ARTICLE IN PRESS

Surgical Oncology 13 (2004) 716

Management of primary malignant epithelial parotid tumors

K. Harish*
Department of Surgical Oncology, M.S. Ramaiah Medical College & Hospital, Bangalore 560054, India

Abstract

Parotid cancers are infrequently encountered. These tumors carry a prolonged risk of recurrence and metastasis. Controversies
surrounding pre-treatment evaluation by imaging and ne needle aspiration, utility of operative frozen section are partly resolved.
Though surgery remains the mainstay of treatment, radiation is being recognized as a useful adjuvant. Facial nerve preservation is
one of the important goals at surgery. The role of chemotherapy is still investigational. The prognosis and necessity of elective neck
treatment are mainly guided by the tumor grade and stage.
r 2003 Elsevier Ltd. All rights reserved.

Keywords: Parotid cancer; Diagnosis; Staging; Histopathology; Neck dissection

The usual salivary tumor is a tumor in which the 2. Pre treatment evaluation and management of primary
benign variant is less benign and the malignant
variant is less malignantAckerman and del Regato 2.1. Imaging

In the recent years, the emphasis on imaging in

1. Introduction
Salivary gland neoplasms constitute less than 3% of
all tumors with about 80% of tumors occurring in the
parotid. But only 2040% of such tumors are malignant
[1]. These tumors are infrequent, with diverse biologic
behavior, and have a prolonged risk of recurrence and
metastases. Such factors make the treatment challen-
ging. But they also make decisions on evaluation and
treatment controversial; more so in view of limited
experience of most clinicians.
A detailed pathology of the malignant tumors is
beyond the scope of this article. Although the WHO
classication of malignant tumors of parotid incorpo-
rates all the pathological types, it would be more useful
for the clinician to compartmentalize the commoner
amongst them as low- and high-grade tumors (Table 1).
Such grade-based classication of tumors indicate the
general behavior, but an element of unpredictability of
these tumors must be recognized. Perhaps a more useful
prognosticator would be the unied TNM staging
system (Table 2) [2].
*#2866, 13th Main, E Block, Subramanyanagar, Bangalore 560010,
India. Tel.: +91-80-3322307; fax: +91-80-3601924.
E-mail address: drkhari@yahoo.com (K. Harish).
salivary glands has been on ultrasound, computerized
tomography (CT) scan and magnetic resonance imaging
(MRI) as against an earlier approach which relied on
plain lms and sialograms. In general, it is agreed that
CT scan images an inammatory lesion better while
MRI is better to image tumors as it best evaluates the
borders of a lesion.
The characterization of a lesion as either benign or
malignant can be made in nearly 90% of cases if clinical
ndings are correlated with CT or MRI ndings, while
the same distinction by imaging alone could be less
certain [35]. The common low-grade salivary gland
malignancies develop pseudo-capsules that cause them
to appear as smoothly outlined lesions much similar to
capsulated benign lesions (Fig. 1). Conversely, high-
grade malignancies have irregular, inltrating, indistinct
margins with the adjacent salivary tissue (Fig. 2 and 3).
Rarely a benign mass is surrounded by inammation or
hemorrhage and presents an aggressive sectional ima-
ging appearance. Benign tumors and low-grade malig-
nancies contain signicant gland secretions and hence
MR images show a low T1 weighted and a high T2
weighted intensities; while high-grade tumors have
negligible gland secretions resulting in low to inter-
mediate signal intensities on all imaging sequences. Thus
a low T2 weighted signal should alert the possibility

0960-7404/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.suronc.2003.10.002
 ARTICLE IN PRESS
8 K. Harish / Surgical Oncology 13 (2004) 716

of a high-grade tumor. On MRI, a well-delineated mass periparotid fat strip separating the deep lobe of parotid
is most probably benign; but there is always a possibility gland from the parapharyngeal space is an important
of a low-grade tumor. Hence MRI appearance cannot anatomic landmark and allows the differentiation of
be used to condently distinguish a benign from a
low-grade malignant lesion [6,7]. On the contrary,
an inltrating, irregular mass suggests a high-grade
malignancy.
MRI or CT scanning is useful to delineate the extent
of deeply invasive or advanced tumors, including those
with facial nerve involvement [8,9]. A retromandibular
component or an involvement of parapharyngeal space
by the deep lobe of parotid are better identied. The

Table 1
Classication of malignant tumors

Low-grade tumors High-grade tumors

Mucoepidermoid carcinoma Mucoepidermoid carcinoma

Acinic cell carcinoma
Epithelial myoepithelial carcinoma
Basal cell adenocarcinoma
Low-grade adenocarcinoma
(terminal duct carcinoma)
Squamous cell carcinoma
Adenocarcinoma
Undifferentiated carcinoma
Malignant mixed tumor
Adenoid cystic carcinoma
Salivary duct carcinoma Fig. 1. Transverse section showing a benign well encapsulated parotid
tumor with septations suggestive of Warthins tumor (arrow).

Table 2
TNM staging of parotid cancer

Tprimary tumor
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor 2 cm or less in greatest dimension without extraparenchymal extensiona
T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension without extraparenchymal extension
T3 Tumor having extraparenchymal extension without VII nerve involvement and/or more than
4 cm but not more than 6 cm in greatest dimension
T4 Tumor invades base of skull, VII nerve, and/or exceeds 6 cm in greatest dimension

N-regional lymph nodes

NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
N2a Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N3 Metastasis in a lymph node more than 6 cm in greatest dimension

M-distant metastasis
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis

Stage grouping
Stage I T1/T2 N0 M0
Stage II T3 N0 M0
Stage III T1/T2 N1 M0
Stage IV T4 N0 M0
T3/T4 N1 M0
Any T N2/N3 M0
Any T Any N M1

Midline nodes are considered ipsilateral nodes.

a
Extraparenchymal extension is clinical or macroscopic (not microscopic alone) evidence of invasion of skin, soft tissues, bone or nerve.
 ARTICLE IN PRESS
K. Harish / Surgical Oncology 13 (2004) 716
deep lobe tumors in the parapharyngeal space from
tumors arising within parapharyngeal structures. The
use of contrast with MRI is useful to distinguish a solid
tumor from a cystic mass in addition to evaluating
perineural spread of a malignant tumor [10]. MRI
cannot provide a histologic diagnosis but can provide
accurate tumor mapping including relationship to
carotids, facial nerve and periglandular spread. Normally,
the facial nerve itself is not imaged. The recent use of
high-resolution three-dimensional Fourier transform
MR imaging, however, has allowed the facial nerve to
Fig. 2. Coronal section showing malignant parotid tumor.
Fig. 3. (a) Transverse section showing malignant tumor of the parotid (white arrow) involving the temporomandibular joint and infratemporal fossa
(black arrow). (b) Coronal section showing involvement of mandibular nerve (white arrow).
9
be consistently visualized on contiguous scans [11]. MR
imaging spectroscopy has limited clinical application
and it is essentially an investigative tool.
Controversy exists regarding the need for evaluation
beyond a history and physical examination before
performance of denitive surgery [12,13]. It is argued
that MRI and CT scan does not add any useful
information which assists in surgical decision making.
There is no categorical answer as to whether these
investigations are required in every case but as a broad
guideline, a supercial mobile parotid mass does not
warrant a scan while in xed, deeper placed tumors and
those in close proximity to facial nerve a MRI scan may
be useful. CT or MRI may also be required to assess
involvement of adjacent organs like external auditory
canal, mastoid, mandible or muscles.
2.2. Fine needle aspiration cytology
Salivary glands are generally not subjected to a core
needle or an incisional biopsy due to an apprehension of
a resultant stula. In addition, there could be a
possibility of a tumor seeding of the tract. However
the same apprehensions are unfounded with ne needle
aspiration cytology (FNAC). Even then, the value of
FNAC is controversial and unresolved [14,15]. Adding
credence to such a stand are the accepted facts that the
ne needle may not sample the representative area, that
the cytologist must be experienced at interpreting these
slides and some reports of poor specicity for malignant
tumors [16,17]. Since all parotid masses need surgical
removal, the type is dictated more by other considera-
tions such as facial nerve, some surgeons do not
advocate the use of FNAC.
A contrary argument is that the purpose of FNAC
may not always be to provide a type specic diagnosis as
 ARTICLE IN PRESS
10 K. Harish / Surgical Oncology 13 (2004) 716
it is not a substitute for histopathology. In a step wise
manner, FNAC performed on the mass must prove or
contradict the origin of the lesion from the salivary
gland, characterize the lesion as neoplastic or otherwise,
classify as benign/low-grade/high-grade malignancy if
neoplastic and lastly a type specic exact tumor type
only if there are unequivocal ndings [18]. With such an
understanding of the purpose, usefulness and limita-
tions, a liberal use of FNAC is desirable. Two recent
large studies of salivary gland FNAC showed 9798%
accuracy, 9298% sensitivity to the presence of a
neoplasm and 98100% specicity for absence of a
neoplasm [19,20]. Certain tumor types like mucoepider-
moid, acinic cell and adenoid cystic could be difcult to
diagnose on FNAC. FNAC can identify nonneoplastic
lesions, patients who are not candidates for surgery,
prepare the operating team for more extensive proce-
dures in high-grade tumors and in pre-op evaluation
(different treatment plans for primary carcinoma/
lymphoma/metastasis). As with all tests, the results of
FNAC must be used with caution, particularly if the
result does not t into the clinical picture. Repeat
FNAC or a direct surgical procedure may be required
in some instances. An open biopsy is seldom
indicated as tumor spillage could occur resulting in
recurrence of a benign tumor like pleomorphic adenoma
and incomplete oncologic clearance of a malignant
tumor. In addition, the availability of FNAC and
per-operative frozen section (FS) study precludes its
usage.
2.3. Frozen section
Evaluation of efcacy and usefulness of FS study
have yielded varying results. Though benign lesions have
been diagnosed with reasonable accuracy, one study
could diagnose only 9 of 25 malignant lesions; while
others showed sensitivity of 61% and could accurately
type the malignancy in only 51% showing that FS study
requires expertise [17,21,22]. Some other authors report
sensitivity and accuracy in a range upwards of 92%
[2325]. Having accepted the possibility of some errors,
wherever experienced pathologists are available, the
accuracy of FS is sufciently high and could be helpful
in making important intra-operative decisions.
As pointed out earlier, the plan for surgical treatment
is based on considerations like tumor size, stage and
facial nerve involvement among other factors. A precise
diagnosis made by FS modifying the planned surgical
procedure is infrequent though assigning the tumor as
malignant or grading of such a tumor could be useful.
The pitfalls of such a study would be limited sections
studied and the availability of expertise. More often, FS
is utilized to assess the margins of resection; again only
if it would impact the surgical decision making. One
such situation would be when facial nerve resection is
planned and FS is utilized to study the nerve margins for
adequacy of resection.
Evaluation by imaging, FNAC and FS are contro-
versial. But if the surgeon requests and interprets the
results of these tests judiciously in the backdrop of clinical
ndings, these investigations could be very valuable.
3. Surgery
Surgery for malignant parotid tumor should address
both the primary disease and the nodal disease if
necessary. Optimal surgical therapy for parotid lesions
is best done by a single operative procedure. Secondary
procedures can be performed only at increased risk to
the surrounding structures and will be less effective in
permanent eradication of tumor. Although the techni-
que of facial nerve identication and parotid tissue
removal is reasonably well standardized, controversy
persists regarding the extent of parotidectomy required
to adequately address the neoplasm, FS study and the
need for elective cervical lymphadenectomy.
Surgery is the most important modality in manage-
ment of salivary neoplasms. Parotidectomies are classi-
ed as shown in Table 3. Parotidectomy is described as
either supercial or total. When it is the latter, it is further
claried with respect to facial nerve as total radical or
total conservative parotidectomy. The point of debate is
whether the surgery for malignant parotid tumors should
always be a total parotidectomy or not. Many emphasize
that treatment approach must be modied according to
tumor grade with high grade tumors requiring nerve
sacrice, nodal dissection and post operative radiation.
Controversy exists regarding not only which tumors must
be considered high grade, but also whether grade is an
important variable to be considered for treatment
decisions. More than grade, clinical stage is considered
by many to be more prognostically important [2628].
3.1. Extent of parotidectomy
By the principles of oncology, a malignant parotid
salivary gland tumor would have to be dealt with by a
Table 3
Classication of parotidectomies
With reference to facial nerve
Radical Facial nerve sacriced
Semi-conservative Some branches of facial nerve sacriced
Conservative All branches of facial nerve preserved
With reference to extent of tissue removed
Supercial Gland lateral to facial nerve removed
Deepa Gland medial to facial nerve removed
Total Whole gland removed
a
Deep parotidectomy is not usually performed in isolation.
 ARTICLE IN PRESS
K. Harish / Surgical Oncology 13 (2004) 716
Table 4
Oncologic concepts in parotid cancer
Concerns Current thinking
Oncologically affected organ Wide excision is as effective;
must be radically excised sometimes there is a need to add
adjuvant therapy
Unilobar organ Facial nerve considerations are
important
Presence of intra-parotid nodes Almost all such nodes are
removed in supercial
parotidectomy
Multicentric disease Extremely rare in malignancy
radical total parotidectomy. But, as the facial nerve
traverses through the gland its preservation becomes one
of the very important goals at surgery. Hence the aim in
parotid surgery would be to radically attack the tumor
and not the gland. The original concerns which led to
advocating radical total parotidectomy and present
concepts leading to more conservative surgeries are
shown in Table 4. The arguments of authors supporting
total parotidectomy is based more on the fact that
parotid is a single unilobar organ with continuity of
gland parenchyma on either side of facial nerve than
from evidence of higher cure rates with total paroti-
dectomy compared with supercial parotidectomy [6].
The concept of adequate parotidectomy is dictated
by the extent of clinical disease and would be supercial
parotidectomy for small lesions conned to supercial
lobe [27,29]. It would be reasonable to suggest a
supercial parotidectomy for all low-grade tumors
placed in the lateral lobe and a supercial parotidectomy
along with removal of most of deep lobe for high-grade
tumors (total conservative parotidectomy). These sur-
geries address the margins aggressively within the
constraints of facial nerve preservation.
3.2. Facial nerve considerations
It is felt that if malignant lesions are to be treated
adequately, intentional sacrice of part or all of the
nerve may be occasionally necessary [29]. In an era when
radiation was thought to be ineffective against parotid
tumors, facial nerve sacrice resulting in radical total
parotidectomy was recommended for most malignant
parotid tumors [30,31]. With the advent of radiotherapy,
patients with high-grade tumors treated with more
conservative surgery (facial nerve preservation) followed
by radiation were found to have same survival and low
recurrence despite 74% patients having a microscopi-
cally positive margin [28]. The decision to sacrice facial
nerve when no pre-op facial involvement is documented
must be made on case to case basis taking into
considerations many factors including tumor histology,
patients desires, overall prognosis and most impor-
11
tantly intra-operative ndings. Proponents of conserva-
tive surgery preserving the facial nerve suggest that
leaving behind microscopic disease but not gross disease
is acceptable if done for the sake of preserving the facial
nerve especially if the nerve is functionally intact pre-
operatively [32]. If tumor free margins are obtained,
sacrice of facial nerve for the sake of performing a
radical parotidectomy is unacceptable. A functionally
intact nerve needs to be preserved even at the cost of
leaving behind microscopic disease. It should be
remembered that with the availability of adjuvant
radiation, though more conservative surgeries can be
planned, sometimes leaving behind microscopic disease,
it is not a license to leave gross residual tumor behind. If
the nerve is paralyzed pre-operatively, there is no reason
to preserve it when the surgery is planned for a
malignant tumor. If nerve is intact pre-operatively but
there is gross involvement intra-operatively, sacrice of
the nerve may be mandatory. If nerve sacrice is
required, every attempt must be made to preserve more
important branches like the one to the eye. If main trunk
needs to be sacriced, it must be reconstructed
immediately. Structures other than facial nerve like
skin, mandible, muscles and temporal bone are removed
as determined by the extent of primary lesion. FS may
be used to determine the adequacy of margin including
the extent of facial nerve excision.
4. Management of neck
Cervical nodal metastasis reduces the 5 year survival
from 74% to 9% but is uncommon occurring in about
1316% of malignant parotid tumors [3335]. Clinical
neck examination is a reliable predictor of regional
nodal metastasis [36]. Clinically positive nodes are
generally treated by neck dissection, the type dictated
by the extent of nodal disease. When a comprehensive
neck dissection is planned, a modied radical neck
dissection sparing the accessory nerve would be appro-
priate. The results of several retrospective studies
indicate that postoperative radiation is of value in
improving local-regional control and survival in patients
with salivary gland cancer who have cervical lymph
node metastases but it is unclear whether all patients or
only those with multiple nodal disease or only those
with perinodal spread need adjuvant radiation [3740].
The 5-year local-regional control rate is 69% for
patients with nodal metastases treated with radiation
to the neck, and 40% for patients treated with surgery
alone while survival rates are 49% and 19%, respec-
tively [33].
The treatment of N0 neck is more debatable. The
incidence of occult nodal metastases are signicantly
higher in high-grade tumors like anaplastic, salivary
duct, epidermoid, adenocarcinoma and high grade
 ARTICLE IN PRESS
12 K. Harish / Surgical Oncology 13 (2004) 716

Table 5 metastases to contralateral nodes are negligible [34].

Nodal metastasis in N0 neck Though the argument of superiority of either radiation
Character % of occult nodal metastasis or surgery would continue, the current thinking is that
an elective neck dissection is seldom if ever indicated
High grade 1849 (overall)
and that elective radiation would be more appropriate
Anaplastic 100
Salivary duct 80 [33,41]. It must be recognized that radiation is not
Epidermoid 4150 complication free. This approach of elective radiation
Adenocarcinoma 1825 has not been tested prospectively and one must be
Mucoepidermoid (high grade) 23 cautious of extrapolating this to nonsquamous tumors
like anaplastic and high-grade adenocarcinomas [50]. In
Low-grade o5
Size addition, elective neck dissection and elective neck
o3 cm 49 radiation have not been compared to establish the
>3 cm 1520 superiority of one over the other.
T status
T1 or T2 713
T3 1633 5. Radiation therapy
T4 2450
When radical surgery is used alone for malignant
Facial nerve salivary tumors, facial paralysis (86%) and tumor
No palsy 8
recurrence in the surgical eld (2764%) are the
Paralyzed 3360
distressing sequelae [42,51]. In the past, it was believed
that salivary gland tumors were radioresistant. Changes
in radiotherapy including different types of beams,
improved design of treatment elds and delivery systems
mucoepideroid cancers while it is less than 10% in other have resulted in better treatment outcomes which have
varieties (Table 5) [33,41]. Similarly, occult nodal changed the earlier opinion. When properly combined
metastases are higher for tumors larger than 3 cm with surgery, radiotherapy can result in preservation of
and T3, T4 lesions including those with facial palsy facial nerve function and reduced incidence of local
[33,38,4143]. These criteria predict the higher possibi- recurrences.
lity of nodal metastases. Recommendations for treat- For an operable malignant lesion, surgery is the
ment of N0 neck has ranged from no elective neck mainstay of treatment. Surgery alone could be adequate
dissection to comprehensive neck dissection for certain for small lesions (less than 3 cm) with no high risk
categories based on one or more of the above criteria. factors [52,53]. The major role of radiation is when it is
Other recommendations include a selective neck dissec- administered as an adjuvant therapy post operatively.
tion or even elective post operative radiation without This helps preserve facial nerve, is useful in patients with
neck dissection [33,34,41,4448]. high risk features including stage III and IV lesions, high
N0 neck can be addressed by elective surgery grade histologic types and in those with positive nodal
[33,46,49]. An elective neck dissection is useful to stage disease. When the disease is advanced and inoperable,
the nodal disease and in addition, it treats the micro- radiation may be able to control some tumors [54].
metastasis. Necessity for elective neck dissection is based The minimum treatment volume would include the
on one or more criteria discussed earlier. Another entire parotid compartment, including the drainage of
approach used by some clinicians is to perform a node lymph nodes in the pre-auricular and upper neck areas.
biopsy; FS of which then determines the necessity and It would perhaps be more appropriate to cover the
extent of elective nodal dissection [13,45,48]. entire neck in a high-grade tumor. There have been no
N0 neck can also be treated by elective neck radiation. documented differences in response based on histologic
Incidentally, the characters that predict occult metas- features. A dose of 60 Gy in 30 fractions should sufce.
tases are also independent indications for adjuvant However, in tumors with close margins or those with
radiation. Thus when the indication for adjuvant residual tumor, an increase up to 70 Gy with shrinking
radiation is established, it seems reasonable to leave eld technique might be required. The recommended
the neck surgically unexplored more so when it is therapy employs singly or in combination a high-energy
clear from literature that salivary gland tumor is photon or electron beam or a neutron beam. Fast
sensitive to radiation [34,3840,45]. In addition, these neutron therapy would be the choice of treatment for
predictive factors make the usefulness of surgical staging advanced tumors but is hampered by lack of universal
dubious. availability [55,56].
Whether the neck is treated electively with surgery or Considering all histologic features, adjuvant radia-
radiation, only ipsilateral neck need be treated as tion reduces the recurrence rates from 29.6% to 9.1%
 ARTICLE IN PRESS
K. Harish / Surgical Oncology 13 (2004) 716
[57]. The 5-year survival is highest for acinic cell
carcinoma (92%) and the least for undifferentiated
carcinoma (33%) while the rest range between 50% and
75% [57]. Comparable results are also reported in the
recent Swedish 10 years survival report for acinic cell
carcinoma (88%), undifferentiated carcinoma (44%),
adenocarcinoma (50%) and the rest (7480%) [58].
6. Management of metastatic disease
Occurrence of metastasis varies depending on the
histology (Table 6) but an overall incidence is about
20% [38,45,59]. The sites involved are lung, bone, liver
and brain. Metastasis can manifest sometimes 510
years later due to long tumor doubling times emphasiz-
ing the need for long-term follow-up [60]. There is even a
suggestion that metastasis at cellular level could occur
many years prior to clinical presentation of primary [61].
Though ominous, some patients like those with meta-
static adenoid cystic carcinoma can live with disease for
a further 35 years without treatment. It would be
tempting to offer metastatectomy for solitary metastasis
though the usefulness of such a procedure is unproven.
Chemotherapy can be recommended in a setting of
metastatic disease even though adequate studies dening
the exact nature of benet are lacking.
6.1. Chemotherapy
Studies of chemotherapy in adjuvant and neo-
adjuvant settings have been far and few. Interpretation
of study data has been hampered by small numbers and
diverse histopathologic types; more so in the context of
probable histopathology related susceptibility to che-
motherapy. Single agents show a response in the range
of 1040% and include cisplatin, 5-uorouracil (5-FU),
adriamycin, epirubicin, mitoxantrone and vinorelbine.
Newer drugs like paclitaxel and carboplatin have also
been found to have modest activity [62]. Combination
chemotherapy with adriamycin, cisplatin and 5-FU have
shown responses of 3060% and have been used in
adenocarcinoma and adenoid cystic carcinoma [6366].
Table 6
Distant metastasis and histology of primary
Histology of lesion Metastasis (%)
Adenoid cystic carcinoma 42
Undifferentiated carcinoma 36
Adenocarcinoma 27
Carcinoma in pleomorphic adenoma 21
Squamous cell carcinoma 15
Acinic cell carcinoma 14
Mucoepidermoid carcinoma 9
13
High-grade mucoepidermoid carcinoma appears to be
more sensitive to cisplatinum, bleomycin, methotrexate
and 5 FU [67,68]. Little data is available to comment on
other less common histologic variants. End points of
improvement in disease free survival and overall survival
would be very difcult to comment. For the present, the
use of chemotherapy has been conned to progressive
loco-regional disease not amenable to surgical or
radiation therapy and in the setting of metastatic
disease.
6.2. Prognosis and survival
Many factors affect the prognosis but two most
signicant of them are the tumor grade and the clinical
stage. TNM staging is a good prognosticator [69].
Among other important factors, prognostication of
nodal and metastatic diseases has already been dis-
cussed. The reported 5-year survival of tumors less than
3 cm is 85% and for those more than 6 cm is 14%
[70,71]. Low grade tumors have a 5-year survival greater
than 90% while the survival of high-grade tumors like
undifferentiated and high-grade mucoepidermoid
tumors could be less than 20% [72,73]. Overall crude
5-year survival is about 50% which progressively
decreases from 65% and 50% for stages I and II to
21% and 9% for stages III and IV, respectively [69].
Facial nerve involvement is reported in 1214% of
malignant parotid tumors but varies with tumor
histology. The average survival is 2.7 years with a
5-year survival of 911% [74,75]. The prognosis remains
grim despite radical resection including facial nerve [76].
The incidence of recurrences varies between 27% and
38% despite aggressive surgery and is one of the
arguments for preservation of facial nerve [77,78].
Recurrence occurs between 5% and 15% for acinic cell
carcinoma and mucoepidermoid carcinoma but is seen
in a range upwards of 50% for other varieties [79]. The
survival of 67% in nonrecurrent parotid cancer drops to
less than 50% and in some series to 17% for recurrent
cancers [80,81].
Parotid cancer poses a diagnostic and therapeutic
challenge. Treatment must be individualized but general
treatment guidelines are summarized in Tables 7 and 8.
The diverse histologic patterns and limited experience of
individual surgeons add to the woes. Late recurrences
make long-term follow-up mandatory. On the ip side,
FNAC is used more often today as pathologists have
gained more experience. MRI and FS have been used
more often to aid the surgical decision making. In
addition to optimal surgical tumor resection, facial
nerve preservation and reconstruction are important
surgical goals. Radiation has established its usefulness
in an adjuvant setting while chemotherapy is still
investigational.
 ARTICLE IN PRESS
14 K. Harish / Surgical Oncology 13 (2004) 716

Table 7
General guidelines on treatment of primary

Tumor category Tumor location Treatment

T1/T2, low grade Supercial lobe Supercial parotidectomy

Deep lobe Total conservative parotidectomy7radiation

T1/T2 high grade Either lobe Total conservative parotidectomy+radiation

T3, either grade, recurrent tumor Either lobe Total conservative/radical parotidectomya+radiation

T4, either grade Either lobe Total radical parotidectomya+removal of involved structures+radiation

Inoperable primary or Inoperable recurrence Palliative radiation7chemotherapy

a
Reconstruct facial nerve whenever it is resected, facial nerve reconstruction is not a contraindication for radiation

Table 8
General guidelines on treatment of nodes and metastasis

Nodal/metastatic status Tumor characters Treatment plan

N0 Low-grade tumor T1/T2 No elective treatment for neck

N0 High-grade tumor T3/T4 Elective neck treatment with surgery/radiation

Some T2>3 cm

N+ Operable Modied radical neck dissection or radical neck dissection

N+ Inoperable Palliative radiation/palliative chemotherapy

M1 Palliative chemotherapy

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Harish K.
Harish K. hailing from India, graduated from Mysore
Medical College and received General Surgical training
from Bangalore Medical College. He subsequently com-
pleted a formal Surgical Oncology training leading to a
post-doctoral qualication from Cancer Institute, Adyar,
Chennai, in 1995. He is a Diplomate of National Board in
Surgery. He is presently an Associate Professor and
heading the Department of Surgical Oncology at M.S.
Ramaiah Medical College, Bangalore, India. He is life
Member of Indian Medical Association and Association of
Surgeons of India. He is a Fellow of Association of Indian
Surgeons and Fellow of International College of Surgeons.
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