Synchronous malignancy of left parotid gland and left eye balla case report

A 40 year old man was admitted to Shaheed Suhrawardy hospital, Dhaka with swelling of left parotid gland and left eye ball. Previously incisional biopsy was done from upper conjuntival swelling at National Institute of Opthalmology (NIO), Dhaka which revealed moderately differentiated Squamous cell carcainoma. Later on FNAC of left parotid swelling was done which revealed poorly differentiated adenocarcinoma. The patient under went left Radical Parotidectomy with left sided selective neck dissection and exenteration of left eye ball at SSH, Dhaka. Histopathology report showed poorly differentiated carcinoma of parotid, conjunctival tissues & necknodes. As synchronous malignancy of parotid gland, eyeball with metastatic neck nodes is rare, so this case has been selected to publish in the medical journal.


Introduction
Of all the cancers treated by Head & Neck oncologists, malignant salivary gland tumours are arguably the most difficult.Patients are not infrequently young and the cure rates are very poor for most histological types.Why malignant salivary neoplasms and adenoid cystic carcinoma, in particular, are so resistant to treatment is not known even with the twenty first century explosion in the techniques of molecular biology.The natural history of the cancers tends to be long and patient may under go multiple treatments in attempt to control their disease at least 1 .
According to Batsakis et al. 2 , The incidence of primary SCC of the salivary glands is some where between 0.3% &1.5%.Squamous cell carcinoma (SCC) involving the salivary gland is much more common and, to be defind as a salivary carcinoma, certain criteria must be met.The tumour must arise from the gland itself and not from lymph nodes within the gland.There must be no regional or adjacent tumour especially of the skin & needless to say, a high-grade mucoepidermoid carcinoma must be excluded.The Memorial Hospital, when reviewing their histology, found that s.c.c.accounted for only 12.5% of all malignant salivary gland tumour.Over almost a 30 year period the same group reported only 10 of these tumours in the parotid & 15 in the submandibular gland, 2,3 .In an analysis of 50 cases of SCCs of the salivary gland over a 30 year period, 42 cancers of the parotid gland were recorded & only 6 of the submandibular gland 4 .Most patients present without pain but approximately 20% do have pain, and facial palsy occurs in 10%.Nearly half of all patients had neck node matastases at the time of presentation.Distal metastasis occur approximately in 10% of patients and advanced age, tumour fixation, lymph node metastasis are associated with poor a prognosis 5 .Whatever the treatment, the cure rate for this disease is disastrous with almost no five-year survivors 6 .Orbital metastases from malignant neoplasms are rare & can originate from Orbital metastasis from malignant neoplasms are rare and can originate from any where in the body commonly breast and lung carcinoma but this patient develops multiple primary malignancy, like, orbit parotid 7 .Here Orbital tumour and Parotid tumour are of separate origin and same duration of history and there is no relationship between these two tumours.nodes.After wound healing he was treated by radiotherapy.On follow up visits, the patient stated that he was satisfied with the results but a small upper eyelid swelling was seen and advised for excision and to continue the treatment (therapy).

Discussion
Most authors suggest that one in six parotid tumours are malignant.Not all of the oncologist agree with this rather a much higher figure of one in four or even one in three has been quoted.According to Liverpool head neck data base, 24% of all parotid tumours are malignant tumours of the main body.Malignant tumour may enlarge rapidly and facial nerve paralysis is not uncommon.Facial nerve paralysis as a presenting sign appears in approximately one third of patients.Pain is a symtom of malignancy.Carcinoma of the deep lobe expand medially in to pharynx.Although about 10% of parotid tumours are from the deep lobe, fortunately malignancy is fairly unusual at this site.The commonest malignancy is the mucoepidermoid carcinoma followed by adenoid cystic carcinoma.It should be remembered that the parotid gland contains lymph nodes, superficial lobe contain 3 to 7, and deep lobe contain 0 to 3 nodes.Regional nodal involvement is seen approximately in 13% of parotid cancers but the risk of recurrence in a previously involved neck is greater than 50%.Owing to these findings, either a selective neck dissection clearing area 1, 2 and 3 or even a radical neck dissection in high grade tumours should probably be carried out.Post operative irradiation almost certainly improves loco regional control, although these are no randomized trials to support this view.

Conclusion
As synchronous malignancy of parotid gland, eyeball with metastatic neck nodes is rare, so this case has been selected to publish in the medical journal.
Bangladesh J of Otorhinolaryngology 2008; 14(2) : 75-77 .Biopsy was done from upper conjunctival mass at NIO, Dhaka which revealed poorly differentiated S.C.C and FNAC of left parotid swelling was done by Maxillo facial department which revealed adenocarcinoma.CT scan of face was done which revealed left sided parotid mass with suspected cervical lymphadenopathy.Then patient was transferred to the ENT department where other investigations were done.Ultrasonography of whole abdomen revealed single calculous and echo cardiography revealed Left ventricular Hypertrophy with good L.V systolic function.The chest radiograph and other Biochemical reports were normal.