Epidemiology of Warthin's tumour of the parotid gland in an Asian population

Triple Assessment of a Palpable Parotid Lump in "One-Stop" Clinics

Introduction

The National Institute of Clinical Excellence in the UK (NICE) recommended the use of "one-stop" clinics for the assessment and management of head and neck lumps like those established for breast lumps. "One-stop" clinics should follow a triple assessment protocol involving physical examination, radiological imaging and fine-needle aspiration cytology (FNAC).

Methods

A retrospective analysis of 144 patients with suspected parotid tumours from 2005 to 2011 was done. Patients were assessed for individual modalities and compared against the final histological diagnosis. Statistical analysis was used for sensitivity and specificity, as well as positive and negative predictive values. All calculations were performed using SPSS version 16 (Statistical Packages for the Social Sciences, Chicago, IL). A p value of < 0.05 was considered to indicate statistical significance.

Results

A total of 105 patients underwent all the three modalities. Out of them, 93 had imaging that was considered radiologically benign and 12 were reported to have a malignant lesion. Cytologically, 75 were found to have a benign tumour, 13 were malignant, and 17 were considered to be indeterminate. The most common benign neoplasm was pleomorphic adenoma followed by Warthin's tumour. The sensitivity and specificity of triple assessment were 96% (p value 0.878-0.984) and 73% (p value 0.42-0.904), respectively. The positive predictive value was 96% (p value 0.878-0.984) and negative predictive value came out to be 93% (p value 0.42-0.904).

Conclusions

The overall accuracy of triple assessment was found to be 92%. This study concludes that triple assessment is a useful assessment tool to evaluate a patient with parotid lump.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-021-01590-5.

Function-preserving surgery via single transverse cervical incision for Warthin's tumor in the parotid gland

BACKGROUND

This study evaluated functional and disease control outcomes after gland-preserving surgery via a single transverse cervical incision for Warthin's tumor of the parotid gland.

METHODS

One-hundred eleven patients with Warthin's tumor underwent the preservation of most normal parotid tissues and the facial nerve combined with the en-bloc resection of tumors. Postoperative complications, subjective satisfaction, salivary function, and metachronous tumor were assessed in each patient.

RESULTS

No patients had an extension to modified Blair or periauricular incision with the median operation time of 32 min. Temporary and permanent paralysis of the facial nerve was 5 (4.0%) and none of 125 tumor resection sides, respectively. Postoperative complications were minimal. The secretory functions between the affected and unaffected glands did not differ. One patient had metachronous tumor for a median follow-up of 72 months.

CONCLUSION

Functional gland-preserving surgery via single transverse cervical incision can safely treat Warthin's tumor in the parotid gland.

Clinicopathological features of incidental parotid lesions

Background

The purpose of this study is to determine the histopathological spectrum and risk of primary malignancy of asymptomatic parotid lesions incidentally discovered on cross-sectional imaging.

Methods

Over a 10-year period, 154 patients underwent 163 ultrasound-guided parotid lesion biopsies at our institution. This retrospective chart review included 89 lesions in 87 patients with asymptomatic parotid lesions discovered on cross-sectional imaging studies performed for unrelated clinical indications. The histopathologic findings of all sampled lesions were reviewed. We evaluated the patient demographics and pathological diagnoses of sampled parotid lesions to determine the histopathological spectrum and risk of malignancy.

Results

The average age was 67.5 years and 92 % were males. 25 % of patients had bilateral lesions. The average size of the parotid lesions was 1.5 cm and 91 % were located in the superficial lobe. 92.1 % of lesions were benign with Warthin tumor being the most common diagnosis followed by pleomorphic adenoma. 2.3 % of lesions were primary parotid malignant neoplasms, while 5.6 % were metastatic lesions in patients with known malignancy.

Conclusions

The incidence of primary parotid malignant neoplasm in asymptomatic incidentally discovered parotid lesions is low. Imaging or clinical follow-up may be considered in patients with incidental parotid lesions who prefer to avoid biopsy.

Analysis of the Clinical Relevance of Histological Classification of Benign Epithelial Salivary Gland Tumours

INTRODUCTION

A vast increase in knowledge of numerous aspects of malignant salivary gland tumours has emerged during the last decade and, for several reasons, this has not been the case in benign epithelial salivary gland tumours. We have performed a literature review to investigate whether an accurate histological diagnosis of the 11 different types of benign epithelial salivary gland tumours is correlated to any differences in their clinical behaviour.

METHODS

A search was performed for histological classifications, recurrence rates and risks for malignant transformation, treatment modalities, and prognosis of these tumours. The search was performed primarily through PubMed, Google Scholar, and all versions of WHO classifications since 1972, as well as numerous textbooks on salivary gland tumours/head and neck/pathology/oncology. A large number of archival salivary tumours were also reviewed histologically.

RESULTS

Pleomorphic adenomas carry a considerable risk (5-15%) for malignant transformation but, albeit to a much lesser degree, so do basal cell adenomas and Warthin tumours, while the other eight types virtually never develop into malignancy. Pleomorphic adenoma has a rather high risk for recurrence while recurrence occurs only occasionally in sialadenoma papilliferum, oncocytoma, canalicular adenoma, myoepithelioma and the membranous type of basal cell adenoma. Papillomas, lymphadenoma, sebaceous adenoma, cystadenoma, basal cell adenoma (solid, trabecular and tubular subtypes) very rarely, if ever, recur.

CONCLUSIONS

A correct histopathological diagnosis of these tumours is necessary due to (1) preventing confusion with malignant salivary gland tumours; (2) only one (pleomorphic adenoma) has a considerable risk for malignant transformation, but all four histological types of basal cell adenoma can occasionally develop into malignancy, as does Warthin tumour; (3) sialadenoma papilliferum, oncocytoma, canalicular adenoma, myoepithelioma and Warthin tumour only occasionally recur; while (4) intraductal and inverted papilloma, lymphadenoma, sebaceous adenoma, cystadenoma, basal cell adenoma (apart from the membranous type) virtually never recur. No biomarker was found to be relevant for predicting recurrence or potential malignant development. Guidelines for appropriate treatment strategies are given.

The growth rate and the positive prediction of needle biopsy of clinically diagnosed Warthin's tumor

PURPOSE

This study reports the clinical course, including the growth rate, of Warthin's tumor (WT) and evaluates the positive prediction of needle biopsy for WT.

METHODS

The medical records of 182 patients clinically diagnosed with WT were retrospectively reviewed. Tumor growth rates were measured in patients who underwent serial radiologic exams with minimum 6-month time intervals, and the positive prediction value (PPV) of needle biopsy was evaluated in comparison with surgical pathology in patients who underwent surgical excision of the tumors.

RESULTS

Serial radiologic exams were available for growth rate measurement in 31 tumors (size 0.7-9.1 cm) from 25 patients. Among these, 24 tumors increased in size, and 7 were stable. The median follow-up duration was 23.5 months [interquartile range (IQR) 14.8-51.9], and the tumor growth rate ranged from - 0.36 to 2.26 cm per year (median 0.26, IQR 0.07-0.44). Needle biopsy results were available for comparison with postoperative pathology specimens in 147 patients. The PPV was 97.7% for fine-needle aspiration biopsy and 100% for core-needle biopsy. There were no reports of inflammation, facial nerve paralysis, or admission event during the follow-up.

CONCLUSIONS

WT glows slowly and can be predicted by needle biopsy. Therefore, parotid masses diagnosed as Warthin's tumor can be treated or left untreated based on the patient's needs and clinical decision-making.

Investigation of the surgical strategies for unilateral multifocal cystadenolymphomas of the parotid gland

OBJECTIVES

The aim of the study was to compare multifocal extracapsular dissection with complete parotidectomy in the treatment of unilateral multifocal cystadenolymphomas of the parotid gland.

MATERIALS AND METHODS

The records from all patients treated for unilateral multifocal cystadenolymphomas of the parotid gland at a tertiary referral center between 2000 and 2016 were retrospectively analyzed.

RESULTS

203 patients were included in the study. 96 patients were managed by multifocal extracapsular dissection, 107 patients underwent complete parotidectomy. Metachronous tumors were detected in 7 cases (3.4%) with a significant difference in the occurrence rate between multifocal extracapsular dissection (7/96, 7.3%) and complete parotidectomy (0/107, 0%) (p = 0.004). Permanent facial palsy was significantly more common after complete parotidectomy (21/107, 19.6%) than multifocal extracapsular dissection (2/96, 2.1%) (p = 0.000).

CONCLUSIONS

The functional benefit of multifocal extracapsular dissection was counterbalanced by the advantage of complete parotidectomy, in terms of recurrences. Extracapsular dissection is at its limit in cases of multifocal cystadenolymphomas and the indication for it should be thoroughly verified in each and every case.

Benign Parotid Tumors

This article reviews the epidemiology, embryology, risk factors, clinical presentation, diagnostic work-up, and basic management principles for the more common benign parotid neoplasms. The various histopathologies are also discussed and summarized.

A Case-Control Study of Risk Factors for Salivary Gland Cancer in Canada

Aim. To assess the effect of various lifestyle risk factors on the risk of salivary gland cancer in Canada using data from a population-based case-control study. Methods. Data from a population-based case-control study of 132 incident cases of salivary gland cancer and 3076 population controls were collected through self-administered questionnaire and analysed using unconditional logistic regression. Results. Four or more servings/week of processed meat product was associated with an adjusted odds ratio (OR) and corresponding 95% confidence interval (CI) of 1.62 (1.02–2.58). Nonsignificantly increased ORs were also related to obesity, >7 drinks/week of alcohol consumption, and occupational exposure to radiation. Furthermore, nonsignificantly decreased ORs were found to be associated with high education level (>12 years) (OR = 0.65), high consumption of spinach/squash (OR = 0.62) and all vegetables/vegetable juices (OR = 0.75), and >30 sessions/month of recreational physical activity (OR = 0.78). Conclusions. This study suggests positive associations with consumption of processed meat, smoking, obesity, alcohol drinking, and occupational exposure to radiation as well as negative associations with higher education, consumption of spinach/squash, and physical activity, which suggest a role of lifestyle factors in the etiology of salivary gland cancer. However, these findings were based on small number of cases and were nonsignificant. Further larger studies are warranted to confirm our findings.

Demographics of benign parotid tumours: Warthin's tumour versus other benign salivary tumours

CONCLUSION

Some variation from the 'classical' clinical picture for Warthin's tumours is evident in these patients. A predilection for the parotid tail and a propensity for multiplicity has been confirmed.

OBJECTIVES

This study sought to analyse demographic and clinical features of a Warthin's patient population.

METHODS

Retrospective review of patients presenting with a benign parotid tumour. The group of Warthin's tumours was compared with the group of patients with other benign parotid tumours.

RESULTS

Of 170 primary parotid tumours, 41 (24%) were Warthin's tumour. Mean age of Warthins patients was significantly older (60 years vs 48 years, p = 0.001) and male gender more prevalent (61% vs 33%, p = 0.015) than in other benign tumours. Most (86%) Warthin's tumours were found in the parotid tail, compared with 61% of other benign tumours (p = 0.002). There was no significant ethnic predilection for Warthin's tumours. Bilaterality (30%) and multiplicity (27%) were common. Significance of gender differences disappeared with logistic regression analysis.

Synchronous parotid and nasopharyngeal Warthin tumor

BACKGROUND

Warthin tumor is the second most common benign salivary gland neoplasm after pleomorphic adenoma. Warthin tumors occur almost exclusively in the parotid gland and periparotid lymph nodes, extraparotid localization is rare.

METHODS AND RESULTS

We describe a case of a patient presenting with a synchronous unilateral parotid gland and nasopharyngeal Warthin tumor.

CONCLUSION

We propose that, although this occurrence of a synchronous parotid gland and nasopharyngeal Warthin tumor may be coincidental, it is more likely to be an effect of a systemic factor.

Genetic polymorphisms in UDP-glucuronosyltransferase 1A6 and 1A7 and the risk for benign Warthin's tumors of the parotid gland

BACKGROUND

Warthin's tumors of the parotid gland are associated with smoking, whereas pleomorphic adenomas are not. Genetic polymorphisms in biotransformation enzymes, involved in detoxification of toxins and carcinogens in cigarette smoke, might modify the corresponding enzyme activity and influence detoxifying capacity. We hypothesize that these genetic polymorphisms may influence the individual risk for Warthin's tumor, but not for pleomorphic adenomas.

METHODS

Blood from 146 patients with benign parotid gland tumors and 437 controls were investigated for polymorphisms in several biotransformation enzymes. Based on these polymorphisms, patients and controls were divided according to predicted enzyme activity (low, intermediate, and high).

RESULTS

Prevalence of predicted intermediate and high activity UGT1A7 and UGT1A6 genotypes was significantly higher in the patients with Warthin's tumors, but not in patients with pleomorphic adenomas, compared with healthy controls.

CONCLUSION

Predicted intermediate and high activity UGT1A7 and UGT1A6 genotypes are associated with an increased risk for Warthin's tumor. © 2015 Wiley Periodicals, Inc. Head Neck 38: E717-E723, 2016.

Parotid gland tumours in a West Indian population: Comparison to world trends

The epidemiology of parotid gland tumours in Trinidad and Tobago and the wider Caribbean is currently unknown. Therefore, an analysis of the pathological records was conducted to determine the pattern of this disease in Trinidad and Tobago. A retrospective analysis was conducted on all parotid gland tumours and the demographic and histological data were analysed. Data from 60 cases were collected over a period of 8 years (October, 2003 to February, 2012), including 56 primary and 4 secondary tumours (1 basal cell carcinoma and 3 metastatic tumours). The patients included 31 men and 29 women, with a mean age of 48.7 years and an age range of 21-73 years (peak age, 51-60 years). The surgical interventions included 53 superficial parotidectomies, 6 radical parotidectomies and 1 biopsy. Of the 56 primary tumours, 41 were benign [34 pleomorphic adenomas and 7 Warthin's tumours (adenolymphomas)], accounting for 73.2% of the cases. The malignant lesions included 6 squamous cell carcinomas, 3 mucoepidermoid carcinomas, 2 acinic cell carcinomas, 2 adenoid cystic carcinomas, 1 anaplastic carcinoma and 1 papillary carcinoma, accounting for 26.8% of the total cases, without any age predominance. The pattern of disease distribution was similar to that indicated by worldwide data, with benign primary lesions accounting for ~80% of the cases (pleomorphic adenomas, 80% and Warthin's tumours, 20%). The most common carcinomas were mucoepidermoid and adenoid cystic types, as indicated by worldwide data; however, in our series, squamous cell carcinoma was the most common type, followed by mucoepidermoid, acinic cell and adenoid cystic carcinomas. The present study will hopefully provide useful information on parotid pathology in Trinidad and Tobago and encourage further research in this field.

Warthin's Tumour: A Case Report and Review on Pathogenesis and its Histological Subtypes

Warthin's tumour/ Papillary cystadenoma lymphomatosum (PCL) constitutes a minority of salivary gland neoplasms and it is a monomorphic adenoma which primarily involves the parotid gland. Warthin's tumour shows multiple cysts that have numerous papillations covered by bilayered columnar and basaloid oncocytic epithelium. The connective tissue portion shows proliferation of follicle- containing lymphoid tissue which necessitates careful distinction for diagnosis. Although, Warthin's tumour presents as a clinically benign, slow-growing, usually asymptomatic lesion with low rates of recurrences and malignant transformation, but still this tumour is considered unique because of its histological appearance and unknown origin and pathogenesis. Here, we report a case of Warthin's tumour of five years duration in a 50-year-old male patient in the right parotid gland and also review and discuss various concepts concerning the development of this tumour along with a comprehensive literature on its clinic-pathologic features.

Pattern of salivary gland tumors in Manipur, India: A 10 year study

BACKGROUND

Salivary gland lesions, especially the neoplastic lesions constitute a highly heterogeneous histopathologic group. Several studies have reported a significant difference in the global distribution of salivary gland tumors, but no formal study has been carried out in this part of the globe.

OBJECTIVES

To document the pattern of various salivary gland tumors in Manipur, a state in North Eastern India.

MATERIALS AND METHODS

This is a 10 years (2002-2011) retrospective study of all salivary gland specimens received at our referral teaching hospital in Manipur, India. All the histopathology slides of salivary gland specimens during the study period were reviewed and clinical details were obtained from the archives. Restaining of slides and fresh sections of tissue blocks were performed whenever required. Data thus collected were analyzed.

RESULTS

A total of 104 cases of salivary gland lesions were studied during the study period. Age ranged from 5 years to 78 years with an overall slight female preponderance (M:F = 1:1.08). Parotid (56.65%) was the commonest gland involved followed by submandibular gland (31.73%).Neoplastic lesions comprised of 78 (75%) cases and non-neoplastic lesions constituted 25% (26 cases). Among the neoplastic lesions, benign lesions (53.85%) predominated over malignant lesions (21.15%). Pleomorphic adenoma was the commonest benign neoplastic lesion and mucoepidermoid carcinoma was the commonest malignant tumor. Chronic sialadenitis was the predominant lesion in the non-neoplastic group.

CONCLUSION

The principal site for salivary gland tumors was the parotid gland and pleomorphic adenoma outnumbered all the other tumors. Females are more affected in the malignant group.

Warthin's Tumor of Bilateral Parotid Glands: A Case Report

Bilateral Warthin's tumours of parotid constitute a small proportion of all salivary gland tumours. We present a case report of surgical management of a prototype case.

Bilateral multifocal Warthin's tumors in upper neck lymph nodes. Report of a case and brief review of the literature

Cystadenolymphomas (Warthin's tumors) are the second most frequent lesions of the parotid gland. Due to their benign clinical behavior, the low rates of recurrence and malignant transformation they were classified as tumor-like lesions. In addition, a polyclonal growth of the epithelial components of the tumor could be detected. Warthin's tumors occur bilateral in 7-10%, whereas a multifocal appearance is extremely rare. Even if the pathogenesis is still unclear a heterotopia of salivary tissue during embryogenesis is the most likely explanation for the origin of these tumors in the upper neck and periparotideal region. Here we present a rare case of bilateral, multifocal, extraglandular Warthin's tumors in lymph nodes of the upper neck and give a brief review of the literature. If a primary malignancy can be excluded by a careful staging procedure prior to the operation an isolated excision of the lesions of the neck is the adequate treatment.

[Thirteen years' experience with superficial partial parotidectomy as treatment for benign parotid tumours]

INTRODUCTION

Most authors agree that surgery is the treatment of choice for benign tumours of the parotid gland. However, the best surgical technique and the extent of surgery remain controversial. This study attempts to establish whether the implementation of a partial superficial parotidectomy (PSP) is appropriate for the treatment of benign parotid gland tumours.

MATERIAL AND METHODS

We selected 63 patients with benign parotid gland surgery, of whom 43 had a pleomorphic adenoma and 20, a Warthin tumour. Of this group of 63 patients, 6 could not be included. We consequently studied 57 patients, 41 of them diagnosed as pleomorphic adenoma and 16, as Warthin tumours. In all of them, a PSP was performed without intraoperative monitoring of the facial nerve.

RESULTS

Transient facial nerve paralysis, 14 patients (24.5%). Ten cases were resolved within the first month after surgery and 4 before the third month, after indicating facial physiotherapy. One patient (1.7%) had a permanent difficulty in keeping one side of the lower lip aligned under pressure-mobility, without altering commissure mobility. None of the patients studied had a recurrence (control, 3-13 years).

CONCLUSIONS

Although PSP is a technique with a few complications, it has a recurrence rate comparable to or lower than other techniques used for the treatment of pleomorphic adenomas or Warthin parotid tumours. Intraoperative facial nerve monitoring can be helpful during surgery. The lack of monitoring would not be considered a contraindication for surgery.

Using time-dependent covariate analysis to elucidate the relation of smoking history to Warthin's tumor risk

The authors aimed to elucidate the relation of the time-dependent smoking history parameters--age at smoking initiation and smoking intensity, duration, and latency--to the risk of Warthin's tumor, a benign tumor of the salivary gland for which cigarette smoking is a strong risk factor. They studied 117 cases of Warthin's tumor and 336 matched controls included in an Israeli nationwide case-control study of parotid gland tumors conducted from 2002 to 2003 by using the Cox regression model with time-dependent covariates, with age as the time axis. When current age and smoking duration were included in the statistical model, the authors show that the coefficient of a latency variable does not represent latency as such, but a balancing of the effects of age at initiation and time since cessation. They found a strong positive linear effect of duration of smoking, together with a positive nonlinear effect of intensity that levels off at higher intensities, and a negative effect of latency from 25 years onward. The latter finding implies that the effect of time since cessation dominates the effect of age at initiation, with risk decreasing sharply after smoking cessation. The relation of smoking variables to Warthin's tumor agrees with the patterns reported for lung cancer.

Smoking and risk of parotid gland tumors: a nationwide case-control study

BACKGROUND

Because existing data regarding the relation between smoking and salivary gland tumors are sparse, tobacco is currently not classified as a salivary gland carcinogen. The objective of the current study was to assess the association between smoking and benign and malignant parotid gland tumors (PGTs) in a nationwide study.

METHODS

The sample included 459 patients with incident PGT, aged > or =18 years, who were diagnosed between 2001 and 2003 and a group of 1265 individually matched, population-based controls. Analyses of the risk of PGT associated with various smoking variables were performed by using conditional logistic regression. Data also were stratified by histologic type; statistical significance tests were 2-sided.

RESULTS

Ever smoking cigarettes was associated with an odds ratio (OR) of 1.66 (95% confidence interval [95% CI], 1.31-2.11) for developing a PGT. The risk was strongest for early ages at smoking initiation, and trends of increasing risk were observed with increasing smoking intensity, pack-years, latent period, and smoking duration (P for trend <.001 for each). Analysis by histologic type indicated remarkably high risks for Warthin tumor (OR for ever cigarette smokers: 15.3; 95% CI, 6.1-38.5). For pleomorphic adenomas and malignant tumors, the risks associated with ever smoking were 1.01 (95% CI, 0.75-1.37) and 1.69 (95% CI, 0.81-3.51), respectively.

CONCLUSIONS

Smoking plays an important role in the development of Warthin tumor. Although no association was observed for pleomorphic adenoma, the possible indication of increased risk of malignant tumors requires further investigation in larger studies.

Parotid tumors: a 10-year experience

PURPOSE

The aim of the present study was to analyze the clinical presentation, histopathology, and complications of parotid tumors, as well as the management of malignant parotid tumors.

METHODS

We retrospectively reviewed the medical records of 271 patients who underwent parotidectomy from August 1996 to July 2006. Data including age, sex, clinical signs and symptoms, histologic findings, complications, malignant tumor stage, and prognosis were collected from medical charts.

RESULTS

Of the 271 patients who underwent parotidectomy, 229 (85%) had benign tumors, 33 (12%) had malignant tumors, and 9 had chronic inflammatory disease (3%). The most common benign tumor was pleomorphic adenoma (51%), and the most common malignant tumor was mucoepidermoid carcinoma (3%). The 5-year overall survival rate was 42%, and the disease-specific survival rate for malignant tumor was 72%. Only disease stage was the statistically significant prognostic factor of malignancy. The most common complication of parotidectomy was transient facial palsy (18%).

CONCLUSIONS

Standardized superficial and total parotidectomy are safe procedures for treating parotid tumors. Management of malignant tumors depends on tumor stage and histologic grade. Advanced tumor stage is a predictor of poor outcome.

Multifocal multi-site Warthin tumour

The unique case of a 55-year-old man with multifocal adenolymphoma (Warthin's tumour) of both parotid glands, the neck and post-nasal space is presented. Warthin tumour is almost exclusively a parotid tumour but is known to be bilateral in 7-10% of cases and multifocal in 2% of cases. Most extraglandular Warthin tumours have been located in neck lymph nodes and only a few cases have been reported from other sites. The presented case is unique in having synchronous and metachronous Warthin tumours, as well as one of the tumours being neither truly parotid, nor within a lymph node.

Role of salivary gland scintigraphy with Tc-99m pertechnetate in determining treatment of solitary parotid gland tumors: a retrospective study

PURPOSE OF THE REPORT

Although salivary gland scintigraphy has been useful for the diagnosis of Warthin's tumor (WT), there are no reports concerning the clinical impact of this scintigraphy.

MATERIALS AND METHODS

We retrospectively investigated 127 patients with solitary parotid tumors who had undergone salivary gland scintigraphy.

RESULTS

For patients who had surgery, the sensitivity, specificity, and accuracy of differentiating WT from non-WTs were 95%, 91%, and 92%, respectively. There was a significant correlation between scintigraphic results and the treatment decisions made for the 127 patients (chi2=16.5, P=0.00026). The proportion of WT patients among those who underwent surgery was 19%, whereas 42% of those who were suspected to have WT from scintigraphy were followed without surgical intervention. The main reasons for clinical observation in these patients were comorbidity, refusal of surgery, and age.

CONCLUSIONS

The high percentage of nonsurgical patients suspected to have WT can be explained by the high diagnostic accuracy of salivary gland scintigraphy, which is useful for determining further management when surgery is contraindicated or is refused by the patient.

Outcome of surgery for parotid tumours: 5-year experience of a general surgical unit in a teaching hospital

BACKGROUND

Most of the recent reports on the surgical management of parotid gland disorders come from specialist divisions of otolaryngology, head and neck, or faciomaxillary surgery. The aim of the present study was to evaluate the outcome of surgery for parotid tumours in a general surgical unit of a teaching hospital.

METHOD

A prospective clinicopathological study was undertaken over a 5-year period for consecutive patients operated on for parotid gland tumours in the King Saud University Unit of Riyadh Medical Complex. Parameters analyzed were demographic details, clinical presentation, diagnostic work-up, type of surgery, and outcome in terms of early and late morbidity.

RESULTS

Thirty seven parotid operations were performed on 36 consecutive patients. All patients presented with parotid gland swelling. Mean age was 51.6 years with a male preponderance. Fine-needle aspiration diagnosed the pathology in 33 out of 37 lesions. Pleomorphic adenoma was the commonest pathology observed in 24 patients (64.9%). Warthin's tumour was more common among male patients and was the only pathology with bilateral involvement. Malignant tumour was found in five patients (13.5%). Superficial conservative parotidectomy was the most frequently performed operation (84%). Overall postoperative morbidity was 13.5%. Transient facial nerve palsy was observed in seven cases (19%). There was no recurrence identified in patients with benign diseases during the mean follow up of 38.5 months.

CONCLUSION

Parotid gland surgery can still be performed in a general surgery unit with comparable outcome. However, the operation should be performed in units with special interest and experience in surgery for parotid gland disorders.

Salivary Gland Tumors at in Vivo Proton MR Spectroscopy

PURPOSE

To prospectively evaluate whether proton magnetic resonance (MR) spectroscopy can be used to characterize salivary gland tumors (SGTs).

MATERIALS AND METHODS

Ethics committee approval and informed consent were obtained. Hydrogen 1 ((1)H) MR spectroscopy was performed with echo times of 136 and 272 msec at 1.5 T in both SGTs and normal parotid glands. Spectra were analyzed in the time domain by using prior knowledge in the fitting procedure to obtain peak amplitudes of choline (Cho), creatine (Cr), and unsuppressed water. Mean Cho/Cr and Cho/water ratios for each subgroup of SGTs were obtained, and results were compared by using a nonparametric t test.

RESULTS

Successful spectra were acquired in 56 patients (35 men, 21 women; mean age, 56 years) with a total of nine malignant tumors and 47 benign SGTs (24 Warthin tumors, 22 pleomorphic adenomas, one oncocytoma). At an echo time of 136 msec, Cho/Cr ratios were obtained in 26 (47%) of 55 spectra, with a mean value (+/- standard deviation) of 1.73 +/- 0.47, 5.49 +/- 1.86, 3.46 +/- 0.84, and 2.45 for malignant tumors, Warthin tumors, pleomorphic adenomas, and oncocytoma, respectively. Differences were significant between Warthin tumors and pleomorphic adenomas (P = .028) and between benign SGTs and malignant tumors (P < .001). At an echo time of 272 msec, Cho/Cr ratios were obtained in 16 (30%) of 53 spectra, with a mean value of 2.27 +/- 0.69, 6.92 +/- 1.47, and 3.67 +/- 1.23 for malignant tumors, Warthin tumors, and pleomorphic adenomas, respectively. Differences were also significant between Warthin tumors and pleomorphic adenomas (P = .041) and benign SGTs and malignant tumors (P = .004). There was a significant difference in mean Cho/water ratio for Warthin tumors versus pleomorphic adenomas at echo times of 136 msec (P = .003) and 272 msec (P = .002) but not for benign SGTs versus malignant tumors.

CONCLUSION

(1)H MR spectroscopy may be used to characterize SGTs, but a larger study is required to validate these initial results.

Coexisting Facial Nerve Schwannoma and Monomorphic Adenoma of the Parotid Gland

We describe the case of a patient with a parotid mass that was found to consist of both a facial nerve schwannoma and a monomorphic adenoma. To our knowledge, this is the first report of these two lesions presenting as a single tumor. We also discuss the incidence, diagnosis, and treatment of parotid facial nerve schwannomas.

Bilateral parotid voluminous masses: a case report

The case of a 75-year-old woman with voluminous bilateral symmetrical masses of the parotid glands is reported, and the literature relevant to the differential diagnosis in bilateral neoplastic and nonneoplastic parotid masses is reviewed. The presurgical workup was based on clinical evaluations, nuclear magnetic resonance imaging findings, and cytologic examination to obtain the differential diagnosis. Benign or malignant tumors were excluded. Surgery was performed for esthetic reasons and in consideration of progressive enlargement of lesions. Histopathologic examination of resected masses revealed benign lymphoepithelial cysts with polyclonal infiltration of lymphoid cells. Serological testing for tuberculosis, cytomegalovirus, human immunodeficiency virus, and Epstein-Barr virus (EBV) and testing using the in situ hybridization technique for the presence of cytomegalovirus and EBV were negative for productive infection or viral replication. A diagnosis of retention cysts was suspected on the basis of presurgical evaluation, histopathological examination, and serologic analysis. In this case, bilateral obstruction of the parotid ducts by a mobile denture probably played the main role in the pathogenesis and development of bilateral parotid retention cysts, because any other specific cause for the pathogenesis was not found with diagnostic tools.

Parotid gland surgery: 4-year review of 118 cases in an Asian population

BACKGROUND

To determine the presentation and management of parotid lesions requiring excision in a largely Chinese Asian population.

METHODS

Retrospective study of 118 consecutive parotidectomies.

RESULTS

Thirty-seven percent were Warthin's tumor (WT), 33% pleomorphic adenoma (PA), 21% other benign disease (OBD), and 9% malignant tumor (MT). Mean age was significantly different between benign (51 years) and malignant (40 years) lesions. MT decreased above 50 years, but increased five times with pain and two times with a noninferior pole lesion. Sensitivity of fine-needle aspiration (FNA) for differentiating benign from MT = 78%, for WT =5 8%, for PA =82%, for OBD = 28%, and for MT = 38%. CT scans did not alter WT management. Facial nerve (FN) paresis was not associated with histology, tumor size, site, or parotidectomy type.

CONCLUSIONS

This is the first report documenting that most benign parotid tumors are WT and not PA. MT risk is greater in those less than 50 with pain and a noninferior pole lesion. Cystic lesions such as WT require great care in the evaluation of FNA findings.

False diagnosis caused by Warthin tumor of the parotid gland combined with actinomycosis

A case is reported in which a unilateral parotid gland cystadenolymphoma was combined with actinomycosis. A 48-year-old woman presented with a mass in the left parotid region and paresis of the lower left palpebra. The computed tomography, echography, and parotid radiographic findings did not exclude a neoplasm of the left parotid gland. The ramus of the mandible was involved in the process. Intraoperative freezing histology, total parotidectomy, and partial mandibulectomy were performed, with sacrifice of the facial nerve followed by nerve reconstruction. The final histological evaluation was Warthin tumor with actinomycosis. Four years after treatment, the patient is free of disease. No similar cases seem to have been reported thus far.

Synchronous Parotid and Nasopharyngeal Warthin's Tumors: First Report of a Case

Only a few isolated reports of Warthin's tumor of the nasopharynx have been published in the literature. None of the patients cited in those reports had another Warthin's tumor elsewhere. We describe the case of a patient who had synchronous nasopharyngeal and parotid Warthin's tumors—a case that we believe is the first to be reported in the literature. Our case provided us with a unique opportunity to study and compare the two tumors in a single patient. Their simultaneous presence might have been more than coincidental; it is possible that these two tumors were the result of the influence of one or more unknown systemic factors on trapped salivary elements in the lymphoid stroma.

Salivary gland tumors in a Brazilian population: a retrospective study of 124 cases

Salivary gland tumors constitute a highly heterogeneous histopathologic group. There are few epidemiological studies of large series of benign and malignant salivary gland tumors in Brazil.

MATERIAL AND METHODS

Hospital records of 124 patients with salivary gland tumors diagnosed from January 1993 to December 1999 were reviewed. The patients were analyzed according to gender, age, size, location, and histopathology of the tumor.

RESULTS AND CONCLUSIONS

Patients with benign and malignant tumors presented with a mean age of 47.7 and 48.8 years, respectively. The frequency of benign tumors was 80% (n = 99) and malignant tumors 20% (n = 25). Tumors were localized in the parotid gland 71% (n = 88), in the submandibular gland 24% (n = 30), and in the minor salivary glands 5% (n = 6). The most common benign tumors were pleomorphic adenoma in 84% (n = 84) and Warthin's tumor in 13% (n = 13). Among malignant tumors, mucoepidermoid carcinoma was the most common in 52% (n = 13), adenoid cystic carcinoma occurred in 20% (n = 5), and carcinoma ex pleomorphic adenoma was detected in 12% (n = 3).

Parotid Warthin's tumour Bristol Royal Infirmary (1985-1995): a study of histopathology in 33 cases

This is a study of 33 (32 patients) confirmed Warthin's tumours (adenolymphomas) treated surgically at Bristol Royal Infirmary (1985--1995) focussing specifically upon 17 salient histopathological features together with capsular measurement by micrometry. Twenty-four out of 33 tumours had 'thin' capsules (< or = 200 microm), whereas 5/9 'thick' capsules were associated with gross tumour degeneration. The degenerative features including cystic change, squamous metaplasia, corpora amylacea like bodies, etc. were quantified. Tumours were classified into subtypes (typical, stroma poor, etc). These variations were not associated with age or sex. In 20/33 tumours a marginal sinus suggested a lymph node origin. Fine needle aspiration cytology (FNA) smears showing degeneration features are a diagnostic problem, but histopathological features are reflected in such smears and their recognition enhances diagnostic precision, enabling controlled surgical enucleation, the ideal operation, to be performed in most cases. In this study only 12 tumours were so treated; 11 others received parotidectomy. The theories of histogenesis are reviewed and discussed.

Warthin's tumour: a study of 78 cases with emphasis on bilaterality, multifocality and association with other malignancies

The authors reviewed the clinical records and the histopathological preparations of 78 cases of Warthin's tumours (WTs), treated at the Department of Dental Sciences, Centre for the Study of Oral Tumours, of the University of Bari. All the surgical specimens had been fixed in neutral buffered formalin, sampled according to the step-serial, whole-specimen sectioning technique, embedded in paraffin and stained with haematoxylin-eosin, periodic acid Schiff and Gomori's reticulin. The results showed that Warthin's tumours characteristically affect the parotid gland, and most frequently arise in adults (mean age=57 years) and in males (95%). Multiple tumours were detected in 16 cases (20.5%), and five of these were bilateral (6.5%). One of the multifocal tumours involved an intra-parotideal lymph node and the laryngeal piriform sinus. In addition, 13 cases (16.6%) were associated with other malignancies. These data indicate that multiple (synchronous or metachronous) WTs may occur more frequently than previously reported. The high rate of multiple WTs detected in the current study may result from extensive and accurate sampling of these neoplasms for histopathological evaluation. Consequently, complete preoperative work-up of patients harbouring parotideal tumours consistent with or suspicious for WT is necessary. The work-up should include CT scans and/or magnetic resonance imaging of both parotid glands, to exclude the occurrence of multiple tumours, which may be clinically undetectable. Also, fine needle aspiration biopsy may be an accurate tool for excluding malignant neoplasms and for better planning subsequent surgical procedures. These usually consist in (bilateral) superficial parotidectomy and should be followed by long term follow up of the patients, in view of possible metachronous WTs, even after prolonged time intervals.

Steroid hormone receptors in parotid gland cystadenolymphoma (Warthin's tumour)

The aetiopathogenesis of cystadenolymphoma is mostly unknown. Cystadenolymphomas have a significantly higher incidence in the male than the female population. This might be as a result of endocrine dependency in this kind of tumour. The purpose of the present study was to determine the sex hormone receptor status in cystadenolymphoma. Tissue samples of cystadenolymphoma, pleomorphic adenoma and normal samples of the parotid gland were examined immunohistochemically for oestrogen and progesterone receptors. Progesterone-positive cells could be found in the salivary duct system of normal glands and in the epithelial components of cystadenolymphomas. There was no evidence for the presence of oestrogen receptor in any sample studied. The evidence of progesterone receptors in cystadenolymphoma may implicate a potential role of endocrine factors in the development of this tumour.

Management of intraparotid facial nerve schwannomas

BACKGROUND

The purpose of the present paper was to review the management of intraparotid facial nerve schwannoma so as to discuss its clinical presentation, evaluate the various possible diagnostic investigations, and compare the various surgical options and outcome.

METHODS

Case series was undertaken of five (1.3%) patients with facial nerve schwannoma out of 400 consecutive parotidectomies at Singapore General Hospital.

RESULTS

There were three men and two women with an age range of 29-65 years. Three patients presented with painless parotid lumps while two had painful parotid swellings. None had facial nerve paresis. Only one patient had preoperative diagnosis suspicious of schwannoma by fine-needle aspiration cytology (FNAC). Diagnoses were made intraoperatively. Four patients had excision with cable grafting of the nerve defect. achieving facial nerve grade II-IV (House-Brackmann scale). One patient who underwent enucleation of tumour with nerve preservation achieved grade II.

CONCLUSIONS

Preoperative diagnosis is difficult but it is important for discussion of the extent and options of surgery. Fine-needle aspiration cytology holds promise in making a preoperative diagnosis. Enucleation with nerve preservation where possible seems to offer better facial function whereas nerve excision with cable graft can give satisfactory results.