Metastatic melanoma of the parotid lymph nodes

Metastatic melanoma of the parotid lymph nodes

R. A. Ord Department of Oral and Maxillofacial Surgery, Sunderland District Hospital, Kayll Road, Sunderland, UK

R. A. Ord: Metastatic melanoma of the parotid lymph nodes. Int. J. Oral Maxillofac. Surg. 1989; 18." 165-167. Abstract. A case of primary m e l a n o m a o f the neck with lymph node metastasis of the parotid gland is reported. M a n a g e m e n t o f head and neck melanoma, b o t h primary and metastatic to parotid and cervical nodes is reviewed.

The parotid gland contains lymphoid tissue, both as lymph nodes and as aggregations o f lymphocytes. The parotid lymph nodes drain the scalp, face, external ear, eyelid, external nose, lacrimal gland, paranasal sinuses, nasopharynx and o r o p h a r y n x 4. Virtually all the metastases to the parotid nodes arise from Primary skin cancers o f the face and neck and are usually melanomas (45.7%), or squamous cell carcinomas (37%) 9. Metastases from squamous cell carcinomas o f the facial skin is uncomm o n and unpredictable. LBB et al. 17 found the ear to be the c o m m o n e s t primary site, while MENDENHALL et al. 18 found the temple to be the most frequently involved. Melanomas metastasizing to the parotid lymph nodes are usually f r o m similar skin sites 7. Occasionally, however, the primary site o f malignant m e l a n o m a may be unknown 23. A m e l a n o m a of the neck metastasizing to the parotid gland is reported. The m a n a g e m e n t of head and neck m e l a n o m a is reviewed. Case report

A 52-year-old Caucasian man was referred by the Dermatology Department to the Department of Oral and Maxillofacial Surgery in November 1986. The patient gave a 5-year history of a lesion on the right neck which had gradually expanded. Initially it was uniformly pigmented. Later the center of the lesion began to depigment and "clear up". 1 year prior to presentation, he had noticed a nodule appear at the centre and 10 weeks prior to presentation, a lump behind his right ear. Examination revealed a circular lesion 18 x 18 mm in the posterior neck, 3 cm'behind the ear, with areas of pigmentation and depigmentation with a nodular centre 4 x 4 mm raised 3 mm above the skin (Fig. 1).

Key words: melanoma; lymph node metastasis; parotid gland. Accepted for publication 12 November 1988

There was an obvious parotid swelling with a discrete mass 1.5 x 1.5 cm palpable in the retromandibular region. There was no cervical or axillary lymphadenopathy and his liver edge was just palpable. Investigations included full blood count, urea and electrolytes, liver function tests, chest X-ray and liver ultrasound. The results of these tests were all within normal limits. He was admitted to the hospital. The lesion was excised with a 5 cm margin, and an incontinuity radical neck dissection with extended posterolateral neck clearance and total parotidectomy with sacrifice of the facial nerve was carried out (Fig. 2). A tarsorrhaphy was performed and the primary defect repaired with a split skin graft. Post-operatively, the patient made a good recovery and was discharged 10 days later. " Histological examination showed a nodular malignant melanoma involving the underlying dermis to a depth of 2.7 mm measured from the granular layer (Clark level IV). There was metastatic tumour in 2 of the parotid nodes; a further 24 regional cervical nodes examined were tumour free. The patient was reviewed regularly and some 4 months later, he started to complain of increasingly severe pain in his chest and sides. Initially, the pains were in the left chest and thigh, but later located between the shoulder blades, the pain being severe, constant and cramping. Plain radiographs of the chest and spine were not helpful. Liver function tests, however, showed an alkaline phosphatase of 680 (Normal range 110-295) and AIt.S.G. E T. of 87 (0-25 Normal range). A provisional diagnosis of bony metastases was made and an isotope bone scan performed. This confirmed the presence of metastatic disease in the thoracic spine, left and right ribs, sacro-iliac region and left femur. A single course of palliative radiotherapy to the spine was given with little success. He died 1 month later.

ly doubling in the last 20 years, a trend which has been evident for 35-40 years 1°,12,14. Approximately 20% of all melanomas occur in the head and neck 12'22. Prognosis is closely related to depth o f invasion or thickness of the primary tumour. This may be measured by Clark's level of invasion, which classifies depth of invasion using normal histological landmarks in the skin 8. The risk o f dying varies from 0% in level 1 to 90% for level V. Accurate assessment of Clark's level, however, is not always possible in skins that may be altered by excessive solar exposure. BRESLOW& MACHT'S6 method o f direct measurement o f t u m o u r thickness overcomes this problem. Thin lesions with a good

Discussion

Fig. 1. Lateral view to show post-auricular melanoma. The patient's hair has been shaved post-operatively to allow access for postero-lateral neck dissection.

The incidence o f m e l a n o m a world-wide is increasing dramatically, approximate-

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Fig. 2. Resection specimen to show excised primary melanoma with 5 cm margin. Note (a) indicates postero-lateral contents, (b) indicates parotid and (c) submandibular region.

prognosis should be less than 0.75 ram, intermediate lesions 0.76 tom-1.5 mm and thick lesions greater than 1.5 ram. BRESLOW & MACHT6 also found that lesions with a large surface area have a worse prognosis. The site of the primary lesion also has prognostic significance. Patients with melanoma of the head and neck have a worse survival than those with melanomas of the limbs, but better than patient's with melanomas of the trunk 12. Within the head and neck, ROUTLEDGE22found the scalp and neck to be the least favourable primary sites, a finding confirmed by UR~ST et al. 27. Earlier work by DAY et al. 13had already given rise to the BANS concept that lesions of the upper back, upper posterior arms, posterior neck and posterior scalp (BANS) had a significantly worse survival than lesions of similar thickness in other primary sites. This concept, however, has been questioned and not corroborated 29. Melanomas of the head and neck may be classified as lentigo maligna, lentigo maligna melanoma, superficial spreading melanoma or nodular melanoma. The lentigo maligna (Hutchinson's freckle) is non-invasive and has an excellent prognosis, while the nodular melanoma is the most deeply invasive. Incisional biopsy is contra-indicated and frozen section may be difficult to interpret by a non-specialist pathologist. Therefore, if the diagnosis is in doubt, or when disfiguring surgery is contemplated, initial treatment by exci-

sion biopsy with a 1 cm margin with urgent paraffin section is recommended. This allows further wider excision within 48 h if indicated. The excision biopsy does not appear to compromise radical excision after 48 h. In the case reported, no doubt existed about the diagnosis, so excision biopsy was not carried out. The 5 cm margin advocated for excision of melanomas of the limbs and trunk is obyiously difficult to apply in the facial skin. Fortunately, lentigo maligna can be excised with margins of 5 mm and lentigo maligna melanoma appears to require a 1 cm margin. Thin lesions (Breslow thickness less than 0.75 ram) can be excised with a clearance of 1 cm 6. In thicker lesions, there is more controversy. ROUTLEDGE22 advocating a 1-3 cm margin and StmN & MYERS26a 2-5 cm margin. In the reported case, a 5 cm margin was thought advisable in view of the nodular component. Where cervical nodes are involved, most authors have advocated radical neck dissection, although more recently modified neck dissections have been proposed 7. It should be noted, however, that primary skin tumours of the posterior neck or scalp may drain to lymph nodes outside the boundaries of a conventional neck dissection. In the present case, a postero-lateral neck dissection, to encompass the retro-auricular and sub-occipital nodes 16,21, was carried out in continuity with a classical radical

neck dissection. In dealing with parotid nodes involved by melanoma, most authors advocate superficial parotidectomy, with preservation of the facial nerve 25. However, BAKER2 reported recurrence with melanoma treated by superficial parotidectorny and suggested total parotidectomy, with sacrifice of the facial nerve if there was a bulky mass within the gland. Melanoma may present with a mass in the parotid gland, as an initial finding with no obvious primary lesion. There are 2 possible explanations; either the melanoma represents a secondary deposit from an unknown primary, or has arisen as a primary tumour of the parotid gland. Certainly parotid involvement from an unknown primary melanoma is well described in the literature 2°,23. This may be explained by metastasis from either an occult primary in an inaccessible site, e,g., the paranasal sinuses, or by autoimmune destruction of the original primary turnout. Interestingly, melanoma of unknown primary site, presenting as a cervical or parotid node, is said to have a better prognosis than where the primary site has been identified24. Alternatively, the melanoma could have arisen as a primary parotid lesion. GREEN & BERNIER15 demonstrated that the parotid gland contained melanoblasts, and reported 5 cases of primary melanoma of the parotid. In addition to the demonstration of melanoblasts in the normal parotid tissue, their criteria for primary melanoma were the presence of malignant melanoma in the parotid and the inability to demonstrate another primary site. These authors also noted that primary parotid melanomas were not located in lymph nodes, but were infiltrative and poorly demarcated. Controversy surrounds the elective treatment of clinically negative nodes in melanoma. Certainly elective node dissection has not been shown to be indicated in melanoma of the limb in a prospective controlled study 28. In the head and neck for early melanoma i.e., Clark levels I or II, and thin Breslow lesions, there is no evidence of better prognosis with prophylactic dissection. ROUTLEDGE22, AMES et a D WOODS et al. 29

found no benefit from prophylactic dissection, regardless of thickness of the primary lesion. However, BALCn et a l ? have presented results supporting the use of elective dissections for intermediate thickness lesions. Other authors advocate prophylactic dissection for thick

Metastatic melanoma Breslow lesions 19. A t present, this aspect o f t r e a t m e n t is unresolved. A l t h o u g h surgery is the t r e a t m e n t o f choice for m e l a n o m a , o t h e r modalities have been used. M e l a n o m a is relatively radio-resistant, b u t does r e s p o n d to high f r a c t i 6 n a t i o n radiotherapy. R a d i o t h e r a p y is useful to palliate p a i n f r o m b o n e metastases. C h e m o t h e r a p y has so far n o t p r o v e n useful in the t r e a t m e n t o f m e l a n o m a . Because o f the m a r k e d i m m u n e r e s p o n s e the disease produces, high h o p e s were entertained for i m m u notherapy, s t i m u l a t i n g the b o d y ' s imm u n e system to destroy the tumour. A t the present time, these hopes h a v e n o t been realised. References 1. Ames, F. C., Sugarbaker, E. V. & Ballantyne, A. J.: Analysis of survival and disease control in Stage I melanoma of the head and neck. Am. J. Surg. 1976: 132: 484-491. 2. Baker, H. W.: In discussion section of Storm, K. F. et al. A prospective study of parotid metastases from head and neck cancer. Am. J. Surg. 1977: 134: 115-119. 3. Balch, C. M., Urist, M. M., Maddox, W A. & Soong, S. J.: Melanoma in the Southern United States: experience at the University of Alabama in Birmingham. In: Cutaneous melanoma, Balch, C. M. and Milton, G. W. (eds.): Philadelphia, J. B. Lippincott, 1985: 397-406. 4. Batsakis, J. G.: Tumours of the head and neck, clinical and pathological considerations, 2nd edsition. Baltimore: Williams and Wilkins 1979: 177-187. 5. Breslow, A.: Thickness, cross sectional areas and depths of invasion in the prognosis of cutaneous melanoma. Ann. o f Surg. 1970: 172: 902-908. 6. Breslow, A. & Macht, S. D.: Optimum size of resection margin for thin cutaneous melanoma. Surg. Gynaecol. Obst. 1977: 145: 69-75. 7. Byers, R. M.: The r61e of modified neck dissection in the treatment of cutaneous of the head and neck. Arch. of Surg. 1986: 121: 1338-1341.

8. Clark, W. H. Jr., From, L., Bernadino, E. A. & Mihm, M. C.: The histogenesis and biologic behaviour of primary human malignant melanomas of the skin. Cancer Research 1969: 29: 705-710. 9. Conley, J. & Arena, S.: Parotid gland as a focus for metastasis. Arch. of Surg. 1963: 87: 757-764. 10. Cosman, B., Heddle, S. B. & Crikelar, G. E: The increasing incidence of melanoma. Plast. Reeonstr. Surg. 1976: 57: 5O-56. 11. Davis, N. C.: Cutaneous melanoma. The Queensland experience. Curr. Probl. Surg. 1976: 13: 1-63. 12. Davis, N. C., McLeod, R., Beardmore, J. C., Little, J. H., Quinn, R. L. & Holt, J.: Primary cutaneous melanoma: a report from the Queensland melanoma project. C.A. 1976: 26: 80-107. 13. Day, C. L., Mihm, M.C., Sober, A. J., Harris, M. N., Kopf, A. W., Fitzpatric, B. T., Low, R. A., Harrist, T. J., Golomb, F. B., Postel, A., Hennesey, E, Woods, W. C., Roses, D. E, Gorskin, E., Rigley, D., Friedman, R. J. & Mintzi, M. M.: Prognostic factors for melanoma patients with lesions 0.76 1.69 mm in thickness. Ann. of Surg. 1982: 195: 30-34. 14. Elwood, J. W. & Lee, J. A. M.: Recent data on the epidemiology of malignant melanoma. Seminars in Ontology, 1975: 2: 149-156. 15. Greene, G. W. & Bernier, J. L.: Primary malignant melanomas of the parotid gland. Oral Surg. 1961: 14: 108-116. 16. Goepfert, H., Jesse, R. H. & Ballantyre, A. J.: Postero-lateral neck dissection. Arch. Otolaryng. 1980: 106: 618-620. 17. Lee, K., McKean, M. E. & McGregor, I. A.: Metastatic patterns of squamous carcinoma in the parotid lymph nodes. Br. J. Plast. Surg. 1985: 38: 6-10. 18. Mendenhall, N. E, Million, R. R. & Cassisi, N. J.: Parotid area lymph node metastases from carcinoma of the skin. Int. J. Rad. One. Biol. Phys. 1985: II: 707-714. 19. Nichols, R. D., Pinnock, L. A. & Szymanowski, R. T.: Metastasis to parotid nodes. The Laryngoscope 1980: 90: 1324-1328. 20. Pain, J. A., Collier, D. St. J. & Conn, E C.: Malignant melanoma of a parotid lymph gland. An unusual case. Int. J.

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Oral Maxillofac. Surg. 1986: 15: 645-647. 21. Rochlin, D. B.: Postero-lateral neck dissection for malignant neoplasms. Surg. Gynaec. Obst. 1962: 115: 369-373. 22. Routledge, R. T.: In: Head and neck cancer, Rhys Evans, R H., Robin, E E. & Fielding, J. W. C. (eds.). Castle House Publications Ltd., Kent, 1983: pp. 61 80. 23. Santinni, H., Byers, R. M. & Wolf, P. F.: Melanoma metastatic to cervical and parotid nodes from an unknown primary site. Am. J. Surg. 1975: 150: 510-512. 24. Singletary, E.: Unpublished data quoted by Santinni, parotid nodes from an unknown primary site. Am. Y. Surg. 1985: 150: pp. 512. 25. Storm, K. F., Eilber, R. F., Sparks, E C. & Morton, D. C.: A prospective study of parotid metastases from head and neck cancer. Am. J. Surg. 1977: 134: 115-119. 26. Suen, J. Y. & Myers, E. N.: In: Cancer o f the head and neck. Churchill Livingstone, 1981: pp. 202 and 227-238. 27. Urist, H. M., Balch, C. M., Soong, S. J., Milton, G. W., Shaw, H. M., McGovern, V. J., Murad, T. M., McCarthy, W. H. & Maddox, W. A.: Head and neck melanoma in 534 stage I patients. Ann. Surg. 1984: 200: 769-775. 28. Veronesi, U., Adamus, J., Bardiera, D. C., Brennhaud, I. O., Caceres, E., Cascinelli, N., Claudio, F., Ikonopisov, R. L., Javorski, V. V., Kirov, S., Kulakowski, A., Lacour, J., Lejeune, F., Mechl, Z., Marabito, A., Rode, I., Sergeer, S., Slooten, E., yon Szczygrel, K., Trapenznikow, N. N. & Wagner, I. I.: Delayed regional lymph node dissection in Stage I melanoma of the lower extremeties. Cancer 1982: 49: 2420-2430. 29. Woods, J. E., Taylor, W. F., Pritchard, D. J., Sim, F. M., Irvins, J. C. & Bergstralh, E. J.: Is the BANS concept for malignant melanoma valid? Am. J. Surg. 1985: 150: 452-455. Address: Address." R. A. Ord Department of Oral and Maxillofacial Surgery Sunderland District General Hospital Kayll Road Sunderland UK