Carcinosarcoma Parotid in Progress

8/7/2019 Carcinosarcoma Parotid in Progress

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Carcinosarcoma of theParotid Gland: Case Report


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Case Presentation

49 y/o white male presented with 3 month

historyof a rapidly enlarging right parotid

mass, and a 1 month history offacial

paralysis. I cant feel the right side of my face and feel

dizzy


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History

PMHx: HTN

PSHx: ORIF of tibia

Allergies: NKDA

Meds: none

Social Hx: 3 packs/day for 30 years!


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Physical Exam

Physical Exam (abnormal findings):

HEENT/Neuro:

Facial asymmetry and abnormal facial strength (CN-VII

palsy) 2 x 4 cm tender palpable mass overlying the right parotid

gland, adherent/fixed to underlying tissue.


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Work-up (outside hospital)

CT scan of neck- Large necrotic mass involving both the superficial

and deep aspects of the right parotid gland.

Mass measures almost 4 cm in greatestdimension.

FNA of the parotid mass-

Most c/w Mucoepidermoid Carcinoma.


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MRI Report

4.5 x 2.7 x 2.9 cm mass partially replacing the

the superficial and deep lobes of the right

parotid gland.

Intermediate signal on T1 and low signal on

T2 indicating a high cellularity tumor.

Base of skull (jugular foramen) shows lytic

lesions with same characteristics as themass involving the parotid gland c/w tumor

metastasis.


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Assessment/Plan

Right Parotidectomy

Right Neck Dissection (levels I,II,III)

Right jugular foramen approach with

excision of posterior fossa lesion


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Pathology

02/15/2010

Received:

Right parotid gland.

Right neck dissection, levels I-III.

Facial nerve biopsy.

Multiple right mastoid biopsies.


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Pathology

2.1 x 1.1 x 0.8 cm ill defined area, that grossly

appeared confined to the parotid gland


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IHC Stains

Pan keratin: +++ neoplastic cells with glandular differentiation

EMA:

+++ neoplastic cells with glandular differentiation Mucicarmine

+ luminal material in foci of glandulardifferentiation.

S-100 + cells in areas of solid growth pattern

SMA + spindle cells in areas of solid growth pattern


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Pathology

Diagnosis:

Carcinosarcoma of parotid gland.

2.1 x 1.1 x 0.8 cm- pT2

Margins uninvolved by tumor and no extension beyondparotid gland.

+ LVI

+ PNI

Metastatic carcinoma in four of forty-two lymph

nodes (4/42)- pN2b

Metastatic carcinoma in right mastoid bone- pM1


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Malignant Mixed Tumors of

the Salivary Gland 3 Types

1) Carcinoma ex pleomorphic adenoma

Carcinoma arising in a mixed tumor

Most common form

2) Carcinosarcoma

(true malignant mixed tumor)

3) Metastasizing pleomorphic adenoma


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Carcinosarcoma

Definition:

Biphasic tumor with both a carcinomatous and

sarcomatous component.

Thought to arise de novo (vs carcinoma expleomorphic adenoma which arises from pre-

existent benign mixed tumor).


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Epidemiology

Rare and aggressive entity with only 70

cases documented in literature.

Ages (15-85 y/o)

No predilection to gender


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Etiology

Two schools of thought


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Histology

Carcinomatous component:

Poorly differentiated adenocarcinoma, undifferentiated

carcinoma or squamous cell most common.

May also include adenoid cystic, mucoepidermoid or

salivary duct carcinoma.

Sarcomatous component:

Most common is chondrosarcoma.

Others include spindle cell sarcomaNOS, fibrosarcoma,

osteosarcoma, liposarcoma, and rhabdosarcoma.

The relative proportion of the 2 components is

variable, and either component may dominate the

histologic picture.


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Case Presentation


history of a right parotid mass, and a 1

month history of facial paralysis (described it

as loss of feeling.


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Case Presentation




as loss of feeling.


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Case Presentation




as loss of feeling.


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Work-up: FNA

FNA of the parotid mass done at anotherinstitution was reported as aMucoepidermoid Carcinoma.


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FNA

Abundant amorphous debris with

benign acinar cells and few atypical

keratinized squamous cells, cannot rule

out malignancy.


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Work-up: Imaging

CT: superior to physical exam and otherimaging modalities.

Does not provide specific info regardinghistologic diagnosis, but provides info about

bilateralism and benign vs. malignantmasses.

MRI superior to CT in demonstrating internalarchitecture.

Location in relationship to fascial planes andspaces (for operative planning).


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MRI Report


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MRI Report

4.5 x 2.7 x 2.9 cm mass partially replacing the

the superficial and deep lobes of the right

parotid gland.

Intermediate signal on T1 and low signal onT2 indicating a high cellularity tumor.

Base of skull shows lytic lesions with same

characteristics as the mass involving the

parotid gland c/w tumor metastasis.


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Embriology and Microscopic

Anatomy

Ectodermal origin.

4-6th week of gestation.

Serous and mucous cells, arranged inacini, drained by series of ducts.

Parotid: serous acini.

Submandibular: serous and mucinousacini.

Minor SG: mucinous acini.


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Cellular Origins of Salivary

Gland Neoplasms

Multicenter theory:

Each type originates from a distinctive cell

type.

E.g.Whartins / oncocytic: striated duct

cells.

Acinic cell: acinar cells.

Mixed: intercalated and myoepithelialcells.

Dardick I: Mounting evidence against current histogenetic

concepts for salivary gland tumorigenesis. Eur J

Morphol 1998; 36:257-261.


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Cellular Origins of Salivary

Gland Neoplasms

Bi-cellular reserve cell theory:

All tumors arise from the basal cells ofeither the excretory or intercalated ducts.

These cells act as reserves, with thepotential to differentiate into variousepithelial cell lines.

E.g. pleomorphic adenomas and oncocytic

tumors: intercalated ducts. SCC and mucoepidermoid tumors:

excretory ducts.

Batsakis JG: Histogenesis of salivary gland neoplasms: a

postulate with prognostic implications. J Laryngol

Otol 1989; 103:939-944.


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Pathology

Mucoepidermoid carcinoma.

Low grade.

Abundant infarction necrosis. 0/18 zone II lymph nodes.


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Prognosis Mucoepidermoid

Carcinoma

Evenson JW. Malgnant neoplasms of the salivary glands.

In: Thompson LDR (Eds.). Head and neck pathology.

Churchill Livingston, Philadelphia, PA, pp. 321-370.

40% incidence of local recurrence.

15% incidence of spread to regional

LNs and distant sites.

5-year survival rate 80%.

Female>male, mean age 47 years.

Prognosis depends on clinical stage,site, grading and margins.

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Carcinosarcoma Parotid in Progress