Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2016) 17, 111–114

HO ST E D BYEgyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied

Sciences

www.ejentas.com

CASE REPORT

An ulcerated giant pleomorphic adenoma of the

parotid gland – A case report

* Corresponding author. Cell: +91 09556524887.

E-mail address: santoshvoltaire@yahoo.co.in (S.K. Swain).

Peer review under responsibility of Egyptian Society of Ear, Nose,

Throat and Allied Sciences.

http://dx.doi.org/10.1016/j.ejenta.2016.01.0012090-0740 � 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Santosh K. Swain a,*, Mahesh C. Sahu b, Satyajit Mishra c

aDepartment of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar,Bhubaneswar 751003, Odisha, IndiabCentral Research Laboratory, IMS and SUM Hospital, Siksha ‘‘O” Anusandhan University, K8, Kalinganagar,Bhubaneswar 751003, Odisha, IndiacDepartment of Otorhinolaryngology, VSS Institute of Medical Science and Research, Burla, Odisha, India

Received 22 December 2015; accepted 28 January 2016

Available online 17 June 2016

KEYWORDS

Pleomorphic adenoma;

Parotid gland;

Giant;

Salivary gland

Abstract Pleomorphic adenoma (PA) is the most common salivary gland tumour. It accounts for a

majority of parotid gland tumour. Neglected and untreated PAs can grow in size and weigh several

kilograms. Complete resection of the tumour and preservation of the facial nerve are the main prin-

ciples of surgery. Giant PA of the parotid gland is reported as a rarity in medical literature. We

report a rare giant PA with ulceration over the mass in a 92 year old man on the right side of

the face. Patient had undergone superficial parotidectomy with good cosmetic outcome. The excised

specimen was 20 cm � 1 5cm � 12 cm in dimension and 3.8 kg in weight. Even an ulcerated, malig-

nant transformation was not seen in the tumour.� 2016 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-

nd/4.0/).

1. Introduction

Neoplasms of salivary gland are relatively rare, comprising lessthan 3% of all tumours of head and neck region. Pleomorphic

adenoma (PA) is the most common variant of salivary glandtumour, affecting 60–80% of the benign neoplasms of salivaryglands and constitute 60–70% of all neoplasms of parotid

gland. PA is more common in right side than left side andmore common among females than males (2:1).1 UntreatedPA may grow in size to several centimetres and several

kilograms in weight. Often giant PA of the parotid gland formsa single but irregular, nodular and painless mass whichstretches the overlying skin. Some of these long standingtumours may show malignant transformation. Usually malig-

nant changes can be suspected by a sudden increase in the sizeof the tumour and local features of malignancy like pain,ulceration, spontaneous bleeding and deep tissue invasion.2

Although uncommon, few cases of giant PA have beendescribed in the parotid glands. The giant size of the tumouris usually seen because of the negligence by the patient or fear

of surgery. There are very few cases of giant PA of the parotidreported in the medical literature. The first case of giant PAwas reported in the medical literature by Spence in 1863.3

Whenever possible, early excision of the tumour is ideal despitethe relatively low risk of malignant transformation. Here, we

Figure 2 CT scan showing a large mass confined to the

superficial lobe of the right parotid without invasion to surround-

ing structures.

112 S.K. Swain et al.

present a case of 92 year old male who present with a huge sizemass in parotid with ulcerative changes over it and histopatho-logical examination proved to be a benign PA of the parotid

gland.

2. Case report

A 92 year old male came to outpatient department of Otorhino-laryngology for a large growth on the right side of the face(Fig. 1). The painless swelling had gradually increased in size

over a period ofmore than 25 years. The parotidmassmeasured20 cm � 15 cm in dimensions and got ulcerated since 6 months.The patient was asymptomatic and not consulted any physi-

cians all these years because of his low socioeconomic statusand being neglected by his family members. On examinationit was multi-nodular swelling, firm in consistency and mobile

without fixity to the adjacent structures. Despite the large sizeof the mass, there was no sign of facial nerve paralysis. Hehad no cervical lymphadenopathy. Skin over the mass wasshowing ulceration due to repeated trauma during sleeping pos-

ture as per patient’s saying. Fine needle aspiration cytology(FNAC) performed, showed myoepithelial cells, ductal cellsand chondromyxoid matrix suggestive with PA. Computed

tomography (CT) scan was done to evaluate the extent of themass (Fig. 2). The mass was attached to the superficial lobe ofthe parotid gland. The patient underwent superficial parotidec-

tomy with preservation of facial nerve under general anesthesia.Despite the giant size of the parotid mass, a clear plane of dis-section was found. The patient achieved excellent cosmeticand functional outcome, without damage or recurrence and

no facial nerve palsy. The postoperative period was uneventful.On histopathological analysis and immunohistochemistry,

the lesion was identified as a PA with negative for malignant

Figure 1 Clinical photograph showing a giant mass over the

right parotid gland with ulceration over the mass.

changes. Multiple sections of the tumour mass studied, show-ing tumour cells are arranged in biphasic pattern consisting of

epithelial components and stromal components. Histopatho-logical picture was showing predominately myoepithelial cellsmyxohyaline and chondroid stroma with frequent ductal dif-

ferentiation (Fig. 3). No nuclear atypia and atypical mitosisare seen in histopathology.

3. Discussion

PA is the most common type of salivary gland tumour. Com-mon site of occurrence of PA is the parotid gland, affecting

patients of any age group, but most frequently between thefifth and sixth decades of life.4 PA typically present in thelower pole and superficial lobe of the parotid gland. Approxi-

mately 10% of all parotid PA are thought to arise from deeplobe of the parotid gland.5 The weight of the PA can rangefrom several grams to more than 8 kg and the weight appearsto increase the duration of the tumour.6 Our case is an unusual

giant PA arising in the right parotid gland of 3.8 kg with sur-face ulceration.

Although PA is an essentially a benign tumour, aggressive

behaviour of tumour may suspect a malignant transformation.The incidence of malignant transformation often shows acorrelation between the length of the history of PA and

development of malignancy.7 The classical history of carci-noma ex-pleomorphic adenoma is slow growing mass for sev-eral years and with a recent fast growth phase. Malignantchanges may occur in PA which includes three pathological

entities: carcinoma in PA, carcinosarcoma and benign metas-tasising PA. The incidence of malignant transformation inPA ranges from 2% to 7%.8 The chances of malignant trans-

formation increases in cases of long standing evolution oftumour, advanced ages of the patient, recurrences and locationin major salivary gland.9 Sudden change in growth rate of PA

and local signs of malignancy including pain, ulceration,bleeding and superficial and deep tissue invasion are in favourof malignant transformation in PA. Our patient did not have

any features of malignant transformation except ulcerationand histopathological picture revealed no evidence malignantchanges in tumour and in ulcerated region. In our case,the ulceration over the tumour was due to repeated trauma

Figure 3 Histopathological photomicrograph showing strands and islands of epithelial cells arranged in myxochondroid stroma with

frequent ductal differentiation (Haematoxylin and eosin, 400X).

An ulcerated giant pleomorphic adenoma of the parotid gland 113

particularly during sleeping posture of the patient. Some

documented the risk of malignant transformation increasesfrom 1.6% in tumours with less than 5 years of evolution, to9.5% of those presenting more than 15 years.10 The classical

clinical evidence of carcinoma ex-pleomorphic adenoma is aslow growing mass for several years with a recent fast growthphase. Our patient was of very old age and ulcerated giant

mass, however histopathology showed no evidence of malig-nant transformation.

Diagnostic options in this case are imaging modalities and

histopathological examinations such as fine needle aspirationcytology (FNAC) or incisional biopsy are useful tools in addi-tion to clinical pictures. FNAC is a reliable procedure that canguide the surgeon, even though it would not be the first choice

diagnostic tool. Often FNAC helps to choose the right surgicalapproach before surgery.11 High resolution ultrasound is help-ful for guiding the fine-needle aspiration for cytological diag-

nosis. Open neck biopsies should be avoided, since openingthe tumour capsule increases the chance of recurrence. Prefer-ably computed tomography (CT) scan, magnetic resonance

imaging (MRI) are useful to detect malignant transformation,tumour invasion to deeper structures as it is superior sensitivityon soft tissue.12 Here we have done CT scan as it gives detailsof mass lesions including nature of the mass, deep lobe inva-

sion and lymphatic extension. Before surgery we had doneFNAC. After surgery, all areas of the surgical specimen weremicroscopically analysed and none showed any evidence of

malignant changes.Histologically it consists of both epithelial and mesenchy-

mal elements. In our case, histopathological picture showed

islands of epithelial cells arranged in myxochondroid stromawith ductal differentiation which are characteristics of PA.Although it is accepted that the majority of giant PA remain

non-malignant as happened in our case, early excision isdesirable.

4. Conclusion

We present this case of an unusually giant size of the parotidmass with ulceration over it and did not show any malignant

changes, without facial nerve involvement and no cervical

lymphadenopathy. As this giant PA of the parotid is often aneglected clinical condition, early diagnosis and treatmentare crucial. Untreated PA can enlarge progressively up to sev-

eral kilograms in weight over years. Some may go for malig-nant transformation. Therefore, early diagnosis and excisionof such giant tumours are essential. Superficial parotidectomy

gives excellent results if PA is confined to only to superficiallobe of the parotid.

Conflict of interest

None declared.

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