A 60-year-old multiparous postmenopausal female patient, with no prior known medical or surgical comorbidities or any drug allergy, presented with a history of lump in the right breast of 4 weeks’ duration which is gradually increasing in size. The lump was not associated with any pain, deformity, or bloody nipple discharge. There was no history of any axillary swelling, trauma, surgery, or systemic symptoms such as fever or weight loss. Family history was insignificant. On examination, there was 4 cm × 3 cm lump in the lower quadrant of the breast, not fixed to underlying structures or skin. The fine-needle aspiration cytology (FNAC) of lump was suspicious of malignancy, while biopsy revealed invasive ducal carcinoma Grade III, which demonstrated estrogen and progesterone receptor positive and HER2/Neu receptor negative. She underwent right breast conservation surgery with oncoplastic reconstruction. Final histopathology report revealed an invasive ducal carcinoma Grade III, with tumor size of 2.3 cm × 3.0 cm and node negative status, that is, Stage IIA (T2N0M0) breast cancer. She received six cycles of adjuvant chemotherapy with five flurouracil, epirubicin, and cyclophosphamide followed by adjuvant radiation therapy and then started on adjuvant hormonal therapy with tablet anastrozole 1 mg OD.\nWithin 9 months of adjuvant endocrine therapy, she presented with swelling over right preauricular region which she noticed incidentally. There was no history of any associated pain, trauma, sialorrhea, or difficulty in chewing food. PET scan revealed a focus of increased avidity in the right parotid gland without any metastatic focus elsewhere in the body [] while contrast-enhanced computed tomography (CT) fused 18F-fluorodeoxyglucose (18F-FDG) PET/CT axial and coronal sections showed a well-defined nodular lesion measuring 1.8 cm × 1.7 cm × 1.6 cm in the right parotid gland with good postcontrast enhancement and mild FDG avidity []. She underwent right superficial parotidectomy with Level II and Level III neck node dissection which revealed metastatic infiltrating ductal carcinoma involving the right parotid gland with intraparotid node [Panel A, ]. On immunohistochemistry, cells were positive for CK 7 and GATTA 3, while negative for CK 20, PAX 8, and TTF1 suggesting metastasis from breast primary [Panel B, ]. In view of limited parotid metastasis and no other evidence of any visceral crisis, she was started on second-line hormonal therapy with tablet exemestane 25 mg OD and tablet everolimus 5 mg OD. At resent, she is on regular follow-up on same second-line hormonal therapy and disease free for the last 16-month postsurgery.
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.