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 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.