Oral Oncology xxx (xxxx) xxxx

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Oral Oncology
journal homepage: www.elsevier.com/locate/oraloncology

Letter to the editor

Regarding the “Tumour spillage of the pleomorphic adenoma of the parotid gland: A proposal for
intraoperative measures”

ARTICLE INFO

Keywords:
Fine‑needle aspiration biopsy (FNAB)
Parotid tumor
MRI
Cancer
Malignant tumor
Benign tumor

Introduction of recurrence, primarily if the shedding of tumor masses was controlled

We read with colossal interest the manuscript of Konstantinos
Mantsopoulos and Heinrich Iro entitled “Tumour spillage of the pleo­
morphic adenoma of the parotid gland: A proposal for intraoperative
measures” [1]. The authors concluded that recurrence after tumor rupture is
by no means an inevitability. However, the question is not obvious, as most
surgeons are still reluctant to report capsule tears as a cause of recurrence in
their cases. The authors suggested that following a standardized in­
traoperative algorithm in case of tumor spillage can increase the radicality
of treatment parotid gland tumors. Also, it could be more effective than a
“wait-and-see” approach. We agree with the authors of the publication.
However, we would like to pay attention to several aspects concerning the
treatment of parotid tumors, especially with regards to so rare (near 1%),
but so characteristic parotid tumor as a pleomorphic adenoma (PA).
It should remember that PA, apart from pseudopodia and satellite
nodules, is characterized by a focal microscopic discontinuity of the
pseudocapsule and the possibility of its exposure beyond the salivary gland
flesh. Moreover, pseudocapsule can adhere directly to the facial nerve and
even contain its branches. There are cases where the exposure of the tumor
pseudocapsule reaches three-quarters of the tumor surface. It means that,
to this extent, it was enucleated during parotidectomy! More often, it
concerns extracapsular dissection (ECD) of the parotid tumors. Leaving a
tumor fragment or pseudopodium usually leads to the formation of a
single focal tumor recurrence. On the other hand, the dissemination and
implantation of tumor cells in the surgical field result in multifocal re­
currence, making it extremely difficult or even impossible to radical re-
surgery while maintaining the continuity of the facial nerve.
Based on our experience, we believe that the most significant risk of
PA recurrence occurred when its pseudocapsule was damaged during
intra-parenchymal preparation. Mainly it concerns a situation when the
continuously on its surface.
We strongly agree with the authors that a standardized intraoperative
algorithm needs to use in each case of the rupture of the tumor pseudo­
capsule during surgery. We routinely use at least two rinses of the surgical
field (sodium chloride 0.9% at 37 °C using a 20 ml syringe) after each
pleomorphic adenoma resection. We observed that PA cells were found in
approximately 2% of cases in the cytological examination of the aspirate
obtained after the first washing of the wound. However, there was no
macroscopic damage to the tumor pseudocapsule. They were never found
in the aspirate after the second washing of the wound.
Our doubts were only raised by the need for such an intense and
prolonged follow-up proposed by Konstantinos Mantsopoulos and
Heinrich Iro [1]. Generally, the dynamics of PA recurrence is low in­
tensity, and the main and probably the best (certainly the cheapest) tool
for its detection is patient self-monitoring (palpation) education. It is
essential to provide the patient with complete information about the
risk of residual disease and the possibility of tumor recurrence, even
several years after the first surgery.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ­
ence the work reported in this paper.
References
[1] Mantsopoulos K, Iro H. Tumour spillage of the pleomorphic adenoma of the parotid
gland: A proposal for intraoperative measures. Oral Oncol
2020;2020:104986https://doi.org/10.1016/j.oraloncology.2020.104986.

tumor is situated medially to the plane of the facial nerve or nerve

branches extend in close connection with the pseudocapsule. For ex­
ample, hook damage to a tumor pseudocapsule while lifting it with a
fragment of the salivary gland (extra-parenchymal) does not pose a risk
Dmitry Tretiakow , Dominik Stodulski, Boguslaw Mikaszewski
⁎
Department of Otolaryngology, Medical University of Gdansk, Poland
E-mail address: d.tret@gumed.edu.pl (D. Tretiakow).

⁎
Correspondent author at: Department of Otolaryngology, Medical University of Gdansk, Smoluchowskiego str. 17, 80-214 Gdansk, Poland.

https://doi.org/10.1016/j.oraloncology.2020.105026
Received 17 September 2020; Accepted 21 September 2020
1368-8375/ © 2020 Elsevier Ltd. All rights reserved.