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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