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\title{46-Year-Old Man with Bilateral Metachronous Pleomorphic Adenoma of the Parotid Gland}
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\begin{document}

             \author[1]{Zahra  Sarafraz}

             \affil[1]{  Shahid sadoughi medical science university}

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\date{\small \em Received: 6 December 2013 Accepted: 2 January 2014 Published: 15 January 2014}

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\begin{abstract}
        


The occurrence of multiple distinct tumors in major salivary glands is quite rare.Although the most common tumor with bilateral synchronous or metachronous development is Warthin's tumor, on rare occasions, pleomorphic adenomas have been diagnosed simultaneously as well. In this paper, we present the case of a 46-year-old man with bilateral metachronous pleomorphic adenoma of the parotid gland.

\end{abstract}


\keywords{pleomorphic adenoma, bilateral, metachr-onous, parotid gland.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
The occurrence of multiple distinct tumors in major salivary glands is quite rare. Pleomorphic adenoma is the most common benign neoplasm of the parotid gland. However, bilateral synchronous pleomorphic adenomas occur infrequently, accounting for less than 0.2\% of all parotid gland tumors \hyperref[b0]{(1)}. Bilateral synchronous or metachronous neoplasms of the parotid gland are rarely encountered in clinical practice. The most common bilateral tumor is Warthin's tumor, with a reported incidence of 5-14\%, followed by pleomorphic adenoma (2.3). Histologically, they are divided into unifocal or multifocal lesions. Even if it might be very difficult to establish, they also can be distinguished as synchronous or metachronous tumors regarding the time of their detection \hyperref[b3]{(3)}. In this paper, we present a 46-year-old man with bilateral metachronous pleomorphic adenoma of the parotid gland, which was unique in the duration of the disease and the size of the mass. 
\section[{II.}]{II.} 
\section[{Case Presentation a) Clinical presentation}]{Case Presentation a) Clinical presentation}\par
A 46-year-old man with a slow growing mass in the left parotid that was first diagnosed five years ago and small-sized mass in the right parotid that was diagnosed one year ago (bilateral metachronous neoplasm of the parotid gland).\par
In palpation and bimanual examination, the mass in the left parotid gland was approximately 5 x 6 cm, and it was firm and mobile without any tenderness or erythema. The facial nerve was intact (Figure  {\ref 1}). The mass in the right parotid gland was 3 x 2 cm, and it was firm and mobile without any inflammation. The overlying skin of mass was normal and the facial nerve had good function.\par
There was no weight loss, sweating, or fever. The patient did not complain of odynophagia or disphagia. There was no bulging in the oral cavity. 
\section[{b) Past History}]{b) Past History}\par
The patient had no past history of cancer or infectious diseases. 
\section[{c) Imaging}]{c) Imaging}\par
An axial CT scan showed the well-defined border of the mass in the left parotid gland with a size of 67 x 58 mm. It had solid and cystic foci with heterogeneous enhancement without any extension to stylomastoid and parapharyngeal space. On the right side, he had a well-defined, solid border mass in the right parotid with the size of 32 x 22 mm (Figure2). Serologic tests for Sjogren syndrome, tuberculosis, cytomegalovirus, human immunodeficiency virus, and Ebstein-Barr virus were negative.\par
FNA (fine needle aspiration) smears of right and left parotid masses showed several isolated sheets, acini of bland epithelial cells merging with the fibrillar and amorphous myxoid matrix and some bare nuclei that suggested a mixed tumor of the salivary gland (Figure \hyperref[fig_1]{3}). Permanent Pathology revealed a 7 x 5 x 5-cm mass with a creamy color and a nodular surface in the left parotid gland and a 3 x 3x 2-cm firm mass with a grayish color in the right parotid gland Microscopic Pathology showed epithelial and myoepithelial components with a chondroid background. After general anesthesia, left standard parotid incision (Blair Incision) was done, and the sub-platismal flap was elevated. Facial nerve trunk and branches were exposed and preserved and then a total parotidectomy was performed. For the right side, after facial nerve preservation, a superficial parotidectomy was performed. The facial nerve was intact, and there was no recurrence at the six-month follow-up. 
\section[{III.}]{III.} 
\section[{Discussion}]{Discussion}\par
Pleomorphic adenoma, called mixed tumor because of its either epithelial and connectival component, accounts for 80\% of all parotid tumors. It is mostly located at the superficial lobe of the parotid gland. The average age of onset is between 30 and 50; our case was 46.\par
Some authors have indicated that the mean duration of symptoms prior to diagnosis 22.9 months, with 36.5 months in male patients and 22.9 months in female patients (4). But our case had the left parotid mass for about 60 months.\par
Currently, according to the international literature, the most widely-used surgical procedure for the excision of a superficial lobe benign parotid tumor is superficial parotidectomy. Other inappropriate surgical treatments, such as enucleation, are strongly associated with high rates of tumor recurrence \hyperref[b5]{(4,}\hyperref[b6]{5)}.\par
The simultaneous surgical approach for parotid tumors has not been discussed extensively in the international literature. Nevertheless, some authors have stated that simultaneous parotidectomy for bilateral benign parotid glands tumours should be avoided to prevent possible bilateral facial nerve palsy \hyperref[b7]{(6)}.\par
In 2007, C.ungari et al. (Department of Maxillofacial Surgery in Italy) indicated that bilateral pleomorphic adenoma could be surgically removed simultaneously with successful preservation of the facial nerve \hyperref[b8]{(7)}.\par
Silva et al. from Brazil (2006) reported a patient with metachronous bilateral pleomorphic adenoma and performed total and superficial parotidectomy for the left and right tumors. However, on the left side, some facial nerve branches were removed, inducing partial paralysis \hyperref[b9]{(8)}.\par
Thus, we would suggest simultaneous bilateral parotidectomy as the most indicated surgical approach, particularly in healthy patients with assured clinical and cytological diagnosis and without evidence of any other systemic diseases.\par
IV. 
\section[{Conclusion}]{Conclusion}\par
We would suggest simultaneous bilateral parotidectomy as the most indicated surgical approach, particularly in healthy patients with assured clinical and cytological diagnosis and without evidence of any other systemic disease.\begin{figure}[htbp]
\noindent\textbf{2}\includegraphics[]{image-2.png}
\caption{\label{fig_0}Figure 2 :}\end{figure}
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\noindent\textbf{3}\includegraphics[]{image-3.png}
\caption{\label{fig_1}Figure 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-4.png}
\caption{\label{figure4}}\end{figure}
 			\footnote{© 2014 Global Journals Inc. (US)} 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{document}
