Salivary gland tumour on FNA.

1. Speaker: Dr. Mahesh
Guide: Dr. H. P. Srilakshmi

2.  Major : - Parotid
- Submandibular(Sub maxillary)
 Minor: - Sublingual
- lips, gingiva, floor of mouth, cheek, hard
and soft palate, tongue, tonsillar areas,
and oropharynx
 Parotid : Pure serous
 Submandibular: Mixed(Serous + Mucinous) Serous
predominance
 Sublingual : Mixed with Mucinous predominance

3.  Acinar and Ductal epithelial cells
 Intraparotid Lymph nodes
 Acinar cells are large, with abundant cytoplasm and
small round uniform nuclei.
- serous gland: Cytoplasm fine granular
- Mucous gland: Cytoplasm clear or finely
vacuolated
 Intercalated duct: Cuboidal cell
 Striated duct: Columnar cells

5. Intra parotid lymph node
 Due to late encapsulation in foetal life small lymph
nodes are enclosed within parotid.
 Often confuses with enlarged lymph nodes and
sialomegaly

6.  Benign Epithelial tumour
- Pleomorphic adenoma
- Warthin tumour
- Oncocytoma
- Myoepithelioma
- Basal cell adenoma

7.  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
- Myoepithelial carcinoma
- Squamous cell carcinoma

8. Soft tissue tumour
- Hemangioma
Haematolymphoid tumour
- Diffuse large B cell lymphoma
- Extranodal marginal zone lymphoma
- Hodgkin’s lymphoma
Secondary tumour

9.  Most common Neoplasm of salivary gland
 Most frequent in 4th decade of life
 F> M
 Parotid> Submandibular> Sublingual (Rare)
 Parotid: Superficial lobe > deep lobe
 C/ F: - smooth painless enlarging mass below ear
- On palpation, the tumor feels firm, round,
or bossilated and may be movable

10. Microscopy
 Mixture of epithelial and stromal component
 Epithelial component: Myoepithelial and ductal
cells present in various proportions
 Myoepithelial cells:
-Poorly cohesive sheets, clusters and singly
-Rounded, ovoid, plasmacytoid or spindle shape
-well defined cytoplasm
-finely granular nuclear chromatin
 Stromal component :
-chondromyxoid stromal fragments and
myoepithelial cells embedded within

11.  Sometimes
- Metaplastic cells: squamous, oncocytic,
sebaceous
- Mucus production
- Hyaline globules
- Tyrosine crystals are seen
Differentai diagnosis
 Well differentiated adenoid cystic carcinoma
 Basal cell adenoma,
 Low grade mucoepidermoid carcinoma
 Carcinoma ex pleomorphic adenoma

14.  Almost exclusively in parotid
 Common in male in 6th to 7th decade of life
 10% bilateral and often associated with smoking
 C/F:
- Slowly growing soft, usually cystic, painless
lobulated tumour in parotid region
- On palpation feel soft or boggy but in
situations of increased fluid accumulation
they may feel quite tense and firm

15.  Microscopy:
 Aspirate is mucoid, murky fluid
 3 Components: Oncocytes, reactive lymphocytes and
cellular debris in mucoid background
 Oncocytes :
- Monolayered sheets with irregular outline.
- Small round central nucleus, bland chromatin
and abundant granular cytoplasm
 Reactive lymphocytes in the background
 Background is dirty- mucoid and degenerated cells
 Occasionally mucin secreting cells and sebaceous
cells are seen.

18. Differential Diagnosis
 Oncocytoma
 Low grade mucoepidrmoid carcinoma
 Acinic cell carcinoma
 Squamous cell carcinoma

19.  Common in adult age group and F>M
 Most common in parotid
 Smaller than benign mixed tumour
 Microscopy
 Basaloid cells:
- Small, uniform
- Arranged in clusters with occasionally
peripheral palisading appearance
- Scanty pale basophilic cytoplasm, bland
round to oval nuclei with granular chromatin
 Eosinophilic hyaline material usually adjacent to cell
cluster

20.  Scanty fibrous stroma
 Frequent squamous metaplasia
Variants: Based on Histological architectural pattern
- solid
- trabecular
- tubular
- membranous
 Differentail Diagnosis
- Adenoid cystic carcinoma
- Pleomorphic adenoma with scanty stroma
- Basal cell adenocarcinoma
- Dermal tumour (Eccrine cylindroma)

23.  Benign, solid tumour
 Occur in parotid, submandibular or minor salivary
gland
 Common in 70 year age group and F>M
 Often h/o Radiation
Microscopically
 Oncocytes:
- Arranged in multilayered aggregates
- Abundant granular eosinophilic cytoplasm,
- small round central nuclei

24.  Absence of fluid, cellular debris, lymphocytes
Differential diagnosis
 Warthin tumour
 Acinic cell carcinoma

26. Myoepithelial adenoma:
 Cells are arranged in loose cohesive clusters
 Cells can be spindly or plasmacytoid cell
 Diagnosis supported by IHC.
 Differential Diagnosis
 Oncocytoma
 Pleomorphic adenoma with scanty stroma
 Myoepithelial carcinoma

28.  Other rare benign tumour include
sebaceous adenoma, lymphadenoma, duct
pailloma and benign mesenchymal tumour
like lipoma, schwannoma and hemangioma.

29.  Most common salivary gland malignancy of adult and
2nd most common in Children
 Most common in parotid but also seen in minor
salivary gland, palate, floor of mouth, tongue, RMT
 C/F: Well demarcated, painless at origin
 Tumour divided into
 Low grade
 High grade

30.  Cell types can be identified: mucin producing,
intermediate and squamous
 Intermediate cells:
- Predominant cell type
- in cohesive sheets
- Rounded cell, well defined cytoplasm, bland nuclei
- appearance intermediate between mucous
secreting and squamous
 Mucous cells : - cohesive sheets and in cluster of
intermediate cells
- cytoplasm vacuolated with basally
located nuclei

31.  Squamous cells
- Small aggregates or singly
- Eosinophilic cytoplasm with variable intensity
of keratin staining and best appreciated on
PAP stain.
 True squamous differentiation and keratinisation is
uncommon in low grade tumour.
 Background: dirty and contains mucus and debris
and sometimes lymphoid cells

32. Characteristic High grade Low grade
Cellularity Highly cellular Hypocellular
Predominance cell
Squamous and
intermediate
Mix mucous
producing and
intermediate
Keratinisation
Present and even
squamous pearl
Not seen
Background Less mucin
Abundant thick
mucin
Mitosis Numeous Very rare

33. Characteristic High grade Low grade
Demarcation
Less well
demarcated
Well demarcated
Infiltration
Into surrounding
tissue
Localised
Perineural invasion
Present and often
fascial nerve palsy
Not present
Distant metastasis Common Very rare
Pain Painful Painless

37.  Differential diagnosis
 Low grade
 Warthin tumour
 Chronic sialadenitis and kuttner’s tumour
 High grade
 Primary or metastatic SCC

38.  Highly malignant slow growing tumour
 Common in middle aged and elderly
 Commonly involves minor salivary glands and
occasionally presents at unusual sites such as
upper airways, nose, sinuses, lacrimal glands, and
external auditory canals
 C/F:
- Initially painless slow growing mass in oral cavity
later become painful

39. Microscopy
 Cellular smear
 Predominantly basaloid cells
- tight clusters
- rosette like formation,
- cup shaped fragments
- adherent to hyaline globules
- naked nuclei in background
 Basaloid cells :
- uniform round to oval hyper chromatic nuclei,
- High N:C ratio, scanty cytoplasm, coarse nuclear
chromatin and nuclear moulding

40.  Hyaline stromal material appear as
- spherical globules of varying
size with adherent tumour cell
- finger like and beaded fragments
between cell clusters

42.  Differential Diagnosis
• Cellular pleomorphic adenoma with hyaline globule
• Polymorphous low grade adenocarcinoma
• Basal cell adenomas
• Epithelial myoepithelial carcinoma

43.  6.5% of all salivary gland tumour
 Most common malignant salivary gland tumour in
children and adolescents
 Affect all age group
 Parotid most common site
Microscopy
 Abundant cellular material in clean background
 scanty fibro-vascular stroma

44.  Tumour cells:
- irregular clusters
- microacinar patterns
- many bare nuclei in background
- abundant fragile, finely vacuolated cytoplasm
and occasionally dense oncocyte like
- rounded medium sized nuclei, and bland
chromatin
- mild to moderate anisokaryosis
- Sometimes clear cell appearance
 Differential Diagnosis
- Normal salivary gland acinar cells
- Oncocytoma
- Warthin tumour

47.  Almost exclusively in intraoral minor salivary gland
 Palate most common site
 Most patients in age group 50 to 70 years
 Microscopically
 Cellular aspirate
 Tumour cells :
- clusters
- sheets,
- pseudopapillae
- single
 Cells arranged in papillae with central core of
hyaline material (Pseudopapillae)

48.  Tumour cells:
- cuboidal to columnar epithelial cell
- Round or ovoid nucleus, fine chromatin
- scanty cytoplasm
 There is little pleomorphism, no necrosis and
mitosis are absent or rare
 Hyaline stromal globules are often present
Differential diagnosis
-Adenoid cystic carcinoma
- Epithelial myoepithelial carcinoma

51.  1% of total salivary gland tumour
 60% occur in parotid
 Common age group: 6th to 7th decade
Microscopically
 Aspirates: cellular
 Biphasic appearance
 Epithelial cells:
- gland like structure
- Large uniform cells
- Bland round nuclei
- Minimal variation in size

52.  Myoepithelial cells
- dispersed, cluster and as naked nuclei
- Small spindly bipolar nuclei
- very fragile cytoplasm disrupt in background
- mild pleomorphism
 Hyaline stromal globules may be prominent
 Aggregates may have strands of fibrous stroma and
pseudo papillary pattern
Diffferential Diagnosis
- Pleomorphic adenoma
- Acinic cell carcinoma
- Polymorphous low grade adenocarcinoma

55.  Highly aggressive adenocarcinoma
 Usually presents after age of 50 years
 Parotid is the commonest site
 Histologicaly resembles comedo carcinoma of breast
Microscopy
 Cellular smear
 Large anaplastic cells: cluster, sheets, papillae
- large nuclei, granular chromatin and prominent
nucleoli, moderate cytoplasm, high N:C ratio

56.  Necrosis is common in background
 No typical stromal fragments seen
 Occasionally squamous differentiation is seen
Differential Diagnosis
 Other high grade carcinomas like mucoepidermoid,
adenocarcinoma not otherwise specified and
metastatic breast carcinoma

59.  It refers to malignant transformation of long
standing pleomorphic adenoma
 Usually presents in 6th to 7th decade of life
 Often history of recent increase in size of long
standing tumour
 Carcinoma is most frequently poorly differentiated
adenocarcinoma

60. Microscopy
 Moderate to highly cellular
 Both benign and malignant component
 Benign component: -fibrillar metachromatic stroma
 Malignant component :
- Epithelial cells arranged in discohesive sheets,
clusters and singly
- Nuclear changes of malignancy well appreciated

62.  It is difficult to decide on FNA that SCC is of primary
origin or metastatic
 Distinction from poorly differentiated
mucoepidermoid carcinoma is extremely difficult
 Atypical metaplastic and degenerative squamous
cells are seen in various benign condition like
necrotising sialometaplasia, warthin tumour, and
pleomorphic adenoma.

64. Malignant Lymphoma
 Most commonly seen in parotid
 Average age 65 year
 Common types
- Extra nodal Marginal Zone B Cell
lymphoma (MALT lymphoma)
- Follicular lymphoma and
- Diffuse large B cell lymphoma.

66.  Mainly occurs in chinese and Eskimo
 Very similar to
nasopharangyeal
carcinoma
 Sheets of large maligant epithelial cells surrounded by
aggregates of lymphocytes

67.  Myoepithelial Carcinoma and Basal cell carcinoma
are difficult to differentiate from their benign
counterpart on FNA.
 Depends on histological findings of infiltration of
surrounding tissue and perineural invasion
 Other rare primary malignant tumour of salivary
gland include clear cell ca. NOS, carcinosarcoma,
adenocarcinoma NOS, small cell carcinoma, large cell
carcinoma, oncocytic carcinoma.

68.  Common site- Parotid
 Malignant tumour of head and neck are common
- Squamous cell carcinoma
- Malignant melanomas
 Other malignant metastatic tumour include
carcinoma from lung, breast, renal cell carcinoma,

70.  Certain very rare tumour secondary to parotid
include embryonal rhadomyosarcoma, Ewing’s
sarcoma, fibromas and fibrosarcomas and nodular
fascitis.

71.  Case 1: 40 year female with painless
swelling in parotid

72. Case 1: Pleomorphic Adenoma

74. Case 2 Ans
Warthin Tumour

75.  Koss diagnostic cytology and it’s
histopathological bases 5th edition
 Fine needle aspiraton cytology- 5th edition
Svante R Orell, Greggery F Sterrett, Darell
Whitaker
 Rosai and Ackerman’s Surgical Pathology 10th
edition
 Diagnostic cytopathology Winifred Gray and
Gabrijela Kocjan 3rd edition
 Internet

76. THANK YOU