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A case report of metachronous salivary gland neoplasia
Letters
to the Editor
135
A CASE REPORT OF METACHRONOUS SALIVARY GLAND NEOPLASIA
Fig. 1. - 1994-1995
Mersey and North West regions’ benign salivary gland and oral/facial malignant pathology (ICD9 codes 527. 140- 149) for ENT. general and oral and maxillofacial surgery.
oral mucocoele is grouped within ICD9 527 and is generally only treated by us (Fig. 1). Benign salivary gland surgical cases could all be referred to general surgery or the remaining specialty should ENT or maxillofacial surgery be moved from their traditional place at the district general hospital. Parotid gland surgery with preservation of the facial nerve is time consuming and any change in referral pattern to another specialty would significantly affect waiting lists. Malignant disease of the oral/facial/head and neck areas is predominantly undertaken by ENT and oral and maxillofacial surgery (Fig. 1). The provision for malignant surgery is to be changed in the light of the Calman report. Specialists in malignant disease are to undertake the bulk of this work with an emphasis on local care at cancer units and centres. The new North West region identified 317 new head and neck neoplasms diagnosed in the old Mersey region for the year 1990. It could be argued that the widespread presentation of this relatively rare malignant group of neoplasms particularly occurring amongst the underprivileged and often alcoholic members of our society for treatment compliance should be treated as near to the patient’s local residence as possible. Cases of impacted wisdom teeth (ICD9 524) were only seen by oral and maxillofacial surgeons and otitis externa (ICD9 380) by ENT surgeons. It therefore follows the only conditions to effectively centralise the treatment are those that are monopolies to a single specialty. However, these conditions are so common and present in such large numbers that they must warrant local treatment. The patient and referring practitioner can only be given Hobson’s choice for a truly workable regionalisation policy and in view of this perhaps the concept should be abandoned. G. D. Wood Consultant Oral and Maxillofacial Wirral Hospital Wirral Merseyside
Surgeon
References The NW Region Cancer Services Steering Group, Cancer Units, 1995. 2. Calman K. A policy framework for commissioning cancer services: guidance for purchasers and providers of cancer services. Report by the Expert Advisory Group on Cancer Department of Health. 1995.
Sir, With regard to the increasing evidence of the genetic basis of neoplasia and prognostic value of genetic abnormalities in oral squamous cell carcinoma, I present a case which may be of some interest in the management of salivary gland neoplasia. A 29-year-old male patient presented with two distinct tumours: the first was in the left palate and tuberosity. It was a soft, fluctuant mass, 30 mm in diameter and blueish in colour. Incisional biopsy and histopathology suggested a low grade variant of mucoepidermoid carcinoma. The second was a firm, rubbery, lobulated mass, 50 mm in diameter overlying the right angle of the mandible. It was discovered that a previous mucoepidermoid carcinoma had been removed from the left palate some IO years previously and with a view to this tumour’s capricious nature this seemed to be very likely to be a local recurrence. Subsequently the patient underwent left hemimaxillectomy and prosthetic reconstruction of the defect. Diagnosis of the second tumour was confirmed as pleomorphic adenoma after superficial parotidectomy. Multiple or bilateral salivary gland tumours are rare but well documented.‘m8 particularly in the case of Warthin’s tumour. However, tumours of differing pathology and involving contralateral minor and major glands are particularly rare. This raises the question of whether genetic abnormalities in this patient may be responsible for both tumours. If this were the case, it may well be that the patient is highly pre-disposed to further glandular primary neoplasms and should be screened appropriately. Parallels exist between this case and those of young patients with oral squamous cell carcinoma despite the absence of environmental risk factors. This may lend weight to a theory of genetic aetiology but unfortunately DNA analyses were not performed. R. J. Shaw Medical Student University of Glasgow Glasgow
References I
2. 3.
4.
5.
6.
7.
I
8.
Goh PMY. Cheah E. Synchronous tumours of the parotid gland with different histology. Br J Oral Maxillofdc Surg 1989: 27: 198-202. Bab IA. Ulmansky M. Simultaneously occurring salivary gland tumours of different types. J Oral Surg 1979; 37: 826-828. Pontilena N. Rankow RM. Coexisting benign mixed tumor and mucoepidermoid carcinoma of the pagotid gland. Annals of Otorhinolarvneoloev 1979: 88: 327 -330. Takeda Y. Ku&da%. Suzuki A. Synchronous benign epithelial tumours arising in the palatal minor salivary gland. Acta Pathol Jpn 1990; 40: 143-148. Janecka IP, Perzin KH, Sternschein MJ. Rare synchronous parotid tumors of different histologic types. Plast Reconstr Surg 1983; 72: 798-802. Brill AH, Fitz-Hugh GS. Bilateral synchronous mixed tumours of the parotid gland. Arch. Otorhinolarygology 1975; 101: 751-753. Lumerman H. Freedman P, Caracciolo P, Remigio PS. Synchronous malignant mucoepidermoid tumour of the parotid gland and Warthin’s tumour in adjacent lymph node. Oral Surg Oral Med Oral Pathol 1975; 39: 953-958. Johns ME. Shikhani AH, Kashima HK, Matanoski GM. Multiple primary neoplasms in patients with salivary gland or thyroid gland tumours. Larygoscope 1986; 96: 718 721,
to the Editor
135
A CASE REPORT OF METACHRONOUS SALIVARY GLAND NEOPLASIA
Fig. 1. - 1994-1995
Mersey and North West regions’ benign salivary gland and oral/facial malignant pathology (ICD9 codes 527. 140- 149) for ENT. general and oral and maxillofacial surgery.
oral mucocoele is grouped within ICD9 527 and is generally only treated by us (Fig. 1). Benign salivary gland surgical cases could all be referred to general surgery or the remaining specialty should ENT or maxillofacial surgery be moved from their traditional place at the district general hospital. Parotid gland surgery with preservation of the facial nerve is time consuming and any change in referral pattern to another specialty would significantly affect waiting lists. Malignant disease of the oral/facial/head and neck areas is predominantly undertaken by ENT and oral and maxillofacial surgery (Fig. 1). The provision for malignant surgery is to be changed in the light of the Calman report. Specialists in malignant disease are to undertake the bulk of this work with an emphasis on local care at cancer units and centres. The new North West region identified 317 new head and neck neoplasms diagnosed in the old Mersey region for the year 1990. It could be argued that the widespread presentation of this relatively rare malignant group of neoplasms particularly occurring amongst the underprivileged and often alcoholic members of our society for treatment compliance should be treated as near to the patient’s local residence as possible. Cases of impacted wisdom teeth (ICD9 524) were only seen by oral and maxillofacial surgeons and otitis externa (ICD9 380) by ENT surgeons. It therefore follows the only conditions to effectively centralise the treatment are those that are monopolies to a single specialty. However, these conditions are so common and present in such large numbers that they must warrant local treatment. The patient and referring practitioner can only be given Hobson’s choice for a truly workable regionalisation policy and in view of this perhaps the concept should be abandoned. G. D. Wood Consultant Oral and Maxillofacial Wirral Hospital Wirral Merseyside
Surgeon
References The NW Region Cancer Services Steering Group, Cancer Units, 1995. 2. Calman K. A policy framework for commissioning cancer services: guidance for purchasers and providers of cancer services. Report by the Expert Advisory Group on Cancer Department of Health. 1995.
Sir, With regard to the increasing evidence of the genetic basis of neoplasia and prognostic value of genetic abnormalities in oral squamous cell carcinoma, I present a case which may be of some interest in the management of salivary gland neoplasia. A 29-year-old male patient presented with two distinct tumours: the first was in the left palate and tuberosity. It was a soft, fluctuant mass, 30 mm in diameter and blueish in colour. Incisional biopsy and histopathology suggested a low grade variant of mucoepidermoid carcinoma. The second was a firm, rubbery, lobulated mass, 50 mm in diameter overlying the right angle of the mandible. It was discovered that a previous mucoepidermoid carcinoma had been removed from the left palate some IO years previously and with a view to this tumour’s capricious nature this seemed to be very likely to be a local recurrence. Subsequently the patient underwent left hemimaxillectomy and prosthetic reconstruction of the defect. Diagnosis of the second tumour was confirmed as pleomorphic adenoma after superficial parotidectomy. Multiple or bilateral salivary gland tumours are rare but well documented.‘m8 particularly in the case of Warthin’s tumour. However, tumours of differing pathology and involving contralateral minor and major glands are particularly rare. This raises the question of whether genetic abnormalities in this patient may be responsible for both tumours. If this were the case, it may well be that the patient is highly pre-disposed to further glandular primary neoplasms and should be screened appropriately. Parallels exist between this case and those of young patients with oral squamous cell carcinoma despite the absence of environmental risk factors. This may lend weight to a theory of genetic aetiology but unfortunately DNA analyses were not performed. R. J. Shaw Medical Student University of Glasgow Glasgow
References I
2. 3.
4.
5.
6.
7.
I
8.
Goh PMY. Cheah E. Synchronous tumours of the parotid gland with different histology. Br J Oral Maxillofdc Surg 1989: 27: 198-202. Bab IA. Ulmansky M. Simultaneously occurring salivary gland tumours of different types. J Oral Surg 1979; 37: 826-828. Pontilena N. Rankow RM. Coexisting benign mixed tumor and mucoepidermoid carcinoma of the pagotid gland. Annals of Otorhinolarvneoloev 1979: 88: 327 -330. Takeda Y. Ku&da%. Suzuki A. Synchronous benign epithelial tumours arising in the palatal minor salivary gland. Acta Pathol Jpn 1990; 40: 143-148. Janecka IP, Perzin KH, Sternschein MJ. Rare synchronous parotid tumors of different histologic types. Plast Reconstr Surg 1983; 72: 798-802. Brill AH, Fitz-Hugh GS. Bilateral synchronous mixed tumours of the parotid gland. Arch. Otorhinolarygology 1975; 101: 751-753. Lumerman H. Freedman P, Caracciolo P, Remigio PS. Synchronous malignant mucoepidermoid tumour of the parotid gland and Warthin’s tumour in adjacent lymph node. Oral Surg Oral Med Oral Pathol 1975; 39: 953-958. Johns ME. Shikhani AH, Kashima HK, Matanoski GM. Multiple primary neoplasms in patients with salivary gland or thyroid gland tumours. Larygoscope 1986; 96: 718 721,