HEAD & NECK CASE STUDY:

PAROTID GLAND
Alyssa Mellott

PATIENT DETAILS

Gender: Female

Age: 35

James
Oncor

SOCIAL & MEDICAL HISTORY

Single
Smoked for 8 years
Quit

in 2004

No alcohol or drug use

Family
Mother:

breast cancer
Sister: thyroid cancer
Maternal Grandfather: prostate cancer
Paternal Grandfather: prostate cancer

Parotidectomy for a benign growth in 2010 &

recovered fully (OSU has requested review)
No

other medical history listed

PRESENTATION

Presented with a mass in the right parotid

region

Facial nerve synkinesis

Abnormal

involuntary facial movement that

occurs with voluntary movement of a different
facial muscle group

Lip elevation with blinking

PRESENTATION CONT.

Shooting pains in V2
distribution

Sensation of cold water on

face when eating

No facial weakness or
numbness

No weight loss, fevers, or

lymphadenopathy (abnormal
lymph nodes)

DIAGNOSTIC IMAGES

MRI Before Parotidectomy

MRI After Parotidectomy

DIAGNOSTIC IMAGES

MRI

DIAGNOSTIC IMAGES

Axial contrast-enhanced CT scans (sup. inf.)

EPIDEMIOLOGY

Salivary gland tumors make up 6% of all head

and neck tumors (>1% overall)
700 deaths annually
80% in the parotid glands
Of

which 80% are benign

Most commonly in the 6th decade of life

Malignant

Older than 60
Equally distributed between sexes

Benign

Older than 40
More prevalent in females

ETIOLOGY

Risks:
Radiation

Therapy in low doses (15-20 years

later)
Occupational exposure to silica and dust
Older age
Possibility of family history, high fat diet, cell
phone use links
Smoking and alcohol are highly associated with
head and neck squamous cell carcinoma but no
link to salivary gland malignancies
Not fully understood

SIGNS & SYMPTOMS

A lump or swelling in the

mouth, cheek, or jaw

Pain in your mouth,

cheek, jaw, or ear that
doesnt go away

A difference between the

size and or shape of the
left and right sides of the
face or neck
Numbness in part of your
face

Weakness of the
muscles on one side
of your face

Trouble opening
your mouth widely

Fluid draining from

ear

Trouble swallowing

ANATOMY & PHYSIOLOGY

1 of the 3 major salivary

glands
1.

Parotid
2. Submandibular
3. Sublingual

Anterior to the mandibular

ramus

Divided into superficial and

deep lobes

Drains to the oral cavity

through Stensons Duct
(parotid duct)

LYMPH NODE DRAINAGE

Pre-auricular

Infra-auricular

Deep jugular

HISTOLOGY & GRADE

Acinic cell adenocarcinoma of right parotid

gland
Mucoepidermoid

CA (adenocarcinoma) is the
most common histology for parotid malignancy

Low grade

AJCC STAGING: TUMOR

T groups for major salivary gland cancers

TX: The main (primary) tumor cannot be assessed; information not
known.
T0: No evidence of a primary tumor. (For example, the cancer was first
found in the lymph nodes, but the main tumor itself cant be found.)
T1: Tumor is 2 cm (about 34 inch) across or smaller. Its not growing
into nearby tissues.
T2: Tumor is larger than 2 cm but no larger than 4 cm (about 112 inch)
across. Its not growing into nearby tissues.
T3: Tumor is larger than 4 cm across and/or is growing into nearby soft
tissues.
T4a: Tumor is any size and is growing into nearby structures such as the
jaw bone, skin, earcanal, and/or facial nerve. This is known as
moderately advanced disease.
T4b: Tumor is any size and is growing into nearby structures such as
the base of the skull or other bones nearby, or it surrounds the carotid
artery. This is known as very advanced disease.

AJCC STAGING: NODES

N groups for major salivary gland cancers.

NX: Nearby (regional) lymph nodes cannot be assessed; information
not known.
N0: No spread to regional lymph nodes.
N1: The cancer has spread to 1 lymph node on the same side of the
head or neck as the primary tumor. The lymph node is no larger than
3 cm (about 114 inch) across.
N2: This group includes 3 subgroups:
N2a:

The cancer has spread to 1 lymph node on the same side as the primary
tumor. Thelymph node is larger than 3 cm but not larger than 6 cm (about
212 inches) across.
N2b: The cancer has spread to more than 1 lymph node on the same side as
the primary tumor, but none of the lymph nodes are larger than 6 cm across.
N2c: The cancer has spread to 1 or more lymph nodes, none larger than 6 cm
across, either on the side opposite the primary tumor or on both sides of the
neck.

N3: The cancer has spread to a lymph node that is larger than 6 cm
across.

AJCC STAGING: METASTASIS

M0: The cancer has not spread to tissues or

organs far away from the salivary glands.

M1: The cancer has spread to tissues or

organs far away from the salivary glands.

METHODS OF TREATMENT

Surgery most common

She

recently had a revision of her previous

parotidectomy

Positive margins

Radiation Therapy if inoperable or post op.

IMRT
Photon

& Electron
Wedge pair

Dose: 60-70 Gy
Loss

of salivary function in gland after 35 Gy

TREATMENT PLAN

Total Dose: 60 Gy
30

fractions 20 Gy/fraction

6 Field IMRT
No

supraclav

DRRS

CRITICAL STRUCTURE TDS

DOSE DISTRIBUTIONS

DOSE VOLUME HISTOGRAM

POSITIONING &
IMMOBILIZATION

Supine

Conformal board

Head and shoulder aquaplast mask

Custom head rest

Knee sponge

POTENTIAL SIDE EFFECTS

Short Term:

At
44
G

y
irritation
Irritation of
mouth/throat
Loss of hair
Fullness in ears
Hoarseness
Swelling/soreness in
neck/jaw
Dry mouth
Decrease in blood counts
Fatigue
Skin

Long Term:
Decrease

in thyroid

function
Decreased hearing
Loss of taste
Swelling in neck/jaw
Scar tissue
Decrease mobility of
neck/jaw
Brain stem injury
Damage to larynx
Damage to brachial plexus
Damage to neck vessels

PROGNOSIS & SURVIVAL

Major determinants of survival are history

and clinical stage

Overall 5-year survival for all stages and

histologic types is approximately 62%

The overall 5-year survival for recurrent

disease is approximately 37%

METASTATIC SITES

20% of patients with parotid gland tumors

will develop distant metastasis
Most

common site is the lungs

Can have many metastatic sites

Chemo would most likely be used in this situation

REFERENCES

American Cancer Society. Salivary Gland Cancer. N.p.:

American Cancer Society, 2014. PDF.

Amirlak, Bardia. "Malignant Parotid Tumors." MedScape.

WebMD, 27 Feb. 2013. Web. 18 Mar. 2014.
<http://emedicine.medscape.com/article/1289616-overview>.

Hackworth, Ruth. "Paranasal Sinuses and Orbits." Feb. 2014.

Lecture.

Lee, Steve. "Salivary Gland Neoplasms." MedScape. WebMD, 8

Mar. 2013. Web. 18 Mar. 2014.
<http://emedicine.medscape.com/article/852373overview#a0112>.