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Salivary gland pathoology 1


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Oral Pathology II …

Oral Pathology II
Forth Year

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  • 1. Februray 29, 2009 Salivary Glands Classification, General Considerations & Tumors Like Conditions By Louay Jaber DDS, MSc, MSD, PhD
  • 2. The Normal Salivary Gland • The system is comprised of major & minor salivary glands – Major: Parotid, submandibular & sublingual. – Minor: • They produce the fluid that constitute oral saliva – Parotid: serous – Submandibular: serous & mucous – Sublingual: mucous & serous • • • • Palate: mucous Tongue: mucous & serous Lip: mucous Buccal mucosa: mucous Oral mucosa Acinus Intercalaetd-Striated-Excretory “ducts”
  • 3. The Normal Salivary Gland (Cont.) “Parotid gland” Lymph node Serous Acini & striated duct Facial nerve
  • 4. The Normal Salivary Gland (Cont.) “Submandibular, sublingual & minor glands” Submandibular Sublingual Minor
  • 5. Mucocele 70% in the lower lip The remainders floor of the mouth, tongue & buccal mucosa Third decades of life Men > women (slight) Small dome-shaped swelling Size 0.2-1.0 cm Mucoceles of the floor of the mouth can be a large size (several centimeters-Ranula) Mucocele Ranula
  • 6. Mucocele Pts might report a fluctuation in size related to meals or rupture They are generally soft & fluctuant (older becomes firmer) They are painless They develop rapidly within hours to days Ruptured mucocele Mucocele
  • 7. Mucocele Microscopically Pool of mucus It is a rounded pool of mucus within fibrous connective tissue Inflammatory reaction (Macrophages that contain phagocytized mucus) Phagocytic macrophages
  • 8. Mucus Retention Cyst  Etiology: It results from obstruction of salivary flow because of sialolith, periductal scar or impinging tumor  Clinical features: it is commonly found in the upper lip, palate, cheek and floor of the mouth. It represents asymptomatic swelling Microscopically  Retention cyst: Epithelial-lined fibrous tissue wall surrounds the mucus pool  Little or no inflammatory reaction (no epithelial rupture Cuboidal epithelium
  • 9. Ranula  It is a clincial term that includes mucus extravasation phenomenon and mucus retention cyst  Occur specifically in the floor of t he mouth  Etiology:  Trauma & ductal obstruction  Sialolith: represents precipitation of calcium salts around the central nidus of cellular debris  Clinical features:  it is fluctuant, unilateral soft tissue mass in the floor of the mouth  Histopathology:  It is similar to mucus retention cyst
  • 10. Necrotizing Sialometaplasia Clinically  It is a reactive inflammatory condition of the salivary glands  Average age is 46 years  Male predominence 2:1  Palatal location preference  Deep crater-like ulcer, develops rapidly & slow to heal  Size 1-5 cm. Unilateral ulcer of necrotizing sialometaplasia
  • 11. Necrotizing Sialometaplasia Pathogenesis: Ischemic necrosis or infarction  Traumatic injury  Dental injection  Denture use  Adjacent tumor & cyst  Surgery  Upper respiratory infection or allergy Swelling but no ulceration of necrotizing sialometaplasia
  • 12. Necrotizing Sialometaplasia Acini necrosis Histologically The principle characteristics are:  Lobular coagulative necrosis of acini  Squamous metaplasia of ducts  Pseudoepitheliomatous hyperplasia  inflammation Necrotizing sialometaplasia
  • 13. Necrotizing Sialometaplasia Necrotic mucous acini & mild inflammatory infiltrate Squamous metaplasia (ducts)
  • 14. Infectious Conditions  Mumps:  It is an infectious , acute viral sialadenitis primarily affected the parotid glands  It is the most common salivary gland diseases  Etiology:  The causative agent is a paramyxovirus  2-3 weeks incubation period  Transmission by direct contact with salivary droplets
  • 15. Mumps  Clinical features:  Fever  Malaise  Headache  Chills  Preauricular pain  Parotid swelling  Male = female  Young adults & children
  • 16. Mumps  Complications:  Serious complication in adults can occur:  Oophoritis  Orchitis  Widspread involvement can include  Liver  Pancreas  Kindney  Nervous system
  • 17. Mumps  Differential diagnosis  Bacterial infection (suppurative parotitis)  Salivary calculi  Lymphoma  Lymphoepithelial lesion  Metabolic diseases
  • 18. Mumps  Treatment & Prognosis  Symptomatic therapy  Bed rest  Analgesics  Corticosteroids (variable success)  Vaccination is now available
  • 19. Metabolic Conditions Sialadenosis  It is non-neoplastic & non-inflammatory salivary gland enlargement  It is related to metabotic factor or secretory dysfunction  Painless bilateral swellings  Peak incidence: 5th & 6th decades of life  Slight female predominence  Swelling develops slowly, painless & accompanied by decreasing salivary secretion
  • 20. Metabolic Conditions Sialadenosis It is usually associated with systemic conditions:  Diabetes mellitus  Malnutrition  Liver cirrhosis (Chronic Alcoholism)  Hyperlipidemia  Acromegaly Enlargement of parotid associated with chronic alcoholism & liver cirrhosis
  • 21. Metabolic Conditions Sialadenosis Microscopically As the disease persistsAtrophy of the paranchymal tissue but compensatory increase in the amount of adipose tissue Inflammatory cell infiltrates are absent Atrophy of parotid parenchymal tissue & increase of intraglandular fat
  • 22. Sjögren Syndrome  It is the expression of an autoimmune process that principally results in  Rheumatoid arthritis  Dry eyes (keratoconjunctivitis sicca)  Dry mouth (xerostomia)  Lymphocytic replacement of lacrimal and salivary glands
  • 23. Sjögren Syndrome  Clinical features:  Peak age: 50 yo  Parotid gland enlargment  Treatment:  Artificial saliva and tears & preventive oral measures
  • 24. Sjögren Syndrome Focal aggregates of lymphocytes, periductal lymphocytes & dilated ducts
  • 25. Mixed Tumors “Pleomorphic Adenoma”  It is the most common benign neoplasm of salivary glands origin  It represents 45-74% of all salivary gland tumors  Slow growing & asymptomatic,  Average age is about 43 yo.  Recurrent lesion occurs as multiple nodules & are less mobile than initial lesion.
  • 26. Mixed Tumors “Pleomorphic Adenoma” CT revealed a mixed tumor medial to the mandibular ramus It has prominent cartilagenous & osseous elements that led initially to diagnosis of osteochondroma
  • 27. Mixed Tumors “Pleomorphic Adenoma”  The most common intraoral site is the palate followed by the upper lip & buccal mucosa  Mobility is limited for palatal tumors.  Large intraoral tumors are susceptible to trauma
  • 28. Mixed Tumors “Pleomorphic Adenoma” Submandibular Small glistening capsular surface  Gross finding: It is irregular round to ovoid mass & well defined borders Parotid Homogeneous tan or tan white surface
  • 29. Mixed Tumors “Pleomorphic Adenoma” Gross findings Translucent central zone represents myxochondroid tissue The presence of multiple individual nodules are typical of recurrent mixed tumor
  • 30. Mixed Tumors “Pleomorphic Adenoma” Microscopic findings Composed of epithelial & mesenchymal like tissue Present or absent of fibrous capsule
  • 31. Mixed Tumors “Pleomorphic Adenoma” Cystic degeneration Prominent osseous differentiation in mixed tumor Epithelial cell in mixed tumor Cytokeratin immunoteactivity in epithelial cells
  • 32. Mixed Tumors “Pleomorphic Adenoma” Microscopic findings  In the absence of surgical intervention, viable epithelial cells within necrotic tissue suggest a malignant transformation  Rarely tumor cells are seen within vascular spaces
  • 33. Mixed Tumor “Treatment”  Parotidectomy & excision of the scar tissue with preservation of the facial nerve are recommended (specially recurrent)  Long term follow up is recommended more than 5 years  The risk of malignant degeneration increases with time  Radiotherapy has been found by some investigators to be useful in some recurrent mixed tumor
  • 34. Carcinoma Ex-Mixed Tumor “Clinical Features”  It arises from a benign mixed tumor (diagnosis requires identification of mixed tumor)  20% of patients had previous operation for mixed tumor  The risk for malignant transformation correlates with the duration of mixed tumor  Painless mass or sometimes associated with facial nerve pain or palsy  Tumor is freely movable or sometime fixed to underlying tissue (especially with recurrent tumors)
  • 35. Carcinoma Ex-Mixed Tumor “Microscopic Findings” Myxochondoid bening elements & carcinomatous elements Capsular invasion
  • 36. Carcinoma Ex-Mixed tumor “Treatment” 38-53% develop recurrence Distant metastasis to lung, bone, brain, liver & subcutaneous tissue Radiotherapy alone has proven ineffective, although it may have a beneficial role when combined with surgery
  • 37. Basal Cell Adenoma It is composed of cells predominantly of one type Basal cell adenoma: Occurs mainly in parotid Slow growing & painless Can be multinodular Age 35-80 Male predominence Well circumscribed mass near the inferior pole of the parotid
  • 38. Basal Cell Adenoma Solid Trabecular Solid
  • 39. Basal Cell Adenoma Immunostaining for cytokeratin Histology: Ultrastructure shows ductal cells
  • 40. Basal Cell Adenoma Basal cell adenoma usually lack cribriform pattern Histology: Adenoid cystic carcinoma with clear cytoplasm & angular nuclei
  • 41. Basal Cell Adenoma Treatment & prognosis: Conservative surgical excision including a margin of normal uninvolved tissue Prognosis is good and recurrence rate is so low Small cells in the periphery of the epithelial islands And larger cells adjacent to the tumor islands
  • 42. Malignant Epithelial Tumors “Mucoepidermoid Carcinoma” It is the most common malignant salivary glands tumor It represents 15.5% of all benign & malignant tumors at all sites resemble a mucoceles. Size varies from 1-12cm
  • 43. Mucoepidermoid Carcinoma It is believed to arise from salivary duct system Normal duct-lining epithelium Neoplastic transformation
  • 44. Mucoepidermoid Carcinoma  Ionizing radiation increases the risk for its developing  Occurrence:  45% Parotid gland  7% Submandibular gland  1% Sublingual gland  21% in the palate and 19% for the rest of the minor salivary glands.  Mean age is about 47 years with the age range between 8 to 92 yo.  Women > men
  • 45. Mucoepidermoid Carcinoma  Typically, it is a solitary painless mass  2/3 of pts. are asymptomatic  if growing rapidly, usually accompanied with pain & mucosal ulceration, and sometimes a discharge of fluid resemble abscess.  6 years average between onset & diagnosis (high grade lesions demonstrate a 1.5-year interval before diagnosis).
  • 46. Mucoepidermoid Carcinoma According to cytologic features, it is divided into: - Low - Intermediate - High grade types.  All grades of this neoplasm are carcinomas and have the potential to metastasize.  They are epithelial mucin-producing tumor
  • 47. Mucoepidermoid Carcinoma (Central) This lesion may also arise centrally within the mandible  (Differential diagnosis: giant cell granuloma & odontogenic tumors). Asymptomatic radiolucencies Mandibule > maxilla Third molar region is the most likely to be involved
  • 48. Mucoepidermoid Carcinoma (Central) It arises from either: Ectopic salivary gland tissue Neoplastic transformation of epithelial lining of odontogenic cysts Glandular odontogenic cyst Mayer’s mucicarmine stain highlights numerous mucus cells in a dentigerous cyst
  • 49. Mucoepidermoid Carcinoma Treatment & Prognosis:  low grade usually follow a benign course. However, in several instances low grade lesions have metastasize widely.  High grade metastasize widely (60% of cases).  Surgical, or surgery plus postoperative radiotherapy (high grade)  Central mucoepidermoid carcinoma is usually of low grade (40% recurrence rate).
  • 50. Adenoid Cystic Carcinoma Oral mucosa overlying this palatal mucosa is ulcerated Clinical Features • 50-70% starts in the minor salivary glands. • If major salivary gland (parotid is the most affected) • Age: 5th and 7th decades This tumor appears deceptively well circumscribed
  • 51. Adenoid Cystic Carcinoma  No gender predilection  (slight female predominance).  Unilocular mass  Firm on palpation  Occasional pain or tenderness  Slow growth rate  Bone invasion occurs  Lung metastasis Sublingual gland tumor.
  • 52. Adenoid Cystic Carcinoma Treatment & prognosis:  Surgery is the treatment of choice  Radical resection is justified to obtain surgical margins that are free of tumor  Multiple-agent chemotherapy showed some promise for postoperative treatment  High recurrence rate
  • 53. Acinic Cell Carcinoma Clinical features  Age: 5th  No to 6th decades of life gender predilection  It represents 14% of parotid gland tumor  9% of total salivary gland carcinoma of all sites  50% of cases, the clinical appearance is a benign lesion
  • 54. Acinic Cell Carcinoma Usually less than 3 cm in diameter Pain The interval between the initial appearance & treatment is 6 months to 5 years The origin is the ductal cells
  • 55. Acinic Cell Carcinoma Treatment & prognosis:  Surgery is the preferred treatment  Seldom metastasize  Tendency to recur
  • 56. Polymorphous Low-Grade Adenocarcinoma • It is considered to be low grade malignancy and low risk of metastasis • Age: 5th to 8th decades • No gender predilection • Occurs in minor salivary glands (palate) • Firm, non-ulcerated & non tender • Size between 1-4 cm • Slow growth Well circumscribed mass at the junction of the hard & soft palate
  • 57. Polymorphous Low-Grade Adenocarcinoma Partially circumscribed but lack encapsulation
  • 58. Polymorphous Low-Grade Adenocarcinoma Treatment & prognosis:  Conservative surgical excision  Prognosis is good
  • 59. Carcinoma Ex-Mixed Tumor “Microscopic Findings” The carcinomatous elements appeared separated from benign element Apparent malignant transformation
  • 60. Carcinomatous & benign Components of ExMixed • w
  • 61. Mucoepidermoid Carcinoma Fluctuant because of cyst formation Mucin filled cystic spaces
  • 62. Mucoepidermoid Carcinoma Microscopic features:  The name is a contraction of  epidermoid and mucus-secreting carcinoma A close association of mucous & epidermoid cells Mayer’s mucicarmine hightlights the extracellular & Intracytoplasmic mucin
  • 63. Mucoepidermoid Carcinoma Mucoepidermoid carcinoma incites secondary lymphoid proliferation The lymphoid response extends along the periphery of the tumor
  • 64. Mucoepidermoid Carcinoma Low grade. Note Intracystic spaces Intermediate grade. hyperchromatic nuclei & several microcystic spaces High grade Focal necrosis
  • 65. Epidermoid & mucus cells Epidermoid cells solid & infiltrative Central Mucoepidermoid Carcinoma Cyst Solid & cystic neoplastic area Characteristic variety of cell types
  • 66. Adenoid Cystic Carcinoma Tubular pattern in the top & bottom. A cribriform pattern in the center Epithelial cells have a clear Cytoplasm, poorly defined border & irregular shaped nuclei Immunoreactivity of the tumor cells for cytokeratin
  • 67. Adenoid Cystic Carcinoma Mitotic figures The tumor appears well circumscribed Myoepithelial & ductal cells
  • 68. Adenoid Cystic Carcinoma Neural invasion Comedo-type necrosis
  • 69. Acinic Cell Carcinoma Well differentiated acinar cell » Cytoplasmic granules. » Slightly basophilic cytoplasm » Eccentricaly located nuclei Acinar cells
  • 70. Acinic Cell Carcinoma Papillary cystic growth pattern Follicular pattern
  • 71. Acinic Cell Carcinoma Cluster of neoplastic epithelial cells & numerous electron dense cytoplasmic granules
  • 72. Polymorphous Low-Grade Adenocarcinoma The nuclei are round or ovoid & have a slightly irregular contour Tumor cells are often concentrically arranged