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Melanoma arising within the parotid salivary gland—a case report and review of management
Case reports
201
Melanoma arising within the parotid salivary gland and review of management
a case report
A. J. Renaut Academic Surgical Unit, Ro)'al London Hospital, Whitechapel, London E1 IBB, UK
Melanoma arising within the parotid salivary gland is an unusual, though well-recognized, phenomenon. Melanocytes are derived, embryologically, from neural crest tissue and are not a constituent of normal salivary tissue. It is, therefore, reasonable to assume that a melanoma within the parotid has arisen either as a metastasis to a parotid lymph node or as a metastasis to the gland itself. The primary lesion cannot always be identified--spontaneous regression of melanomas is an equally well-recognized phenomenon. This is a report of such a case, with a review of the management.
Ke), words: melanoma; parotid salivary gland.
Case report
A 70-year-old male presented to the clinic with a 2-year history of swelling of the right side of the face which had rapidly increased in size. accompanied by constant pain. in the preceding 2 months. He had no other symptoms and his past medical history was unremarkable. Examination confirmed the presence of an irregular mass. 15 × 10cm. arising from the region of the lower pole of the right parotid gland, with inflammation of the overlying skin (Fig. 1). Facial nerve function was intact.
Fig. 2. H & E section ( x 25) demonstrating poorly-differentiated malignant melanoma/left) infiltrating normal salivary tissue IrightJ. Chest radiography and plain radiography of the facial bones were normal. Computerized tomography of the head and neck region demonstrated a large mass in the region of the right parotid gland of mixed attennation. Fine-needle aspiration cytology revealed poorly differentiated neoplastic cells without indicating a cell line of origin. Endoscopic examination of the nasopharynx was unremarkable. The patient underwent a total radical parotidectomy, ipsilateral cervical lymphadenectomy and reconstruction of the soft tissue defect using a delto-pectoral flap. Histological examination of the excised specimen showed a poorly differentiated malignant melanoma which had widely infiltrated and destroyed the parotid salivary ghmd (Fig. 2). Tumour reached the overlying skin but no definite site of genesis was identified. One of 22 lymph nodes contained metastatic tumour. Immunohistochemistry using SI00 confirmed the diagnosis of melanoma. Further questioning of the patient, post-operatively, and a repeat examination of the head and ,~eck region failed to reveal a primary lesion. It is assumed that the lesion within the parotid gland was a metastasis from a primary that had remained undetected by the patient and had undergone spontaneous regression. Within 9 months of presentation he became cachetic and rapidly succumbed to a generalized malignant process. Fig. 1. Full facial view demonstrating mass arising within the right parotid salivary gland.
Review of management
Correspondence to: A. J. Renaut. Acadcmic Unit. Royal London Hospital. Whitechapel. London El I BB. UK.
A similar case has been reported by Vuong et al.~--the authors concluded that the lesion was a primary malignant melanoma,
Case reports
202
whilst accepting that it is a controversial entity, and a rarity (0.68% of all parotid tumours). Ball and Thomas-' reported a series of eight patients with parotid metastases from cutaneous melanoma of the head and neck, in whom local control was obtained by superficial parotidectomy. Elective neck dissection is advocated to ensure optimal Ioco-regional palliation. A parotidectomy, with neck dissection, is also advocated by Vaglini et al) in all patients with melanoma originating in the temporo-zygomatic area, following a series of 46 patients. Caldwell and Spiro4 concluded that clinical evaluation of parotid nodal status was inaccurate in a series of 65 patients with melanoma, all of whom underwent parotidectomy as part of the initial treatment. Patients with parotid nodal metastases had a significantly decreased survival at 5 years (22% compared with 67% in the patients with uninvolved nodes). Balm et al) confirm that a lymph node metastasis in the neck or parotid region from an unknown primary is an uncommon occurrence. Out of a total of 300 patients with head and neck melanoma 17 (5.7%) presented in this way, with the parotid region being the second commonest site (n=4). Finally, Shah et al.6 reviewed a consecutive series of 111 patients with primary malignant melanoma and histologically-proven regional metastases to determine the pattern of nodal metastases. All patients underwent radical neck dissection. Thirty-three of the 57 patients undergoing parotidectomy had positive results for metastases and the authors conclude that parotidectomy should be an integral part of a regional lymphadenectomy (whether elective or therapeutic) for primary melanomas on the ear, face and anterior scalp.
Conclusions Primary melanoma of the parotid salivary gland is a controversial entity, since neural crest-derived cells are not a constituent of salivary tissue. A much more plausible explanation of a melanoma arising within the parotid is that it is a metastasis from a primary within the head and neck region. If the latter cannot be identified then it is likely that it has undergone spontaneous regression.
Parotid lymph nodes are a commonly involved site for metastases from a primary melanoma in the head and neck region and a parotidectomy should be included in a radical neck dissection, whether elective or therapeutic, if this is part of the primary treatment.
Acknowledgements I would like to thank Mr P. K. B. Davis MS FRCS, Consultant Plastic Surgeon, Queen Mary's University Hospital, Roehampton for allowing me to report on his patient, the Histopathology Department at the same hospital, and the Medical Illustration Department at The Royal London Hospital. References
1. Vuong PN, Cassembon F, Houissa-Vuong S, Koubbi G, Balaton A. Primary malignant melanoma of the parotid gland: anatomico-clinical study. Apropos of a case and review of the medical literature. (in French). Oto-Laryngol Chh'urg CervicoFaciale 1986; 103: 45-55. 2. Ball AB, Thomas JM. Management of parotid metastases from cutaneous melanoma of the head and neck. J Larvngol Otol 1990; 104: 350-1. 3. Vaglini M, Belli F, Santinami M, Cascinelli N. The role of parotidectomy in the treatment of nodal metastases from cutaneous melanoma of the head and neck. Eur J Surg Oncol 1990; 16: 28-32. 4. Caldwell CB, Spiro RH. The role of parotidectomy in the treatment of cutaneous head and neck melanoma. Am J Surg 1988; 156: 318-22. 5. Balm AJ, Kroon BB, Hilgers FJ, Jonk A, Mooi WJ. Lymph node metastases in the neck and parotid gland from an unknown primary melanoma. Clin OtolaITngol 1994: 19: 161-5. 6. Shah JP, Kraus DH, Dubner S, Sarkar S. Patterns of regional lymph node metastases from cutaneous melanomas of the head and neck. Am J Surg 1991; 162: 320-3.
CORRESPONDENCE
Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom Sir, I was very interested to read in the October edition of your journal, the Guidelines for Surgeons in the Management of Symptomatic Disease in the United Kingdom. I am aware that this document has been approved by the Senate of the Royal Surgical Colleges. I wonder whether, through the columns of your Journal, I could enlarge on the problems related to the management of metastatic disease, and make a plea for the place of specialist orthopaedic units in the management of these unfortunate patients. The object of treatment for patients with metastatic disease is to improve their quality of life and survival. Many of the patients with metastatic disease of the breast have deposits in bone, particularly in the spine, pelvis and proximal femur. Pathological fractures, particularly where they result in paraplegia, greatly influence the morbidity of these patients in their terminal illness.
Patients presenting with such deposits should have them managed in centres where there is a full spectrum of spinal reconstructive surgery, replacement arthroplasty and the management of pathological fractures. Unfortunately, in many instances this is not the case. Prompt treatment of these metastases will not only improve the quality of life for these patients but also, with other adjuvant therapy, extend their survival time. There seems to be no doubt that the quality of life of patients suffering from terminal metastatic disease can be severely com.plicated by the occurrence of pathological fracture and paraplegia. Prompt and appropriate care in specialist units, contrary to the view of your guidelines, greatly improves their quality of life.
A Catterall, MChir, FRCS President, British Orthopaedic Association, Royal College of Surgeons, 35--43 Lincoln's Inn Fields, London WC2A 3PN, UK
201
Melanoma arising within the parotid salivary gland and review of management
a case report
A. J. Renaut Academic Surgical Unit, Ro)'al London Hospital, Whitechapel, London E1 IBB, UK
Melanoma arising within the parotid salivary gland is an unusual, though well-recognized, phenomenon. Melanocytes are derived, embryologically, from neural crest tissue and are not a constituent of normal salivary tissue. It is, therefore, reasonable to assume that a melanoma within the parotid has arisen either as a metastasis to a parotid lymph node or as a metastasis to the gland itself. The primary lesion cannot always be identified--spontaneous regression of melanomas is an equally well-recognized phenomenon. This is a report of such a case, with a review of the management.
Ke), words: melanoma; parotid salivary gland.
Case report
A 70-year-old male presented to the clinic with a 2-year history of swelling of the right side of the face which had rapidly increased in size. accompanied by constant pain. in the preceding 2 months. He had no other symptoms and his past medical history was unremarkable. Examination confirmed the presence of an irregular mass. 15 × 10cm. arising from the region of the lower pole of the right parotid gland, with inflammation of the overlying skin (Fig. 1). Facial nerve function was intact.
Fig. 2. H & E section ( x 25) demonstrating poorly-differentiated malignant melanoma/left) infiltrating normal salivary tissue IrightJ. Chest radiography and plain radiography of the facial bones were normal. Computerized tomography of the head and neck region demonstrated a large mass in the region of the right parotid gland of mixed attennation. Fine-needle aspiration cytology revealed poorly differentiated neoplastic cells without indicating a cell line of origin. Endoscopic examination of the nasopharynx was unremarkable. The patient underwent a total radical parotidectomy, ipsilateral cervical lymphadenectomy and reconstruction of the soft tissue defect using a delto-pectoral flap. Histological examination of the excised specimen showed a poorly differentiated malignant melanoma which had widely infiltrated and destroyed the parotid salivary ghmd (Fig. 2). Tumour reached the overlying skin but no definite site of genesis was identified. One of 22 lymph nodes contained metastatic tumour. Immunohistochemistry using SI00 confirmed the diagnosis of melanoma. Further questioning of the patient, post-operatively, and a repeat examination of the head and ,~eck region failed to reveal a primary lesion. It is assumed that the lesion within the parotid gland was a metastasis from a primary that had remained undetected by the patient and had undergone spontaneous regression. Within 9 months of presentation he became cachetic and rapidly succumbed to a generalized malignant process. Fig. 1. Full facial view demonstrating mass arising within the right parotid salivary gland.
Review of management
Correspondence to: A. J. Renaut. Acadcmic Unit. Royal London Hospital. Whitechapel. London El I BB. UK.
A similar case has been reported by Vuong et al.~--the authors concluded that the lesion was a primary malignant melanoma,
Case reports
202
whilst accepting that it is a controversial entity, and a rarity (0.68% of all parotid tumours). Ball and Thomas-' reported a series of eight patients with parotid metastases from cutaneous melanoma of the head and neck, in whom local control was obtained by superficial parotidectomy. Elective neck dissection is advocated to ensure optimal Ioco-regional palliation. A parotidectomy, with neck dissection, is also advocated by Vaglini et al) in all patients with melanoma originating in the temporo-zygomatic area, following a series of 46 patients. Caldwell and Spiro4 concluded that clinical evaluation of parotid nodal status was inaccurate in a series of 65 patients with melanoma, all of whom underwent parotidectomy as part of the initial treatment. Patients with parotid nodal metastases had a significantly decreased survival at 5 years (22% compared with 67% in the patients with uninvolved nodes). Balm et al) confirm that a lymph node metastasis in the neck or parotid region from an unknown primary is an uncommon occurrence. Out of a total of 300 patients with head and neck melanoma 17 (5.7%) presented in this way, with the parotid region being the second commonest site (n=4). Finally, Shah et al.6 reviewed a consecutive series of 111 patients with primary malignant melanoma and histologically-proven regional metastases to determine the pattern of nodal metastases. All patients underwent radical neck dissection. Thirty-three of the 57 patients undergoing parotidectomy had positive results for metastases and the authors conclude that parotidectomy should be an integral part of a regional lymphadenectomy (whether elective or therapeutic) for primary melanomas on the ear, face and anterior scalp.
Conclusions Primary melanoma of the parotid salivary gland is a controversial entity, since neural crest-derived cells are not a constituent of salivary tissue. A much more plausible explanation of a melanoma arising within the parotid is that it is a metastasis from a primary within the head and neck region. If the latter cannot be identified then it is likely that it has undergone spontaneous regression.
Parotid lymph nodes are a commonly involved site for metastases from a primary melanoma in the head and neck region and a parotidectomy should be included in a radical neck dissection, whether elective or therapeutic, if this is part of the primary treatment.
Acknowledgements I would like to thank Mr P. K. B. Davis MS FRCS, Consultant Plastic Surgeon, Queen Mary's University Hospital, Roehampton for allowing me to report on his patient, the Histopathology Department at the same hospital, and the Medical Illustration Department at The Royal London Hospital. References
1. Vuong PN, Cassembon F, Houissa-Vuong S, Koubbi G, Balaton A. Primary malignant melanoma of the parotid gland: anatomico-clinical study. Apropos of a case and review of the medical literature. (in French). Oto-Laryngol Chh'urg CervicoFaciale 1986; 103: 45-55. 2. Ball AB, Thomas JM. Management of parotid metastases from cutaneous melanoma of the head and neck. J Larvngol Otol 1990; 104: 350-1. 3. Vaglini M, Belli F, Santinami M, Cascinelli N. The role of parotidectomy in the treatment of nodal metastases from cutaneous melanoma of the head and neck. Eur J Surg Oncol 1990; 16: 28-32. 4. Caldwell CB, Spiro RH. The role of parotidectomy in the treatment of cutaneous head and neck melanoma. Am J Surg 1988; 156: 318-22. 5. Balm AJ, Kroon BB, Hilgers FJ, Jonk A, Mooi WJ. Lymph node metastases in the neck and parotid gland from an unknown primary melanoma. Clin OtolaITngol 1994: 19: 161-5. 6. Shah JP, Kraus DH, Dubner S, Sarkar S. Patterns of regional lymph node metastases from cutaneous melanomas of the head and neck. Am J Surg 1991; 162: 320-3.
CORRESPONDENCE
Guidelines for surgeons in the management of symptomatic breast disease in the United Kingdom Sir, I was very interested to read in the October edition of your journal, the Guidelines for Surgeons in the Management of Symptomatic Disease in the United Kingdom. I am aware that this document has been approved by the Senate of the Royal Surgical Colleges. I wonder whether, through the columns of your Journal, I could enlarge on the problems related to the management of metastatic disease, and make a plea for the place of specialist orthopaedic units in the management of these unfortunate patients. The object of treatment for patients with metastatic disease is to improve their quality of life and survival. Many of the patients with metastatic disease of the breast have deposits in bone, particularly in the spine, pelvis and proximal femur. Pathological fractures, particularly where they result in paraplegia, greatly influence the morbidity of these patients in their terminal illness.
Patients presenting with such deposits should have them managed in centres where there is a full spectrum of spinal reconstructive surgery, replacement arthroplasty and the management of pathological fractures. Unfortunately, in many instances this is not the case. Prompt treatment of these metastases will not only improve the quality of life for these patients but also, with other adjuvant therapy, extend their survival time. There seems to be no doubt that the quality of life of patients suffering from terminal metastatic disease can be severely com.plicated by the occurrence of pathological fracture and paraplegia. Prompt and appropriate care in specialist units, contrary to the view of your guidelines, greatly improves their quality of life.
A Catterall, MChir, FRCS President, British Orthopaedic Association, Royal College of Surgeons, 35--43 Lincoln's Inn Fields, London WC2A 3PN, UK