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THOUGHTS ABOUT THE BASIC PRINCIPLES OF PAROTID SURGERY DO YOU PERFORM SUBTOTAL PAROTIDECTOMY IN THE EVENT OF A WARTHIN’S TUMOR (?). Huszka, J.J. Szent István Hospital ENT, Head&Neck Surgery Budapest/Hungary. Types of Parotid Operations (1999-2006) No.185.
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THOUGHTS ABOUT THE BASIC PRINCIPLES OF PAROTID SURGERYDO YOU PERFORM SUBTOTAL PAROTIDECTOMY IN THE EVENT OF A WARTHIN’S TUMOR (?) Huszka, J.J. Szent István Hospital ENT, Head&Neck Surgery Budapest/Hungary
Types of Parotid Operations (1999-2006) No.185 • Parotidectomia subtotalis 147 • Parotidectomia totalis 21 • Parotidectomia subtotalis + Neck dissection 3 • Parotidectomia totalis + Neck dissection 4 • Parotidectomia totalis + Neck dissection + n.VII resection & reconstruction 4 • Enucleation 6
Histopathological DiagnosisBenign:155 (83,8%) • Warthin’s tumor 66 (35,7%) • Pleomorphic adenoma 53 (28,6%) • Parotitis chr. 11 • Cysta symplex, Keratinocysta 5 • Myoepithelioma 5 • Lipoma 3 • Lipomatosis 2 • Lymphangioma 2 • Ben.lymphoepith.laesio 2 • Oncocytoma, Monomorph adenoma,Haemangioma, Sarcoidosis,Tuberculosis,Toxoplasmosis 1-1
Histopathological Diagnosis Malign:30(16,2%) • Mucoepidermoid carcinoma 6 • Carcinoma in tumore mixto 4 • Carcinoma squamocellulare 4 • Adenoidcysticus carcinoma 4 • Adenocarcinoma 4 • Acinussejtes carcinoma 2 • Lymphoma malignum 2 • Oncocytoma, 1 • Ductalis carcinoma 1 • Sinovialis sarcoma 1 • Epithelialis-myoepithelialis carcinoma 1
Warthin’s tumor • Cystadenolymphoma papillare, adenolymphoma • Albrecht-Artz tumor (1910) • Hildebrand (1895) • Warthin (1929) • Can mostly be found in the parotid gland, the second most frequent type, parotid -extraparotid location15:1 • This type of tumor accounts for 2-30 % of all parotid tumor (35,7% of our patients) • In general this tumor develops in the outer lobe, in the posterior and inferior part of the gland. • Frequently bilateral and can be multifocal (Foote & Frazell, Gläser,Morehead) • Male predominance, age span 50-70 years
Warthin’s tumor • Usually asymptomatic • Presents as a slow growing mass, it can become inflamad with pain and rapid growth (asp.cytology) • Theories of the histopathogenesis (Eneroth,Székely,Ellies et al,Gallo&Bocciolini,Ogata et al) • Histologiacally classified into four subtypes is based on the ratio of the epithelium to the lymphoid stroma(Seifert et al)
Malignant transformation of Warthin’s tumor is very rare (Seifert et al found only one in 1431) • Mucoepidermoid carcinoma (Yamada et al, Varshavskii, Claros et al, Khadaroo et al) • Epidermoid carcinoma (Croce et al, Skalova et al) • Dediff.carcinoma (Ferrero et al) • Carcinoma planocell.(Morrison & Shaw, Baker et al, Damjanov et al, Gunduz et al, Seifert et al) • Malignant Warthin’s tumor (Therkildsen et al, Moosavi et al) • Non-Hodgkin lympoma (Bunker & Locker) • Adenocarcinoma (Seifert et al)
Treatment of Warthin’s tumor • Radiation therapy - unacceptable • Enucleation (Heller és Attie: 113 patients) • Enucleation from the inner lobe (Batori et al) • Parotidectomia partialis(Friedman et al) • Parotidectomia subtotalis – totalis with preservation of the facial nerve (Székely, Mielke et al, Leverstein et al)
Warthin’s tumor patients operated onNo. of operations 66No. of patiens 62 (35,7%) • 3 bilateral • One reoperation • 14 multifocal ( 10 bifocal; 4 three-six foci) • Unusual location • 3 synchronous tumors (adenocaricinoma, pleomorphic adenoma,BLL)
Important • 17 out of 62 patients had unusual findings (27,4%) • Synchronous unilateral neoplasms were irrelevant to the Warthin’s tumors. (for example: pleomorphic adenoma occurred in the inner lobe, Wathin’s tumor in the outer lobe) • The preoperativ investigations did not reveal the additional tumors in 90% of cases (palpation,US,CT,MRI) • Fine-needle aspiration cytology under US controll detected potencial malignancy in two cases. ( histology: squamous metaplasia)
Summary Do you perform subtotal parotidectomy in the event of a Warthin’s tumor? Yes ! • Tumor is often multifocal (21% of our cases) • Synchronous tumors can exist (it can be malign!) + often multifocal • 27%! of our patients – out of 62 patients 17 had a combination of these factors • Malignant neoplasm can arise from Warthin’s tumor • Fine-needle aspiration cytology is very important but even with the additional various preoperative examinations we can not be able to be a 100% certain the type of tumor we will find. • In the event of needing to reoperate after enucleation or parotidectomia partialis the risk of nerve damage is higher. • The risk of nerve damage is less or minimal in the hands of an experienced surgeon.
Concluding thoughts • Parotid gland surgery is not an easy field. • It is not always as easy as it looks. • Even after years of experience a surgeon can find himself in difficulties. However he still needs to be able to solve these. • The surgen must adhere to the basic principles of parotid surgery. • One must be able to critique the work of others and of themselves too. • One must only operate within their field of expertise. • You should only operate on places where it is possible to repair the damaged nerves and where your expertise extends to. • The interest of the patient should be above any other consideration.
