Deep Lobe Involvement Research Articles

Minimal Margin Surgery and Intraoperative Neuromonitoring in Benign Parotid Gland Tumors: Retrospective Clinical Study.

Extracapsular dissection (ECD) was introduced for the removal of superficial and small benign parotid tumors. According to a recent proposal, ECD is reserved for tumors that are 3 cm or less, mobile, and close to the parotid borders in cases of pleomorphic adenoma. The aim of the study is to evaluate the effectiveness of ECD for treatment of benign parotid tumors also in cases of tumors that were larger than 3 cm and deeper. All ECD for benign parotid neoplasms conducted between 2007 and 2017 were reviewed. The lesions included were limited to primary parotid tumors and categorized by Quer proposal. Facial nerve monitoring was used in all cases. Facial nerve palsy and local recurrences were assessed. The 88 ECD performed met inclusion criteria. The mean lesion size was 4.26 cm. Of the tumors, 68 were less than 3 cm in diameter and 20 were larger, 64 were superficial, and 24 were deep. The most common lesion types were pleomorphic adenoma (88.6%). There was no significant difference in complication rates between the size of tumor (p = 0.9) and location (p = 0.91). Our results suggest that extracapsular dissection could be considered an option for first-time diagnosed benign parotid tumors, even in cases of large dimensions and deep lobe involvement.

Diagnostic value of various criteria for deep lobe involvement in radiologic studies with parotid mass: a systematic review and meta-analysis.

To assess the diagnostic utility of various radiologic criteria such as the lateral margin or dislocation of the retromandibular vein (RMV), Utrecht line, facial nerve line, Conn's arc, lines passing from the lateral margin of the masseter muscle to the facial nerve trunk or RMV, minimum distance from the fascia to the tumor (MDFT), and direct tracing of the intraparotid facial nerve (DT) for differentiating a parotid deep lobe tumor from a superficial lobe tumor. Twenty-one studies with 2225 participants from PubMed, Embase, Web of Science, Cochrane Library, SCOPUS, and Google Scholar up to March 2022 were analyzed. Sensitivity, specificity, and negative and positive predictive values of the methods were extracted. The diagnostic odds ratio (DOR) of radiologic criteria compared to surgical findings was 18.9109. The area under the summary receiver operating characteristic curve was 0.879. The sensitivity and specificity were 0.6663 and 0.9190. MDFT (DOR 61.2917) and DT (DOR 91.9883) showed superior results as diagnostic landmarks. For tumors crossing the anatomical criteria line, strict way (any tumor crossing the line) could help differentiate a deep lobe tumor more accurately than conventional way (> 50% of the tumor volume located medial to the line). Various radiologic criteria, especially MDFT and DT, showed good diagnostic accuracy for differentiating a parotid deep lobe tumor.

CLINICO PATHOLOGICAL STUDY OF TUMOURS OF PAROTID GLAND IN TERTIARY CARE HOSPITAL , PENCHIKALAPADU, KURNOOL

purpose: The objective of the study was to study age and sex pattern in parotid gland tumors, and determine the accuracy of ne needle aspiration cytology in diagnosing parotid gland tumors, and also analyze different modes of surgeries for parotid gland tumors. Detailed study of thirty cases of parotid gland tumors admitted to viswabharathi medical college, penchikalapadu,Design: Kurnool from January -2021 to January 2022, Out of 30 cases , 23 were benign tumors , 19, pleomporphic adenoma , 2 warthin's tumor,Results: 2 basal cell adenoma, while of 19 pleomorphic adenoma , male being 10 as compared to 9 female . The maximum of cases were seen in fourth and sixth decade followed by third and then fth decade. Malignant tumors has male to female ratio of 4:3 with predominance of third and sixth decade. All 23 cases of benign parotid tumors, i.e., 19 pleomorphic adenomas, 2 warthin's tumor and 2 basal cell adenomas were correctly diagnosed by FNAC. Hence the accuracy of FNAC in diagnosing benign parotid tumors in this series was 100%. In malignant tumors, ve of seven cases were correctly diagnosed by FNAC. The accuracy of FNAC in diagnosing malignant parotid tumors is 71.4 %. All pleomorphic adenomas were offered supercial parotidectomy except one where a total parotidectomy with conservation of facial nerve was done due to involvement of deep lobe. Of the other 4 benign tumors, all underwent supercial parotidectomy. In malignant tumors supercial parotidectomy with irradiation was offered in 3 cases, total conservative parotidectomy with irradiation in 1 case , total radical parotidectomy was offered in 3 cases. parotid gland tumors, has a male preponderance in both benign and malignant tumors, with 10:9 and 4:3 respectively. TheConclusion: accuracy of FNAC is 100% in benign tumors as compared to 71.4%. FNAC is a good tool in diagnosing benign parotid gland tumors, but should be cautiously interpreted in malignant tumors.

Three-dimensional double-echo steady-state with water excitation magnetic resonance imaging to localize the intraparotid facial nerve in patients with deep-seated parotid tumors.

To assess the utility of three-dimensional double-echo steady-state with water excitation (3D-DESS-WE) imaging for localizing deep-seated parotid tumors in relation to the facial nerve. A prospective study comparing the surgical outcomes of parotidectomy with or without 3D-DESS-WE sequence is currently enrolling the patients. Magnetic resonance imaging data from the first 25 patients with 3D-DESS-WE sequence were reviewed. Visibility of the intraparotid facial nerve was independently assessed by two neuroradiologists. The diagnostic performance of the 3D-DESS-WE sequence for prediction of deep lobe involvement was compared with that of two conventional methods based on the retromandibular vein line (RMVL) and facial nerve line (FNL). The relationship between the tumor and the main trunk of the facial nerve was also evaluated on the 3D-DESS-WE sequence. On 3D-DESS-WE images, the main trunk, temporofacial division, and cervicofacial division of the intraparotid facial nerve were visualized in 100% (25/25), 48% (12/25), and 36% (9/25) of patients, respectively. The diagnostic accuracy of the 3D-DESS-WE sequence for prediction of deep lobe involvement was 92% (23/25), which was significantly superior to that of the RMVL (68% [17/25]; p = 0.008) and FNL (64% [16/25]; p = 0.004) methods. The relationship between the tumor and the main trunk of the facial nerve was correctly predicted in 92% (23/25) of 3D-DESS-WE images. By direct visualization of the facial nerve, the 3D-DESS-WE sequence improved the preoperative localization of the intraparotid facial nerve in deep-seated parotid tumors. This information may help better surgical planning for deep-seated parotid tumors.

DEMOGRAPHIC STUDY OF SALIVARY GLAND SWELLING

Introduction: Salivary glands, major and minor, comprise a complex anatomic and physiologic “organ” system-producing enzyme, lubrication, mixing agent and immune factors. Salivary gland swellings can be broadly classified into inflammatory, non- inflammatory and neoplastic swellings like calculi, benign tumours such as pleomorphic adenoma, oncocytoma, warthin’s tumour or malignant tumours like adenocarcinoma, adenoid cystic carcinoma and undifferentiated carcinoma. Connective tissue diseases like haemangioma, lymphangia, neurofibroma and other auto immune diseases like Sjogren’s syndrome, Mikulicz disease etc. Appropriate therapeutic management may be planned earlier, whether it is local excision for a benign neoplasm, radical surgery for a malignant one or any other alternate treatment. With non-neoplastic lesions, metastasis and lymph proliferative disorders, conservative management, chemotherapy or radiotherapy might be respectively preferable.
 Material and Methods: 40 cases of salivary gland swelling are studied, which were analyzed and conclusion drawn. The statistics have been compared with different standard studies conducted on same subject by various authors around world. Associated medical conditions like diabetes, hypertension and anemia were managed and controlled before surgery with the patient’s advice. As a part of general work up of surgery in all patients, hemoglobin level, bleeding time, clotting time, urine, sugar albumin, microscopy, chest screening, ECG, Blood urea, serum Creatinine, RBS was estimated. Specific investigations like FNAC, X-rays of Mandible were done for all patients in the study group. Demographic profile of all the study population was recorded.
 Results: Age of the patients varied from 9 years to 80 years. Average age of the patient was 40.6 years. The case of lowest age group i.e., 9 years was of non-inflammatory swelling and the case of highest age i.e., 80 years was of tumor swelling. Out of 40 cases 15(35%) cases was of male and 25(65%) cases of female. In this study, all cases presented with, symptoms of swelling (100%), 65% (26) presented with pain. 55 % (22) presented with tenderness. Three cases were with deep lobe involvement (11.4%), 19 cases of ear lobe elevation (47.5%). Facial nerve paralysis occurred in one case (2.8%).
 Conclusion: Diagnosis of the salivary gland tumors must be considered in any patient presenting with salivary gland swelling. Salivary gland swelling occur more commonly in 3rd and 4th decades of life and seen most common in females.
 Keywords: salivary gland, tumour, benign, malignant

SURGICAL APPROACH AND OUTCOMES IN SALIVARY GLAND SWELLING

Introduction: Salivary gland tumours are rare tumours and majority of these are benign and about 20% are malignant. The incidence of salivary gland cancers ranges from 0.5 to 2 per 100,000 in different parts of the world. Salivary gland swellings in the parotid or submandibular glands usually present as an enlarging mass and may be associated with neurological symptoms like facial nerve paralysis or pain. Minor salivary gland tumours present as a submucosal intraoral mass which subsequently ulcerates. Acute inflammatory conditions generally can be diagnosed by history and physical examination alone, whereas chronic inflammatory diseases and granulomatous disorders require supplemental diagnostic information including lab tests, imaging studies and biopsy. FNAC of salivary gland tumours is advantageous to both the patient and the clinician because of its immediate results, accuracy, lack of complications and economy. Appropriate therapeutic management may be planned earlier, whether it is local excision for a benign neoplasm, radical surgery for a malignant one or any other alternate treatment.
 Material and Methods: All patients admitted to surgical wards due to obstructions of the salivary duct and neoplasia were included in the study. Demographic data from all the patients were collected, also they were evaluated for clinical examination, routine laboratory investigations and specific investigations. After evaluation of the swellings by clinical examination and by specific investigations, a surgical plan was formulated. The final decision was taken by the operative surgeon.
 Results: 40 cases of salivary gland swellings were admitted during study period. Age of the patients varied from 9 years to 80 years. 62.5% (25 cases) were found in the parotid gland, 30% cases (12) in submandibular gland and 7.5% cases (3) in the sublingual gland. Surgery was the treatment for all cases of tumors. Superficial parotidectomy was done in all the 21 cases of parotid tumour (56.41%) without deep lobe involvement and total parotidectomy was done in 3 cases (7.6%) with deep lobe involvement. In all the cases of submandibular gland lesions, excision of submandibular gland was done. Excision of the sublingual gland was done in 3 cases of ranula. One case of adenoid cystic cacinoma was referred to higher center because of the advanced malignancy.
 Conclusion: Salivary gland tumors occur more commonly in the parotid gland, most often benign, pleomorphic adenoma constitute majority of all neoplasm. Surgery is the main modality of treatment in salivary gland sialolithiasis. Most commonly done surgery is excision of submandibular salivary gland & superficial parotidectomy and also for salivary gland tumors. Awareness and early referral is necessary, as prognosis is good if treated early.
 Keywords: SALIVARY GLAND, TUMOUR, NEOPLASM, SURGERY

Mystery in parotid

Background: Parotid gland is the largest of the salivary glands present in the body. Neoplastic lesions in parotid gland always causes difficulty in tissue diagnosis due to their diversified histology. Lesion in the superficial lobe of parotid is more amenable for clinical diagnosis but deep lobe lesion requires imaging to confirm the diagnosis. Managing parotid swelling seems like a mystery due to these issues.Methods: There were 30 patients who presented with complaints of swelling in the parotid region. For all these patients detailed history was taken and clinical examination was done and findings noted. Contract enhanced computed tomography (CECT) of the parotid region was done followed by fine needle aspiration cytology (FNAC) and the management was planned accordingly.Results: All the 30 patients were within the age group of 25 years to 65 years. All the patients presented with swelling in the parotid region. Among the 30 patients, 10 patients had complaints of associated pain in the parotid region. On clinical examination, all the patients had lesion in the superficial lobe of parotid and 2 patients had deep lobe involvement. 1 patient had features of facial nerve palsy. Contrast enhanced computed tomography (CECT) and Fine needle aspiration cytology (FNAC) was done. For all the patients’ surgical management was planned accordingly.Conclusions: Routinely submitting all parotid swelling patients to Fine needle aspiration cytology and computed tomography helps to solve the mystery of diversified histology and presentation.

Incidence of facial nerve sacrifice in parotidectomy for primary and metastatic malignancies

IntroductionThe parotid gland may become involved by primary parotid malignancies and secondarily by metastases from other primary sites. Surgical resection of these tumors can be technically challenging due to the intimate relationship of the parotid gland and the facial nerve. The primary aim of this project was to determine the incidence of facial nerve sacrifice in parotidectomy for primary and secondary malignancies of the parotid. MethodsA retrospective chart review of was performed. Patients who received parotidectomy with final pathology consistent with a malignant neoplasm were included. The primary outcome studied was necessity for facial nerve sacrifice. Co-variates included preoperative facial nerve function, preoperative pain, superficial versus total parotidectomy and pathologic diagnosis. Univariate analysis was performed using student t-test to determine odds ratios. ResultsWe identified 75 patients who had a parotidectomy for a malignant process in our review. 30 patients had facial nerve sacrifice: 14 total and 16 partial sacrifices. Patients were more likely to require facial nerve sacrifice when they presented with preoperative facial nerve dysfunction [100% vs 19.6%, p=0.0006, OR 154.3, CI (8.66–2750.9)], pre-op pain [76.5% vs. 29.3%, p=0.001, OR 7.84, CI (2.23–27.50)], and required excision of both superficial and deep lobes of the parotid gland [64.9% vs 15.8%, p=0.0001, OR 9.85, CI (3.27–29.66)]. ConclusionOur data illustrates that many patients with normal facial nerve function, even in the setting of malignancy, can have their facial nerve preserved. Pain, deep lobe involvement and preoperative facial nerve dysfunction are associated with an increased risk of needing at least partial facial nerve sacrifice in the setting of parotid gland malignancies.

Outcomes and prognostic factors in modern era management of major salivary gland cancer

There is a dearth of prospective evidence regarding cancer of the major salivary glands. Outcomes and management of major salivary gland are based largely on retrospective series spanning many decades and changes in surgical, radiation, imaging and systemic therapy strategies and technique. We sought to report contemporary patterns of relapse and prognostic factors for major salivary gland cancer. 112 patients with major salivary gland cancers underwent resection with or without adjuvant therapy between January 1997 and September 2010. Outcomes were documented with follow-up until December 2014. Survival was calculated by the Kaplan-Meier method. Log-rank test and Cox proportional hazards regression were performed with locoregional control (LRC), distant control (DC) and overall survival (OS) as the primary outcome variables. Median follow-up was 55.1 months. Rates of LRC for stage I/II and III/IV at five years were 95.7% and 61.9% respectively. Rates of DC at five years for stage I/II and III/IV were 93% and 56.9% respectively. Multivariate analysis identified larger tumor size, clinical nerve involvement and in parotid cancers, advanced T stage, no adjuvant radiation, and older age at diagnosis to be associated with increased risk of locoregional recurrence (all p<0.05). Distant metastasis was associated with sublingual site, degree of clinical nerve involvement, high grade, tumor size and in parotid tumors additionally deep lobe involvement on multivariate analysis (all p<0.05). Several prognostic factors were identified that may help guide decisions regarding adjuvant therapy. DM remains a significant concern in the management of this disease.

Deep lobe parotid tumors in a tertiary care center

Background: Salivary gland tumors are uncommon, accounting for between 2 to 6.5 percent of all neoplasms of the head and neck. About 70% of all salivary gland tumors arise in the parotid gland and a great number of these are benign tumors, with an average prevalence of 75%-85%.Parotid gland can give rise to a wide variety of neoplasms because of their mixed array of cells and tissues. Involvement of deep lobe is common in malignancy. Methods: The aim of the study is to analyze the deep lobe involvement in parotid tumors and to study incidence of facial nerve injury in deep lobe parotid tumors. Our study is a prospective study done between April 2012 to October 2014 in the Department of General Surgery, Sri Ramachandra University, Chennai, Tamilnadu. Results: In our study in about 36% of the tumors, the deep lobe was involved and facial nerve injury was present in 55.5% of the patients. Conclusions: We conclude that deep lobe involvement in parotid tumors are rare and identifying it by clinical and imaging modalities plays an important role in reducing the perioperative complications like facial nerve injury.

Biomarkers pS6 and pERK as Predictors of Skin Cancer Aggressiveness

Objectives: The role of elective parotidectomy and the extent of surgery for occult nodal metastasis in cutaneous squamous cell carcinoma (SCC) is controversial. We wanted to determine if the MEK/ERK pathway and pathologic features in the tumor could predict skin cancer aggressiveness and allow for preemptive treatment of occult metastasis. Methods: Retrospective experimental laboratory study and chart review. Specimens from basal cell carcinoma (BCC; n = 13), squamous cell carcinoma (SCC; N = 10), and SCC with parotid metastasis (n = 11) were analyzed by immunohistochemistry (IHC) for pERK (Thr202/Tyr204) and pS6 (Ser235/236) and scored by the study pathologist. Simple logistic regression analysis evaluated all subjects with previous resection of cSCC and parotidectomy (n = 13) for independent risk factors of disease aggressiveness. Results: Expression of pS6 increased in cSCC with parotid metastasis ( P = .01) compared with other groups. BCCA and SCCA comparison showed an increase in pS6 expression in SCC ( P &lt; .01). There was no significant difference in pERK expression between groups. Factors associated with cSCC with nodal metastasis were previous skin positive margins ( P = .03) and parotid perineural invasion ( P = .04). Positive margins on primary lesions is an independent risk factor for deep lobe involvement ( P = .03). Conclusions: Positive margins on primary skin lesions, perineural involvement of parotid specimens, and Biomarker pS6 appear to be predictors of aggressiveness in cSCC and should prompt increased monitoring or elective treatment. As pERK was not significantly activated, pS6 overexpression could indicate activation of the Akt/mTOR pathway.

Pathology Quiz Case 3

A 59-YEAR-OLD MAN PRESENTED WITH A long history of a right parotid mass, which had gradually enlarged over the past 2 years. The lesion had initially been evaluated 8 years earlier, when the findings of fine-needle aspiration were suggestive of pleomorphic adenoma. Although surgical excision was offered, the patient declined. On presentation to our clinic, he reported no symptoms and denied pain, numbness, and facial weakness. He had no other medical problems, had quit smoking 20 years earlier, and denied alcohol use. The physical examination was notable for a palpable 4 3-cm mass at the tail of parotid gland, with elevation of the auricular lobule. The mass was mobile within the parotid gland and not attached to the overlying skin. Facial nerve function was intact, and there was no palpable cervical lymphadenopathy. Contrast-enhanced computed tomography revealed a 4.5 3.4 3.3-cm solidcystic, heterogeneous mass in the superficial aspect of the right parotid gland extending inferiorly into the tail (Figure 1). Extension into the stylomandibular tunnel indicated deep lobe involvement. No cervical adenopathy was seen. The patient underwent a near-total parotidectomy with facial nerve preservation. Intraoperatively, the superior component of the mass was delivered from the stylomastoid foramen without violation of the specimen. Histopathologic examination revealed a neoplasm that was composed of cytologically bland myoepithelial cells within a loose myxoid matrix (Figure 2). Centrally, there was a large area of dense hyalinized stroma (Figure 3) merging with benign myoepithelial cells (Figure 3, right), while adjacent areas of the tumor contained cohesive groups of glandular cells (Figure 3, upper left) with marked nuclear atypia and necrosis (Figure 4). The tumor was noninvasive (contained within the mixed tumor capsule) and well circumscribed. The patient underwent postoperative radiation therapy and 3 years later was still without evidence of disease. What is your diagnosis? Figure 1.

Mucoepidermoid parotid carcinoma after renal transplantation

Mucoepidermoid parotid carcinoma after renal transplantation

Predicting facial nerve invasion by parotid gland carcinoma and outcome of facial reanimation

We sought to define risk factors for facial nerve involvement in parotid gland carcinoma and assess the outcome of facial nerve reanimation. Medical records were reviewed of 66 patients who underwent surgery for parotid carcinoma in 2000–2007 at a tertiary hospital. Patient and tumor characteristics were compared between patients with and without facial nerve involvement and were analyzed on their influence on functional outcome following reanimation. Facial nerve involvement was verified intraoperatively in 24 patients, of whom 16 underwent reanimation during ablative surgery. Deep lobe invasion was significantly associated with intraoperative finding of facial nerve involvement. Tumors larger than 4 cm and salivary duct carcinoma had an obvious trend for facial nerve involvement. House-Brackmann score at 12 months was 3-4 in most patients. Deep lobe involvement and large tumor size may identify patients at risk of facial nerve involvement. Reanimation is associated with good functional outcome regardless of patient's age.

Giant, Deep Parotid Lobe Tumor: A Challenging Surgical Case

Background and Aim: Parotid tumors are relatively frequent, representing approximately 2% of all tumors in the neck area. The pleomorphic adenoma is usually found in the superficial lobe of the parotid gland, whereas deep lobe involvement is relatively rare. However, such tumors involving the deep parotid lobe may present with a neck mass that may have an intraoral extension (sometimes a dumb-bell mass). The surgical approach depends on size and location of the tumor and may be transoral, cervical, transmandibular, transparotid, retromandibular approach, or a combination.

Acinic cell carcinomas arising in salivary glands: a clinicopathologic study.

Fifty-one cases of acinic cell carcinoma (ACC) arising in major and minor salivary glands are reported (primary sites: parotid 37, submandibular, six, and oral cavity, eight.) These lesions usually produced painless slowly growing masses. Of 49 patients with follow-up information, 17 (35%) developed local recurrences following original surgical resection, and two (4%) had locally persistent disease. At last follow-up, 27 patients (55%) never had a recurrence, seven (14%) had experienced local recurrences but the tumors were apparently controlled by further surgical excisions, five (10%) were living with persistent disease, and 10 (20%) had died (one due to local tumor and nine due to metastases, usually to bones and lungs). The determinate 5-, 10- and 15-year survival rates were 78%, 63%, and 44%, respectively. Prognostic factors included: demonstrable tumor on lines of surgical excision, involvement of deep lobe of parotid, size of primary lesion, degree of mitotic activity and nuclear atypia, infiltrative rather than circumscribed borders, and lymph node involvement. Local recurrence was associated with an increased incidence of locally uncontrollable and metastatic disease. Type of initial therapy correlated with prognosis. Locally recurrent or persistent tumor was found in 14 of 15 patients treated with limited local excisions (including one biopsy only). Recurrences were seen in only three of 28 patients treated by wide local excisions and in two of six following radical en bloc resections. Seven of 17 patients with local recurrence were apparently cured by further more extensive resection. Radiotherapy did not appear effective in controlling these neoplasms.