Primary Squamous Cell Robert K.
Carcinoma of the Parotid Gland
Gaughan, MD; Kerry D. Olsen, MD; Jean
We reviewed all cases of possible primary squamous cell carcinoma of the parotid gland treated at Mayo Clinic, Rochester, Minn, from 1960 through 1988. Eighteen cases of primary squamous cell carcinoma ofthe parotid gland were identified. We report the clinical behavior and results of treatment of these rare parotid gland neoplasms. The age at diagnosis ranged from 48 to 86 years; the majority of patients were aged 65 years or older. Half of the patients presented with an asymptomatic parotid gland mass; a painful mass occurred in 33% of patients. Facial paralysis was noted in 17%, and a neck mass was the presenting symptom in 11% of patients. All patients underwent parotidectomy, and all or part of the facial nerve was sacrificed in 66% of patients. A neck dissection was performed in 12 patients, five of whom had pathologic confirmation of neck metastasis. Adjunctive radiation therapy was performed in 55% of patients. The overall survival at 5 years was 50%. Deep fixation and facial nerve paralysis were associated with a poor prognosis. Most recurrences developed within 1 year of initial treatment. Regional recurrence was always associated with a rapid death. Our data suggest that aggressive treatment and early detection may result in a better prognosis than is commonly associated with these tumors. (Arch Otolaryngol Head Neck Surg. 1992;118:798-801) \s=b\
carcinoma (SCC) originating in the pa¬ is a rare occurrence. The frequency of pri¬ parotid gland is between only 0.3% and mary 4.3%.1"6 These tumors are frequently associated with a rapid death.6-7 Metastatic SCC and mucoepidermoid carci¬ noma must be excluded to make the diagnosis of primary SCC of the parotid gland.5-8*11 Herein, we review the clin¬ ical behavior and treatment results in patients with pri¬ mary SCC of the parotid gland treated at our institution.
cell rotid gland Squamous SCC of the
MATERIALS AND METHODS All cases of possible primary SCC of the parotid gland treated at the Mayo Clinic, Rochester, Minn, between 1960 and 1988 were studied retrospectively. Fifty-eight cases were identified and re¬ viewed in detail. Our inclusion criteria for primary SCC of the pa¬ rotid gland included the following: (1) no history of SCC of the ip¬ silateral scalp, forehead, eyelid, cheek, or auricular skin area during the preceding 5 years and (2) identification of mucoepidermoid car¬ cinoma and other malignant neoplasms by mucin stains and other histologie analysis. Cases were excluded if the following findings were present: (1) evidence of parotid gland invasion from an over¬
lying cutaneous structure and (2) SCC confined to an intraparotid gland node or subsequent identification of a primary tumor of the head or neck compatible with parotid gland metastasis. An extensive histologie analysis of all specimens was performed
publication April 8, 1992. Department of Otorhinolaryngology (Drs Gaughan and Olsen) and the Section of Surgical Pathology (Dr Lewis), Mayo Clinic and Mayo Foundation, Rochester, Minn. Presented at the annual meeting of the American Society for Head and Neck Surgery, Waikoloa, Hawaii, May 9, 1991. Reprint requests to the Department of Otorhinolaryngology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Dr Olsen).
Accepted
From the
for
E. Lewis, MD
by one of us (J.E.L.), and all specimens were specifically stained to
detect the presence of mucin. After review, 40 cases (69%) were elim¬ inated. The tumors proved to be metastatic, a result of direct inva¬ sion from skin or oral mucosa, or of a different histologie type. The 18 cases that fulfilled our criteria are the basis for this report. Staging was done according to the current guidelines established by the American Joint Committee on Cancer (Table 1 ).'2 Statistical data were generated with the Kaplan-Meier Product-Limit Method.
Clinical Features
patients, 16 were male and two were female. The age diagnosis ranged from 48 to 86 years (mean, 68 years). Eleven pa¬ tients (61 %) were aged 65 years or older. Sufficient information was available to allow clinical staging in 16 patients; stage I disease was present in eight patients, stage II disease in one patient, stage III dis¬ ease in six patients, and stage IV disease in one patient. Only one patient had received prior irradiation to the parotid gland area (2000 cGy to a parotid gland mass 18 years earlier). Data were insufficient Of the 18
at
assess tobacco and alcohol consumption as causative factors. The initial complaint in 15 patients was the presence of a parotid gland mass. Six patients (33%) with a parotid gland mass experi¬ enced pain, and nine masses (50%) were asymptomatic. Two pa¬ tients (11%) initially presented with the complaint of a neck mass; one of these patients was noted to also have a parotid gland mass on physical examination, and the other patient had an incidental finding of diffuse SCC of the parotid gland at the time of excision of a large thyroid adenoma (the patient's presenting complaint). Three patients first noted facial paralysis (17%), which was found to be complete in all three patients on physical examination (two in conjunction with a painful parotid gland mass and one with a firm, fixed parotid gland prompting exploration of the gland). The tumors were equally divided between the right and left sides. A discrete mass was palpable in 16 patients: 12 tumors were firm, and four were believed to be fixed to deep structures. The overlying skin was not grossly involved in any case. Two patients had clin¬ ically palpable neck masses (one Nl and one N2a) and a palpable parotid gland mass. Clinical findings are summarized in Table 2.
to
Treatment The initial treatment in five
patients was radical parotidectomy
(removal of the parotid gland and facial nerve). Total parotidectomy
with partial excision of the facial nerve was performed in five pa¬ tients. One patient underwent a superficial parotidectomy with par¬ tial excision of the facial nerve. Total parotidectomy and superficial parotidectomy with facial nerve preservation were performed in four and two patients, respectively. Radiation therapy was per¬ formed initially in one patient in accordance with that patient's wishes. A summary of the treatments is shown in Table 3. Complete tumor removal was believed to be accomplished in 16 patients. Two patients with persistent disease postoperatively had unresectable disease due to extensive deep lobe tumor. In 12 patients, a neck dissection was also performed during the initial operation (Table 3). Of these 12 patients, five (42%) had patho¬ logic confirmation of neck metastasis (two had clinically positive metastasis and three had occult metastasis). Therefore, 30% of the patients with no palpable cervical metastasis who underwent a neck dissection had detectable metastatic disease. Planned postoperative radiation therapy was performed in nine patients; six of whom underwent a preceding neck dissection. The radiation dose to the parotid gland and neck regions ranged from 1512 to 15139 cGy.
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RESULTS Cancer recurred in seven of 16 patients (two of the total 18 patients had persistent disease). Local recurrence was found in five patients. The local recurrence developed within 1 year of initial treatment in four patients and at 2 years in one pa¬ tient. Two patients showed no evidence of disease more than 5 years after treatment of their recurrent disease; both had had recurrence at 7 months (one was treated with radiation and the other with wide local excision). Both patients have since died of other causes with no evidence of recurrent pa¬ rotid gland disease. Three patients died of their disease within 2 years of local recurrence: two had no further treat¬ ment because of their age and extensive recurrent disease (one had recurrence at 6 months and one at 2 years), and the remaining patient was initially treated with radiation, sufTable 1.—Clinical Staging in Primary Squamous Cell Carcinoma of the Parotid Gland*
Stage
Primary Tumor
I
Tía T2a
II
Tib T2b T3a T3b T4a
III
Any IV
T4b
Regional NO NO NO NO NO NO NO N1
(except T4b)
Any
Any Any
Nodes
Distant Metastasis MO MO MO MO MO
MO MO MO MO MO
N2, N3 Ml Any *T1 indicates tumor less than 2 cm; T2, tumor greater than 2 cm but less than 4 cm; T3, tumor greater than 4 cm but less than 6 cm; T4, tu¬ mor greater than 6 cm; a, no local extension; b, local extension; NO, no regional lymph node metastasis; NI, metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension; N2, metastasis in a sin¬ gle ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or metastasis in multiple ipsilateral lymph nodes, not
more than 6 cm in greatest dimension, or metastasis in bilateral or con¬ tralateral lymph nodes, not more than 6 cm in greatest dimension; N3, metastasis in a lymph node more than 6 cm in greatest dimension; MO, no distant metastasis; and M1, distant metastasis present. Data are from the American Joint Committee on Cancer.12
Table 2.—Clinical Features in 18 Patients With
Case/Sex/Age, 1/F/65t
y
Clinical
Stage
fered a recurrence after 11 months, and died 2 years after wide local excision of the recurrent tumor. Regional recurrence was noted in two patients. These two patients had previously undergone a neck dissection with pathologic confirmation of neck metastasis (one clinical and one occult). One received postoperative radiation therapy. Both had regional recurrences within 6 months of initial treatment and underwent excision of the recurrence. Both died of their disease within 1 year of recurrence. Sex, age greater than 65 years, cervical metastasis, pain, facial nerve paralysis, deep fixation, and stage of disease were all evaluated for statistical significance as prognostic findings. Deep fixation and seventh nerve paralysis were the only statistically significant factors adversely affecting sur¬ vival evident in our study population (P
Carcinoma of the Parotid Gland
Gaughan, MD; Kerry D. Olsen, MD; Jean
We reviewed all cases of possible primary squamous cell carcinoma of the parotid gland treated at Mayo Clinic, Rochester, Minn, from 1960 through 1988. Eighteen cases of primary squamous cell carcinoma ofthe parotid gland were identified. We report the clinical behavior and results of treatment of these rare parotid gland neoplasms. The age at diagnosis ranged from 48 to 86 years; the majority of patients were aged 65 years or older. Half of the patients presented with an asymptomatic parotid gland mass; a painful mass occurred in 33% of patients. Facial paralysis was noted in 17%, and a neck mass was the presenting symptom in 11% of patients. All patients underwent parotidectomy, and all or part of the facial nerve was sacrificed in 66% of patients. A neck dissection was performed in 12 patients, five of whom had pathologic confirmation of neck metastasis. Adjunctive radiation therapy was performed in 55% of patients. The overall survival at 5 years was 50%. Deep fixation and facial nerve paralysis were associated with a poor prognosis. Most recurrences developed within 1 year of initial treatment. Regional recurrence was always associated with a rapid death. Our data suggest that aggressive treatment and early detection may result in a better prognosis than is commonly associated with these tumors. (Arch Otolaryngol Head Neck Surg. 1992;118:798-801) \s=b\
carcinoma (SCC) originating in the pa¬ is a rare occurrence. The frequency of pri¬ parotid gland is between only 0.3% and mary 4.3%.1"6 These tumors are frequently associated with a rapid death.6-7 Metastatic SCC and mucoepidermoid carci¬ noma must be excluded to make the diagnosis of primary SCC of the parotid gland.5-8*11 Herein, we review the clin¬ ical behavior and treatment results in patients with pri¬ mary SCC of the parotid gland treated at our institution.
cell rotid gland Squamous SCC of the
MATERIALS AND METHODS All cases of possible primary SCC of the parotid gland treated at the Mayo Clinic, Rochester, Minn, between 1960 and 1988 were studied retrospectively. Fifty-eight cases were identified and re¬ viewed in detail. Our inclusion criteria for primary SCC of the pa¬ rotid gland included the following: (1) no history of SCC of the ip¬ silateral scalp, forehead, eyelid, cheek, or auricular skin area during the preceding 5 years and (2) identification of mucoepidermoid car¬ cinoma and other malignant neoplasms by mucin stains and other histologie analysis. Cases were excluded if the following findings were present: (1) evidence of parotid gland invasion from an over¬
lying cutaneous structure and (2) SCC confined to an intraparotid gland node or subsequent identification of a primary tumor of the head or neck compatible with parotid gland metastasis. An extensive histologie analysis of all specimens was performed
publication April 8, 1992. Department of Otorhinolaryngology (Drs Gaughan and Olsen) and the Section of Surgical Pathology (Dr Lewis), Mayo Clinic and Mayo Foundation, Rochester, Minn. Presented at the annual meeting of the American Society for Head and Neck Surgery, Waikoloa, Hawaii, May 9, 1991. Reprint requests to the Department of Otorhinolaryngology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Dr Olsen).
Accepted
From the
for
E. Lewis, MD
by one of us (J.E.L.), and all specimens were specifically stained to
detect the presence of mucin. After review, 40 cases (69%) were elim¬ inated. The tumors proved to be metastatic, a result of direct inva¬ sion from skin or oral mucosa, or of a different histologie type. The 18 cases that fulfilled our criteria are the basis for this report. Staging was done according to the current guidelines established by the American Joint Committee on Cancer (Table 1 ).'2 Statistical data were generated with the Kaplan-Meier Product-Limit Method.
Clinical Features
patients, 16 were male and two were female. The age diagnosis ranged from 48 to 86 years (mean, 68 years). Eleven pa¬ tients (61 %) were aged 65 years or older. Sufficient information was available to allow clinical staging in 16 patients; stage I disease was present in eight patients, stage II disease in one patient, stage III dis¬ ease in six patients, and stage IV disease in one patient. Only one patient had received prior irradiation to the parotid gland area (2000 cGy to a parotid gland mass 18 years earlier). Data were insufficient Of the 18
at
assess tobacco and alcohol consumption as causative factors. The initial complaint in 15 patients was the presence of a parotid gland mass. Six patients (33%) with a parotid gland mass experi¬ enced pain, and nine masses (50%) were asymptomatic. Two pa¬ tients (11%) initially presented with the complaint of a neck mass; one of these patients was noted to also have a parotid gland mass on physical examination, and the other patient had an incidental finding of diffuse SCC of the parotid gland at the time of excision of a large thyroid adenoma (the patient's presenting complaint). Three patients first noted facial paralysis (17%), which was found to be complete in all three patients on physical examination (two in conjunction with a painful parotid gland mass and one with a firm, fixed parotid gland prompting exploration of the gland). The tumors were equally divided between the right and left sides. A discrete mass was palpable in 16 patients: 12 tumors were firm, and four were believed to be fixed to deep structures. The overlying skin was not grossly involved in any case. Two patients had clin¬ ically palpable neck masses (one Nl and one N2a) and a palpable parotid gland mass. Clinical findings are summarized in Table 2.
to
Treatment The initial treatment in five
patients was radical parotidectomy
(removal of the parotid gland and facial nerve). Total parotidectomy
with partial excision of the facial nerve was performed in five pa¬ tients. One patient underwent a superficial parotidectomy with par¬ tial excision of the facial nerve. Total parotidectomy and superficial parotidectomy with facial nerve preservation were performed in four and two patients, respectively. Radiation therapy was per¬ formed initially in one patient in accordance with that patient's wishes. A summary of the treatments is shown in Table 3. Complete tumor removal was believed to be accomplished in 16 patients. Two patients with persistent disease postoperatively had unresectable disease due to extensive deep lobe tumor. In 12 patients, a neck dissection was also performed during the initial operation (Table 3). Of these 12 patients, five (42%) had patho¬ logic confirmation of neck metastasis (two had clinically positive metastasis and three had occult metastasis). Therefore, 30% of the patients with no palpable cervical metastasis who underwent a neck dissection had detectable metastatic disease. Planned postoperative radiation therapy was performed in nine patients; six of whom underwent a preceding neck dissection. The radiation dose to the parotid gland and neck regions ranged from 1512 to 15139 cGy.
Downloaded From: http://archotol.jamanetwork.com/ by a University of Calgary User on 05/25/2015
RESULTS Cancer recurred in seven of 16 patients (two of the total 18 patients had persistent disease). Local recurrence was found in five patients. The local recurrence developed within 1 year of initial treatment in four patients and at 2 years in one pa¬ tient. Two patients showed no evidence of disease more than 5 years after treatment of their recurrent disease; both had had recurrence at 7 months (one was treated with radiation and the other with wide local excision). Both patients have since died of other causes with no evidence of recurrent pa¬ rotid gland disease. Three patients died of their disease within 2 years of local recurrence: two had no further treat¬ ment because of their age and extensive recurrent disease (one had recurrence at 6 months and one at 2 years), and the remaining patient was initially treated with radiation, sufTable 1.—Clinical Staging in Primary Squamous Cell Carcinoma of the Parotid Gland*
Stage
Primary Tumor
I
Tía T2a
II
Tib T2b T3a T3b T4a
III
Any IV
T4b
Regional NO NO NO NO NO NO NO N1
(except T4b)
Any
Any Any
Nodes
Distant Metastasis MO MO MO MO MO
MO MO MO MO MO
N2, N3 Ml Any *T1 indicates tumor less than 2 cm; T2, tumor greater than 2 cm but less than 4 cm; T3, tumor greater than 4 cm but less than 6 cm; T4, tu¬ mor greater than 6 cm; a, no local extension; b, local extension; NO, no regional lymph node metastasis; NI, metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension; N2, metastasis in a sin¬ gle ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or metastasis in multiple ipsilateral lymph nodes, not
more than 6 cm in greatest dimension, or metastasis in bilateral or con¬ tralateral lymph nodes, not more than 6 cm in greatest dimension; N3, metastasis in a lymph node more than 6 cm in greatest dimension; MO, no distant metastasis; and M1, distant metastasis present. Data are from the American Joint Committee on Cancer.12
Table 2.—Clinical Features in 18 Patients With
Case/Sex/Age, 1/F/65t
y
Clinical
Stage
fered a recurrence after 11 months, and died 2 years after wide local excision of the recurrent tumor. Regional recurrence was noted in two patients. These two patients had previously undergone a neck dissection with pathologic confirmation of neck metastasis (one clinical and one occult). One received postoperative radiation therapy. Both had regional recurrences within 6 months of initial treatment and underwent excision of the recurrence. Both died of their disease within 1 year of recurrence. Sex, age greater than 65 years, cervical metastasis, pain, facial nerve paralysis, deep fixation, and stage of disease were all evaluated for statistical significance as prognostic findings. Deep fixation and seventh nerve paralysis were the only statistically significant factors adversely affecting sur¬ vival evident in our study population (P
