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British Journal of Oral and Maxillofacial Surgery 53 (2015) 9496

Short communication

Bilateral parotid gland metastases from carcinoma of the


breast that presented 25 years after initial treatment
M. Duncan , M. Monteiro, M. Quante
Royal Sussex County Hospital, Brighton, United Kingdom
Accepted 24 September 2014
Available online 18 October 2014

Abstract
We report a case of a 76-year-old woman with metastases to both parotid glands almost 25 years after mastectomy and chemotherapy for
primary carcinoma of the breast. Immunohistochemical staining is invaluable in establishing the origin of metastatic deposits, in this case,
expression of oestrogen receptors in a previously resected adenocarcinoma of the breast. The information can be used to target treatment
accurately in selected cases of advanced malignancy.
2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Bilateral parotid metastases; Breast adenocarcinoma; Cytokeratins; Immunohistochemistry; Tamoxifen; Letrozole

Introduction
Metastases to the parotid glands from malignancies of the
head and neck are relatively uncommon, and usually arise
from ipsilateral primary cancers of the skin or mucosa. These
primary cancers are well known to metastasise to either one or
both parotid glands by direct extension through neighbouring
tissues, lymphatic channels, or less commonly, through
haematogenous spread.1 However, parotid metastases from
infraclavicular malignancies are rare (0.160.4%),2 and most
often use the haematogeneous route. Numerous reports have
shown unilateral parotid metastases from other tumours
such as those of the lung and kidney, and from ductal
breast carcinoma, malignant melanoma, rhabdomyosarcoma
of the lower limb, testicular seminoma, and Merkel cell
carcinoma.24 There is scant evidence, however, of metastases to both parotid glands from malignancies in sites other
than the head and neck, with isolated reports of spread from

Corresponding author. Tel.: +44 07540 372116.


E-mail addresses: Miles.Duncan@bsuh.nhs.uk,
smilesduncan@hotmail.com (M. Duncan), Michael.Monteiro@bsuh.nhs.uk
(M. Monteiro), Mara.Quante@bsuh.nhs.uk (M. Quante).

hypernephroma,4 renal cell carcinoma,5 hepatocellular carcinoma, and small cell carcinoma of the lung.6 We know of
no previous reports of metastases to both parotid glands from
carcinoma of the breast.

Case report
A 76-year-old woman presented to our department with
an ill-defined, firm, non-tender 2 cm diameter mass in the
right parotid tail. She had previously been diagnosed with a
1.5 cm diameter primary carcinoma of the mammary duct of
the right breast in December 1989, and had subsequently
had mastectomy and axillary sampling (7 nodes sampled
showed no signs of metastases) followed by 5 years of
tamoxifen. History elicited a progressive unilateral facial
palsy in the 2 months before initial review at the clinic, and
examination showed she had a HouseBrackmann grade IV
deficit and was not able to close her right eye. Core biopsy
specimens of the lesion showed poorly differentiated adenocarcinoma with strong expression of oestrogen receptors,
and less strong expression of E-cadherin and CK7. No CK20
and HER 2 receptors were expressed (Figs. 1 and 2). Six

http://dx.doi.org/10.1016/j.bjoms.2014.09.023
0266-4356/ 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

M. Duncan et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 9496

95

Fig. 1. Core biopsy specimen from left parotid. Immunohistochemical staining for oestrogen receptors in poorly differentiated adenocarcinomatous cells
(original magnification 80); similar staining in right parotid core.

Fig. 3. Axial computed tomogram showing diffuse infiltrative lesions in both


parotid glands.

Fig. 2. Immunohistochemical staining for CK7 in left parotid core (original


magnification 40); similar staining in right parotid.

weeks later she developed a swelling in the left parotid,


and core biopsy specimens similarly showed adenocarcinoma with identical immunostaining. Computed tomography
(CT)-parotids showed a malignant infiltrative process in both
glands (Fig. 3). There was no evidence of any other active disease. After discussion at the head and neck multidisciplinary
team clinic, the parotid lesions were treated with letrozole.
She responded well, but showed no objective improvement
in facial nerve function.

Discussion
Our patient presented with 2 findings: first, parotid metastases
that had arisen from breast cancer treated 25 years previously,
and secondly, bilateral parotid swellings that arose within a
short period of time. There is some reported evidence to suggest that primary malignancies of the salivary glands can
express sex hormone receptors, but most express androgen
receptors, and few express oestrogen receptors.7 It therefore
seems improbable that these metastases were 2 distinct primaries in the parotid glands. One possible reason for the
recurrence was that at the time of initial mastectomy she had
only the axillary nodes sampled rather than a level III axillary clearance. However, extensive surgery had been deemed

inappropriate at the time, as none of the 7 nodes sampled had


contained metastatic cells. A second more plausible reason is
the reduction over time in the therapeutic effect of tamoxifen
on tumour cells that express oestrogen receptors, given that 2
decades had passed since the standard 5-year hormonal treatment had stopped. The recent ATLAS trial has shown that
mortality from oestrogen receptor positive breast cancer is
reduced from 33.1% to 23.9% if adjuvant tamoxifen is given
for 10 years.8
This case highlights the importance of immunohistochemical analysis in the diagnosis of parotid tumours. Expression
of oestrogen receptors directs adjuvant treatment towards
tamoxifen in premenopausal women and aromatase inhibitors
(letrozole, anastrozole) in postmenopausal cases. E-cadherin
status differentiates between intraductal and lobular carcinoma of the breast. All salivary gland tumours stain for
CK7 and not for CK209 but this pattern is more specific for
certain types of metastatic adenocarcinoma, mainly of the
breast; it is also seen in endometrial, ovarian, and pulmonary
tumours. Staining for CK20 and not for CK7 is commonly
seen in colorectal adenocarcinoma.10 Given this combination of staining patterns, it seems likely that, in this case,
both parotid lesions originated from the breast carcinoma.

Conict of interest
No conflict of interest.

Patient permission statement


The patients confidentiality was maintained throughout.

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M. Duncan et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 9496

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