck, but without
any more evidence in the literature, it is still indi-
cated. Distant metastasis occurs in some patients,
especially in ACC, in which an indolent progression is
compatible with a longer survival, but possibly com-
ing to a tragic outcome in other patients with malig-
nant types from the sublingual gland.
Acknowledgments. This study used the Brazil-
ian National Cancer Institute database. The interpre-
tation and reporting of these data are the sole
responsibility of the authors. A. L. Castro and K. C.
Souza from Federal University of Uberlandia contrib-
uted to the data collection. F. L. Dias contributed to the
interpretation of the data and the drafting and critical
revision of the manuscript. P. A. Faria contributed to
the pathologic review of the surgical specimens and
critical revision of the manuscript. M. M. Barbosa and
R. A. Lima contributed to the critical revision and final
approval of the manuscript. F. L. Dias had the final ap-
proval for the submission of the manuscript for publi-
cation. The authors thank all physicians who were
responsible directly or indirectly for the treatment of
patients in the Brazilian National Cancer Institute.
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