Pleomorphic Adenoma of the parotid gland –

A case report

Pleomorphic adenoma is the most common salivary gland

neoplasm and accounts for 63% of all parotid gland
tumours,59.5% of all submandibular gland tumours and 42.9% of
all minor salivary gland tumours. Intraorally the tumour is
common in the palatal region.1 It constitutes to about 38% to
43% of all minor salivary gland tumours. Pleomorphic adenoma is
also the most common type of salivary gland tumour in Children.2

Pleomorphic adenoma occurs most frequently in 4th to 6th

decades. However many cases have been reported in younger
age groups. Females are most frequently affected when
compared to males. If left untreated the extraoral pleomorphic
adenoma can grow to large size and cause facial disfugurement
and cosmetic concern. When the tumour occurs in the parotid, it
is the superficial lobe that is mostly involved. Malignant
transformation of epithelial component of previously benign
pleomorphic adenoma has been reported as a majour
complication of untreated tumours.(3)

Pleomorphic adenomas are characterized by its polymorphic

microscopic appearance and varied clinical presentations.
Histologically, this polymorphic appearance consists in that the
main cellular components of this neoplasm (ductal and
myoepithelial cells) which are arranged forming different
structures like ducts, solid groups or sheets in a mesenchyme like
background. The “stromal” changes could be observed as hyaline,
myxocontroid and bone like tissue as well as keratin pearls and
epidermoid zones. The marked stromal variety observed in this
neoplasia results from factors such as the quantity and
distribution of proteins of the matrix produced by epithelial &
myoepithelial tumor cells. Frequently myoepithelial cells display
different shapes like stellate, polygonal, plasmacytoid, fusiform &

round or oval. Med Oral Patol Oral Cir Bucal 2007;12:E110-5.(5)

Case report:

A sixty two years old female patient reported to Department of

Oral Medicine & Radiology, SPPGIDMS Lucknow with a chief
complaint of a painless swelling on the right side of the face since
twelve years. Patient noticed a small swelling which gradually
increased in size to attain the present size. Patient had mild
discomfort and esthetic concerns. Her past medical history and
family history were non-contributory . She had the habit of pan
chewing for the past 15 years.

Extraoral examination revealed a large lobulated swelling

extending from the tragus of the ear upto 1.5cms below the
inferior border of the mandible. Anteroposteriorly the swelling was
extending from zygomatic arch region upto 1cm posterior to the
lobule of the year. The skin over the sewlling appeared normal.
Upon palpation the lesion was found to be rubbery in consistency
however no tenderness was elicited. Left submandibular
lymphnodes were palpable and mobile.

Intraorally patient had few attrided posterior upper and lower

teeth and root stumps in relation to lower anteriors. Obverall oral
hygiene was poor with presence of calculus and tobacco stains.

A differential diagnosis of pleomorphic adenoma, warthins

tumour, along with other rare benign salivary gland tumours were
considered.

An Incisional biopsy was performed to facilitate the diagnosis. The

biopsy revealed a capsular region and the glandular lesional
tissue. Numerous Proliferating neoplastic cells were observed
which were arranged in sheets and ducts.(0198.jpg) The tumour
appeared to be predominantly consisting of myoepithelial cells
which appeared as angular and spindle shaped.(0199.jpg)
Between the clusters of cells eosinophilic hyalinized material was
observed .

Characteristically numerous angular and spindle shaped

myoepithelial cells were observed in many areas of the
sections.The stroma consisted of loosely arraged fibrous
component and areas of myxomatous component.(0204.jpg)
Vascularity was moderate and inflammatory component minimal
with sparse infiltration of lymphocytes . Based on these
observations, a diagnosis of pleomorphic adenoma with
predominant myoepithelial component was arrived at.

Discussion: The pleomorphic adenoma or benign mixed tumour is

the most common salivary gland neoplasm. They are basically
derived from a mixture of ductal and myoepithelial elements. The
tumour is known for its microscopic diversity as the appearance
may differ from tumour to tumour or with in different areas of the
same tumour.

Most pleomorphic adenomas occur in the parotid with clinical

presentation as swelling infront of the ear overlying the
mandibular ramus. If neglected the tumour can grow to large size.
Sometimes the tumour grow in a medial direction between the
ascending ramus and stylomandibular ligament, resulting in a
dumbbell shaped tumour mass. 3. Intraorally the mixed tumour
has a predilection for palatal glands followed by lip and buccal
mucosa.

These tumours generally appear as painless, firm and mobile

masses that rarely ulcerate the overlying skin mucosa. When it
occurs in submandibular gland it is difficult to distinguish it from
malignant neoplasms and indurated lymphnodes.4

Pleomorphic adenomas are well circumscribed encapsulated

tumours. However in many tumours the neoplastic cells are found
to project into the depth of the capsule. It is more evident in
palatal tumours.

The tumour basically consists of a mixture of glandular epithelium

and myoepithelial cells within a mesenchyme like background.
Some tumours show predominantly the parenchymal component
and they are thus relatively cellular in nature. Others may show a
prominent mesenchymal component with minimal cellularity. The
epithelial component often forms ducts and cystic structures and
are also arranged in sheets and islands of cells. Keratinizing
squamous cells and mucous producing cells are occasionally seen
with in the tumour.3
Presence of numerous angular and spindle shaped myoepithelial
cell is another feature of this tumour as observed in our present
case. Myoepithelial cells are ectodermally derived contractile
cells, routinely identified in many normal tissues with a secretory
function such as major and minor salivary glands, lacrimal glands,
sweat glands, breasts and the prostate (8, 9). These cells are one
of the most frequent components of salivary gland tumours.
Salivary-gland neoplasms that frequently contain myoepithelial
cells are pleomorphic adenoma, adenoid-cystic carcinoma and
epithelial-myoepithelial carcinoma of intercalated duct origin.
Neoplasms composed exclusively of myoepithelial cells are
uncommon accounting for less than 1% of all salivary gland
tumours. Most of these tumours are located in the parotid gland,
while others occur in the submandibular gland or in the accessory
glands of the oral cavity (hard and soft palate, lip, cheek, tongue,
floor of the mouth, gingiva, retromolar area). They sometimes
arise from the glands of the respiratory tract (nasal cavity,
nasopharynx, larynx, lung). Patients are generally over 50 years
of age.6

Plasmacytoid myoepithelial cells are observed in some tumours

especially that involving the palatal glands. The characteristic
stromal changes resulting in chondroid, myxoid,osteoid and
fibroid areas are believed to be produced by myoepithelial cells.
The presence of these elements accounts for the name
‘pleomorphic adenoma or mixed tumour”. The tumour perse is
not a true mixed tumour that is derived from more than a germ
layer.3

Investigations like fine needle aspiration cytology for cell

morphological characteristics and preoperative evaluation of the
tumour,(9) Contrast enhanced computed tomography for the
assessment of the extention and involvement of the tumour,
Magnetic resonance imaging for the extension of tumour (10) ,
Colour Doppler study to know the extension as well as vascularity
of the tumour etc can be undertaken as and when necessary.

Pleomorphic adenomas are best treated with surgical excision.

Treatment for Individual case depends on the information
obtained after various investigative techniques. Carrau RL et al
(2000) stated that the use of CT scan and MRI, and selective
use of angiography, allowed to ascertain the location, size,
vascularity and relation of the tumour to other anatomic spaces
and structures.(8)

The choice of surgical approach is assessed by the size, location,

relationship to vessels and nerves. The risk lies in the fact that
the parotid gland is intimately related to the major nerves and
vessels. Limited parotidectomy is associated with very low rates
of morbidity and recurrence. Complete superficial parotidectomy
is unnecessary in the treatment of benign localized parotid
tumours.(9) According to some authors It is mandatory to treat
all pleomorphic adenomas to avoid malignant transformation at a
later stage(11,12)

Complications can occur after parotidectomy. Permanent partial

or total facial nerve paralysis occurs in less than 3%of patients,
and temporary nerve paralysis can occur in 10 to 30% of patients.
A salivary fistula is a relatively common complication after parotid
surgery.

The risk associated with pleomorphic adenoma of the

submandibular gland includes hemmorhage, infection, injury to
hypoglossal, lingual, or marginal mandibular nerves.

The treatment of pleomorphic adenoma of minor salivary salivary

gland depends on the location and extent of disease. Complete
excision is usually the choice of treatment for all benign tumours
in minor salivary glands.

Most recurrences can be attributable to inadequate surgical

techniques such as simple enucleation leaving behind microscopic
pseudopod-like extensions. Rupture of the capsule or tumor
spillage is also believed to increase the risk of recurrence, so
meticulous dissection is paramount. Pleomorphic adenoma
generally does not recur after adequate surgical excision.

Bibliography;

1. Ito FA, Ito K, Vargar PA, De ameida OP, lopes MA. Salivary
gland tumours in a Brazilian population. A retrospective
study of 496 cases. Int J Oral maxillofac surg.2005 Jul:
34(5);533-6.

2. Main JHP, Orr JA, McGurk FM, et al. Salivary gland tumours: A
review of 643 cases .J Oral Pathol 1976; 5:88-102.
 3. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and
maxillofacial pathology: Saunders Elsivier 3rd Ed.

4. BurkitsI. Text book Quote ..10th edition

5. Ponce-Bravo S, Ledesma-Montes C, López-Becerril U, Morales-Sánchez I.

Myoepithelial cells are the main component in pleomorphic adenomas? Med
Oral Patol Oral Cir Bucal 2007;12:E110-5.

6. E. FERRI, I. PAVON1, E. ARMATO, S. CAVALERI, P. CAPUZZO, F.IANNIELLO.

Myoepithelioma of a minor salivary gland of the cheek: case report. Acta
Otorhinolaryngol Ital 26, 43-46, 2006.

7. O’Brien CJ, .Current management of benign parotid tumours-

The role of limited superficial parotidectomy. HeadNeck.
2003 Nov, 25(11) 946-2.

8. Carrau RL, Myers EN, Johnson JT, Management of tumours

arising in the parapharyngeal space. Larngoscope.1990 Jun
100(6); 583-9.

9. Som PM, Curtin HD. Lesions of parapharygeal space. Role of

MR imaging.

Otolaryngol Clin North Am.1995 Jun; 28(3) 515-42.

10. Spiro RH, Salivary neoplasms.Overview of a 35 year

experience with 2807 patients.Head Neck surg.1986,8: 177-84.
11. Moody AB, Avery CME, Taylor j, Langdon JD, A comparison
of one hundred and fifty consecutive parotidectomies for
tumours and inflammatory diseases. J oral Maxillofac
Surg.1999; 28:211-5.

12.Stafford ND, Wilde A. Parotid cancer. Surg Oncol.1997;

6(4):209-13.

1. Go through the article and see the references are correct

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