Lect.2. salivary gland pathology

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salivary gland pathology

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  • Pleomorphic Adenomas: PAIM
  • Batsakis- pg 6
  • Figure 16-16 .
  • Batsakis-Pg 6
  • Figure 16-17 Pleomorphic adenoma.
  • Batsakis-Pg 8
  • Batsakis-Pg 8
  • Warthins: WHALE = W arthins H as A bundant L ymphoid and E pithelial components
  • Batsakis-Pg 8
  • Figure 16-18 Warthin tumor.
  • Batsakis- Pg 8
  • Figure 16-19
  • Figure 16-20
  • Batsakis-Pg 22
  • Lect.2. salivary gland pathology

    1. 1. SALIVARY GLAND PATHOLOGY SMS 2044 Dr. Mohanad r. alwan
    2. 2. SALIVARY GLAND DISEASES <ul><li>Although diseases primary to the major salivary glands are in general uncommon, the parotids bear the brunt of these involvements. </li></ul><ul><li>Among the many possible disorders, attention is restricted here to sialadenitis and salivary gland tumors. </li></ul><ul><li>Sialadenitis </li></ul><ul><li>Inflammation of the major salivary glands may be of viral, bacterial, or autoimmune origin. </li></ul><ul><li>Dominant among these causations is the infectious viral disease mumps , which may produce enlargement of all the major salivary glands but predominantly the parotids. </li></ul>
    3. 3. Micrograph showing chronic sialadenitis .
    4. 4. SALIVARY G…….. <ul><li>Although a number of viruses may cause mumps, the dominant cause is a paramyxovirus, an RNA virus related to the influenza and parainfluenza viruses. </li></ul><ul><li>It usually produces a diffuse, interstitial inflammation marked by edema and a mononuclear cell infiltration and, sometimes, by focal necrosis. </li></ul>
    5. 5. <ul><li>Although childhood mumps is self-limited and rarely leaves residua, mumps in adults may be accompanied by pancreatitis or orchitis. </li></ul><ul><li>Bacterial sialadenitis most often occurs secondary to ductal obstruction resulting from stone formation (sialolithiasis), </li></ul><ul><li>but it may also arise after retrograde entry of oral cavity bacteria under conditions of severe systemic dehydration such as the postoperative state. </li></ul>
    6. 6. <ul><li>The sialadenitis may be largely interstitial or cause focal areas of suppurative necrosis or even abscess formation. </li></ul><ul><li>Chronic sialadenitis arises from decreased production of saliva with subsequent inflammation. </li></ul><ul><li>The dominant cause is autoimmune sialadenitis , which is almost invariably bilateral. </li></ul><ul><li>This is seen in Sjögren syndrome . All of the salivary glands (major and minor), as well as the lacrimal glands, may be affected in this disorder, which induces dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca) . </li></ul><ul><li>The combination of salivary and lacrimal gland inflammatory enlargement, which is usually painless, and xerostomia. </li></ul><ul><li>The causes include sarcoidosis, leukemia, lymphoma, and idiopathic lymphoepithelial hyperplasia. </li></ul>
    7. 7. TREATMENT <ul><li>Medical management - Hydration, antibiotics (oral versus parenteral), warm compresses and massage, sialogogues (increases the flow of sliva) </li></ul><ul><li>Surgical management - Consideration of incision and drainage versus excision of the gland in cases refractory to antibiotics, incision and drainage with abscess formation, gland excision in cases of recurrent acute sialadenitis </li></ul>
    8. 8. <ul><li>T he salivary glands give rise to a diversity of tumors that belies their small size. </li></ul><ul><li>About 80% of tumors occur within the parotid glands and most of the others in the submandibular glands. </li></ul><ul><li>The dominant tumor arising in the parotids is the benign pleomorphic adenoma , which is sometimes called a mixed tumor of salivary gland origin. </li></ul>Salivary Gland Tumors
    9. 9. SALIVARY GLAND BENIGN TUMORS <ul><li>pleomorphic adenomas originate from the intercalated duct cells and myoepithelial cells </li></ul><ul><li>oncocytic tumors originate from the striated duct cells </li></ul><ul><li>acinous cell tumors originate from the acinar cells, </li></ul><ul><li>Mucoepidermoid tumors and squamous cell carcinomas develop in the excretory duct cells. </li></ul>
    10. 10. STAGING SYSTEM FOR MAJOR SALIVARY GLAND CANCER <ul><li>Tx Primary tumor cannot be assessed </li></ul><ul><li>T0 No evidence of primary tumor </li></ul><ul><li>T1 Tumor < 2cm in greatest dimension </li></ul><ul><li>T2 Tumor 2-4 cm in greatest dimension </li></ul><ul><li>T3 Tumor 4-6 cm in greatest dimension </li></ul><ul><li>T4 Tumor > 6 cm in greatest dimension </li></ul><ul><li>All categories are subdivided: (a) no local extension; (b) local extension. </li></ul><ul><li>Local extension is clinical or macroscopic invasion of skin, soft tissue, bone, or nerve. </li></ul><ul><li>Microscopic evidence alone is not a local extension for classification purposes. </li></ul>
    11. 11. NORMAL HISTOLOGY
    12. 12. PLEOMORPHIC ADENOMA
    13. 13. PLEOMORPHIC ADENOMA <ul><li>Epithelial Components </li></ul><ul><ul><li>Tubular and cord-like arrangements </li></ul></ul><ul><ul><li>Cells contain a moderate amount of cytoplasm </li></ul></ul><ul><ul><li>Mitoses are rare </li></ul></ul><ul><li>Stromal or “mesenchymal” Components </li></ul><ul><ul><li>Can be quite variable </li></ul></ul><ul><ul><li>Attributable to the myoepithelial cells </li></ul></ul><ul><ul><li>Most tumors show chondroid (cartilaginous) differentiation </li></ul></ul><ul><ul><li>Osseous metaplasia not uncommon </li></ul></ul><ul><ul><li>Relatively hypocellular and composed of pale blue to slightly eosinophilic tissue. </li></ul></ul>
    14. 14. PLEOMORPHIC ADENOMA <ul><li>pleomorphic adenoma contains both epithelial (E) and stromal (S) components. </li></ul><ul><li>Pleomorphic adenoma. Slowly enlarging neoplasm in the parotid gland of many years duration. </li></ul><ul><li>The bisected, sharply circumscribed, yellow-white tumor can be seen surrounded by normal salivary gland tissue </li></ul>
    15. 15. PLEOMORPHIC ADENOMA <ul><li>The diverse microscopic pattern of this lesion is one of its most characteristic features. </li></ul><ul><li>Islands of cuboidal cells arranged in ductlike structures is a common finding. </li></ul><ul><li>Loose chondromyxoid stroma, hyalinized connective tissue, cartilage(arrows) and even osseous tissue are observed. </li></ul><ul><li>This neoplasm is typically encapsulated, although tumor islands may be found within the fibrous capsule. </li></ul>
    16. 16. PLEOMORPHIC ADENOMA A, Low-power view showing a well-demarcated tumor with adjacent normal salivary gland parenchyma. B, High-power view showing epithelial cells as well as myoepithelial cells found within a chondroid matrix material.
    17. 17. WARTHIN'S TUMOR <ul><li>Warthin's tumor (benign papillary cystadenoma lymphomatosum) </li></ul><ul><li>the second most common benign tumor of the parotid gland </li></ul><ul><li>It accounts for 2-10% of all parotid gland tumors </li></ul><ul><li>Bilateral in 10% of the cases </li></ul><ul><li>may contain mucoid brown fluid in FNA </li></ul>
    18. 18. WARTHIN’S TUMOR <ul><li>Mid Power </li></ul><ul><li>Thought to arise from salivary gland inclusions within lymph nodes. </li></ul>
    19. 19. WARTHIN’S TUMOR <ul><li>Epithelial Component </li></ul><ul><ul><li>Consists of papillary fronds which demonstrate 2 layers of oncocytic epitheilal cells </li></ul></ul><ul><ul><li>Cytoplasm stains deep pink and shows granularity of an abundance of mitochondria </li></ul></ul><ul><ul><li>Occasionally undergoes squamous metaplasia (may mistakenly diagnose SCCa on FNA) </li></ul></ul>
    20. 20. WARTHIN’S TUMOR <ul><li>Lymphoid Component </li></ul><ul><ul><li>An abundance of this is present </li></ul></ul><ul><ul><li>Occasional germinal centres will be seen </li></ul></ul><ul><ul><li>Lymphoid tissue forms the core or papillary structures </li></ul></ul><ul><li>Both lymphoid and oncocytic epithelial elements must be present to diagnose Warthin’s </li></ul>
    21. 21. WARTHIN’S TUMOR <ul><li>High Power </li></ul><ul><li>Lymphocytc infilterates. </li></ul><ul><li>Bilayer of epithilium. </li></ul>
    22. 22. WARTHIN’S TUMOR A, Low-power view showing epithelial and lymphoid elements. Note the follicular germinal center beneath the epithelium. B, Cystic spaces separate lobules of neoplastic epithelium consisting of a double layer of eosinophilic epithelial cells based on a reactive lymphoid stroma.
    23. 23. MONOMORPHIC ADENOMA <ul><li>Similar to Pleomorphic Adenoma except no mesenchymal stromal component </li></ul><ul><ul><li>Predominantly an epithelial component </li></ul></ul><ul><li>More common in minor salivary glands (upper lip) </li></ul><ul><li>12% bilateral </li></ul><ul><li>Rare malignant potential </li></ul><ul><li>Types: </li></ul><ul><ul><li>Basal Cell Adenoma </li></ul></ul><ul><ul><li>Canicular Adenoma </li></ul></ul><ul><ul><li>Myoepithelioma Adenoma </li></ul></ul><ul><ul><li>Clear Cell Adenoma </li></ul></ul><ul><ul><li>Membranous Adenoma </li></ul></ul><ul><ul><li>Glycogen-Rich Adenoma </li></ul></ul>
    24. 24. BASAL CELL ADENOMA <ul><li>A monomorphic adenoma </li></ul><ul><li>It is composed of uniform basaloid epithelial cells with a monomorphous pattern. </li></ul><ul><li>The arrangement of tumor cells may be trabecular, tubular or solid. </li></ul><ul><li>Histologically, these tumors are distinguished from pleomorphic adenomas by their absence of chondromyxoid stroma and the presence of a uniform epithelial pattern. </li></ul>
    25. 25. MALIGNANT SALIVARY GLAND TUMORS
    26. 26. MUCOEPIDERMOID CARCINOMA <ul><li>Mucoepidermoid carcinoma (MEC) is the most common malignant tumor of the parotid gland and the second-most common malignancy (adenoid cystic carcinoma is more common) of the submandibular and minor salivary glands. </li></ul><ul><li>Stained + by musicarmine. </li></ul><ul><li>MECs constitute approximately 35% of salivary gland malignancy, and 80% to 90% of MECs occur in the parotid gland. </li></ul>
    27. 27. MUCOEPIDERMOID CARCINOMA <ul><li>MECs contain two major elements: </li></ul><ul><li>Mucin-producing cells and </li></ul><ul><li>Epithelial cells of the epidermoid variety. </li></ul><ul><li>MEC is divided into low-grade (well differentiated). </li></ul><ul><li>High-grade (poorly differentiated). </li></ul>
    28. 28. <ul><li>They contain three cellular elements in varying proportions: squamous cells, mucus-secreting cells, and &quot;intermediate&quot; cells. </li></ul><ul><li>Mucous cells (mucocytes) can occur singly or in clusters, and they have pale and sometimes foamy cytoplasm, a distinct cell boundary, and small, peripherally placed, compressed nuclei. </li></ul><ul><li>Mucocytes often form the lining of cysts or duct-like structures. </li></ul><ul><li>Occasionally mucocytes are so scanty that they can be identified with confidence only by using stains such as mucicarmine. </li></ul><ul><li>Epidermoid cells may be uncommon and focally distributed. </li></ul><ul><li>They have abundant eosinophilic cytoplasm, but they rarely show keratin pearl formation or dyskeratosis. </li></ul><ul><li>Oncocytic metaplasia is seen occasionally. </li></ul>
    29. 29. MUCOEPIDERMOID CARCINOMA A, Mucoepidermoid carcinoma showing islands having squamous cells as well as clear cells containing mucin. B, Mucicarmine stains the mucin reddish-pink. (Courtesy of Dr. James Gulizia, Brigham and Women's Hospital, Boston.)
    30. 30. ADENOID CYSTIC CARCINOMA <ul><li>Adenoid cystic carcinoma with Swiss cheese pattern . </li></ul><ul><li>It is the second-most common malignant tumor of the salivary glands. </li></ul><ul><li>ACC is the most common malignant tumor found in the submandibular, sublingual, and minor salivary glands. </li></ul>
    31. 31. ADENOID CYSTIC CARCINOMA <ul><li>Nerve (N) invaded by adenoid cystic carcinoma (the blue area surrounding the nerve). </li></ul><ul><li>Spread may occur by emboli along the nerve lymphatics </li></ul>
    32. 32. ADENOID CYSTIC CARCINOMA Adenoid cystic carcinoma in a salivary gland. A, Low-power view. The tumor cells have created a cribriform pattern enclosing secretions. B, Perineural invasion by tumor cells.
    33. 33. ACINIC CELL CARCINOMA <ul><li>The acinic cell adenocarcinoma occurs mainly in the parotid gland, also known as blue dot tumor. </li></ul><ul><li>Classic multicystic pattern. </li></ul><ul><li>Stained by PAS. </li></ul><ul><li>Cells heavily stained. </li></ul>
    34. 34. ACINIC CELL CARCINOMA <ul><li>This lesion is characterized by a benign histomorphologic picture but by occasional malignant behavior. </li></ul><ul><li>Bilateral involvement occurs in 3% of patients, making acinic cell carcinoma the second-most common neoplasm, after Warthin’s tumor, to exhibit bilateral presentation. </li></ul>
    35. 35. HODGKIN'S LYMPHOMA <ul><li>Hodgkin's disease involving the parotid gland.  </li></ul><ul><li>Note the Reed-Sternberg cell.  (Fine needle aspiration, Pap, 630x) </li></ul>
    36. 36. SALIVARY GLAND TUMORS
    37. 37. HABIS QUESTION?????????????? Q1 . Mention the common types of salivary gland benign tumors with origin of each. Q2. Identify the histological feature for mucoepidermoid carcinoma

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