Warthins: WHALE = W arthins H as A bundant L ymphoid and E pithelial components
Figure 16-18 Warthin tumor.
Lect.2. salivary gland pathology
SALIVARY GLAND PATHOLOGY SMS 2044 DR. MOHANAD R. ALwAN
SALIVARY GLAND DISEASES Although diseases primary to the major salivary glands are in general uncommon, Among the many possible disorders, attention is restricted here to Sialadenitis and salivary gland tumors.Sialadenitis• Inflammation of the major salivary glands may be of viral, bacterial, or autoimmune origin.• Dominant among these causations is the infectious viral disease mumps, which may produce enlargement of all the major salivary glands but predominantly the parotids.
SALIVARY G…….. Although a number of viruses may cause mumps, the dominant cause is a paramyxovirus, an RNA virus related to the influenza and parainfluenza viruses. It usually produces a diffuse, interstitial inflammation marked by edema and a mononuclear cell infiltration and, sometimes, by focal necrosis.
Although childhood mumps is self-limited and rarely leaves residua, mumps in adults may be accompanied by pancreatitis or orchitis. Bacterial sialadenitis most often occurs secondary to ductal obstruction resulting from stone formation (sialolithiasis), but it may also arise after retrograde entry of oral cavity bacteria under conditions of severe systemic dehydration such as the postoperative state.
Chronic sialadenitis arises from decreased production of saliva with subsequent inflammation. The dominant cause is autoimmune sialadenitis, which is almost invariably bilateral. 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). The combination of salivary and lacrimal gland inflammatory enlargement, which is usually painless, and xerostomia. The causes include sarcoidosis, leukemia, lymphoma, and idiopathic lymphoepithelial hyperplasia.
TREATMENTMedical management - Hydration, antibiotics (oral versus parenteral), warm compresses and massage, sialogogues (increases the flow of sliva)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
Salivary Gland Tumors The salivary glands give rise to a diversity of tumors that belies their small size.About 80% of tumors occur within the parotid glands and most of the others in the submandibular glands.The dominant tumor arising in the parotids is the benign pleomorphic adenoma, which is sometimes called a mixed tumor of salivary gland origin.
SALIVARY GLAND BENIGN TUMORSpleomorphic adenomas originate from the intercalated duct cells and myoepithelial cellsoncocytic tumors originate from the striated duct cellsacinous cell tumors originate from the acinar cells,Mucoepidermoid tumors and squamous cell carcinomas develop in the excretory duct cells.
STAGING SYSTEM FOR MAJOR SALIVARY GLAND CANCER Tx Primary tumor cannot be assessed T0 No evidence of primary tumor T1 Tumor < 2cm in greatest dimension T2 Tumor 2-4 cm in greatest dimension T3 Tumor 4-6 cm in greatest dimension T4 Tumor > 6 cm in greatest dimension All categories are subdivided: (a) no local extension; (b) local extension. Local extension is clinical or macroscopic invasion of skin, soft tissue, bone, or nerve. Microscopic evidence alone is not a local extension for classification purposes.
PLEOMORPHIC ADENOMAEpithelial Components • Tubular and cord-like arrangements • Cells contain a moderate amount of cytoplasm • Mitoses are rareStromal or “mesenchymal” Components • Can be quite variable • Attributable to the myoepithelial cells • Most tumors show chondroid (cartilaginous) differentiation • Osseous metaplasia not uncommon • Relatively hypocellular and composed of pale blue to slightly eosinophilic tissue.
PLEOMORPHIC ADENOMA pleomorphic adenoma contains both epithelial (E) and stromal (S) components. Pleomorphic adenoma. Slowly enlarging neoplasm in the parotid gland of many years duration. The bisected, sharply circumscribed, yellow-white tumor can be seen surrounded by normal salivary gland tissue
PLEOMORPHIC ADENOMA Islands of cuboidal cells arranged in duct like structures is a common finding. Loose chondromyxoid stroma, hyalinized connective tissue, cartilage(arrows) and even osseous tissue are observed. This neoplasm is typically encapsulated, although tumor islands may be found within the fibrous capsule.
PLEOMORPHIC ADENOMA A, Low-power view showing a well-demarcated tumor with adjacent normalsalivary gland parenchyma.B, High-power view showing epithelial cells as well as myoepithelial cells foundwithin a chondroid matrix material.
WARTHINS TUMORWarthins tumor (benignpapillary cystadenomalymphomatosum)the second most commonbenign tumor of the parotidglandIt accounts for 2-10% of allparotid gland tumorsBilateral in 10% of thecasesmay contain mucoid brownfluid
WARTHIN’S TUMORMid PowerThought to arise from salivary gland inclusions within lymph nodes.
WARTHIN’S TUMOREpithelial Component Consists of papillary fronds which demonstrate 2 layers of oncocytic epitheilal cells Cytoplasm stains deep pink and shows granularity of an abundance of mitochondria Occasionally undergoes squamous metaplasia (may mistakenly diagnose SCCa)
WARTHIN’S TUMORLymphoid Component An abundance of this is present Occasional germinal centres will be seen Lymphoid tissue forms the core or papillary structuresBoth lymphoid and oncocytic epithelial elements must be present to diagnose Warthin’s
WARTHIN’S TUMORo High Powero Lymphocytc infilterates.o Bilayer of epithilium.
WARTHIN’S TUMORA, Low-power view showing epithelial and lymphoid elements. Note thefollicular germinal center beneath the epithelium.B, Cystic spaces separate lobules of neoplastic epithelium consisting of adouble layer of eosinophilic epithelial cells based on a reactive lymphoidstroma.
MONOMORPHIC ADENOMASimilar to Pleomorphic Adenoma except no mesenchymal stromal component • Predominantly an epithelial componentMore common in minor salivary glands (upper lip)12% bilateralRare malignant potentialTypes: • Basal Cell Adenoma • Canicular Adenoma • Myoepithelioma Adenoma • Clear Cell Adenoma • Membranous Adenoma • Glycogen-Rich Adenoma
MUCOEPIDERMOID CARCINOMAMucoepidermoid 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.MECs constitute approximately 35% of salivary gland malignancy, and 80% to 90% of MECs occur in the parotid gland.
MUCOEPIDERMOIDCARCINOMA• MECs contain two major elements:• Mucin-producing cells and• Epithelial cells of the epidermoid variety.• MEC is divided into low- grade (well differentiated).• High-grade (poorly differentiated).
They contain three cellular elements in varying proportions: squamous cells, mucus-secreting cells, and intermediate" cells.Mucous cells (mucocytes) can occur singly or in clusters, pale and sometimes foamy cytoplasm and small, peripherally placed, compressed nuclei. Mucocytes often form the lining of cysts or duct-like structures.Occasionally mucocytes are so scanty that they can be identified with confidence only by using stains such as mucicarmine.Epidermoid cells may be uncommon and focally distributed.They have abundant eosinophilic cytoplasm, but they rarely show keratin pearl formation or dyskeratosis. Oncocytic metaplasia is seen occasionally.
MUCOEPIDERMOID CARCINOMAA, Mucoepidermoid carcinoma showing islands having squamous cells aswell as clear cells containing mucin.B, Mucicarmine stains the mucin reddish-pink. (Courtesy of Dr. JamesGulizia, Brigham and Womens Hospital, Boston.)
ADENOID CYSTIC CARCINOMAAdenoid cystic carcinoma with Swiss cheese pattern.It is the second-most common malignant tumor of the salivary glands. ACC is the most common malignant tumor found in the submandibular, sublingual, and minor salivary glands.
ADENOID CYSTIC CARCINOMANerve (N) invaded by adenoid cystic carcinoma (the blue area surrounding the nerve).Spread may occur by emboli along the nerve lymphatics
ADENOID CYSTIC CARCINOMAAdenoid cystic carcinoma in a salivary gland.A, Low-power view. The tumor cells have created a cribriform pattern enclosingsecretions.B, Perineural invasion by tumor cells.
HODGKINS LYMPHOMAHodgkins disease involving the parotid gland.Note the Reed-Sternberg cell. (Fine needle aspiration, Pap, 630x)