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 61-year-old Chinese male presented with a progressive painful swelling in the right parotid gland for one month prior to attending our hospital. The patient had a history of heavy smoking, but did not complain of hemoptysis or other symptoms related to lung cancer. A clinical examination showed the size of the mass to be approximately 1 × 1 cm, with a good activity and a moderate texture. An ultrasound showed there to be a hypoechoic nodule with a size of 1.3× 1.3 × 0.9 cm. Therefore our initial diagnosis was that of a primary parotid tumor and we recommended surgical treatment. However, in preoperative routine examinations, a chest X-ray (Figure ) showed there to be a high density shadow in the right hilar. At this stage we highly suspected that the mass was metastases and required further examination. A lung computational tomography (CT) scan (Figure ) revealed a shadow in the right upper lobe, with a size of approximately 5.4 × 6.3 cm. The CT value was 40HU, and the enhanced CT value was 60HU, with multiple lymph nodes in the mediastinum appearing enlarged. After consulting with the patient, we performed an operation constituting of a partial parotidectomy and facial nerve dissection. Postoperative pathology reported a small-cell lung cancer metastases to parotid (Figure ). Immunohistochemistry showed TTF(thyroid transcription factor)-1(+), Syn (Synaptophysin) (+), actin (-), S-100(-), P63 (-), EMA (epithelial membrane antigen) (-), ck(cytokeratin)20 (-). Therefore, we recommended that the patient receive postoperative radiation and chemotherapy.