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Salivary gland pathology
- 1. Salivary Gland Tumors Dr. Arsalan Malik Assistant Professor (Oral Pathology) ِيم ِحَّالر ِمنْحَّالر ِهللا ِمْسِب 1
- 2. 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 2
- 3. Functions of Saliva • Protection • Lubrication • Buffering • Digestion • Taste • Antimicrobial • Tooth integrity 3
- 4. Normal histology of salivary gland 4
- 5. Acinar cells of Salivary Glands Classified as either: • Serous cells: produce a thin watery secretion • Mucous cells: produce a more viscous secretion 5
- 6. Salivary gland secretory unit • Composed of terminal acini • Intercalated, striated and excretory ducts • Myoepithelial cells 6
- 7. Major Glands/Secretions • Major SG are paired structures and include the parotid, submandibular and sublingual • Parotid: serous • Submandibular: mucous & serous • Sublingual: mucous 7
- 8. Diseases of Salivary Glands • Neoplastic • Developmental • Infectious • Inflammatory • Autoimmune • Ischemic 8
- 10. Etiologic Factors • Radiation exposure • Genetic predisposition • Tobacco • Chemical carcinogens • Viruses 10
- 11. 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% 11
- 12. 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 12
- 13. Salivary Gland Tumors • Benign • Malignant Relative proportion of malignancy increasing in the smaller glands (rule of thumb is the 25/50/75 rule) 13
- 14. Salivary Gland Tumors Benign ► Pleomorphic adenoma ► Warthin`s tumor ► Oncocytoma ► Myoepithelioma ► Ductal papilomas ► Monomorphic adenoma 1. Basal cell adenoma 2. Canalicular adenoma Malignant ►Mucoeidermoid carcinoma ►Acinic cell carcinoma ►Adenoid cystic carcinoma ►Polymorphous low grade adenocarcinoma ►Carcinoma arising in pleomorphic adenoma 14
- 15. BENIGN SAIVARY GLAND TUMORS 15
- 16. 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 16
- 17. Salivary Gland Tumors Benign ► Pleomorphic adenoma ► Warthin`s tumor ► Oncocytoma ► Myoepithelioma ► Ductal papilomas ► Monomorphic adenoma 1. Basal cell adenoma 2. Canalicular adenoma Malignant ►Mucoeidermoid carcinoma ►Acinic cell carcinoma ►Adenoid cystic carcinoma ►Polymorphous low grade adenocarcinoma ►Carcinoma arising in pleomorphic adenoma 17
- 18. 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 18
- 19. Pleomorphic Adenoma Gross Pathology: - well circumscribed firm tan white solid or partially cystic mass Histology: - ductal epithelial cells - myoepithelial cells - stroma: myxoid, chondroid, fibrohyaline 19
- 21. Pleomorphic Adenoma Treatment: • Surgical excision • Superficial parotidectomy • Prognosis: excellent • Complications: • recurrence – multifocal • malignant transformation (5%) 21
- 22. Salivary Gland Tumors Benign ► Pleomorphic adenoma ► Warthin`s tumor ► Oncocytoma ► Myoepithelioma ► Ductal papilomas ► Monomorphic adenoma 1. Basal cell adenoma 2. Canalicular adenoma Malignant ►Mucoeidermoid carcinoma ►Acinic cell carcinoma ►Adenoid cystic carcinoma ►Polymorphous low grade adenocarcinoma ►Carcinoma arising in pleomorphic adenoma 22
- 23. Warthin’s Tumor (Papillary Cystadenoma Lymphomatosum) • Benign salivary gland tumor • Incidence: common • Gender: male > female • Age: 5-7th decades • Symptoms: painless mass • Site: parotid, multi-focal/bilateral (14%) • Etiology: smoking (8 fold risk) 23
- 24. Warthin’s Tumor • Gross Pathology: • Well circumscribed cystic mass • Papillations • “machine oil fluid” Histology: • Encapsulated cystic lesion • Papillary fronds • Oncocytic columnar cells • Lymphoid stroma 24
- 26. Warthin’s Tumor Treatment: • Surgical excision • Superficial parotidectomy • Prognosis: excellent Complications: • Recurrence – 6-12% (multicentric) • Association with other salivary tumors • Malignant transformation – extremely rare 26
- 27. Salivary Gland Tumors Benign ► Pleomorphic adenoma ► Warthin`s tumor ► Oncocytoma ► Myoepithelioma ► Ductal papilomas ► Monomorphic adenoma 1. Basal cell adenoma 2. Canalicular adenoma Malignant ►Mucoeidermoid carcinoma ►Acinic cell carcinoma ►Adenoid cystic carcinoma ►Polymorphous low grade adenocarcinoma ►Carcinoma arising in pleomorphic adenoma 27
- 28. 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 28
- 29. Oncocytoma • Encapsulated • Trabecular-organoid • Oncocytic epithelial cells • Fibrous septae • Clear cells 29
- 30. Oncocytoma Treatment • Surgical excision Prognosis • Excellent • Recurrence uncommon • Oncocytic Adenocarcinoma - sinonasal tract 30
- 31. Oncocytoma • Electron Microscopy: -Mitochondrial hyperplasia -60% of cell volume 31
- 32. Ductal Papillomas Present in three forms • 1-Simple ductal papilloma • 2-Inverted ductal papilloma • 3-Sialadenoma papilliferum 32
- 33. 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 33
- 34. 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 seen 34
- 35. 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 cells 35
- 36. Salivary Gland Tumors Benign ► Pleomorphic adenoma ► Warthin`s tumor ► Oncocytoma ► Myoepithelioma ► Ductal papilomas ► Monomorphic adenoma 1. Basal cell adenoma 2. Canalicular adenoma Malignant ►Mucoeidermoid carcinoma ►Acinic cell carcinoma ►Adenoid cystic carcinoma ►Polymorphous low grade adenocarcinoma ►Carcinoma arising in pleomorphic adenoma 36
- 37. 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 37
- 38. Canalicular Adenoma • Benign salivary gland neoplasm • Monomorphic adenoma • Site: upper lip (75%) • Age: 7th decade • Gender: female predilection • Symptoms: slow growing mass • Multifocal 38
- 40. Canalicular Adenoma Treatment • Conservative surgical excision • Enucleation not recommended Prognosis • Excellent • Rare recurrence • Can be misdiagnosed as a malignancy 40
- 41. Basal Cell Adenoma • Benign salivary gland neoplasm • Monomorphic adenoma • Incidence: 2% of salivary gland tumors • Site: parotid gland (75%) • Age: 4-9th decades • Gender: female predilection (2:1) • Symptoms: slow growing mass (< 3cm) 41
- 42. Basal Cell Adenoma • Solid • Most common • Solid nests of tumor cells • Uniform, hyperchromatic, round nuclei, indistinct cytoplasm • Peripheral nuclear palisading • Scant stroma 42
- 43. Basal Cell Adenoma Trabecular pattern `Elongated anastomosing cords of basal cells, surrounded by connective tissue stroma. 43
- 44. Basal Cell Adenoma Tubular Pattern `Basaloid cells surrounds the duct like structure. 44
- 45. Basal Cell Adenoma Membranous or dermal analogue adenoma `Tumor islands moulded in jig saw puzzle fashion surrounded by hylinized basal lamina 45
- 46. Basal Cell Adenoma Treatment • Complete surgical excision Prognosis • Excellent • Recurrences may occur • Malignant transformation is rare • Hybrid tumor 46
- 48. 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% 48
- 49. 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 49
- 50. 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 50
- 51. 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 51
- 52. Salivary Gland Tumors Benign ► Pleomorphic adenoma ► Warthin`s tumor ► Oncocytoma ► Myoepithelioma ► Ductal papilomas ► Monomorphic adenoma 1. Basal cell adenoma 2. Canalicular adenoma Malignant ►Mucoeidermoid carcinoma ►Acinic cell carcinoma ►Adenoid cystic carcinoma ►Polymorphous low grade adenocarcinoma ►Carcinoma arising in pleomorphic adenoma 52
- 53. 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 53
- 54. Mucoepidermoid Carcinoma • Gross pathology • Well-circumscribed to partially encapsulated to unencapsulated • Solid tumor with cystic spaces 54
- 55. Mucoepidermoid Carcinoma • Histology—Low-grade • Mucus cell > epidermoid cells • Prominent cysts • Mature cellular elements 55
- 56. Mucoepidermoid Carcinoma • Histology—Intermediate- grade • Mucus = epidermoid • Fewer and smaller cysts • Increasing pleomorphism and mitotic figures 56
- 57. Mucoepidermoid Carcinoma • Histology—High-grade • Epidermoid > mucus • Solid tumor cell proliferation • Mistaken for SCCA • Mucin staining 57
- 58. Mucoepidermoid Carcinoma • Histology—High-grade • Epidermoid > mucus • Solid tumor cell proliferation • Mistaken for SCCA • Mucin staining 58
- 59. 59
- 60. Mucoepidermoid Carcinoma Treatment Influenced by site, stage, grade Stage I & II Wide local excision Stage III & IV Radical excision +/- neck dissection +/- postoperative radiation therapy 60
- 61. 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 61
- 62. Salivary Gland Tumors Benign ► Pleomorphic adenoma ► Warthin`s tumor ► Oncocytoma ► Myoepithelioma ► Ductal papilomas ► Monomorphic adenoma 1. Basal cell adenoma 2. Canalicular adenoma Malignant ►Mucoeidermoid carcinoma ►Acinic cell carcinoma ►Adenoid cystic carcinoma ►Polymorphous low grade adenocarcinoma ►Carcinoma arising in pleomorphic adenoma 62
- 63. 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 63
- 64. Acinic Cell Carcinoma • Gross pathology • Well-demarcated • Most often homogeneous 64
- 65. Histopathology • Circumscribed • Variable growth patterns • Variable cytology • Low grade tumor • Scant stroma • Lymphoid infiltrate 65
- 66. Histopathology • Histology • Solid and microcystic patterns • Most common • Solid sheets • Numerous small cysts • Polyhedral cells • Small, dark, eccentric nuclei • Basophilic granular cytoplasm 66
- 67. 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 67
- 68. 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 68
- 69. 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 69
- 70. Adenoid Cystic Carcinoma • Gross pathology • Well-circumscribed • Solid, rarely with cystic spaces • infiltrative 70
- 71. Adenoid Cystic Carcinoma • Histology— • cribriform pattern • Most common • “swiss cheese” appearance 71
- 72. 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 72
- 73. Adenoid Cystic Carcinoma Treatment 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% 73
- 74. Salivary Gland Tumors Benign ► Pleomorphic adenoma ► Warthin`s tumor ► Oncocytoma ► Myoepithelioma ► Ductal papilomas ► Monomorphic adenoma 1. Basal cell adenoma 2. Canalicular adenoma Malignant ►Mucoeidermoid carcinoma ►Acinic cell carcinoma ►Adenoid cystic carcinoma ►Polymorphous low grade adenocarcinoma ►Carcinoma arising in pleomorphic adenoma 74
- 75. 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 75
- 76. 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 76
- 77. 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 77
- 78. Polymorphous low grade adenocarcinoma • Histology • Isomorphic cells, indistinct borders, uniform nuclei • Peripheral “Indian-file” pattern • Treatment • Complete yet conservative excision 78
- 79. Lymphoepithelial Carcinoma • Rare • High grade/poorly differentiated carcinoma • Lymphoid stroma • Asians, Greenlanders • Epstein-Barr virus • Prognosis - guarded 79
- 80. Lymphoepithelial Carcinoma • undifferentiated tumor associated with a dense lymphoid stroma 80
- 81. Salivary Adenocarcinoma NOS • Some tumours still defy the current classification of salivary gland tumours • These are labelled as Salivary Adenocarcinoma Not Otherwise Specified (NOS) 81
- 82. 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. 82