Pleomorphic salivary adenoma of the parotid gland: which operation to perform?

"Unraveling the Tapestry": A Retrospective Exploration of Recurrent Parotid Pleomorphic Adenoma Cases

The standard surgical procedure for treating the parotid gland's recurrent pleomorphic adenoma (RPA) is parotidectomy with facial nerve preservation (FN). Treatment of RPA remains challenging since controversies occur regarding recurrence, degree of revision surgery, postoperative radiation, and difficulty in conserving the FN. A retrospective review of patient's medical records treated for benign parotid neoplasms was conducted between 2017 and 2022 to identify individuals who underwent surgery for RPA. Demographic information, surgical intervention details, pre-and postoperative facial nerve function, histopathological analysis, and recurrence rates were collected. These variables were compared in patients with single recurrent tumors versus patients with multiple recurrent tumors. Twenty-one patients met the criteria, including 13 with a first recurrence, 7 with a second recurrence, and 1 with a third recurrence. Following surgery for multiple RPA, long-term FN outcomes were significantly worse (P = 0.005). There were no observable risk factors for tumor recurrence. The interval between the initial revision surgery and subsequent ones was drastically shortened. Our study suggests that the risk of permanent facial paralysis is greater with subsequent surgical procedures. Early detection of recurrence can aid in early re-operation.

Long-term outcomes and quality of life following parotidectomy for benign disease

Objective

Parotidectomy worsens quality of life (QoL) in the short-term, but the long-term impact is unknown. In this study, we analysed the long-term effects of parotidectomy on QoL.

Methods

In this prospective long-term follow-up study, participants were divided into three groups: short-term (ST) follow-up of six weeks, long-term (LT) follow-up of 13 years and short- and long-term (SLT) follow-up. QoL was assessed using the Parotidectomy Outcome Inventory (POI-8). Parotidectomies were classified based on whether the great auricular nerve (GAN) had been preserved or sacrificed.

Results

In total, 164 observations were analysed, 74 in the LT group, 57 in the ST group and 33 in the SLT group. Hypoaesthesia was a major problem and facial palsy was a minor problem. Pain (p < 0.01) and hypoaesthesia (p < 0.001) were significantly lower after 13 years compared with after six weeks, and QoL was higher after 13 years compared with after six weeks (p = 0.04). The disease-specific impairment rate decreased from 70% at short-term follow-up to 30% at long-term follow-up. Removal of the GAN was associated with hypoaesthesia in the ST group (p = 0.028).

Conclusions

Hypoaesthesia has a long-term impact on the QoL, and this should be emphasised during preoperative discussions.

Nasopharyngeal Pleomorphic Adenoma: A Rare Case Report and Review of the Literature

Salivary gland tumors are rare among all head and neck tumors. Pleomorphic adenoma (PA) is the most commonly seen subtype, and 85% of the cases are located in the parotid gland. PA may very rarely be seen in minor salivary glands. Minor salivary gland PAs are mostly located in the hard and soft palates. Nasopharyngeal PA is very rare, and a total of 8 cases have been published to date. In this case report, a 51-year-old female patient who had nasopharyngeal PA with chondroid metaplasia is presented, and we review the relevant literature.

Post Parotidectomy Quality of Life in Patients with Benign Parotid Neoplasm: A Prospective Study

Parotid tumours are not uncommon. The management is surgical for benign and malignant parotid neoplasm. Due to the location of parotid gland and its intricate relationship with facial nerve, cosmetic and functional outcomes after parotid surgery are extremely important. Objectives of the study were to analyse facial nerve functions with emphasis on the quality of life of patients undergoing surgery for parotid neoplasm. A prospective study was conducted on patients presented with parotid neoplasm and undergone parotid surgery. Patient with malignant neoplasm were excluded. 30 patients with benign parotid neoplasm in final histopathology were included in the study. Post operative assessment of facial nerve was done using postparotidectomy facial nerve grading system. Symptom-specific QOL was assessed with the parotidectomy outcome inventory-8. Aesthetic outcome was evaluated with an ordinal scale. Posterior belly of digastric muscle and tragal pointer were the commonest landmark used for facial nerve identification. Temporary facial nerve dysfunction was present in six (20%) patients with marginal mandibular branch most commonly involved. 96% of the female patients and 91% of the male patients rated the cosmetic result as good or very good. A statistically significant difference is noted between superficial parotidectomy and total Parotidectomy for cosmetic outcome and sensory impairment. We noted that changed appearance due to resection of the parotid gland and scar and sensory impairment in the area affect the quality of life of patients and such affect are more after total conservative parotidectomy.

The role of insulin-like growth factor I-II receptor on development of pleomorphic adenoma

Pleomorphic adenoma is a slow-growing salivary gland tumor frequently arising from the parotid gland. In this study, we investigated the role of the insulin-like growth factor I-II receptor (IGFI-IIR) levels on the development of parotid gland pleomorphic adenomas. The study included 20 males and 20 females who had superficial parotidectomy with a histopathological diagnosis of pleomorphic adenoma in Fırat University Otorhinolaryngology Clinic between 2000 and 2011. The ages of the patients ranged between 20 and 50 years. The control tissues were obtained unilaterally from the parotid glands of five female and five male cadavers during autopsy, and consisted of 0.5 × 0.5 cm sized normal parotid gland tissues. The expression of IGFI-IIR were measured in both tumor and tumor-free normal parotid tissue in the study group while only the normal parotid tissues were studied in the cadavers. Primary polyclonal antibodies against IGFI-IIR were used with "Streptavidin-Biotin Complex" method for immunohistochemical staining of both the study and the control groups' tissue sections. In this study, the IGFI-IIR levels were found significantly higher in the pleomorphic adenoma tissue (p < 0.05). In addition, IGFI-IIR expression was greater in normal parotid tissues of the study group when compared to the normal parotid tissues of the cadavers. However, the difference was not statistically significant (p > 0.017). Greater expression for IGFI-IIR in pleomorphic adenoma when compared to normal parotid tissues of the patients and the cadavers suggests that IGFI-II may be important factors in the development of pleomorphic adenoma.

Charcoal Suspension Tattoo: A New Technique for Intraoperative Detection of Small Tumors of the Parotid Gland

OBJECTIVE

The current surgical trend in the treatment of pleomorphic adenomas of the parotid gland is to limit the extent of resection. This raises the need to correctly identify the mass within the normal parenchyma so as to avoid dissecting the entire superficial lobe of the gland. We describe ultrasound-guided tattooing as a technique to facilitate identification and excision of parotid pleomorphic adenomas.

METHODS

We reviewed 23 consecutive patients with pleomorphic adenoma of the parotid gland. All patients underwent ultrasound-guided tattooing of the lesions with a charcoal suspension. Baseline tumor and patients' characteristics, major and minor complications, and subjective tolerance to the procedure were recorded. We assessed the number of intralesionally marked masses and the percentage of intraoperatively detected marked lesions.

RESULTS

The injection was well tolerated. No major complications were recorded. In 2 cases (9%), a transient increase in lesion size was observed. No other minor complications were encountered. Charcoal was found inside the tumor in 19 cases (83%). In 4 cases (17%), it was found in the tissues above the lesion. Twenty-three lesions were intraoperatively detected (100%) and dissected.

CONCLUSION

Charcoal suspension tattooing is safe and well tolerated for the detection of small pleomorphic adenomas during parotid surgery.

Dynamic contrast-enhanced MRI for differentiation of major salivary glands neoplasms, a 3-T MRI study

OBJECTIVES

Pre-operative differentiation of salivary gland neoplasms is of great importance. This study was designed to evaluate the use of dynamic contrast-enhanced MRI (DCE-MRI) for differentiation between malignant, Warthin and benign non-Warthin (BNW) neoplasms of major salivary glands.

METHODS

46 major salivary gland tumours (SGTs) underwent pre-operative DCE-MRI. Post-surgical histopathological evaluation showed 30 BNW, 6 Warthin and 10 malignant tumours. Time-signal intensity curves (TICs) were categorized as (a) Tpeak >43 s and washout ratio at 180 s (WR180) <4.6%; (b) Tpeak <43 s and WR >22%; (c) Tpeak >43 s and WR180 = 4.6-22.0%

RESULTS

Accuracy of Tpeak was 98.9% for differentiation between BNW and Warthin tumours, 83.7% between BNW and malignant and 80% between malignant and Warthin tumours. All Warthin tumours showed Tpeak ≤43 s, while one BNW had Tpeak <43 s. A Tpeak <63.5 s differentiated 8/10 (80%) malignant tumours from BNW tumours, whereas 4/30 of BNW tumours had a Tpeak <63.5 s. Two malignant tumours had Tpeak <43 s. WR180 had an accuracy of 100% for differentiation between Warthin and BNW tumours, 87.3% between BNW and malignant, and 93.3% between Warthin and malignant tumours. 29 (96.7%) BNW tumours had a washout <4.60%, while 8 (80%) malignant tumours had a washout >4.60%. All Warthin tumours had a WR180 >22%, while two malignant tumours had a WR180 >22%. 29/30 of BNW tumours demonstrated TIC curve Type A and 1 tumour demonstrated Type C. 6/10 of malignant tumours had TIC Type C, 2 had TIC Type A and 2 Type B. All Warthin tumours were categorized as Type B.

CONCLUSIONS

This study showed that DCE-MRI could be helpful in pre-operative differentiation of SGTs; especially for discrimination between Warthin and BNW tumours.

Remarkable Triple Pleomorphic Adenoma Affecting both Parotid and Submandibular Glands

The objective of this article is to present the first case reported in the literature of metachronous pleomorphic adenoma of bilateral parotid glands and submaxillary gland. The authors report the case of a 27-year-old female with metachronous mixed tumors in her right parotid and submandibular glands. The patient has no history of previous radiotherapy. All three lesions were diagnosed by fine-needle aspiration. The histopathologic evaluation of all three major salivary gland masses demonstrated pleomorphic adenomas, with no occult malignancy observed on serial sections. The presentation of pleomorphic adenomas in the parotids and submandibular glands probably represents three unrelated primary sites of tumor, yet the possibility of metastasis from one gland to the other cannot be excluded.

Quality of life following surgical treatment of benign parotid disease

To evaluate the quality of life after surgery for benign neoplastic disease of the parotid gland. Forty-nine patients who underwent surgery for benign parotid disease between January 2004 and December 2008 were included in this retrospective study. EORTC QLQ-C30 and EORTC QLQ-H&N35 questionnaires were used to determine the quality of life. The variables of these questionnaires were compared with age, gender, educational status, histopathologic diagnosis and Frey syndrome. A statistically significant correlation was noted between the female gender and post-surgical pain, sleeplessness and the use of non-steroid anti-inflammatory drugs (p < 0.001). There was a significant difference between age and difficulties in moving the mouth (p < 0.001). Frey syndrome related to social functions, economical difficulties, speech defect, reduced sexuality, and nutritional parameters were found to be statistically significant (p < 0.001). Frey syndrome is the most common complication that affects the quality of life in patients who had parotidectomy due to a benign parotid disease. Therefore, all patients should be informed about Frey syndrome before parotidectomy.

Pleomorphic adenoma of the parotid: formal parotidectomy or limited surgery?

BACKGROUND

Optimal surgery for pleomorphic adenoma of the parotid is controversial. In the present review, we discuss the advantages and disadvantages of the various approaches after addressing the surgical pathology of the parotid pleomorphic adenoma capsule and its influence on surgery.

DATA SOURCES

PubMed literature searches were performed to identify original studies.

CONCLUSIONS

Almost all pleomorphic adenomas can be effectively treated by formal parotidectomy, but the procedure is not mandatory. Extracapsular dissection is a minimal margin surgery; therefore, in the hands of a novice or occasional parotid surgeon, it may result in higher rates of recurrence. Partial superficial parotidectomy may be a good compromise. The tumor is removed with a greater cuff of healthy parotid tissue than in extracapsular dissection. This may minimize the recurrence rate. On the other hand, the removal of healthy parotid tissue compared with formal parotidectomy is limited, thus minimizing complications such as facial nerve dysfunction and Frey syndrome.

Extracapsular dissection for benign parotid tumors: a meta-analysis

OBJECTIVES/HYPOTHESIS

Recent studies suggest that extracapsular dissection (ECD) is an option for the resection of certain benign parotid tumors. This study investigates complication rates and effectiveness of ECD versus superficial parotidectomy (SP) for the treatment of primary benign parotid neoplasms.

STUDY DESIGN

Systematic literature review with meta-analysis.

METHODS

Studies available for inclusion evaluated the complications and effectiveness of ECD and SP as surgical techniques for the treatment of solitary, benign parotid tumors. An Ovid/Medline search revealed nine articles that met inclusion criteria. A critical review and meta-analysis of these articles was performed.

RESULTS

The included studies evaluated a total of 1,882 patients. There was no observed difference in tumor recurrence between the ECD and SP groups (odds ratio [OR], 0.557; 95% confidence interval [CI], 0.271-1.147). There was a significantly lower rate of transient facial nerve paresis (OR, 0.256; 95% CI, 0.174-0.377) in the ECD group (59 of 741; 8.0%) compared to the SP group (81 of 397; 20.4%); however, there was no observed difference in permanent facial paralysis between the ECD and SP groups (OR, 0.878; 95% CI, 0.282-2.730). Frey's syndrome was less often observed (OR, 0.117; 95% CI, 0.071-0.191) after ECD (27 of 602; 4.5%) compared to SP (75 of 287; 26.1%).

CONCLUSIONS

This systematic review with meta-analysis suggests that ECD has a similar recurrence rate as SP with fewer postoperative complications. ECD may be considered an alternative surgical modality for select benign parotid neoplasms.

Parotid tumors: a 10-year experience

PURPOSE

The aim of the present study was to analyze the clinical presentation, histopathology, and complications of parotid tumors, as well as the management of malignant parotid tumors.

METHODS

We retrospectively reviewed the medical records of 271 patients who underwent parotidectomy from August 1996 to July 2006. Data including age, sex, clinical signs and symptoms, histologic findings, complications, malignant tumor stage, and prognosis were collected from medical charts.

RESULTS

Of the 271 patients who underwent parotidectomy, 229 (85%) had benign tumors, 33 (12%) had malignant tumors, and 9 had chronic inflammatory disease (3%). The most common benign tumor was pleomorphic adenoma (51%), and the most common malignant tumor was mucoepidermoid carcinoma (3%). The 5-year overall survival rate was 42%, and the disease-specific survival rate for malignant tumor was 72%. Only disease stage was the statistically significant prognostic factor of malignancy. The most common complication of parotidectomy was transient facial palsy (18%).

CONCLUSIONS

Standardized superficial and total parotidectomy are safe procedures for treating parotid tumors. Management of malignant tumors depends on tumor stage and histologic grade. Advanced tumor stage is a predictor of poor outcome.

Role of limited parotidectomy in management of pleomorphic adenoma

There is continued controversy over the extent of parotidectomy required for removal of a benign pleomorphic adenoma from the parotid gland. Currently, consensus exists that the integrity of the facial nerve must be preserved when the tumour is totally removed.

As a result of experience gained in the first half of the twentieth century, it was recommended that superficial parotidectomy with facial nerve dissection should be the minimal biopsy for pleomorphic adenoma. Since that time, however, research has indicated that partial parotidectomy or extracapsular dissection of benign pleomorphic adenoma can be accomplished with preservation of the facial nerve without an increase in tumour recurrence. Partial parotidectomy or extracapsular dissection results in impaired cosmetic results and a lower incidence of Frey's syndrome, and thus may be the preferred approach when undertaken by experienced surgeons.

Impact of lateral parotidectomy for benign tumors on quality of life

CONCLUSION

This study supports the use of lateral parotidectomy as a safe and standardized type of surgery for benign parotid gland disease.

OBJECTIVE

To assess quality of life in patients with benign salivary gland tumors who underwent lateral parotidectomy.

PATIENTS AND METHODS

Fifty-one patients suffering from benign parotid gland disease were included in this prospective study. Using the EORTC QLQ-C30 and EORTC-QLQ-H&N35 questionnaire, surgery-affected changes in quality of life were assessed in 34 patients who completed this survey.

RESULTS

Overall results show no alterations in quality of life 1 year after lateral parotidectomy.

Metachronous bilateral pleomorphic adenoma of the parotid gland

Bilateral salivary gland tumors are very rare, accounting for 3% of all parotid gland tumors. Although the most common tumor with bilateral development is the Warthin tumor, pleomorphic adenomas (PA) have been diagnosed simultaneously as well, but in a smaller incidence. Because of this, the prevalence, etiology, pathogenesis, and behavior of the PA in this context are poorly understood. We present a case of bilateral metachronous PA affecting the parotid gland in a 63-year-old woman. Clinically, the lesions presented with similar aspects as seen in cases of solitary PA with slow-growing asymptomatic nodule. Both lesions were diagnosed by fine-needle aspiration biopsy at an interval of 2 years between them. A total and superficial parotidectomy for left and right tumors, respectively, was performed. Only on the left side some facial nerve branches were removed that induced partial paralysis in the patient. A review of the pertinent literature is included.