Adenoid Cystic Carcinoma Parotid Mr

Figure 8.11a. CT scan of large superficial lobe tumor in 22-year-old woman.

Images Parotid Gland

Figure 8.11c. Complete parotidectomy. The facial nerve was not involved.

The reported survival related to stage varies between authors, which may reflect differences in therapy as well as different patterns of histopathol-ogy. Luukkaa, Klemi, and Leivo et al. (2005) found

Figure 8.11b. Clinical appearance; the tumor has no signs of malignancy.
Parotid Acinic Cell Carcinoma Pet Scan

Figure 8.11d. Histopathology of acinic cell carcinoma. The patient is alive and well 8+ years postoperatively.

5-year survival Stage I-IV 78%, 25%, 21%, and 23%, while Lima et al. (2005) found 10-year disease-specific survival Stage I-IV 97%, 81%, 56%, and 20%.

In considering management, Kaplan and Johns (1986) divide parotid cancers into 4 groups to recommend treatment. Group I T1-2 low-grade tumors are treated by parotidectomy with preservation of the facial nerve (Figures 8.11 and 8.12). Group II T1-2 high-grade are treated with paroti-dectomy plus first echelon node removal and postoperative radiation therapy (RT) (Figure 8.13). Group III T3 tumors, any positive nodes and recurrent tumor not in Group IV, are treated with radical parotidectomy with sacrifice of the facial nerve if necessary and radical neck dissection plus RT. Group IV includes T4 and tumors with significant local extension; they are treated by radical paroti-

Mucoepidermoid Carcinoma The Body
Figure 8.12a. Patient who had a "skin cyst" biopsied; it was histologically a low-grade mucoepidermoid carcinoma of the parotid. Note preauricular biopsy scar.
Mucoepidermoid Carcinoma Incision

Figure 8.12b. Operative image shows Blair incision incorporating 1 cm skin margin surrounding the biopsy.

Adenoid Cystic Carcinoma Parotid

Figure 8.12c. The level II nodes (first echelon nodes) will be taken in continuity in this case.

Figure 8.12d. Histology shows a focus of mucoepidermoid carcinoma (arrow) in the biopsy scar between the skin and parotid, demonstrating the importance of excising "seeded" skin.

Scrotal Blood Spots

Figure 8.12e. Mucicarmine stain confirms intracellular mucus.

Blair Incision Scar

Figure 8.12f. Surgical specimen.

Figure 8.12f. Surgical specimen.

Figure 8.12g. The patient is alive and disease-free 14 years postoperatively.

dectomy plus skin, muscle, and bone as indicated with radical neck dissection and postoperative RT (see chapter 11, Figure 11.16).

Controversy exists in the exact indications for RT, neck dissection, and facial nerve sacrifice. The majority of recent papers do show that RT is indicated for advanced parotid carcinoma and confers a survival benefit (Bhattacharyya and Fried 2005) or longer disease-free survival (Hocwald, Korkmaz, and Yoo et al. 2001). However, there is a move toward suggesting RT for earlier stage disease. Zbaren, Nuyens, and Caversaccio et al. (2006) retrospectively analyzed T1-2 carcinomas with and without postoperative RT and found local recurrence rates of 3% and 33%, respectively, and actuarial and disease-free survival of 93% and 92% with and 83% and 70% without RT. In an earlier publication from the same unit RT was suggested not just for high-grade tumors but low-grade T2-4 (Zbaren, Schupbach, and Nuyens et al. 2003). So perhaps RT is indicated for earlier stage disease than was previously recommended. The latest data regarding fast neutron therapy in the management of advanced salivary cancer with gross residual disease shows a 6-year local-regional control of 59%, and 100% with no evidence of gross residual disease (Douglas et al. 2003.) Benefits of chemotherapy have not been clearly demonstrated for parotid cancer.

Similarly, although lymph node dissection was recommended for positive nodes and highgrade tumors, there is an increasing interest in the N0 neck. Occult metastasis rates of 22-45% led Stennert, Kisner, and Jungehuelsing et al. (2003) and Zbaren, Schupbach, and Nuyens et al. (2003) to recommend an elective neck dissection in the

Intraocular Tumor Fine Needle Biopsy
Figure 8.13a. MR of parotid tumor that radiologically was diagnosed as a pleomorphic adenoma, but fine needle aspiration biopsy showed adenoid cystic carcinoma.
Adenoid Cystic Carcinoma Prognosis

Figure 8.13b. In view of the cytologic diagnosis, proposed treatment includes resection of overlying skin (which clinically was felt to be tethered) and level II cervical nodes.

NO neck for parotid cancer (Figure 8.14). Elective neck dissection for high-grade tumors and >T2 low-grade tumors should encompass levels I—III and upper V (Teymoortash and Werner 2002). In comparing elective neck dissection for the NO neck against observation, Zbaren et al. (2005) found an

Lvel Neck Dissection

Figure 8.13c. Surgical specimen shows parotid with skin. The arrows show where level II nodes and fat are in continuity with the parotid tail. Final diagnosis was cellular pleomorphic adenoma with the FNAB diagnosis being a false positive.

actuarial and disease-free survival of 80% and 86% for the elective neck dissection patients vs. 83% and 69% for the observation group in a retrospective study.

Regarding the facial nerve, Spiro and Spiro (2003) recommend preservation unless the nerve is adherent to/embedded in the tumor. They feel that close margins to the nerve can be treated successfully by RT. This view is supported by the work of Carinci, Farina, and Pelucchi et al. (2001), who found that sacrifice of the nerve was not always able to improve survival rate. In a series of 107 patients with parotid cancer, 91 had normal nerve function preoperatively and facial nerve preservation was possible in 79 patients. The 5-year disease-free rate and 5- and 10-year survival rates were 65%, 83%, and 54% in the preserved nerve cohort and 56%, 62%, and 42% in the patients with nerve sacrifice. The authors felt that

Testicular Torsion

Figure 8.14a. High-grade parotid malignancy with skin fixation and NO neck. Incision modified to include skin excision (arrow), and cervical incision extended to allow supra-omohyoid neck dissection.

Figure 8.14d. The surgical site following parotidectomy and selective neck dissection.

Epididymal Cyst

Figure 8.14b. The skin flaps developed with the skin overlying the tumor left on the parotid gland.

Fotos Ins Litas Del MundoNeck Dissection Levels Parotid Gland

Figure 8.14e. The surgical specimen with the parotid superiorly and level I nodes pinned out with white pins.

Figure 8.14c. The selective neck dissection is complete with the specimen in continuity with the parotid gland. The facial nerve trunk has been exposed and the superficial parotidectomy is being performed.

Figure 8.14e. The surgical specimen with the parotid superiorly and level I nodes pinned out with white pins.

preservation of the facial nerve by careful dissection gave favorable oncologic results (Guntinas-Lichius, Klussman, and Schroeder et al. 2004). Finally, a disease-free survival in patients with normal, partially, and completely impaired facial nerve function preoperatively of 69%, 37%, and 13% despite the use of facial nerve sacrifice and postoperative RT indicates what a poor prognosis invasion of the nerve confers (Terhaard, Lubsen, and Tan et al. 2006).

In specific histologic tumor types variable results for different treatments have been reported. Mucoepidermoid carcinoma is the commonest salivary malignancy and most cases are fortunately low or intermediate grade. A series of 89 cases at the Mayo Clinic, 69 T1-2, 85 N0, and 83 low/intermediate grade, were treated by parotidectomy with "appropriate" neck dissection and only 7 had RT. Kaplan-Meier estimated cancer-specific survival rates at 5, 15, and 25 years were 98.9%, 97.4%, and 97.4% (Boahene, Olsen, and Lewis et al. 2004). Using a point grading system for histopathologic features in a series of 234 mucoepidermoid carcinomas of the major salivary glands, cystic component <20%, 4 or more mitotic figures per 10 high power fields, neural involvement, necrosis, and anaplasia were found to have prognostic significance for parotid MEC (Goode, Auclair, and Ellis 1998). Intermediate-grade MEC tends to behave more like low-grade MEC, while high-grade MEC behaves aggressively with local recurrence and regional and distant metastases in the majority of cases. Other low-grade tumors such as acinic cell carcinoma, epimyoepithelial carcinoma, and low-grade adeno-carcinoma all can be treated like low-grade MEC. Polymorphous low-grade adenocarcinoma is rare in the major glands, being seen mostly in the minor salivary glands of the oral cavity.

On the other hand, results for high-grade tumors such as primary squamous carcinoma of the parotid are poor; in one published series two-thirds were treated with radical surgery and RT and one-third with RT alone, but 5-year actuarial survival and disease-free survival was 31% and 33%, respectively (Lee, Kim, and Parks et al. 2001). Malignant change in PAs is most commonly seen as carcinoma ex-pleomorphic adenoma, and prognosis will depend on the histologic type of malignancy and whether the malignancy has spread outside the capsule. In carcinoma ex-pleo-morphic adenoma the use of postoperative RT improved 5-year local control from 49% to 75%

and improved survival in patients without cervical metastasis (Chen, Garcia, and Bucci et al. 2007). Two other forms of malignant PA occur, both rare: the "true" malignant mixed tumor or carci-nosarcoma where malignant change is seen in both the epithelial and myoepithelial component of the PA, and the benign metastasizing PA, which as its name suggests retains a benign histologic appearance despite the presence of metastases.

It is hard to interpret survival figures in some series, as ACC is very slow growing and 5-year survival is less meaningful in this neoplasm as survival continues to fall on 20-year follow-up. Thus in series with short follow-up ACC will erroneously be thought to have a good prognosis. Typical long-term survival figures are 84.3% 2 year, 75.9% 5 year, 50.49% 10 year, and 20.11% after 20 years (Issing, Hemmanouil, and Wilkens et al. 2002). The type of histologic appearance, solid vs. cylindrical, and the presence of perineural invasion are important prognostic factors. Even with documented lung metastases patients can live 5+ years, the average survival between the appearance of lung metastases and death being 32.3 months in one series (van der Waal et al. 2002). Wide field adjuvant RT post-radical surgery is usually recommended for ACC.

The histologic grade of the tumor must be taken into account as well as TNM staging when interpreting survival results in reported series. Every parotid cancer will be unique and the decision for what is the correct surgery will be made on an individual basis for each patient.

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