British Journal ofPlastic Surgery (1983) 36, 79-80 !S! 1983 The Trustees of British Association of Plastic Surgeons
Metastatic tumour in the submandibular salivary gland A. L. H. MOSS Department
of Plastic and Jaw Surgery,
SummaryMetastatic disease in the salivary glands is rare. The primary neoplasms are usually found in the head and neck region. This is the ninth reported case of metastatic deposit in the submandibular salivary gland from a distant primary tumour outwith the head and neck. A brief review of the literature is
parotid gland include tumours arising in the lung, breast, stomach, pancreas and rectum (Meyers and Olshock, 1981). On review of the literature only eight cases could be found involving metastases to the submandibular gland from distant primaries: four from lung neoplasms, one from the kidney and three from the breast (Solomon et al., 197.5; Meyers and Olshock, 1981). Grage and Lober (1962) reported that of the ten submandibular malignancies in their series, one was from a distant primary lesion, in this instance a scirrhous carcinoma of the breast, excised 13 years previously. In the case reported by Solomon et al. (1975), the patient had mastectomies for bilateral lobular carcinomata 14 and 8 years prior to presentation of a submandibular gland metastasis. This patient had also had a solitary lung lesion excised five years previously, of uncertain histology (? primary lung ? metastatic). Meyers and Olshock’s (1981) patient had a right radical mastectomy for carcinoma and a left simple mastectomy for fibrocystic disease, 14 and 12 years respectively, prior to presenting with a right submandibular triangle nodule, the histology of which showed a “borderline in situ metastatic carcinoma”. Three years later, she presented with a further mass in the same area with soft tissue and jugulo-digastric lymph node involvement. Biopsy showed an adenocarcinoma with positive oestrogen receptors, compatible with her breast lesion. In the present case report, there was an interval of 11 years from excision of her primary breast carcinoma to presentation of the secondary deposit in the submandibular salivary gland. This metastasis was originally thought to be associated with the melanoma partly due to its rapid appearance after surgery. Since there was a suspicion that there might be a relationship
Case report In 1971, a 51-year-old Caucasian female had a rightsided extended simple mastectomy followed by radiotherapy for an adenocarcinoma with histological involvement of three out of four lymphatic nodes. In 1977, she was given further radiotherapy for a presumed metastasis to the right retina and was started on a course of Tamoxifen. She presented again in January 1982 with a bleeding melanoma at the angle of the right mandible. This lesion was excised along with an underlying lymph node. Histological examination confirmed a superficial spreading malignant melanoma with central nodularity (7.0 mm thick, level III). The lymph node was also invaded by tumour. Six weeks later, she developed a fixed firm mass in the left submandibular triangle which was thought to be associated with the melanoma. Histological examination of the excised submandibular gland showed . . . extensive infiltration in the sero-mutinous salivary gland by a moderately well to poorly differentiated adenocarcinoma. The conclusion was that this was a secondary deposit from the breast neoplasm rather than a primary tumour of salivary gland origin’. Discussion Approximately 0.4% of all malignancies occur in the salivary glands and of these lo-15% involve the submandibular gland (Grage and Lober, 1962). are the most common Primary neoplasms malignancies affecting these glands. Secondary tumours in the submandibular gland are unusual even in advanced carcinoma involving adjacent soft tissues and lymph nodes (Evans and Cruickshank, 1970). The parotid gland is most commonly involved with metastatic tumour, usually from malignant melanomata or squamous cell carcinomata from the head and neck region (Grage and Lober, 1962; Solomon et al., 1975). Distant
which have metastasised to the 79
between the development of the melanoma and the reappearance of the breast carcinoma, this patient’s immUnOlOgiCa State Was investigated by Dr T. B. Wallinaton of Southmead Hosnital in Bristol whose rep&t reads as follows: _ “Limited immunological studies were undertaken to follow the hypothesis that the patient’s susceptibility to malignancy was due to a fault in appropriate immunological responses. Normal numbers of lymphocytes were found in the peripheral blood (2.44 x log/l). Of these 0.07 x log/1 were B lymphocytes, as defined by the possession of surface immunoglobulin, 1.64 x log/1 were T lymphocytes splitting as subsets into 1.07 x log/1 putative helper T cells and 0.81 x log/1 putative suppressor/cytotoxic T cells all as defined by the O.K.T. series of monoclonal antibodies (Rheinher? and Schlossman, 1981). The numbers of these cells all fall within the normal range but the ratio of the T cell subsets at 1.33 was abnormal suggesting an imbalance of immunoregulatory lymphocytes in the direction of suppressing the patient’s immune response. It must be emphasised that these are not functional studies but the result is tantalizing when viewed against the background of functional animal experiments which suggest suppression may inhibit an immune response that would otherwise control the growth of a tumour (Greene et al., 1977).” Berg et al. (1968), in a series of 396 patients with salivary gland tumours, found an incidence of primary breast carcinoma exceeding eight times the normal incidence of breast cancer. Therefore, the likelihood of finding a salivary gland and breast cancer in the same patient is not as remote as might at first be imagined.
BRITISH JOURNAL OF PLASTIC SURGERY
Postscript Since this paper was accepted for publication the patient described in this report has been readmitted to hospital with local and regional recurrences of the malignant melanoma in the right side of her neck and radiological metastases in bone, presumably from her breast carcinoma.
References Berg, J. W., Hutter, R. V. and Foote, F. W. (1968). The unique association between salivary gland cancer and breast cancer. Journal of the American Medical Association, 204, II 1. Evans, R. W. and Cruickshank, A. H. (1970). Carcinoma: in Epithelial turnout-s of the salivary glands. Philadelphia: W. B. Saunders Company. Grage, T. B. and Lober, P. H. (1962). Mafignant tumours of the major salivary glands. Surgery (St Louis), 52, 284. Greene, M. I. ef al. (1977). Reduction of syngeneic tumor growth by an anti-I-J alloantiserum. Proceedings of the National Academy of Sciences, USA, 74, 5118. Meyers, A. D. and Olshock, R. (1981). Metastasis to the submaxillary gland from the breast: a case report and literature review. Journal of Otolaryngology (Toronto}, 10, 278.
Rheinhen, E. L. and Schlossman, S. F. (1981). Characterization and function of human immunoregulatory T lymphocyte subsets. Immunology Today. April 1981,69. Solomon, M. P., Rosen, Y. and Gardner, B. (1975). Metastatic malignancy in the submandibular gland. Oral Surgery, Oral Medicine and Oral Pathology (St Louis), 39, 469.
The Author A. L. H. Moss, MBBS, FRACS, Senior House Officer in Plastic Surgery, Frenchay Hospital, Bristol.
Acknowledgements I would like to thank Mr R. T. Routledge for allowing me to present this patient: the Pathology Department at Frenchay Hospital for the review of the histology and Dr T. B. Wallington, Consultant Immunologist of the South Western Blood Transfusion Centre, Southmead Hospital, Bristol, for his help with the immunological investigations.
Requests for reprints to: Mr A. L. H. Moss, MBBS, FRACS, Department of Plastic Surgery, Frenchay Hospital, Bristol, BS16 1LE.