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On Sep 2018




Prof. Somashekhar Nimbalkar

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : ER01 - ER04 Full Version

Histopathological and Immunohistochemical Analysis of Rare Parotid Tumours: A Case Series


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/60206.17375
Sayantan Dey, Piyali Kundu, Sona Das, Madhumita Mondal

1. Senior Resident, Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India. 2. Demonstrator, Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India. 3. Senior Resident, Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India. 4. Assistant Professor, Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India.

Correspondence Address :
Madhumita Mondal,
QR. No. C-12, 242, AJC Bose Road, Kolkata, West Bengal, India.
E-mail: rgkarmadhumita@gmail.com

Abstract

Malignant salivary gland tumours are rare representing only 2% of all head and neck malignancies. The most common malignant salivary gland tumour is mucoepidermoid carcinoma followed by adenoid cystic carcinoma while parotid is the most common site. But there are presence of other rare variants with diverse biological feature of malignancy including Salivary Duct Carcinoma (SDC), basal cell adenocarcinoma, Carcinoma ex Pleomorphic Adenoma (CXPA), polymorphous adenocarcinoma which represent 1-5% of all salivary gland neoplasm. They typically are high-grade carcinomas with presence of lymph nodal metastases. Hereby, author report five rare cases of parotid gland malignancy detected by histopathological examination along with confirmation by immunohistochemical examination. A 60-year-old and 65-year-old male diagnosed with salivary duct carcinoma of left parotid and right parotid, respectively with ipsilateral cervical lymph node involvement but peripheral resection margins were free from tumour invasion. A 50-year-old female diagnosed with basal cell adenocarcinoma of left parotid with lymph node metastasis and resection margin was involved by the tumour. A 60-year-old male presented with recurrent swelling in left parotid region, diagnosed as carcinoma ex pleomorphic adenoma with lymph node involvement in a case of pleomorphic adenoma of parotid, reported previously. A 52-year-old male presented with right-sided parotid region swelling for last six months having Fine Needle Aspiration Cytology (FNAC) report of pleomorphic adenoma. Parotidectomy revealed diagnosis of polymorphous adenocarcinoma while surgical resection margins were free. Surgery is the main mode of treatment in these tumours. Involvement of resection margins, extraparotid extension, lymphovascular and perineural invasion along with lymph node metastasis are the common indicator for postoperative radiation therapy.

Keywords

Cytology, Carcinoma, Microscopic examination, Salivary gland

The parotid gland is most common site for salivary gland tumours. Primary carcinomas of the salivary glands are uncommon, fewer than 0.3% of all cancers. Though most common presentation is parotid region swelling, pain, facial palsy, lymph node involvement, fixity, and deep lobe involvement indicate malignant behaviour. Parotidectomy is the main modality of treatment in addition to that preoperative imaging and Fine Needle Aspiration Cytology (FNAC) report may be helpful in correct diagnosis and in early management also (1).

Malignant tumour occurs in older age compared to its benign counterpart while mean age ranges from 41.9-43 years. Although majority of the tumour occur in parotid gland (60-84%), malignancy rate is lower than benign one. Out of all cases pleomorphic salivary adenoma is the most prevalent salivary gland tumour in approximately 42% cases while three most common malignant tumours are adenoid cystic carcinoma, mucoepidermoid carcinoma and acinic cell carcinoma (2). The other rare malignant tumours include adenocarcinoma, squamous cell carcinoma, poorly differentiated carcinoma and Lymphoma also. of salivary glands is rare and commonly involves parotid gland (3).

Hereby authors discusses five rare cases of parotid gland malignancy detected by histopathological examination of parotidectomy specimen with or without lymph node dissection from January 2021 in the Department of Pathology. Two were salivary duct carcinoma, others were basal cell adenocarcinoma, carcinoma ex pleomorphic adenoma and polymorphous adenocarcinoma with emphasis on resection margin involvement, lymph node metastasis and lymphovascular or perineural invasion, depicting their aggressiveness and prognostic outcome. Detailed clinical history, previous biopsy report, FNAC report, haematological, biochemical parameters along with relevant radiological reports were documented. Various immunohistochemical markers like HER2/neu, S100, vimentin, Ki67, P63, ER, PR, CK7 and EMA were being used to confirm the diagnosis of those five parotid tumours.

Case Report

Case 1

A 60-year-old male had rapidly growing large left-sided parotid swelling for last one year with left cervical lymphadenopathy. The swelling was hard in nature with mild tenderness and overlying skin showed no ulceration. In FNAC from parotid, it described as malignant epithelial neoplasm (Table/Fig 1)a. On gross examination superficial parotid lobe measuring 6×4×3 cm (Table/Fig 1)b, on cutting it showed variegated appearance. Microscopic examination showed pleomorphic epithelial cells having abundant eosinophilic cytoplasm, vesicular chromatin and prominent nucleoli and in-situ component of cribriform pattern with comedonecrosis with presence of marked desmoplasia (Table/Fig 1)c. Lymphovascular and perineural invasion were seen with free resection margins (Table/Fig 1)d. 10 cervical lymph node showed metastatic deposit. Histological features were resembled like infiltrating duct carcinoma of breast-so it diagnosed as salivary duct carcinoma of left parotid with stage being T3N2Mx. Postoperatively patient was closely followed-up for any signs of recurrence or any other lymph node involvement. Any features of prolonged facial palsy was absent. Patient was also undergone radiation therapy in the Department of Radiotherapy.

Case 2

A 65-year-old male presented with huge rapidly increasing firm to hard right parotid swelling with bilateral cervical lymphadenopathy for last 10 months. There was no history of skin ulceration, fever, night sweats or drastic weight loss but decreased appetite was described. Preoperative FNAC reported as malignant epithelial neoplasm (Table/Fig 2)a. On gross whitish growth with areas of cystic changes and necrosis measuring 6×5×3 cm (Table/Fig 2)b.

Microscopic examination revealed comedonecrosis and pleomorphic cells with eosinophilic cytoplasm arranged in glands, cords, nests-suggestive of salivary duct carcinoma (Table/Fig 2)c. Lymphovascular invasion was present but margins were free. Two right nodes showed metastatic deposit with stage of T3N2Mx. Patient died on day two due to postoperative complication.

Immunohistochemically both cases showed HER2/neu was positive (Table/Fig 2)d along with expression of CK7 and EMA but CK 20, ER and PR were negative.

Case 3

A 50-year-old female presented with left parotid swelling for last five year. The swelling was firm in nature which increased in size rapidly in last four months.There was no tenderness, skin ulceration or palpable lymph node clinically. Imaging study revealed possibility of pleomorphic salivary adenoma with multiple cervical lymphadenopathy (Table/Fig 3)a. Parotidectomy with modified radical neck dissection was done. After receiving the specimen whitish growth noted measuring 5×5x3 cm (Table/Fig 3)b. Histopathology revealed a tumour mass composed of basaloid cells in nests arranged in jigsaw puzzle appearance with cells showing peripheral palisading-consistent with basal cell adenocarcinoma (Table/Fig 3)c. Peripheral resection margins were involved by the tumour. Total one lymph node out of 13 was involved by neoplastic cells with stage of T3N1Mx. Immunohistochemical expression of HER2/neu (Table/Fig 3)d, CK7 and P63 (Table/Fig 3)e were positive although Ki67 expression level were below 5% (Table/Fig 3)f. Patient was doing well postoperatively and no signs of facial palsy noted while she was regularly followed-up in Outpatient Department.

Case 4

A 60-year-old male presented with sudden increase of painful, firm to hard left parotid region swelling for four months with history of pleomorphic adenoma of parotid diagnosed seven years back. Skin ulceration with weight loss noted but no signs of facial palsy was documented. Positron Emission Tomography and Computed Tomography (PET-CT) scan revealed large lesion probably neoplastic in nature in left parotid region (Table/Fig 4)a. On gross fungating whitish growth noted measuring 17×15×12 cm (Table/Fig 4)b. Microscopy revealed pleomorphic hyperchromatic epithelial cells arranged mainly in glands with areas of pleomorphic adenoma with free margins but having lymphovascular invasion (Table/Fig 4)c,d. Total five lymph nodes showed tumour deposit. Diagnosed as carcinoma ex pleomorphic adenoma with stage of T4aN2Mx. Immunohistochemical expression of HER2/neu was 3+ (positive) but ki67 expression was not that significant (Table/Fig 4)e,f. The CK7 and EMA were also expressed but ER and PR were negative. Postoperatively patient was doing well and he was referred to Radiotherapy Department where he received radiation therapy and follow-up also done by the Radiotherapy department also.

Case 5

A 52-year-old male had right parotid region swelling for last six months. Swelling was firm in nature with no tenderness, skin ulceration or any other palpable neck swelling. FNAC from parotid region showed features suggestive of pleomorphic adenoma of salivary gland (Table/Fig 5)a. Superficial parotidectomy was done only. Solid-cystic tissue piece measuring 6×5×4 cm with cut section of solid area was whitish and homogenous (Table/Fig 5)b. Microscopically, tumour mass arranged in tubular and papillary pattern with lining cells having pleomorphic vesicular nuclei with eosinophilic secretion intraluminally but and free surgical resection margin (Table/Fig 5)c. Diagnosed as polymorphous adenocarcinoma with stage T3NxMx. Immunohistochemical expression of CK7 and HER2/neu were positive (Table/Fig 5)d along with vimentin (Table/Fig 5)e and S100 (Table/Fig 5)f. Although postoperative status was uneventful but patient did not come for further follow-up. All the above five cases are summarised in (Table/Fig 6).

Discussion

Malignant salivary gland tumours, heterogeneous group of malignancies with diverse biological behaviours are rare, representing only 2% of all head and neck malignancies. In addition to age, type of tumour, lymphovascular involvement, perineural invasion and lymph node metastasis appear to be an important prognostic factor in parotid gland malignancy (4). The most common malignant salivary gland tumour is mucoepidermoid carcinoma followed by adenoid cystic carcinoma, adenocarcinoma, malignant mixed tumour, Acinic cell carcinoma, squamous cell carcinoma. Other variant represent less than 3% of all salivary gland malignancy (5).

Salivary duct carcinomas are rare aggressive, high grade salivary tumours (0.2-2%) affecting parotid gland, with high mortality upto 70% of cases, commonly found in elderly males and has a propensity for early lymph node involvement (6),(7). SDC consist of solid invasive nests with polygonal cells surrounding a comedo-necrosis. It is usually diagnosed histopathologically as it looks like ductal carcinoma of breast, but immunohistochemistry may require to confirm diagnosis and for therapy also (7),(8). Immunohistochemically, tumour cells are diffusely positive for cytokeratin 7 and androgen receptor. HER2/neu positivity occurs in 15-40% of patients with SDC. Postoperative radiotherapy after wide surgical excision along with lymph node dissection is most standard treatment for SDC (9).

In present case series two cases that diagnosed histologically as salivary duct carcinoma, were male having age above 60 with size of being 6 cm. Lymhovasucular invasion and perineural invasion was observed while margin being free microscopically. Both cases cervical lymph node involvement was observed with stage of T3N2Mx. Immunohistochemically HER2/neu was positive along with CK7 but CK 20 was negative. Adjuvant radiation therapy was given postoperatively in one patient while other patient died due to sepsis.

Basal cell adenocarcinoma comprises only less than 2% of all major salivary gland malignancy, mostly from parotid either de novo or from pre-existing basal cell adenoma (10). The peak incidence was in the sixth decade and parotid was the predominant site. A solid type growth configuration along with membranous, trabecular, and tubular types were also found (11). The tumour sizes ranged from 0.9-8.5 cm. Histologically, tumour cells had basophilic nuclei, scanty cytoplasm and palisading. Tumour that metastasised had higher nuclear grade features. High mitotic count was one of the notable features. Ki-67 antigen interpretation ranged from 0.4-53.3% (12). Morphologically it showed histologic features of invasion, mitotic activity, and neural or vascular involvement which helps to differentiate from basal cell adenoma. The differential diagnosis of pleomorphic adenoma is also kept in mind (13). In the present case series a 50-year-old female presented with left parotid swelling measuring 5 cm across and in imaging study reported as pleomorphic adenoma of salivary gland. Histopathologically tumour mass composed of basaloid cells in nests with cells showing peripheral palisading. Total one lymph node out of 13 was involved by neoplastic cells, being stage of T3N1Mx while patient was doing well postoperatively and closely followed for any recurrence. Immunohistochemically, p63, CK7 and HER2/neu were positive, Ki67 expression level were below 5%.

Carcinoma ex Pleomorphic Adenoma (CXPA) is an epithelial and/or myoepithelial malignancy developing from primary or recurrent Pleomorphic Adenoma (PA) of parotid mainly- 3.6% of all salivary gland tumour (11). Tumour mostly arises in the background of a recurrent pleomorphic adenoma and can be composed of various histologic categories. The level of invasion, lymph node involvement, and local or distant metastasis are one of the most notable pathological parameters to determine the prognosis (11). The primary management is surgical resection followed by radiotherapy (14).

Carcinoma ex pleomorphic adenoma having component of salivary duct carcinoma component, showed strong positivity for HER2 protein (15). In the present case series a 60-year-old male presented with sudden increase of painful, firm to hard large fungating whitish growth revealed pleomorphic hyperchromatic epithelial cells arranged in glands with areas of pleomorphic adenoma with free margins morphologically. Total five lymph nodes showed tumour deposit with stage of T4aN2Mx. Immunohistochemical expression of HER2/neu was 3+ (positive) but ki67 expression was not that significant and underwent for radiation therapy. Polymorphous adenocarcinoma is a rare salivary gland neoplasm having indolent behaviour, primarily occurring the minor salivary glands but can rarely present in the major glands also particularly in parotid (16). In PAC, the tumour cells show round or polygonal, small to medium sized, slightly increased nuclear-cytoplasmic ratio, round or oval vesicular nuclei and eosinophilic cytoplasm. It may show various cytoarchitectural patterns include solid sheets, cords, tubules, cribriform. PAC cells stain for vimentin, CK 7 and S-100 also. Ki67 proliferation index is usually less than 5%. Primary wide surgical excision was mainstay of treatment for PAC. The prognostic factors include site, angiolymphatic-invasion, perineural-invasion or bone invasion, necrosis, size, stage, papillary and pseudocribriform components, positive resection margins and the use of radiotherapy without surgery (17).

Here, 52-year-old male patient, on parotidectomy cystic tissue piece measuring 6×5×4 cm with a nodular area of 2.5 cm in maximum dimension noted having cut section of whitish, homogenous. Microscopically this cystic tumour cells arranged in branching tubular and focal papillary areas with eosinophilic secretion noted intraluminally. Resection margins are also free from invasion. As may be because of preoperative FNAC reported it as benign condition, no lymph node dissection was done and patient did not come for further treatment. Immunohistochemical expression of CK7 and HER2/neu were positive along with S100 and vimentin also but Ki67 proliferation index was less than 5%.

Conclusion

Primary malignant salivary gland are rare malignancy and salivary duct carcinoma, basal cell adenocarcinoma, carcinoma ex pleomorphic adenoma and polymorphous adenocarcinoma are one of the uncommon and rare malignancy occur in the parotid. Although sometime preoperative imaging or cytology findings may be beneficial but histopathological features along with immunohistochemical diagnosis of parotidectomy specimen are helpful for correct diagnosis as well as early treatment while emphasis on surgical resection margin, lyphovascular invasion, lymph node metastasis and stage should be prioritised for disease free survival of the patient.

References

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DOI and Others

DOI: 10.7860/JCDR/2022/60206.17375

Date of Submission: Sep 13, 2022
Date of Peer Review: Sep 24, 2022
Date of Acceptance: Oct 18, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 15, 2022
• Manual Googling: Oct 08, 2022
• iThenticate Software: Oct 17, 2022 (11%)

ETYMOLOGY: Author Origin

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