Gallego et al. Journal of Medical Case Reports 2011, 5:11 http://www.jmedicalcasereports.com/content/5/1/11 Page 3 of 4 Figure 2 A) Computed tomography image four years after first surgery revealing a cervical lymph node enlargement (red arrow). B) Histopathological study of cervical specimen showing metastatic tumor infiltration by oncocytic cells (hematoxylin and eosin stain, original magnification 400×). salivary oncocytic tumors include: (1) local lymph node metastasis; (2) distant metastasis; (3) peri-neural, vascu- lar or lymphatic invasion; (4) frequent mitoses and cel- lular pleomorphism with extensive invasion and destruction of adjacent structures [6]. This tumor is pre- dominantly composed of round or polyhedral cells arranged in small clusters and occasional solid sheets. Cells have abundant eosinophilic cytoplasm, a result of excessive numbers of mitochondria [1]. Although not commonly used, it has been reported that anti-mito- chondrial antibody is highly specific and sensitive to confirm the oncocytic nature of the granular cytoplasm [7]. FNAC is less sensitive for oncocytic neoplasms, per- haps due to the rarity of these tumors and diagnostic pitfalls previously associated with FNAC (for example, sampling errors and overinterpretation of paucicellular specimens) [2]. Approximately one-third of patients with oncocytic carcinoma of the parotid develop a painful mass or experience facial paralysis. The skin overlying the gland is occasionally discolored or wrinkled [1]. In our case, there was no facial paralysis or discoloration of the overlying skin. The average age of patients has been estimated to be about 60 years, with a male predomi- nance [1,8]. As with other high-grade salivary gland neoplasms, aggressive surgical intervention is indicated. Therapy for OCs consists of surgical intervention, and total paroti- dectomy with preservation of the facial nerve whenever possible. The efficacy of radiotherapy is unclear. Radia- tion does not appear to favorably alter the biological behavior of this tumor. In the case reported, intra- operative frozen sections of the tumor would have been indicated for pathological diagnosis and would have altered the surgical decision. FNAC alone did not deter- mine a correct diagnosis and the first surgical manage- ment was inadequate. A number of studies have reported multiple recur- rences of this tumor and regional or distant metastases [2,6,8-10]. The cervical lymph nodes may be affected as with other malignant tumors of the parotid gland, but prophylactic neck dissection must be considered indivi- dually in the absence of consensus in the literature. Nakada et al. published a review of 28 cases of oncocy- tic carcinoma of the parotid gland [8]. They concluded that distant metastasis appeared to be the most impor- tant prognostic feature of oncocytic carcinoma; local lymph node metastasis was not necessarily a critical fac- tor in the overall prognosis. Distant metastasis sites include the lung, liver, kidney, mediastinum, thyroid gland and bone. Prophylactic neck dissection may be indicated for tumors larger than 2 cm in diameter [10] (our patient’s tumor was 2.5 cm at its greatest diameter). This likely indicates a worse prognosis. The clinical course of our case, with the appearance of cervical lymph node metas- tases after four years of follow-up, supports the approach of Goode and Corio [10]. The prognosis of oncocytic carcinomas is not well known because of their low incidence. Patients with malignant oncocytoma appear to have good short-term survival, but poor long-term survival [11]. The average survival period has been estimated at 3.8 years with metastasizing tumors [12]. Further investigation of the