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Superficial tissues
Malignant Melanoma Metastasis to Parotid Gland
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Author(s) :
Danilo Sirigu, MD
 
Presentation A 79-year-old with a history of cutaneous melanoma of the head is referred for ultrasound examination for bilateral swelling of the parotid glands. 
 
 
 
Caption: Right Parotid Gland
Description: A lobulated complex hypoechoic solid mass is seen within the right parotid gland.
 
 
 
Caption: Right Parotid Gland Color Doppler
Description: Color Doppler of a second mass indicates flow within the mass. The lesion exhibits a well defined margin, internal echoes and a small highly echogenic focus that causes shadowing, suggesting a stone within the mass.
 
 
 
Caption: Left Parotid Gland
Description: Another irregularly lobulated hypoechoic mass is seen within the left parotid gland.
 
 
 
Caption: Left Parotid Gland Color Doppler
Description: On color Doppler a few sparse areas of flow are noted within the mass. In this view there appears to be a well defined and smooth posterior wall to the lesion and moderately enhanced through transmission of sound.
 
 
Caption: Gray scale imaging of both parotid glands
Description: Note shape, internal echo pattern, margination and through transmission of the multiple masses seen within the parotid gland. The normal prarotid gland echo pattern is similar to that of the thyroid, presenting a very finely granular echo pattern and a moderate level of echogenicity.
 
 
Caption: Color Doppler of both parotid glands
Description: 
 
Differential Diagnosis Benign masses
Retention cyst
Pleomorphic adenoma
Warthin's tumor (cystadenolymphoma)
Oncocytoma
Lipoma
Hemangioma
Neurogenic tumor

Primary malignancy
Mucoepidermoid carcinoma
Adenoid cystic carcinoma

Metastasis
 
Final Diagnosis Metastatic infiltration of the intraparotid lymph nodes from cutaneous melanoma of the head.
 
Discussion Ultrasound demonstrates multiple ovoid hypoechoic solid masses in both parotid glands. One of the lesions presents an intranodular calcification.  On Color Doppler evaluation there is evidence of blood flow within the substance of the lesions.  

The patient's prior history of cutaneous melanoma of the head and the presence of multiple, bilateral ovoid hypoechoic lesions that are well marginated suggests metastatic infiltration of the parotid lymph nodes.

Several types of parotid tumors, both benign and malignant, can present as lobulated hypoechoic lesions. With current ultrasound technology it is not possible to definitively distinguish between these types of lesion or between malignant and benign hypoechoic lesions.  However, the ultrasound findings established the presence of multiple discreet masses in both parotid glands and suggested a need for further investigation.
 
Case References
  1. J.G. Batsakis and E. Bautina. Metastases to major salivary glands. Ann Otol Rhinol Laryngol 99 (1990), pp. 501–503
  2. R.A. Prayson and B.A. Sebek. Parotid gland malignant melanomas. Arch Pathol Lab Med 124 (2000), pp. 1780–1784.
  3. Y. Ismail, N.R. Mc Lean and A.J. Chippindale. MRI and malignant melanoma of the parotid gland. Br J Plast Surg 54 (2001), pp. 636–645
  4. D. Andreadis, A. Poulopoulos, A.Nomikos, A. Epivatianos, C. Barbatis. Diagnosis of metastatic malignant melanoma in parotid gland Oral Oncology Extra, Volume 42, Issue 4, April 2006, Pages 137-139
  5. M.Gross, B. Maly, A. Maly, M. Lotem, R. Eliashar. Metastatic Malignant Melanoma Involving the Parotid Lymph Node Region: A Clinicopathologic Report of 5 Cases Journal of Oral and Maxillofacial Surgery, Volume 66, Issue 4, April 2008, Pages 809-813

Recommend Reading
High resolution ultrasound assessment of the parotid gland.  A Pictoral Review by D C Howlett, MRCP (UK), FRCR
British Journal of Radiology (2003) 76, 271-277
http://bjr.birjournals.org/cgi/content/full/76/904/271

US of the Major Salivary Glands: Anatomy and Spatial Relationships, Pathologic Conditions, and Pitfalls
Ewa J. Bialek, MD, PhD, Wieslaw Jakubowski, MD, PhD, Piotr Zajkowski, MD, PhD, Kazimierz T. Szopinski, MD, PhD and Antoni Osmolski, MD, PhD.  May 2006 RadioGraphics, 26, 745-763.
http://radiographics.rsna.org/content/26/3/745.full
 
Technical Details A special thanks to Dr. Danilo Sirigu who generously contributed this case from his outstanding web site www.ecomovies.it
Please visit http://www.ecomovies.it  to access a wide range of very high quality video cases.