In March 2011, a 28-year-old caucasian woman was admitted to our ENT department, at the University Federico II of Naples (Italy), with one-year history of a painless nodules in both pre-auricular areas, that had slowly en- larged. Physical examination revealed a solid mass at the left parotidgland larger than the right parotid one, both well defined, hard-elastic, with no fixation to the adjacent anatomic structures. There weren’t facial nerves palsy or cervical lymphadenopathies.
In the anterosuperior mediastinum, thymic neo- plasms mainly include thymoma and thymic carcinoma. Thymic carcinoma is a malignant epithelium-derived tumor . The most com- mon symptoms are chest pain, also cough, fatigue, fever, loss of appetite, and weight loss. Although thymic carcinoma outside the anterior mediastinum is rare, it most often occurs in the lungs, and less often in the neck, cervical, and parietal pleura. However, this case occurring in the parotidgland is even more rare. As a result of their unexpected location, ectopic thymic carcinomas have not previously been imaged and they are easily misdiagnosed as other com- mon tumors in this area. To date, only a few case reports have been published in the English-language literature [2-6]. Diagnosis of ectopic thymic carcinoma requires morphologi- cal and immunohistochemical support . Not long ago, we discovered a case of ectopic thy- mic carcinoma that occurred in the parotidgland.
The peculiarity of our case was the presence of a bone metastasis, originating from an acinic cell carcinoma of a parotidgland. It was in the right iliac crest in the appen- dicular skeleton. The pelvis is the second most common site of bone metastases after the spine, for this type of sal- ivary gland tumor. Generally, this type of bone lesion shows through the onset of pain, mechanical instability due to extensive bone destruction and pathological frac- tures. For this reason, the goals in the treatment of these lesions are the control of pain, the prevention and treat- ment of fractures, maintaining the patient's independence and preventing progression of the tumor. Surgeons, radio- therapists, medical oncologists and pain clinicians should work together to improve the longevity and the quality of life of patients.
Computed tomography scan confirmed a large irregular lobulated out-lines heterogeneous mass lesion measuring (56x50x50 mm) in size involving the soft tissue structures of the left side of the cheek (directly abutting to the maxillary sinus wall and upper maxilla) invading the under-lying muscular compartment (Figure 2). A diagnosis of an accessory parotid tumor was considered in the differential diagnosis. The patient sent for fine needle aspiration cytology (FNAC) the result showed pleomorphicadenoma and suggest excision for final diagnosis. The patient underwent operation through a standard parotidectomy incision with temporal extension. In the operation, the tumor was found to be arising from the accessory parotidgland lying on the masseter muscle, with the parotid duct deeper to it (Figure 3). The buccal branch of the facial nerve had become invaded by the tumor, identification of buccal branch of the facial nerve and ligation of parotid duct It was dissected free and the tumor was excised.
Objective: To report an extremely rarecase of neuroendocrine tumour with simultaneous in- volvement of both the facial nerve and the deep lobe of parotidgland. Method: case report and English language literature review concerning neuroendocrine neoplasm involving the facial nerve with emphasis on clinical presentation. Results: We report a unique case of adenoma with neuroendocrine differentiation which involved both the mastoid segment of the right facial nerve and also the deep lobe of the parotidgland on the ipsilateral side. Both tumours were not con- tiguous and were anatomically separate from each other. A CT scan of the whole body revealed no other neuroendocrine tumours. Conclusion: To the best of our knowledge, this is the first report in the English language literature of a neuroendocrine tumour to involve both the vertical mastoid segment of the facial nerve with simultaneous involvement of the deep lobe of parotidgland as a separate lesion.
Salivary gland tumors are among the pathologies in the head and neck that may be challenging in diagnosis and treatment. Most benign tumors occur in the parotidgland. PleomorphicAdenoma is the most common type. Basal Cell Adenoma is a subtype of the Monomorphic Adenoma with rare occurrence. Proper diagnosis and clinical evaluation by the use of radiography can lead the physician to the best treat- ment plan for this neoplasia. Many surgical treatment modalities have been described in the literature ranging from total parotidectomy to dissection of the tumoral area alone. Extensive surgery will lead to malfunction and unacceptable esthetics due to resection of the parotidgland. One of the best approaches for treating the encapsulated and well-circumscribed pathologies is extra-capsular dissection without invading the major salivary gland. A rarecase of Basal Cell Adenoma of the parotidgland in a 47-year-old female will be discussed.
Carcinosarcoma, also called true malignant mixed tumor, is an aggressive malignant neoplasm of the saliv- ary gland. It is an extremely rare malignancy, comprising 0.04 to 0.16% of all salivary gland tumors and 0.4% of all malignant salivary gland neoplasms. The mean age at presentation is in the sixth to seventh decade of life, but can range from 14 to 87 years [1–3]. Although de novo carcinosarcomas can occur in the salivary gland, many patients have a history of long standing or recurrent pleomorphic adenomas, a condition described as carci- nosarcoma ex pleomorphicadenoma [4–6]. Most of these lesions arise in the major salivary glands, with two thirds in the parotid glands . Patients typically present with a rapidly growing mass.
Pleomorphicadenoma (PA) is the most common salivary gland neoplasm, accounting for over 60% of parotidgland tumors. Most originate within the superficial lobe, but less frequently involve the deep lobe ; of these, even fewer extend medially through the stylomandibular tunnel into the prestyloid parapharyngeal space (PPS). There may be significant PPS extension before symptom onset; indeed, until the tumor is at least 2.5 cm in diame- ter it cannot be detected by palpation . Symptoms are usually rare or insignificant, most commonly presenting asasymptomatic gradual swelling without facial nerve involvement—a nonspecific finding seen in the majority of parotid masses . Rapid growth, change in consis- tency, pain and onset of facial nerve deficit are signs of carcinomatous transformation, the incidence of which increases with duration of a known PA . Tumor re- currence, radiation therapy and advanced age are addi- tional risk factors. Development of malignancy is esti- mated to occur in less than 10% of cases [3,4].
Abstract: Intramedullary spinal cord metastasis (ISCM) is an infrequent lesion of systemic malignant tumors, and the most common primary sources of ISCM are lung and breast cancers, as well as melanoma and lymphoma. Pa- tients with ISCM usually accompany with rapidly progressive neurological compromise and the prognosis of ISCM is poor. We present a case of a 40-year-old male with a history of parotidgland carcinoma ex pleomorphicadenoma (CXPA) who had undergone surgical excision and chemotherapy presented with progressive paralysis and hypotonia of the bilateral upper and lower extremities. Magnetic resonance imaging (MRI) revealed two intramedullary metas- tases at the C5 and T6 level, respectively. The patient underwent surgical resection after intramedullary spinal cord metastasis was diagnosed and survived 8 months without any systemic progression and with partially neurological improvement following surgery. The aim of this study was to present the clinical features, diagnosis, and treatment of a patient with ISCM resulting from parotidgland CXPA. The present case highlighted the importance of early di- agnosis and surgery when ISCM is suspected. Clinicians should choose the optimum management considering the patient’s individual condition when ISCM is suspected.
Carcinoma ex pleomorphicadenoma is a rare tumor arising from the salivary glands that spreads through direct extension, through the lymphatic vessels, and, rarely, hematogenously. When distant metastases have been found, they have been reported mainly in the lung. We present an unusual case of carcinoma ex pleomorphicadenoma of the parotidgland with splenic metastases. The patient presented with a primary carcinoma ex pleomorphicadenoma of the parotidgland and he underwent a total parotidectomy with laterocervical lymphadenectomy ipsilateral and adjuvant radiation therapy to the right parotid area. One year later, the patient showed an ipsilateral supraclavicular lymph node recurrence, treated with surgery and radiation therapy. Two more years later, the patient developed lung and splenic lesions, detected through CT and PET. He underwent splenectomy and pathologic assessment of the specimen showed metastatic carcinoma ex pleomorphicadenoma. To our knowledge, there is no reported case of a carcinoma ex pleomorphicadenoma metastasizing to the spleen. Patients treated for carcinoma ex pleomorphicadenoma should be investigated for distant metastases with a long-term follow-up examination for local and distant metastases and new splenic lesions in these patients should be investigated.
On the other hand, the luminal SDC carcinoma cells rarely show immunohistochemical expression of S-100 protein and p63, whereas the ‘reminiscent’ benign myoe- pithelial cells reveal those strong expression in the ‘intra- ductal’ and PA components [9-11,20-22], even while the lost of myoepithelial cells is occasionally seen in the transition areas from ‘intraductal’ to ‘extraductal’ compo- nents , as in our case. Indeed, myoepithelial cells can be considered as natural tumor suppressors, distinguish- ing between early and advanced malignant tumors in the transition from in situ to invasive carcinomas, and can rarely undergo malignancy. However, in the present case, the neoplastic-like enlarged myoepithelial cells in the transition areas were sometimes negative for the above myoepithelial markers. These features indicate that those cells would not have apparent myoepithelial phenotypes, but potentially neoplastic character, probably confirmed by the ultrastructural findings. We could provide the evidence for the first time that invasive SDC ex PA may arise within or from PA as a result of neoplastic trans- formation of outer supporting myoepithelial cells, as well
Such auxiliary examinations as B-ultrasound, computed tomography (CT) and magnetic reso- nance imaging (MRI) are deemed common in diagnosing parotidgland tumors. However, to obtain a more accurate diagnosing result, rich experience and comprehensive understanding of the sufferer’s medical history are necessary. But imaging tests are unreliable when diagnos- ing a co-existence of tumors with different his- tological types. MRI scan is a good choice of diagnosing parotidgland tumors because of its remarkable identifying ability towards soft tis- sue. For instance, pleomorphic adenomas usu- ally reflect round like and are enveloped by a layer of smooth surface , with bright signal areas on the T2-weighted images and prompts low-intensity edges where the envelope exists . Ultrasound guided fine needle aspiration cytology (Ultrasound-guided FNAC) is consid- ered as a relatively simple examination of which the accuracy of identifying the benign tumors with the malignant tumors can reach to 85%- 97% . But it’s diagnostic sensitivity towards the parotid disease sensitivity is not high. Pre- operative physical examinations, especially pal- pation is significant in the diagnosis of parotid tumor. The difficulty arises when diagnosing tumors from the deep lobe of parotidgland. Resection stands in the first place when deal- ing with multiple parotidgland tumors. Ethun- andan M  believes such benign multiple tumors basically happening in the superficial parotid should be adopted palpation during operation and superficial parotidectomy owing to the difficulty of precisely judging the number of tumors and their pathological types before operation. Whether to adopt the surgical meth- od of parotidectomy of total lobe should be decided by the position and features of the tumor.
The most important reason we focus on PA is that there is malignant transformation possibil- ity in tumors with long-term evolution, recur- rence, advanced age of patients or location in a minor salivary gland [6, 9], which ranges from 1.9%-23.3% . Malignant changes include three different types: carcinoma ex-pleomor- phic adenoma (CXPA, also called malignant mixed tumor), carcinosarcoma, and metasta- sizing PA, and the last twos are relatively rare . The classic clinical history of CXPA is a slow-growing mass for many years, which expe- rienced a sudden fast growth phase. Like other malignant tumors, CXPA could spread through direct extension, distance metastasis through Figure 3. The macroscopical images of excisional mass. A. The mass mea-
Controversies are evident from this work and mostly relate to the type of operation and the use of post-operative radiotherapy. Often clinicians adopt a pragmatic view that takes into account the location of the recurrent tumour, whether it is a multinodular or uninodular recurrence, the size and the rate of growth as well as the patient’s co-morbidities. Selected cases can be observed. Conservative surgical management can include partial superficial parotidectomy or extracapsular dissection. In patients that are symptomatic but unfit for a surgical intervention, radiotherapy could be suggested as an alternative for surgery. Total parotidectomy, is appropriate in many patients, but may be inadequate to control recurrent pleomorphic adenomas. Adjuvant radiotherapy seem to significantly improved control in multinodular recurrences 56 . Sometimes the clinical scenario may include elderly patients with multifocal recurrences where the facial nerve is engulfed by scar and tumour. Limited data 55,60 suggested a role for radical parotidectomy with immediate nerve reconstruction.
tomy and an ipsilateral lymph node dissection. He did not receive postoperative thyroid hor- mone suppressive therapy, but was comfort- able. He had distant metastases in the left hip joint 6 months after treatment. Subsequently, he received radiotherapy (left ilium bone: DT 30 Gy/10 F, right chest wall: DT 30 Gy/12 F) and radioactive strontium treatment. However, the disease was not controlled very well. Three months later, the patient presented with a rap- id-growing, painless mass on the left side of the neck. FNAB guided by ultrasonography of the mass on the left side of the neck revealed metastasis of poorly differentiated thyroid car- cinoma with necrosis. Enlarged left neck tumor resection and regional lymph node dissection was performed. The final diagnosis was meta- static medullary carcinoma of the thyroid with vascular invasion, but no lymphatic metastasis. Subsequently, he underwent radioactive stron- tium treatment, to control bone metastases, but the disease was still not well-controlled. 1.5 years after the diagnosis of parotid metas- tasis, the patient presented with a rapid-grow- ing, painful mass near the left ear. FNAB guid- ed by ultrasonography of the mass revealed metastasis of poorly differentiated thyroid car- cinoma with necrosis. CT showed a gigantic heterogeneous density in the left parotid region and metastatic lymphadenopathy. The patient appeared with symptoms of cachexia, and his family members refused further treatments. The patient died of the disease 39 months after the diagnosis of parotid metastasis.
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).
In the present study, we have aspirated 84 cases of parotid swelling. In 78 cases aspiration produced adequate material and in six cases, materials were inadequate even after repeated aspiration. We found 45 male patients (53.57%) and 39 female cases (46.43%) in the study group. Patients ranged in age from 8 years to 71 years with a mean age of 38.73 years. Age distribution reveals large number of cases in the age group of 21-50 years. (Figure 1) Mean age of malignant cases (53.14years) was higher than benign cases (38.19 years). In the present study, four cases (5.12%) were bilateral. We found most of the cases were benign (40 cases, 51.28%) and non-neoplastic (23 cases, 29.48%); whereas only 14 cases (19.23%) were malignant. (Table 1) Among the non-neoplastic cases, most common lesion was chronic sialoadenitis (20 cases). Among the benign parotid swellings PSA was the commonest subtype (30 cases, 38.46%). Other benign parotid tumors diagnosed are warthin’s tumor (6 cases), monomorphic adenoma (3 cases) and oncocytoma (one case). [Table 1] Most common malignant parotid tumor in our study was mucoepidermoid carcinoma (5 cases, 6.41%). Other malignancies were adenoid cystic carcinoma, acinic cell carcinoma and salivary duct carcinoma etc. We found single case of non-Hodgkin’s lymphoma, pleomorphicadenoma ex carcinoma and metastatic melanoma respectively in the present study group. [Table 1]
Numerous functions of MEC have been elucidated but the most important role as far as pathologists are concerned is its ability to suppress tumour formation and hence acts as a prognostic marker. These cells have been studied under varied conditions and various stains but still a proper IHC marker for either the normal or NMEC has not been found. Also the fact that these cells have complex make- up, the NMEC has the ability to take any of several very different morphological forms, and another important aspect regarding the MEC is that it plays a significant role in tumour pathogenesis and understanding this cell in detail is required to comprehend the pathogenesis of numerous salivary gland tumours. Hence, proper research and techniques has to be applied to obtain significant knowledge regarding MEC and its role in salivary gland tumours.
Size, Location, and Marginal Morphology. The average maximal cross-sectional diameter was 2.8 cm (range, 1.0 –5.8 cm). Seven tumors were located in the superficial lobe of the parotidgland and one was located in the deep lobe of the parotidgland (Table). All tumors had well-defined margins with smooth contours. On T1WI and T2WI, a capsule-like low-SI rim was detected in only one tumor.
has a superficial and a deep lobe. The facial nerve, retromandibular vein and the external carotid artery are enclosed by the Parotid. The gland is situated in the pre - auricular area. It is paired and bilateral and is situated on either side upon the mandibular ramus. It is encapsulated by the masseteric fascia. The parotid plexus is formed by the branches of the facial nerve. It passes through the parotidgland and divides it into a superficial and a deep part but does not innervate it. The parotid duct is called as Stensen's duct. It opens through parotid papilla opposite to the upper second molar tooth (8) . Accessory parotid