Acinic cell carcinoma of the parotid gland: a 15-year review limited to a single surgeon at a single institution.

Abstract

The course of acinic cell carcinoma of the parotid gland following surgical and nonsurgical interventions is variable. The objective of this study was to report our experience in treating this disease and to evaluate the factors that might be involved in the treatment of the tumor and the prognosis of the patient. To limit the contributory variables that are usually found in most studies, we included only those patients (n = 11) who had been treated by a single surgeon at a single institution from 1988 through 2003. Hospital and office records were evaluated for demographic information, signs and symptoms, treatment modalities, pathology, and outcomes. Additional follow-up data were obtained through telephone interviews. For the most part, treatment included either superficial parotidectomy or total parotidectomy with facial nerve preservation; 1 patient with coexisting adenocarcinoma underwent a more radical procedure, and 4 patients underwent adjuvant radiation therapy. The most prevalent morphologic pattern of these tumors was microcystic. Follow-up ranged from 1 year and 3 months to 10 years and 9 months (mean: 4 yr and 11 too). During that time, we found no recurrences of acinic cell carcinoma and no evidence of metastatic disease. Therefore, we conclude that acinic cell carcinoma can be successfully treated with a superficial or total parotidectomy with sparing of the facial nerve. Radiation therapy may provide adjunctive benefit.

Introduction

Acinic cell carcinoma is a relatively uncommon malignancy, accounting for 1 to 6% of all salivary gland tumors and 15% of all malignant tumors of the parotid gland. (1,2) It is the fourth most common malignant salivary gland tumor, following mucoepidermoid carcinoma, adenoid cystic carcinoma, and carcinoma ex pleomorphic adenoma; it occurs more frequently than primary squamous cell carcinoma. (2-4) With regard to the prevalence of parotid gland cancers in children, acinic cell carcinoma is second only to mucoepidermoid carcinoma. (5,6) Most acinic cell carcinomas occur between the ages of 40 and 49 years. (1-7) Ellis and Corio reported that the tumor is most common among whites (90% of cases); blacks account for 8% of cases. (8) It affects twice as many females as males. (4-6) Acinic cell carcinomas of the parotid gland occur bilaterally in 3% of cases, a rate of bilaterality that is second only to that of Warthin's tumor. (2,5,6,9) Acinic cell carcinomas rarely occur in the minor salivary glands. (2)

The results of treating acinic cell carcinoma are quite variable. Local recurrences have been reported in 8 to 56% of patients, but the recurrence rate rarely exceeds 20%. (4-17) Reported rates of lymph node and distant metastases range from 0 to 16%, but most are less than 10%. (5,8,10-16) Mortality from the disease is usually less than 10% at 5 years, but by 20 years it has been reported to be as high as 50%. (4-7,9,17)

Most published series of patients with acinic cell carcinoma are limited, and they represent the experiences of institutions rather than individual surgeons. Therefore, it is not possible to know for certain if the high degree of variability in treatment outcomes is associated with variations in tumor characteristics or with variations in different treatment strategies. With that in mind, we conducted a study of a series of patients with acinic cell carcinoma who were treated at one institution by one surgeon in an attempt to reduce these variabilities.

Patients and methods

We reviewed medical records from the Harper University Hospital and identified those patients who had been operated on by the senior author (R.H.M.) for acinic cell carcinoma of the parotid gland from 1988 through 2003. We noted each patient's sex and age and the site and size of the tumor (table 1); type of treatment, involvement at the surgical margins, and the tumors' histologic patterns (table 2); and postoperative complications, adjuvant therapy, and the duration of follow-up (table 3). We also assessed tumors for the presence of perineural and/or vascular invasion and metastasis. For those patients who were eventually lost to follow-up, information regarding recurrence and metastasis was obtained through telephone interviews.

In all, 11 patients--3 males and 8 females (10 whites and 1 black), aged 14 to 73 years (mean: 43.4)--were included in this review.

Case summaries

Patient 1. A 61-year-old white man presented with a recurrent 0.6-cm lesion of the left superficial parotid gland. Eight years earlier, he had developed facial swelling near the left parotid gland, and a 3.2-cm lesion was detected in the left superficial lobe. At that time, he underwent superficial parotidectomy at another institution, and he had remained disease-free since.

The senior author treated the 0.6-cm recurrence with a total parotidectomy with sparing of the facial nerve. No signs of metastatic disease were evident, and the surgical margins were negative. Histologically, the lesion was predominately microcystic in structure. Postoperatively, the patient experienced transient weakness of the left corner of the mouth and a mild depression on the left side of the face. Because he had already experienced one recurrence, he was administered 3,000 cGy of radiation to the surgical bed. There was no recurrence during 3 years and 7 months of follow-up.

Patient 2. A 32-year-old white woman presented with facial swelling and pain in the right parotid gland. A 3-cm lesion was detected in the right superficial lobe, and a superficial parotidectomy was performed. Margins were negative, and there was no evidence of metastatic disease. Histologically, the structure of the lesion was predominately microcystic. Postoperatively, she experienced transient weakness of the right face and a mild depression at the surgical site. There was no evidence of Frey's syndrome. No recurrence was evident at 2 years and 6 months.

Patient 3. A 46-year-old white man presented with facial swelling and tenderness of the left parotid gland. The lesion measured 2 cm in the deep lobe of the gland. He underwent a total parotidectomy with sparing of the facial nerve. Margins were negative and there was no evidence of metastatic disease. Histologically, the lesion was predominantly microcystic. Postoperatively, he experienced transient weakness of the left side of the lip. He also had a mild depression at the surgical site. No Frey's syndrome was present. There was no recurrence at 2 years and 6 months.

Patient 4. A 58-year-old white woman was evaluated for facial swelling near the left parotid gland. A 1-cm lesion was found in the superficial lobe. Her treatment was a superficial parotidectomy. Margins were negative, and there was no evidence of metastatic disease. Histologically, the lesion was predominantly papillary cystic in structure. Postoperatively, she had transient facial weakness near the left eye. There was a mild depression at the surgical site, and no evidence of Frey's syndrome. There was no recurrence at 5 years and 10 months.

Patient 5. A 41-year-old white woman presented with facial swelling of the left parotid gland, the result of the recurrence of an acinic cell carcinoma that had first arisen more than 10 years earlier. At that time, she underwent a left superficial parotidectomy for removal of the primary tumor. However, the surgical margin was positive.

The 0.9-cm recurrent mass was excised during a total parotidectomy with sparing of the facial nerve and a left modified neck dissection. The margins were negative, and there was no evidence of metastatic disease. Histologically, the lesion was predominantly microcystic in structure. Postoperatively, there was no facial weakness, a mild facial depression, and no complaints of gustatory sweating. In light of her initial positive margin, she underwent 2,160 cGy of radiation therapy to the parotid area. There was no recurrence during a follow-up of 6 years and 10 months.

Patient 6. A 16-year-old white boy was referred to us 1 month after he had undergone a superficial parotidectomy at another institution for removal of a mass in the left superficial lobe. When facial swelling persisted, he was referred to Harper University Hospital. During our examination, a residual 1.3-cm lesion was found to extend to the surgical margin of the resection. We performed a total parotidectomy with facial nerve sparing. No cancer was found in the parotidectomy specimen itself, and histologically, the original lesion was predominantly microcystic in structure. Postoperatively, the patient exhibited transient upper facial weakness, mild facial depression, and no evidence of Frey's syndrome. Considering his age, no adjuvant radiation therapy was initiated. No recurrence was evident at 7 years and 6 months.

Patient 7. A 41-year-old white woman presented with facial swelling. A 2-cm lesion was identified in the left deep lobe of the parotid gland. She underwent a total parotidectomy with sparing of the facial nerve. A platysma/ sternocleidomastoid muscle flap was used to reconstruct the defect. The tumor extended near the margin of the resection, but no signs of metastasis were found. Histologically, the lesion was predominantly solid in structure. Postoperatively, the patient exhibited no facial weakness and a mild facial depression on the side of the surgery. Because the tumor was very close to the margin of the resection, she was administered 5,400 cGy of radiation therapy to the surgical site. There was no recurrence at 7 years and 8 months.

Patient 8. A 57-year-old white woman had earlier undergone a right neck dissection of a 4-cm tumor near the right angle of the mandible at another institution. The tumor was identified as a poorly differentiated metastatic adenocarcinoma, and she was referred to our institution.

On examination, we identified a 2.5-cm mass in the deep lobe of the right parotid. The senior author performed a radical parotidectomy, a complete neck dissection, and a mastoidectomy with facial nerve resection and nerve grafting. The final pathologic examination of the parotid revealed the presence of both an adenocarcinoma and an acinic cell carcinoma. The margins were positive for cancer, but no distant metastasis was discovered. Histologically, the acinic cell tumor featured a microcystic cribriform pattern. Postoperatively, the patient exhibited a complete loss of right facial function and a moderate depression of the tissues of the right face. In view of the presence of both an adenocarcinoma and an acinic cell carcinoma at the surgical margins, she underwent 3,000 cGy of radiation therapy and 3 courses of chemotherapy with 5-fluorouracil and cisplatinum. However, the adenocarcinoma recurred 2 years later and metastasized to the neck and lung; the acinic cell carcinoma did not recur. The patient died of adenocarcinoma 3 years following resection.

Patient 9. A 73-year-old white woman presented with facial swelling and pain. A 1.5-cm tumor was located in the right superficial lobe of the parotid, and she underwent a right superficial parotidectomy. The margins were positive, but there were no signs of metastatic disease. Histologically, the lesion was of the papillary cystic variety. Postoperatively, the frontal branch of the facial nerve on the right side of the face was weak, but there was no facial depression. Even with the positive margins, the patient did not wish to undergo any further treatment. During 10 years and 9 months of close follow-up, no signs of recurrence were evident.

Patient 10. A 14-year-old white girl presented with right facial swelling that had been present for several years. A tumor measuring 2 cm was found in the right tail of the parotid, and she underwent a superficial parotidectomy. The margins were positive next to the trunk of the facial nerve, but there were no signs of metastatic disease. Histologically, the lesion was of the microcystic variety. Postoperatively, the patient experienced no weakness of the face and no facial depression. Adjuvant radiation therapy was considered, but in view of the patient's young age and the relatively benign course of these tumors, a conservative wait-and-watch approach was adopted. No signs of recurrence were observed during 2 years and 8 months of close follow-up.

Patient 11. A 38-year-old black woman presented with a 6-month history of a tender right facial mass. She reported that 20 years earlier, she had undergone a superficial parotidectomy for removal of an acinic cell carcinoma of the left parotid. Her new mass measured 1.5 cm and was noted in the right tail of the parotid gland. She was treated with a right total parotidectomy with facial nerve sparing. Histologically, the tumor was of the solid variety. The margins were negative, and there were no signs of metastasis. Postoperatively, the patient exhibited no facial weakness and no facial depression. No signs of a recurrence were observed during 1 year and 3 months of follow-up.

Results

The most common presenting symptom in this series was facial swelling. Six of the tumors were located in the left parotid and five on the right. Eight of the 11 tumors were located in the superficial lobe of the parotid and 3 in the deep lobe. Tumors ranged in size from 0.6 to 3.2 cm. Three of the tumors were recurrent or residual lesions (table 1).

Preoperative evaluations included computed tomography with contrast for all patients, fine-needle aspiration biopsy (FNAB) for 10, and magnetic resonance imaging for a few. One patient refused FNAB, but in the other 10, its predictive value was questionable, as only 5 of the l0 FNABs correctly identified the acinic cell carcinoma.

In our series, only 1 patient had experienced bilateral disease (patient 11); she had developed left-sided disease 20 years prior to presenting to us with right-sided disease. Another patient had both an adenocarcinoma and an acinic cell carcinoma within the same parotid gland (patient 8).

Histologically, 7 tumors were of the microcystic type, 2 were papillary cystic, and 2 were solid. In 3 patients, surgical margins were positive after resection at our institution (table 2).

There were no cases of perineural or vascular invasion or metastasis.

Superficial parotidectomy was the initial treatment for acinic cell carcinoma in 7 of these patients, including the 3 who had been initially treated at other institutions. Three patients with deep-lobe tumors were treated with a total parotidectomy, and the 1 patient who had a coexisting adenocarcinoma underwent a radical parotidectomy. Three patients who had either a positive margin or a recurrence following a superficial parotidectomy later required salvage total parotidectomy. It is interesting that the 3 patients who we treated for either recurrent or residual disease all had the microcystic form of the tumor.

Follow-up ranged from 1 year and 3 months to 10 years and 9 months (mean: 4 yr and 11 mo). None of our patients developed a recurrence or metastasis following final treatment. Four patients underwent adjuvant radiation therapy because they had either recurrent disease (patients 1 and 5), tumor extension up to the surgical margin (patient 7), or a positive surgical margin (patient 8). Another patient had a positive surgical margin next to the facial nerve trunk (patient 10), but in view of her young age (14 yr), the radiotherapist recommended against radiation therapy. One patient requested that radiation therapy be discontinued after she had received 2,160 cGy (patient 5). Finally, the patient who had a concomitant adenocarcinoma (patient 8) received chemotherapy in addition to radiation therapy (table 3).

Postoperatively, transient facial weakness was seen in 6 patients and a complete loss of facial muscle function was seen in 1. Eight patients had some form of facial depression at the surgical site. No patient complained of gustatory sweating (table 3).

Discussion

Our findings support the view that acinic cell carcinoma can occur at any age (as early as 14 yr) but that it is more common among patients in midlife. (8) We also found a predisposition toward whites and females. (4-6) As reported by others, we found that the tumor usually appeared as a painless mass in either the superficial or deep lobe of the parotid gland. (3,5,6,8,17) As was the case in our study, patients do not usually present with facial weakness. (3,5,6,8,17)

One of the controversies surrounding acinic cell carcinoma is its malignant potential. Prognostic variables include traditional considerations such as tumor site, size, and histologic growth pattern, as well as the presence or absence of metastasis. In our series, tumor size ranged from 0.6 to 3.2 cm. According to Timon et al, large tumors (e.g., 2.92 cm) carry a worse prognosis than do small tumors (e.g., 1.93 cm). (17)

According to Batsakis et al, acinic cell carcinomas are derived from the intercalated ducts of the salivary duct and tubular system. (18) The tumor can be multifocal in origin and arise bilaterally, which would account for its similarity to Warthin's tumor; one of our patients (patient 11) experienced bilateral tumors, which manifested 20 years apart. According to Batsakis and colleagues, acinic cell carcinomas develop in seven histologic patterns: acinar-lobular, microcystic, follicular, papillary cystic, medullary, ductoglandular, and primitive tubular. (2,18) Ellis and Corio developed a simpler system of three categories: cystic papillary, follicular, and solid. (8) However, neither of these systems apparently correlates well with the biologic course of the tumor. Timon et al reported that solid tumors are associated with the worst prognosis. (17) Only 2 of our patients had solid tumors (patients 7 and 11), and neither recurred, although one of these patients (patient 11) subsequently developed a tumor on the other side. Seven of the patients in our series had microcystic tumors, 3 of whom had presented with recurrent or residual disease. None of these patients developed a recurrence after treatment at our institution.

Batsakis proposed a two-part (high-grade and low-grade) staging system in which the characteristics of high-grade tumors included intravascular extension, fingerlike invasion, and medullary, ductoglandular, or primitive tubular foci. (2) However, he conceded that such a classification system was not without shortcomings. (2) By Batsakis's standards, none of the tumors in our series were high-grade. Eneroth and colleagues reported a correlation between the invasiveness of acinic cell carcinoma and the quantitation of DNA, but they observed that this relationship did not necessarily predict the patient's clinical course. (19,20)

This "ambiguity over the malignancy of acinic cell neoplasm," as Batsakis (2) wrote in 1979, poses difficulties in our attempts to determine optimal treatment strategies. In the 1960s, Eneroth and colleagues (19,21) suggested that the malignant potential of acinic cell carcinoma is significant, but this was not evident in our experience. Those investigators who believe that the tumor is indeed malignant have recommended the most aggressive form of treatment--that is, total parotidectomy and neck dissection. (19-21) On the other hand, Goodwin et al were not convinced of the malignant potential of this tumor, and they recommended conservative management and excision of the tumor with a margin of the parotid gland. (22) Enucleation should not be performed because it has been associated with some of the high recurrence rates that have been reported. (2,21)

Our experience supports the idea of complete extirpative surgery as definitive, and we do not advocate radical procedures. We suggest that the failure of an initial superficial parotidectomy to eradicate the tumor is probably attributable to an insufficient margin of normal tissue. It seems to us that an adequate superficial parotidectomy with sparing of the facial nerve should be quite effective in removing a tumor in the superficial lobe. Conversely, a total parotidectomy appears to be necessary for recurrent tumors and for primary tumors located in the deep lobe. Radical parotidectomy with removal of the facial nerve, as proposed by Grage et al (23) in 1961, appears to be advisable only when a patient has another aggressive malignancy, as did our patient who had a coexisting adenocarcinoma (patient 8).

The role of radiation therapy has not been fully evaluated. Batsakis and others have suggested that acinic cell carcinoma is relatively radiosensitive and that external radiation therapy should be considered for locally advanced tumors, late-stage disease, and residual lesions. (2,24-26) Some authors have contended that adjuvant radiation therapy provides only limited benefit against small superficial tumors. (24,26) Others have suggested that radiation therapy is indicated for acinic cell carcinoma in cases of (1) recurrent tumors, (2) equivocal or positive margins or tumor spillage, (3) tumors adjacent to the facial nerve, (4) deep-lobe involvement, (5) lymph node metastases, (6) extraparotid extensions, and (7) large tumors (>4 cm). (3,27,28) In our series, we tended to reserve external radiation therapy for patients with positive margins or a history of recurrence. Two patients received radiation therapy after surgical resection of locally recurrent disease (patients 1 and 5), 1 patient received radiation therapy for extension of disease to near the surgical margin (patient 7), and 1 patient received both radiation and chemotherapy for positive margins and the presence of coexisting adenocarcinoma (patient 8). None experienced a recurrence of acinic cell carcinoma.

In view of the low incidence of metastasis (~10%), (5,8,10-16) elective neck dissection does not appear to be warranted. The senior author performed a selective neck dissection on patient 8 because we believed that she possibly had a metastasis. Obviously, if lymph node positivity is suggested by imaging studies or is otherwise suspected, the surgeon can sample the nodes and perform a neck dissection when indicated.

Although we restricted our series to the experience of a single surgeon at a single institution--and thereby reduced operative and outcome variability--our results must be interpreted with caution. The size of our series was small, and our follow-up period was relatively short, ranging from 1 year and 3 months to 10 years and 9 months (mean: 4 yr and 11 mo). Other authors have maintained that a follow-up of at least 20 years is necessary to adequately determine final treatment outcomes. (3,11) Long-term follow-up is necessary because cure rates at 5, 10, and 15 years decline from 76% to 63% to 44%, respectively. (3,16) In their review of 11 cases, Grage et al reported that the 4 patients who died of acinic cell carcinoma survived an average of 13 years following diagnosis and treatment. (23) Batsakis also reported that death can occur after a significant length of time. (2)

Another limitation of our study is that we did not study a selected group of patients whose prognoses were necessarily good. In fact, 3 of our patients had already been treated for previous disease, and 4 others had positive or near-positive margins.

In summary, acinic cell carcinoma is considered to be a low-grade malignancy without well-defined predictors of local or regional recurrence or metastasis. Patients treated with superficial or total parotidectomy with facial nerve sparing, either as the initial therapy or as salvage therapy, appear to survive with little if any recurrence. Postoperatively, patients may experience temporary facial weakness, but this morbidity appears to be insignificant compared with the overall benefit of reducing the risk of recurrence and its associated morbidity and mortality. Some patients may benefit from adjuvant radiation therapy. Even though our findings are limited by the short duration of follow-up, we believe they support the effectiveness of our treatment strategy.

References

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(2.) Batsakis JG. Tumors of the Head and Neck: Clinical and Pathological Considerations. 2nd ed. Baltimore: Williams & Wilkins, 1979:39-44.

(3.) Spafford PD, Mintz DR, Hay J. Acinic cell carcinoma of the parotid gland: Review and management. J Otolaryngol 1991;20:262-6.

(4.) Napier SS, Herron BT, Herron BM. Acinic cell carcinoma in Northern Ireland: A 10-year review. Br J Oral Maxillofac Surg 1995;33:145-8.

(5.) Colmenero C, Patron M, Sierra I. Acinic cell carcinoma of the salivary glands. A review of 20 new cases. J Craniomaxillofac Surg 1991; 19: 260-6.

(6.) Batsakis JG, Luna MA, el-Naggar AK. Histopathologic grading of salivary gland neoplasms: II. Acinic cell carcinomas. Ann Otol Rhinol Laryngol 1990;99:929-33.

(7.) Oliveira P, Fonseca I, Soares J. Acinic cell carcinoma of the salivary glands. A long term follow-up study of 15 cases. Eur J Surg Oncol 1992;18:7-15.

(8.) Ellis GL, Corio RL. Acinic cell adenocarcinoma. A clinicopathologic analysis of 294 cases. Cancer 1983;52:542-9.

(9.) Kaplan MJ, Johns ME. Malignant neoplasms. In: Cummings CW, ed. Otolaryngology-Head & Neck Surgery. 3rd ed. St. Louis: Mosby, 1998:1043-78.

(10.) McGuirt WF. Management of occult metastatic disease from salivary gland neoplasms. Arch Otolaryngol Head Neck Surg 1989;115:322-5.

(11.) Chong GC, Beahrs OH, Woolner LB. Surgical management of acinic cell carcinoma of the parotid gland. Surg Gynecol Obstet 1974;138: 65-8.

(12.) Eneroth CM, Jakobsson PA, Blanck C. Acinic cell carcinoma of the parotid gland. Cancer 1966; 19:1761-72.

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(14.) Seifert G, Miehlke A, Haubrich J, Chilla R. Diseases of the Salivary Glands. Stuttgart: Georg Thieme Verlag, 1986:224-30.

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(16.) Lewis JE, Olsen KD, Weiland LH. Acinic cell carcinoma. Clinicopathologic review. Cancer 1991;67:172-9.

(17.) Timon CI, Dardick I, Panzarella T, et al. Clinico-pathological predictors of recurrence for acinic cell carcinoma. Clin Otolaryngol Allied Sci 1995;20:396-401.

(18.) Batsakis JG, Wozniak KJ, Regezi JA. Acinous cell carcinoma: A histogenetic hypothesis. J Oral Surg 1997;35:904-6.

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(20.) Eneroth CM, Zetterberg A. A cytochemical method of grading the malignancy of salivary gland tumours preoperatively. Acta Otolaryngol 1976;81:489-95.

(21.) Eneroth, CM, Jakobsson PA, Blanck C. Acinic cell carcinoma of the parotid gland. Cancer 1964; 19:1761-72.

(22.) Goodwin JT, Forte FW, Frazell EL. Acinic cell adenocarcinoma of the parotid gland. Am J Pathol 1954;30:465-77.

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(24.) Armstrong JG, Harrison LB, Spiro RH, et al. Malignant tumors of major salivary gland origin. A matched-pair analysis of the role of combined surgery and postoperative radiotherapy. Arch Otolaryngol Head Neck Surg 1990;116:290-3.

(25.) Shidnia H, Homback NB, Hamaker R, Lingeman R. Carcinoma of major salivary glands. Cancer 1980;45:693-7.

(26.) Matsuba HM, Thawley SE, Devineni VR, et al. High-grade malignancies of the parotid gland: Effective use of planned combined surgery and irradiation. Laryngoscope 1985;95:1059-63.

(27.) Rice DH. Diagnostic imaging. In: Cummings CW, ed. Otolaryngology-Head & Neck Surgery. 2nd ed. St. Louis: Mosby, 1986:1027-69.

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From the Department of Otolaryngology-Head and Neck Surgery, Harper University Hospital and the Wayne State University School of Medicine, Detroit.

Reprint requests: Robert H. Mathog, MD, Department of Otolaryngology-Head and Neck Surgery, Wayne State University, 5E-UHC 4201 St. Antoine, Detroit, MI 48201. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

S. Alex Kim, MD; Robert H. Mathog, MD

Table 1. Patient demographics and tumor characteristics

                                                      Size
Pt.   Age/sex/race   Tumor       Tumor site           (cm)

 1    61/M/White     Recurrent   Left, superficial    0.6
 2    32/F/White     Primary     Right, superficial   3.0
 3    46/M/White     Primary     Left, deep           2.0
 4    58/F/White     Primary     Left, superficial    1.0
 5    41/F/White     Recurrent   Left, superficial    0.9
 6    16/M/White     Residual    Left, superficial    1.3
 7    41/F/White     Primary     Left, deep           2.0
 8    57/F/White     Primary     Right, deep          2.5
 9    73/F/White     Primary     Right, superficial   1.5
10    14/F/White     Primary     Right, superficial   2.0
11    38/F/Black     Primary     Right, superficial   1.5

Table 2. Surgical treatment and histology

      Previous         Study             Surgical      Histologic
Pt.   treatment        treatment         margin        pattern

 1    Superficial      Total             Negative      Microcystic
      parotidectomy    parotidectomy
      for a 3.2-cm     w/nerve sparing
      tumor 8 yr
      earlier

 2    N/A              Superficial       Negative      Microcystic
                       parotidectomy

 3    N/A              Total             Negative      Microcystic
                       parotidectomy
                       w/nerve sparing

 4    N/A              Superficial       Negative      Papillary cystic
                       parotidectomy

 5    Superficial      Total             Negative      Microcystic
      parotidectomy    parotidectomy
      for a tumor      w/nerve
      >10 yr earlier   sparing,
                       modified neck
                       dissection

 6    Superficial      Total             Negative      Microcystic
      parotidectomy    parotidectomy
      for a tumor      w/nerve sparing
      1 mo earlier

 7    N/A              Total             Near margin   Solid
                       parotidectomy
                       w/nerve
                       sparing,
                       muscle flap
                       reconstruction
                       of the defect

 8    N/A              Radical           Positive      Microcystic
                       parotidectomy,                  cribriform
                       complete neck
                       dissection,
                       mastoidectomy
                       w/facial nerve
                       resection and
                       nerve grafting


 9    N/A              Superficial       Positive      Papillary cystic
                       parotidectomy

10    N/A              Superficial       Positive      Microcystic
                       parotidectomy

11    N/A              Total             Negative      Solid
                       parotidectomy
                       w/nerve sparing

Table 3. Postoperative characteristics

          Facial        Facial                         Frey's
Pt.      weakness     depression                      syndrome

 1     Transient      Mild                              None
 2     Transient      Mild                              None
 3     Transient      Mild                              None
 4     Transient      Mild                              None
 5     None           Mild                              None
 6     Transient      Mild                              None
 7     None           Mild                              None
 8 *   Complete       Moderate                          None

 9     Transient      None                              None
10     None           None                              None
11     None           None                              None

          Facial                Adjuvant
Pt.      weakness               therapy               Follow-up

 1     Transient      Radiation, 3,000 cGy           3 yr, 7 mo
 2     Transient      None                           2 yr, 6 mo
 3     Transient      None                           2 yr, 6 mo
 4     Transient      None                           5 yr, 10 mo
 5     None           Radiation, 2,160 cGy           6 yr, 10 mo
 6     Transient      None                           7 yr, 6 mo
 7     None           Radiation, 5,400 cGy           7 yr, 8 mo
 8 *   Complete       Radiation, 3,000 cGy;          3 yr
                        5-fluorouracil/cisplatinum
 9     Transient      None                           10 yr, 9 mo
10     None           None                           2 yr, 8 mo
11     None           None                           1 yr, 3 mo

* Patient 8 had coexisting adenocarcinoma and acinic cell carcinoma.
The adenocarcinoma recurred 2 years postoperatively and metastasized.
She died 1 year later. There was no evidence of recurrence of the
acinic cell carcinoma.