Oral Oncology EXTRA (2006) 42, 137 139

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CASE REPORT

Diagnosis of metastatic malignant melanoma

in parotid gland
Dimitrios Andreadis a, Athanasios Poulopoulos
Apostolos Epivatianos a, Calypso Barbatis b

a,*

, Alexandros Nomikos b,

Department of Oral Medicine and Maxillofacial Pathology, Dental School, Aristotle University of Thessaloniki,
Thessaloniki 54124, Greece
b
Department of Histopathology, Red Cross Hospital of Athens, Athens 11526, Greece
Received 3 October 2005; accepted 5 October 2005

KEYWORDS

Summary Parotid gland is an extremely rare location for primary malignant melanoma and
the majority of reported melanoma cases in parotid appear to represent metastasis from the
skin of head and neck areas. We describe a rare case of a malignant melanoma of the oral cavity
which had metastasized in parotid gland and we present the microscopic and immunohistochemical findings in parotid gland metastasis. Metastatic infiltrations were observed in periand intraparotid lymph nodes and the characteristic microscopic appearance together with
the immunoreactivity of neoplastic cells for vimentin, S-100 protein and HMB-45 established
the final diagnosis.
c 2005 Elsevier Ltd. All rights reserved.

Malignant melanoma;
Parotid gland;
Metastasis

Introduction
Primary melanoma of the parotid gland is an extremely rare
event and salivary gland melanomas are nearly always best
regarded as metastases1 associated with in and around the
gland, lymph node metastasis from a head and neck cutaneous primary melanoma.2 The routine preoperative diagnostic procedure for parotid melanomas that enable accurate
staging, include computerized tomography, magnetic resonance imaging and fine-needle aspiration cytology (FNAC).3
* Corresponding author. Tel./fax: +30 2310 833760.
E-mail address: akpoul@yahoo.gr (A. Poulopoulos).

For melanoma patients with clinically palpable lymphadenopathy in the region of the parotid gland, most investigators advocate a therapeutic parotidectomy and ipsilateral
modified radical neck digestion,4 whereas adjuvant radiotherapy and chemotherapy may also be given. Prognosis is
generally poor, and only rarely, patients may survive a long
period of time following surgery.5
Intraoral melanomas are uncommon accounting for 0.5%
of oral malignancies.6 Nearly 80% of the cases affect hard
palate, the upper and lower gingivae and buccal mucosa.7
They exhibit far more aggressive behaviour than cutaneous
melanomas.8 Despite the anatomic site of the oral melanomas, prognosis is quite poor with a 15% five-year survival

1741-9409/$ - see front matter c 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ooe.2005.10.003

138
rate.9 Metastases spread to regional lymph nodes, lungs,
liver, brain and bones due to satellite formation, angiolymphatic invasion and submucosal spread.10
The aim of our study is to present a rare case of malignant melanoma of parotid gland as a metastasis from the
oral cavity.

Case report
A 65-year-old male, with a history of a treated, oral melanoma on the anterior maxillary alveolar ridge, without evidence of any local invasion or distant metastasis, based on
CT images, six months before, was presented again with a
two-month, painful swelling, located to the angle of the right
mandible. FNACs findings of the parotid swelling were indicative for a malignant melanoma. A total parotidectomy was
performed in Red Cross Hospital, Athens Greece, and formalin-fixed, paraffin-embedded sections were studied histochemically and immunohistochemically with markers S-100
protein (N 1573, Dakocytomation, Glostrup, A/S Denmark),
vimentin (N 1521, Dakocytomation, Glostrup, A/S Denmark)
and HMB 45 using an Envision/HRP automated technique
(Dakocytomation, Glostrup, A/S Denmark). Antigen retrieval
was performed by microwaving in citrate buffer.
Microscopically, the peri and intraparotid lymph nodes
were infiltrated by malignant melanoma, whereas the adja-

D. Andreadis et al.
cent parotid tissue was clear (Fig. 1a). Metastatic lesion was
consisted by epithelioid neoplastic cells with foamy cytoplasm, marked cytologic and nuclear atypia, nuclear
grooves, large eosinophilic nucleoli, and abundant atypical
mitotic figures. Areas with melanin pigmentation, necrosis
with haemmorage and marked fibroblastic response were
also seen (Fig. 1b).
Immunohistochemically, neoplastic cells showed strong
nuclear and cytoplasmic reactivity for S-100 protein
(Fig. 2a) and immunoreactivity for vimentin and mainly for
HMB45 (Fig. 2b) was also a characteristic consistent feature
of the great majority of the neoplastic cells whereas there
was not immunostaining with AE1/AE3 cytokeratins.

Discussion
Although melanocytes can exist in the intralobular duct of
the parotid gland potentially serving as origin for primary
melanoma,11 almost all cases of parotid melanomas appear
to represent metastatic lesions, often from cutaneous head
and neck primaries.2 Noteworthy, cutaneous melanoma is
the second after squamous cell carcinomas of the head
and neck region most common metastatic tumor of the parotid gland, accounting for approximately 40% of cases.5,12
The direct invasion of melanoma from adjacent soft tissue
or skin is a possibility but uncommon way to parotid tissue

Figure 1 (a) The metastatic melanoma in lymph node is separated from the intact, adjacent parotid tissue (Hematoxylin/
eosin 100). (b) Histologic appearance of metastatic melanoma in parotid lymph node characterized by infiltration with epithelioid
neoplastic cells showing atypical mitotic figures, areas with melanin pigmentation, necrosis with haemmorage and marked
fibroblastic response (hematoxylin/eosin 300).

Figure 2 (a) Strong nuclear and cytoplasmic reactivity of neoplastic cells for S-100 protein (envision-HRP 300). (b) Immunoreactivity for HMB45 of the neoplastic cells (envision-HRP 300).

Diagnosis of metastatic malignant melanoma in parotid gland

and metastasis of head and neck melanoma in parotid results by intralymphatic spread of tumor in the area of lymphatic drainage of the parotid lymph nodesincluding
forehead, anterior frontal and temporal region, eyelids
and conjuctiva, lacrimal gland, anterior ear, cranial vault
and posterior cheek regions.13 In contrast, facial, oral,
and anterior oropharyngeal carcinomas commonly metastasize to the submandibular lymph nodes and gland.1 The
treatment of choice for primary and metastatic melanoma
in parotid is wide excision, but prognosis even with treatment appears to be poor.14 It has been recommended that
patients undergoing regional lymphadenectomy for primary
melanomas of the ear, face, and anterior scalp, be considered for parotidectomy as well.15
In contrast to cutaneous melanoma, oral malignant melanoma typically presents a more aggressive vertical growth
phase, with invasion of the underlying submucosa.16 It grows
rapidly, may be flat or raised or nodular, asymptomatic initially but may later become ulcerated, painful and may
bleed.17 It is more inclined to metastasize into regional
and distant sites or recur locally, exhibiting cervical lymph
node metastases in 548% of cases at the time of diagnosis.
Mucosal melanomas have a poor prognosis with a mean survival rate less than cutaneous accounting for only 17,1%8
and radio-chemotherapy are not effective more than surgical excision alone.18
Malignant melanoma is easily identified microscopically
because of its junctional activity, diffuse arrangement of
round or spindle cells with abundant eosinophilic cytoplasm,
marked cytologic atypia, nuclear grooves, folds and
pseudoinclusions, large eosinophilic nucleoli, and abundant
mitotic figures, some of them atypical. These findings
are accompanied by prominent melanin pigmentation,
necrosis and invasion of the surrounding tissue. Immunohistochemistry such as positive staining for vimentin, S-100
protein, HMB-45, MART-1/Melan A, tyrosinase, NKI/C-3
and microphthalmia transcription factor (MiTF) aid the diagnosis. Vimentin is the most consistent but the least useful
diagnostically. Positivity for S-100 is nonspecific but due
to the fact that S-100 is negative in most of the tumors that
enter in the differential diagnosis, S-100 staining is very
important. HMB 45 is a much more specific marker than S100 protein. Melan A is positive in approximately 80% of
melanomas. The positivity of MiTF is in the range of over
90%.17
In conclusion, in cases of head and neck malignant melanomas attention may be given in salivary glands either
have or not any symptoms. Preoperative CT/MRI examination of head and neck region including major salivary glands
and their lymph nodes is necessary. Furthermore, any postoperative clinically palpable lymphadenopathy in the region
of the parotid or submandibular gland may be associated

139
with a metastasis of malignant melanoma and FNA cytology
detection is necessary for the definition of diagnosis.

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