salivary gland pathology

Salivary Gland Tumors

Dr. Arsalan MalikAssistant Professor (Oral Pathology)

حيم الر حمن الر الله بسم

Anatomy of Salivary Glands

Three major salivary glands

• Parotid gland (Stensen’s duct)

• Submandibular gland (warthin’s duct)

• Sublingual gland (Bartholin’s duct)

• Innumerable minor salivary glands in mucosa and oral cavity

Functions of Saliva• Protection• Lubrication• Buffering• Digestion• Taste• Antimicrobial • Tooth integrity

Normal histology of salivary gland

Acinar cells of Salivary Glands

Classified as either:

• Serous cells: produce a thin watery secretion

• Mucous cells: produce a more viscous secretion

Salivary gland secretory unit

• Composed of terminal acini

• Intercalated, striated and excretory ducts

• Myoepithelial cells

Major Glands/Secretions

• Major SG are paired structures and include the parotid, submandibular and

sublingual

• Parotid: serous

• Submandibular: mucous & serous

• Sublingual: mucous

Diseases of Salivary Glands

• Neoplastic

• Developmental

• Infectious

• Inflammatory

• Autoimmune

• Ischemic

Salivary Gland Tumors

Etiologic Factors

• Radiation exposure

• Genetic predisposition

• Tobacco

• Chemical carcinogens

• Viruses

Salivary Gland Tumors• Incidence: • 6 % of head & neck neoplasms

• Age: 6 – 7th decades - peak incidence• Gender: female predilection• Site: • Parotid: 64 - 80% • Minor glands (palate): 9 -23%• Submandibular gland: 8 - 11% • Sublingual gland: < 1%

Tumors of the salivary gland may arise from -- the salivary epithelium (the parenchyma) --or the supportive stroma (mesenchymal)

Benign parenchymal tumors are known as Adenomas Malignant tumors are known as adenocarcinomas .

Salivary gland tumors may arise form any cellular component including the basal cells ductal, striated intercalated ducts, acini and the myoepithelial cells.

Salivary gland Tumors

Salivary Gland Tumors• Benign• Malignant

Relative proportion of malignancy increasing in the smaller glands (rule of thumb is the 25/50/75 rule)

Salivary Gland TumorsBenign

► Pleomorphic adenoma► Warthin`s tumor ► Oncocytoma► Myoepithelioma ► Ductal papilomas► Monomorphic adenoma1. Basal cell adenoma 2. Canalicular adenoma

Malignant ►Mucoeidermoid carcinoma►Acinic cell carcinoma►Adenoid cystic carcinoma►Polymorphous low grade adenocarcinoma►Carcinoma arising in pleomorphic adenoma

BENIGN SAIVARY GLAND TUMORS

General Characteristics• Grow slowly,

• Asymptomatic,

• Do not fluctuate in size

• Usually of long duration

• Present a single nodule

• Not fixed to overlying skin or mucous membrane

• Recurrent lesion may be multi- nodular

Pleomorphic Adenoma• Benign glandular neoplasm

• Incidence: common

• 70% of salivary tumors

• Gender: female > male

• Age: 3-6th decades

• Site: parotid, palate, upper lip, buccal mucosa

• Symptoms: slow growing painless mass

Pleomorphic Adenoma Gross Pathology:

- well circumscribed firm tan white solid or partially cystic mass

Histology: - ductal epithelial cells - myoepithelial cells - stroma: myxoid, chondroid, fibrohyaline

Pleomorphic Adenoma

Pleomorphic AdenomaTreatment:

• Surgical excision

• Superficial parotidectomy

• Prognosis: excellent

• Complications:

• recurrence – multifocal

• malignant transformation (5%)

Warthin’s Tumor (Papillary Cystadenoma Lymphomatosum)• Benign salivary gland tumor

• Incidence: common

• Gender: male > female

• Symptoms: painless mass

• Site: parotid, multi-focal/bilateral (14%)

• Etiology: smoking (8 fold risk)

Warthin’s Tumor• Gross Pathology:• Well circumscribed cystic mass• Papillations • “machine oil fluid”

Histology: • Encapsulated cystic lesion• Papillary fronds• Oncocytic columnar cells• Lymphoid stroma

Warthin’s Tumor

Warthin’s TumorTreatment:• Surgical excision• Superficial parotidectomy• Prognosis: excellentComplications: • Recurrence – 6-12% (multicentric)• Association with other salivary tumors • Malignant transformation – extremely rare

Oncocytoma

• Benign salivary gland neoplasm• Incidence: rare (1% of salivary tumors)• Site: parotid gland (85-90%)• Age: 6-8th decades• No gender predilection• Symptoms: painless mass (<4 cm)• Multifocal/bilateral

Oncocytoma

• Encapsulated

• Trabecular-organoid

• Oncocytic epithelial cells

• Fibrous septae

• Clear cells

OncocytomaTreatment

• Surgical excision

Prognosis

• Excellent

• Recurrence uncommon

• Oncocytic Adenocarcinoma - sinonasal tract

Oncocytoma• Electron Microscopy:

-Mitochondrial hyperplasia

-60% of cell volume

Ductal Papillomas

Present in three forms

• 1-Simple ductal papilloma

• 2-Inverted ductal papilloma

• 3-Sialadenoma papilliferum

Simple ductal papilloma

-Exophytic lesion, papillary surface and pedunculated base

-Reddish in color present on palate or buccal mucosa

-It consist of non-keratinized epithelium, columnar, supported by a core of vascular fibrous connective tissue

Inverted ductal papilloma

-Present as a nodule of oral mucosa of adults. No

distinctive clinical features

-Histologically it consist of squamous, cuboidal,or

columnar cells which proliferate into duct to form a

bulbous masses.

Mucous cells and micro cyst with mucous may be

Sialadenoma Papilliferum

-The lesion occurs in adults

-Exophitic papillary lesion of hard palate

-Luminal layer of columnar cells on cuboidal

basal layer.

-Connective tissue papillae contain plasma

Monomorphic adenoma

• Consists of single epithelial cells type

• Basal cell, canalicular, sebaceous, glycogen-rich, clear cell

• Most common types are

- Basal Cell Adenoma

- Canalicular Adenoma

Canalicular Adenoma

• Benign salivary gland neoplasm

• Monomorphic adenoma

• Site: upper lip (75%)

• Age: 7th decade

• Gender: female predilection

• Symptoms: slow growing mass

• Multifocal

Canalicular Adenoma

Canalicular AdenomaTreatment

• Conservative surgical excision

• Enucleation not recommended

Prognosis

• Excellent

• Rare recurrence

• Can be misdiagnosed as a malignancy

Basal Cell Adenoma• Benign salivary gland neoplasm

• Monomorphic adenoma

• Incidence: 2% of salivary gland tumors

• Site: parotid gland (75%)

• Gender: female predilection (2:1)

• Symptoms: slow growing mass (< 3cm)

Basal Cell Adenoma

• Solid

• Most common

• Solid nests of tumor cells

• Uniform, hyperchromatic, round nuclei,

indistinct cytoplasm

• Peripheral nuclear palisading

• Scant stroma

Basal Cell Adenoma

Trabecular pattern `Elongated anastomosing cords of basal

cells, surrounded by connective tissue stroma.

Basal Cell Adenoma

Tubular Pattern `Basaloid cells surrounds the duct like

structure.

Basal Cell Adenoma

Membranous or dermal analogue adenoma

`Tumor islands moulded in jig saw

puzzle fashion surrounded by

hylinized basal lamina

Basal Cell AdenomaTreatment• Complete surgical excision

Prognosis• Excellent• Recurrences may occur• Malignant transformation is rare • Hybrid tumor

Malignant Epithelial Tumors

Malignant Epithelial Tumors Mucoepidermoid carcinoma – 29% Adenocarcinoma, NOS –

27% Acinic cell carcinoma –

17% Polymorphous low grade

carcinoma – 19.6% Adenoid cystic carcinoma – 7.5%

Basal cell adenocarcinoma – 2.9%

Epithelial myoepithelial carcinoma – 1%

Clear cell carcinoma – 1%

Salivary duct carcinoma – 0.5%

Malignant salivary gland tumors

• Shorter duration than benign

• Grow rapidly or history of slow growth with sudden rapid activity

• Fixed to surrounding tissues

• Overlying skin or mucous membrane may be ulcerated or inflamed

• Surface talengectasia

Malignant salivary gland tumors

• Parotid gland tumors associated with facial nerve paralysis or neurological

symptoms

• Regional lymph nodes may be enlarged

• Palate and retromolar gland tumors infiltrate bone,produce radiolucencies and

loosening of teeth

Salivary Gland Tumor Staging

• T1: tumor < 2 cm

• T2: tumor 2 - 4cm

• T3: tumor > 4 cm or extraparenchymal

• T4a: invades skin, mandible, ear canal or facial nerve

• T4b: tumor invades skull base, pterygoid plates or encases carotid artery

Mucoepidermoid Carcinoma• Malignant epithelial salivary gland tumor• 2nd most common salivary gland tumor • 30% of malignant salivary gland tumors• Age: 2nd – 7th decades• Gender: slight female predilection• Site: parotid gland, palate• Etiology: radiation exposure• Asymptomatic swelling

Mucoepidermoid Carcinoma• Gross pathology

• Well-circumscribed to partially encapsulated to unencapsulated

• Solid tumor with cystic spaces

Mucoepidermoid Carcinoma

• Histology—Low-grade

• Mucus cell > epidermoid cells

• Prominent cysts

• Mature cellular elements

• Histology—Intermediate- grade

• Mucus = epidermoid

• Fewer and smaller cysts

• Increasing pleomorphism and

mitotic figures

• Histology—High-grade

• Epidermoid > mucus

• Solid tumor cell proliferation

• Mistaken for SCCA

• Mucin staining

• Histology—High-grade

• Epidermoid > mucus

• Solid tumor cell proliferation

• Mistaken for SCCA

• Mucin staining

Mucoepidermoid CarcinomaTreatment

Influenced by site, stage, grade

Stage I & II

Wide local excision

Stage III & IV

Radical excision

+/- neck dissection

+/- postoperative radiation therapy

Prognosis• Recurrence

• Metastasis – lymph nodes, lung, bone, skin

• Low to intermediate grades

• – good prognosis ( 90% 5 year survival )

• High grade

• – poor prognosis (40% 5 year survival)

• Site: submandibular, floor of mouth, tongue

Acinic Cell Carcinoma

• 2nd most common parotid and pediatric malignancy

• 5th decade

• F>M

• Bilateral parotid disease in 3%

• Presentation

• Solitary, slow-growing, often painless mass

Acinic Cell Carcinoma

• Gross pathology

• Well-demarcated

• Most often homogeneous

Histopathology

• Circumscribed

• Variable growth patterns

• Variable cytology

• Low grade tumor

• Scant stroma

• Lymphoid infiltrate

Histopathology

• Histology

• Solid and microcystic patterns

• Most common

• Solid sheets

• Numerous small cysts

• Polyhedral cells

• Small, dark, eccentric nuclei

• Basophilic granular cytoplasm

Acinic Cell Carcinoma Treatment:

- surgical excision Prognosis: - low-grade malignancy

- 12% recur - 8% metastasize - 6% mortality - prognosis is better for minor gland tumors Undifferentiated carcinoma component (rare) Difficult diagnosis for pathologist

Adenoid Cystic Carcinoma• Overall 2nd most common malignancy

• Most common in submandibular, sublingual and minor salivary glands

• M = F

• 5th decade

• Presentation

• Asymptomatic enlarging mass

• Pain, paresthesias, facial weakness/paralysis

Adenoid Cystic Carcinoma• Gross Pathology:

• - uncapsulated firm solid tan mass

• Histology:

highly infiltrative

small hyperchromatic cells

cribriform (“Swiss cheese”), tubular, solid

mucohyaline stroma

Perineural invasion

Adenoid Cystic Carcinoma• Gross pathology

• Well-circumscribed

• Solid, rarely with cystic spaces

• infiltrative

Adenoid Cystic Carcinoma• Histology—

• cribriform pattern

• Most common

• “swiss cheese” appearance

Adenoid Cystic Carcinoma• Histology—tubular pattern• Layered cells forming duct-

like structures• Basophilic mucinous

substance

• Histology—solid pattern• Solid nests of cells without

cystic or tubular spaces

Adenoid Cystic CarcinomaTreatment

Complete local excision

Tendency for perineural invasion: facial nerve sacrifice

Postoperative Radiations

Prognosis

Local recurrence: 42%

Distant metastasis: lung

Indolent course: 5-year survival 75%, 20-year survival 13%

Polymorphous low grade adenocarcinoma• Malignant epithelial neoplasm

• Oral cavity - minor glands

• Age: wide range – 6-8th decades

• Female gender predilection

• Site: palate (65%), lip, buccal mucosa

• Symptoms: painless swelling

• Duration: weeks to years

Polymorphous low grade adenocarcinoma• Malignant epithelial neoplasm

• Oral cavity - minor glands

• Age: wide range – 6-8th decades

• Female gender predilection

• Site: palate (65%), lip, buccal mucosa

• Symptoms: painless swelling

• Duration: weeks to years

Polymorphous low grade adenocarcinoma• 2nd most common malignancy in

minor salivary glands• 7th decade• F > M• Painless, submucosal mass• Morphologic diversity

• Solid, glandular, cribriform, ductular, tubular, trabecular, cystic

Polymorphous low grade adenocarcinoma• Histology• Isomorphic cells, indistinct borders,

uniform nuclei• Peripheral “Indian-file” pattern

• Treatment• Complete yet conservative excision

Lymphoepithelial Carcinoma• Rare• High grade/poorly differentiated carcinoma• Lymphoid stroma• Asians, Greenlanders• Epstein-Barr virus• Prognosis - guarded

Lymphoepithelial Carcinoma• undifferentiated tumor associated with

a dense lymphoid stroma

Salivary Adenocarcinoma NOS• Some tumours still defy the current classification of salivary gland

tumours• These are labelled as Salivary Adenocarcinoma Not Otherwise

Specified (NOS)

Treatment & Prognosis

• Early stage, well differentiated tumours appear to have a better

prognosis

• The survival rate is better for tumours of oral cavity as compared to

tumours of major salivary gland.

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