Prognostic significance of p16 in squamous cell carcinoma of the larynx and hypopharynx.

PURPOSE: To evaluate the prognostic significance of p16 expression among patients with squamous cell carcinoma of the larynx (LSCC) and hypopharynx (HSCC). METHODS: The medical records of all patients with locally advanced, non-metastatic LSCC/HSCC were reviewed. p16INK4A (p16) protein expression was evaluated on pathological specimens by immunohistochemistry (IHC), and the Kaplan-Meier method was used to estimate overall survival (OS) and locoregional control (LRC). In select cases, p16 expression was correlated to high-risk and low-risk HPV genotypes using in situ hybridization (ISH). RESULTS: Thirty-one patients (23 LSCC; 8 HSCC) were identified. Seventeen (54.8%) patients were p16 negative; 14 (45.2%) were p16-positive. The primary treatment modality was radiation therapy for 22 (71.0%) patients and surgery for 9 (29.0%). Nineteen (61.3%) patients were evaluated for high-risk HPV and low-risk HPV genotypes by IHC, of whom 2 (10.5%) patients were positive for high-risk HPV and 1 (5.3%) was positive for low-risk HPV. For high-risk HPV, the positive predictive value (PPV), sensitivity, and specificity of p16 was 20.0%, 100%, and 52.9%. There was no significant difference in the 2-year actuarial rates of OS (91% vs. 64%, p=0.34) or LRC (51% vs. 46%, p=0.69) between the p16-positive and p-16 negative patients. CONCLUSION: In this small cohort of 31 LSCC and HSCC patients, p16 was not a significant predictive of either LRC or OS. Furthermore, p16 was poorly correlated with HPV genotyping as identified by ISH.

Laryngeal oncocytic cystadenomas masquerading as laryngoceles.

OBJECTIVE: To describe an experience with laryngeal oncocytic cystadenomas and review the published literature regarding this uncommon diagnosis. METHODS AND RESULTS: A clinical review of patients presenting with cystic laryngeal masses in an urban academic medical center between January and December 2013 was performed. Three patients, two female and one male, with a mean age of 68 years, were diagnosed with oncocytic cystadenomata of the larynx. Major presenting symptoms included dysphonia, globus, and ipsilateral otalgia. Endoscopic examinations revealed a cystic structure arising from varied subsites of the larynx: laryngeal ventricle, aryepiglottic fold, and pre-epiglottic space. Cross-sectional radiographic imaging was obtained in each case. The patients were treated with transoral (CO2) laser microsurgery (TLM). In all three cases, pathological analysis revealed oncocytic cystadenoma with clear margins. CONCLUSIONS: Oncocytic cystadenoma is a rare entity of the larynx predominantly affecting elderly patients. Clinical presentation and imaging may suggest the diagnosis of an internal laryngocele. Complete excision is both diagnostic and therapeutic, and typically can be achieved using TLM. When clear margins are obtained, no adjuvant therapy is indicated. Although laryngoceles and malignancies are more commonly encountered, oncocytic cystadenomas should remain in the differential of cystic laryngeal masses.

Hepatic Fibrinogen Storage Disease in a Patient with Hypofibrinogenemia: Report of a Case with a Missense Mutation of the FGA Gene.

We report a 9-year-old patient with abnormal liver tests found incidentally during routine bloodwork as part of a preoperative evaluation for excision of a benign cyst. A liver biopsy demonstrated hepatocytes to have pale and expanded cytoplasm that contained multiple vague globular eosinophilic inclusions. Electron microscopy showed fingerprint-like structures in the dilated cisternae of the rough endoplasmic reticulum, characteristic of fibrinogen. Whole exome sequencing identified a heterozygous missense mutation at codon 35 of the fibrinogen α (FGA) gene. No mutation was identified in the ß or γ chains. His plasma fibrinogen levels were found to be decreased to 85 mg/dL (normal range 215-464). His family history was pertinent for his mother and maternal grandfather with hypofibrinogenemia. He had not had any significant bleeding episodes except for minor bruising over the shins. This case illustrates a rare etiology of storage disease that causes abnormal liver function tests.

Basaloid squamous cell carcinoma of the maxilla: Report of a case and literature review.

PURPOSE: Basaloid squamous cell carcinoma (BSCC) is a rare variant of squamous cell carcinoma characterized by a highly aggressive clinical course. Though typically found in the larynx, oropharynx, and hypopharynx, we report a rare case of BSCC originating in the maxillary sinus in an otherwise healthy 32-year-old male. MATERIALS AND METHODS: Single case report of a patient with BSCC of the maxillary sinus and retrospective chart review of all cases of BSCC of the maxilla at a single academic institution between January 1, 1986 and December 31, 2013. The MEDLINE database was additionally queried for all case series or reports of BSCC arising in the maxilla, and pertinent clinical data were extracted. RESULTS: The clinical presentation, disease course, and management of a patient with BSCC of the maxilla are presented. In this recent case, the patient presented with persistent alveolar pain and a nonhealing tooth infection. Radiographic studies demonstrated a large necrotic mass in the left maxillary sinus that was biopsy-proven as BSCC. The patient underwent surgical resection followed by postoperative radiation without complications. CONCLUSIONS: BSCC of the maxilla is a rare oncologic entity that may progress to late disease stage without obvious clinical signs or symptoms. Optimal treatment involves complete surgical resection followed by postoperative.

Tumor cells with low proteasome subunit expression predict overall survival in head and neck cancer patients.

BACKGROUND: Experimental and clinical data suggest that solid cancers contain treatment-resistant cancer stem cells that will impair treatment efficacy. The objective of this study was to investigate if head and neck squamous cell carcinoma (HNSCC) also contain cancer stem cells that can be identified by low 26S proteasome activity and if their presence correlates to clinical outcome. METHODS: Human HNSCC cells, engineered to report lack of proteasome activity based on accumulation of a fluorescent fusion protein, were separated based on high (ZsGreen-cODCneg) or low (ZsGreen-cODCpos) proteasome activity. Self-renewal capacity, tumorigenicity and radioresistance were assessed. Proteasome subunit expression was analyzed in tissue microarrays and correlated to survival and locoregional cancer control of 174 patients with HNSCC. RESULTS: HNSCC cells with low proteasome activity showed a significantly higher self-renewal capacity and increased tumorigenicity. Irradiation enriched for ZsGreen-cODCpos cells. The survival probability of 82 patients treated with definitive radio- or chemo-radiotherapy exhibiting weak, intermediate, or strong proteasome subunit expression were 21.2, 28.8 and 43.8 months (p = 0.05), respectively. Locoregional cancer control was comparably affected. CONCLUSIONS: Subpopulations of HNSCC display stem cell features that affect patients' tumor control and survival. Evaluating cancer tissue for expression of the proteasome subunit PSMD1 may help identify patients at risk for relapse.

Solitary fibrous tumor of the hypopharynx: case report and literature review.

Solitary fibrous tumors are rare mesenchymal neoplasms that are increasingly being described in the head and neck. Clinical presentations may include compression by these tumors on vital surrounding structures. While malignant transformation is rare, treatment entails wide local excision. We present the case of a 74 year-old female with an increasingly enlarging symptomatic hypopharyngeal solitary fibrous tumor that was found on carotid duplex ultrasound. Transoral surgical excision resulted in relief of symptoms. Treatment options are discussed and a literature review of this uncommon disorder presented.

Spindle Cell Lipoma Arising from the Supraglottis: A Case Report and Review of the Literature.

Lipomas are common benign mesenchymal neoplasms. Although 13% of lipomas are found in the head and neck, only 0.6% have been reported in the larynx. Of all lipomas, the spindle cell variant is the least common. In the present study, we report a case of supraglottic spindle cell lipoma and review the literature of laryngeal spindle cell lipoma. A 35-year-old male presented with dysphagia and dyspnea and was found to have bilateral supraglottic lesions causing airway obstruction. The masses were resected endoscopically. Final pathology demonstrated mature adipocytes and spindle cells, with immunohistochemical patterns supportive of spindle cell lipoma. Spindle cell lipomas have rarely been reported in the upper airway. To our knowledge, this is the youngest patient reported to date. These lipomas are uncommon benign neoplasms and should be distinguished from aggressive mesenchymal neoplasms such as liposarcoma variants to guide appropriate conservative but curative therapy.

Perineural invasion detected by high-field 3.0-T magnetic resonance imaging.

The presence of perineural invasion (PNI) with cutaneous squamous cell carcinoma portends a poor prognosis. PNI may be detected radiographically or clinically, with motor or sensory deficits, and is confirmed by histologic evaluation. Recent interest has grown regarding the role of imaging in determining the presence of PNI and its preoperative implications. We report on a patient with cutaneous squamous cell carcinoma invading the parotid gland with clinical evidence of facial nerve weakness. On standard 1.5 Tesla (T) magnetic resonance imaging (MRI), bilateral parotid glands were symmetric; however, a second high-field 3-T MRI revealed asymmetric enhancement of the left facial nerve at the stylomastoid foramen and extending throughout the left parotid gland. PNI was later confirmed on histopathology. The presurgical determination of PNI was essential in our mapping the exact tumor location and in our surgical planning.

Temporal bone verrucous carcinoma: outcomes and treatment controversy.

Verrucous carcinoma is a rare tumor that presents in the head and neck with the most common sites being the oral cavity and larynx. Fourteen cases of verrucous carcinoma of the temporal bone have been described in literature; this study aims to examine treatment outcomes and discuss the controversy surrounding postoperative radiation. The study design included a literature review along with individual case report in the setting of a tertiary care medical center. Outcome analysis of all cases of verrucous carcinoma of the temporal bone, which are documented in the English literature, and presentation of a single patient report including gross, histologic and radiologic analyses were performed. The longest recorded survival for verrucous carcinoma of the temporal bone occurs in patients treated with surgery alone. Poorer outcomes for patients treated with adjuvant (chemo)radiation may be due to more advanced stage of disease at the time of treatment. Early reports of radiation leading to tumor dedifferentiation or early recurrence are not supported by more recent studies. Whether adjuvant radiation therapy is indicated in verrucous carcinoma of the temporal bone remains controversial.

Sebaceous adenoma of the parotid gland: a case report with fine needle aspiration findings and histologic correlation.

BACKGROUND: Sebaceous adenoma of the salivary gland is an extremely rare, benign neoplasm that predominantly involves the major salivary glands. The major problem in dealing with sebaceous adenoma is the recognition of this entity to avoid confusion with other more aggressive neoplasms, such as mucoepidenmoid carcinoma. In particular, recognition of this entity in cytologic specimens is important to avoid radical surgery. CASE: A 29-year-old woman presented with an enlarging parotid mass. Fine needle aspiration (FNA) biopsy showed cellular smears composed of sheets and aggregates of cuboidal to low columnar cells with slightly irregular nuclear contours, prominent nucleoli and a moderate amount of cytoplasm that appeared squamoid and finely vacuolated. The FNA was misinterpreted as possible low grade mucoepidermoid carcinoma. CONCLUSION: We report a case ofa rare and unusual tumor of the salivary glands. The major problem in dealing with sebaceous adenoma is the recognition ofthis entity in cytologic specimens to avoid confusion with other more aggressive neoplasms such as low grade mucoepidermoid carcinoma and potentially to avoid radical surgery. In this paper, the clinical presentation, pathological findings on the fine needle aspirate and surgical resection specimen, and review of the literature will be discussed.

Histopathological and ultrastructural analysis of vestibular endorgans in Meniere's disease reveals basement membrane pathology.

BACKGROUND: We report the systematic analysis of the ultrastructural and cytological histopathology of vestibular endorgans acquired from labyrinthectomy in Meniere's disease. METHODS: 17 subjects with intractable Meniere's disease and ipsilateral non-serviceable hearing presenting to the Neurotology Clinic from 1997 to 2006 who chose ablative labyrinthectomy (average age = 62 years; range 29-83 years) participated. The average duration of symptoms prior to surgery was 7 years (range 1-20 years). RESULTS: Nearly all vestibular endorgans demonstrated varying degrees of degeneration. A monolayer of epithelial cells occurred significantly more frequently in the horizontal cristae (12/13 = 92%) (p < 0.001), the superior cristae (5/5 = 100%) (p < 0.005), the posterior cristae (2/2) compared with the utricular maculae (4/17 = 24%). Basement membrane (BM) thickening was more common in all of the cristae ampullares (18 out of 20) than the utricular maculae. Although only four saccular maculae were obtained, 3 out of 4 exhibited BM thickening and monolayer degeneration. Monolayer degeneration was highly significantly correlated with the presence of BM thickening (p < 0.001). Other degenerative changes noted equally among the five vestibular endorgans which were not significantly correlated with BM thickening or monolayer degeneration included hair cell vacuolization and stereocilia loss, microvesicles in the supporting cells, and increased stromal intercellular spaces. Transmission electron microscopy demonstrated disorganization of the BM collagen-like fibrils, and normal ultrastructural morphology of the nerve terminals and myelinated fibers. Stromal fibroblasts and endothelial cells of stromal blood vessels demonstrated vacuolization, and stromal perivascular BMs were also thickened. CONCLUSION: Systematic histopathological analysis of the vestibular endorgans from Meniere's disease demonstrated neuroepithelial degeneration which was highly correlated with an associated BM thickening. Other findings included hair cell and supporting cell microvessicles, increased intercellular clear spaces in the stroma, and endothelial cell vacuolization and stromal perivascular BM thickening.

Immunologic mediators of outcome for irradiated oropharyngeal carcinoma based on human papillomavirus status.

PURPOSE: To investigate the prognostic value of pre-treatment immune parameters including white blood cell count (WBC) and circulating lymphocyte count (CLC) among patients with oropharyngeal carcinoma treated by radiation therapy. METHODS AND MATERIALS: A total of 136 consecutive patients were treated by radiation therapy for locally advanced (stage III/IV) squamous cell carcinoma of the oropharynx with known human papillomavirus (HPV) status. Medical records were reviewed to identify patients with documented pre-treatment laboratory bloodwork. The Kaplan-Meier method and linear regression models were used to evaluate the association between pre-treatment CBC and CLC values with survival endpoints. RESULTS: One hundred and eleven patients satisfied inclusion criteria. Median age was 62 years (range, 22-91). Eighty-four patients were HPV-positive (76%) and 27 (24%) were HPV-negative. There was no difference in WBC and CLC mean values at baseline between HPV-positive and HV-negative (p > 0.05, for both). Trends were detected in the HPV-positive cohort favoring patients with higher CLC, with respect to 2-year local-regional control (93% vs. 82%, p = 0.06) and distant control (88% vs. 82%, p = 0.10) using the median CLC as cut-off. HPV-positive patients with CLC values in the lowest quartile had inferior local-regional control compared to those in the upper 3 quartiles (69% vs. 89%, p = 0.01). CONCLUSION: Low pre-treatment CLC was correlated with local-regional recurrence and distant failure among HPV-positive patients. These associations were not observed in the HPV-negative cohort.

Determination of perineural invasion preoperatively on radiographic images.

OBJECTIVE: Perineural invasion in head and neck cancers has important prognostic implications, and even if clinically silent, can be radiographically evident. This study analyzed the frequency of preoperative diagnosis, radiographic features, and importance of the preoperative diagnosis in treatment planning. STUDY DESIGN: Radiographic studies of 38 patients with histopathologically proven perineural spread from head and neck cancer were retrospectively reviewed and compared with preoperative reports. SUBJECTS AND METHODS: The percent agreement with pathology, kappa values, and 95 percent confidence intervals were determined for relevant nerves. Salient radiographic findings were compared with the contralateral normal side. RESULTS: Preoperative agreement was less than 10 percent for all nerves, and retrospectively was 56 percent for the trigeminal nerve and 40 percent for the facial nerve. Radiographic features included neural thickening and enhancement, and foraminal widening. CONCLUSION: Cancers of the head and neck can spread perineurally. Preoperative radiographic determination, although underreported, is imperative, because diagnosis impacts management and prognosis.

Enteroendocrine cell dysgenesis and malabsorption, a histopathologic and immunohistochemical characterization.

Enteroendocrine cell dysgenesis was observed in 3 patients with intestinal failure of unknown cause. Enteroendocrine cell dysgenesis is a congenitally acquired life-threatening malabsorptive condition with a unique clinical phenotype paired with a histologically identifiable disease pattern. Two cases were first presented at the Ninth International Small Bowel Transplantation Symposium, Brussels 2005, and were subsequently published (N Engl J Med 2006;355:270). We now present the histopathologic and immunohistochemical findings of the gastric antrum, small bowel, and colon in greater detail. The clinical phenotype of the patients was unusual in that the affected patients demonstrated profound malabsorption of all nutrients, except water, from birth. The small intestine in each patient demonstrated almost no abnormality, except a near absence of endocrine cells in the mucosa. The colon appeared similarly affected. Known causes of congenital malabsorption, inflammatory, and infectious causes of diarrhea were excluded. The defect is secondary to point mutations in NEUROG3, which result in an arrest of endocrine cell development in the small intestine and colon. This work describes the pathologic characterization of enteroendocrine cell dysgenesis using routine techniques. The pattern of injury is distinct from other histopathologically assessed congenital malabsorptive conditions such as microvillus inclusion disease, tufting enteropathy, and abetalipoproteinemia. It is also easily distinguished from inflammatory conditions such as food allergy, gluten-sensitive enteropathy, autoimmune enteropathy, IPEX (immune dysfunction, polyendocrinopathy, enteropathy, and X-linked inheritance), and inflammatory bowel disease. The histopathology of disease is similar to what has been found transiently in a single patient with autoimmune polyglandular syndrome type I.

Acellular dermal matrix grafts for prevention of microarterial thrombophlebitis.

OBJECTIVE: To examine the role of acellular dermal matrix grafts for prevention of microarterial anastomotic thrombophlebitis. DESIGN: Bilateral femoral artery microvascular anastomoses were created in the field of established wounds infected with Staphylococcus aureus in 12 rats. In each animal, 1 femoral microarterial anastomosis was wrapped with an acellular dermal matrix graft, and the contralateral femoral anastomosis was left unprotected. The incidence of femoral artery thrombosis was determined after 4 days by wound reexploration. SETTING: David Geffen School of Medicine, University of California, Los Angeles. MAIN OUTCOME MEASURE: The patency of femoral artery anastomoses was determined after 4 days by wound reexploration. RESULTS: The incidence of femoral artery thrombosis in vessels wrapped with acellular dermal matrix grafts was 17%. The incidence of femoral artery thrombosis in unprotected vessels was 100%. This difference was statistically significant (P<.05). CONCLUSION: Acellular dermal matrix grafts seem to have a protective effect in the prevention of acute thrombophlebitis when arterial microvascular anastomoses are performed in infected surgical fields.

Incidental finding of lymphoma after septoplasty.

INTRODUCTION: Septoplasty, or surgical correction of the deviated septum, is an elective, routinely performed rhinologic procedure to address nasal airway obstruction. In many cases, resected septal cartilage and bone fragments are sent for pathologic review, although there is no consensus on this practice. We reported two cases of incidentally diagnosed lymphoma after elective septoplasty and discussed clinical presentation, diagnosis, and management. METHODS: Retrospective chart review of two patients who underwent septoplasty at a tertiary academic medical center and found to have incidental lymphoma based on histopathology. RESULTS: Two patients who underwent septoplasty had an incidental diagnosis of lymphoma on pathologic analysis. One patient was noted to have an S-shaped septal deviation that produced bilateral nasal obstruction. She underwent a difficult septoplasty, in which the mucoperichondrial flap was firmly adherent to the underlying septum and bone. Final pathology demonstrated diffuse large B-cell lymphoma. She was treated with chemoradiation and remained free of disease at 59 months. The other patient had a history of nasal trauma, which produced left septal deviation. He underwent an uncomplicated septoplasty, with pathology that demonstrated low-grade B-cell lymphoma. Because there was no evidence of active disease, the decision was made to not treat and to observe the patient clinically. CONCLUSIONS: This is the first reported series of septal lymphoma incidentally diagnosed on routine septoplasty. Although histopathologic review of specimens from routine nasal and sinus surgery is not routinely performed, this report highlighted the importance of this process, on a case-by-case basis, in detecting unexpected malignancies that otherwise were clinically silent.

Solitary fibrous tumor: report of a case with an unusual presentation as a spindle cell parotid neoplasm.

BACKGROUND: Initially described as a pleural tumor, solitaryfibrous tumor of the parotid gland (SFT) is rare and has been reported at a wide range ofanatomic sites. Although cases of SFT arising in the parotid gland have been previously described, a review of the literature failed to reveal cytology-based reports of this entity. CASE: A 42-year-old man presented with a right parotid mass that had gradually enlarged over 3 years. He was otherwise asymptomatic. Fine needle aspiration biopsy of the mass showed a hypercellular smear composed of spindle cells in both clusters and isolated forms, with ovoid nuclei, evenly distributed chromatin, inconspicuous nucleoli and scant to moderate cytoplasm with focally wispy, collagenous, intercellular material. The background was hemorrhagic, without chondromyxoid matrix or inflammatory cells. There was no evidence of a myoepithelial component. A diagnosis of spindle cell neoplasm was rendered. Histologic examination of the total parotidectomy specimen revealed a SFT arising in the parotid gland. The diagnosis was supported by immunohistochemical studies. CONCLUSION: SFT is a well-circumscribed neoplasm composed of short, spindled, plump cells with scanty cytoplasm growing in a haphazard or "patternless" pattern. Tumor cells are intimately admixed with collagenous stroma. Hemangiopericytomalike vessels are frequently seen. Although SFT rarely occurs in the salivary gland and a definitive diagnosis based on cytologic preparations alone is difficult, the diagnosis of SFT can be considered when cytologic examination reveals a hypercellular smear composed of isolated, cohesive clusters of spindled, fibroblastlike cells associated with a collagenous component in ahemorrhagic background. The preoperative magnetic esonance image findings of a highly vascular neoplasm support the diagnosis.

Chondroid chordoma of the sella turcica mimicking a pituitary adenoma.

We report an unusual case of a chondroid chordoma of the sella turcica that mimicked the clinical and radiologic presentation of the more common pituitary adenoma. A 50-year-old man presented with bitemporal visual field deficits. Magnetic resonance imaging (MRI) detected a sellar mass that was suggestive of a pituitary adenoma. However, the intraoperative appearance of the mass was not consistent with an adenoma, and frozen-section pathology was obtained. Pathology identified the mass as a malignant lesion. Based on this finding, the mass was treated more aggressively. Chondroid chordomas are rare and slowly growing but locally aggressive tumors. The prognosis depends on the ability to totally resect the mass, so differentiating this tumor from a benign lesion is critical. An intrasellar chordoma can be confused clinically and radiologically with a pituitary adenoma. These two lesions are nearly identical on MRI, although T2-weighted imaging sometimes demonstrates higher intensity with a chondroid chordoma. Computed tomography may be helpful in demonstrating bony destruction by these lesions, as can the presence of intralesional calcifications. Intraoperative findings of bony invasion or a purple-red color may also lead the surgeon to suspect a diagnosis other than pituitary adenoma.

Carcinoma ex-pleomorphic adenoma of the parotid gland consisting of high-grade salivary duct carcinoma and keratinizing squamous cell carcinoma.

Carcinoma ex-pleomorphic adenoma (CXPA) is a rare salivary gland malignancy that presents diagnostic difficulties partly because of its wide range of histologic presentations. We report a case of a 77-year-old man, who presented with a 6-year history of a parotid mass that had undergone rapid growth within weeks. Magnetic resonance imaging revealed an infiltrative mass in the parotid gland, and the fine-needle aspiration (FNA) biopsy result was highly suspicious for carcinoma. Subsequent excision of the tumor demonstrated a poorly differentiated epithelial neoplasm consisting of keratinizing squamous cell carcinoma (SCC) and adenocarcinoma with regions of both ductal carcinoma in situ and invasive salivary duct carcinoma (SDC). Only focal areas exhibited a benign pleomorphic adenoma component. To our knowledge, this is the first case of a CXPA that consists of both a high-grade SDC and a keratinizing SCC in the parotid gland.

An unusual initial presentation of mantle cell lymphoma arising from the lymphoid stroma of warthin tumor.

BACKGROUND: Warthin tumors presenting concomitantly with a lymphoma is vanishingly rare with only 15 reported cases in English literature. Herein, we report an unusual initial presentation of a mantle cell lymphoma involving the lymphoid stroma of a Warthin tumor. CASE PRESENTATION: A seventy-seven year old otherwise healthy gentleman with a 50-pack year smoking history presents with a slowly enlarging left cheek mass. CT scan of the neck demonstrated a left parotid gland tumor measuring 3.4 cm in greatest dimension. He underwent a left superficial parotidectomy, with subsequent histopathologic examination revealing a Warthin tumor with extensive expansion of the lymphoid stroma. Flow cytometric, immunohistochemical, and cytogenetic studies of the stromal component of the tumor confirmed the presence of a mantle cell lymphoma. Clinical staging demonstrated stage IVa disease, and was considered to be at low to intermediate risk due to the slow growth of the parotid lesion. The patient is undergoing close follow up with repeat PET-CT scans at six months. CONCLUSION: To the best of our knowledge, this is the first well documented collision tumor between mantle cell lymphoma and a Warthin tumor. This case also brings to light the significance of thorough evaluation of the lymphoid component of Warthin tumor.