Apr 10, 2013 - We report a known case of adenoid cystic carcinoma of right parotid gland in ... needle aspiration cytology (FNAC) from right parotid bed confirmed the ... grade salivary gland malignancies with relatively low FDG uptake may ...
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The official publication of Association of Radiation Oncologists of India (AROI) JCRT is now indexed with PubMed / MEDLINE.
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Search CORRESPONDENCE Year : 2013 | Volume : 9 | Issue : 1 | Page : 148-150
Detection of atypical metastases in recurrent adenoid cystic carcinoma of parotid gland
Anshu Tewari, Subramanyam Padma, Palaniswamy Shanmuga Sundaram > Similar in PUBMED » Search Pubmed for
Department of Nuclear Medicine & PETCT, Amrita Institute of Medical Sciences, Cochin, Kerala, India
Tewari A Padma S Sundaram PS
Date of Web Publication
10-Apr-2013
» Search in Google Scholar for Correspondence Address: Tewari A Padma S
Anshu Tewari
Sundaram PS Department of Nuclear Medicine & PETCT, Amrita Institute of Medical Sciences, Cochin, Kerala »Related articles India Adenoid cystic carcinoma fluorodeoxyglucose DOI: 10.4103/0973-1482.110374 parotid gland positron emission tomography trucut biopsy
> Article in PDF (1,441 KB) > Abstract
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We report a known case of adenoid cystic carcinoma of right parotid gland in a 36-year-old Indian male, diagnosed 5 years ago for which he underwent surgery followed by radiotherapy. Now the patient has presented to the surgical
> Email Alert * oncologist with a mass near angle of right jaw. Computed tomography (CT) performed elsewhere was reported negative for local recurrence. Subsequently,
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F Fluorodeoxyglucose positron emission tomography-CT (FDG PET-CT)
* Registration required (free) demonstrated local recurrence in right parotid bed. Surprisingly, metabolically active metastatic skeletal deposits were also identified, thus the disease was upstaged and management was changed. Trucut biopsy from left iliac bone lesion
confirmed metastases from adenoid cystic carcinoma. Thus a whole body PET-CT has a significant impact on management of patients with salivary gland malignancies in assessing both local recurrence as well as distant metastases,
> Abstract > Introduction
especially in atypical and unsuspected sites.
> Case Report > Discussion > References > Article Figures Keywords: Adenoid cystic carcinoma, fluorodeoxyglucose, parotid gland, positron emission tomography, trucut biopsy Article Access Statistics Viewed
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How to cite this article: Tewari A, Padma S, Sundaram PS. Detection of atypical metastases in recurrent adenoid cystic carcinoma of parotid gland. J Can Res Ther 2013;9:148-50
How to cite this URL: Tewari A, Padma S, Sundaram PS. Detection of atypical metastases in recurrent adenoid cystic carcinoma of parotid gland. J Can Res Ther [serial online] 2013 [cited 2013 Apr 11];9:148-50. Available from:http://www.cancerjournal.net /text.asp?2013/9/1/148/110374
> Introduction
Click on image for details.
Tumors of salivary glands are rare and represent less than 1% of all cancers and approximately 5% of head and neck cancers. Parotid glands, being the largest salivary gland are also the most common site of salivary tumors, accounting for
75% of salivary gland malignancies. Among the salivary neoplasms, adenoid cystic carcinoma also known as cylindroma is very rare and constitutes 1% of major and minor salivary glands malignancies and accounts for only 15% of parotid
malignancies. [1]
> Case Report
We report a known case of adenoid cystic carcinoma of right parotid gland in a 36-year-old Indian male, diagnosed 5 years ago for which he underwent total parotidectomy followed by postoperative adjuvant radiotherapy (RT) elsewhere (60 18 Gy/30 fractions). Now patient has presented to the surgical oncologist with a mass near right angle of jaw. F Fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) was performed on a PET 8 slice CT 18 scanner to assess the present disease status. Eight millicurie of F FDG was injected intravenously in euglycemic status and head to mid thigh imaging was performed an hour later. The whole body PET-CT scan revealed abnormal
enhancing lesions with increased FDG uptake in right parotid bed, that is, posterior to mandibular condyle, anterior to external auditory canal and another lesion in digastric groove lying posterior to styloid process (standard uptake value
(SUV) max is 5.7 g/ml) consistent with local tumor recurrence and associated infiltration of tumor into facial nerve[Figure 1]. Although clinically only a local recurrence was suspected, PET-CT revealed metabolically active skeletal metastases
involving the spine of right scapula and left iliac bone (SUV max 4.1 and 2.6 g/ml, respectively)[Figure 2] and [Figure 3]. Thus PET-CT has upstaged the disease and changed the management. Trucut biopsy from left iliac bone lesion and fine
needle aspiration cytology (FNAC) from right parotid bed confirmed the lesions to be metastases from adenoid cystic carcinoma and local recurrence [Figure 4]. Patient underwent completion parotidectomy along with right sural nerve graft and
gold weight right upper eye lid repair for ptosis followed by a palliative RT to the scapula and iliac crest with 30-45 Gy in 15 fractions. Three months post therapy PET-CT scan showed partial metabolic response (reduction in SUV) of right
parotid, left iliac, and right scapular lesions with no further progression of disease [Figure 5].
Figure 1: 18 F FDG PET-CT fused transaxial image of neck: shows abnormal enhancing lesions with an increased FDG uptake in right parotid bed, that is, posterior to mandibular co another lesion in digastric groove that lies posterior to styloid process (standard uptake value (SUV) max is 5.7 g/ml) consistent with local tumor recurrence and associated infiltratio Click here to view
Figure 2: 18 F FDG PET-CT fused transaxial image shows metabolically active skeletal deposit in spine of right scapula (SUV Max 4.1) Click here to view
Figure 3: FDG PET-CT fused transaxial image shows FDG avid left iliac bone skeletal deposits (SUV Max 2.6) Click here to view
Figure 4: Histopathological section of local recurrence: High power (400 ×) view of H and E stained biopsy demonstrating cribriform pattern. Smears were cellular comprising of we surrounding mucoid, hyaline globules or clear spaces also, forming honey comb (cribriform) pattern consistent with adenoid cystic carcinoma parotid gland Click here to view
Figure 5: Comparison images (top row shows CT images, bottom row shows fused PET-CT images in transaxial view) of pre- and post therapy fused PET-CT showing partial meta of 5.7 became 2.3 gm/ml now). Please note pre- and post radiotherapy CT images show persistence of lytic lesions in right scapula thus highlighting its insensitivity in reporting the Click here to view
> Discussion
, Salivary gland tumors are usually benign and by far the most common site is the parotid. Of the parotid gland malignancies, mucoepidermoid carcinoma is the most frequent with an incidence of 21.8%. [1] [2] Other parotid malignancies that are
known to occur are adenocarcinoma, squamous cell carcinoma, and adenoid cystic carcinoma in descending order of incidence. [2]
18
F-FDG PET has been shown to be superior to conventional imaging in evaluating patients with head and
neck malignancies. [3] In major types of head and neck malignancies like squamous cell carcinoma and lymphomas, FDG PETCT is now used in initial staging, management of recurrent cancers, and therapeutic monitoring. [4] According to recent
reports, [5] the higher sensitivity and diagnostic accuracy of PET-CT endows it with many advantages over CT alone in managing malignancies around the salivary gland, especially in high-grade types. Enhanced glucose metabolism, as
determined by the SUV, is a strong index of tumor grade in several malignancies. [4] A correlation exists between
aggressive if SUV is greater than 4.0. High-grade salivary malignancies tend to have higher
18
18
F-FDG uptake and tumor invasiveness. Tumour histologic grade is significantly related to FDG uptake. The tumour is
F-FDG uptake than low- or intermediate-grade salivary tumors. The preoperative diagnosis of salivary gland masses should include fine needle
18 aspiration biopsy (FNAB), CT, or magnetic resonance imaging (MRI) as well as F-FDG PET. In detecting metastatic neck disease, preoperative FDG PET is more sensitive than CT. Main limitation with FDG PET-CT is the fact that low-
grade salivary gland malignancies with relatively low FDG uptake may be easily obscured by the normal physiologic FDG uptake of the salivary glands with reported SUV of less than 2.9 g/ml. [5] In addition, FDG uptake may be increased by
inflammatory processes, contributing to false-positive results. [5] These errors can be corrected when conventional CT or MRI is combined with FDG PET.
, The sensitivity and specificity of CT in detecting extracranial adenoid cystic carcinoma of oral cavity and oropharyngeal tumors with perineural spread are 88% and 89%, respectively. [8] [9] However, false negative results on CT are commonly
associated with inherent insensitivity in identifying especially lymph nodal micro metastases (nodes less than 1 mm in size) and skeletal deposits
, [6] [8] suggesting that CT alone may be insufficient in staging, particularly in patients with high-grade
salivary gland malignancies. [9]
Distant metastases from primary malignant parotid tumors are quite rare,[5] lungs being the most common followed by bone and liver. Although literature review reported metastases in context to adenoid cystic carcinoma, acinic cell carcinoma, [5]
none of them reported scapular and ilium as site of distant metastases. Only one humeral metastases from parotid adenocarcinoma has been described in a canine. [7] Our case may be the first report of parotid adenoid cystic carcinoma
presenting with scapular and iliac bone metastases. These tumors are slow growing with propensity to recur to adjacent structures easily. Recurrence and metastases usually happens years after initial presentation, therefore long-term follow . up and constant vigilance is necessary . On the contrary, this patient presented with local recurrence as well as skeletal metastases in a span of 5 years. FDG PECT-CT has a significant role in diagnosing such atypical and highly
unsuspected site of distant metastases in the management of patients with adenoid cystic carcinoma of parotid gland.
> References
1.
Spiro RH. Salivary neoplasms: Overview of a 35-year experience with 2,807 patients. Head Neck Surg 1986;8:177-84.
2.
Buchner A, Merrell PW, Carpenter WM. Relative frequency of intraoral minor salivary gland tumors: A study of 380 cases from northern California and comparison to reports from other parts of the world. J Oral Pathol Med 2007;36:207-14.
3.
18 Kresnik E, Mikosch P, Gallowitsch HJ, Kogler D, Wiesser S, Heinisch M, et al. Evaluation of head and neck cancer with F-FDG PET: A comparison with conventional methods. Eur J Nucl Med 2001;28:816-21.
4.
18 Jeong HS, Chung MK, Son YI, Choi JY, Kim HJ, Ko YH, et al. Role of F-FDG PET/CT in management of high-grade salivary gland malignancies. J Nucl Med 2007;48:1237-44.
5.
Lima RA, Tavares MR, Dias FL, Kligerman J, Nascimento MF, Barbosa MM, et al. Clinical prognostic factors in malignant parotid gland tumors. Otolaryngol Head Neck Surg 2005;133:702-8.
6.
Mukherji SK, Weeks SM, Castillo M, Yankaskas BC, Krishnan LA, Schiro S. Squamous cell carcinomas that arise in the oral cavity and tongue base: Can CT help predict perineural or vascular invasion? Radiology 1996;198:157-62.
7.
Habin DJ,Else RW. Parotid salivary gland adenocarcinoma with bilateral ocular and osseous metastases in a dog, J Small Anim Pract 1995;36:445-9.
8.
Nakamoto Y, Tatsumi M, Hammoud D, Cohade C, Osman MM, Wahl RL. Normal FDG distribution patterns in the head and neck: PET/CT evaluation. Radiology 2005;234:879-85.
9.
Hanna E, Vural E, Prokopakis E, Carrau R, Snyderman C, Weissman J. The sensitivity and specificity of high-resolution imaging in evaluating perineural spread of adenoid cystic carcinoma to the skull base. Arch Otolaryngol Head Neck Surg 2007;133:541-5.
Figures
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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