jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf What Happens Next: Unexpected Malignancies After Extracapsular Dissection of Parotid Tumors

jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf What Happens Next: Unexpected Malignancies After Extracapsular Dissection of Parotid Tumors | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 29 May 2025 V1 Latest version Share on jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf What Happens Next: Unexpected Malignancies After Extracapsular Dissection of Parotid Tumors Authors : Kerem Ozturk [email protected] and Efe İşler 0000-0002-9689-5958 Authors Info & Affiliations https://doi.org/10.22541/au.174850399.97835892/v1 150 views 79 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: This study aimed to evaluate the long-term oncologic and functional outcomes of extracapsular dissection (ECD) as the primary surgical approach for low-grade malignant parotid tumors. Methods: We retrospectively analyzed 17 patients who underwent ECD between 2012 and 2020, all of whom were diagnosed postoperatively with low-grade parotid malignancies despite benign or non-diagnostic preoperative FNAB. Patients were followed for a minimum of 60 months, with surgical outcomes, recurrence, and adjuvant therapy requirements assessed. Results: The most common histopathologic diagnosis was low-grade mucoepidermoid carcinoma. ECD alone was sufficient in 76.5% of patients, while 17.7% required completion parotidectomy due to positive surgical margins. Adjuvant therapy was needed in 11.76% of cases due to perineural invasion. Over a mean follow-up of 89.7 months, no recurrences were observed. Two patients died of unrelated causes. Conclusion: ECD may offer an oncologically safe and functionally favorable alternative to traditional parotidectomy in well-selected low-grade parotid malignancies. Our results support a risk-adapted surgical approach and represent the longest follow-up data published to date in this context. Abstract Objective: This study aimed to evaluate the long-term oncologic and functional outcomes of extracapsular dissection (ECD) as the primary surgical approach for low-grade malignant parotid tumors. Methods: We retrospectively analyzed 17 patients who underwent ECD between 2012 and 2020, all of whom were diagnosed postoperatively with low-grade parotid malignancies despite benign or non-diagnostic preoperative FNAB. Patients were followed for a minimum of 60 months, with surgical outcomes, recurrence, and adjuvant therapy requirements assessed. Results: The most common histopathologic diagnosis was low-grade mucoepidermoid carcinoma. ECD alone was sufficient in 76.5% of patients, while 17.7% required completion parotidectomy due to positive surgical margins. Adjuvant therapy was needed in 11.76% of cases due to perineural invasion. Over a mean follow-up of 89.7 months, no recurrences were observed. Two patients died of unrelated causes. Conclusion: ECD may offer an oncologically safe and functionally favorable alternative to traditional parotidectomy in well-selected low-grade parotid malignancies. Our results support a risk-adapted surgical approach and represent the longest follow-up data published to date in this context. Keywords Extracapsular dissection; Parotid tumor; Low-grade malignancy; Mucoepidermoid carcinoma; Head and neck surgery; Facial nerve preservation. Key Points 1. Extracapsular dissection (ECD) is increasingly utilized as a less invasive technique for parotid tumors initially presumed to be benign. 2. Unexpected malignancies following ECD represent a clinical dilemma regarding the adequacy of initial surgery. 3. Our long-term single-institution experience demonstrates that oncologic outcomes can remain favorable in carefully selected low-grade malignancies. 4. In most cases, no additional surgery or adjuvant therapy was required, with no recurrence observed during follow-up. 5. These findings support a tailored, risk-adapted surgical strategy for selected parotid tumors discovered to be malignant postoperatively. Introduction Malignant tumors of the parotid gland represent a heterogeneous group of neoplasms with diverse biological behaviors, histopathological subtypes, and varying metastatic potential. Traditionally, the gold standard for surgical management has been total or superficial parotidectomy, often accompanied by elective neck dissection when indicated, to ensure optimal oncologic control [1,2]. However, growing evidence suggests that a tailored surgical approach, guided by tumor histology and grade, may be appropriate for selected low-grade malignancies, potentially minimizing surgical morbidity without compromising oncologic safety [2,3]. Extracapsular dissection (ECD) has long been established as a safe and effective surgical technique for benign parotid tumors, offering functional advantages such as superior facial nerve preservation and reduced postoperative complications compared to more extensive resections. More recently, its application in well-selected cases of low-grade malignant parotid tumors has garnered increasing interest. Several studies have indicated that ECD may yield oncologic outcomes comparable to those of more radical surgery, particularly for small, well-circumscribed, low-grade tumors lacking adverse pathological features [1,4]. Guidelines from the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) support risk-adapted surgical strategies, proposing that limited resections may be appropriate for certain T1-T2, low-grade tumors. Nonetheless, concerns persist regarding the possibility of microscopic residual disease, recurrence risk, and the potential need for adjuvant therapy in these patients. In this study, we aimed to evaluate the oncologic outcomes of ECD as the primary surgical approach in patients with low-grade malignant parotid tumors. We hypothesized that ECD would offer comparable oncologic safety while providing superior functional outcomes relative to more extensive parotidectomy techniques, particularly in well-selected cases. jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf Materials and Methods This study was conducted at the Department of Otorhinolaryngology, Ege University Faculty of Medicine, between January 2012 and 2025. It was carried out in accordance with international ethical standards and the principles outlined in the Declaration of Helsinki by the World Health Organization. The study received approval from the institutional ethics committee, and written informed consent was obtained from all participants. Patient Selection Patients who underwent extracapsular dissection (ECD) of the parotid gland between January 2012 and 2020 were retrospectively evaluated. Included in the study were patients whose preoperative fine-needle aspiration biopsy (FNAB) results were either benign or non-diagnostic, but who were subsequently diagnosed with low-grade malignancy based on postoperative histopathological evaluation. A total of 17 patients (6 males, 11 females) met the inclusion criteria. These criteria were as follows: • Preoperative FNAB reported as benign or non-diagnostic, • Histopathological confirmation of malignancy after surgery, • A minimum postoperative follow-up period of 60 months. Exclusion criteria included any histology other than primary parotid tumors, clinically suspicious malignant lesions, recurrent tumors, and a previous history of facial nerve paralysis. All surgeries were performed by a single experienced head and neck surgeon (K.O.) using ECD as the primary technique. Preoperative assessment included clinical examination, contrast-enhanced magnetic resonance imaging (MRI), FNAB for cytology, and facial nerve function evaluation. Adjuvant therapy decisions were made by a multidisciplinary tumor board (MTB). Demographic, clinical, radiologic, and histopathologic data were obtained from electronic health records. All patients were contacted via telephone and invited for a final follow-up examination. Results Patient ages ranged from 18 to 86 years, with a mean age of 53.3 years (SD: 18.4) and a median age of 52 years. Among the 17 patients included in the study, 64.7% (n = 11) were female and 35.3% (n = 6) were male. Table 1 presents the distribution of the patients. Preoperative fine-needle aspiration biopsy (FNAB) results were classified as either benign cytology in 64.7% (n = 11) or non-diagnostic cytology in 29.4% (n = 5) of cases. Postoperative histopathological examination revealed low-grade mucoepidermoid carcinoma as the most common malignancy (52.9%, n = 9), followed by adenoid cystic carcinoma (17.7%, n = 3) and acinic cell carcinoma (17.7%, n = 3). Intermediate-grade mucoepidermoid carcinoma and secretory carcinoma were each identified in 5.9% (n = 1) of patients. The majority of patients (76.5%, n = 13) did not require further surgical intervention following ECD. However, 17.7% (n = 3) of cases underwent superficial parotidectomy as a secondary procedure due to positive pathological surgical margins; no residual tumor was detected in the postoperative pathology after the second surgery. Adjuvant therapy was not required in 82.35% (n = 14) of patients. Conversely, two patients (11.76%) received adjuvant treatment based on multidisciplinary tumor board (MTB) recommendations, as perineural invasion was identified. The mean follow-up duration was 89.71 months (~7.5 years), ranging from 61 months (~5.1 years) to 138 months (~11.5 years). Postoperative surveillance included clinical evaluation, ultrasound, or MRI at six weeks post-surgery, followed by assessments every three months for two years, every six months for the subsequent three years, and annually thereafter. All patients remained disease-free with no evidence of recurrence during follow-up. However, two patients (11.76%) died due to causes unrelated to their primary disease. Table 1. Clinicopathological features and outcomes of 17 patients undergoing ECD for low-grade parotid malignancy. Discussion The treatment strategy for malignant parotid tumors has historically followed a standardized surgical approach, most commonly involving total or superficial parotidectomy, and often accompanied by neck dissection when necessary. This has been widely accepted as the optimal method for achieving oncologic control by removing all potential microscopic disease [1,2]. However, in recent years, it has become increasingly evident that salivary gland malignancies constitute a highly heterogeneous group of tumors, with over 20 recognized histological subtypes, each exhibiting distinct biological behaviors and metastatic potentials. While certain subtypes are aggressive and require radical surgical management, others—such as acinic cell carcinoma or low-grade mucoepidermoid carcinoma—tend to be indolent, well-circumscribed, and associated with a low risk of metastasis [1–3]. ASCO guidelines emphasize the importance of tailoring the extent of surgical intervention to the tumor’s histological grade. For small, low-grade, early-stage tumors (e.g., T1 low-grade mucoepidermoid or acinic cell carcinoma), conservative resections can be appropriate. Surgery with negative margins remains the cornerstone of treatment. Several clinical series have reported excellent local control with surgery alone for T1–T2 low- to intermediate-grade tumors, even when margins are narrow, provided that no additional adverse features are present [4]. Given the biological variability of salivary gland tumors, a uniform surgical approach may not be suitable for all cases. Instead, a risk-adapted strategy based on tumor biology could provide similar oncologic outcomes while reducing surgical morbidity [5,6]. Our findings support this perspective. Specifically, our data suggest that patients with small (<4 cm), low-grade tumors can achieve excellent disease control through conservative surgery, with no increased risk of recurrence. These results are consistent with previous investigations assessing the feasibility of extracapsular dissection (ECD) as an alternative to parotidectomy in select patients [1,7]. Mantsopoulos et al. (2015) reported on a cohort of patients initially presumed to have benign tumors but ultimately diagnosed with malignancy after undergoing ECD. Among 25 patients who received subsequent completion parotidectomy, only three had residual tumor, indicating that limited initial surgery did not compromise oncologic safety [7]. Moreover, their analysis underscored the functional advantages of avoiding extensive resections, as the majority of patients retained normal postoperative function [7,8]. The latest data from Mantsopoulos et al. (2023) provide the longest reported follow-up to date for patients treated with ECD alone. Nevertheless, the follow-up duration in our study exceeds that of their report [9]. Their analysis of 16 patients with low-grade malignant tumors treated exclusively with ECD demonstrated 100% local disease control and disease-specific survival at five years. The authors concluded that for small, well-defined, low-grade tumors, conservative surgery may be sufficient without compromising oncologic outcomes [9]. Our findings echo these conclusions. Similar to Mantsopoulos et al., we observed that limited surgery achieved effective oncologic control in patients with small, well-circumscribed, low-grade tumors. Lim et al. reported a 90% local control rate using conservative parotid surgery in carefully selected cases [4]. Moreover, a systematic review by Quer et al. found that 88–91% of patients treated with less extensive resections remained disease-free when negative margins were obtained [10,11]. These results collectively suggest that, in well-selected cases, limited surgery may yield oncologic outcomes comparable to traditional parotidectomy while reducing complications such as facial nerve dysfunction [8,9]. Our study adds to the growing body of evidence supporting the notion that limited surgery may be adequate for truly low-risk tumors. Consistent with previous research [8–10], our cohort was highly selected: all patients had tumors with favorable characteristics—low-grade histology, T1 stage, superficial location, no clinical nodal involvement, and negative surgical margins. Under these conditions, oncologic outcomes (i.e., local-regional control and survival) were equivalent to those reported for standard parotidectomy, thus supporting the feasibility of a personalized surgical strategy. Nonetheless, not all conservative surgeries yield positive results. Some studies have reported higher recurrence rates when overly minimal excision techniques, such as enucleation, are applied [11]. These findings underscore the importance of appropriate patient selection and meticulous surgical technique. Limited resections such as ECD or partial parotidectomy should only be considered when negative margins can be confidently achieved [2,3]. Our approach reserves conservative surgery for tumors that exhibit favorable preoperative characteristics (e.g., well-defined margins on imaging, absence of high-grade features) and mandates histologically confirmed negative margins. When margin status is uncertain or adverse features (e.g., high grade, lymphovascular invasion) are present, we advocate for prompt completion surgery or adjuvant therapy in accordance with established protocols. A key question remains: must every case of parotid malignancy be managed with definitive surgery, or could some low-risk tumors be safely monitored following limited excision? Our findings, supported by emerging literature, suggest that observation may be a reasonable option in well-selected patients. This strategy is increasingly gaining support among head and neck oncology experts [9,11]. Conclusion Our findings indicate that a single standardized surgical approach may not be suitable for all cases of malignant parotid tumors. Instead, individualized surgical planning—guided by tumor histology, grade, and clinical features—may offer equivalent oncologic efficacy while minimizing unnecessary surgical morbidity. Although total parotidectomy continues to be regarded as the gold standard, increasing evidence supports the viability of more selective approaches in appropriately selected low-risk patients. Specifically, our results suggest that extracapsular dissection (ECD) may represent an oncologically safe and functionally superior alternative to total parotidectomy for selected low-grade malignant tumors of the parotid gland. This method has the potential to reduce surgical morbidity while maintaining oncologic outcomes, aligning with findings from previous studies. However, larger, multi-institutional prospective trials are necessary to definitively establish ECD as a standard of care for specific patient subgroups. In conclusion, ECD demonstrates excellent oncologic outcomes in carefully selected cases of low-grade parotid malignancies, with high disease-free survival and minimal recurrence. Ensuring its success as a standalone treatment requires meticulous patient selection, strong compliance, and close long-term follow-up. 1. Mantsopoulos K, Koch M, Iro H. (2017). Extracapsular dissection as sole therapy for small low-grade malignant tumors of the parotid gland. The Laryngoscope, 127: 1804–1807. https://doi.org/10.1002/lary.26482 2. van Herpen C, Vander Poorten V, Skalova A, et al. (2022). Salivary gland cancer: ESMO-European Reference Network on Rare Adult Solid Cancers (EURACAN) Clinical Practice Guideline. ESMO Open, 7(6):100602. https://doi.org/10.1016/j.esmoop.2022.100602 3. Geiger JL, Ismaila N, Beadle B, et al. (2021). Management of Salivary Gland Malignancy: ASCO Guideline. J Clin Oncol, 39(17):1909–1941. https://doi.org/10.1200/JCO.21.00449 4. Lim YC, Lee SY, Kim K, et al. (2005). Conservative parotidectomy for the treatment of parotid cancers. Oral Oncol, 41(10):1021–1027. https://doi.org/10.1016/j.oraloncology.2005.06.004 5. Di Villeneuve L, Souza IL, Tolentino FDS, et al. (2020). Salivary Gland Carcinoma: Novel Targets to Overcome Treatment Resistance in Advanced Disease. Front Oncol, 10:580141. https://doi.org/10.3389/fonc.2020.580141 6. Bou Zerdan M, Kumar PA, Zaccarini D, et al. (2023). Molecular Targets in Salivary Gland Cancers: A Genomic Analysis of 118 Mucoepidermoid Carcinomas. Biomedicines, 11(2):519. https://doi.org/10.3390/biomedicines11020519 7. Mantsopoulos K, Velegrakis S, Iro H. (2015). Unexpected Detection of Parotid Gland Malignancy during Primary ECD. Otolaryngol Head Neck Surg, 152(6):1042–1047. https://doi.org/10.1177/0194599815578104 8. Mantsopoulos K, Mueller S, Goncalves M, et al. (2019). Completion surgery after ECD of low-grade parotid tumors. Head Neck, 41(9):3383–3388. https://doi.org/10.1002/hed.25863 9. Mantsopoulos K, Thimsen V, Sievert M, et al. (2023). Limited parotid surgery as sole treatment: Long-term results. Am J Otolaryngol, 44(2):103735. https://doi.org/10.1016/j.amjoto.2022.103735 10. Quer M, Olsen KD, Silver CE, et al. (2020). Is There A Role for Limited Parotid Resections? Surgeries, 1(1):2–9. https://doi.org/10.3390/surgeries1010002 11. Ozturk K, Ozturk A, Turhal G, et al. (2019). Comparative outcomes of ECD and superficial parotidectomy. Acta Otolaryngol, 139(12):1128–1132. https://doi.org/10.1080/00016489.2019.1669821 Information & Authors Information Version history V1 Version 1 29 May 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Kerem Ozturk [email protected] Ege Universitesi Tip Fakultesi View all articles by this author Efe İşler 0000-0002-9689-5958 Ege Universitesi Tip Fakultesi View all articles by this author Metrics & Citations Metrics Article Usage 150 views 79 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Kerem Ozturk, Efe İşler. jabbrv-ltwa-all.ldf jabbrv-ltwa-en.ldf What Happens Next: Unexpected Malignancies After Extracapsular Dissection of Parotid Tumors. Authorea . 29 May 2025. DOI: https://doi.org/10.22541/au.174850399.97835892/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. 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