Salivary gland pathoology 1


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Oral Pathology II
Forth Year

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Salivary gland pathoology 1

  1. 1. Februray 29, 2009 Salivary Glands Classification, General Considerations & Tumors Like Conditions By Louay Jaber DDS, MSc, MSD, PhD
  2. 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. 3. The Normal Salivary Gland (Cont.) “Parotid gland” Lymph node Serous Acini & striated duct Facial nerve
  4. 4. The Normal Salivary Gland (Cont.) “Submandibular, sublingual & minor glands” Submandibular Sublingual Minor
  5. 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. 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. 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. 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. 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. 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. 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. 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. 13. Necrotizing Sialometaplasia Necrotic mucous acini & mild inflammatory infiltrate Squamous metaplasia (ducts)
  14. 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. 15. Mumps  Clinical features:  Fever  Malaise  Headache  Chills  Preauricular pain  Parotid swelling  Male = female  Young adults & children
  16. 16. Mumps  Complications:  Serious complication in adults can occur:  Oophoritis  Orchitis  Widspread involvement can include  Liver  Pancreas  Kindney  Nervous system
  17. 17. Mumps  Differential diagnosis  Bacterial infection (suppurative parotitis)  Salivary calculi  Lymphoma  Lymphoepithelial lesion  Metabolic diseases
  18. 18. Mumps  Treatment & Prognosis  Symptomatic therapy  Bed rest  Analgesics  Corticosteroids (variable success)  Vaccination is now available
  19. 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. 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. 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. 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. 23. Sjögren Syndrome  Clinical features:  Peak age: 50 yo  Parotid gland enlargment  Treatment:  Artificial saliva and tears & preventive oral measures
  24. 24. Sjögren Syndrome Focal aggregates of lymphocytes, periductal lymphocytes & dilated ducts
  25. 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. 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. 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. 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. 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. 30. Mixed Tumors “Pleomorphic Adenoma” Microscopic findings Composed of epithelial & mesenchymal like tissue Present or absent of fibrous capsule
  31. 31. Mixed Tumors “Pleomorphic Adenoma” Cystic degeneration Prominent osseous differentiation in mixed tumor Epithelial cell in mixed tumor Cytokeratin immunoteactivity in epithelial cells
  32. 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. 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. 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. 35. Carcinoma Ex-Mixed Tumor “Microscopic Findings” Myxochondoid bening elements & carcinomatous elements Capsular invasion
  36. 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. 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. 38. Basal Cell Adenoma Solid Trabecular Solid
  39. 39. Basal Cell Adenoma Immunostaining for cytokeratin Histology: Ultrastructure shows ductal cells
  40. 40. Basal Cell Adenoma Basal cell adenoma usually lack cribriform pattern Histology: Adenoid cystic carcinoma with clear cytoplasm & angular nuclei
  41. 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. 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. 43. Mucoepidermoid Carcinoma It is believed to arise from salivary duct system Normal duct-lining epithelium Neoplastic transformation
  44. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 55. Acinic Cell Carcinoma Treatment & prognosis:  Surgery is the preferred treatment  Seldom metastasize  Tendency to recur
  56. 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. 57. Polymorphous Low-Grade Adenocarcinoma Partially circumscribed but lack encapsulation
  58. 58. Polymorphous Low-Grade Adenocarcinoma Treatment & prognosis:  Conservative surgical excision  Prognosis is good
  59. 59. Carcinoma Ex-Mixed Tumor “Microscopic Findings” The carcinomatous elements appeared separated from benign element Apparent malignant transformation
  60. 60. Carcinomatous & benign Components of ExMixed • w
  61. 61. Mucoepidermoid Carcinoma Fluctuant because of cyst formation Mucin filled cystic spaces
  62. 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. 63. Mucoepidermoid Carcinoma Mucoepidermoid carcinoma incites secondary lymphoid proliferation The lymphoid response extends along the periphery of the tumor
  64. 64. Mucoepidermoid Carcinoma Low grade. Note Intracystic spaces Intermediate grade. hyperchromatic nuclei & several microcystic spaces High grade Focal necrosis
  65. 65. Epidermoid & mucus cells Epidermoid cells solid & infiltrative Central Mucoepidermoid Carcinoma Cyst Solid & cystic neoplastic area Characteristic variety of cell types
  66. 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. 67. Adenoid Cystic Carcinoma Mitotic figures The tumor appears well circumscribed Myoepithelial & ductal cells
  68. 68. Adenoid Cystic Carcinoma Neural invasion Comedo-type necrosis
  69. 69. Acinic Cell Carcinoma Well differentiated acinar cell » Cytoplasmic granules. » Slightly basophilic cytoplasm » Eccentricaly located nuclei Acinar cells
  70. 70. Acinic Cell Carcinoma Papillary cystic growth pattern Follicular pattern
  71. 71. Acinic Cell Carcinoma Cluster of neoplastic epithelial cells & numerous electron dense cytoplasmic granules
  72. 72. Polymorphous Low-Grade Adenocarcinoma The nuclei are round or ovoid & have a slightly irregular contour Tumor cells are often concentrically arranged