A 65-year-old lady from Syrian descent was referred to our institution in September 2014 for painless rapidly enlarging mass of the right cheek, which she noted only for 2 months prior to presentation. Relevant history included an early stage right breast invasive ductal carcinoma diagnosed 6 years earlier and treated by a lumpectomy with ipsilateral axillary lymph nodes dissection, followed by 6 cycles of adjuvant chemotherapy with CMF (cyclophosphamide, methotrexate, and 5-fluorouracil), focal radiotherapy to the chest wall and right axilla, and subsequent hormonal manipulation with letrozole for 5 years.\nThe patient was disease-free for the following 6 years until a growing right cheek mass led her to seek medical advice.\nPhysical exam revealed a palpable firm, nontender, nonmobile right inferior parotid mass of 2 cm at the level of the angle of the mandible. The right corner of the mouth dropped with asymmetry that increased with facial expression, thus indicating right mandibular branch palsy. The rest of the exam did not reveal any palpable cervical, supraclavicular, or axillary lymph nodes on both sides. Fibroscopy was done and was normal.\nContrast enhanced MRI scan of the neck revealed the presence of a 2 cm ill-defined mass of the right parotid gland at the inferior border, hypointense on T1 and mild hyperintense on T2 with moderate enhancement after gadolinium injection. No cervical lymphadenopathy was detected. Fine needle aspiration biopsy (FNAB) of the parotid mass revealed the presence of malignant cells of breast origin. Staging FDG-PET CT scan was obtained showing accumulation of 18-FDG in the right parotid and ruled out other distant or locoregional metastases ().\nA total parotidectomy was subsequently done with preservation of all facial nerve branches. However, the dissection of the mandibular branch was done with probable remnant of tumor cells on the nerve. The retroauricular vein was sacrificed because of direct invasion by the tumor. The anatomic pathology report confirmed the secondary nature of the tumor (of breast origin) invading the parotid parenchyma with perineural and perivascular invasion (). Although immunocytochemistry was not done on the FNA sample and was not needed for diagnosis, immunostaining with anti-estrogen receptor (ER) antibodies was performed on the final surgical pathology specimen and further supported the diagnosis as the tumoral cells were ER positive (). GATA3 immunostaining, a specific marker for breast cancer, was also done confirming the breast origin of the tumor ().\nThe patient tolerated well the procedure and was referred for adjuvant radiotherapy.
A 36-year-old woman presented to our department with a swelling in her left parotid gland, not able to close her left eye completely, and the corner of the mouth turned to the right when smiling like peripheral facial paralysis (Fig. ) in May 2017, which appeared two months ago. Meanwhile, the patient presented with right upper limb and right shoulder pain. The study has been approved by the Shandong Cancer Hospital Affiliated to Shandong University Ethics Committee (No. SDTHEC20171004). Written, informed consent was obtained from the patient.\nThe patient was diagnosed with carcinoma in left breast in January, 2015, and received breast conservative surgery and axillary lymph node dissection in another hospital. Invasive ductal carcinoma of 1.2 cm × 1.0 cm and grade II with lymph vessel invasive were confirmed by routine pathology examination, and all margins were negative, whereas 2 of 22 lymph nodes were metastases. Positive by immunohistochemistry (IHC) for estrogen receptor (ER) (70% of nuclei stained) and progesterone receptor (PR) (about 50% of nuclei stained), and negative for human epidermal growth factor receptor-2 (HER-2) by IHC. The average Ki-67 labeling index was 40%, which belonged to luminal B subtype. Adjuvant chemotherapy, radiotherapy, and endocrine therapy were recommended according to the clinical practice guideline of breast cancer, but all strategies for postoperation treatment were declined by the patient.\nBecause patient did not receive any treatments after breast cancer surgery, distant metastases were suspected when admitted first time to our department. So, PET/CT was recommended to the patient. The results of PET/CT revealed accumulation of standardized uptake value (SUV) 6.5 in the parotid gland (Fig. ) and identified a hypermetabolic mass in the contralateral side of the primary lesion (right breast) with a SUV 5.3. Additionally, PET/CT scan found multiple lymph nodes metastases (including left rotter lymph node, left supraclavicular lymph node, right hilar region lymph node, and mediastinal lymph node), multiple bone metastases, and bilateral interlobular pleural metastasis.\nLumpectomy of the mass in the right breast was performed, and invasive carcinoma was confirmed by routine pathology examination. The results of IHC were as follows: ER (+50%), PR (−), Her-2 (−). The average Ki-67 labeling index was 2%. The molecular subtype was also luminal B. According to the conclusion of multidisciplinary team, the patient decided and received 8 cycles of first-line rescue chemotherapy (4 cycles of bi-weekly epirubicin [100 mg/m2] plus cyclophosphamide [600 mg/m2], followed by 4 cycles of 3-weekly docetaxel [100 mg/m2]), combining with 4 mg zoledronic acid in treatment of bone metastasis every 4 weeks, followed by the combination of endocrine therapy (Tamoxifen 10 mg, twice daily) and ovarian function suppression (Goserelin 10.8 mg, every 3 months) after chemotherapy. No serious side effects were found. The size of the tumor in the parotid gland was clinical complete response revealed by PET/CT examination after 8 cycles of chemotherapy (Fig. ). Follow-up 6 months after chemotherapy, the patient is in stable condition and undergoing endocrine therapy.