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Two patients are described in whom a parotid metastasis occurred 10 years after initial treatment for carcinoma of the breast. The parotid is a very unusual site of metastasis and in both patients it was only one detectable. Parotidectomy with post-operative radiotherapy is advocated in this situation not only to obtain local tumour control but to exclude a primary parotid tumour.
Although mucoepidermoid carcinoma (MEC) is the most common malignant salivary gland neoplasm in childhood and adolescence, it is rarely found in children under the age of 10. A 6-year-old girl had an asymptomatic neck mass for 5 months. Clinical examination findings showed a 1.5-cm smooth and firm but mobile nontender mass located in the upper left anterior cervical triangle, clinically separate from the parotid gland. Ultrasound examination findings showed a vascular mass, with a cystic component, possibly within the tail of the parotid gland. An excisional biopsy was performed and frozen section showed a low-grade MEC. A left superficial parotidectomy was then performed. Final histopathologic examination showed one positive resection margin. Subsequently, reexcision of the surgical site and an upper modified neck dissection was undertaken. This unusual presentation of MEC as a neck mass in one of the youngest reported patients illustrates that the anatomic region for parotid tumors is large. Possibly some of these tumors may arise from heterotopic or accessory parotid tissue.
The natural history of a rare parotid tumor, the sialoblastoma (embryoma) is reported. It is a blastematous neoplasm said to recapitulate the epithelial differentiation of a gland at various stages of development. The tumor grew in a period of 5 years (from shortly after birth until it was excised) to a firm asymptomatic mass measuring 5 cm in greatest diameter. With a diagnosis of adenoid cystic carcinoma (a common misdiagnosis), the patient was referred to the reporting institution, where the diagnosis was revised. Five months later, completion parotidectomy for presumed recurrence failed to demonstrate residual tumor. One year later, the patient appears to be free of disease. The authors propose that sialoblastomas should be regarded neither as benign nor malignant, but as one single disease with local infiltrative potential. Based on this concept, sialoblastomas can be treated with early conservative surgery alone, provided that free margins are obtained.
INTRODUCTION: The aim of this study is to emphasize the difficulties of diagnosing parotid gland tuberculosis because of its non specific symptoms and to incite the physician to seek it more frequently. MATERIAL AND METHOD: Six cases of parotid gland tuberculosis were diagnosed within a 4-year period and included in a retrospective study. RESULTS: There were two men and four women, mean age 45 years. Four patients underwent superficial parotidectomy with frozen section analysis which enabled us to rectify the diagnosis. Medical treatment was based on a 6-month course of bactericidal chemotherapy. Outcome was favorable in all the cases with nine months average follow. DISCUSSION: Symptoms of parotid gland are misleading, pathologic findings are of increasing importance for diagnosis, which with the new serology techniques may improve further.
INTRODUCTION: Desmoid tumor is a benign microscopic tumor that belongs to the group of the deep fibromatosis. It usually arises from facial or musculoaponeurotic structures in the abdomen but rarely is located in the head or neck. Locally, it is characterized by a massive invasion with strong potential for recurrence. CASE REPORT: A 37-year-old woman was hospitalized for a swelling of the left parotid gland region which had progressed for eight years. Physical examination revealed a tumor in the parotid gland, which was hard and adherent deeply, measuring 4 cm/3 cm and sensitive to palpation; without satellite nodes nor facial paralysis. The treatment consisted in a superficial parotidectomy. Pathology was in favor of a desmoid tumor. After an 18-month follow-up, the patient is healthy without any sign of recurrence. DISCUSSION: Desmoid tumors are deep fibromatosis characterized by their slow growth and especially by considerable infiltration of the adjacent structures but without potential for metastasis. Although very rare, the cervical localizations are especially aggressive. This clinical case illustrates the clinical features of this rare affection and offers matter for discussion of therapeutic difficulties.
A review of the more common inflammatory and neoplastic conditions affecting salivary glands has been presented. The use of hydration, massage, antibiotics, and steroids is effective initial treatment for suppurative sialadenitis and usually negates the need for surgical drainage. Total excision of the salivary gland and its duct is necessary in procedures for recurrent infection. Our technique for closure of the floor of the mouth after excision of the submandibular gland and Wharton's duct is described. Salivary neoplasms involving the parotid gland, the submandibular gland, and the minor salivary glands are treated on the basis of their histologic and local findings. Stepwise illustrations of our technique of parotidectomy and surgical considerations, including the counseling of a patient with a parotid mass, are presented to assist surgeons who care for patients with salivary disorders.
A case of dedifferentiated acinic cell carcinoma of the parotid gland is presented. A 46-year-old man presented with a parotid gland mass. At surgery the tumor was found adherent to the temporal bone and cervical adenopathy was present. Treatment included radical parotidectomy and intraoperative radiotherapy. Histologically, the tumor was a composite of a usual low-grade acinic cell carcinoma and high-grade, poorly differentiated carcinoma. Cervical lymph node metastases were composed entirely of high-grade carcinoma. Immunohistochemically, both low- and high-grade malignant components were negative for p53 oncoprotein expression. Moreover, polymerase chain reaction and nonisotopic single-stranded conformational polymorphism analyses were consistent with a germ line configuration of the p53 gene, exons five through eight, in both low- and high-grade elements of the tumor. The literature on this unusual variant of acinic cell carcinoma is reviewed.
Sixty-two patients were treated by some combination of cryotherapy and surgery with an average follow-up of 3.3 years for one of the following diseases: focal or diffuse flat conjunctival primary acquired melanosis (PAM) with atypia but without a nodule of melanoma (10 cases); unifocal malignant melanoma with or without focal or diffuse PAM (30 cases); and multinodular/multicentric melanoma with and without PAM (22 cases). Of the ten patients who had PAM with atypia, invasive nodules of malignant melanoma did not develop. A second treatment was required to control the disease in four of the ten patients with extensive or diffuse lesions, and one has mild persistent disease. Of the 30 patients with unifocal nodules of malignant melanoma, 27 remained free of recurrence after one treatment, and 2 are asymptomatic after two treatments. One patient with a thick nodule at presentation required a parotidectomy and radical neck dissection for cervical metastases after recurrence in the conjunctival sac. In the group of 22 patients with multinodular malignant melanoma, only two did not have recurrent disease after one treatment. Of those who received multiple therapies, seven remained free of recurrence for at least 2 years after the last treatment; regional or distant metastases developed in nine; four required exenteration; and eight died. Conjunctival adjunctive cryotherapy avoids exenteration in extensive lesions of pure PAM and in unifocal melanoma, but even after multiple therapies, multinodular malignant melanoma had a 45% rate of metastasis. Metastasis was related to the presence of PAM sine pigmento in four patients (microscopically but not clinically detectable PAM); to the location of the nodules (9 of 10 patients who experienced metastases had forniceal, palpebral, and/or caruncular nodules); to the thickness or depth of invasion of the nodules (greater than 2 mm); and to the development of intralymphatic spread ("in-transit" local metastasis) within the conjunctival sac in six patients. No metastases were encountered among patients with strictly limbal nodules and among five patients with invasive nodules composed of spindle cells in part or in toto. Therapeutic success in this spectrum of melanocytic proliferations is closely correlated with the clinical extent of the disease when initiating definitive therapy.
We report a new case of myoepithelial carcinoma of the parotid gland in an 8-year-old girl. This is the first case published in a child. The parotid tumour was slightly tender and measured almost 2 cm in diameter. There was no associated facial nerve paralysis despite surgical and histologic evidence of massive facial nerve infiltration. We performed total parotidectomy with resection of the intra-mastoid portion of the facial nerve completed with prophylactic lymph node dissection. Eight months after surgery, MRI revealed a deep-lying recurrence, which required reintervention. There has been no subsequent recurrence 18 months after surgery. Microscopic examination of operative specimens confirmed the diagnosis of parotid myoepithelial carcinoma with fusiform cells. Immunohistochemical markers were positive for cytokeratin, epithelial membrane antigen, smooth muscle actin, S-100 protein, anti-desmine and anti-vimentine. This difficult to diagnose tumour, which was individualised by the World Health Organisation in 1991, is considered a moderate to high-grade malignancy when it develops in a pleomorphic adenoma or appears de novo.
Acinic cell carcinoma is an infrequent malignancy of salivary gland tissue in adults that is very rare in children. Review of the English literature reveals only 25 reported cases of this neoplasm in pediatric populations. This is a case report of the youngest known child to undergo parotidectomy and facial nerve dissection for an acinic cell carcinoma. The unusual clinical and surgical findings might suggest the need for changes in approach to treatment of a tumor that has been previously described as relatively benign.
There is little consensus on the optimal management of postparotidectomy salivary fistulas. Timely treatment is important since fistulas may result in wound dehiscence and infection. Management options include pressure dressings, total parotidectomy, tympanic neurectomy, graft interpositioning, surgical closure of the tract, radiation therapy, and pharmacotherapy. Unfortunately, many therapies require weeks to months for resolution and possess additional risks. The affected patient often suffers social embarrassment from the drainage. Through our work with neurologically impaired children with sialorrhea, we have had success with using glycopyrrolate, an anticholinergic frequently used to decrease salivary secretions. We present a case of a patient with a postparotidectomy fistula which was successfully treated with glycopyrrolate and pressure dressings. The rationale and potential use of glycopyrrolate for the treatment of a salivary fistula are the focus of this presentation.
A rare case of a 9-year-old female with mucoepidermoid carcinoma arising in the accessory parotid gland is reported. She had complained of a painless and round mass of the left cheek for a duration of 14 months. Sialography, ultrasonography, CT scan and MRI were performed preoperatively. Sialography revealed a small duct separating from the Stensen's duct. CT and MRI showed that the tumor with smooth outline was lying on the masseter muscle and detached from the main parotid gland. The preoperative diagnosis was an accessory parotid gland tumor. The tumor was removed without facial nerve injury via standard parotidectomy incision. The tumor was composed of mucous and epidermoid cells. The pathological diagnosis was low-grade mucoepidermoid carcinoma.
In this study we evaluated the effects of surgical and radiotherapy treatment on local control in 126 patients with malignant tumors of the parotid gland. The most frequently observed malignant tumors were high-grade tumors (68%). Surgical treatment was performed in 81 patients (83.5%). Total conservative parotidectomy was the most frequent procedure (74%), and radiotherapy was performed in 81 patients (83.5%). The global survival rate was approximately 54% at 5 years, whereas disease-free survival was 47% at 5 years. No statistically significant difference in survival rate was found between conservative (52% at 5 years) and radical treatment of the seventh cranial nerve (43% at 5 years). The incidence of recurrent cancer was 25.7% (25 of 97), of which 88% developed during the first 2 years. We report some of the clinical and histologic factors that can influence the prognosis of the disease.
INTRODUCTION: Recurrent cutaneous melanoma is generally regarded as having an extremely poor prognosis, particularly when regional lymph nodes are involved. A few reports have documented long-term survival among those patients treated for regionally recurrent melanoma. METHODS: This article reviews patients at our institution undergoing complete neck dissection for recurrent head and neck melanoma. RESULTS: Twenty-six patients with locoregionally recurrent cutaneous melanoma of the head and neck underwent complete neck dissection with or without parotidectomy. Seventeen of these procedures were for clinically evident cervical lymphadenopathy, whereas 9 of the neck dissections were done electively. Fourteen of the 17 patients with clinical adenopathy were confirmed to have cervical lymph node metastases. Two of the 9 patients who underwent elective neck dissections had pathologic lymph nodes. At 5 years, 38% of the patients with isolated neck recurrences not also having concurrent primary site recurrence were alive without disease. CONCLUSIONS: These results provide further evidence suggesting a benefit in the form of long-term survival or cure for patients receiving aggressive surgical treatment for resectable recurrent head and neck melanoma involving cervical lymphatics in the absence of distant metastases.
OBJECTIVE: We sought to evaluate the association of intraoperative facial nerve stimulation and postoperative facial nerve paresis/paralysis. STUDY DESIGN AND SETTING: Eighty-nine consecutive patients who underwent parotidectomy by a single surgeon were retrospectively analyzed for age, gender, size of tumor, tumor histology, and intraoperative use of a facial nerve stimulator. RESULTS: Facial paresis developed in 22% (10 of 46) of the patients who were stimulated and 22% (5 of 23) of the nonstimulated patients. These results were not statistically significant (P = 1.0000). There was no permanent paralysis in either group. The tumor type and size and gender and age of the patient did not affect the outcome. CONCLUSION: There was no difference in the incidence of postoperative facial nerve paresis or paralysis between the stimulated and nonstimulated patients. Routine use of a stimulator is not necessary during parotid surgery because its use does not prevent or promote facial nerve injury.
OBJECTIVE AND STUDY DESIGN: We performed a retrospective study of 28 patients to evaluate the management and outcome of regional metastasis from nonmelanoma cutaneous malignancies. RESULTS: There were 25 squamous cell, 1 basal cell, and 2 eccrine carcinomas. The most common primary locations were the temple, ear, and cheek. Median interval from primary resection to regional metastasis was 9 months, and such were commonly of the parotid, level IB, and level IIA nodes. Twenty-four patients underwent parotidectomy and/or neck dissection; 19 patients, postoperative radiation. Ten patients (36%) died from the disease, 2 patients (7%) have persisting disease, 5 (18%) have died from intercurrent disease, and 11 (39%) have no evidence of disease (minimum follow-up, 22 months; median, 34 months). CONCLUSIONS AND SIGNIFICANCE: Nonmelanoma cutaneous malignancies with regional metastasis have a poor prognosis despite aggressive therapy. When high-risk characteristics are detected, examination of the nearest "sentinel node," prophylactic lymphadenectomy, and/or regional irradiation might be justified; further study is warranted.
Salivary duct carcinoma (SDC) is a highly malignant tumor that is histologically similar to ductal carcinoma of the breast. This article presents the clinicopathologic features of 15 patients with SDC arising in the salivary glands. The majority of patients were male and aged 65 years or older. The tumor was most often located in the parotid gland. Pain, facial palsy, and presence of calcification in the CT scan were diagnostic features suggestive of SDC. Histologically, 27% of the tumors arose from pre-existing pleomorphic adenoma. Perineural and lymphatic invasion were common findings. There was an extensive cervical lymph node involvement (73%). Distant metastasis was the most common cause of failure. Although SDC exhibits an unpredictable clinical course, total parotidectomy with neck dissection and adjunctive radiation therapy appear to be appropriate for local and regional control of this aggressive neoplasm.
Seventeen patients with cutaneous melanomas of the nose were treated at the M. D. Anderson Hospital during the years 1944-1978. The local recurrence rate was 6 per cent. The two-year survival rate was 82 per cent; the five-year survival rate, 29 per cent; the ten-year survival rate, 12 per cent. Only 20 per cent of the patients developed histologically positive lymph nodes, and all died of the disease. Wide local excision with skin grafting is the treatment of choice, with a modified neck dissection and/or superficial parotidectomy reserved for subsequent nodal metastasis.