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Journal of Experimental Medical & Surgical Research

JOURNAL of

Cercetri Experimentale & Medico-Chirurgicale

Experimental

Year XVII Nr.4/2010 Pag. 259 - 263

Medical

Surgical

R E S E A R C H

PAROTID GLAND TUMORS


A. Mag1
S. Cotulbea1
S. Lupescu1
H. tefnescu1
C. Doros1
V. Drgnescu1
D. Neamtu1
N. Balica1
A. Ruja2

SUMMARY:
Salivary gland tumors are rare, generally benign and affect mainly the parotid gland. Their
diagnosis and management is complicated by their relative infrequency, the limited amount
of pre-treatment information available and the wide range of biologic behavior seen with the
different pathologic lesions. The purpose of this study was to retrospectively analyze all
cases of parotid tumors treated in ENT Department Timioara from 2002 to 2009. 104 cases
of parotid tumors were selected; 78 were benign and 26 were malignant. Pleomorphic
adenoma was the most common benign tumor. The most frequent malignant tumors were
the mucoepidermoid carcinoma and carcinoma ex pleomorphic adenoma, in the same
proportion. Therapy in most cases consisted of parotidectomy. Adjuvant therapy mainly
radiotherapy was used in some cases with malignancies and in one patient was the only
therapy that the patient received. Parotid gland tumor pathology represent an important
chapter of ENT surgical pathology. The parotid gland give rise to a surprising variety of
benign and malign tumors, the pathologic diagnosis is the key for these lesions
management. Treatment often includes surgical resection as the primary modality for
benign and malignant lesions.
Key Words: parotid gland, benign tumor, malignant tumor, parotidectomy
TUMORILE GLANDEI PAROTIDE - EXPERIENA CLINICII ORL TIMIOARA

Received for publication: 03.06.2010


Revised: 21.08.2010

Rezumat:
Tumorile glandelor salivare sunt rare, n general benigne i afecteaz n special glanda
parotid. Diagnosticul i tratamentul lor este complicat datorit frecvenei lor sczute,
informaiilor preoperatorii limitate i modificrilor biologice foarte variate ntlnite n
diversele leziuni histopatologice. Scopul acestui studiu a fost o analiz retrospectiv a
tuturor cazurilor cu tumori parotidiene tratate n Clinica ORL Timioara ntre anii 2002-2009.
Au fost selectate 104 cazuri cu tumori parotidiene; 78 de cazuri au fost benigne i 26 de
cazuri au fost maligne. Cea mai frecvent tumor benign a fost adenomul pleomorf. Cele
mai frecvente tumori maligne au fost carcinomul mucoepidermoid i carcinomul ex adenom
pleomorf, ntlnite n aceeai msur. Tratamentul n cele mai multe cazuri a fost
parotidectomia. Tratamentul adjuvant, n special radioterapia s-a folosit la unele cazuri cu
tumori maligne, iar la un pacient a reprezentat singura terapie pe care acesta a urmat-o.
Patologia tumoral a glandei parotide reprezint un capitol important n patologia
chirurgical ORL. Glanda parotid poate genera o varietate mare de tumori benigne i
maligne, unde diagnosticul histopatologic este cheia pentru managementul acestor leziuni.
Cuvinte-cheie: glanda parotid, tumor benign, tumor malign, parotidectomie

1. - Clinica ORL Timioara Universitatea de Medicin i Farmacie Victor Babe Timioara


2. - Clinica Odontoterapie i Endodonie, Facultatea de Medicin Dentar Timioara

Correspondence to: Dr. Anamaria Mag, Clinica ORL Timioara, Bd. Revoluiei No. 6, Telefon: 0740 43 47 40,
Email: anamariamag@yahoo.com

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Table I. The common symptoms at the time of diagnosis.

INTRODUCTION
The salivary glands neoplasms are rare and represent
a variable group of benign and malign tumors with
different behavioral characteristics. Classification of
salivary gland tumors is based on morphology, and these
tumors represent the most histologically heterogeneous
group of tumors of any tissue in the body, which adds to
the complexity of diagnosis and treatment planning (1,2).
The salivary glands neoplasms represents approximately
1-3% of the head and neck tumors (3). Despite the
incidences vary according to the literature, 67,7% to 84%
of the neoplasms start in the parotid gland (4,5,6).
In the evaluation of parotid gland tumors, the
importance of a thorough history and comprehensive
examination of the head and neck is critical. Parotid gland
tumors shows a high histologic heterogenity and
diversity, and this is the reason it requires a pathologist
with experience to obtain a histopathological diagnosis of
confidence for optimal treatment of the patient.
In the parotid gland, the most common histological
subtype is the pleomorphic adenoma (53,3%), followed
by the Warthins tumor (28,3%) and by the
mucoepidermoid carcinoma (9%) (7).
Surgical treatment is the treatment of choice in parotid
gland tumors (2).

MATERIALS AND METHODS


A retrospective analysis was performed on 104
patients with parotid gland tumors treated at ENT Clinic
Timioara between 2001-2009. We followed next
parameters: age, sex, clinical features, histological
diagnosis, TNM classification of malignant tumors,
treatment, factors affecting surgical therapy,
postoperative complications.
Because of histological diversity of parotid gland
tumors we used histological classification propose by
World Health Organization in 2005 (8).
Malignant parotid tumors have been classified
according to the AJCC (American Joint Committee on
Cancer).

RESULTS

Clinical features

Number

Hard consistency

72

Rapid growth

48

Deep fixation

32

Pain

19

Palpable nodes

Facial nerve involvement

Lateral pharyngeal wall bulging

Skin involvement

The common symptoms at the time of diagnosis are


noted in table I.
Most of patients presented a swelling in the area of
affected parotid gland. 21 patients (20,19% of cases) had
associated pain (8 patients with benign lesions and 13
with malignant lesions). 5 patients (4,80% of cases)
presented skin involvement, all of them were diagnosed
with malignant tumors. We observed lesions of facial
nerve in 7 cases (6,73% of cases), of which 5 cases were
malignant tumors. On physical examination, 8 patients
(7,69% of cases) presented palpable cervical nodes
which showed metastasis.
The delay in diagnosis ranged from 3 months to 6
years with a mean delay of 18 months.
Preoperative tumor staging TNM, according to AJCC
(American Joint Cancer Committees) for malignant
tumors is presented in table II.
Two patients were classified in stage I, five patients
were classified in stage II, and in stage III and stage IV
were classified 13, respectively 6 patients.
Table III shows the histopathological diagnosis found
in our study. One patient refuses the surgery and we
performed only the biopsy of the tumor.
The most common benign tumor was pleomorphic
adenoma (67,94% of benign tumors), followed by
Warthins tumor (28,20% of benign tumors). The most
common malignant tumor was mucoepidermoid
carcinoma and carcinoma ex pleomorphic adenoma,
representing each 21,42% off all malignant tumors and,
being more frequently seen in males.

In the study group a number of 88 patients were


Table II. Preoperative tumor staging TNM according to AJCC
diagnosed with benign parotid tumors. 10 cases (American Joint Cancer Committees)
(11,36%) were chronic inflammatory processes. These
T1
T2
T3
T4
cases were excluded from our study. 26 patients were
diagnosed with malignant tumors.
N0
2
5
9
2
The study comprises 49 men and 55 women, with
N1
1
1
2
3
ages between 14 and 82 years.
N2
1

260

Table IV. Surgical interventions

Table III. Histopathological diagnosis

Histopathological diagnosis

Nr. of
cases

Pleomorphic adenoma

53

Warthins tumor

22

Basal cell adenoma

Hemangioendotelioma

Mucoepidermoid carcinoma

Carcinoma
adenoma

Surgical intervention

No.
Pts.

Limited excision

15

Superficial parotidectomy

58

Total parotidectomy with facial nerve


preservation

24

Total
parotidectomy
submaxillectomy

with

Total parotidectomy with sacrification


of facial nerve

Adenoid chistic carcinoma

4
3

Extensive
parotidectomy
sacrification of facial nerve

Adenocarcinoma NOS
Squamocell carcinoma

Total

ex

pleomorphic

Surgical interventions are presented in table IV. All


surgical procedures were performed with surgical
microscope.
The factors who influence surgical therapy
(conservative or removing facial nerve) and
postoperative treatment are: facial nerve invasion, tumor
extension, histological characteristics and positive limits
of the tumor.
Limited excision represent the removal of a parotid
tumor together with a wide cuff of a normal tissue after
findings and dissecting the main trunk and relevant
branches of the facial nerve, but leaving some apparently
normal parotid tissue lateral to the facial nerve. It has
been performed on 15 patients with small benign tumors
that generally had less than 2 cm. in diameter.
Superficial parotidectomy was performed in 60
patients with benign tumors and in 2 patients with
malignant tumors that generally had less than 3 cm. in
diameter, and preoperative with no clinical features to
suspect a malignancy.
Total conservative parotidectomy was performed in
25 cases out of which 18 cases were malignant tumors
and 7 cases were benign tumors. This procedure requires
entire gland removal, but without sacrifice the main trunk
of the facial nerve.
All the cases who necessitated facial nerve sacrifice
were malignant tumors.
Neck dissection was carried out in 19 cases (76%) of
25 cases who received surgery and was performed in all
cases classified T3, T4 and N1, N2. In 12 cases was
performed lateral neck dissection II-IV, in 3 cases was
performed anterolateral neck dissection and radical neck
dissection in four cases.

with

103

Table V. Postoperative complications.

Postoperative complications

No. Pts.

Hypoaesthesia of ear lobe

11

Temporary facial nerve paresis

Permanent facial nerve paralysis

Freysyndrome

Seroma

Salivary fistula

Wound dehiscence

The most common postoperative complications


detected in the parotid gland surgery in order of
frequency were: hypoaesthesia of ear lobe (11 cases),
temporary facial nerve paresis (9 cases), Freys
syndrome (5 cases), permanent facial nerve paralysis (5
cases), salivary fistula (4 cases), seroma (4 cases),
wound dehiscence (2 cases) (Table V).

DISCUSSIONS
Salivary gland tumors consist of a group of
heterogeneous lesions with complex clinicopathological
characteristics and distinct biological behaviors (9).
These tumors represents about 3% of all neoplasms of the
head and neck (10). Diagnosis and management is
complicated by the relative infrequency, the limited
amount of pre-treatment information available and the
wide range of biologic behavior seen with the different
pathologic lesions (11).
About 64 to 80% of all salivary gland epithelial tumors
involve the parotid gland, mostly located in the superficial

261

lobe (3). Most studies show that the mean age is higher
in malignant tumors (about 55 years) compared to benign
tumors (about 45 years) (4,12). Our results confirm these
findings; the mean age in our study was 47,12 years for
benign tumors and 58,30 years for malignancies. There
was a slight overall female predominance, with a male to
female ratio of 1:1.12. This finding is different from other
reports (13,14). But the reports of our study is similar to
others as far as an association between the male sex and
malignant neoplasms and the female sex and benign
neoplasms is concerned (15).
Pathology of the parotid gland has been reviewed
extensively due to the high cost of the surgical morbidity
of facial nerve paresis or paralysis. Proper diagnostic
evaluation should always include a thorough history and
physical examination with consideration of facial nerve
function, onset of disease and identification of associated
lymph node metastasis. The main complaint of patients
with parotid tumor was a lump in the parotid area. In six
cases when parotid tumor arised from the deep lobe of
the gland, the tumor was bulging the lateral wall of the
oropharynx. 72% of patients with malignant tumors
manifested signs of malignancy, such as pain, facial
nerve damage, no mobility, involvement of skin,
increased parotid volume and lymphadenopathy.
In establishing an accurate diagnosis are useful
imaging and laboratory examinations such as:
sonography and Color Doppler ultrasound; contrast
enhanced CT and MRI; fine needle aspiration biopsy
FNA; frozen section; examination slide in paraffin (from
excised piece). Ultrasonography can be used to aid in
core needle biopsy in the diagnosis of parotid tumors
(16). King et al. advocate the use of proton magnetic
resonance (MR) spectroscopy for evaluation of salivary
gland tumors. They noted a significant difference in MR
spectroscopy of benign and malignant lesions (17). FNA
remains the most common preoperative intervention to
distinguish histologic pathology. In a recent article from
New Zeeland, sensitivity and specificity of benign lesions
were noted to be 85% and 97%, respectively. However,
the specificity of malignant lesions was only 85% (18).
Cohen et al. report a slightly lower sensitivity of 73% for
malignant lesions and a similar specificity of 87% (19).
Correct diagnosis is confirmed only by histopathology in
paraffin, sometimes there need for additional
immunohistochemical investigation for a final diagnosis
of certainty.
The pleomorphic adenoma and Warthins tumor are
the most common benign tumors (4). Our data show that
the pleomorphic adenoma and Warthins tumor
comprised 67,94% and 28,20% of cases each. The

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percentage of Warthins tumor in our study was high


compared to other series of parotid tumors, in which this
number generally ranges from 9% to 15% (15,20).
Malignant tumors comprise about 15 to 30% of parotid
tumors; the most commonly reported is mucoepidermoid
carcinoma, followed by the cystic adenoid carcinoma (4).
We also found among our series of malignant tumors that
the mucoepidermoid carcinoma and carcinoma ex
pleomorphic adenoma were the most common tumors,
followed by the cystic adenoid carcinoma and
adenocarcinoma NOS. A. Paramas Rodriguez et al. in
period 1991-1992 have studied 40 patients with
malignant parotid gland tumors and reported the highest
frequency of squamocell carcinoma (20%), followed by
acinar cell carcinoma (15%) and mucoepidermoid
carcinoma and adenocarcinoma in the same proportion
(10%) (21). Other specialized studies (22,23) indicating
mucoepidermoid carcinoma as the most common
malignant hystopathologycal diagnosis.
The prognosis of patient with malignant tumors
depends on size of tumor, tumor type and histological
grade, TNM staging, involment of adjacent structures,
lymphatic metastasis and biological patient status.
Surgical extirpation of parotid gland tumors remains
the preferred option for both diagnosis and therapy.
The treatment of choise for benign tumors of the
parotid gland is superficial parotidectomy, preserving the
facial nerve (24). Generally, superficial parotidectomy is
done in tumors limited to the superficial lobe, which is
fully resected. In our study, superficial parotidectomy
was performed in 56 cases of benign tumors. Removal of
the whole parotid lobe aims to attain adequate surgical
margins and avoid rupture of the capsule, which reduces
the recurrence rate. Total parotidectomy in benign
tumors is done when the deep lobe is involved. In our
study, total parotidectomy was performed in 7 cases of
benign tumors.
The treatment of choice for malignant tumors is partial
or total parotidectomy; the facial nerve is preserved if
possible. We performed superficial parotidectomy in two
cases of malignant tumors. Also we performed total
parotidectomy with preservation of facial nerve in 18
cases of malignant tumors. Safe identification and
preservation of the facial nerve remain key components
in surgical removal of parotid tumors. At many
institutions, facial nerve monitoring is commonplace. Use
of the facial nerve monitor does not improve the
incidence of postoperative facial nerve paralysis;
however, most surgeons consider it a useful surgical
adjunct. Although facial nerve monitoring can be

beneficial, transient facial nerve paresis occurs in


approximately one in five patients (25).
Consideration of the neck dissection remains a
component of treatment of parotid gland malignancies.
Ferlito et al. recently summarized the indications for neck
dissection such as: in the clinically positive neck, neck
dissection is warranted. Characteristics of the primary
tumor are used to determine the necessity of neck
dissection in the clinically N0 neck. High-grade tumors,
advanced T stage, presence of facial nerve paralysis
preoperatively, and histologic demonstration of
extraglandular spread or perilymphatic invasion warrant
elective neck dissection (26).
Radiation therapy should be used in conjunction with
surgery in high-grade malignancies, tumors of the deep
lobe and in patients with clinically positive neck nodes.
The role of chemotherapy is still in its infancy for salivary
gland malignancies. Few clinical trails have been
undertaken. Cisplatinum, doxorubicin, 5-FU and
methotrexate are the most effective, especially in
bringing significant pain relief.
Recurrence rates for benign parotid tumors should be
minimal if proper diagnostic approach and surgical
techniques are employed. The outlook for low-grade
malignant parotid tumors is good if they are treated early,

when the 5-year survival may be 70-100%. However,


high-grade malignancies continue to have a poor
prognosis with a 0-50% five year survival, despite an
aggressive surgical approach and adjunctive measures.

CONCLUSIONS
Parotid gland tumor pathology represents an important
chapter of ENT surgical pathology.
A deep knowledge of the anatomy and physiology of
parotid gland is required for a suitable clinical and
surgical approach.
The parotid gland give rice to a surprising variety of
benign and malign tumors, where the pathologic
diagnosis is the key for these lesions management.
Treatment often includes surgical resection as the
primary modality for benign and malignant lesions.
Treatment of the neck, including neck dissection and
radiotherapy, should be considered in all high-grade
malignancies or malignancies with clinical nodal disease.
Postoperative radiation therapy is indicated in patients
with advanced, recurrent or high-risk disease and in
patients with high-grade tumors. Chemotherapy plays a
limited role, but it may be indicated in patients with
distant metastases or inoperable malignancies.

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