END RESULTS IN PAROTID TUMORS

Management of parotid tumors can be based on a clinical classification of these lesions as being either “encapsulated” or infiltrating.The Warthin tumor (papillary cystadenolymphomatosum) is a benign encapsulated tumor, often occurring multicentrically or bilaterally especially in the lower pole area of the parotid. It is characterized clinically by its softness and fluctuation in size and a high incidence in elderly men.The so-called “capsule” of well demarcated mixed and mucoepidermoid tumors is represented by a condensation of host fibrous stroma, in the interstices of which tumor cells may be present.The “encapsulated” tumors should be excised with a “shell” of uninvolved parotid tissue. To do this safely, the facial nerve should first be isolated.Total parotidectomy is necessary only if the size of the tumor, the multiplicity of recurrences, or the infiltrating nature of the tumor are such that complete eradication of the primary site must be done.Radical neck dissection is never performed electively except in the small group of nonencapsulated infiltrating primary lesions.In a series of cases of previously untreated parotid tumors treated by the method outlined, the local parotid recurrence rate was less than 1 per cent.     

Salivary Gland Tumors and Sialadenitis in Children—Experience at Childrens Hospital of Los Angeles

Parotitis, hemangio-endothelioma and mixed tumors are the most common salivary gland lesions in the pediatric age group. Carcinoma and sarcoma are uncommon. Rapid growth of a tumor and pain suggest malignant change.A conservative non-operative approach is stressed for most cases of chronic parotitis. Scout x-ray films and sialangiographic examination are useful in differentiating an inflammatory lesion from a neoplastic growth. Total parotidectomy is advised if operation is indicated.A case of spontaneous resolution of a hemangioma of the parotid gland is presented. A less aggressive temporizing plan should be considered with these lesions, as the risk of seventh nerve injury in children is considerable.The treatment of choice for a non-inflammatory tumor is surgical excision, for most parotid tumors are radioresistant. Small masses should be completely excised for pathological evaluation. Incisional biopsy may occasionally be indicated in the case of a large diffuse lesion, for it may be inflammatory and total excision unnecessary. Most patients with chronic parotitis came to medical attention because of a non-tender asymptomatic parotid lump or diffuse swelling.     

DNA ploidy of human breast cancer

Ploidy was determined on 663 resectable primary tumors from untreated patients. Nuclei obtained by mechanical disaggregation of frozen tissue were stained with propidium iodide and analysed in a FACS IV. Aneuploidy was detected in 73% of cases. It was not significantly related to nodal involvement or tumor size, although the highest frequencies were observed in large tumors (88%) or with more than 10 positive nodes (77%). Aneuploidy was more frequently observed in ductal infiltrating (81%) than in lobular histology and in tumors lacking both progesterone and estrogen receptors (85%). Analysis of ploidy in primary and synchronous lymph node metastases from the same patient showed a high agreement rate (90%) of DNA patterns simply defined as diploid or aneuploid. However, differences in DNA stemlines and DNA indices between the two synchronous lesions from the same patient were a rather frequent event.     

Parotid tumor operations; the case against enucleation

So-called mixed "encapsulated" parotid tumors are best managed by surgical procedures which avoid contact with the "capsule." Enucleation is often a hazardous and incomplete procedure. Subtotal or total parotidectomy with exposure of the facial nerve to avert accidental damage to it is the treatment of choice. Microscopic study of the periphery of such tumors reveals that the "capsule" does not fully encapsulate; hence, enucleation and lesser procedures may leave neoplastic tissue behind.Surgical procedures to achieve complete excision without endangering the facial nerve were carried out in 123 cases. There was local recurrence in one case.     

Primary neoplasms of the facial nerve

A series of 30 primary facial nerve tumors is reviewed. Most of them were benign (n = 26); there were four malignant tumors. Neoplasms originating within the temporal bone were found to have preoperative facial paralysis in 84 percent of cases; the extracranial tumors had a 35 percent incidence of preoperative facial paralysis. All tumors in this series were treated surgically--by means of a middle fossa or transmastoid approach for the intratemporal group of tumors; the extracranial tumors were removed by the technique of parotid tumor surgery with complete facial nerve dissection. All the patients with preoperative facial weakness required facial nerve transection. Facial paralysis was rehabilitated with nerve grafts, hypoglossal crossover, or muscle transfers. Because "normal" facial expression is still not attainable following repair of complete facial nerve transection, an early diagnosis, hopefully prior to total neurotmesis, is essential. All patients with unexplained facial weakness, especially that which is progressive and persistent, should have the entire course of the facial nerve investigated for the possibility of treatable etiology.     

SALIVARY GLAND TUMORS

In a review of a series of 248 salivary gland tumors, seen over a 28-year period, all pathologic material was brought up to date by reclassification according to more recent criteria and nomenclature. In parotid tumors, a probable lowered recurrence rate and a definite decrease in incidence of permanent facial nerve paralysis was found in the more recent cases in which the "Y" incision was used, with identification of the seventh nerve as it leaves the stylomastoid foramen. The five-year recurrence rate for primary mixed tumor was 8.3 per cent, and in recurrent cases it was found to be 18.1 per cent. Of 44 patients with malignant salivary gland tumors in all sites who were observed for five years or more, 32 or 72.7 per cent survived five years.     

Management of parotid hemangioma in 100 children

Most problematic infantile hemangiomas are successfully treated with pharmacological therapy. However, there are reports that hemangioma of the parotid gland responds poorly to corticosteroid and interferon. To better clarify the management of parotid hemangioma, the authors retrospectively studied the records of 100 consecutive patients, seen between 1975 and 2002. The characteristics of the tumor, including sex ratio, presence at birth, size, side, complications, and involvement of adjacent structures, were recorded. The indications for and response to treatment and the need for surgical procedures were documented and statistically analyzed. The female-to-male ratio was 4.5:1. Forty percent of parotid hemangiomas were on the right side, 36 percent were on the left, and 24 percent were bilateral. Forty-five percent of patients had a premonitory cutaneous lesion at birth. Fifty-nine percent of parotid hemangiomas ulcerated during the early proliferative phase. Eighty-eight percent involved nearby structures (ear, 70 percent; lip, 34 percent; subglottic region, 21 percent; eye, 18 percent; and nose, 3 percent). Seven percent of patients required tracheostomy, and 3 percent had signs of congestive heart failure. Seventy infants received pharmacological treatment. Sixty-seven patients were initially managed with corticosteroids; regression or stabilization was noted in 83 percent of tumors (56 of 67 tumors). Twenty-one patients received interferon: 11 in whom corticosteroid therapy had failed, seven in whom the tumor stabilized with corticosteroid therapy but further regression was needed, and three who had interferon as primary therapy. Ninety-five percent of the lesions that were resistant to corticosteroid subsequently responded to interferon alfa-2a or -2b. The overall response rate to pharmacological therapy was 98 percent. A reconstructive procedure was necessary during the involuting or involuted phase in 66 percent of patients: 92 percent had preauricular excision of redundant skin and/or fibrofatty tissue and 37 percent of patients had auricular revision. In summary, drug therapy was effective in the majority of infants with parotid hemangioma, whether given because the tumor was large, deforming, ulcerated, or involved nearby structures with functional consequences. Infantile hemangioma in the parotid gland responded to pharmacological treatment in a similar manner as hemangioma in other locations.     

Epithelial-myoepithelial carcinoma of the parotid gland,unusual malignancy radiologically simulating a benign lesion: case report

Background

Ultrasound (US), Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are widely used in the clinical diagnosis of parotid gland tumors and their efficacy in identifying benign lesions is well documented. However, problems arise when facing some malignant lesions. Only few cases of salivary gland low grade malignant tumors have been previously reported in the literature complete with the radiological features.

Case presentation

We here describe a case of epithelial-myoepithelial carcinoma (EMC) of the parotid gland, a low grade malignant tumor, with spread to an intraparotid lymph node and with CT and MRI findings mimicking a benign lesion.

Conclusion

All the images revealed sharply outlined profiles and a homogeneous enhancement of the nodule, suggesting a benign tumor and demonstrating that a radiological evaluation of the lesion alone may be unsatisfactory and misleading in the diagnosis of salivary gland tumours, especially in the case of low grade malignant tumors, such as EMC.

     

腮腺腺淋巴瘤的MRI诊断（附12例分析）

目的：探讨腮腺腺淋巴瘤的MR表现特征。方法：回顾性分析12例经病理证实的腺淋巴瘤患者MR及临床资料,男性10例,女性2例,平均年龄59.1岁。观察病灶的数目、部位、形态、边界、大小以及MR信号特点等。结果：12例中,单发9例,多发3例,共17个病灶。其中12个病灶位于腮腺浅叶后下部,13个病灶为纵向生长椭圆形。T1WI上16个病灶为等或稍高于肌肉信号,1个含有高信号。STIR序列中等稍高信号者7个,10个含有大小不等的明显高信号。增强扫描轻到中度强化者15个,明显强化2个。9个病例颈部可见中等大小淋巴结。结论：50岁以上吸烟男性,发现腮腺浅叶后下方边界清楚、纵向生长椭圆占位,STIR序列信号欠均匀,高度提示腺淋巴瘤。     

Noncontrast computed tomography in the diagnosis of tumors of the major salivary glands

Non-contrast computed tomography (CT) of the major salivary glands was made in 127 patients, which revealed 95 space-occupying lesions (88 intraglandular and 7 extraglandular ones). Pleomorphic tumors of the parotid glands are solitary, round, high-density (29.6 +/- 4.2 HU) masses with well-defined, smooth margins. Salivary cysts were characterized by the presence of a dense capsule; the density of cyst contents was 8.0 +/- 2.0 HU. Salivary lipomas had a characteristic tomographic pattern due to the presence of adipose tissue; the lipoma density was -108.3 +/- 7.8 HU. Malignant parotid tumors were characterized by the presence of higher-density masses with irregular shapes and ill-defined, indistinct margins. Benign submandibular gland tumors had no well-defined margins that separated the tumor from the gland; the density of a tumor matched that of the parenchyma; the mean tumor size was 3.6 +/- 1.3 cm; there was an increase in the sizes of the gland as compared to those of the contralateral gland, as well as a displacement of the adjacent soft tissues. Malignant submandibular gland neoplasms tumors were characterized by the presence of inhomogenous lower-density masses with irregular shapes. Enlarged paraglandular lymph nodes were observed. The sensitivity, specificity, and accuracy of native CT in diagnosing space-occupying lesions of the salivary glands were 97.6, 96.4, and 97.6%, respectively.     

Lipomatous lesions of the parotid gland. Potential pitfalls in fine needle aspiration biopsy diagnosis

Nine cases of benign fatty tumors of the parotid studied initially by fine needle aspiration (FNA) biopsy and subsequently diagnosed by open biopsy were reviewed. All lesions presented as enlargements of the parotid gland. The cytologic diagnoses were correct in only five of the nine cases. While four of six FNA samples from lipomas were correctly diagnosed by cytology, the other two samples were classified as inadequate. Three cases of diffuse infiltration of the parotid by mature-appearing adipose tissue were cytologically characterized as "no diagnostic change" in two cases and sialosis in one case. The clinical, radiologic, cytologic and histologic features of these tumors are described to increase the familiarity of cytologists with these lesions, which may prevent unnecessary surgical intervention in some patients.     

High-risk human papillomavirus (HPV) in parotid lesions

Although several studies have reported that oropharyngeal infection with HPV may predispose to tumorigenesis, little is known about the etiological factors of salivary gland tumors and the presence of HPV. We studied 9 parotid lesions for HPV infection including an oncocytoma, an acinic cell carcinoma, a high-grade adenocarcinoma, a low-grade polymorphous adenocarcinoma, a Warthin's tumor and 2 pleomorphic adenomas, a lymphoepithelial cyst and a lipoma of the parotid gland. DNA was extracted from formalin-fixed and paraffin-embedded tissue sections. Solution PCR for HPV detection was performed using the GP5+/GP6+ primers, while HPV typing was carried out by multiplex PCR for HPV6, 11, 16, 18, and 33; positive samples were recorfirmed by PCR with specific primers for each type. Quantitative real-time PCR for the high-risk HPV genotypes 16, 18, 31, 33, 35, 52, 58 and 67 was also performed to quantitate the viral load. Finally, in situ PCR was employed with HPV16-specific primers by direct-detection method. Seven of the 9 parotid lesions were HPV positive while 6 of these 7 had been infected by HPV16 and/or HPV18 oncogenic types. High viral load of highrisk genotypes of HPV was found in the oncocytoma, in one of the pleomorphic adenomas, and in the Warthin's tumor. Finally, in situ PCR indicated that HPV16 amplification occurred in the salivary gland tumors. This is the first time that highrisk HPV genotypes are detected in these histological types of parotid lesions, suggesting the possible involvement of the virus in the disease.     

Fine needle aspiration cytologic diagnosis of metastatic Merkel cell carcinoma in the parotid gland

A case of Merkel cell (trabecular) carcinoma metastatic to the parotid gland and diagnosed clinically by fine needle aspiration cytology is described. The primary tumor was on the left upper eyelid and had been resected four months earlier. This unusual presentation and the incidence of secondary tumors involving the parotid gland are discussed.     

Fine needle aspiration in a malignant lymphoepithelial lesion: a case report

BACKGROUND: A primary malignant lymphoepithelial lesion (MLEL) of the salivary gland is a rare tumor. Though histologic morphology of this lesion is well documented, the cytologic findings regarding fine needle aspiration (FNA) are not yet well described. CASE: A 56-year-old Thai woman from Udonthanee was admitted to Srinagarind Hospital with a 2-year history of a painless mass in the left parotid gland. FNA of the left parotid mass was performed, and findings suggestive of malignancy were discovered. A wide local excision was performed 1 year later, and MLEL with metastasis to the regional lymph nodes was diagnosed by histopathology. CONCLUSION: We report our first experience of cytologic findings from FNA of histologically diagnosed MLEL. The aspirate comprised groups of cohesive and isolated malignant epithelials with a background of numerous lymphocytes. Cytotechnologists should be reminded of this rare lesion when confronted with a lymphocytic background from either benign or malignant lesions.     

Osteoclastomalike giant cell tumor of the parotid gland: report of a case with fine needle aspiration diagnosis

BACKGROUND: Osteoclastomalike giant cell tumor of the parotid gland has been reported rarely. The tumor has occurred rarely at many sites, such as thyroid, pancreas, soft tissue, breast, skin, heart, colon, lung, kidney, ovary and bladder. The exact origin of the tumor is unclear. However, osteoclastlike giant cells have been considered either part of a stromal process reactive to a neoplasm or a component of a primary neoplasm. CASE: A 35-year-old female presented with a mass in the left parotid gland clinically diagnosed as a pleomorphic adenoma. Fine needle aspiration (FNA) was advised before surgical excision. FNA smears revealed numerous osteoclastlike, multinucleated giant cells and many malignant-looking mononuclear cells. The smears were diagnosed as positive for malignancy, suggestive of osteoclastomalike giant cell tumor. The tumor was excised, and histopathologic study confirmed the cytologic diagnosis. CONCLUSION: The cytologic findings of osteoclastomalike giant cell tumor of the parotid gland have not been previously reported. FNA aided the diagnosis and planning of treatment. FNA is important in the diagnosis of parotid tumors.     

Tumor-Immune Interaction, Surgical Treatment, and Cancer Recurrence in a Mathematical Model of Melanoma

Malignant melanoma is a cancer of the skin arising in the melanocytes. We present a mathematical model of melanoma invasion into healthy tissue with an immune response. We use this model as a framework with which to investigate primary tumor invasion and treatment by surgical excision. We observe that the presence of immune cells can destroy tumors, hold them to minimal expansion, or, through the production of angiogenic factors, induce tumorigenic expansion. We also find that the tumor–immune system dynamic is critically important in determining the likelihood and extent of tumor regrowth following resection. We find that small metastatic lesions distal to the primary tumor mass can be held to a minimal size via the immune interaction with the larger primary tumor. Numerical experiments further suggest that metastatic disease is optimally suppressed by immune activation when the primary tumor is moderately, rather than minimally, metastatic. Furthermore, satellite lesions can become aggressively tumorigenic upon removal of the primary tumor and its associated immune tissue. This can lead to recurrence where total cancer mass increases more quickly than in primary tumor invasion, representing a clinically more dangerous disease state. These results are in line with clinical case studies involving resection of a primary melanoma followed by recurrence in local metastases.     

Traitement médical des tumeurs endocrines digestives

Gastroenteropancreatic neuroendocrine tumors constitute a highly heterogeneous group of tumors with very different prognoses. It is important to distinguish between the well-differentiated neuroendocrine tumors (carcinoid tumors affecting the gastrointestinal tract and pancreatic endocrine tumors), which generally progress slowly, and the poorly differentiated endocrine tumors, which are characterized by being aggressive and of rapid progression. The treatment of the poorly differentiated forms is essentially based on chemotherapy, although prognosis remains poor. The well-differentiated forms require a more complex approach – depending on the site of the primary tumor, staging, the resectability of the lesions, and disease spread – and should therefore be defined within a multidisciplinary setting. The treatment of choice remains surgical excision of the primary tumor and metastases. No additional treatment has been demonstrated to be effective. For functional tumors, symptomatic treatment with a somatostatin analog for carcinoid tumors or a protein pump inhibitor for gastrinoma must be started rapidly to reduce the complications related to hormone secretion. For metastatic disease or for tumors that are not amenable to complete resection, several options can be proposed: careful monitoring, chemoembolization of liver metastases, systemic chemotherapy, or enrollment in therapeutic protocols offering targeted therapies. Stepwise introduction of these various therapies prolongs survival, even in metastatic disease.     

Restrictive surgical approach to palliate angina in a patient with coronary three vessel disease and biventricular metastatic hepatocellular carcinoma

Background

Metastatic cardiac tumors may cause different symptoms including angina, symptoms of heart failure and/or arrhythmia. In patients with concomitant coronary artery disease, it may be difficult to distinguish between angina caused by metastases to the heart, for example, by stealing perfusion from the coronary arteries, and angina caused by coronary stenosis. Identifying the origin of the symptoms is, however, essential for designing appropriate surgical strategies.

Case presentation

A 69-year-old male with multifocal recurrence of a hepatocellular carcinoma (HCC) presented with increasing ventricular arrhythmia and angina several weeks after posterior myocardial infarction and PCI of the RCA culprit lesion during which two further lesions present in the distal RCX and a posterolateral branch, and a chronically occluded LAD had not been addressed. MRI showed a large metastatic tumor infiltrating the walls of both ventricles as well as the interventricular septum. His debilitating symptoms were attributed to steal phenomena and/or perivascular compression caused by the metastatic tumor rather than the remaining coronary lesions, and he was offered a restrictive surgical approach consisting of debulking of the metastasis with an option for subsequent coronary intervention. The palliative surgical procedure resulted in a reduction of the tumor mass by half and sufficiently reduced the patient’s symptoms so that further coronary intervention was not required.

Conclusions

Palliative surgery for metastases to the heart may benefit patients, provided that the origin of symptoms is identified correctly. It goes without saying that in a palliative setting, surgery should be limited to treating symptoms rather than performing extensive procedures addressing, for example, coronary artery or valve disease. Interventional cardiac procedures addressing not only CAD but also valve disease may supplement palliative tumor surgery.

     

Detection by immunohistochemistry of c-erbB2 oncoprotein in breast carcinomas and benign mammary lesions.

The presence of the c-erbB2 oncoprotein was demonstrated by immunohistochemistry in a study involving 173 mammary lesions. The lesions included infiltrating cancers, non-invasive neoplasia, as well as atypical and benign lesions. Our aim was to investigate the correlation between the c-erbB2 oncoprotein overexpression and the morphological features of the different mammary tissues analyzed to obtain a better characterization for the growth potential of certain lesions, with emphasis placed on the non-invasive neoplasia and the atypical lesions. Nearly 30% of infiltrating ductal carcinomas (27/89 cases) and 2 out of 24 infiltrating lobular carcinomas were positive. The comedocarcinomas were mostly stained (83%). In contrast, the intraductal carcinomas of cribriform or papillar patterns were consistently negative. No staining was observed in the atypical epithelial hyperplasia located in the vicinity of positive cancers for anti-oncoprotein c-erbB2 antibody. Furthermore, the only 5 positive cases for c-erbB2 out of 32 cancer-free cases were three fibroadenomas and two fibrocystic diseases with atypical ductal hyperplasia. A close correlation was thus observed between c-erbB2 oncoprotein overexpression and cancerous cell morphology, characterized by a marked nuclear hypertrophy often associated with cellular pleomorphism. However, predictive abnormalities of malignant transformation in non-neoplastic epithelial proliferation was difficult to identify, considering only the c-erbB2 expression. A group of tumors with little nuclear abnormalities were found positive for c-erbB2 immunostaining. These probably corresponded to a particular cellular phenotype. Further studies involving other oncogenes should lead to a better characterization of the different tumor phenotypes and help to clarify breast carcinogenesis.