Metastatic cutaneous squamous cell carcinoma to the parotid: the role of surgery and adjuvant radiotherapy to achieve best outcome.

Dona E, Veness MJ, Cakir B, Morgan GJ.   ANZ J Surg. 2003 Sep;73(9):692-6.

Head and Neck Unit, Westmead Hospital, Sydney, New South Wales, Australia.

BACKGROUND: Australia has the highest incidence of cutaneous squamous cell carcinoma in the world. The majority of lesions occur in the head and neck with metastases to the parotid gland lymph nodes reflecting an uncommon, but aggressive, manifestation. Parotidectomy +/- neck dissection followed by adjuvant radiotherapy should be considered as best practice. METHODS: Between 1983 and 2000, seventy-four patients were treated for metastatic cutaneous squamous cell carcinoma to the parotid with surgery and adjuvant radiotherapy at Westmead Hospital, Sydney. Relevant data were extracted from patient files and a prospectively maintained database. Patterns of relapse and outcome were analysed. RESULTS: Median age at diagnosis was 65 years (34-93 years) in 63 men and 11 women. Median follow-up duration was 41 months (12-188 months). All patients underwent parotidectomy with 52 undergoing a simultaneous neck dissection. Twelve patients required sacrifice of the facial nerve (4) or one or more branches (8). All received adjuvant radiotherapy to the parotid region with 56 also receiving radiotherapy to the ipsilateral neck. Despite treatment, 24% developed locoregional recurrence, with a median time to relapse of 7.5 months. The most common site for recurrence was the treated parotid region and upper neck. Most relapsed patients died. No variable independently predicted for locoregional recurrence on multivariate analysis. The 5-year absolute and cause-specific survival rates were 58% and 72%, respectively. CONCLUSION: Parotid gland lymph node metastases from cutaneous squamous cell carcinoma are associated with a high rate of recurrence and cause-specific mortality despite current best practice (surgery and high dose adjuvant radiotherapy). The role of more aggressive surgery, altered fractionation or chemotherapy to enhance locoregional control remains unclear.

Aggressive treatment of metastasis to the parotid.

Raut V, Sinnathuray AR, Primrose WJ.

Royal Victoria Hospital, Belfast BT12 6BA.  Ulster Med J. 2004 Nov;73(2):85-8.

Twelve patients were treated aggressively with at least total parotidectomy and adjunctive therapy, whilst one patient required only a superficial parotidectomy. Ten patients had metastatic cutaneous tumours, and three had metastatic adenocarcinoma. Seven of these 13 patients (53.8 %) are alive and well (six had metastatic cutaneous tumours, one had metastatic adenocarcinoma). Four patients succumbed to tumour (two had metastatic cutaneous tumours and two had metastatic adenocarcinoma), and two patients succumbed from unrelated medical causes (both had metastatic cutaneous tumours). The mean follow-up for those alive is 65.9 months and mean follow-up for those deceased is 15.3 months. CONCLUSIONS: In the absence of systemic spread, parotid metastases from primary cutaneous squamous cell carcinoma should be treated aggressively, while metastases from non-cutaneous primary tumours should be approached with caution.

Parotid and neck metastases from cutaneous squamous cell carcinoma of the head and neck.

Khurana VG, Mentis DH, O'Brien CJ, Hurst TL, Stevens GN, Packham NA.  Am J Surg. 1995 Nov;170(5):446-50.

Department of Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, Australia.

BACKGROUND: Approximately 5% of cutaneous squamous cell carcinomas (SCC) metastasize to regional nodes. Nodal involvement may be more common for cutaneous squamous cell carcinomas of the head and neck, but few large series have reported clinical outcome after treatment of parotid gland and neck metastases from these cancers. PATIENTS AND METHODS: A combined retrospective/prospective study of patients treated between 1983 and 1994 was performed. There were 69 men and 6 women, with a median age of 67 years. Twenty-nine patients had neck metastases, and 33 had parotid gland metastases, while 13 patients had involvement at both sites. Of the 75 patients, 68 were treated surgically and 50 received postoperative radiotherapy. RESULTS: The facial nerve was sacrificed totally in 6 patients and partially in 9. Histologic extranodal spread was present in 48 (71%) of all surgically treated patients. Among 61 patients followed up to recurrence, or for greater than 12 months, 26 (43%) developed recurrence--12 in the parotid gland, 7 in the neck, and 7 in both sites. Multiple recurrences were common and occurred at a median of 8 months after surgery. Positive surgical margins were associated with poorer local disease control (P < 0.05). Cumulative survival at 5 years was 61%, but only 15 of 70 evaluable patients (21%) were eligible for follow-up at this time. Neck involvement with or without parotid gland disease was associated with an increased risk of distant metastases, but this was not statistically significant. Postoperative radiotherapy was not associated with improved disease control. CONCLUSION: Cutaneous, metastatic SCC involving the parotid gland and neck is an aggressive disease with a tendency to an infiltrative growth pattern and multiple recurrences. More aggressive surgery may be justified to reduce the incidence of regional failure after parotidectomy and neck dissection.

Parotidectomy in the treatment of aggressive cutaneous malignancies.

Lai SY, Weinstein GS, Chalian AA, Rosenthal DI, Weber RS.   Arch Otolaryngol Head Neck Surg. 2002 May;128(5):521-6.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Medical Center, 5 Silverstein/Ravdin, 3400 Spruce St, Philadelphia, PA 19104, USA.

BACKGROUND: Aggressive nonmelanoma skin cancer (ANMSC) of the head and neck may require parotidectomy because of neurotropic spread, direct invasion of the parotid gland, or parotid metastasis. OBJECTIVE: To review our experience with parotidectomy in the treatment of these tumors to examine the indications for this procedure and to analyze treatment outcomes. We emphasize the importance of early identification of an ANMSC and a systematic approach to treatment. DESIGN: Review of 23 patients with an ANMSC who required parotidectomy with or without facial (VII) nerve sacrifice between January 5, 1996, and December 27, 1999. Median follow-up for all patients was 24 months. SETTING: Academic tertiary care referral center. PATIENTS: This study focused on 23 (median age, 71 years) of 54 patients treated for an ANMSC. Most tumors were in the periauricular (n = 9) and the frontozygomatic (n = 6) areas. Seven patients presented with facial weakness or paralysis. Three patients had clinically evident parotid metastasis, while 14 patients had tumors directly invading the parotid gland. Eighteen patients had recurrent disease that had been treated previously with Mohs micrographic surgery. INTERVENTIONS: Following wide local excision of the ANMSC, 12 patients had resection of the lateral parotid lobe with preservation of the nerve, while 11 required radical parotidectomy with sacrifice of 1 or more branches. Nineteen patients received cervical lymphadenectomy. Postoperative radiotherapy was administered in 19 patients. MAIN OUTCOME MEASURES: Tumor pathologic findings (specifically, perineural invasion of the facial nerve), locoregional control or recurrence, disease-free survival, disease-specific survival, and overall survival. RESULTS: Neurotropic spread to the facial nerve was present in 6 patients and was more likely to occur in younger patients (51 vs 75 years, P =.006). Locoregional failures occurred in 9 patients following treatment. Patients who required parotidectomy in their surgical treatment for an ANMSC were more likely to have recurrent disease (P =.0002). Disease-specific and overall survival was 79% and 69%, respectively, at 42 months. CONCLUSIONS: Patients with ANMSC may require parotidectomy in the context of neurotropic spread, regional metastasis, or direct invasion into the parotid gland. Surgery combined with postoperative radiotherapy is necessary in most patients because of adverse clinical and pathologic findings. A systematic approach to the management of the parotid and facial nerve in the presence of these aggressive tumors is required. Despite comprehensive treatment, local recurrence of ANMSC and mortality remain high.

Metastatic tumours of the parotid gland.

Malata CM, Camilleri IG, McLean NR, Piggott TA, Soames JV.  Br J Oral Maxillofac Surg. 1998 Jun;36(3):190-5.

West of Scotland Plastic and Oral Surgery Unit, Canniesburn Hospital, Glasgow, UK.

Twenty patients (12 men and 8 women, median age 69 years) with metastatic tumours in the parotid gland who presented over a 12-year period were evaluated retrospectively. Preoperative investigations included fine needle aspiration cytology (n = 11) and computed tomography or magnetic resonance imaging (MRI) (n = 14). Most tumours originated from the head and neck region, the two main types being squamous cell carcinoma (n = 10) and malignant melanoma (n = 7). All 20 presented with a parotid mass and 11/20 (55%) had associated lymphadenopathy. Eleven patients (55%) underwent superficial, five total, and four radical, parotidectomy. Neck dissection was required in 16 patients (80%), and all 11 patients with clinically palpable lymph nodes had evidence of tumour in the neck dissection specimens. Half of all patients (n = 10) received adjuvant postoperative radiotherapy. Three-quarters of the patients (n = 15) were alive after a mean follow-up of 31 months and only one developed a marginal recurrence. The cumulative 5-year survival rate was 51%, and there was no significant difference (P = 0.48) in the 3-year survival rates of patients who had radical compared with those who had modified neck dissections. Patients who had superficial parotidectomy had a longer overall survival compared with those who had total or radical parotidectomy (P = 0.04) perhaps reflecting the advanced nature of tumours that required total or radical excision of the gland. We conclude that superficial parotidectomy is usually an adequate treatment for secondary parotid tumours (when disease is clinically limited to the superficial lobe), and we suggest that patients in whom metastatic disease of the parotid gland is suspected do not require neck dissection if they have no palpable lymph nodes and MRI shows no evidence of spread. There seems to be no survival advantage in radical over modified neck dissection.

Primary and metastatic cancer of the parotid: comparison of clinical behavior in 232 cases.

Bron LP, Traynor SJ, McNeil EB, O'Brien CJ.   Laryngoscope. 2003 Jun;113(6):1070-5.

Sydney Head and Neck Cancer Institute, Royal Prince Alfred Hospital, Australia.

OBJECTIVES/HYPOTHESIS: Parotid malignancy may develop as a primary cancer of salivary tissue or by metastatic involvement of parotid lymph nodes. The aim of the study was to compare the clinical behavior of primary and metastatic parotid cancers by analyzing patterns of treatment failure and clinical outcomes. STUDY DESIGN: Retrospective review of clinical and pathologic data prospectively accessioned onto a computerized database. METHODS: A prospectively documented series of 232 parotidectomies carried out for treatment of cancer from 1988 to 1999 was reviewed. There were 177 male and 55 female patients with a median age of 65 years (age range, 17-97 y). Median follow-up time was 4 years. Pathological groups included 54 patients with primary parotid cancer, 101 with metastatic cutaneous squamous cell carcinoma, 69 with metastatic melanoma, and 8 with other metastatic cancers. RESULTS: Neck nodes were clinically positive in 12 patients with primary cancer, 24 patients with squamous cell carcinoma, 16 with melanoma, and 2 with other metastatic malignancies. Conservative parotidectomy, preserving the main trunk of the facial nerve, was performed in 185 patients, and 47 patients had a radical parotidectomy sacrificing the facial nerve. There were 54 therapeutic and 110 elective neck dissections. Adjuvant radiotherapy was given to 39 patients with primary cancer, 86 with squamous cell carcinoma, 50 with melanoma, and 8 in the other metastatic group (78% of the patients in the series). Local control rates at 5 years in the four groups were 86%, 75%, 94%, and 100%, respectively (P <.01). Survival rates at 5 years were 77%, 65%, 46%, and 56%, respectively (P <.01). CONCLUSIONS: The pattern of parotid malignancy is unique in Australia because of the high incidence of skin cancer, which can metastasize to the parotid gland. Metastatic cutaneous malignancy predominates. The pattern of failure and outcome varied depending on histological findings. Local failure occurred most often in metastatic squamous cell carcinoma, whereas patients with melanoma had the highest incidence of distant spread.

Significance of clinical stage, extent of surgery, and pathologic findings in metastatic cutaneous squamous carcinoma of the parotid gland.

O'Brien CJ, McNeil EB, McMahon JD, Pathak I, Lauer CS, Jackson MA.   Head Neck. 2002 May;24(5):417-22.

Department of Head and Neck Surgery, Royal Prince Alfred Medical Centre, 100 Carillon Avenue, Newtown NSW, Australia 2042.

BACKGROUND: Metastatic cutaneous cancer is the most common parotid malignancy in Australia, with metastatic squamous carcinoma (SCC) occurring most frequently. There are limitations in the current TNM staging system for metastatic cutaneous malignancy, because all patients with nodal metastases are simply designated N1, irrespective of the extent of disease. The aim of this study was to analyze the influence of clinical stage, extent of surgery, and pathologic findings on outcome after parotidectomy for metastatic SCC by applying a new staging system that separates metastatic disease in the parotid from metastatic disease in the neck. METHODS: A prospectively documented series of 87 patients treated by one of the authors (COB) over 12 years for clinical metastatic cutaneous SCC involving the parotid gland and a minimum of 2 years follow-up was analyzed. These patients were all previously untreated and were restaged according to the clinical extent of disease in the parotid gland in the following manner. P1, metastatic SCC of the parotid up to 3 cm in diameter; P2, tumor greater than 3 cm up to 6 cm in diameter or multiple metastatic parotid nodes; P3, tumor greater than 6 cm in diameter, VII nerve palsy, or skull base invasion. Neck disease was staged in the following manner: N0, no clinical metastatic disease in the neck; N1, a single ipsilateral metastatic neck node less than 3 cm in diameter; N2, multiple metastatic nodes or any node greater than 3 cm in diameter. RESULTS: Clinical P stages were P1, 43 patients; P2, 35 patients; and P3, 9 patients. A total of 21 patients (24%) had clinically positive neck nodes. Among these, 11 were N1, and 10 were N2. Conservative parotidectomies were carried out in 71 of 87 patients (82%), and 8 of these had involved surgical margins (11%). Radical parotidectomy sacrificing the facial nerve was performed in 16 patients, and 6 (38%) had positive margins, (p <.01 compared with conservative resections). Margins were positive in 12% of patients staged P1, 14% of those staged P2, and 44% of those staged P3 (p <.05). Multivariate analysis demonstrated that increasing P stage, positive margins, and a failure to have postoperative radiotherapy independently predicted for decreased control in the parotid region. Survival did not correlate with P stage; however, many patients staged P1 and P2 also had metastatic disease in the neck. Clinical and pathologic N stage both significantly influenced survival, and patients with N2 disease had a much worse prognosis than patients with negative necks or only a single positive node. Independent risk factors for survival by multivariate analysis were positive surgical margins and the presence of advanced (N2) clinical and pathologic neck disease. CONCLUSIONS: The results of this study demonstrate that patients with metastatic cutaneous SCC in both the parotid gland and neck have a significantly worse prognosis than those with disease in the parotid gland alone. Furthermore, patients with cervical nodes larger than 3 cm in diameter or with multiple positive neck nodes have a significantly worse prognosis than those with only a single positive node. Also, the extent of metastatic disease in the parotid gland correlated with the local control rate. The authors recommend that the clinical staging system for cutaneous SCC of the head and neck should separate parotid (P) and neck disease (N) and that the proposed staging system should be tested in a larger study population

Cutaneous metastatic squamous cell carcinoma to the parotid gland: analysis and outcome.

Audet N, Palme CE, Gullane PJ, Gilbert RW, Brown DH, Irish J, Neligan P.   Head Neck. 2004 Aug;26(8):727-32.

Princess Margaret Hospital, Wharton Head and Neck Centre 3-951, 610 University Avenue, Toronto, Ontario M4S 1C6, Canada.

BACKGROUND: Our aim was to review the presentation, treatment, and outcome of patients with metastatic cutaneous squamous cell carcinoma involving the parotid gland at a tertiary referral center. METHODS: We performed a retrospective chart review of the cancer registry at the Princess Margaret Hospital, Toronto, from 1970 to 2001. All patients had a previously untreated metastatic cutaneous head and neck squamous cell carcinoma involving the parotid gland. A minimal follow-up of 1 year was mandatory for inclusion in the study. RESULTS: Fifty-six white patients (43 men and 13 women), with a median age of 76 years (range, 49-97 years), were eligible for inclusion. The disease in all patients was retrospectively staged according to a new system. Twenty patients had P1 disease, 14 had P2, and 22 had P3. Therapy included surgery and adjuvant external beam radiation in 37 patients, single-modality external beam radiation in 12, and surgery alone in seven patients. The overall recurrence rate was 29%. The disease-specific survival was significantly worse in patients treated with external beam radiation alone (p <.05). Tumor size >6 cm (p <.01) and the presence of facial nerve involvement (p <.01) were poor prognostic factors. CONCLUSIONS: Metastatic cutaneous squamous cell carcinoma to the parotid gland is an aggressive neoplasm that requires combination therapy. The presence of a lesion in excess of 6 cm or with facial nerve involvement is associated with a poor prognosis

Metastatic malignant disease to the parotid gland.

Yarington CT Jr.   Laryngoscope. 1981 Apr;91(4):517-9.

A survey of over 250 consecutive parotidectomies performed at The Mason Clinic indicates a surprising incidence of metastatic malignant disease to the parotid gland. Four percent of all parotidectomies performed indicated a metastatic focus of malignancy from an unsuspected primary outside areas of the head and neck usually implicated in parotid disease. Twenty-five percent of all cancer discovered at parotidectomy was metastatic malignant disease to the parotid gland. The most common site was the lung. A high index of suspicion, evaluation of pathologic specimens by electron microscopy, and detailed metastatic work-up for patients with malignant disease in parotid lymph nodes are recommendations which should be considered by the surgeon performing parotid procedures.

[Exclusive radiotherapy of parotid metastases. Results in 14 cases]

[Article in Italian]

Krengli M, Pisani P, Pia F.  Radiol Med (Torino). 1993 Nov;86(5):684-6.

Divisione di Radioterapia, Facolta di Medicina e Chirurgia di Novara, Universita di Torino.

Parotid metastases are uncommon lesions. In most cases the skin of the head and neck is the site of the primary tumor, which is usually a squamous cell carcinoma or a melanoma. Infraclavicular or non-cutaneous head and neck cancers one less likely to cause a parotid metastasis. From 1968 to 1991, 38 patients (9 men and 5 women aged 45 to 96 years) affected with parotid metastases, were treated in the Department of Radiotherapy at the Ospedale Maggiore of Novara. All patients received exclusive irradiation. In 12 patients the primary lesion was found in the skin of the head and neck (11 squamous cell carcinomas and 2 melanomas), one had an undifferentiated nasopharyngeal carcinoma and one a squamous cell lung carcinoma. In 9 cases the parotid gland was the only site of metastasis, in 2 cases lateral cervical lymph nodes metastases were also present and in 3 cases distant metastases. Radiotherapy was performed with cobalt 60; the target volume was limited to the parotid region in the N1-N2a cases and included the ipsilateral cervical nodes in the N2b-N3a cases. The doses ranged 24-66 Gy (mean: 50, median-52), with daily fractionation of 1.8-2 Gy for 5 days/week. After radiotherapy local control was obtained in 8/14 cases (57%), maintained at 2 years in 7/14 patients and at 5 years in 2/10 patients (20%). Eight patients (57%) relapsed in the parotid and/or cervical areas and/or exhibited widespread metastases and finally died; 6 patients (43%) were NED after a minimum 3 years' follow-up. Parotid metastases are usually treated by surgical resection; radiotherapy can be used as postoperative or exclusive treatment. Exclusive radiotherapy can be used for the skin cancers which are inoperable for general or local conditions (fixation, necrosis, ulceration), for mucosal head and neck cancers treated by radiotherapy and for infraclavicular tumors as a palliative treatment. Prognosis is different for skin cancer, mucosal and head and neck a carcinoma and infraclavicular neoplasms. The best results can be obtained with N1 nodes and high-dose irradiation.