Pleomorphic Adenoma
A | Facial nerve involvement indicate malignancy | |
B |
It occurs most commonly in parotid gland |
|
C |
Malignant disease is most common variety |
|
D |
Superficial parotidectomy is the treatment of choice |
Which of the following is not true about the pleomorphic adenoma of parotid gland?
A |
Facial nerve involvement indicate malignancy |
|
B |
It occurs most commonly in parotid gland |
|
C |
Malignant disease is most common variety |
|
D |
Superficial parotidectomy is the treatment of choice |
Superficial parotidectomy is the treatment of choice The ratio of malignant to benign tumors by the as well: parotid gland, 80% benign and 20 % malignant; Submandibular gland and sublingual gland, 50% benign and 50% malignant; and minor salivary glands, 25% benign and 75% malignant
Ref: L & B 25/e, page 761-62 ; Sabiston 18/e, page 834-36 ; Robins 7/e, page 791-92 ; Textbook of surgery by S. Das 5/e, page 607-609
A |
Superficial parotidectomy |
|
B |
Radical parotidectomy |
|
C |
Enucleation |
|
D |
Radiotherapy |
- Ans.A
- Pleomorphic adenomas, or benign mixed tumors, are the most common neoplasms of the salivary glands.
- The mixture of epithelial, myoepithelial, and stromal elements is represented by the name, benign mixed tumor.
- Both immunohistochemical stains specific for myoepithelial cells and epithelial cells can help to distinguish pleomorphic adenoma.
- The treatment of choice is surgical excision with a margin of normal tissue (e.g., superficial parotidectomy).
- Superficial parotidectomy with clear margins is the treatment of a pleomorphic adenoma located in the superficial lobe of the parotid gland.
Ramavati a 40 years old female presented with a progressively increasing lump in the parotid region. On oral examinations, the tonsil was pushed medially. Biopsy showed it to be pleomorphic adenoma. The appropriate treatment is ‑
A |
Superficial parotidectomy |
|
B |
Lumpectomy |
|
C |
Conservative total parotidectomy |
|
D |
Enucleation |
Ans. is ‘C’ ie. Conservative total parotidectomy
- In this patient, a deep lobe of parotid is involved (as suggested by medial displacement of the tonsil) so total parotidectomy is done conserving the facial nerve.
- Middle-aged women, around 40 years, are commonly affected.
- The swelling is painless.
- Parotid swelling has the following classical features:
- It presents as a swelling in front, below and behind the ear.
- Raises ear lobule.
- The retromandibular groove is obliterated.
- Conservative superficial parotidectomy is the TOC.
- It is the standard surgery done for benign pleomorphic adenoma.
- It means the removal of the entire lobe containing the tumor which is superficial to the facial nerve.
- The facial nerve should always be preserved.
- Enucleation should never be done as it causes recurrence and can injure the facial nerve.
A |
Most commonly arises in Parotid |
|
B |
Slow growing |
|
C |
Well encapsulated |
|
D |
a and b |
Ans is A (Most commonly arises in Parotid) & B (Slow growing)
Devito writes- “these slow-growing neoplasms are surrounded by an imperfect pseudocapsule traversed by fingers of tumor”
Pleomorphic adenomas are surrounded by an imperfect pseudocapsule, which is traversed by pseudopodia like projections of the tumor. Incomplete removal of these fingers like projections is the cause of recurrence of the tumor.
A |
Involvement of deep lobe |
|
B |
2nd histologically benign recurrence |
|
C |
Microscopically positive margins |
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D |
Malignant transformation |
Ans. is none or (b) is the best option
The above mentioned books mention the following indications of postop radiotherapy in Pleomorphic adenoma of parotid.
Indications for postop radiotherapy in Pleomorphic adenoma
- Involvement of the deep lobe of the parotid
- Recurrent lesions
- Large (> 5 cm) lesions, which may not allow complete surgical excision with adequate margins.
- Microscopically positive margins after surgical resection.
- Malignant transformation within a predominantly benign tumor.
- So all the given options are indications for post op radiotherapy, but if we have to choose one option we would go for option (b) i.e. 2nd histologically benign recurrance, as its the most controversial one.
A | Arises from parotid | |
B |
May turn into malignant |
|
C |
Minor salivary gland can be affected |
|
D |
None |
They represent 60-70% of all parotid tumors and 90% of submandibular benign tumors
M/C age group affected is fourth decade
M/C gland involved – parotid gland
M/C site affected in parotid gland is – tail of parotid gland
They are slow growing painless tumors
Histologically, they contain both epithelial and mesenchymal elements and are therefore called as mixed tumors.
It can rarely undergo malignant transformation (current otolaryngology 2nd/ed )
TOC – Surgery – Complete surgical i.,xcision of the tumor with uninvolved margins is the recommended treatment
Prognosis is excellent with a 95% non-recurrence rate.
A | Superficial parotidectomy | |
B |
Lumpectomy |
|
C |
Conservative total parotidectomy |
|
D |
Enucleation |
For parotid tumors that arise in lateral lobe superficial parotidectomy with preservation of CN VII is indicated. If the tumor extends in to deep lobe of parotid, a total parotidectomy with nerve preservation is performed.
Surgery of choice for pleomorphic adenoma is:
September 2007, 2010
A |
Total parotidectomy |
|
B |
Superficial parotidectomy |
|
C |
Total parotidectomy with lymph node dissection |
|
D |
Radical parotidectomy |
Ans. B: Superficial parotidectomy
Although almost one half of tumors found in the minor salivary glands are malignant, the pleomorphic adenoma is still the most common tumor in these glands.
The current standard is that all pleomorphic adenomas should be surgically removed because the risk of malignancy is 25% if the tumors are left untreated.
All the tumours of the superficial lobe of the parotid gland should be managed by superficial parotidectomy (Superficiall parotidectomy is the commonest procedure done for parotid gland pathology)
Radical parotidectomy is done when there is clear histological evidence of a high grade malignant tumour.
A | Most common tumor of salivary glands | |
B |
Has a tendency to invade perineural space |
|
C |
Most commoly involves the parotid gland |
|
D |
It is also called a mixed tumor |
Ans. B. Has a tendency to invade perineural space
Pleomorphic adenoma
- This is the Commonest neoplasm of Salivary glands.
- The most Common salivary gland involved is Parotid – represent about 60% tumors in the parotid. o Submandibular and minor salivary glands may also be involved rarely.
- Pleomorphic adenoma → Parotid > Submandibular > minor salivary glands.
- They are derived from a mixture of ductal (epithelial ) and myoepithelial cells and therefore they show both epithelial and mesenchymal differentiation – Also called mixed tumor.
A | Parotid salivary gland | |
B |
Submandibular salivary gland |
|
C |
Sublingual gland |
|
D |
Submaxillary gland |
Pleomorphic adenoma is MC variety, d. Superficial parotidectomy is the treatment of choice
In parotid tumors, rapid growth, pain, paraesthesia, enlarged cervical LN and restriction of jaw movements, facial weakness or skin invasion and fixation of mastoid tip is suggestive of malignant transformation.
A 30-year-old man had a pleomorphic adenoma removed from his left parotid gland. His postoperative course was uncomplicated. Two months later, he noted that his left cheek shows the condition as represented in the picture below while he was eating. Most likely diagnosis is ?

A |
Frey’s syndrome. |
|
B |
Gustatory sweating. |
|
C |
Both A and B. |
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D |
None of the above. |
Ans:C.)Both A and B.)Frey’s syndrome and Gustatory sweating
Frey’s Syndrome (Gustatory sweating)
- The pathogenesis is based on the aberrant regeneration of sectioned parasympathetic secretomotor fibres of the auriculotemporal nerve with inappropriate innervation of the cutaneous facial sweat glands that are normally innervated by sympathetic cholinergic fibres.
- As a consequence, Frey syndrome is a disorder characterized by unilateral sweating and flushing of the facial skin in the area of the parotid gland occurring during meals that becomes evident usually 1-12 months after surgery.
- It can develop after a variety of insults to the autonomic nervous system, such as trauma or radiation therapy, but is most commonly encountered as a complication of parotidectomy.
- Diagnosis is made based on clinical signs and symptoms and a starch iodine test, called the Minor Iodine-Starch test.
- Good results have been obtained with local injection of botulinum toxin .
Complications of Patotid Gland Surgery
Intra-operative complications | Post-operative complications | |
Early | Late | |
Transection of facial nerve | Facial nerve paralysis | Facial synkinesis after facial palsy |
Rupture of capsulae of parotid tumour | Haemorrhage or haematoma | Hypoesthesia of greater auricular nerve |
Incomplete surgical resection of parotid tumour | Infection | Recurrent tumour |
Skin flap necrosis | Soft tissue deficit | |
Cosmetic deformity | Hypertrophic scar or keloid | |
Trismus | Frey’s syndrome | |
Parotid fistula |
Pleomorphic adenoma histology is characterized by‑
A |
Epithelial component |
|
B |
Endothelial component |
|
C |
Mesodermal component |
|
D |
Mixed epithelial and mesenchymal components |
Ans. is ‘d’ i.e., Mixed epithelial and mesenchymal components
- They are derived from a mixture of ductal (epithelial ) and myoepithelial cells and therefore they show both epithelial and mesenchymal differentiation -Also called mixed tumor.
Pleomorphic adenoma :‑
- This is the Commonest neoplasm of Salivary glands.
- The most Common salivary gland involved is Parotid – represent about 60% tumors in the parotid.
- Submandibular and minor salivary glands may also be involved rarely.
- Pleomorphic adenoma → Parotid > Submandibular > minor salivary glands.
- They are derived from a mixture of ductal (epithelial ) and myoepithelial cells and therefore they show both epithelial and mesenchymal differentiation – Also called mixed tumor.