Bilateral Acinic Cell Carcinoma of the Parotid Gland

JOHN S. CLARKE,* MAJOR, MC, EDWIN C. HENTZ,** MAJOR, MC,WILLIAIm D. MAHONEY,*** LT. C., MC

From the Department of Surgery, Head and Neck Surgery Service, Walter ReedGeneral Hospital, Walter Reed Army Medical Center, Washington, D. C.

ACINIC cell carcinoma of the salivaryglands is a relatively infrequent tumor al-though, it has been reported in submaxil-lary, sublingual and minor salivary glandsof the tongue.1' 5, 13 The lesion is generallyrestricted to the parotid gland (92% ).1The incidence has been reported as 2.1-5.2% of all parotid gland tumors and 7-19% of malignant tumors of the parotid.' 57, 8, 10-12, 14 Recurrences may be delayed forprolonged periods as in Grange's patientwho was free of symptoms for 27 years.5

In the last 5 years, on the Head andNeck Surgery Service of WValter Reed Gen-eral Hospital, sixty primary parotid glandtumors were treated. The distribution ofthese tumors is given in Table 1. Recentlyan instance of bilateral primary acinic cellcarcinoma of the parotid gland was en-countered. This occurrence has been re-ported in three cases by Eneroth et al.6, 7and one case by Bauer and Bauer.3 In onepatient 7 the interval between the twotumors was 15 years and the second tumorwas soon followed by metastatic disease.We believe that ours is the fifth case ofbilateral primary acinic cell carcinoma ofthe parotid gland reported. Shands 17 re-ported a patient on whom superficial paro-tidectomy was performed for acinic cellcarcinoma and 2 years later superficialparotidectomy on the contralateral side formixed tumor.

Submitted for publication January 8, 1969.* Chief Resident, General Surgery Service,

Walter Reed General Hospital, Washington, D. C.20012.

* Resident, Pathology Service, Walter ReedGeneral Hospital, Washington, D. C. 20012.

*** Chief, Head and Neck Surgery Service,Walter Reed General Hospital, Washington, D. C.20012.

Case ReportA 20-year-old woman had a small nodule in

the left retromandibular area for several yearswhich enlarged slightly in the few months priorto visiting the clinic. When first examined shehad a 2 x 2 cm. minimally tender firm nodule inthe left retromandibular area. There was also, a0.5 x 0.5 cm. firm movable nodule in the rightretromandibular area which had been present forapproximately 2 years. The patient was asympto-matic and had no facial nerve involvement orcervical adenopathy. On 13 May 1968 left super-ficial parotidectomy was performed for a wellencapsulated tumor in the superficial lobe. On 28June 1968 right superficial parotidectomy wasperformed for the tumor in that superficial lobe.On pathologic examination both tumors were typi-cal acinic cell carcinomas. This diagnosis wasconfirmed by the Armed Forces Institute ofPathology.

Pathologic Description: The left superficialparotid lobe measured 5.6 x 4.4 x 0.6 cm. Therewas a firm tan nodule in the inferior portion ofthis gland which measured 2.1 cm. in greatestdimension. The nodule was completely encapsu-lated. The specimen from the right parotid glandwas in two parts. One was a 0.8 x 0.4 X 0.4 cm.nodule of light tan, firm tissue. The other was a4 X 5 X 2 cm. superficial parotid lobe that on cutsurface showed only homogenous salivary gland.

Microscopic sections of the nodule of the leftsuperficial parotid lobe and of the nodule oftissue from the right superficial parotid lobe weresimilar (Figs. 1, 2). A well circumscribed nodulewas composed of cells with small, dark, eccentricnuclei, inconspicuous nucleoli, and a finely granularcytoplasm that in the hematoxylin and eosin stain

TABLE 1. Walter Reed General Hospital ParotidGland Tumors-1963-1968

Mixed tumor 35Warthin's tumor 4Squamous cell carcinoma 4Mtucoepidermoid carcinomia 9Adenocarcinoma iAcinic cell carcinonma 3

Total Cases 60

866

BILATERAL ACINIC CELL CARCINONIA

TABLE 2. Incidence of Acinic Cell Carcinoma of the Parotid Gland

Author

Total No.ParotidTumors

No. ofAcinic CellCarcinomas

of AllParotidTumors

867

%C ofMalignantParotidTumors

Foote & Frazell' 766 21 2.7Beahrs4 760 24 3.2 14.8Grage"l 272 11 4.0 16.9BardWil2 153 8 5.2 7.2Hanna15 300 7 2.3 9.1Mustard'6 287 10 3.4 13.5VandenBero18 145 4 2.1 19.0Eneroth7 2102 63 2.9

Ihatd a fairly bluIish cast. Thesc cells were in closecontact with each othcr in a small amount ofvascular stroma with cruide acinar groups in some

areas. Mitoses were not present. Duct formationswere not present within the tumor (Fig. 3). Thetumor nodules were separated into compartmentsby interlacing bands of fibrous tissue which alsocontained foci of mild chronic inflammation. The

imargins of resection of the paratid glands con-

tained no tumor. Sections of the remainder of theparotid gland were unremarkable.

Discussion

In general treatment of malignant paro-tid tumors has been radical parotidectomy

FIG. 1. Photomicrograph showing normal left parotid gland at the top and the aciniccell adenocarcinoma at the bottom. Hematoxylin and eosin. (From 58X).

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868 CLARKE, HENTZ AND MIAHONEY Annals of Surgery

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FIG. 2. Photomicrograph showing right parotid gland in the upper corner and the aciniccell adenocarcinoma in the re-mainder. Hematoxylin and eosin. (From IIOX)

with standard radical neck dissection.Acinic cell and well differentiated muco-epidermoid carcinomas are considered lowgrade malignancies which require less ex-tensive resections and when confined tosuperficial lobes and are without cervicalmetastases are treated by superficial paro-tid lobectomy. The practice of less radicaloperation may have to be altered in viewof observations of decreased long-term sur-vival in these patients.7' 12

Bilateral salivary gland tumors are in-frequent. Bilateral acinic cell carcinomasmay not be so rare. Eneroth's three bilat-eral cases were from a series of 63 aciniccell carcinomas, a bilateral incidence of4.8%o. Every patient treated for acinic cellcarcinoma should have prolonged fol-low-up with attention to the contralateral

gland. Bilateral tumors may be significantin acinic cell carcinomas of the parotidgland.

SummaryAn instance of bilateral parotid gland

acinic cell carcinomas is reported. The in-cidence, treatment and histopathology arereviewed. This is the fifth case of bilateralacinic cell carcinoma of the parotid glandreported to date.

References1. Abrams, A. M., Cornyn, J., Scofield, H. H. and

Hansen, L. S.: Acinic Cell Adenocarcinomaof the Major Salivary Glands-A Clinico-pathologic Study of 77 Cases. Cancer, 18:1145, 1965.

2. Bardwil, J. M.: Tumors of the Parotid Gland.Amer. J. Surg., 114:498, 1967.

3. Bauer, W. H. and Bauer, J. D.: Classificationof Glandular Tumors of Salivary Glands-

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4,~ ~-a_e:s i i-{f^..4 -

FIc. 3. Photomicrograph showing closely contiguous cells with small pyknotic nuclei andfinely granular cytoplasm. Hematoxylin and eosin. (From 240x)

Study of 143 Cases. Arch. Path., 55:328,1953.

4. Beahrs, 0. H., Woolner, L. B., Carveth, S. W.and Devine, K. D.: Surgical Managementof Parotid Lesions-Review of 760 Cases.Arch. Surg., 80:890, 1960.

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