Dr.Ch.Sushma 2nd year P.G

SVS Medical college.

Cytological Spectrum Of Salivary Gland

Lesions

Introduction:

• FNA is a popular method for diagnostic evaluation of salivary gland masses, due to their superficial nature and easy accessibility for the procedure.

• Salivary gland tumors are generally not subjected to incisional or core needle biopsy.

• In incisional and core biopsy there is a possible risk of causing fistula or disruption of capsule with seeding of tumor cells and subsequent recurrence.

• There is no evidence of that FNA causes either of complications.

Aims And Objectives:

• To classify salivary gland lesions into broad groups.

• Differentiate between benign and malignant neoplasms of salivary glands and typify them.

Materials And Methods:

• All patients(50) presented with swellings of salivary glands during the period of 1year(2014-2015) to our department.

• A 22 gauge needle fitted to 10c.c syringe was used for the FNA, aspirates are smeared over glass slide, alcohol fixed and later on stained with hematoxylin and eosin.

Observation

• Total number of salivary glands aspirated are 50.

• Out of 50 cases ,3 cases were proved uncertain.

Sex Distribution• In sex distribution females slightly outnumbered the males in

ratio of 1.2:1.

Male 44%Fe-

male 56%

Age distribution• Age distribution, shows peak incidence in fourth decade of

the lesions.

1-20 years

21-40 years

41-60 years

61-80 years

0

5

10

15

20

25

No.of Cases

Site distribution

• In our study , parotid swellings predominated with 84% followed by submandibular(12%) and minor salivary glands(2%)

parotid

Submandubular

minor salivary glands

0 5 10 15 20 25 30 35 40 45

42

6

2

Based on cytological diagnosis

In our study, neoplastic lesions were observed in 42/50 cases, followed by non-neoplastic lesions (5/50) . Based on cytology 3/50 cases were uncertain.

Sialadenitis Neoplasms Uncertain0

5

10

15

20

25

30

35

40

45

Subdivision of neoplastic cases

• In our study, out of neoplastic 29 were benign and 13 malignant.

benign malignant

Subdivision of benign neoplasms• In our study, out of 29 benign tumours ,27 are

pleomorphic adenoma and 2 are oncocytoma

Pleomorphic adenomaoncocytoma

Subdivision of malignant neoplasms• In our study, out of 13 malignant tumours ,10 are

mucoepidermoic carcinoma and 2 are acinic cell carcinoma and a single low grade salivary gland tumor

Mucoepider-moic carci-

noma

Acinic cell car-cinoma

Low grade salivary gland

carcinoma

No.of cases

10 2 1

0.52.54.56.58.5

Discussion

• In our study of 50 cases,5 cases are non neoplastic which were found to be sialadenitis.

• 42 cases are neoplastic,out of which 29 cases are benign and 13 cases are reported as malignant.

• 3 cases were reported as uncertain in which diagnosis couldn’t be made.For these cases histopathological evaluation is adviced.

Discussion

• In our study, most of the lesions are in the age group of 41-60 years and predominantly females.

• Similarly Ritu et al*, showed M: F 1.1:1 and mean age of 35 years.

Ritu Jain, D., Madhur Kudesia, M., Ruchika Gupta, M., & Sompal Singh, M. (2013). Fine needle aspiration cytology in diagnosis of salivary gland lesions: A study with histologic comparison.Cytojournal, 2013(10), 5-5

Discussion

• In our study, parotid swellings were observed in 84% similar to study by Perkins Mukunyadzi et al

Perkins Mukunyadzi, M. (n.d.). Review of Fine-Needle Aspiration Cytology of Salivary Gland Neoplasms, With Emphasis on Differential Diagnosis. Am J Clin Pathol, 118(1), S100-S115.

Discussion

• Out of 29 benign neoplastic cases,93% cases are of pleomorphic adenoma and 6.8% cases are oncocytoma.

• Out of 13 malignant cases, 77% of cases are of mucoepidermoid carcinoma and 15% of acinic cell carcinoma and low grade salivary gland carcinoma of 0.1 %.

Tumours of the Parotid gland

Tumours of the parotid gland

• The parotid gland is the most common site for salivary tumours.

• Most tumours arise in the superficial lobe.

• Most of tumours of the parotid gland are benign.

• Fifteen to 32% are carcinomas.

Mostly seen ….

• Overall, PLEOMORPHIC ADENOMA is the most frequent SGT, comprising about 50-60% of cases.

• The second most frequent benign SGT is WARTHIN TUMOR.

• MUCOEPIDERMOID CARCINOMA is the most common malignant SGT.

Location

• Swellings below the ear or in front of the ear

• Upper aspect of the neck. • Less commonly, tumours may

arise from the accessory lobe and present as persistent swellings within the cheek.

• Rarely, tumours may arise from the deep lobe of the gland and present as parapharyngeal masses

Incidence • SGTs predominantly arise in female patients

• The average age of patients with SGT is about 45 years old.

• The peak incidence of most specific types is in the 6th and 7th decades.

• The highest incidence of Pleomorphic adenoma (PA), mucoepidermoid carcinoma (MEC), and acinic cell carcinoma is in the third and fourth decades.

• In the pediatric population, the most common malignant SGT is mucoepidermoid carcinoma.

Classification WHO

Parotid tumours

Epithelial

Benign Malignant

Non epithelial

MOST OFTEN OF SQUAMOUS CELL ORIGINHaemangiomaLymphangiomaschwannoma

neurofibroma lipoma

sarcoma lymphoma, and

metastatic lesions

Benign epithelial tumors

• Pleomorphic adenoma • Warthin tumor• Myoepithelioma • Basal cell adenoma • Oncocytoma • Canalicular adenoma• Sebaceous adenoma • Lymphadenoma • Ductal papilloma• Cystadenoma

Malignant epithelial tumors•Acinic cell carcinoma•Mucoepidermoid carcinoma•Adenoid cystic carcinoma•Polymorphous low-grade adenocarcinoma •Epithelial-myoepithelial carcinoma •Clear cell carcinoma, not otherwise specified•Basal cell adenocarcinoma•Malignant sebaceous tumors •Cystadenocarcinoma•Low-grade cribriform cystadenocarcinoma •Mucinous adenocarcinoma•Oncocytic carcinoma •Salivary duct carcinoma •Adenocarcinoma, not otherwise specified •Myoepithelial carcinoma •Carcinoma ex pleomorphic adenoma •Carcinosarcoma •Metastasizing pleomorphic adenoma •Squamous cell carcinoma •Small cell carcinoma •Large cell carcinoma•Lymphoepithelial carcinoma •Sialoblastoma

Malignant salivary gland tumours

• Low-grade malignant tumours, e.g. acinic cell carcinoma, are indistinguishable on clinical examination from benign neoplasms.

• High-grade malignant tumors usually present as rapidly growing, often painless swellings in and around the parotid gland. Presentation with advanced disease is common, and cervical lymph node metastases may be present.

Invasion

• The facial nerve, may be directly involved by tumors in 10 to 15% of patients.

• Trismus is associated with involvement of the pterygoid musculature by deep parotid lobe malignancies.

Lymph nodal invasion• The incidence of metastatic spread to cervical lymphatics is variable

and depends on the histology, primary site, and stage of the tumor.

• Parotid gland malignancies can metastasize to the intra- and periglandular nodes.

• The next chain of lymphatics for the parotid is the upper jugular nodes.

• Although the risk of lymphatic metastasis is low for most salivary gland malignancies, lesions that are considered high grade or that demonstrate perineural invasion have a higher propensity for regional spread.

Pleomorphic adenoma

PA• Most common form of all salivary gland neoplasms and the majority of the PAs

occur in the parotid gland.

• Incidence - 40% to 70%

• usually occur in the tail of the parotid.

• PA is typically a slowly growing, asymptomatic, discrete nodule most often located in the superficial lobe of the parotid gland.

• These slow growing tumors are surrounded by an imperfect pseudo capsule traversed by fingers of tumors.

• Although PAs are benign tumors, subsets of these tumors have a tendency to recur and/or undergo malignant transformation.

Microscopically….• PA is characterized by its morphological diversity.

• It comprises epithelial and myoepithelial cells variably arranged in a mucoid, myxoid or chondroid background.

• PA usually presents with a variably thick capsule that on serial sectioning may be focally absent.

• The lesion typically harbors few mitoses and cytological atypia.

Pleomorphic adenoma

Pleomorphic adenoma:

Epithelial

• The epithelial component may predominate and in this instance the lesion is called cellular PA.

Cuboidal cell

Squamous cell

Spindle cell

Clear cell

Basaloid cell Epithelial

Cell types

Other component

• The myoepithelial component may form a fine reticular pattern or sheets of spindle cells.

• The mesenchymal tissue is mucoid, myxoid or chondroid, and predominates in some instances.

• Osseous metaplasia or lipomatous differentiation may be seen.

Genetics of PA

inv(8)(q12.1;q12

.1)

•CHCHD7 (Coiled-coil-helix-coiled-coil-helix domain containing 7)•PLAG1 (Pleomorphic Adenoma Gene 1)

ins(8)(q12.1q11.23q11.23)

•TCEA1 (Transcription elongation factor A 1)•PLAG1 (Pleomorphic Adenoma Gene 1)

Warthin’s tumor, or papillary cystadenoma

lymphomatosum

Warthins

• Second most common benign parotid tumor and occurs most often in older white men.

• Because of the high mitochondrial content within oncocytes, the oncocyte rich Warthin tumor and oncocytomas will incorporate technetium-99m and appear as hot spots on radionuclide scans.

Pathology

• These tumors are well encapsulated lesions with cystic and solid areas.

• These tumors consist of an oncocytic epithelial cell component arranged in double layers, which develops cysts and papillary projections, and a variable amount of lymphoid tissue often with germinal centers.

• A few Warthin's tumors (about 8%) show areas of squamous cell metaplasia and regressive changes.

Oncocytoma • Oncocytomas are benign

neoplasms composed of oncocytes; the large eosinophilic cuboidal to columnar cells with more than 60% of their cytoplasm occupied by mitochondria.

• Oncocytomas represent less than 1% of the salivary gland neoplasms and 82% to 90% of them occur in the parotid gland

Oncocytoma

• Oncocytes are one to two times the size of normal acinar cells, display abundant granular eosinophilic cytoplasm and a central pyknotic nucleus.

• The cytoplasmic granularity is due to the accumulation of mitochondria that may occupy up to 60% of the cytoplasm. In contrast, mitochondria occupy only 5.2% of the cytoplasm of normal acinar cells.

• The increased concentration of mitochondria is accompanied by a gradual disappearance from the cytoplasm of other cytoplasmic membrane systems and loss of plasmalemmar specializations.

Malignant tumors of parotid

Mucoepidermoid carcinoma

• Mucoepidermoid carcinoma is the most common malignant tumor of the parotid gland and can be divided into low-grade and high-grade tumors.

• High grade lesions have a propensity for both regional and distant metastases and corresponding shorter survival rates than low grade mucoepidermoid carcinomas.

Mucoepidermoid carcinoma• Cords, sheets and clusters of mucous,

squamous, intermediate and clear cells• Low to high grade, although even high

grade tumors lack marked nuclear atypia, frequent mitotic figures or extensive necrosis

• Occasional focal sebaceous cells, goblet-type cells, oncocytic change, inflammatory reaction to extravasated mucin or keratin

• No squamous cell carcinoma in situ• Low grade: mucinous and intermediate

cells with bland nuclei form glandular spaces

• High grade: solid and infiltrative growth pattern of atypical epidermoid and intermediate cells with cytoplasmic clearing and small number of mucinous cells; <20% intracystic component

AFIP point system:

Low grade - if total score is 0-4 points, Intermediate

grade if 5-6 points, High grade if 7+ points

•if <20% intracystic component•if neural invasion

2 points

•if necrosis•if 4+ mitotic figures/10 HPF

3 points

•if anaplasia4 points

Adenoid cystic carcinoma

• Adenoid cystic carcinoma constitutes 10% of all salivary neoplasms

• An indolent growth pattern and a relentless propensity for perineural invasion characterize adenoid cystic carcinoma.

• Regional lymphatic spread is uncommon

Cribriform

Solid – worst prognosis

Tubular – best

prognosis

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