Parotidectomy in the treatment of aggressive cutaneous malignancies

Background: Aggressive nonmelanoma skin cancer (ANMSC) of the head and neck may require parotidectomy because of neurotropic spread, direct invasion of the parotid gland, or parotid metastasis. Objective: To review our experience with parotidectomy in the treatment of these tumors to examine the indications for this procedure and to analyze treatment outcomes. We emphasize the importance of early identification of an ANMSC and a systematic approach to treatment. Design: Review of 23 patients with an ANMSC who required parotidectomy with or without facial (VII) nerve sacrifice between January 5, 1996, and December 27, 1999. Median follow-up for all patients was 24 months. Setting: Academic tertiary care referral center. Patients: This study focused on 23 (median age, 71 years) of 54 patients treated for an ANMSC. Most tumors were in the periauricular (n = 9) and the frontozygomatic (n = 6) areas. Seven patients presented with facial weakness or paralysis. Three patients had clinically evident parotid metastasis, while 14 patients had tumors directly invading the parotid gland. Eighteen patients had recurrent disease that had been treated previously with Mohs micrographic surgery. Interventions: Following wide local excision of the ANMSC, 12 patients had resection of the lateral parotid lobe with preservation of the nerve, while 11 required radical parotidectomy with sacrifice of 1 or more branches. Nineteen patients received cervical lymphadenectomy. Postoperative radiotherapy was administered in 19 patients. Main Outcome Measures: Tumor pathologic findings (specifically, perineural invasion of the facial nerve), locoregional control or recurrence, disease-free survival, disease-specific survival, and overall survival. Results: Neurotropic spread to the facial nerve was present in 6 patients and was more likely to occur in younger patients (51 vs 75 years, P=.006). Locoregional failures occurred in 9 patients following treatment. Patients who required parotidectomy in their surgical treatment for an ANMSC were more likely to have recurrent disease (P=.0002). Disease-specific and overall survival was 79% and 69%, respectively, at 42 months. Conclusions: Patients with ANMSC may require parotidectomy in the context of neurotropic spread, regional metastasis, or direct invasion into the parotid gland. Surgery combined with postoperative radiotherapy is necessary in most patients because of adverse clinical and pathologic findings. A systematic approach to the management of the parotid and facial nerve in the presence of these aggressive tumors is required. Despite comprehensive treatment, local recurrence of ANMSC and mortality remain high.