Parotidectomy for Parotid Cancer

Abstract

SYNOPSIS Parotidectomy for parotid cancer included management of primary salivary cancer, metastatic cancer to lymph nodes and direct extension from surrounding structures or cutaneous malignancies. Preoperative evaluation should provide the surgeon with enough information to plan a sound operation, reconstruction when needed and adequately counsel the patient. Facial nerve sacrifice is sometimes required but in preoperative functioning nerves, effort should be taken to preserve function. While nerve involvement predicts poor outcome, with a sound oncologic procedure and adjuvant therapy survival of around 50% has been reported for primary parotid malignancy. Metastatic cutaneous squamous cell carcinoma is often a high grade aggressive histology where local control for palliation with an extended parotidectomy can be achieved however overall survival remains poor most often secondary to distant metastasis.

AHNS Series: Do you know your guidelines? Principles of surgery for head and neck cancer: A review of the National Comprehensive Cancer Network guidelines

“…Studies are somewhat heterogeneous, but seem to suggest that local recurrence, positive margin rate, and long-term survival are equivalent whether the nerve is sacrificed or preserved. 16 Thus, given the substantial functional consequences of nerve resection and the questionable oncologic benefit, it is recommended that the practice be limited to those nerves with preoperative paralysis or in instances in which gross disease would otherwise be left behind.…”

The underappreciated role of auriculotemporal nerve involvement in local failure following parotidectomy for cancer

“…Locoregional recurrence continues to be an important route of failure in parotid cancers despite appropriate surgical and radiation management. Poor prognostic predictors include high T stage, deep lobe involvement, PNI, and failure to receive adjuvant radiation therapy 3,4,7 . These factors suggest that local control is paramount, and that medial perineural spread could represent a missed opportunity to surgically clear a patient's disease.…”

“…High grade tumors suffer from a locoregional failure rate of 20% and a distant failure rate of 15% over 2 years 2 . Overall survival following parotidectomy for locally aggressive cancer has been reported as 45% to 74% at 10 years, with worse overall survival for cutaneous malignancies metastatic to the parotid compared to primary parotid malignancies 3‐6 . High T stage, positive margins, perineural invasion (PNI), and failure to receive recommended radiation therapy significantly worsen survival 4 .…”

Surgical anatomy of the lymphatic drainage of the salivary glands: a systematic review

“…7,8,9,19,22 Intraglandular parotid nodes are usually subdivided anatomically into a larger superficial group (range of 3-19 nodes) and a smaller deep group (range of 0-9 nodes), generally corresponding to the superficial and deep parts of the parotid gland respectively. 7,10,11,23 An arbitrary plane marking the intraglandular portion of the facial nerve is universally used to divide the parotid gland, surgically rather than anatomically, into the superficial and deep lobes. 22,24 Interestingly, the intraglandular parotid nodes have been shown to be topographically related to the retromandibular vein as opposed to the facial nerve.…”

“…This finding is surgically relevant in cases of primary superficial parotid malignancy, or cutaneous intraglandular parotid nodes metastasis, as any dissection limited to superficial parotidectomy may potentially leave disease behind, and resection of the deep lobe might be necessary in high-risk cases. 10,20,23…”