The aspirate is suspicious for malignancy based on the following: 1) The aspirate contains basaloid cells with scant clear cytoplasm and dark angulated nuclei suggestive of adenoid cystic carcinoma. 2) Uniform clusters of tumor cells are seen along with hyaline spherical globules adhered to tumor cells. 3) The aspirate has a high risk (70-80%) of being malignant and would require radical resection given the suspicious cytology.

1. Suspicious for Malignancy
 Aspirates which are highly
suggestive of malignancy but not
definitive.
 Often high grade carcinomas with
limited sampling or other limitation
 Suspicious for Malignancy

2. Diagnostic category Risk of
malignancy
Management
Non diagnostic 10-20% Clinical and radiological
correlation/ repeat FNAC
Non-neoplastic 0-20% * Clinical follow up and
radiological correlation
AUS * Repeat FNAC or surgery
Neoplasm
Benign
5-7%
Conservative surgery or
clinical follow up
SUMP 20-40% Conservative surgery
Suspicious for malignancy
(low grade vs high grade)
70-80% Radical resection
Malignant(low grade vs high
grade)
85-95% Radical resection
*- needs to be evaluated further

3. Suspicious for Malignancy
AdCC with Artifact

4. Malignant
 Aspirates which are diagnostic of
malignancy.
 Sub-classify into specific types and
grades of carcinoma: e.g. low grade vs
high grade.
 "Other" malignancies such as
lymphomas, sarcomas and metastases
are also included in this category and
should be specifically designated.

5. Diagnostic category Risk of
malignancy
Management
Non diagnostic 10-20% Clinical and radiological
correlation/ repeat FNAC
Non-neoplastic 0-20% * Clinical follow up and
radiological correlation
AUS * Repeat FNAC or surgery
Neoplasm
Benign
5-7%
Conservative surgery or
clinical follow up
SUMP 20-40% Conservative surgery
Suspicious for malignancy
(low grade vs high grade)
70-80% Radical resection
Malignant(low grade vs high
grade)
85-95% Radical resection
*- needs to be evaluated further

6. Malignant epithelial cell tumour
 Acinic cell carcinoma
 Mucoepidermoid carcinoma
 Adenoid cystic carcinoma
 Polymorphus low grade adenocarcinoma
 Epithelilal myoepithelial carcinoma
 Basal cell adenocarcinoma
 Salivary duct carcinoma
 Carcinoma ex pleomorphic adenoma
 Squamous cell carcinoma

7. Malignant:
Adenoid Cystic Carcinoma
 Uniform basaloid cells with scant clear
cytoplasm
 Dark angulated nuclei
 Metachromatic (magenta in
Romanowsky, translucent in Pap
stain), homogenous matrix material:
globules or cylinders

8. Malignant: Adenoid Cystic
Carcinoma
multi layered dense cell clusters and cup shaped fragments composed of tumor cells
hyaline spherical globules with adherent tumor cells

9. Ovoid or round hyaline globules Tubular and cylindrical or fingerlike structures
Basaloid cells:Compact aggregates of basaloid cells with hyperchromatic nuclei with
coarse chromatin and nucleoli.

10. Finger like and cup shaped cell tumor
cells
Tumor cells in swiss cheese
pattern

11. Basal Cell Adenoma-Tubulotrabecular& Membranous

12. Hyaline gobules though a
striking feature but not
diagnostic
 Basal cell adenoma
 PLGA
 PA
 Epithelial-myoepithelial carcinoma
 Adenoid cystic carcinoma

13. Malignant:
Polymorphous low grade
adenocarcinoma
 Uncommon tumor , occur mainly in minor
salivary glands
 Arises most commonly in fourth to sixth
decade
 Present as slow growing mass

14. Cytology
 Cells are mainly clustered or in epithelial
fragments, which have a trabecular /
pseudopapillary structure with a fibrous stromal
core
 Hyaline stromal globules
 Small basaloid cells, slightly larger ductal cells or
metaplastic squamous cells
 Monotonous cells with fine chromatin
 Mildly enlarged, pale, ovoid, homogenous nuclei

15. Polymorphous low grade adenocarcinoma
showing cluster of small round to oval cells
in the background of fibromyxoid stroma
Small cells, with bland nuclear features, forming
a pseudoglandular space and contains a
homogeneous, metachromatically staining
hyaline globule.

16. Malignant:
Mucoepidermoid carcinoma
 Histologically divided into 3 grades into
low, intermediate and high grade
 Occurs at any age but most common
malignant salivary gland neoplasm in
children

17. Three tier grading system of
mucoepidermoid carcinoma
Low grade Intermediate grade High grade
Amount of
cyst formation
prominent cyst
formation
cyst formation is
seen but less
prominent
cystic component
usually very less
Degree of
cytologic atypia
minimal cellular
atypia with bland
nuclei
cytologic atypia
may or may not be
present
prominent
cytologic atypia
intermediate and
epidermoid cells
present
Relative
number of
cells
High proportion of
mucous cells
Some mucinous
cells
all types of cells
are present but
intermediate cells
are prominent.
Recurrence rate 0-6% 20-39% 61-78%
Metastasis Very rare Some cases common

18. Low-grade mucoepidermoid carcinoma
showing clusters of mucous cells, smaller
intermediate cells, prominent goblet like
cells.
Intermediate cells with high N/C ratio
and epidermoid cells with low N/C ratio
(red arrow)

19. High-grade mucoepidermoid carcinoma. The cells are large,
pleomorphic and show severe cytologic atypia. The
cytoplasm has a dense quality with squamoid features
(Papanicolaou stain)

21. Differential Diagnosis-
 Benign-
 Malignant
 Non neoplastic
◦ Chronic sialadenitis with
squamous metaplasia
◦ Acquired non-neoplastic
mucinous cysts (esp.
mucocele)
◦ Warthins tumor with mucinous
meatplasia
◦ PA with mucinous metaplasia
 HG MEC V/S primary SCC V/S
secondary SCC metastatic to

22. Note
 Any cystic salivary gland lesion
containing mucinous background
should suggest the low-grade
mucoepidermoid carcinoma in the
differential
 MEC generally do not exhibit
keratinization while squamous
metaplasias in pleomorphic adenomas
quite often do. The presence of keratin

23. Malignant: Acinic cell carcinoma
 Large acinar cells, in clusters or dissociated
 Azurophilic cytoplasmic granulation
 Periodic acid-Schiff (PAS) positive, diastase
resistant cytoplasmic zymogen granules
 Lymphoid background
 Rounded, medium sized nuclei, moderate
 anisokaryosis and bland chromatin
 Many naked nuclei in clean background

25. Irregular cluster of acinic cell carcinoma
showing cytoplasmic vacuoles, eccentric
nuclei, and occasional nucleoli.
Tumor cells with papillary arrangement
and singly scattered

26. Acinic Cell Carcinoma
Cytologic Differential
 Normal parotid gland tissue
 Oncocytoma
 Low grade Adenocarcinoma
 Metastatic clear cell renal cell carcinoma

27. Normal Salivary Gland Acinic Cell Carcinoma
Less cellular
N/C ratios low
More cellular
normal-sized to large cells; delicate cell
borders; N/C ratios variable
nuclei small, round, uniform and
basally located; finely granular
chromatin; nucleolus inconspicuous;
abundant, granular cytoplasm
nuclei enlarged, round with granular
chromatin prominent nucleoli;
abundant, granular, vacuolated or clear
cytoplasm
Lobular arrangement Haphazardly arranged
Ducts present Acinic cells only, no ducts or fibrofatty
stroma