Primary Parotid Research Articles

BMET-38METASTASIS TO BRAIN AND LUNG IN CARCINOSARCOMA OF THE PAROTID GLAND - A CASE REPORT

Carcinosarcoma of the parotid gland is a rare and aggressive malignant mixed tumor in which carcinomatous and sarcomatous elements coexist and they may metastasize together or independently. The tumor may occur in patients with previous or coexisting pleomorphic adenoma or may arise de novo of the parotid gland. We report a case of 56-year old male with history of carcinosarcoma of the parotid gland that subsequently developed solitary brain and lung metastases. The patient underwent craniotomy of the metastatic and symptomatic brain lesion and had adjuvant radiosurgery postoperatively. After that, his headache disappeared and the left hemiparesis improved. The next-generation sequencing gene study identified the amplification of IRS2, CDK4, IGF1R, MDM2 and MYC genes in metastatic brain lesion. In primary parotid lesion, genomic alteration identified amplification of RAF1, CDK4, IGF1R, MDM2 and MYC genes. The patient then entered a clinical trial and did not show any improvement. Due to the brain mets re-growth, a 2nd craniotomy was performed. He again improved significantly postoperatively. He currently received salvage chemotherapy for his progressive lung metastasis. The prognosis of carcinoma with distant metastasis is poor and the standard treatment has not been established yet. Herein we will present detailed pathological and molecular abnormality profiles of this case and will review similar cases reported in literatures. To our knowledge, this is the first case with carcinosarcoma of the parotid gland that developed brain and lung metastasis.

Histopathological evaluation of parotid gland neoplasms in Queensland, Australia

Parotid gland tumours are complex neoplasms with a broad histological range. The parotid gland is also a common site of face and scalp skin cancer metastases. Parotidectomies performed by ENT department in the Gold Coast health district from 2006 to 2013. A total of 158 specimens were examined. Of these, 53.80 per cent were benign and 46.20 per cent were malignant. Pleomorphic adenoma was the most common tumour (29.11 per cent), followed by cutaneous squamous cell carcinoma (23.42 per cent) and Warthin's tumour (12.03 per cent). Metastatic squamous cell carcinoma accounted for a large proportion of parotid masses in our case series, reflecting the high prevalence of non-melanoma skin cancer in Australia. Primary parotid neoplasms had similar incidence rates to other studies.

Demographics of benign parotid tumours: Warthin’s tumour versus other benign salivary tumours

Conclusion: Some variation from the ‘classical’ clinical picture for Warthin’s tumours is evident in these patients. A predilection for the parotid tail and a propensity for multiplicity has been confirmed. Objectives: This study sought to analyse demographic and clinical features of a Warthin’s patient population. Methods: Retrospective review of patients presenting with a benign parotid tumour. The group of Warthin’s tumours was compared with the group of patients with other benign parotid tumours. Results: Of 170 primary parotid tumours, 41 (24%) were Warthin’s tumour. Mean age of Warthins patients was significantly older (60 years vs 48 years, p = 0.001) and male gender more prevalent (61% vs 33%, p = 0.015) than in other benign tumours. Most (86%) Warthin’s tumours were found in the parotid tail, compared with 61% of other benign tumours (p = 0.002). There was no significant ethnic predilection for Warthin’s tumours. Bilaterality (30%) and multiplicity (27%) were common. Significance of gender differences disappeared with logistic regression analysis.

Predictors of Nodal Metastasis in Parotid Malignancies: A National Cancer Data Base Study of 22,653 Patients.

(1) To identify predictors of nodal disease in parotid malignancies using various clinical and pathologic variables. (2) To examine the effect of nodal disease on overall survival (OS) in parotid cancers Retrospective database review. National Cancer Data Base (1998-2012). We identified all cases of primary parotid malignancies in the United States between 1998 and 2012 in the National Cancer Data Base. Eight histopathologies, constituting >80% of all cases, were examined for nodal metastasis and survival. We identified 22,653 cases of primary parotid cancer. Eight major histologies were studied, with mucoepidermoid carcinoma (31%), acinic cell carcinoma (18%), adenocarcinoma (14%), and adenoid cystic carcinoma (9%) being most common. Regional nodal disease incidence was 24.4% overall and varied by histopathology. Salivary ductal carcinoma had the highest incidence of both nodal metastasis and occult lymph node metastasis. Overall, N0 patients lived significantly longer than N+ (5-year OS, 79% vs 40%; P < .001). Low-grade disease had significantly better survival than high-grade (5-year OS, 88% vs 69%; P < .001). Occult nodal disease was found in 10.2% and varied by histopathology. Regional lymph node metastasis significantly decreases survival in many parotid malignancies. High-grade cancers had higher incidences of regional disease than did low grade. Adenocarcinoma had the highest mortality when regional disease was present. Incidence of occult disease varied by histology, but incidence was <10% for all low-grade disease. High T stage and grade are significant independent predictors of nodal disease for most histopathologies.

Eyelid-parotid metastasis: do we screen for coexisting masses? A case series

To report three cases illustrating that it is not unusual for a primary eyelid tumour to metastasise to the parotid gland and vice versa. Two patients with malignant parotid tumours underwent radical parotidectomy and presented subsequently with eyelid lesions. Biopsy showed that both eyelid lesions were histologically similar to the primary parotid tumour. A third patient was noted to have ipsilateral upper eyelid and parotid gland tumours. Histology and immunocytochemistry were used to differentiate the primary tumour and the metastasis. These cases illustrate that tumours involving eyelids and parotid glands can present simultaneously or sequentially, and either of these structures could be the focus of primary or metastatic tumour. The important message for oculoplastic and parotid surgeons is to routinely assess both the periocular and parotid area when patients present with a mass in either structure.

Selective deep lobe parotid surgery for benign tumors

Conclusions: Deep-lobe tumor parotidectomy decreases the incidence of parotidectomy post-surgical complications, preserves parotid function, and has a good esthetic appearance. Objective: The existing surgical technique in the parotidectomy of deep-lobe benign tumors can be improved. Methods: Fourteen surgical operations were performed (2004–2015) for selective deep lobe parotidectomy for patients with primary benign parotid tumors. The patients with deep-lobe benign tumors were operated on with the method of superficial lobe preservation, which included methylene blue staining of the gland and intra-operative facial nerve detection. Results: During follow-up, no cases of tumor recurrence, permanent facial nerve injury, postparotidectomy depression, or Frey’s syndrome was found.

Predictors of pathologic outcome of focal FDG uptake in the parotid gland identified on whole-body FDG PET imaging

PurposeThe purpose was to test whether patient’s primary malignancy type and presence of F-18-fluorodeoxyglucose (FDG)-avid cervical lymph node(s) are predictors of pathologic outcome of incidental focal FDG-avid parotid lesions. Basic proceduresA retrospective cohort study of pathologically proven incidental cases was performed. Main findingsFocal parotid FDG uptake in the setting of head and neck cancer/melanoma [odds ratio (OR)=24.6, P<.01], lymphoma (OR=7.2, P=.02), or FDG-avid cervical lymph node(s) (OR=3.6, P=.07) has a higher odds of representing metastases. No malignant primary parotid tumors were incidentally discovered. Principal conclusionsIn patients with head and neck cancer/melanoma, lymphoma, or FDG-avid cervical lymph node(s), there were higher odds that focal parotid FDG uptake was a metastasis.

Assessing the histological type and grade of primary parotid carcinoma by fine-needle aspiration and frozen section.

The aim of this study is to compare preoperative fine needle aspiration cytology (FNAC) and intraoperative frozen section (FS) for the correct identification of malignancy, histological grade, and histological type. FNAC was performed on all 105 patients and FS on 71 patients with parotid carcinoma. The rate of correctly determining the histological grade by FNAC and FS was 32% and 73%, respectively. The correct diagnosis rate for both the histological type and grade by FNAC and FS was 20% and 48%, respectively. The correct grading of both high and low/intermediate grade carcinoma is possible in 70-80% of patients by FS. If the histological grade is identified correctly, the extent of resection can usually be decided appropriately. Therefore, we should put emphasis on determining the histological grade.

Unexpected Detection of Parotid Gland Malignancy during Primary Extracapsular Dissection.

To evaluate the oncologic and functional outcome in cases in which a false preoperative working hypothesis "benign parotid tumor" led to a primary extracapsular dissection being performed rather than a traditional, more radical surgical modality. Case series with chart review. Academic tertiary referral center. The records of all patients treated for malignant tumors of the parotid gland between 2006 and 2012 were retrospectively studied. Patients were excluded from our study sample for insufficient data or if their histories indicated manifestation of malignant tumors without primary parotid origin (squamous cell carcinomas, lymphomas, melanomas), revision surgery, as well as concomitant or past malignant tumors. Consequently, a total of 29 patients with 30 primary malignant tumors of the parotid gland formed our study sample (14 men, 15 women; male:female ratio, 0.93:1; mean age, 55.4 years; range, 14-85 years). Of 30 cases, 22 had low-grade tumors. Further tumor cells were detected in only the histology specimens of the parotid in 3 of the 25 cases treated subsequently with completion parotidectomy. Five patients received adjuvant radiation. Five-year disease-specific survival was 100%; local disease control was 96.6%. Of 30 cases, 28 had House-Brackmann I after tumor treatment; the other 2 cases had a slight paralysis (House-Brackmann II). Beginning with the "false" working hypothesis and performing an extracapsular dissection in unsuspected cases seems to have no adverse impact on patients' survival and postoperative quality of life in cases in which definitive histology reveals malignancy.

Incidence, treatment, and outcome of parotid carcinoma, 1996-2011: a population-based study in Thuringia, Germany.

The objective of this study was to examine patterns of care and survival in a population-based sample of patients with parotid cancer who were treated in Thuringia, a federal state in Germany, between 1996 and 2011. Data of 295 patients with primary parotid cancer from the Thuringian cancer registry were evaluated for patient's characteristics, tumor stage, incidence, and trends in treatment, cancer-specific survival (CSS), and overall survival (OS). Stages IV tumors and the amount of tumors in all age cohorts ≥45 years of age increased significantly during the observation period (p = 0.002; age all p < 0.05, respectively). The highest increase in crude incidence was observed for salivary duct carcinomas [relative risk per decade (RR) 5.46; 95% confidence interval (CI) 1.14-26.14] and rare carcinoma subtypes (RR 9.99; 95% CI 1.85-53.94). CSS at 5 years and at 10 years for all patients was 82.4 and 82.4%, respectively. OS at 5 years and at 10 years for all patients was 60.1 and 48.2%, respectively. CSS and OS did not improve over the time. Salivary duct carcinoma showed the lowest 5-year OS (35.6%). Acinic cell carcinoma had the highest OS rate (85.3%). Multivariate Cox models revealed that higher grading (G3/G4) was a more powerful independent predictor of decreased OS than TNM stage. CSS and OS did not improve during the study period. Incidence of parotid cancer increased significantly in elderly patients. It seems that grading is next to patient's age the better predictor of OS than TNM stage.

The role of partial parotidectomy for benign parotid tumors: A case-control study

Objective: To evaluate the results and complications after partial parotidectomy vs superficial parotidectomy, as primary treatment of benign parotid tumors. Study design: Case-control study. Setting: University hospital. Subjects and methods: A case-control study is presented on parotidectomy, comparing a group of 25 patients treated by partial parotidectomy vs a similar group of 25 patients treated by superficial parotidectomy. All patients had primary benign parotid tumors, were matched by sex and age, and had a minimum follow-up of 4 years. Independent variables included sex, age, medical history, intra-operative variables (surgical time, estimated blood loss, type of drainage, use of collagen), fine-needle aspiration cytology, computed tomography findings, and final histopathological diagnosis. Outcome measures were early and late complications, such as facial nerve paralysis, seroma, sialocele, Frey syndrome, and recurrence. Results: Partial parotidectomy resulted in less early and late complications than superficial parotidectomy, with similar recurrence rates. Temporal facial paresis was found in 4% of partial surgeries, vs 12% of superficial parotidectomies, a significant difference. Three months after surgery, only one patient has a persistent marginal nerve paresis. In contrast, sialocele was more common after partial parotidectomy (28% vs 16%), a significant difference. Conclusions: Partial parotidectomy achieves less early and late complications than superficial parotidectomy, with similar recurrence rates.

Tumor recurrence and complications of parotidectomy using the marginal mandibular branch as a landmark during the retrograde technique.

To investigate the recurrence of tumors and morbidity rates of postoperative complications associated with primary parotid pleomorphic adenomas treated with a parotidectomy using the marginal mandibular branch of the facial nerve as a landmark during the retrograde approach. Our study retrospectively analyzed the clinical data from 71 patients with a primary parotid pleomorphic adenoma who underwent a parotidectomy using the marginal mandibular branch of the facial nerve as a guide during the retrograde approach between November 2003 and August 2012. Three surgical modalities were involved in the study: a partial superficial parotidectomy was performed in 8 cases, a superficial parotidectomy was performed in 54 cases, and a total parotidectomy was performed in 9 cases. The recurrence of tumors and the morbidity rates of postoperative complications, such as transient facial nerve paralysis, permanent facial nerve paralysis, sensory deficiency, Frey syndrome, salivary fistulas, and xerostomia, were investigated. Tumor recurrence occurred in only 1 case. Overall, the morbidity rates for transient facial nerve paralysis, permanent facial nerve paralysis, sensory deficiency, Frey syndrome, and xerostomia were 22.5%, 1.4%, 39.4%, 59.2%, and 8.5%, respectively. No cases developed a salivary fistula. The use of the marginal mandibular branch of the facial nerve as a guide during the retrograde approach is a reliable and safe method for dissecting the facial nerve.

Patient and tumor characteristics predictive of primary parotid gland malignancy: A 20-year experience at the University of Wisconsin

PurposeTo identify patient and tumor characteristics predictive of primary parotid malignancy. Materials and methodsRecords were reviewed for patients who underwent parotidectomy at the University of Wisconsin from 1994 to 2013. Patients with primary parotid neoplasms were separated into benign or malignant subgroups. A multivariate logistic regression model was employed to compare categorical (gender, lesion side, nature of presentation, recurrence) and numerical variables (age, tumor size) between the benign and malignant groups. Mean BMI was compared between the groups by univariate analysis. Results771 patients underwent parotidectomy from 1994 to 2013, and 474 had a primary parotid neoplasm. No relationship existed between malignancy and gender (p=0.610), lesion side (p=0.110), or BMI (p=0.196). Mean age (p=0.015) and tumor size (p=0.011) were significantly different between the benign and malignant groups. Patient presentation was classified into three categories: symptomatic (n=109), palpable and asymptomatic (n=303), and incidentally noted on imaging (n=57). From all patients with symptomatic, asymptomatic or incidentally noted masses, 41.3%, 10.6% and 5.3%, respectively, were diagnosed with malignant disease. There was a significant relationship between the patient’s initial presentation and malignancy (p<0.001), and patients with facial nerve dysfunction or skin involvement had the greatest likelihood of malignancy. Finally, there was a significant association between malignancy and recurrence (p=0.001). ConclusionsIn this study, age, tumor size, and nature of presentation were all associated with primary parotid malignancy. Understanding the impact of these features on the probability of malignancy is valuable in decision making and counseling of patients presenting with a newly diagnosed parotid neoplasm.

WITHDRAWN: Comparison of the effect of total conservative parotidectomy versus superficial parotidectomy in management of benign parotid gland tumor: A systematic review

Since of the 1940s, there has been wide controversy about the most effective surgical treatment for the primary benign parotid tumor. This review investigates the effectiveness and associated complications of superficial parotidectomy versus total conservative parotidectomy in the management of primary benign parotid tumors. An electronic search with restricted dates (1920-2014) and restricted language was performed in August 2014. Thirteen studies were included. In total, 2477 patients were enrolled in the 13 studies, with 1317 patients undergoing superficial parotidectomy and 391 patients undergoing total conservative parotidectomy; 769 patients treated with other surgical techniques were excluded. The maximum follow-up period varied between 2 and 24 years (mean 2.8 years). The incidence of recurrence in the superficial parotidectomy patients ranged from 0% to 15% (mean 5.7%), whereas, in the total conservative parotidectomy patients it ranged from 0% to 16% (mean 3.03%). The incidence of the facial nerve paresis according to collected data in the superficial parotidectomy group ranged from 0% to 23% (mean 6.75%), whereas in the total conservative parotidectomy group it was 0%-45% (mean 15%). The incidence of facial nerve paralysis in the superficial parotidectomy group ranged from 0% to 3% (mean 0.8%), whereas in the total conservative parotidectomy group it was 0%-17 % (mean 4.4%). The results of this review suggest that superficial parotidectomy is superior to total conservative parotidectomy in the management of primary benign tumor in superficial lobes. In addition, superficial parotidectomy showed a minimal recurrence rate for benign tumor in superficial lobes.

An Unusual Case of Carcinoma Ex-pleomorphic Adenoma of the Parotid Gland: A Comprehensive Clinicopathological Review

ABSTRACTCarcinoma ex-pleomorphic adenoma (CaxPA) is a carcinoma arising from a primary or recurrent benign pleomorphic adenoma (PA). It presents approximately 11.6% of all malignant neoplasms of salivary gland and mostly originates from major salivary glands. It is a common histologic subtype of primary parotid malignancy. Location in the minor salivary gland is uncommon and occurs in less than 7% of all cases. The majority of CaxPA develops from epithelial component of PA. Salivary gland tumors are known to have a benign clinical behavior with unrecognized metastatic potential. It often poses a diagnostic challenge to clinicians and pathologists. The entity is difficult to diagnose preoperatively. Pathologic assessment is the gold standard for making the diagnosis. We present a case of a 55-year-old female patient who had a right preauricular mass of 10 years duration, with sudden onset of pain of duration of 1 month.How to cite this articleSharmila PS, Shashikala K, Harish K, Jeychandran P. An Unusual Case of Carcinoma Expleomorphic Adenoma of the Parotid Gland: A Comprehensive Clinicopathological Review. J Med Sci 2015;1(2):44-46.

Oncological and functional results after the surgical treatment of parotid cancer

The objective of this study was to analyze the oncological and functional outcomes after the surgical treatment of parotid cancer. We reviewed 80 primary parotid carcinomas retrospectively. A superficial parotidectomy was performed in 10 patients; 27 patients underwent total parotidectomy and 43 patients underwent radical parotidectomy. A facial–facial nerve anastomosis was chosen for the facial nerve reconstruction in eight patients, while an interpositional graft was selected in 24 patients. The overall N-positive rate of pathology was 21.3%. The rate of occult metastasis was 8.1%. High-grade carcinoma and lymphovascular emboli were independent factors for nodal metastasis. The 5-year disease-free survival and overall survival rates were 79.7% and 78.8%, respectively. Preoperative facial nerve palsy and extraparenchymal invasion were the independent factors associated with poor disease-free survival. Of the 41 patients in the facial nerve preservation group, 13 (31.7%) had transient facial nerve paresis. In the facial nerve sacrifice group of 39 cases, (sub)total recovery (House–Brackmann grade I/II) occurred in 14 (35.9%), partial recovery (House–Brackmann grade III/IV) in 13 (33.3%), and no recovery (House–Brackmann grade V) in 12 (30.8%). Facial nerve palsy upon presentation and extraparenchymal invasion indicate a grave prognosis. Facial nerve function after proper reconstruction is tolerable.

Value of apparent diffusion coefficient and magnetic resonance spectroscopy in the identification of various pathological subtypes of parotid gland tumors

Background and purposePre-operative imaging has a major role in surgical planning of parotid gland tumors. AimTo assess the role of the combined techniques of ADC generated from DWI and MR spectroscopy in identification of various pathological subtypes of parotid gland tumors. Patients and methodsProspective study was conducted on 25 patients with primary parotid tumors (11 males, 14 females, age ranged 22–79years with mean of 53.4±13.6years). DWI and MRS were performed for all patients and the results were correlated with histopathological findings. ResultsThe 18 (72%) benign and 7 (28%) malignant tumors consisted of 11 pleomorphic adenomas, 7 Warthin tumors, and 7 malignant tumors. The mean ADC value for pleomorphic adenomas was 1.89±0.18×10−3mm2/s, for Warthin tumors was 0.92±0.22×10−3mm2/s, and for the malignant tumors was 1.03±0.13×10−3mm2/s, significant difference was seen between benign and malignant tumors (P=0.037). The mean values of Cho/Cr ratios were 3.37±0.78, 5.9±1.75 and 1.72±0.41, for pleomorphic adenomas, Warthin tumors, and malignant tumors, respectively. Difference was significant between benign and malignant tumors (P=0.001). ConclusionDWI and MRS are useful noninvasive diagnostic modalities in identification of various pathological subtypes of parotid tumors.

Surgical Outcomes in Primary Parotid Cancer

Objectives: Surgeries performed for primary parotid malignancies vary, and the oncologic outcomes are undetermined. This study aims to: (1) Describe surgical outcomes of superficial versus total parotidectomy, and (2) describe surgical outcomes of observation versus cervical lymphadenectomy in patients with a N0 neck. Methods: Records of 129 consecutive patients with non-metastatic primary parotid cancer treated from 1988 to 2010 at the University of Utah and Intermountain Healthcare were reviewed. Treatment was superficial (47%) or total (53%) parotidectomy, 31% underwent concurrent cervical lymphadenectomy, and 67% received adjuvant radiotherapy due to high-risk features. Patient demographics, tumor characteristics, surgical treatments, and oncologic outcomes were statistically analyzed. Results: Average age at diagnosis was 52 years. Mean follow-up was 7.4 years. Patient demographics, tumor grade, and histology were not predictive of recurrence or survival. Matching patients with Stage I/II disease (n = 74) and comparing superficial versus total parotidectomy, there was no difference in 5-year disease free rate, and 5- and 10-year overall survival rates (85%, 95%, and 88% versus 84%, 84% and 67%, respectively). Also, for Stage III (n = 18) and IV (n =33) disease there was no difference. For 101 patients with a N0 neck, 81 were observed and 20 underwent an elective cervical lymphadenectomy; there was no difference in outcomes (76%, 85%, and 72% versus 73%, 87%, and 67%, respectively). Conclusions: Treatment of primary parotid cancer requires meticulous surgical dissection and gross tumor resection; however, superficial versus total parotidectomy or observation versus elective cervical lymphadenectomy does not affect tumor recurrence rates or overall survival outcomes.

Is level V neck dissection necessary in primary parotid cancer?

This study aims to evaluate the pattern of nodal metastasis to level V in parotid cancer and to examine the clinical value of level V neck dissection (LVND). Retrospective cohort study. Retrospective chart review of 86 patients (47 N0 nodal metastasis [N0] neck and 39 positive nodal metastasis [N(+) ] neck) who received parotidectomy and neck dissection was performed. The prevalence of pathological nodal metastasis in level V neck was evaluated and correlated with locoregional recurrence. LVND was performed in 10.6% and 28.2% of patients with clinical NO (cN0) and cN(+) neck disease, respectively. The prevalence of pathological positive nodal metastasis was 0% (cN0) and 81.8% (cN(+) ). In patients with cN0 neck, the rate of recurrence in level V was 6%. In our patient cohort with predominantly high-grade parotid cancer, LVND was necessary in patients with cN(+) neck because there was a high likelihood for pathologically positive nodal metastasis. In patients with cN0 neck, the rate of recurrence in level V was low enough not to warrant a routine inclusion of LVND.

고악성도 이하선암종에서 임상적으로 경부 임파선 전이가 없는 환자의 예방적 경부청소술의 필요성: 예비 연구

Background and Objectives: Lymph node metastases has a high prognostic value in patients with parotid gland carcinoma. However, a consensus regarding the indication of elective neck dissection (END) has not been reached. Most authors have advocated performing a neck dissection based on the histology of the primary parotid carcinoma and the tumor grade. Materials and Methods: A retrospective analysis was undertaken targeting 16 patients who were previously treated for primary carcinoma of the parotid gland with a clinically negative neck at Department of Otorhinolaryngology?Head and Neck Surgery. Eleven patients with high grade parotid carcinoma except two cases of the adenoid cystic carcinoma and three cases of low grade parotid carcinoma were evaluated to identify occult neck metastases. Results: Lymph node metastasis was detected in one (9.1 %) of the 11 patients with high grade parotid carcinoma who underwent elective neck dissection. One case of positive lymph node was squamous cell carcinoma as primary parotid cancer (33.3 %). Conclusions: Elective neck dissection seems to be necessary for the treatment of high grade parotid cancer with squamous cell carcinoma. However, there may be controversy over the cases of high grade parotid cancer except for the squamous cell carcinoma. (J Clinical Otolaryngol 2014;25:44-48)