The management of recurrentpleomorphicadenoma (RPA) of the parotid gland presents a challenge to clinicians. This is because surgery is difficult, it is often multinodular 1 and can be associated with facial nerve compromise. Following recurrence there is an increased risk for further recurrences and a risk of malignant transformation that is recently reported as 3.3% 3 . The time interval from the initial treatment can be as long as 15 years 1. The recurrence rates reported in the literature are depended on the initial surgery type. When a superficial parotidectomy has been performed, the recurrence rate may be below 3% 4 . Tumour factors that may have an influence on recurrence include tumour size 5 pathological subtype 6 , satellite nodules 2, incompleteness of encapsulation 7 . In contemporary surgical practice, PA
Although recurrent parotid pleomorphic adenomas have been the subject of much attention in the clinical literature, especially pertaining to management issues, there is a relative paucity of information defining the imaging characteristics of these lesions in the radiologic literature. 15,21-23 Multiplicity of lesions has been described as a reliable indicator of recurrence in the parotidectomy bed of patients with prior pleomorphicadenoma resection. 21 In the present study, we reviewed our institutional experience with imaging of recurrent parotid ple- omorphic adenomas. We describe a spectrum of findings in patients with recurrentpleomorphicadenoma of the parotid gland and emphasize the importance of recognizing tiny (sub- centimeter) lesions.
On clinical examination, the left eye was involved in 19 patients (51.35%), right eye in 17 (45.94%) and a single patient (2.70%) showed bilateral eye involvement. The predominant symptom on presentation was proptosis and upper eyelid swelling (32 cases, 86.48%). Other symptoms in decreasing frequency included reduced lacrimation, ptosis, pain and reduced vision. On histopathological examination, epithelial tumors (23, 62.16%) formed the majority, followed by lymphoid tumors (10, 27.02%) and mesenchymal tumors (3, 8.10%). There was a single case (2.70%) of metastasis (Table 2). The epithelial neoplasms accounted for 23 out of 37 cases (62.16%). Of the 23 cases, 12 (52.17%) were benign, while 11 (47.82%) were malignant. All the benign epithelial tumors in our study were pleomorphicadenoma, presenting mostly in females (7/12, 58.33%) and with a mean age of 45.91 years. There was one case of a recurrentpleomorphicadenoma. Microscopically, all cases showed both epithelial and mesenchymal elements in varying proportions. Epithelial component was mostly seen in the form of ducts, with few in groups and sheets. Squamous metaplasia of the epithelium was seen in one case. The mesenchymal component in all cases was predominantly fibromyxoid with a minor chondromyxoid component. (Fig 1)
The pleomorphicadenoma is the most common benign tumor of the minor salivary glands and is comprised of epithelial and mesenchymal tissues. The majority of the salivary gland tumors occur in the second decade of life with a slight predilection for females. Clinically it presents as a firm or rubbery submucosal mass without ulceration or surrounding inflammation. Diagnosis is established on the clinical examination and histopathology, supplemented with plane radiographs, computerized tomography, and magnetic resonance imaging when necessary. Here, we report a case of pleomorphicadenoma of the hard palate in a 21-year-old female patient with a painless swelling in the left palatal region of nine months duration.
9-year-old Japanese girl with pleomorphicadenoma of the cheek mucosa. Cohen and Kronenberg reported two more cases of juvenile pleomorphic adenomas of the cheek (girls, age <18 years) [13-15]. No recurrence was reported in these cases [13-15]. Dhanuthai et al reported the first case of palatal pleomorphicadenoma in a 13 year-old child . In children, Jorge et al reported five cases of intraoral pleomorphicadenoma in patients under 18 years of age in two Brazilian institutions. Four patients were females and one was male; two cases affected the pal- ate, two the upper lip and one the tongue. The cases were treated by local excision and long-follow up showed no The radiological and gross features of juvenile pleomorphicadenoma of the cheek
Irradiation of head and neck is the most presumable causative factor associated with the development of two pleomorphic adenomas in the parotid gland . In 1983, it was reported an increased incidence of salivary gland tumors after the atomic bomb explosions in Japan and the exposure effects were indicated to be both cumulative and dose dependent .
Results: Seventy nine patients with pleomorphicadenoma were identified. Major salivary gland lesions were most common (n=64, 81.0%); 67% (53 of 64) arising in the parotid and 14% (11 of 64) in the submandibular glands. Minor salivary gland lesions were removed from the palate (8 of 15, 53.3%), parapharyngeal space (3 of 15, 20%), nasal septum (2 of 15, 13.3%), lower lip (1 of 15, 6.7%) and base of tongue (1 of 15, 6.7%). Preoperative imaging done was mainly computed tomography in all the cases however in parapharyngeal space cases magnetic resonance imaging was also done. Surgical excision was performed in all patients except base of tongue case.
Sreedhar, 2005). In our study of 48 patients, dermoids were found to be most common accounting for 33% of cases. Pseudotumors accounted for 25% of all orbital lesions. Orbital pseudo tumor is one distinct disease albeit with many clinical and histopathological guises. It can occur in any age and sex (Radha and Ani Sreedhar, 2005). Hence it is a diagnosis of exclusion. Lacrimal gland tumors accounted for 10% of all orbital tumors. Of the 5 cases of lacrimal gland tumors, all were of epithelial origin four being pleomorphicadenoma and one mucoepidermoid carcinoma. Benign epithelial tumors are generally common. Although pleomorphic adenomas are histologically benign, incomplete excision will lead to relentless recurrences and even malignant transformation. Hence when suspected, lateral orbitotomy is mandatory and entire tumor must be excised enbloc (Halli et al., 2011) Majority of malignant tumors are adenoid cyst carcinoma- Major cause of death is intracranial spread hastened by perineural invasion. Treatment is exenteration and post op radiotherapy (Radha and Ani Sreedhar, 2005).
The slides were deparaffinized and rehydrated, then boiled in Tris-EDTA buffer (pH 9.0), for 15 minutes in a pressure cooker. After cooling for 30 minutes, they were incubated for 1 h at 37°C with the following primary antibodies: anti-MYB antibody (EP769Y, Abcam, UK) at 1:2000 dilution, Ki-67 (DAKO, Denmark) at 1:200 dilution. EnVision method (DAKO, Denmark) was used for detection, employing diaminobenzidine as the chromogen. Hema- toxylin was used in the counterstaining of the sections. A specimen each of ACC and basal cell adenoma was used as negative control, respectively, along with an internal control when interpreting the results.
the pleomorphicadenoma among non malignant tumors of salivary glands could be explained by the cellular di- versity of salivary glandular tissue. The pleomorphicadenoma is indeed a mixed tumor. Its microscopy shows epithelial and myoepithelial cells in an abundant stroma with some chondroma or myxoid areas [2,5,16,17]. Ma- lignant tumours represented 38.89% of all the tumours (80.95% of carcinomas and 19.05% of sarcomas). The epithelial nature predominating in salivary glands cells could explain the predominance of carcinoma [18,19].
Plasmacytoid cells are distinguishable by their dense, nongranular or hyaline, abundant eosinophilic cytoplasm, whereas epithelioid cells are round to polygonal cells, with centrally located nuclei and a variable amount of eosinophilic cytoplasm. Finally, clear cells contain large amounts of the glycogen but are devoid of mucin or fat . These different types of cells may be arranged in several architectural patterns, which are non-myxoid (solid), myxoid (pleomorphicadenoma-like), reticular (canalicular- like) and mixed .
studied the relative frequency and distribution of minor salivary gland tumors cases between 1971 and 2008 in Tamil Nadu Government Dental College, Chennai. The study represented mainly Australoid/Dravidian/Tamil population found in southern India state of Tamil Nadu. In the said population pleomorphicadenoma is the most frequently encountered benign tumor. Mucoepidermoid carcinoma, adenoid cystic carcinoma, polymorphous low grade adenocarcinoma, not specified and basal cell adenocarcinoma are the most frequently encountered malignant tumor. Assessment revealed a gradual increase in number of malignant minor salivary gland tumors and predilection towards male gender. The 3 rd to 7 th decades accounted for most minor salivary gland tumors, 4-5 th decade being peak for benign tumor, 5-6 th for malignant tumor. Palate was the most frequent site for pleomorphicadenoma and mucoepidermoid carcinoma followed by adenoid cystic carcinoma and polymorphous low grade
Abstract: Obstructive sleep apnea syndrome (OSAS) is always caused by anatomic abnormalities, including nasal cavity, pharynx, and neuromuscular dysfunctions, leading to airway narrowing. OSAS associated with a mass in the aerodigestive tract is rare. In the present study, we report OSAS caused by 9 cases of preoperative uncom- mon tumors in the aerodigestive tract. Two tumors in the parapharyngeal space were pleomorphicadenoma, one oropharyngeal tumor was mucoepidermoid carcinoma, one tumor in the right tonsil was schwannoma, and five tumors were non-Hodgkin’s lymphoma (NHL). Of the five NHL cases, one in the nasopharynx was diffuse large B-cell lymphoma, two were mantle cell lymphoma, one was chronic lymphocytic leukemia/small lymphocytic lymphoma, and one was NHL. Tumors in the aerodigestive tract should be considered in the differential diagnosis of OSAS upon exacerbation of snoring or sudden gasping. Further examinations should be performed, including a routine workup (computed tomography (CT) and magnetic resonance imaging) and positron emission tomography/CT.
It commonly presents as a solitary well-defined, slow growing and painless swelling. Mean age of the patient is around 46 years and females are commonly affected than male. Pleomorphicadenoma is also known as mixed tumor as it contains both epithelial and also mesenchymal or stromal material. The tumor possibly develops from the pluripotent reserve cells of the intercalated duct.
Salivary gland neoplasms [n = 39, 60.0%] were the commonest lesions in this study followed by sialolithiasis [21.5%]. Mucous retention/extravasation cysts accounted for 13.9% [n = 9] of the cases [Figure 1]. Pleomorphicadenoma was the predominant tumor in this series [87.2%] while Warthin’s tumor and low grade mucoepidermoid carcinoma accounted for 7.8% and 5.1% respectively. Parotid gland was the commonest site for pleomorphicadenoma [n = 20, 58.8%] followed by the palate [n = 8, 23.5%] [Figure 2]. The two cases of mucoepider- moid carcinoma encountered occurred, one each in the parotid and submandi- bular glands. Warthin’s tumor affected only the submandibular gland.
Results : A total of 12 patients with pleomorphicadenoma of minor salivary gland of hard palate were included in the study. 8 patients were male while 4 patients were females. Most common complaint was a slow growing painless palatal mass. FNAC was done for all patients and was suggestive of Pleomorphicadenoma of hard palate. Wide local excision was done in all cases with a margin of about 1cm. Wounds were allowed to heal secondarily and no reconstruction was required. Palatal acrylic splint was given in all patients. All wounds healed uneventfully and there were no recurrences in our study.
in size over a 1-year period. Her past medical history is remarkable for left submandibular gland PA treated with enucleation more than 30 years ago. The details of the operative report from this first procedure were not available. On physical examination, head and neck revealed a 4 × 3 . 5 × 3 cm well-defined-enlarged-multilobulated submandibular gland. No pain or signs of facial nerve weakness or palsy were present. MRI of orbit, face, and neck without IV contrast showed ipsilateral cervical adenopathies and fluid signal intensity lymph nodes. The largest node measured 1.2 × 1.1 cm. Chest X-ray was unremarkable. Fine Needle Aspiration Biopsy of left submandibular gland yielded myoepithelial cells and myxoid stroma consistent with pleomorphicadenoma. Selective Left Neck Dissection of IA, IB, IIA, IIB, and III levels and total left parotidectomy were performed. Facial nerve and all its branches were identified and preserved during surgery with the aid of a nerve monitor. No tumor involvement of facial nerve was found. Despite nerve monitoring and appropriate nerve preservation, the patient shows a residual left facial nerve marginal branch weakness. Intraoperative pathology consul- tation revealed left submandibular gland with characteristic epithelial proliferation and focal myxoid changes of pleo- morphic adenoma. Permanent histopathology diagnosed MPA of the left submandibular with 58/59 nodules positive for the lesion as well as 3 out of 5 left parotid gland nodules positive for lesion. The margins of surgical specimen were free of tumor (see Figures 1, 2, and 3). Therefore, this patient presented with local recurrence and simultaneous metastatic disease. Immunohistochemistry staining done on this tumor tissue revealed positive immunoreactivity for p16 (similar positive immunoreactivity in both nuclear and cytoplasmic compartments) and Bcl-2, whereas negative for Ki-67 and p53. Postoperative stay was unremarkable. The patient was discharged home in stable condition. Currently, the patient has completed adjuvant radiotherapy. There is no evidence of recurrence so far in 10 months after surgery.