Unremarkable parotid tumours that prove to be malignant

Of 539 patients with clinically unremarkable lumps treated by formal parotidectomy, subsequent histological examination indicated that 20 of these lesions were malignant. After a follow-up of 1-18 years, only one patient has suffered a recurrent tumour and none has died from disease related causes. The results indicate that formal parotidectomy is an acceptable means of treating the small number of malignant tumours presenting in this way, and strengthen the argument that attempts to obtain a histological diagnosis before treatment are contraindicated.     

Transoral approach to accessory parotid tumours: case series and literature review

Accessory parotid tumours are rare, accounting for less than 10% of parotid neoplasms. Although similar tumours affect both the accessory parotid and parotid, accessory parotid tumours are associated with higher rates of malignancy. Surgery is first line management. Standard surgical management involves a similar approach to superficial parotidectomy, despite the anterior location of these lesions. This approach requires extensive subcutaneous access and facial nerve dissection and therefore, poses significant risk. It can also result in poor cosmetic result due to scarring and Frey's Syndrome. On the contrary, a transoral approach to reduces the risk of cosmetic deformity, reduces recovery time and does not increase risk to the facial nerve. We present a case series of patients with accessory parotid masses, which have been successfully excised transoral and without endoscopic assistance.     

Signs and symptoms of malignant parotid tumours: an objective assessment

BACKGROUND: The clinical features that may be associated with malignancy in parotid tumours are well known. Classical teaching dictates caution in their presence but this raises a false alarm in many cases. Formal studies looking at these features are few. The aim of this article was to study quantitatively those features that provide a better prediction of malignancy. METHODS: Clinical records of 186 consecutive patients treated for parotid tumours over a 12-year period were reviewed. Presence of suspicious clinical features and the final histology in each patient were noted. RESULTS: The overall pick-up rate for malignancy, based on clinical features alone, was around 30%. Palpable cervical lymph nodes, facial nerve palsy, deep fixation and rapid enlargement of the tumour were significant parameters indicative of malignancy (p = 0.000 for all 4 parameters, chi-squared test). The risk of malignancy increased when multiple parameters were present together at the same time. CONCLUSION: Clinical features remained the most important single modality identifying malignancy in patients with parotid tumours. The logistic regression model allowed for simple clinical prediction of malignancy with improved sensitivity and much better specificity.     

Enucleated parotid tumours

Five pleomorphic, one monomorphic adenoma and one acinic cell lower pole parotid tumours were thought to be lymph nodes and enucleated. Wide excision of the operative site within 2 months revealed microscopic recurrence in three cases. Three carcinomas were enucleated and two had recurred rapidly. It is suggested that such cases of inadvertent enucleation should undergo wide resection of the operative site with nerve dissection.     

Malignant epithelial parotid tumours

Formal parotidectomy was performed in 120 patients by one surgeon over 7 years. Eighteen patients were referred with malignant salivary tumours (eight recurrent). Low-grade tumours (LGT) were treated by surgery alone; untreated high-grade tumours (HGT) were treated by pre- or post-operative radiotherapy according to clinical findings. The aim of surgery was to obtain tumour clearance, to preserve the facial nerve where possible, and to perform radical neck dissection for HGT when peroperative jugulodigastric lymph node biopsy confirmed metastasis. Five patients (all HGT) with complete facial palsy due to tumour underwent radical parotidectomy; of the remainder, only one suffered further deterioration of facial nerve function after surgery. After 5 years median follow-up from presentation, four patients with HGT have died from metastases; one has developed local recurrence. No patient with LGT has died or developed local recurrence. The survival difference between patients with HGT and LGT is statistically significant (P less than 0.05). A logical management policy for malignant parotid tumours requires knowledge of tumour grade.     

Surgical approach to pineal tumours

During a period of 10 years (1977-1986) 40 cases of tumour of the pineal region have been treated at the Istituto Neurologico "C. Besta"-of Milan. Out of these 40 cases, 27 (67.5%) were in the paediatric (10-15 years) or juvenile (15-20 years) age at the time of operation. Since 1983 a specific diagnostic and therapeutic protocol has been adopted and thereafter direct surgical removal of the tumour was performed only when the neuroradiological investigations were highly suggestive of a benign extrinsic lesion. Sixteen cases in this series underwent direct surgical removal; in the remaining 24 cases stereotactic biopsy of the tumour was performed in the first instance. On the basis of the histological diagnosis obtained by this procedure surgical excision of the tumour (9 cases) or radiotherapy (15 cases) was then performed. 25 cases underwent surgical removal of the lesion. In all the cases the infratentorial supracerebellar approach as introduced by Krause and then modified by Stein was adopted. On analysis of the data of this series it was observed that in 25% of the cases completely benign resectable tumours were found; in 25% of the cases astrocytoma (grade I-II) which could be treated at least by partial removal were present; in 30% of the cases radiosensitive lesions were encountered. In the remaining 20% of the cases highly malignant tumours were found which should be treated only by radiotherapy and/or chemotherapy.     

Metastatic tumours of the parotid region

Metastatic disease in the parotid gland and its associated lymph nodes is generally thought to be uncommon. A review of 121 cases was undertaken to study the incidence, histology and prognosis of secondary malignancy in the parotid region. Forty-two per cent of the cases were secondary malignancies. The majority of these were squamous cell carcinoma, and in this group the prognosis was poor.     

Surgical approach to retromandibular parotid tumors.

Because of the anatomy of the deep lobe of the parotid and its restrictive boundaries, retromandibular tumors may be asymptomatic until reaching massive size. Removal by an intraoral approach may be not only disappointing but also disastrous, with disintegration of the tumor and generalized spillage in the wound. Our experience suggests that the best approach to any type of tumor in this region is through the upper lateral cervical tissues with consideration of a mandibular osteotomy if the tumor extends into the retropharynx or the nasopharynx. This review of 12 patients who required osteotomy describes a high success rate with minimal complications.     

Thoraco-abdominal approach to large retroperitoneal tumours

OBJECTIVES: To evaluate the thoraco-abdominal approach for resection of retroperitoneal tumours, as this approach is rarely used because, although exposure is excellent, morbidity is presumed to be increased. PATIENTS AND METHODS: From October 2003 to September 2005, 21 patients (six female, 15 male), aged 14-76 years, underwent resection of very large and/or T4 retroperitoneal tumours through a thoraco-abdominal approach. RESULTS: In 16 (76%) patients tumour resection was complete. There were no significant complications during surgery. After surgery, there were complications in six patients (29%), in four of whom there was no long-term impairment. One patient died at 75 days after surgery from a complicated retroperitoneal haematoma. The mean (range) estimated blood loss was 2883 (50-20 000) mL, the intensive-care unit stay was 3.85 (0-30) days and the intermediate-care unit stay 2.6 (0-9) days. With a mean follow-up of 9.6 (1-19) months, 15 patients (72%) are recurrence-free, two (10%) have progressive disease, and four (19%) have died from malignancy. CONCLUSIONS: The thoraco-abdominal approach permits excellent exposure of the retroperitoneum for large and/or T4 tumours, allowing radical surgery in cases considered otherwise inoperable. Additional advantages are the possibilities of early vascular control and easy surgical extension of the procedure. These facts, combined with the reasonable morbidity found in our series, support the integration of the thoraco-abdominal approach in the regular options for urological surgery.     

Elastosis in malignant tumours

Elastosis is common in infiltrating ductal and lobular carcinomas of the breast, occurring in approximately 90% of cases. It is also well described in some benign lesions of the breast and tumours of the salivary gland. Reports of venous elastosis in association with large-bowel carcinomas are rare. We describe elastosis in single cases of prostatic, gastric, bronchiolar-alveolar and cervical carcinoma.     

An experimental approach to specific adoptive immunotherapy for malignant brain tumors

With the aid of interleukin 2 (IL-2), two phenotypically different cytotoxic T lymphocyte (CTL) clones were established with target specificity against syngeneic murine malignant brain tumor (a methylcholanthrene-induce ependymoblastoma of C57BL/6 mouse origin, 203-glioma). Furthermore, the cloned CTL lines were characterized in vitro, and their in vivo effectiveness was investigated by intracerebral (i.c.) tumor neutralization assay and adoptive immunotherapy with the clones for i.c. tumor-bearing mice. Each CTL clone retained an IL-2 dependency with a defined functional activity. G-CTLL 1 with a phenotype of Lyt-1-.2.3+ exhibited a target cytotoxicity against 2 kinds of murine glioma cells, syngeneic 203-glioma and allogeneic RSV-M glioma (Schmitt-Ruppin rous sarcoma virus-induced malignant astrocytoma). It is noted that G-CTLL 1 cells produced gamma interferon (IFN) by stimulation with glioma antigens. The spontaneous release of gamma IFN paralleled the amounts of exogenous IL-2 added into the cultures, but IL-2 had no synergistic effects on IFN release in the presence of tumor antigens. Furthermore, by adding anti-mouse gamma IFN antibody, the IFN production of G-CTLL 1 cells was inhibited but their lytic potential was hardly reduced in vitro. In contrast, G-CTLL 2 cells expressed a cell surface phenotype of Lyt-1+.2.3+ with more restricted target specificity against only syngeneic 203-glioma cells, although they showed a weaker cytotoxicity than G-CTLL 1 cells and no release of gamma IFN. The in vivo therapeutic efficacy using G-CTLL 1 cells was confirmed in both adoptive immunotherapy and tumor neutralization assays.(ABSTRACT TRUNCATED AT 250 WORDS)     

Superficial parotidectomy as first choice for parotid tumours

Parotid neoplasms represent 3% of all head and neck tumours, and most are benign. Malignant tumours account for 14-25% of cases. Surgery is the treatment of choice, with options ranging from simple enucleation to radical parotidectomy. Sixteen patients presented with a history of a painless parotid lump. Diagnosis was achieved by ultrasound scan and MRI. Fifteen superficial parotidectomies and 1 nerve-sparing total parotidectomy were carried out. At histology, 10 pleomorphic adenomas, 4 Warthin's tumours, 1 lymphoepithelial cyst and 1 sebaceous adenocarcinoma were detected. In the single case of carcinoma, the 6 peri-glandular lymph nodes included in the specimen were metastasis-free. In 3 patients (20%) a transient paresis of the facial nerve was noted. The capsule appeared breached in only 1 case of pleomorphic adenoma. Four patients (26%) were diagnosed as suffering from Frey's syndrome. A salivary fistula was recorded in 2 patients (13%). During follow-up ranging from 3 to 96 months no tumour recurrence was recorded. Superficial parotidectomy seems to be the best choice of treatment for benign parotid tumours, since it allows complete excision of the tumour with sparing of the facial nerve. A radical procedure is, however, needed if malignancy is confirmed at frozen section.     

True malignant mixed tumor of parotid

Carcinosarcoma is a rare malignant neoplasm of salivary glands that manifests both carcinomatous and sarcomatous components. Specimen of a recurrent parotid tumor of a 55-year-old male was received for histopathology. Diagnosis of a biphasic malignant neoplasm was made. Morphology and immunohistochemical profile were consistent with carcinosarcoma i.e. true malignant mixed tumor.