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British Journal of Oral and Maxillofacial Surgery 53 (2015) 94–96

Available online at www.sciencedirect.com

hort communication

ilateral parotid gland metastases from carcinoma of thereast that presented 25 years after initial treatment. Duncan ∗, M. Monteiro, M. Quante

oyal Sussex County Hospital, Brighton, United Kingdom

ccepted 24 September 2014vailable online 18 October 2014

bstract

e report a case of a 76-year-old woman with metastases to both parotid glands almost 25 years after mastectomy and chemotherapy forrimary carcinoma of the breast. Immunohistochemical staining is invaluable in establishing the origin of metastatic deposits, in this case,xpression of oestrogen receptors in a previously resected adenocarcinoma of the breast. The information can be used to target treatment

ccurately in selected cases of advanced malignancy.

2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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eywords: Bilateral parotid metastases; Breast adenocarcinoma; Cytokerat

ntroduction

etastases to the parotid glands from malignancies of theead and neck are relatively uncommon, and usually ariserom ipsilateral primary cancers of the skin or mucosa. Theserimary cancers are well known to metastasise to either one oroth parotid glands by direct extension through neighbouringissues, lymphatic channels, or less commonly, throughaematogenous spread.1 However, parotid metastases fromnfraclavicular malignancies are rare (0.16–0.4%),2 and mostften use the haematogeneous route. Numerous reports havehown unilateral parotid metastases from other tumoursuch as those of the lung and kidney, and from ductalreast carcinoma, malignant melanoma, rhabdomyosarcomaf the lower limb, testicular seminoma, and Merkel cell

2–4

arcinoma. There is scant evidence, however, of metas-ases to both parotid glands from malignancies in sites otherhan the head and neck, with isolated reports of spread from

∗ Corresponding author. Tel.: +44 07540 372116.E-mail addresses: Miles.Duncan@bsuh.nhs.uk,

milesduncan@hotmail.com (M. Duncan), Michael.Monteiro@bsuh.nhs.ukM. Monteiro), Mara.Quante@bsuh.nhs.uk (M. Quante).

tpedsnaa

ttp://dx.doi.org/10.1016/j.bjoms.2014.09.023266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Pu

unohistochemistry; Tamoxifen; Letrozole

ypernephroma,4 renal cell carcinoma,5 hepatocellular car-inoma, and small cell carcinoma of the lung.6 We know ofo previous reports of metastases to both parotid glands fromarcinoma of the breast.

ase report

76-year-old woman presented to our department withn ill-defined, firm, non-tender 2 cm diameter mass in theight parotid tail. She had previously been diagnosed with a.5 cm diameter primary carcinoma of the mammary duct ofhe right breast in December 1989, and had subsequentlyad mastectomy and axillary sampling (7 nodes sampledhowed no signs of metastases) followed by 5 years ofamoxifen. History elicited a progressive unilateral facialalsy in the 2 months before initial review at the clinic, andxamination showed she had a House–Brackmann grade IVeficit and was not able to close her right eye. Core biopsy

pecimens of the lesion showed poorly differentiated ade-ocarcinoma with strong expression of oestrogen receptors,nd less strong expression of E-cadherin and CK7. No CK20nd HER 2 receptors were expressed (Figs. 1 and 2). Six

blished by Elsevier Ltd. All rights reserved.

M. Duncan et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 94–96 95

Fig. 1. Core biopsy specimen from left parotid. Immunohistochemical stain-ing for oestrogen receptors in poorly differentiated adenocarcinomatous cells(original magnification 80×); similar staining in right parotid core.

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Fig. 3. Axial computed tomogram showing diffuse infiltrative lesions in bothp

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ig. 2. Immunohistochemical staining for CK7 in left parotid core (originalagnification 40×); similar staining in right parotid.

eeks later she developed a swelling in the left parotid,nd core biopsy specimens similarly showed adenocarci-oma with identical immunostaining. Computed tomographyCT)-parotids showed a malignant infiltrative process in bothlands (Fig. 3). There was no evidence of any other active dis-ase. After discussion at the head and neck multidisciplinaryeam clinic, the parotid lesions were treated with letrozole.he responded well, but showed no objective improvement

n facial nerve function.

iscussion

ur patient presented with 2 findings: first, parotid metastaseshat had arisen from breast cancer treated 25 years previously,nd secondly, bilateral parotid swellings that arose within ahort period of time. There is some reported evidence to sug-est that primary malignancies of the salivary glands canxpress sex hormone receptors, but most express androgeneceptors, and few express oestrogen receptors.7 It thereforeeems improbable that these metastases were 2 distinct pri-aries in the parotid glands. One possible reason for the

ecurrence was that at the time of initial mastectomy she hadnly the axillary nodes sampled rather than a level III axil-ary clearance. However, extensive surgery had been deemed

P

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arotid glands.

nappropriate at the time, as none of the 7 nodes sampled hadontained metastatic cells. A second more plausible reason ishe reduction over time in the therapeutic effect of tamoxifenn tumour cells that express oestrogen receptors, given that 2ecades had passed since the standard 5-year hormonal treat-ent had stopped. The recent ATLAS trial has shown thatortality from oestrogen receptor positive breast cancer is

educed from 33.1% to 23.9% if adjuvant tamoxifen is givenor 10 years.8

This case highlights the importance of immunohistochem-cal analysis in the diagnosis of parotid tumours. Expressionf oestrogen receptors directs adjuvant treatment towardsamoxifen in premenopausal women and aromatase inhibitorsletrozole, anastrozole) in postmenopausal cases. E-cadherintatus differentiates between intraductal and lobular carci-oma of the breast. All salivary gland tumours stain forK7 and not for CK209 but this pattern is more specific forertain types of metastatic adenocarcinoma, mainly of thereast; it is also seen in endometrial, ovarian, and pulmonaryumours. Staining for CK20 and not for CK7 is commonlyeen in colorectal adenocarcinoma.10 Given this combina-ion of staining patterns, it seems likely that, in this case,oth parotid lesions originated from the breast carcinoma.

onflict of interest

o conflict of interest.

atient permission statement

he patient’s confidentiality was maintained throughout.

9 al and

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26–32.10. Tot T. Patterns of distribution of cytokeratins 20 and 7 in special types

6 M. Duncan et al. / British Journal of Or

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