General Data

Age : 39 y/o

Gender : female

Marriage : 已婚
Chief Complaint

A palpable mass over right cheek which
was found for 1 year
Present Illness

A palpable mass about 1.5 x 1.5 cm was
found in 1 year ago.

The mass become bigger recently

Intermittent neck pain and stiffness

No pain, no tenderness, no wound, no
numbness
Past history

T-colon cancer, s/p segmental resection at
新光, chemotherapy in 北醫 about 4 years
ago

DM (-)

Hypertension (-)

Allergy (-)
Lab data

WBC : 6.89 10^3/u

RBC : 4.47 10^6/uL

Na : 133 mEq/L

K : 3.8 mEq/L

There is an ill-defined round mass, about 2.0x1.9x1.5 cm
in size, with inhomogeneous parenchymal enhancement
in the anterior superficial lobe of right parotid gland.
D/D from Image

Plemorphic adenoma

Warthin’s tumor

Mucoepidermoid carcinoma

Adenoid cystic carcinoma

Squamous cell carcinoma

Metastasis
D/D from parotid gland

Location
The lobe of Parotid gland
Parapharyngeal area, tonsillar area, Cervical lymph node

Symptoms
Facial nerve paralysis

Age
Benign tumor → 40 ~ 60 y/o
Malignancy → elderly

Gender
大部分均是女性較多
Warthin’s tumor → 男性較多
Diagnosis approach

CT

MRI

Ultrasound

Fine needle aspiration

Core biopsy
Plemorphic adenoma

Most common benign tumor of salivary
gland

Location : tail or superficial lobe

CT : isodense to muscle and shows
moderate enhancement

MRI : the mass is T1 hypointense (T2
hyperintense) to surrounding fat
Warthin’s tumor

The second most common benign tumor
of parotid

Bilateral in 10% of cases and favors the
tail of the parotid gland

MRI : T1 hypointense to the surrounding
parotid fat
Mucoepidermoid carcinoma

Most common malignant tumor of the
parotid gland.

CT : the mass is isodense to muscle

MRI : T1 hypointense to surrounding
parotid fat but variable on T2
Adenoid cystic carcinoma

The second most common malignant
tumor of parotid

CT : isodense to muscle

MRI : T1 hypointense to surrounding
parotid fat but variable on T2
Final diagnosis

Surgery :
1. excision of parotid gland tumor
2. superficial parotidectomy

Pathology :
Epithelial-myoepithelial carcinoma
Discussion
Parotid gland tumor

The most common location of salivary
gland tumors

Tumor usually present with a solitary,
discrete, slowly growing, asymptomatic
mass.
The rule of 80

80% of parotid tumors are benign

80% of parotid tumors are pleomorphic
adenomas

80% of parotid pleomorphic adenomas
occur in the superficial lobe

80% of untreated pleomorphic adenomas
remain benign
Diagnostic evaluation

Fine needle aspiration

Identify the causes of parotid enlargement

Determine whether it is primary to the
salivary gland or metastatic from another
site

The accuracy of FNA depends upon
operator experience
Core needle biopsy

Ultrasound-guided core needle biopsy of
parotid masses is highly accurate
(97~100%)

More accurate typing and grading of
malignant lesions
Image study

Ultrasond
Location, the nature of the mass

CT & MRI :
Provide important diagnostic information
about overall dimension, adjacent tissue
infiltration, and vascular invasion
It might be malignancy…

Tumors of the deep parotid lobe or those which
extend into the parapharyngeal space

Recurrent tumors

Direct facial nerve invasion, skin involvement, or
extension into bone

Locally extensive lesions

The presence of pathologic cervical
lymphadenopathy
Staging system
Tumor size

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tumor 2 cm or less in greatest dimension without
T1
extraparenchymal extension
Tumor more than 2 cm but not more than 4 cm in greatest
T2
dimension without extraparenchymal extension
T3 Tumor more than 4 cm and/or extraparenchymal extension
T4
Tumor invades skin, mandible, ear canal, and/or facial nerve.
a
T4 Tumor invades skull base, and/or pterygoid plates and/or
b encases carotid artery
 Staging system
Nodal status

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension

Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6
cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than
N2
6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
N2 Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm
a in greatest dimension
N2 Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest
b dimension
N2 Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest
c dimension
N3 Metastasis in a lymph node more than 6 cm in greatest dimension
Staging system
Tumor stage grouping
Stage I T1 N0 M0
Stage II T2 N0 M0
T3 N0 M0
Stage III
T1-3 N1 M0
T4a N0-1 M0
Stage IVA
T1-4a N2 M0
T4b Any N M0
Stage IVB
Any T N2-3 M0
Stage IVC Any T Any N M1
Treatment---T1/T2

Superficial or total parotidectomy with
conservation of the facial nerve

low-grade T1 and T2 primaries can be
adequately treated by surgery alone

RT is recommended for …..

Deep lobe parotid tumors

Close or positive histologic surgical margins

Undifferentiated or high-grade histology

Recurrent malignancy

Bone or connective tissue involvement

Metastatic regional cervical lymph nodes

Perineural involvement

Intraoperative tumor spillage or capsular rupture
Treatment---T3/T4

Superficial or total parotidectomy +
postoperative radiotherapy

Five-year survival rates for patients treated
with and without RT were :
51% : 10%
Prognosis

10-year survival rates ：
Stage Ⅰ 85%

Stage Ⅱ 69%

Stage Ⅲ 43%

Stage Ⅳ 14%
 Epithelial-myoepithelial carcinoma
( EMEC )

A rare tumor accounting for slightly fewer
than 1% of salivary gland neoplasms.

Most often in elderly patients

More prevalent in women

The slow-growing mass is well defined,
bulky lobulated fashion
CT & MRI

CT : isodense to muscle

MRI : hypointense on T1

CT and MRI appearances of EMEC are
nonspecific, and that EMEC cannot be
differentiated from more common parotid
neoplasms on the basis of its imaging
characteristics.
Pathology

The tumor has a distinctive histopathologic
pattern with epithelial tubules or ductules
surrounded by neoplastic myoepithelial
cells
Treatment

Wide surgical resection, including adjacent
lymph nodes

Immediate postoperative radiotherapy

Regular follow up
Prognosis

There is a high reported rate of local
recurrence, approaching 50%

Resection of recurrences usually results in
a good prognosis, with less than 10% of
patients dying as a result of this tumor
Reference

Uptodate : salivary gland tumor

Robbins

電腦斷層攝影入門

Journal of clinical pathology :
Epithelial-myoepithelial carcinoma of salivary glands

American Society of Neuroradiology
Epithelial-Myoepithelial Carcinoma of the Parotid Gland