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.
A 19-year-old woman with pain and swelling in her right parotid gland was referred to Shohada Hospital (Tehran-Iran) with no underlying diseases. She has complained of a mobile mass on the parotid region for a duration of 3 months. In her clinical examination, the oral mucosa and overlying skin were observed as intact with normal color. The patient's magnetic resonance imaging (MRI) indicated a high signal of a lobular-contoured, as a 4 × 2.5 cm solid mass lesion in the superior lobe of her right parotid gland (Figure ). A fine needle aspiration biopsy was performed by a maxillofacial surgeon and then a pathologic report indicated an unknown type of soft tissue malignancy. The primary diagnosis and the surgical treatment plan were discussed for the patient and a written consent was then obtained from her. At the operation session, following conducting the frozen-sections evaluation, malignant spindle cell tumor was diagnosed. Thereafter, a total parotidectomy was performed. As well, the gross examination of the specimen revealed a solid creamy mass with an almost well-defined border, invading the superficial lobe of the parotid gland. In addition, the permanent microscopic sections demonstrated a malignant neoplasm composed of fascicles of atypical spindle-shaped cells with large pleomorphic vesicular nuclei, prominent nucleoli, and clear-to-pale eosinophilic cytoplasm arranged in a storiform pattern (Figure ). Multinucleated giant cells and lymphocytic infiltration were observed as well. Notably, mitotic activity was about 4/10 HPF. By performing an immunohistochemically analysis, it was found that the atypical cells were HMB45 (Figure ) and S100 positive (Figure ). However, other markers such as Myo D1, Desmin, PanCK, and CK5/6 were negative. The microscopic feature along with IHC findings was consistent with the result of melanoma diagnosis.\nTo discover the primary origin of the recent melanoma lesion, a comprehensive past medical history was taken from the study case. As a result, we found that she had a history of congenital scalp pigmented nevus with no pathological consultation or any report of metastasis after 2 years (Figure ). Considering the possibility that the scalp lesion may be the origin of metastatic malignant melanoma, we suggested her to undergo excisional biopsy of the newly developed scalp lesion. In this regard, the patient was referred to the dermatology department for both consultation and performing the excisional biopsy operation. Thereafter, the newly formed scalp lesion was surgically removed. As well, the gross examination of the specimen showed safe border margins (0.6–1 cm) as well as a pigmented lesion in the center. Sections also demonstrated skin tissue with dissipated pigments from the epidermis to deep dermis. Moreover, the proliferation of atypical spindle cells scattered in the stroma was arranged from the superficial epidermis to hypodermis with vesicular nuclei and eosinophilic nucleolus (Figure ). Of note, the mitotic activity was about 1 in 10 HPF. In this patient, immunohistochemical staining showed the HMB45 intense positivity, but Ki67 was estimated as lower than 5%. Therefore, according to all these findings, the diagnosis of malignant melanoma was confirmed. After a month, she underwent parotidectomy due to swelling and pain in the left parotid gland. The histopathological report showed the same malignant melanoma. Thereafter, adjuvant chemotherapy and radiotherapy were performed for her during 6 and 4 sessions, respectively. She followed her disease by administrating complementary medicines too (homeopathy). After 18 months of follow-up, the lesion has not recurred and she has still been on a regular follow-up program.