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Recurrent Pleomorphic Adenoma, malignant transformation, carcinoma, CT scan, pain on neck

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Recurrent Pleomorphic Adenoma - to radiate or not?
Hello. My 42-year old husband (non-smoker, good health) has just had his third parotidectomy (multiple recurrent benign pleomorphic adenomas). Our ENT surgeon advised that the tumors would continue to come back again through his life, and obviously we are concerned about the risk of these tumors transforming to malignancies after multiple surgeries, as time goes by. The surgeon mentioned radiation (low-dose) as a way of putting this to an end (hopefully), and has offered to send us to the radiation oncologist (but advised that it wouldn't hurt to wait 6 months to do another CT Scan and then going if that's what we chose). We are unsure if the risk is greater to wait it out and keep having surgeries with the risk of carcinoma ex pleomorphic adenoma - or if we should pursue radiation (now or later?), knowing that there are inherent risks of malignant transformation in that. My husband seems to be healing well (3 weeks post-op) from this go-round, however, he gets quite light-headed occasionally, is very tired and has pain in the back of his neck (top of spine). There is no pain at the surgical site but seems to be nerve-related at the back of the neck. Thank you so much.

A loving wife in XXXXXXX
Posted Tue, 22 May 2012 in Cancer
Answered by Dr. Sumit Bhatti 3 hours later

Thank you for your query.

1. Pleomorphic adenoma is the most common neoplasm of the parotid gland. It is a benign tumor. Treatment of recurrent cases is a dilemma. Though there are many hypotheses for recurrent pleomorphic adenoma, including multi-centric origins and genetic factors, reasons for recurrent disease are:
a. Intra-operative or unnoticed tumor spillage,
b. Incomplete excision due to thinning or absence of the pseudocapsule,
c. Presence of finger-like projections (pseudopods) of the tumor,
d. Disruption of the pseudocapsule of the tumor.
e. Tumor adherent to the skin or facial nerve.

2. Radiotherapy may be given, now that he has had multiple recurrences. This is done in many cases where further surgical treatment of recurrent disease is not possible. If you have a recent MRI imaging, you may share some images here. By now the tumor should be involving the skin or subcutaneous fat, sitting on the facial nerve. How is his facial nerve function? Complete tumor removal with a cuff of tissue in this case may require sacrifice of the overlying skin (with a skin flap repair), facial nerve or some of it's branches.

3. The risk of carcinoma ex pleomorphic adenoma or worse, an adenocarcinoma is high after multiple surgeries and often discovered later on histopathology of the excised specimen.

4. The full dose of Radiotherapy can be given only once in a lifetime and hence a low dose has been advised. However it also carries a risk of malignant transformation that increases over time. Hence I would recommend a full dose.

5. You should also explore Image Guided Radiotherapy (IGRT), Gamma Knife and Cyber Knife.

I hope that I have answered your queries. If you have any further questions, I will be available to answer them.

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