Speaker: Dr. Mahesh
Guide: Dr. H. P. Srilakshmi
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
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
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
Benign Epithelial tumour- Pleomorphic adenoma
- Warthin tumour
- Oncocytoma
- Myoepithelioma
- Basal cell adenoma
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
Soft tissue tumour- Hemangioma
Haematolymphoid tumour- Diffuse large B cell lymphoma
- Extranodal marginal zone lymphoma
- Hodgkin’s lymphoma
Secondary tumour
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
Microscopy Mixture of epithelial and stromal component
Epithelial component: Myoepithelial and ductalcells 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
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
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
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.
Differential Diagnosis Oncocytoma
Low grade mucoepidrmoid carcinoma
Acinic cell carcinoma
Squamous cell carcinoma
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
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)
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
Absence of fluid, cellular debris, lymphocytes
Differential diagnosis Warthin tumour
Acinic cell carcinoma
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
Other rare benign tumour include sebaceous adenoma, lymphadenoma, duct pailloma and benign mesenchymal tumour like lipoma, schwannoma and hemangioma.
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
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
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
Characteristic High grade Low grade
Cellularity Highly cellular Hypocellular
Predominance cellSquamous and intermediate
Mix mucous producing and intermediate
KeratinisationPresent and even squamous pearl
Not seen
Background Less mucinAbundant thick
mucin
Mitosis Numeous Very rare
Characteristic High grade Low grade
DemarcationLess well
demarcatedWell demarcated
InfiltrationInto surrounding
tissueLocalised
Perineural invasionPresent and often fascial nerve palsy
Not present
Distant metastasis Common Very rare
Pain Painful Painless
Differential diagnosis
Low grade
Warthin tumour
Chronic sialadenitis and kuttner’s tumour
High grade
Primary or metastatic SCC
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
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
Hyaline stromal material appear as
- spherical globules of varying
size with adherent tumour cell
- finger like and beaded fragments
between cell clusters
Differential Diagnosis• Cellular pleomorphic adenoma with hyaline globule
• Polymorphous low grade adenocarcinoma
• Basal cell adenomas
• Epithelial myoepithelial carcinoma
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
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
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)
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
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
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
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
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
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
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
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.
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.
Mainly occurs in chinese and Eskimo
Very similar to
nasopharangyeal
carcinoma
Sheets of large maligant epithelial cells surrounded by aggregates of lymphocytes
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.
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,
Certain very rare tumour secondary to parotid include embryonal rhadomyosarcoma, Ewing’s sarcoma, fibromas and fibrosarcomas and nodular fascitis.
Case 1: 40 year female with painless
swelling in parotid
Case 1: Pleomorphic Adenoma
Case 2 Ans
Warthin Tumour
Koss diagnostic cytology and it’s histopathological bases 5th edition
Fine needle aspiraton cytology- 5th edition Svante R Orell, Greggery F Sterrett, DarellWhitaker
Rosai and Ackerman’s Surgical Pathology 10th
edition
Diagnostic cytopathology Winifred Gray and Gabrijela Kocjan 3rd edition
Internet
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