Pleomorphic Adenoma

Pleomorphic Adenoma

Q. 1

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

Q. 1

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

Ans. C

Explanation:

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

Facial nerve palsy is an infrequent presenting complaint and indicate malignancy.
Pleomorphic adenoma (mixed tumor):
This is the commonest tumor of the major salivary gland and its marked feature id histological diversity.

It is called mixed because beside epithelial element there is also myxoid, hyline, chondroid (cartilaginous) and even osseous bone.
About 90% of pleomorphic adenoma is seen in parotid gland ,7% is seen in submandibular gland. tail of the parotid is commonest location in the tail of parotid.
 
Nature of tumor:
It is basically a benign tumor.

Recurrence rate, which is reported to be high, was mostly due to fault in the surgical technique in the form of simple enucleation which was often used earlier.

The incidence of malignant transformation increases with the duration of the tumor, being 2% for tumors present with less than 5 years duration and 10% for those of more than 15 years duration.
Treatment:
This tumor is radioresistant, so excision is treatment of choice.

Superficial parotidectomy is the treatment of choice, this operation is known as patey’s operation.

In case of submandibular gland neoplasm, the whole gland is excised with particular care to preserve the lingual and hypoglossal nerve.

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


Q. 2

A female presented with swelling over angle of mouth. Investigation shows pleomorphic adenoma of the superficial lobe.Treatment of choice is:

 A

Superficial parotidectomy

 B

Radical parotidectomy

 C

Enucleation

 D

Radiotherapy

Q. 2

A female presented with swelling over angle of mouth. Investigation shows pleomorphic adenoma of the superficial lobe.Treatment of choice is:

 A

Superficial parotidectomy

 B

Radical parotidectomy

 C

Enucleation

 D

Radiotherapy

Ans. A

Explanation:

Pleomorphic adenomas, or benign mixed tumors, are the most common neoplasms of the salivary glands.

They represent approximately 60–70% of all parotid tumors and 90% of submandibular benign tumors.

The mixture of epithelial, myoepithelial, and stromal elements is represented by the name, benign mixed tumor.

Any of these individual components may predominate in the histology, but all three must be present to confirm the diagnosis.

Both immunohistochemical stains specific for myoepithelial cells and epithelial cells can help to distinguish pleomorphic adenoma.

Complete surgical excision of the tumor with uninvolved margins is the recommended treatment.

For example, a superficial parotidectomy with clear margins is the treatment of a pleomorphic adenoma located in the superficial lobe of the parotid gland. 
 
Ref: Butt F.Y. (2012). Chapter 18. Benign Diseases of the Salivary Glands. In A.K. Lalwani (Ed), CURRENT Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery, 3e.

Q. 3

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 tratment is ‑

 A

Superficial parotidectomy

 B

Lumpectomy

 C

Conservative total parotidectomy

 D

Enucleation

Q. 3

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 tratment is ‑

 A

Superficial parotidectomy

 B

Lumpectomy

 C

Conservative total parotidectomy

 D

Enucleation

Ans. C

Explanation:

Ans. is ‘c’ ie. Conservative total parotidectomy 

In this pt. deep lobe of parotid is involved (as suggested by medial displacement of the tonsil) so total parotidectomy is done conserving the facial nerve.

Schwartz writes- “Benign tumors of the superficial lobe of parotid should be removed with a clear margin by superficial lobectomy. If the deep lobe is involved, total parotidectomy may be required even for benign disease.”

Quiz In Between


Q. 4

True about pleomorphic adenoma is:

 A

Most commonly arises in Parotid

 B

Slow growing

 C

Well encapsulated

 D

a and b

Q. 4

True about pleomorphic adenoma is:

 A

Most commonly arises in Parotid

 B

Slow growing

 C

Well encapsulated

 D

a and b

Ans. D

Explanation:

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.


Q. 5

Which of the following is not an indication of radiotherapy in Pleomorphic adenoma of parotid‑

 A

Involvement of deep lobe

 B

2nd histologically benign recurrence

 C

Microscopically positive margins

 D

Malignant transformation

Q. 5

Which of the following is not an indication of radiotherapy in Pleomorphic adenoma of parotid‑

 A

Involvement of deep lobe

 B

2nd histologically benign recurrence

 C

Microscopically positive margins

 D

Malignant transformation

Ans. B

Explanation:

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

  1. Involvement of the deep lobe of the parotid
  2. Recurrent lesions
  3. Large (> 5 cm) lesions, which may not allow complete surgical excision with adequate margins.
  4. Microscopically positive margins after surgical resection.
  5. 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.

Q. 6

All are true for pleomorphic adenoma except:

 A

Arises from parotid

 B

May turn into malignant

 C

Minor salivary gland can be affected

 D

None

Q. 6

All are true for pleomorphic adenoma except:

 A

Arises from parotid

 B

May turn into malignant

 C

Minor salivary gland can be affected

 D

None

Ans. D

Explanation:

 

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.

Quiz In Between


Q. 7

A 40-year-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

Q. 7

A 40-year-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. C

Explanation:

 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.


Q. 8

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

Q. 8

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

Explanation:

Ans. B: Superficial parotidectomy

The pleomorphic adenoma is by far the most common benign salivary gland tumor, accounting for as many as 80% of all such tumors.

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.


Q. 9

Which of the following is true about pleomorphic adenoma except ‑

 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

Q. 9

Which of the following is true about pleomorphic adenoma except ‑

 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

Explanation:

 

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.

Quiz In Between


Q. 10

The commonest site of Pleomorphic adenoma is 

 A

Parotid salivary gland

 B

Submandibular salivary gland

 C

Sublingual gland

 D

Submaxillary gland

Q. 10

The commonest site of Pleomorphic adenoma is 

 A

Parotid salivary gland

 B

Submandibular salivary gland

 C

Sublingual gland

 D

Submaxillary gland

Ans. A

Explanation:

Q. 11

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.

 D

None of the above.

Q. 11

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.

 D

None of the above.

Ans. C

Explanation:

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

 



Q. 12

Pleomorphic adenoma histology is characterized by‑

 A

Epithelial component

 B

Endothelial component

 C

Mesodermal component

 D

Mixed epithelial and mesenchymal components

Q. 12

Pleomorphic adenoma histology is characterized by‑

 A

Epithelial component

 B

Endothelial component

 C

Mesodermal component

 D

Mixed epithelial and mesenchymal components

Ans. D

Explanation:

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.

Quiz In Between



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