Recurrent Pleomorphic Adenoma - to radiate or not?

[Sunflower1975914]

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 Virginia

[Sumit Bhatti, MD]

Dear Sunflower1975914,

Thanks for writing in.

I understand your concern.

Treatment of recurrent cases of pleomorphic adenoma is a dilemma. As of now, for your husband, radiotherapy may be given, given 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. I would like to know 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.

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.

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

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.

Hope that this information helps and hope that you will get better soon.

Thank you for using MedHelp's "Ask an Expert" Service, where we feature some of world's renowned medical experts in their fields. Millions have benefitted from our service to get personalized advice for them and for their loved ones.

Best Regards,
Dr. Sumit Bhatti

[Sunflower1975914]

Thank you, Dr. Bhatti.  His facial nerve function is good now.  During surgery #2, they did a complete parotidectomy and nerve dissection but surgery #3 was a superficial last month.  The surgeon says that this time, the tumors (observed as one on the CT scan, but turned out to be multiple) were in a "good place", and are not sitting on the nerve.  Nevertheless, he seems to think that those tumors will come back in generally the same spot so I am not sure if that means future facial nerve function would be compromised, but I seem to think that with a 4th surgery that we're "inviting trouble" and I don't understand the involvement of other nerves that could cause the headaches and other neck pain.  We will certainly ask the radiation oncologist about the Cyber, gamma radiation methods as possibilities.  We don't want to let these tumors and tissue grow into adenocarcinoma.  No beuno.  

Most sincere thanks,
Sunflower1975 in Northern VA