Synchronous benign and malignant tumors in the ipsilateral parotid gland.

Synchronous benign and malignant tumors in the ipsilateral salivary glands are extremely rare. We report a unique case of synchronous unilateral parotid tumors in a 71-year-old man. The main parotid lesion was preoperatively suggested to be adenocarcinoma by fine needle aspiration cytology. A coexisting Warthin's tumor was also diagnosed on microscopic examination of total parotidectomy specimens. We describe this case of rare synchronous salivary gland tumors exhibiting both benign and malignant components with a review of the literature.

Sebaceous lymphadenocarcinoma of parotid gland.

The sebaceous lymphadenocarcinoma of the salivary glands is extremely rare and represents carcinomatous transformation of sebaceous lymphadenoma. There are only four reported patients in the medical literature. A patient who presented with a recent increase of a left infraauricular mass, of more than 10 years duration, underwent surgery. The microscopic examination revealed a typical sebaceous lymphadenoma with transition to a sebaceous adenocarcinoma. After postoperative adjuvant radiotherapy, the patient remains disease-free at 24 months postoperatively. We here report a fifth case of this tumor and the youngest age at diagnosis among reported cases.

[Tumors of the salivary glands]. / Les tumeurs des glandes salivaires.

Tumors of salivary glands arise mainly from the parotid gland. Magnetic Resonance Imaging (MRI) is mandatory not only to localize precisely the tumor within the gland but also to differentiate between benign and malignant neoplasms, in competition with cytology in fine-needle aspiration biopsy. Tumors without risk of transformation, such as adenolymphoma, are not systematically operated on. Indications of roentgenotherapy and irradiation volumes depend on histologic type, localisation and size of the tumor.

[Radiotherapy for an adenolymphoma of the parotid gland (Warthin tumor)]. / Radiotherapie bei einem Zystadenolymphom der Parotis (Warthin-Tumor).

BACKGROUND: With 17.6% of all primary parotid neoformations the benign Warthin's tumor (cystadenolymphoma) is the second common parotid gland tumor. Males > 50 years are affected predominantly. After surgery the recurrence rate is less than 5%. Histomorphologically the tumor is characterized by cystoid ducts lined by epithelial cells as well as lymphoid stroma. The lymphoid component has been described as radioresponsive whereas the epithelial parts are less radiosensitive. Since 1960 only one patient treated by primary radiotherapy has been published. CASE REPORT: A 77-year-old woman suffered from cystadenolymphoma (maximal diameter 7 cm). Because of its extension and the reduced performance status of the patient surgery was no option. Radiotherapy was performed with a total dose of 50 Gy. Clinically, the tumor regressed completely after 30 Gy, which was confirmed by CT at 6 weeks after completion of radiotherapy. After 6 and 12 months the patient stayed free of tumor. EPICRISIS: In our case the cystadenolymphoma was unusually large (7 cm). Radiotherapy with 50 Gy induced complete tumor regression. The good clinical response after 30 Gy suggests that the necessary dose may be lower for less extended cystadenolymphomas. CONCLUSION: We present a case of cystadenolymphoma treated by radiotherapy with 50 Gy resulting in a complete remission. Due to missing published experiences no common recommendation for the total dose can be given. In the following situations radiotherapy should be considered: 1. high surgical risk of damage to the facial nerve, 2. unfavorable cosmetic outcome after surgery, 3. inoperability for internal risks, 4. refusal of operation.

Multiple neoplasms of the salivary gland and the lung.

We describe a patient who presented with Warthin's tumour of the salivary gland which was followed by a bronchial carcinoid and subsequently by a squamous cell carcinoma of the lung. Such a presentation of three neoplasms in an individual is an uncommon occurrence.

Long-term follow-up of over 1000 patients with salivary gland tumours treated in a single centre.

Between 1947 and 1992, 1403 patients with 1432 salivary gland tumours were treated at the Christie Hospital, Manchester. There were 1194 epithelial neoplasms: parotid, 1082 (91 per cent); submandibular, 47 (4 per cent); minor glands, 65 (5 per cent). The commonest histological diagnoses were pleomorphic adenoma (n = 776) and adenolymphoma (n = 159). A total of 244 carcinomas were seen (adenoid cystic carcinoma, n = 75). Treatment was primarily surgical, conservative where possible, and determined by tumour extent and not histology. Adjuvant radiation therapy was used in over half the definitively treated malignancies. The recurrence rate following the treatment of 551 new parotid pleomorphic adenomas was 1.6 per cent at median follow-up 12.5 (range 1-34) years, increasing to 15 per cent in the secondarily referred group (n = 170). For patients with definitively treated primary salivary carcinomas (n = 148), the disease-free survival rate at 5, 10 and 15 years was 58, 47 and 45 per cent respectively. Using multivariate analysis, clinical stage was the most important predictor of survival; the 10-year survival rate for stages I-IV was 96, 70, 47 and 19 per cent respectively.

Oncocytic tumors of major salivary glands. A study of 68 cases with follow-up of 44 patients.

Oncocytic tumors rarely occur in major salivary glands and generally account for less than 1% of all salivary tumors. Until now, a large series of these tumors with long-term follow-up has been lacking. We report on 68 cases of oncocytic major salivary gland tumors with clinical data on 44 patients. Eighty-four percent occurred in the parotid (male to female ratio of 1:1), and 11% arose in the submandibular gland (six males, one female). Additionally, 5% were incidentally found in salivary nests of the upper cervical lymph nodes. The mean age of all patients was 58 years. Unexpectedly, 20% of the patients had either radiotherapy to the face or upper torso or long-term occupational radiation exposure, 5-40 years prior to tumor discovery. Patients with previous radiation exposure had a mean age of 43 years at tumor discovery as compared with 63 years for all other patients (p less than 0.01). Among 44 patients, there were four definite, documented cases of recurrences: two were multiple and bilateral. A minimum 7% incidence of bilateral disease was noted. An association exists among bilateral disease, tumor recurrence, and extensive clear cell change ("clear cell oncocytosis"). Only one case metastasized: an oncocytic adenocarcinoma of the submandibular gland. None of the oncocytomas studied (including three with perineural spread) metastasized after 0.5-38 years' follow-up (mean 12 years). The literature is reviewed with regard to cases of metastasizing malignant oncocytomas.

Histologic subclassification of the cystadenolymphoma of the parotid gland. Analysis of 275 cases.

Cystadenolymphomas (CAL) of the parotid gland are variable in their epithelial differentiation and the ratio of the epithelial tumor component to lymphoid stroma. Two hundred and seventy five cases of CAL from the files of the Salivary Glands Register of the Institute of Pathology, University of Hamburg (1965-1979) were analysed. Their pathogenesis from parenchyma included in regional lymph nodes is discussed. The following subclassification was established. 1. Depending on to the ratio of epithelial tumor component to lymphoid stroma, three subtypes were distinguished. Subtype 1, "typical CAL" with an epithelial tumor component of 50%, amounted to 77% of all cases of CAL studied. Oncocytic differentiation and focal metaplasia to goblet cells or squamous epithelium was also found. 13.5% of CAL were classified as subtype 2, "stroma-poor CAL" with an epithelial tumor component of 70 to 80%. The tumor structure was similar to that of an oncocytoma in places. Two per cent of the CAL were in subtype 3, "stroma-rich CAL" with an epithelial tumor component of only 20 to 30%. Subtype 3 was found solely in men. The average age at presentation (61 years) was slightly lower than that of all the cases studied (65 years). 2. In 7.5% of the cases large areas of squamous cell metaplasia and regressive changes was found within a CAL. These cases were classified as subtype 4 ("metaplastic CAL"). The average age was 67 years. The case histories showed that 20% of these metaplastic CAL had previously been irradiated. 3. Bilateral CAL was found in 7.5% of the cases. In 4% multifocal CAL occurred in the parotid gland unilaterally. Recurrences were observed in 2% of all CAL. 4. Carcinoma in CAL is rare (we found two cases in our own material). In 50% of all cases reported radiotherapy was mentioned in the case histories. 5. Malignant tumors coincident with CAL were recorded in 3% of the cases. 6. The lymphoid stroma showed reaction patterns similar to those of the regional lymph nodes. These included granulomatous changes (foreign body granuloma with cholesterol deposits, tuberculosis) and tumor metastases. In the neighborhood of oncocytic tumor epithelium focal accumulations plasma cells forming IgA and IgG were found. Metaplasia to squamous epithelium is believed to be caused by circulatory disturbances, irradiation, and other noxae. In the differential diagnosis of the stroma-poor subtype 2, oncocytoma and cystic sialadenoma must be excluded, and in the differential diagnosis of subtype 4 (the metaplastic CAL), sebaceous adenoma, mucepidermoid tumor, squamous cell carcinoma, lymphoepithelioma, and other non-tumorous lesions of the parotid gland (lymphoepithelial cysts, myoepithelial parotitis) must be ruled out. Our findings suggest that CAL develops from parenchyma included in parotid lymph nodes with the oncocytic ductal epithelium representing the neoplastic component.

Clinical evaluation of Warthin's tumor. An analysis of 43 cases.

Forty-three patients with Warthin's tumor (26 males and 17 females) were analyzed and the following results were obtained: All tumors were related to the parotid gland with no bilateral involvements. The ages of the patients were 20-84 years old and the average age was about 62. The interval between tumor recognition and first examination was 1 week to 16 years with the average interval of 20-22 months. The method of treatment was complete enucleation. However, radiation therapy was also done in three cases, two of which were irradiated after operation. The other received palliative radiation therapy because of old age and poor general condition. Recurrence was observed in two cases in the course of the follow up, but the examination at the end of June 1977 revealed neither recurrence nor metastasis in the cases followed. A rare case of synchronous occurrence of warthin's tumor and another histological tumor was included in this series and similar cases are reviewed briefly in the literature.