Warthin-like mucoepidermoid carcinoma of the parotid gland: a diagnostic and therapeutic dilemma

Mucoepidermoid carcinoma (MEC) is the most common malignant salivary gland tumor. Although the parotid gland is the most common site of involvement, other major salivary glands and the minor salivary glands­most commonly of the palate­also can be involved. The management of mucoepidermoid carcinoma depends on the grade of the tumor and the adequacy of resection. We present the case of a 56-year-old female presenting a painless progressive cheek mass over 2 months. Imaging and fine-needle aspiration cytology provided the diagnosis of Mucoepidermoid carcinoma. A superficial parotidectomy was done, and the histopathology revealed a predominantly cystic tumor with a bilayered epithelium of oncocytic and basal cells. Moderate nuclear pleomorphism with infiltration of atypical squamous cells in few glandular cysts was seen. Special staining revealed the presence of intracellular mucin. A diagnosis of Warthin-like variant of MEC was made, based on these findings. After the surgical procedures, the patient is disease-free at 8 months of follow-up. The Warthin-like variant is a rare variant of MEC with fewer than 10 cases described in the English literature. Various differential diagnoses include the malignant transformation of Wartin tumor (WT), squamous metaplasia of WT, and metastasis from a distant primary. We emphasize the role of routine microscopy in identifying rare variants of common malignancies. Even though translocation studies are helpful in diagnosis, the typical histopathological findings should confirm it.

Spindle cell myoepithelioma of the parotid gland

Myoepithelioma was recognized as a histological distinct entity by the World Health Organization (WHO) in 1991. Myoepithelial cells are believed to be of ectodermal origin. In salivary glands, the myoepithelial cells that surround the intercalated ducts are spindled, which is in contrast to the large stellate ones that envelop the acini. Myoepithelioma is a benign salivary gland tumor that consists entirely of myoepithelial cells. A 53-year-old man presented with a 1-year history of a painless mass originating from the right parotid gland. The mass grew rapidly reaching a size of approximately 6 cm. The patient had no facial paralysis. The authors performed right parotidectomy. Immunohistochemistry study of this tumor showed that it was positive for vimentin, positive for S-100, focally positive for pancytokeratin, and focally positive for p63 and that it had a Ki-67 labeling index (below 10%). Additionally, the tumor was negative for epithelial membrane antigen, negative for actin, negative for desmin, negative for CD34 and negative for anaplastic lymphoma kinase. The authors present a case of benign spindle cell myoepithelioma of the parotid gland in a 53-year-old man diagnosed after immunohistochemistry study, describing its importance, along with a brief review of the literature.

Prediction of Location of the Parotid Tumors that Cross Over Anatomical Criteria for Facial Nerve on Computed Tomography / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: To find more accurate way to determine the location of parotid tumors that cross anatomical criteria for the facial nerve (FN). SUBJECTS AND METHOD: Two hundred patients were included in the study and retrospectively studied. Five anatomical criteria were used to predict the location of parotid tumors on computed tomography (CT). Deep portion of tumors was measured and then, cut-off value was obtained after receiver operator curve analysis. The location of tumor was predicted by using the cut-off value and by the conventional way, in which the side where most of the tumor is located is determined as the tumor site. RESULTS: The parotid tumors were located in superficial lobes in 148 cases, and in deep lobes in 52 cases by operative record. The tumors that cross the anatomical criteria were defined as ‘crossing tumor.’ The cut-off values for prediction of ‘crossing tumor’ location on CT were 6.7 mm for anatomical line, 6.4 mm for FN line, 11.2 mm for retromandibular vein, 4.9 mm for Utrecht line and 3.8 mm for Conn's arc. The accuracy of 5 anatomical criteria for ‘crossing tumor’ was between 55.9% and 81.6% when the cut-off value was used, whereas the accuracy was between 25.7% and 68.9% when conventional way was used. CONCLUSION: In cases of ‘crossing tumor,’ the cut-off value obtained by measurement of deep portion of tumor can be applied to improve the diagnostic performance for the prediction of tumor location.

Mixed Tumor in Deep Lobe and Versatility of Acellular Dermal Matrix

Frey's syndrome and infra-auricular depressed deformities are the ones of the most common complications that can occur after total parotidectomy. We report 1 case of pleomorphic adenoma occurred in the deep lobe that obtained good results from using acellular dermal matrix (ADM) after total parotidectomy. A 24-year-old man visited the hospital with oval shape mass in right mandibular angle which of 4 cm in size was found in the deep lobe of right parotid gland from Magnetic resonance imaging scanning and a pleomorphic adenoma was suspected. A total parotidectomy was performed while preserving the facial nerve. The material known as ADM were placed in the depressed part from where the mass was removed, and the site was sutured. The surgery site was healed well without any complications such as Frey's syndrome or infra-auricular depressed deformities. The pathological result was confirmed as pleomorphic adenoma. In addition to these advantages, it does not have little potential of deformation by the gravity after the surgery, and there is no restraint on circulation, which makes fabrication free and each deformation into various shapes can be described as another advantage of the reconstruction using the ADM.

Mixed Tumor in Deep Lobe and Versatility of Acellular Dermal Matrix

Frey's syndrome and infra-auricular depressed deformities are the ones of the most common complications that can occur after total parotidectomy. We report 1 case of pleomorphic adenoma occurred in the deep lobe that obtained good results from using acellular dermal matrix (ADM) after total parotidectomy. A 24-year-old man visited the hospital with oval shape mass in right mandibular angle which of 4 cm in size was found in the deep lobe of right parotid gland from Magnetic resonance imaging scanning and a pleomorphic adenoma was suspected. A total parotidectomy was performed while preserving the facial nerve. The material known as ADM were placed in the depressed part from where the mass was removed, and the site was sutured. The surgery site was healed well without any complications such as Frey's syndrome or infra-auricular depressed deformities. The pathological result was confirmed as pleomorphic adenoma. In addition to these advantages, it does not have little potential of deformation by the gravity after the surgery, and there is no restraint on circulation, which makes fabrication free and each deformation into various shapes can be described as another advantage of the reconstruction using the ADM.

Accuracy of fine needle aspiration biopsy in diagnosing parotid gland malignancy

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To determine the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of FNAB in detecting parotid malignancies in our institution.<br /><strong>METHODS:</strong><br /><strong>Design:</strong> Restrospective Chart Review<br /><strong>Setting:</strong> Tertiary Government Hospital<br /><strong>Participants:</strong> Postoperative records of seventy six (76) patients with tumors of the parotid gland preoperatively diagnosed by FNAB. <br /><strong>RESULTS:</strong> The sensitivity of FNAB was 46%. The specificity and positive predictive value were both 100% and negative predictive value was 90%. Overall accuracy in diagnosing malignant parotid tumor was 91%.<br /><strong>CONCLUSION:</strong> FNAB in this institution is a poor predictor of malignancy, having a sensitivity rate of only 46%. While this may serve as a basis for not recommending pre-operative FNAB for patients with parotid tumors in the interim, other factors should also be considered, including concerns with the actual performance and interpretation of FNAB in our institution.<br /><br /> </p>

Microfilaria in Fine Needle Aspiration Cytology Smear of Mixed Parotid Tumor - A Case Report

Filariasis is a major public health disease in India especially at coastal areas of Andhra Pradesh, India. Microfilaria is some time seen as an incidental finding during fine needle aspiration cytology smear (FNAC). But it is very rare to find microfilaria in cytological smears of parotid lesions. This is unique finding not reported till to date at our institute. Microfilaria is seen mainly in peripheral blood smear. Wuchereria bancrofti is the most common parasite which causes lymphatic filariasis in India. Here we reported a case in which microfilaria is seen in cytological smears of parotid lesion, first time at our institute of Gandhi Medical College, Telangana, India.

Modified Blair Incision versus Modified Facelift Incision Combined with Sternocleidomastoid Muscular Flap in Parotidectomy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: To evaluate the feasibility of a modified facelift incision with sternocleidomatoid muscular (SCM) flap as a first-line surgical approach for a parotidectomy by comparison with the modified Blair incision. SUBJECTS AND METHOD: From March 2011 to February 2014, 66 patients who underwent parotidectomy were enrolled in the study and their medical records were reviewed retrospectively. Patients with suspicious malignant tumor, metastatic lymph node, and parapharyngeal tumor in the preoperative examination were excluded from the study. Patients and tumor profiles, surgical outcomes, complications, and cosmetic outcomes were studied to compare the modified facelift incision between the SCM flap group (n=32) and the modified Blair incision group (n=34). RESULTS: There were no significant differences between the two groups with respect to tumor location, tumor size, extent of surgery, operative times, postoperative drainage, and any type of complications. The modified facelift incision with SCM flap group had higher scar satisfaction scores than the modified Blair incision group (8.5 vs. 5.7, p<0.001). CONCLUSION: Modified facelift incision with SCM flap can be used as a first-line surgical approach for parotidectomy in benign parotid tumor with better cosmetic outcome without increased complications.

Tratamiento quirúrgico de los tumores de parótida: experiencia de 10 años / Surgical treatment of parotid neoplasms: a 10 years experience

Background: Parotid neoplasms correspond to 3 percent of head and neck tumors. Most are benign, treatment is parotidectomy. Aims: To analyze the results of treatment, histology, complications and recurrence. Patients and Methods: Retrospective analysis of patients with parotid tumors treated in our center among 2001-2010. Results: The series consisted of 82 patients, 52 (63 percent) women. Average age: 46 years (range, 17-77), 73 (89 percent) had benign tumors, 7 (8.5 percent) were malignant and 2 (2.4 percent) had chronic inflammatory disease. The most common benign tumors were pleomorphic adenoma (55 percent) and Warthin's tumor (20 percent). The most common malignant tumors were mucoepidermoid carcinoma (5 percent) and acinar cell carcinoma (4 percent). The technique was total parotidectomy in 10 patients (12 percent), total suprafacial 53 (64.6 percent) and partial in 19 (23 percent). The most common complication was transient facial nerve dysfunction in the immediate postoperative period in 38 cases (46.3 percent), 14 (17 percent) had surgical bed depression, 15 (18.3 percent), dysesthesia periauricular, 2 (2.4 percent) permanent paralysis of the facial nerve (tumor) and 6 (7.3 percent) Frey Syndrome. No patient had a disagreement with his scar and pain periauricular, there were no recurrences. There was lesser transient facial nerve paralysis with partial suprafacial parotidectomy than with total suprafacial parotidectomy (21 percent and 53 percent), RR 0.4 IC 95 percent (0.16-0.99). Discussion: The application of less invasive surgical techniques such as partial parotidectomy suprafacial allow comparable results in benign conditions, with low morbidity without increasing recurrence.

Introducción: Las neoplasias parotídeas corresponden al 3 por ciento de los tumores de cabeza y cuello. La mayoría son benignas, el tratamiento es la parotidectomía. Objetivo: Analizar los resultados del tratamiento, histología, complicaciones y recurrencia. Pacientes y Métodos: Análisis retrospectivo de los pacientes con tumores parotídeas intervenidos en nuestro centro entre 2001-2010. Resultados: La serie estuvo compuesta por 82 pacientes, 52 (63 por ciento) mujeres. La edad promedio: 46 años (rango, 17-77); 73 (89 por ciento) tuvieron tumores benignos, 7 (8,5 por ciento) malignos y 2 (2,4 por ciento) presentaron enfermedad inflamatoria crónica. Los tumores benignos más frecuentes fueron el adenoma pleomorfo (55 por ciento) y el tumor de Warthin (20 por ciento). Los tumores malignos más frecuentes fueron el carcinoma mucoepidermoide (5 por ciento) y el carcinoma de células acinares (4 por ciento). La técnica fue parotidectomía total en 10 pacientes (12 por ciento), suprafacial total en 53 (64,6 por ciento) y parcial en 19 (23 por ciento). La complicación más frecuente fue la disfunción transitoria del nervio facial en el postoperatorio inmediato en 38 casos (46,3 por ciento); 14 (17 por ciento) presentaron depresión del lecho operatorio, 15 (18,3 por ciento) disestesia periauricular, 2 (2,4 por ciento) parálisis permanente del nervio facial (tumor maligno) y 6 (7,3 por ciento) Síndrome de Frey. Ningún paciente presentó disconformidad con su cicatriz ni dolor periauricular; no hubo recidivas. Se observó menos parálisis transitoria del nervio facial con la parotidectomía suprafacial parcial que con la parotidectomía suprafacial total (21 por ciento y 53 por ciento, respectivamente), RR 0,4 IC 95 por ciento (0,16-0,99). Discusión: La aplicación de técnicas quirúrgicas menos agresivas como la parotidectomía suprafacial parcial permite obtener resultados comparables en patologías benignas, con bajas tasas de morbilidad, sin aumentar la recurrencia.

A Review Of Parotid Tumours In Negeri Sembilan, Malaysia

Background/Objective: Parotid tumours represent one of many groups of tumours in the field of Otorhinolaryngology. However, a local demographical evaluation of parotid tumours and its annual incidences has never been undertaken. This study intends to review local demography in relation to incidence of parotid tumour seen in Otorhinolaryngology (ORL) clinic, Hospital Tuanku Ja’afar Seremban, Negeri Sembilan from the year 2007 till 2012. Methods: A retrospective demographical study on parotid cases seen in ORL clinic, Hospital Tuanku Ja’afar Seremban between 2007 till 2012 involving 56 cases. Data that was collected include patient details, facial nerve involvement on presentation, type of surgery performed, site of tumour, facial nerve injury post operation and final histopathological diagnosis. Results: An average of 10 cases per year was noted from 2007 to 2012. Male to female ratio was found to be 1.4:1. Age range of sample population were 9 to 79 years old with a mean age of 47 at time of diagnosis. Superficial lobe was found to be the most common tumour site (63%). Majority of cases consists of benign tumours in 51 out of 56 cases with Warthin’s tumour and Pleomorphic Adenoma being the most common histopathological finding. Post operative facial nerve injury were noted in 17 cases in which 13 cases were temporary while 4 others were permanent.

Warthin's Tumor with Skin Ulceration Mimicking Parotid Malignancy / 대한이비인후과학회지

Warthin's tumor with skin ulceration is extremely uncommon. We report on a 64-year-old man with Warthin's tumor with skin ulceration in the right parotid gland. The ulceration may have resulted from malignant transformation of either the epithelial or lymphoid component, or, as in very rare cases, an inflammatory process crossing the capsule of the tumor into the adjacent parotid parenchyma and overlying skin. Although Warthin's tumor is a common benign tumor of the parotid area, once ulcerated, it is difficult to make a clinical diagnosis. The gross finding of the case reported herein was close to the malignant form, but because an fine needle aspiration biopsy history existed, the possibility of whether more inflammatory changes might have occurred was considered. Therefore, since complications such as facial nerve injury may arise, extensive surgeries should be avoided.

Development and history in parotid pleomorphic adenoma surgery / 中国肿瘤临床

Pleomorphic adenoma ranks first among parotid gland tumors. Surgical procedure, which includes enucleation, ex-tra-capsular resection, partial superficial parotidectomy (PSP), superficial parotidectomy (SP), and total parotidectomy (TP), remains to be the treatment of choice for pleomorphic adenoma. In the last century, physicians lacked understanding on the pathological character-istics of pleomorphic adenoma and facial neurotomia. Thus, simple enucleation of tumors has always been the major therapy for pa-tients to reduce the rate of facial nerve injury. However, postoperative recurrence was frequently observed in patients that have under-gone simple enucleation. In this study, the surgeons attempted to control the relapse rate by enlarging the scope of excision when remov-ing a pleomorphic adenoma, and by performing an extra-capsular resection procedure that was developed in the clinic. Although the tu-mor peplos was excised, the surgeons failed to control the relapse rate. SP and TP apparently decreased the relapse rate of the pleomor-phic adenomas. However, these therapies seem to be overcorrected by the aggravation of facial nerve injuries. PSP is a relatively ad-vanced technique that is currently used in parotid surgery. PSP reduces the rate of relapse and facial nerve injury, as verified by basic pa-thology research. Nevertheless, the controversy between advanced PSP and classic SP still exists. Plastic surgery, pathology research, and gene testing were used to evaluate the advantages of advanced PSP and classic SP. However, the research failed to derive a con-firmed result that can determine which treatment method is fit and unfit to treat pleomorphic adenoma. Our study reviews the trend of parotid surgery from a historic point of view.

Recurrent acinic cell carcinoma in the parotid gland with cardiac metastasis and hypertrophic osteoarthropathy / 영남의대학술지

Acinic cell carcinoma (ACC) is an uncommon malignant tumor of the salivary glands that is difficult to diagnose. It grows slowly and shows distant metastasis rarely. We experienced a case of recurrent ACC in the parotid gland with cardiac metastasis and hypertrophic osteoarthropathy. The 29-year-old man had been suffering from severe multiple bones and joints pain for 2 months. Ten years earlier, he underwent superficial parotidectomy due to a right subauricular mass. The mass was diagnosed with ACC. After surgery, the tumor recurred twice. Then the patient was diagnosed with cardiac metastasis via positron emission tomography-computed tomography and trans-thoracic echocardiography. He also had hypertrophic osteoarthropathy with multiple bone metastasis. He was given palliative radiotherapy and conservative treatment. ACC in the parotid gland with cardiac metastasis and hypertrophic osteoarthropathy has not yet been reported in literature. From this case, it is recommended to evaluate multiple distant metastasis in the ACC of the parotid gland when joint and bone pain are present.

Conservative Parotidectomy for Benign Parotid Tumors / 대한이비인후과학회지

Superficial parotidectomy is the most widely accepted form of the treatment for benign parotid tumors. But the risk of postoperative complications for the treatment of a benign condition cannot be ignored. Recent studies suggest that conservative parotidectomy (partial superficial parotidectomy or extracapsular dissection) might be the reliable option for the resection of benign parotid tumors. Conservative parotidectomy showed similar recurrence rate and lesser post operative complications than superficial parotidectomy.

Diagnostic value of MDCT in parotid gland basal cell adenoma / 中国基层医药

Objective To investigate MSCT findings of CT features of basal cell adenomas in the parotid gland, and improve its diagnostic value.Methods 12 cases plain and enhanced CT findings of basal cell adenomas in the parotid gland were retrospectively analyzed for their position, numbers, size, shape, edge, density and enhancement features,which were all verified pathologically after surgery.Results (1) There were 4 males and 8 females, of which 7 females were in the age of 50 ～59; (2) There were 14 lesions in 12 cases,11 cases were single and 1 case was unilateral multiple ( 3 lesions) ; (3) 12 lesions were situated in superficial lobe of the parotid gland, and 2 lesions were situated between superficial lobe and deep lobe of the parotid gland; (4) The maximum diameter of all lesions were <3cm,of which 5 lesions were < 1em,and 6 lesions were 1 ～2cm,and 3 lesions were >2cm; (5) The boundary of all lesions were clear;The edge of 13 lesions were smooth and 1lesion was aot smooth; (6) The density of 3 lesions were uniform, of which the diameter of 2 lesions were < 1 cm.There were 4 lesions showed a regular cystic zone in the center,and 7 lesions showed a irregular cystic zone in the center;The area of cystic zone were >50%in 5 lesions; (7)All of 14 lesions were enhanced obviously in enhanced CT scans.Increase of CT values were ≥40HU.Conclusion Single less lesions situated in superficial lobe of parotid gland, with clear boundary, smooth edge, cystic zone in the lesions, and enhanced obviously were the CT features of basal cell adenomas.Recognizing this CT features combined with the patients' gender and age could make for a definite diagnosis.

A Clinical Experience of Direct Extension to Parotid Gland of Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma has a high incidence. However, regional metastasis occurs infrequently because skin cancer is usually recognized and treated early. We report the case of squamous cell carcinoma around the earlobe in a 74-year-old male patient. The cutaneous squamous cell carcinoma invaded ipsilateral parotid gland directly without lymphatic spreading. Wide excision was made with 1.5 cm margin and immediate reconstruction was performed with radial forearm fasciocutaneous free flap. During operation facial nerve was preserved. No recurrence was noted for 5 years and the patient was satisfied with good aesthetic result. Cutaneous squamous cell carcinoma spreads to the parotid gland usually through lymph nodes and there are few reports of invasive organ damage by direct invasion. We experienced a case of direct invasion to parotid gland without lymph node involvement of cutaneous squamous cell carcinoma and treated the cancer adequately with wide excision and free flap coverage.