West Visayas State University

COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippinesa
* Trunkline: (063) (033) 320-0870 to 78 loc.1313* Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

DEFINITION
Pleomorphic adenoma is a benign salivary gland tumor that exhibits wide cytomorphologic and
architectural diversity. The tumor has the following 3 components:
 An epithelial cell component
 A myoepithelial cell component
 A stromal (mesenchymal) component

Identification of these 3 components, which may vary quantitatively from one tumor to another, is
essential to the recognition of pleomorphic adenoma. This tumor is also referred to as a benign mixed
tumor.

EPIDEMIOLOGY
Pleomorphic adenoma is the most common salivary gland tumor in both children and adults. In
most series, it represents 45-75% of all salivary gland neoplasms; the annual incidence is approximately
2-3.5 cases per 100,000 population.
Pleomorphic adenoma occurs in individuals of all ages. However, it is most common in the third
to sixth decades; the average age at presentation is between 43 and 46 years. Pleomorphic adenoma is
seen more often in females than in males (2:1 ratio).

ETIOLOGY
Although the etiology of pleomorphic adenoma is unknown, the incidence of this tumor has
been found to increase 15-20 years after exposure to radiation. One study suggests that the simian virus
(SV40) may play a causative role in the development of pleomorphic adenoma.

LOCATION
Among the major salivary glands, the tail of the superficial lobe of the parotid salivary gland is
the most common site of occurrence for pleomorphic adenoma (70-80% of cases), although this lesion
can occur in any parotid location. [6] The tumor is less commonly seen in the submandibular salivary
gland (10%) and is seldom encountered in the sublingual gland (1%).

With regard to the minor salivary glands (5-10% of cases), the palate (specifically, the junction of
the soft and hard palates) and the lip are the most common sites for pleomorphic adenoma. Other sites
of minor salivary gland involvement include the nose, the paranasal sinuses, and the larynx.

Rare or unusual sites of occurrence include ectopic salivary gland tissues (eg, in the mandible,
neck lymph nodes, or axilla). A case has been reported of a pleomorphic adenoma presenting as a
midline nodule in the isthmus of the thyroid in a 66-year-old man. [9]
Multiple tumors are unusual (1:40,000), but metachronous and synchronous tumors do
occur. Synchronous occurrence of pleomorphic adenoma and Warthin tumor (the second most
common benign salivary gland tumor) has been reported.

CLINICAL FEATURES AND IMAGING

Pleomorphic adenoma usually presents as a slow-growing, painless mass, which may be present
for many years. Symptoms and signs depend on the location.

When the tumor occurs in the parotid gland, signs of facial nerve weakness are seldom
encountered; however, if the tumor is large and has been neglected, facial nerve weakness is likely to
arise as the result of malignant change. Pleomorphic adenoma in the deep lobe of the parotid gland may
present as an oral retrotonsillar mass or parapharyngeal space tumor; indeed, tumors arising at this site
are the source of the most common parapharyngeal space tumors. Rapid enlargement of a tumor
nodule should raise concern about the development of malignant change.

Patients with minor salivary gland tumors may present with a variety of symptoms, depending
on the site of the tumor; such symptoms include dysphagia, dyspnea, hoarseness, difficulty in chewing,
and epistaxis.
 West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippinesa
* Trunkline: (063) (033) 320-0870 to 78 loc.1313* Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

MOLECULAR/GENETICS
Most cases of pleomorphic adenomas (70%) show cytogenetic aberrations. These aberrations
manifest themselves in the following 3 patterns:

 Rearrangement of chromosome band 8q12 (the target gene is pleomorphic adenoma gene 1
[PLAG1]) - 39% of cases
 Rearrangement of chromosome band 12q13-15 (the target gene is the high mobility group AT-
hook 2 gene, HMGA2) - 8% of cases
 Sporadic or clonal changes not involving the above 2 chromosomes - 23% of cases

Both PLAG1 and HMGA2 gene translocations have been identified as tumor-specific in
pleomorphic adenoma; their detection by means of real-time polymerase chain reaction (RT-PCR) or
fluorescence in situ hybridization (FISH) aids in establishing the diagnosis.
One study has demonstrated the presence of the simian virus (SV40) sequence in human
pleomorphic adenoma, suggesting an etiologic link.
The mucin 1 gene (MUC1) has been found to be related to the recurrence of pleomorphic
adenoma and to be associated with malignant transformation of this tumor, with carcinoma cells
overexpressing MUC1.

PROGNOSIS AND PREDICTIVE FACTORS

For most patients with benign, well-circumscribed tumors, the prognosis is excellent after
surgical resection. However, recurrence can be a problem with pleomorphic adenomas, particularly
those occurring in the parotid gland. Recurrence has been related to many factors, including an
incomplete capsule, extension of tumor nodules beyond the capsule, and intraoperative tumor
rupture, in which tumor contents spill into the operative field.
Recurrence usually occurs in a multinodular fashion. In some cases, it involves microscopic
elements, which render operative control extremely difficult and increase the risk of multiple further
recurrences, as well as the risk of future malignant transformation. Recurrences have been related to
tumors with high mesenchymal content, particularly chondroid and myxoid stroma. In some series,
recurrences seem to be more common in younger patients than in older ones.
Malignant change occurs in 2-7% of cases and shows some association with multiple
recurrences, deep lobe tumors, male gender, and older age.

A pleomorphic adenoma may undergo a malignant change that is not fully appreciated, because
the malignant tumor is well differentiated and has a bland cellular morphology at a level
indistinguishable from its benign counterpart, particularly with a small biopsy specimen or fine-needle
aspiration (FNA). As a result, a malignant recurrence may be erroneously presumed to be benign.

DIAGNOSTIC EVALUATION
The following exams and procedures may be used in the diagnosis of Pleomorphic Adenoma of Salivary
Gland:

 Evaluation of the individual’s medical history and a through physical examination

 Plain X-ray of the head and neck region
 Ultrasound scan of the affected salivary gland
 CT or CAT scan with contrast of the head and neck may show a well-defined mass. This
radiological procedure creates detailed 3-dimensional images of structures inside the scanned
region
 MRI scans of head and neck region: A magnetic field is used to create high-quality pictures of
certain parts of the body, such as tissues, muscles, nerves, and bones. These high-quality
pictures may reveal the presence of the tumor
 Fluorescence in situ hybridization (FISH): It is a test performed on the blood or bone marrow
cells to detect chromosome changes (cytogenetic analysis). The test helps in identifying genetic
abnormalities that may not be evident with an examination of cells under a microscope
 West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippinesa
* Trunkline: (063) (033) 320-0870 to 78 loc.1313* Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

 Polymerase chain reaction (PCR): It is used to measure the presence of certain biomarkers in
blood or bone marrow cells. The test is ultrasensitive and detects extremely low amounts of
biomarkers remaining in blood, which can be missed by cytogenetic methods, such as FISH,
karyotype, or flow cytometry. PCR allows a more sensitive follow-up of patients in remission and
can help determine whether additional treatment is necessary.

Although the above modalities can be used to make an initial diagnosis, a tissue biopsy of the tumor is
necessary to make a definitive diagnosis to begin treatment. The tissue for diagnosis can be procured in
multiple different ways which include:

 Fine needle aspiration (FNA) biopsy of the tumor: A FNA biopsy may not be helpful, because one
may not be able to visualize the different morphological areas of the tumor. Hence, a FNA
biopsy as a diagnostic tool has certain limitations, and an open surgical biopsy may be
recommended.
 Salivary gland core biopsy of the tumor
 Salivary gland open biopsy of the tumor

Tissue biopsy:

 A tissue biopsy of the tumor is performed and sent to a laboratory for a pathological
examination. A pathologist examines the biopsy under a microscope. After putting together
clinical findings, special studies on tissues (if needed) and with microscope findings, the
pathologist arrives at a definitive diagnosis. Examination of the biopsy under a microscope by a
pathologist is considered to be gold standard in arriving at a conclusive diagnosis
 Biopsy specimens are studied initially using Hematoxylin and Eosin staining. The pathologist
then decides on additional studies depending on the clinical situation
 Sometimes, the pathologist may perform special studies, which may include
immunohistochemical stains, molecular testing, and very rarely, electron microscopic studies to
assist in the diagnosis

A differential diagnosis, to eliminate other tumor types are often considered, before arriving at a
definitive diagnosis. Pleomorphic Adenoma of Salivary Gland is also known to be misdiagnosed as the
following tumors:

 Adenoid cystic carcinoma

 Oncocytoma

Based on the components present in the tumor, on histological examination, the tumor may be termed:

 Cellular pleomorphic adenoma

 Chondroid pleomorphic adenoma (tumor forms cartilage type tissue)
 Hyaline pleomorphic adenoma
 Lipomatous pleomorphic adenoma
 Myxoid pleomorphic adenoma
 Osseous pleomorphic adenoma (tumor with bone formation)

1. NURSING MANAGEMENT

Primary prevention is concerned with reducing risks of disease through health promotion strategies.

1. One way to reduce risk of tumors/cancers is to instruct to avoid known carcinogens such as
tobacco smoking and harmful radiation exposure;
2. The continuous or prolonged use of mobile phones may also be associated with neoplasm
development according to some studies, although such claims still remain unverified;
3. Assess Cranial Nerves esp. Cranial nerve VII;
4. Assess the pain using pain assessment scales;
 West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippinesa
* Trunkline: (063) (033) 320-0870 to 78 loc.1313* Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

5. Inspect and palpate for nodes or any deviation around the neck;
6. Monitor incision site for signs and symptoms of infection;
7. Encourage to make dietary and lifestyle changes (decreased caloric intake, smoking
cessation, increased physical activity;
8. Proper wound dressing;
9. Emphasized importance of adequate hydration;
10. Emphasized to take adequate rest periods;

Nursing management in Radiation Therapy

1. Assess the patient’s skin and oropharyngeal mucosa regularly;

2. Avoid use of soaps, perfumes, cosmetics, powders, lotions, ointments;
3. Avoid exposing the are to sunlight or cold weather;
4. Decrease anxiety by encouraging verbalization of feelings, and concerns;
5. Antidepressants for patients with depression; hypnotics for patients with sleep disturbances;
psychostimulants for some patients with advanced cancer or fatigue that does not respond to
other intervents;;

 Tramadol – Management of pain. Inhibits reuptake of norepinephrine, serotonin and enhances

serotonin release. It alters perception and response to pain by binding to mu-opiate receptors in
the CNS.
 Sultamicillin tosylate- Belong to the class of penicillin, including beta-lactamase inhibitors. Used
in the treatment of infection.

 Chemotherapy
In general, salivary gland neoplasms respond poorly to chemotherapy, and adjuvant
chemotherapy is currently indicated only for palliation. Single agent or combination chemotherapy
with doxorubicin, cisplatin, cyclophosphamide, and 5 F-U Platinum-based agents, in combination
with mitoxantrone or vinorelbine, are also effective in controlling recurrent salivary gland
malignancy. A new form of 5-fluorouracil called fluoropyrimidine that has increased activity against
malignant cells and while having fewer gastrointestinal side effects has shown to be efficacious
against malignant salivary cancers and to potentiate the effects of radiotherapy by increasing
apoptosis.
Newer trials with anti microtubule agents with and without concomitant radiotherapy have
shown efficacy. Using a platinum-based agent, cisplatin, and an antimicrotubule drug, docetaxel, with
radiation shows some promise in advanced carcinomas of the salivary gland. Using paclitaxel (Taxol),
another anti microtubule drug, alone has had moderate activity against mucoepidermoid tumors and
adenocarcinomas but no effect adenoid cystic carcinoma.
Various targeted biologic agents such as trastuzumab, imatinib, and cetuximab are currently being
investigated. [1]
 Radiotherapy
Radiotherapy is rarely the definitive treatment modality for salivary gland neoplasms, being
used alone usually for tumors that are considered nonresectable. More studies have quantified the use
of radiotherapy in the postoperative setting. The use of radiation in T1 and T2 parotid gland tumors
found that 5-year disease-free survival increased from 70% to 92% with postoperative radiation. A
second study investigated postresection radiotherapy for carcinoma ex pleomorphic adenoma and
found a 26% improvement in 5-year local control (from 49% to 75%). Nonetheless, prospective
randomized controlled studies are needed to confirm the usefulness of postoperative radiotherapy.

Newer techniques for postoperative radiation in salivary gland malignancies have been proven
effective. These include gamma-knife stereotactic radiosurgery and brachytherapy (radioactive seeds or
 West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippinesa
* Trunkline: (063) (033) 320-0870 to 78 loc.1313* Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

sources are placed in or near the tumor itself, giving a high radiation dose to the tumor while reducing
the radiation exposure in the surrounding healthy tissues).
Iodine-125 seeds have been found to be an effective treatment for incompletely resected or
unfavorable histological salivary gland malignancies of the hard and soft palate. Gamma-knife
treatments after neutron therapy are useful if the local failure risk is still high.

3. SURGICAL MANAGEMENT
Early removal of pleomorphic adenoma is advised a) to reduce morbidity; b) to avoid
the risk of malignant transformation and c) to allow thorough histopathological sampling for
diagnosis.

 The treatment of choice is a Superficial Parotidectomy, which has resulted in low morbidity,
with recurrence rates of less than 2% to 3%.
An attempt should be made to remove the tumor en bloc while maintaining the
integrity of the capsule, with a 5-mm cuff of normal tissue. When the capsule is encountered on
the deep aspect, it must be carefully dissected from the facial nerve.
Complications include: paresis of Cranial Nerve VII and Frey Syndrome (auriculotemporal nerve
syndrome or gustatory sweating).

Parotid gland
The histopathologic diagnosis of parotid masses is often unknown prior to surgery. Thus, the
minimum procedure that should be performed for masses in the parotid gland is a superficial
parotidectomy with identification and preservation of the facial nerve. The shift from enucleation, which
was popular prior to 1950, to superficial parotidectomy as the minimal procedure for parotid tumors has
substantially reduced recurrence rates for both benign and malignant disease. For benign pathology, this
procedure is curative.
The specimen removed by superficial parotidectomy should be sent to the pathology
department for frozen section analysis to intraoperatively determine whether a lesion is benign or
malignant. Malignant diagnoses deserve special consideration.
The facial nerve should not be sacrificed for benign tumors.
On the basis of the histologic classification and clinical stage, a useful management schema has been
developed and is shown in the Further Reading section.
Four groups are identified. (Tumor, nodes, and metastases [TNM] stages are described in Staging.)
 Group 1 includes T1 and T2 low-grade tumors (eg, low-grade mucoepidermoid
carcinoma, acinic cell carcinoma). For these tumors, perform parotidectomy (superficial
or total) with an adequate margin of normal tissue with preservation of the facial nerve.
Inspect first-echelon nodes at the time of surgery and send suspicious nodes to the
pathology department for evaluation. For complete excision without tumor spillage and
no evidence of cervical metastases, radiation therapy is not performed.

 Group 2 includes T1 and T2 tumors with high-grade features (eg, high-grade

mucoepidermoid carcinoma, adenoid cystic carcinoma, squamous cell carcinoma,
adenocarcinoma, carcinoma ex-pleomorphic adenoma). For these tumors, perform total
parotidectomy, including the first-echelon lymph nodes. Perform further neck dissection
(modified radical neck dissection or selective neck dissection) for upper nodes
confirmed to be positive for malignancy on frozen sections or for clinically palpable
cervical disease. Preserve the facial nerve unless it is directly infiltrated by tumor. In this
case, the nerve is resected until the frozen section shows clear margins, and it is
immediately reconstructed with cable grafting. Administer postoperative radiation
therapy to the parotid region and the neck.
 West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippinesa
* Trunkline: (063) (033) 320-0870 to 78 loc.1313* Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

 Group 3 includes any T3 tumor, any N+, and any recurrent tumors not in group 4.
Tumors in this group generally require radical parotidectomy with sacrifice of the facial
nerve in order to obtain sufficient tumor-free margins. Perform frozen sectioning of the
facial nerve stump with continued excision until the margin is free. Immediately
reconstruct the facial nerve with a cable graft. Perform neck dissection for positive
nodal disease and treat the parotid bed and neck with postoperative radiation therapy.

 Group 4 includes T4 tumors. Direct excision is performed based on tumor size and
location. Perform radical parotidectomy with excision of the involved structures (eg,
facial nerve, mandible, mastoid tip, skin) as required to obtain tumor-free margins.
Complex reconstruction, including free tissue transfer, is usually required to maximize
functional restoration. Perform neck dissection for N+ disease and administer
postoperative radiation therapy.

 Extracapsular dissection, in which the tumor and capsule are carefully dissected from the
parotid gland, while preserving facial nerve. Upon excision, the specimen should be delivered to
pathology intact, to allow microscopic evaluation of the integrity of the capsule.

 Superficial Parotidectomy with cranial nerve VII preservation was also performed through a
face lift incision. The tumor was excised with a 5 to 10mm margin of uinvolved surrounding
tissue, with the exception of the deep margin, where the capsule was carefully dissected. The
procedure is done with a Blair incision. A nerve stimulator is used for verification. The roots of
the facial nerve are then identified, from the frontal, zygomatic, buccal, marginal mandibular
and cervical aspects. The parenchyma of the parotid is then elevated in a superficial plane over
the preserved nerve roots. The parotid gland is mobilized anteriorly to include the pleomorphic
adenoma.

 Limited parotidectomy
Limited parotidectomy, also called extracapsular dissection, has recently been espoused as a
method to surgically manage benign tumors of the parotid gland. The impetus for this approach came
from a study that demonstrated that, in superficial parotidectomy specimens, no margin of normal
parenchyma on the deep aspect existed, as the margin was the facial nerve. This information negated
the notion that a cuff of normal tissue was needed to prevent recurrence of benign lesions.
A few studies have demonstrated that even with greater than 10-year follow-up, recurrence
rates between limited and superficial parotidectomy for pleomorphic adenomas are the same. The
advantages of limited parotidectomy are improved cosmesis and decreased rate of Frey syndrome. A
potential disadvantage is the seemingly increased risk of unintentional damage to the facial nerve.
However, studies have not shown any increased risk of facial nerve injury with limited parotidectomy.
In this technique, the incision and flap elevation are the same as for superficial parotidectomy;
however, instead of identifying the main trunk of the facial nerve, the parotid is incised over the tumor.
The tumor capsule is then dissected taking care to have adequate visualization and to use a nerve
stimulator as needed to avoid injury to branches of the facial nerve. Being as certain as possible that the
neoplasm is benign before using limited parotidectomy is important. Preoperative imaging, physical
examination, history, and FNA should be consistent with a benign process.
Total parotidectomy
Strictly speaking, total parotidectomy is a misnomer. The procedure, by definition, involves
removal of as much parotid tissue medial and lateral to the facial nerve as possible, along with the
accompanying tumor. The exact approach varies depending on tumor location, but it usually involves a
superficial parotidectomy to identify and preserve the facial nerve, followed by removal of parotid tissue
and tumor deep to the facial nerve.
Attempt to preserve the facial nerve at all times. The nerve is never sacrificed for benign disease
and only sacrificed if malignancy is found to be directly infiltrating the nerve. In these situations, remove
the involved branch with the specimen and obtain frozen sections to ensure clearance of tumor.
 West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippinesa
* Trunkline: (063) (033) 320-0870 to 78 loc.1313* Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

Removal of dumbbell-shaped tumors and parapharyngeal space tumors requires additional

exposure. This may be accomplished either transcervically after removal of the submandibular gland or
via an extended approach with mandibulotomy and/or lip-splitting incision. This is discussed in the
Medscape Reference article Parapharyngeal Space Tumors.
For cases of recurrent tumor and in cases in which difficult dissection is anticipated, intraoperative facial
nerve monitoring may be helpful in identifying and preserving the facial nerve.
Submandibular gland excision
Submandibular excision is generally performed with the patient under general anesthesia
without paralysis. Make a 5-cm incision in a skin crease of the neck approximately 2-3 cm below the
inferior border of the mandible. Carry the incision through the platysma and create small subplatysmal
flaps inferiorly and superiorly. The surgeon must avoid injuring the marginal mandibular branch of the
facial nerve. The procedure may be accomplished by direct identification and dissection superiorly or by
incision of the fascia overlying the gland and ligation of the posterior facial vein. The vein and fascia are
reflected superiorly, protecting the marginal mandibular nerve.
In managing bulky tumors or malignancy, positive identification and dissection of the marginal
mandibular branch not only provides wider exposure but also allows complete excision of the level 1
perifacial lymph nodes with the surgical specimen.
The gland and surrounding tissues are then freed from the undersurface of the mandible. The
facial artery is usually divided as it approaches the mandible. Dissect the inferior portion of the gland
from the digastric muscle. The facial artery is encountered again inferiorly near its origin from the
external carotid artery and ligated. Retract the specimen laterally to expose the mylohyoid muscle. The
mylohyoid muscle is dissected free and retracted medially. This maneuver exposes the hypoglossal
nerve inferiorly, the lingual nerve superiorly, and the submandibular duct (Wharton duct). Retract the
specimen inferiorly and identify the submandibular ganglion along the lingual nerve. The hypoglossal
nerve is identified inferiorly. Once the lingual nerve, hypoglossal nerve, and submandibular duct are
positively confirmed, ligate and transect the submandibular duct and ganglion. Final soft tissue
attachments are divided, and the specimen is removed.
If a neck dissection is indicated, this dissection is performed in continuity. Again, nerves are
preserved unless directly involved with tumor. With neurotrophic tumors (adenoid cystic carcinoma),
frozen sections may be taken from the epineurium with excision of involved nerves.
Achieve careful hemostasis, insert a closed suction drain or Penrose drain, and close the wound in
layers. Antibiotic ointment and a gauze dressing may be applied.

Submandibular gland surgery

Submandibular gland surgery is performed with the patient under general anesthesia with
endotracheal intubation. Head rotation is to the opposite side of the tumor.
An incision at least 2 cm below the body of the mandible is made through the platysma to permit
identification of the superficial layer of the deep cervical fascia. To avoid injury to the marginal
mandibular branch of the facial nerve, a technique of dividing the facial vein and raising a fascial
flap/plane may be employed to ensure that dissection is deep to the nerve. Other approaches include
direct identification of the nerve to avoid injury during dissection.
Another potential complication during submandibular gland or tumor excision is injury to the
hypoglossal nerve or the lingual nerve. Careful dissection with appropriate identification and
preservation of these structures is recommended.

SOURCES:
Cancer. (n.d.) In Mosby’s dictionary of medicine, nursing health profession. Retrieved from
http://www.nursing consult.com/nursing/index. Accessed last September 20, 2018.

Edge, S.B. & Compton, C.C (2010). The American Joint Committee on Cancer: the 7th edition of the AJCC
Cancer staging ang the future of TNM. Annals of Surgical Oncology, 17 1471-1474
 West Visayas State University
COLLEGE OF NURSING
Luna St., La Paz, Iloilo City 5000
Iloilo, Philippinesa
* Trunkline: (063) (033) 320-0870 to 78 loc.1313* Telefax No.: (033) 320-0879
* Website: www.wvsu.edu.ph * Email Address: con@wvsu.edu.ph

Itano, J. K. (2016). Core Curriculum for Oncology Nursing (5th edition). St. Louis, Missouri: Elsevier.

Lee, S. C., & Meyers, A. D. (2018, August 17). Salivary Gland Neoplasms Treatment & Management:
Medical Therapy, Surgical Therapy, Intraoperative Details. Retrieved September 20, 2018, from
https://emedicine.medscape.com/article/852373-treatment
Olsen, KD Lewis . Carcinoma ex pleomorphic adenoma: a clinicopathologic review . Head and Neck 2001.

Newton, S., Hickey, M., & Brant, J. M. (n.d.). Mosby's Oncology Nursing Advisor E-Book: A
Comprehensive Guide to Clinical Practice (2nd ed.). St. Louis
Said, S. (2016, June 01). Pathology of Pleomorphic Adenoma: Definition, Epidemiology, Etiology.
Retrieved September 20, 2018, from https://emedicine.medscape.com/article/1630933-overview#a