Is a lumpectomy a reasonable treatment for pleomorphic adenoma?

From the Guidelines

A lumpectomy is not the preferred treatment option for pleomorphic adenoma, instead, a partial superficial parotidectomy is recommended for appropriately located superficial tumors. This approach is based on the clinical behavior of these tumors, which is similar to low-grade salivary gland cancers, as noted in the ASCO guideline 1. The goal of treatment is complete excision of the tumor, but there is no need to remove additional parotid tissue containing adjacent lymph nodes due to the low rate of metastatic spread.

When considering treatment options for pleomorphic adenoma, several factors come into play, including:

• The location and size of the tumor
• The potential for recurrence
• The risk of facial nerve damage
• The overall health and preferences of the patient According to the ASCO guideline 1, partial superficial parotidectomy is a suitable approach for appropriately located superficial T1 or T2 low-grade salivary gland cancers, and by extension, pleomorphic adenomas. This procedure allows for complete excision of the tumor while minimizing the risk to the facial nerve.

Key points to consider when treating pleomorphic adenoma include:

• Complete surgical removal is crucial to reduce the risk of recurrence
• The procedure should be performed by a surgeon experienced in salivary gland surgery
• Potential complications include facial nerve damage, infection, bleeding, and scarring
• Follow-up appointments are necessary to monitor healing and check for any signs of recurrence. The study by Zenga et al, as mentioned in the ASCO guideline 1, demonstrated excellent disease control with complete surgical resection, even with narrow surgical margins, in the absence of adverse features. Similarly, Stodulski et al observed a 5-year DFS of 90.6% in patients with low- or intermediate-grade parotid cancers managed with surgery alone with negative but close surgical margins. These findings support the recommendation for partial superficial parotidectomy as a reasonable treatment option for pleomorphic adenoma.

From the Research

Lumpectomy for Pleomorphic Adenoma

• A lumpectomy, or the removal of a tumor with a minimal amount of surrounding tissue, may not be the most effective treatment for pleomorphic adenoma, as it can result in higher rates of recurrence 2, 3, 4.
• Studies have shown that formal parotidectomy, or the removal of the entire parotid gland, is not always necessary, but a more extensive removal of tissue, such as partial superficial parotidectomy, may be beneficial in reducing recurrence rates 2, 3.
• The use of extracapsular dissection, a minimal margin surgery, is not recommended due to the high risk of recurrence, especially in the hands of inexperienced surgeons 2, 3, 5.
• The risk of recurrence is higher with enucleation, or the simple removal of the tumor, and with positive resection margins 4.
• A study on pleomorphic adenoma of the breast recommends complete excision of the lesion with a cuff of normal tissue to reduce the risk of recurrence and malignant transformation 6.

Surgical Approaches

• Superficial parotidectomy and partial superficial parotidectomy are commonly practiced surgical approaches for the treatment of pleomorphic adenoma 2, 3.
• Extracapsular dissection is also used, but its effectiveness is debated due to the high risk of recurrence 2, 3, 5.
• Total parotidectomy is not always necessary, but may be considered in certain cases, such as large tumors or tumors with high-risk features 3, 4.

Complications and Outcomes

• Postoperative complications, such as hematoma, hypoaesthesia, transient facial nerve injury, Frey syndrome, and facial paralysis, are more common after superficial parotidectomy than after extracapsular dissection 5.
• The risk of recurrence is higher with younger age, enucleation, and positive resection margins 4.
• Long-term follow-up is necessary to monitor for recurrence and other complications 5.