Particle Beam Therapy and Surgery as Radical Treatments for Parotid Malignancies-A Single-Center Preliminary Case Study.

Background/Objectives: Particle beam therapy (PBT) was approved in April 2018 for head and neck malignancies and has since been introduced as a radical therapy for parotid malignancies. However, its prevalence and effectiveness in relation to surgical treatment have not been investigated. Methods: In this study, we evaluated 36 patients with parotid malignancy who underwent surgery (n = 26) or PBT (n = 10) and then analyzed the annual changes in the number of patients, survival rates, and clinical factors affecting prognosis. Results: Of the ten patients who opted for PBT, two and eight patients underwent PBT before and after 2018, respectively. There was a significant difference between these two groups of patients (p = 0.04). Of the ten patients who underwent PBT, five patients were recurrent cases; meanwhile, all twenty-six patients who underwent surgery were receiving initial treatment. Only one patient in each group had local recurrence after the treatment. Conclusions: The use of PBT as a radical therapy for parotid malignancies has been increasing since 2018, and patients with recurrent tumors tended to choose PBT. The outcome of the patients who underwent PBT did not seem to be inferior compared with those of the patients who underwent surgery. The histopathological type was a crucial issue in the outcomes of patients who underwent radical therapy for parotid malignancies.

Research trends and perspectives on immediate facial reanimation in radical parotidectomy (Review).

For patients diagnosed with advanced malignant parotid tumour, radical parotidectomy with facial nerve sacrifice is part of the treatment. Multiple surgical techniques have been developed to cure facial paralysis in order to restore the function and aesthetics of the face. Despite the large number of publications over time on facial nerve reanimation, a consensus on the timing of the procedure or the donor graft selection has remained to be established. Therefore, the aim of the present study was to conduct a bibliometric analysis to identify and analyse scientific publications on the reconstruction of the facial nerve of patients who underwent radical parotidectomy with facial nerve sacrifice. The analysis on the topic was conducted using the built-in tool of the Scopus database and VOSviewer software. The first 100 most cited articles were separately reviewed to address the aim of the study. No consensus was found regarding the recommended surgical techniques for facial nerve reanimation. The most used donor cranial nerves for transfer included the following: Masseteric branch of the V nerve, contralateral VII nerve with cross-face graft, the XI nerve and the XII nerve. The best timing of surgery is also controversial depending on pre-exiting pathology and degree of nerve degeneration. However, most of the clinical experience suggests facial nerve restoration immediately after the ablative procedure to reduce complications and improve patients' quality of life.

A Rare Case of Muco-epidermoid Carcinoma Parotid in a 6-Year-Old Girl and Review of Literature.

Mucoepidermoid carcinoma (MEC) is the commonest malignant salivary gland tumor affecting the parotid gland in adults and children. In children and adolescents, there is a peak incidence in the second decade. We came across a 6-year-old girl with intermediate-grade MEC parotid gland, which is very unusual below 10 years of age. A global literature search revealed only 3 other similar cases in children below 10 years of age. She presented with a 2-year history of left parotid gradually increasing hard swelling involving the overlying skin and underlying sternocleidomastoid muscle which was confirmed on a contrast-enhanced computed tomography (CECT) scan of the face and neck as well as a core biopsy to be a MEC left parotid. The patient underwent a left radical parotidectomy sacrificing the main trunk of the facial nerve while carefully preserving its distal branches along with a left selective neck dissection (SND) followed by facial reanimation using primary neurorrhaphy. Histopathology confirmed an intermediate-grade MEC pT4aN2bMx with close deep lobe margin warranting adjuvant radiotherapy. Albeit very rare, salivary gland neoplasms may occur in children in the first decade of life. Appropriate planning regarding oncological resection with/without facial reanimation, appropriate rehabilitation followed by adjuvant treatment based on histopathology ensures a good prognosis.

Uncommon Sites of Lymphoepithelial Carcinoma in Head and Neck Region.

We present two cases of Lymphoepithelial carcinoma (LEC) which were found in uncommon sites, the first at the right parotid salivary gland and the second at the base of the tongue. Both patients presented with painless neck masses and were diagnosed with histologic analysis. There is an association with Epstein-Barr virus (EBV) infection in the first case, but none was found in the second case. The primary and metastatic LEC are indistinguishable through histological studies. Therefore, examination of nasopharynx and neck imaging is vital to differentiate primary and metastatic LEC in non-nasopharyngeal sites. A collaboration between surgeons and pathologists is essential for accurate diagnosis of LEC. Radiotherapy is the main choice of treatment for LEC, similar to the cases in the nasopharynx.

Survival in Patients with Primary Parotid Gland Carcinoma after Surgery-Results of a Single-Centre Study.

This study aims to analyse a single-centre cohort series of patients who underwent parotidectomy for primary malignant parotid tumours. A retrospective chart review of 64 consecutive patients treated from November 2010 to March 2022 was performed. Outcomes were analysed by Kaplan-Meier curves. Sixty-four patients with a primary parotid malignancy were included in the study, with one bilateral case in this cohort. Patients were classified as stage I-II in 39 cases and stage III-IV in 26 cases. The five-year overall survival (OS), disease-specific survival (DSS), local relapse-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were 78.4%, 89%, 92.5%, and 87.1%, respectively. Univariate analysis showed that high-risk histology, stage IV disease, lymphovascular invasion, perineural invasion, node metastasis, skin involvement, facial nerve involvement, and positive or close margins were risk factors associated with poorer outcomes. At present, the best evidence suggests that radical surgery should be the standard approach, and adjuvant therapy, in terms of radiotherapy/chemoradiotherapy, is recommended in patients with risk factors.

Utility of Elective Neck Dissection in Clinically Node-Negative Parotid Malignancy.

OBJECTIVE: We sought to investigate the utility of elective neck dissection (END) in clinically node-negative parotid malignancy through the evaluation of factors that are associated with receiving END and survival analysis of patients who received END. STUDY DESIGN: Retrospective cohort database study. SETTING: The National Cancer Database (NCDB). METHODS: The NCDB was used to extract patients with clinically node-negative parotid malignancy. END was defined as having 5 or more lymph nodes examined pathologically, as previously defined in the literature. Univariate and multivariate analyses were used to compare predictors of receiving END, rates of occult metastasis, and survival. RESULTS: Of the 9405 included patients, 3396 (36.1%) underwent an END. END was most frequently performed for squamous cell carcinoma (SCC) and salivary duct histology. All other histologies were significantly less likely to undergo END compared to SCC (p < .05). Salivary ductal carcinoma and adenocarcinoma had the greatest rates of occult node disease (39.8% and 30.0%, respectively), followed by SCC (29.8%). Kaplan-Meier survival analysis showed a statistically significant increase in 5-year overall survival in patients who received END with poorly differentiated mucoepidermoid (56.2% vs 48.5%, p = .004) along with moderately and poorly differentiated SCC (43.2% vs 34.9%, p = .002; 48.9% vs 36.2%, p < .001, respectively). CONCLUSION: Histological classification is a benchmark for determining which patients should receive an END. We demonstrated an increase in overall survival in patients who undergo END with poorly differentiated tumors of mucoepidermoid and SCC histology. As such, histology should be considered along with clinical T-stage and rate of occult nodal metastasis to determine eligibility for END.

Diagnostic Accuracy and Post-Procedural Complications Associated with Ultrasound-Guided Core Needle Biopsy in the Preoperative Evaluation of Parotid Tumors.

Correct diagnosis of a parotid neoplasm based on histology preoperatively is of utmost importance in order to guide patient management. The aim of this study was to evaluate the diagnostic accuracy of an ultrasound-guided core needle biopsy of a parotid lesion and to describe associated post-procedural complications. A retrospective study was conducted between January 2015 and March 2021 of all patients who were referred to a tertiary care center for evaluation of a parotid lesion and who underwent core needle biopsy due to high-risk features or when malignancy was suspected on clinical examination or ultrasonography. Patient characteristics, histological findings, and post-procedural complications were recorded and evaluated. Among 890 patients referred for evaluation of a parotid lesion, in 138 patients a core needle biopsy was undertaken. On the basis of core needle biopsy findings, 11 lymphomas and 82 non-lymphoma malignancies were diagnosed in the parotid gland. The sensitivity of the core needle biopsy predicting the accurate tumor type was 97.56% (95% CI 91.47-99.70%) and the specificity 94.64% (95% CI 85.13-98.88%). The accuracy for the correct histopathological diagnosis was 93.48% (95% CI 87.98-96.97%). Post-procedural minor complications occurred in 19 patients (13.8%). In conclusion, a core needle biopsy can identify malignancy in the parotid gland with high sensitivity and specificity in a safe manner and therefore guide surgical treatment.

Sclerochoroidal calcification as an incidental finding during oncological staging of a patient with parotid malignancy: A case report.

INTRODUCTION: Incidental finding of mass lesion in the choroid represents a very challenging situation for the ophthalmologist. We describe a case of an incidental, computed tomography (CT)-hyperintense, choroidal lesion in a patient with parotid malignancy and renal failure, and how multimodal imaging helped us reaching the correct diagnosis. CASE DESCRIPTION: A 63-year-old man with parotid gland malignancy was brought to our attention because preoperative staging CT showed a hyperintense choroidal lesion of the right eye. Fundus examination showed a yellow elevated lesion near the superior temporal branch retinal artery. Enhanced depth imaging optical coherence tomography (EDI-OCT), A- and B-scan ultrasonography, and Indocyanine Green Angiography (ICGA) allowed us to exclude a malignant lesion and to diagnose a sclerochoroidal calcification. CONCLUSION: Multimodal imaging can guide the clinician to choose the appropriate therapeutic approach even in case of uncommon conditions like sclerochoroidal calcification.

The role of total parotidectomy in high-grade parotid malignancy: A multisurgeon retrospective review.

PURPOSE: Determine rates of intra-parotid and neck nodal metastasis, identify risk factors for recurrence, and report outcomes in patients with primary high-grade parotid malignancy who undergo total parotidectomy and neck dissection. MATERIALS & METHODS: Retrospective review of patients undergoing total parotidectomy and neck dissection for high-grade parotid malignancy between 2005 and 2015. The presence and number of parotid lymph nodes, superficial and deep, as well as cervical lymph nodes involved with metastatic disease were assessed. Risk factors associated with metastatic spread to the parotid deep lobe were identified and recurrence rates reported. RESULTS: 75 patients with median follow-up time of 47 months. 35 patients (46.7%) had parotid lymph node metastasis. Seven patients (9.3%) had deep lobe nodal metastasis without metastasis to the superficial lobe nodes. Nine patients (12%) had positive intra-parotid nodes without positive cervical nodes. Cervical nodal disease was identified in 49.3% patients (37/75). Local, parotid-bed recurrence rate was 5.3% (4/75). Regional lymph node recurrence rate was also 5.3% (4/75). Rate of distant metastasis was 30.6% (23/75). The overall disease free survival rate for all patients at 2 and 5 years were 71% and 60% respectively. CONCLUSION: Parotid lymph node metastasis occurred at a similar rate to cervical lymph node metastasis (46.7% and 49.3%, respectively). Deep lobe parotid nodal metastasis occurred in nearly a quarter of patients and can occur without superficial parotid nodal metastasis. Rate of recurrence in the parotid bed, which may represent local or regional recurrence, was similar to regional cervical lymph node recurrence. Total parotidectomy and neck dissection should be considered high-grade parotid malignancy regardless of clinical nodal status.

Primary First Bite Syndrome of the Parotid Gland: Case Report and Literature Review.

OBJECTIVE: A case of primary first bite syndrome (FBS), diagnosed in a patient with nonspecific adenocarcinoma of the deep lobe of the parotid gland. DATA SOURCES: A Medline literature search was conducted on PubMed, using the keywords "first bite syndrome." REVIEW METHODS: Using primary FBS and existence of a definite etiology as inclusion criteria. RESULTS: We report on an unusual case of primary FBS, which had no surgical history. After multiple examinations, the pain was localized to a mass in the deep lobe of the parotid gland. After tumorectomy, the FBS pain was significantly relieved. The postoperative pathological examination determined that the excised mass was a nonspecific adenocarcinoma. Reviewing the literature, we found that primary FBS was mostly caused by malignant tumors in the inferior temporal fossa, the deep lobe of the parotid gland, and (or) the parapharyngeal space. Surgery was reported to be an effective treatment. CONCLUSION: The case highlights the critical importance of identifying the etiology of primary FBS. When manifested with a primary FBS, malignant tumors must be high on the differential diagnosis list, especially those in the region of the inferior temporal fossa, the deep lobe of the parotid gland, and the parapharyngeal space.

Parotid Salivary Duct Carcinoma With a Prominent Squamous Component: Immunohistochemical Profile, Diagnostic Pitfalls, and Therapeutic Implications.

Salivary duct carcinoma of the parotid gland is a highly aggressive epithelial malignancy morphologically resembling high-grade, invasive, and in situ breast carcinoma. It can occasionally present with variable morphology making it diagnostically challenging in cases with unusual morphological components. Ancillary testing, particularly androgen receptor (AR) positivity on immunohistochemistry, can be very helpful in cases that demonstrate extensive squamous morphology, since AR positivity is uncommon in both the primary salivary gland and metastatic squamous cell carcinomas to the parotid. In this report, we describe a case of salivary duct carcinoma that showed only a squamous cell carcinoma component on the initial primary tumor site biopsy, as well as in subsequent contralateral neck lymph node and skin metastases. Apart from the variable morphology, the typical salivary duct and squamous cell carcinoma tumor components also showed significant immunohistochemical differences, including differential staining of human epidermal growth factor receptor 2/neu. The associated diagnostic pitfalls, distinct immunoprofiles of the tumor components, helpful adjuncts for making the correct diagnosis, and associated therapeutic implications are discussed.

Metastases of Cutaneous Squamous Cell Carcinoma Seem to be the Most Frequent Malignancies in the Parotid Gland: A Hospital-Based Study From a Salivary Gland Center.

Malignant parotid tumors account for approximately 20% of all parotid lesions. In addition to the various primary parotid lesions there are secondary parotid malignancies, such as metastases or lymphomas. Data on histopathological distribution of all malignancies-including secondary parotid lesions-is limited. Recent evidence indicated a rising surgical incidence of secondary parotid malignancies. This study aims to review the distribution of malignancies in parotid resections from a salivary gland center. A retrospective review of prospectively collected data for all patients who had received parotidectomy between 2014 and 2019 was performed. Histopathological distribution was displayed separately for all parotid malignancies and for primary parotid malignancies. Further, patients` characteristics were compared between benign and malignant parotid lesions and between the two most common malignant parotid lesions. Out of 777 patients, 614 (78.9%) patients had a benign and 164 (21.1%) patients had a malignant parotid lesion. The most common parotid malignancy was metastatic cutaneous squamous cell carcinoma (cSCC) accounting for 35.4% of all parotid malignancies. 71.5% of all malignant lesions were secondary malignancies. Patients with metastatic cSCC were significantly older (p < 0.001) and significantly more likely to be male (p < 0.001) than patients with primary parotid malignancies. No significant difference was found when the lesion size of metastatic cSCC was compared to primary parotid malignancies (p = 0.216). The present study shows the high prevalence of secondary parotid malignancies in patients who had received parotidectomy. Furthermore, it confirms a rising surgical incidence of metastatic cSCC to the parotid gland in a series from a salivary gland center. At this time, parotid surgery for malignant lesions is more likely to be performed for metastases than for primary parotid malignancies.

Incidence and survival trends of parotid malignancies over 42 years.

BACKGROUND: There is a paucity of information regarding the incidence and survival of parotid malignancies over time. METHODS: The Surveillance, Epidemiology, and End Results population-based cancer registry was queried for parotid malignancies from 1973 to 2015. RESULTS: The age-adjusted incidence of parotid malignancies has increased by 58.1% (7.87-12.44 per 1 000 000). Analysis of histologic type revealed an increased annual percent change (APC) of acinar cell carcinoma (1.38) and squamous cell carcinoma (1.58), but decreased APC of adenoid cystic carcinoma (-1.63) and adenocarcinoma NOS (-0.86) (P < .05). The disease-specific survival of mucoepidermoid carcinoma, adenocarcinoma NOS, and squamous cell carcinoma significantly improved (P < .05) over time. CONCLUSION: The incidence of parotid cancer is rising steadily since 1973, while the incidence of overall head and neck cancer has decreased. Further research is necessary to understand the etiology, risk factors, and pathophysiology of parotid cancer to curb its rising incidence. LEVEL OF EVIDENCE: 4.

Understanding primary parotid squamous cell carcinoma - A systematic review.

INTRODUCTION: The true incidence of primary parotid squamous cell carcinoma (SCC) is unknown and likely overestimated in the literature. The aim of this systematic review is to examine the diagnosis, aetiology and incidence of parotid SCC by analysing studies evaluating primary parotid SCC. METHODS: A systematic search of Medline, EMBASE and Cochrane library was performed. A narrative synthesis was done. RESULTS: A total of 14 observational retrospective studies on primary parotid SCC were included. There are currently no standard criteria for ascertainment of primary parotid SCC. Primary parotid SCC is thought to be due to squamous metaplasia within the ductal epithelium and subsequent invasive squamous carcinoma. Histological features that favour primary disease includes SCC confined to parotid parenchyma with no direct communication to the skin and the absence of mucin. Incidence of primary parotid SCC varied from 1.54 to 2.8 cases per million person-years. Around 30%-86% of patients recorded to have primary parotid SCC on clinical records, when scrutinised, were in fact secondary to parotid lymph node involvement following regional advancement from skin or upper aerodigestive tract SCC. CONCLUSION: Primary parotid SCC is rare and it is currently a diagnosis of exclusion. Thorough clinical assessment including endoscopy, preoperative imaging and the scrutiny of histopathological findings allow for differentiation between primary and secondary SCC within the parotid. This thus affects both initial treatment and subsequent follow-up.

Reconstruction of complex defects of the extracranial facial nerve: technique of "the trifurcation approach".

PURPOSE: Reconstruction of complex defects of facial nerve (FN) after extensive cancer surgery requires individualized solutions. We describe the trifurcation technique as a modification of the combined approach on example of two patients with locally advanced parotid cancer. METHODS: Due to perineural invasion, extensive resection of the FN from the mastoid segment to the peripheral branches was required. For reanimation of the upper face, a complex cervical plexus graft was sutured end-to-end to the mastoid segment of the FN trunk. The branches of the graft enabled reanimation of three peripheral temporal and zygomatic branches. The mandibular branch was sutured end-to-side to the hypoglossal nerve (hypoglossal-facial nerve transfer, HFNT). Additionally, the buccal branch was independently reanimated with ansa cervicalis. RESULTS: Facial reanimation was successful in both patients. Good resting tone and voluntary movement were achieved with a mild degree of synkinesis after 13 months. Patient 1 showed the Sunnybrook (SB) composite score 69 [76 (voluntary movement score) - 0 (resting symmetry score) - 7 (synkinesis score)]. In patient 2, the SB composite score was 76 (80 - 0 - 4, respectively). CONCLUSIONS: In this trifurcation approach, cervical cutaneous plexus provides a long complex nerve graft, which allows bridging the gap between proximal FN stump and several peripheral branches without great expenditure. In combination with the HFNT and ansa cervicalis transfer, this procedure enables the facial reanimation with low grade of synkinesis.

Chronic atypical first bite syndrome and primary squamous cell carcinoma of the parotid.

BACKGROUND: First bite syndrome is a well-recognized complication of parapharyngeal space surgery. There are no reported cases of protracted first bite syndrome and subsequent diagnosis of a primary squamous cell carcinoma (SCC) of the parotid. METHODS: We present the case of a 73-year-old man with no surgical history and 9 years of first bite syndrome who was ultimately diagnosed with a primary SCC of the parotid. Diagnostic workup, including MRI and biopsy, along with oncologic treatment, were performed. RESULTS: Surgical treatment confirmed malignancy and also resulted in complete resolution of the first bite syndrome. CONCLUSION: First bite syndrome without prior surgery may warrant further diagnostic workup with imaging to evaluate for salivary gland pathology. When no radiographic mass lesion is detected but the patient displays protracted symptoms unresponsive to conservative therapy, one should maintain an index of suspicion for malignancy, especially in the presence of symptom escalation.

Utility of metabolic heterogeneity factor in differentiating malignant versus benign parotid uptake on 18F FDG PET-CT.

Differentiation of benign and malignant parotid uptake on Fluorine 18 Fluro-Deoxy-Glucose Positron Emission Tomography-Computed Tomography (18F FDG PET-CT) is of paramount importance due to the poor prognosis of the later but usual quantitative measures such as standardized uptake value (SUV) are not reliable for this purpose. Metabolic heterogeneity, being a characteristic of malignant tumors, would potentially be able to make this distinction. In this study, seventy-one FDG-avid parotid lesions were retrospectively separated histologically into benign and malignant groups. The heterogeneity factor (HF) of all the lesions was then calculated and compared between the two groups. There was significant difference in HF between malignant (median -0.17) and benign group (median -0.03); P=0.0006. On receiver operating characteristic (ROC) analysis, a cut-off value of ≤ -0.06 for HF was associated with the highest sensitivity and specificity (sensitivity and specificity of 94.6% and 60.0%, respectively-AUC=0.789; P=0.0001). Hence, it was concluded that HF is a reliable value in distinguishing benign from malignant parotid uptake on 18F FDG PET-CT.

Incidence of facial nerve sacrifice in parotidectomy for primary and metastatic malignancies.

INTRODUCTION: The parotid gland may become involved by primary parotid malignancies and secondarily by metastases from other primary sites. Surgical resection of these tumors can be technically challenging due to the intimate relationship of the parotid gland and the facial nerve. The primary aim of this project was to determine the incidence of facial nerve sacrifice in parotidectomy for primary and secondary malignancies of the parotid. METHODS: A retrospective chart review of was performed. Patients who received parotidectomy with final pathology consistent with a malignant neoplasm were included. The primary outcome studied was necessity for facial nerve sacrifice. Co-variates included preoperative facial nerve function, preoperative pain, superficial versus total parotidectomy and pathologic diagnosis. Univariate analysis was performed using student t-test to determine odds ratios. RESULTS: We identified 75 patients who had a parotidectomy for a malignant process in our review. 30 patients had facial nerve sacrifice: 14 total and 16 partial sacrifices. Patients were more likely to require facial nerve sacrifice when they presented with preoperative facial nerve dysfunction [100% vs 19.6%, p=0.0006, OR 154.3, CI (8.66-2750.9)], pre-op pain [76.5% vs. 29.3%, p=0.001, OR 7.84, CI (2.23-27.50)], and required excision of both superficial and deep lobes of the parotid gland [64.9% vs 15.8%, p=0.0001, OR 9.85, CI (3.27-29.66)]. CONCLUSION: Our data illustrates that many patients with normal facial nerve function, even in the setting of malignancy, can have their facial nerve preserved. Pain, deep lobe involvement and preoperative facial nerve dysfunction are associated with an increased risk of needing at least partial facial nerve sacrifice in the setting of parotid gland malignancies.

Parotid adenoid cystic carcinoma: Retrospective single institute analysis.

PURPOSE: Adenoid cystic carcinoma (ACC) is a uncommon salivary malignant tumor. Our aim was to review our experience with parotid ACC, to identify clinical-pathological parameters predictive for outcome. MATERIALS AND METHODS: We retrospectively reviewed 228 patients affected by parotid gland carcinomas surgically treated at our Institution. Forty-four ACC were included in this study. Multivariate analysis risk models were built to predict recurrence free probability (RFP), distant recurrence free probability (DRFP), overall survival (OS) and disease free survival (DFS). RESULTS: Twenty-one patients (47.7%) died from ACC and 2.3% for other causes. The 41% presented local-regional recurrence, with a regional-RFP rate of 93%, and the 34% reported distant metastases (DM). The five and ten-year OS rates were 74% and 50%, respectively. CONCLUSIONS: Recurrences were mainly influenced by the presence of perineural invasion and nerve paralysis, whilst female gender and age<50 were predictors for good prognosis.

Predictors of Nodal Metastasis in Parotid Malignancies: A National Cancer Data Base Study of 22,653 Patients.

OBJECTIVE: (1) To identify predictors of nodal disease in parotid malignancies using various clinical and pathologic variables. (2) To examine the effect of nodal disease on overall survival (OS) in parotid cancers STUDY DESIGN: Retrospective database review. SETTING: National Cancer Data Base (1998-2012). SUBJECTS AND METHODS: We identified all cases of primary parotid malignancies in the United States between 1998 and 2012 in the National Cancer Data Base. Eight histopathologies, constituting >80% of all cases, were examined for nodal metastasis and survival. RESULTS: We identified 22,653 cases of primary parotid cancer. Eight major histologies were studied, with mucoepidermoid carcinoma (31%), acinic cell carcinoma (18%), adenocarcinoma (14%), and adenoid cystic carcinoma (9%) being most common. Regional nodal disease incidence was 24.4% overall and varied by histopathology. Salivary ductal carcinoma had the highest incidence of both nodal metastasis and occult lymph node metastasis. Overall, N0 patients lived significantly longer than N+ (5-year OS, 79% vs 40%; P < .001). Low-grade disease had significantly better survival than high-grade (5-year OS, 88% vs 69%; P < .001). Occult nodal disease was found in 10.2% and varied by histopathology. CONCLUSION: Regional lymph node metastasis significantly decreases survival in many parotid malignancies. High-grade cancers had higher incidences of regional disease than did low grade. Adenocarcinoma had the highest mortality when regional disease was present. Incidence of occult disease varied by histology, but incidence was <10% for all low-grade disease. High T stage and grade are significant independent predictors of nodal disease for most histopathologies.