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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.
Micrograph showing chronic
       sialadenitis.
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.
TREATMENT

Medical 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 TUMORS

pleomorphic adenomas
 originate from the
 intercalated duct cells
 and myoepithelial cells
oncocytic tumors
 originate from the
 striated duct cells
acinous 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.
NORMAL HISTOLOGY
PLEOMORPHIC ADENOMA
PLEOMORPHIC ADENOMA

Epithelial Components
 • Tubular and cord-like arrangements
 • Cells contain a moderate amount of cytoplasm
 • Mitoses are rare
Stromal 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 normal
salivary gland parenchyma.
B, High-power view showing epithelial cells as well as myoepithelial cells found
within a chondroid matrix material.
WARTHIN'S TUMOR

Warthin's tumor (benign
papillary cystadenoma
lymphomatosum)
the second most common
benign tumor of the parotid
gland
It accounts for 2-10% of all
parotid gland tumors
Bilateral in 10% of the
cases
may contain mucoid brown
fluid
WARTHIN’S TUMOR

Mid Power
Thought to arise from
 salivary gland
 inclusions within lymph
 nodes.
WARTHIN’S TUMOR

Epithelial 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 TUMOR

Lymphoid Component
 An abundance of this is present
 Occasional germinal centres will be seen
 Lymphoid tissue forms the core or papillary structures
Both lymphoid and oncocytic epithelial
 elements must be present to diagnose Warthin’s
WARTHIN’S TUMOR

o High Power
o Lymphocytc
  infilterates.
o Bilayer of epithilium.
WARTHIN’S TUMOR




A, Low-power view showing epithelial and lymphoid elements. Note the
follicular germinal center beneath the epithelium.
B, Cystic spaces separate lobules of neoplastic epithelium consisting of a
double layer of eosinophilic epithelial cells based on a reactive lymphoid
stroma.
MONOMORPHIC ADENOMA

Similar to Pleomorphic Adenoma except no
 mesenchymal stromal component
 • Predominantly an epithelial component
More common in minor salivary glands (upper lip)
12% bilateral
Rare malignant potential
Types:
 •   Basal Cell Adenoma
 •   Canicular Adenoma
 •   Myoepithelioma Adenoma
 •   Clear Cell Adenoma
 •   Membranous Adenoma
 •   Glycogen-Rich Adenoma
MALIGNANT SALIVARY GLAND
        TUMORS
MUCOEPIDERMOID CARCINOMA

Mucoepidermoid 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.
MUCOEPIDERMOID
CARCINOMA
• 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 CARCINOMA




A, Mucoepidermoid carcinoma showing islands having squamous cells as
well as clear cells containing mucin.
B, Mucicarmine stains the mucin reddish-pink. (Courtesy of Dr. James
Gulizia, Brigham and Women's Hospital, Boston.)
ADENOID CYSTIC CARCINOMA

Adenoid 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 CARCINOMA

Nerve (N) invaded by
 adenoid cystic carcinoma
 (the blue area surrounding
 the nerve).
Spread may occur by emboli
 along the nerve lymphatics
ADENOID CYSTIC CARCINOMA




Adenoid cystic carcinoma in a salivary gland.
A, Low-power view. The tumor cells have created a cribriform pattern enclosing
secretions.
B, Perineural invasion by tumor cells.
HODGKIN'S LYMPHOMA

Hodgkin's disease
 involving the parotid
 gland.
Note the Reed-Sternberg
 cell. (Fine needle
 aspiration, Pap, 630x)
SALIVARY GLAND TUMORS

             •
Habis

            Question??????????????

Q1. Mention the common types of salivary gland benign
tumors with origin of each.


Q2. Identify the histological feature for mucoepidermoid
carcinoma

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Lect.2. salivary gland pathology

  • 1. SALIVARY GLAND PATHOLOGY SMS 2044 DR. MOHANAD R. ALwAN
  • 2. 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.
  • 4. 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.
  • 5.  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.
  • 6.  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.
  • 7. TREATMENT Medical 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
  • 8. 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. 
  • 9. SALIVARY GLAND BENIGN TUMORS pleomorphic adenomas originate from the intercalated duct cells and myoepithelial cells oncocytic tumors originate from the striated duct cells acinous cell tumors originate from the acinar cells, Mucoepidermoid tumors and squamous cell carcinomas develop in the excretory duct cells.
  • 10. 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.
  • 13. PLEOMORPHIC ADENOMA Epithelial Components • Tubular and cord-like arrangements • Cells contain a moderate amount of cytoplasm • Mitoses are rare Stromal 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.
  • 14. 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
  • 15. 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.
  • 16. PLEOMORPHIC ADENOMA A, Low-power view showing a well-demarcated tumor with adjacent normal salivary gland parenchyma. B, High-power view showing epithelial cells as well as myoepithelial cells found within a chondroid matrix material.
  • 17. WARTHIN'S TUMOR Warthin's tumor (benign papillary cystadenoma lymphomatosum) the second most common benign tumor of the parotid gland It accounts for 2-10% of all parotid gland tumors Bilateral in 10% of the cases may contain mucoid brown fluid
  • 18. WARTHIN’S TUMOR Mid Power Thought to arise from salivary gland inclusions within lymph nodes.
  • 19. WARTHIN’S TUMOR Epithelial 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)
  • 20. WARTHIN’S TUMOR Lymphoid Component An abundance of this is present Occasional germinal centres will be seen Lymphoid tissue forms the core or papillary structures Both lymphoid and oncocytic epithelial elements must be present to diagnose Warthin’s
  • 21. WARTHIN’S TUMOR o High Power o Lymphocytc infilterates. o Bilayer of epithilium.
  • 22. WARTHIN’S TUMOR A, Low-power view showing epithelial and lymphoid elements. Note the follicular germinal center beneath the epithelium. B, Cystic spaces separate lobules of neoplastic epithelium consisting of a double layer of eosinophilic epithelial cells based on a reactive lymphoid stroma.
  • 23. MONOMORPHIC ADENOMA Similar to Pleomorphic Adenoma except no mesenchymal stromal component • Predominantly an epithelial component More common in minor salivary glands (upper lip) 12% bilateral Rare malignant potential Types: • Basal Cell Adenoma • Canicular Adenoma • Myoepithelioma Adenoma • Clear Cell Adenoma • Membranous Adenoma • Glycogen-Rich Adenoma
  • 25. MUCOEPIDERMOID CARCINOMA Mucoepidermoid 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.
  • 26. MUCOEPIDERMOID CARCINOMA • 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).
  • 27. 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.
  • 28. MUCOEPIDERMOID CARCINOMA A, Mucoepidermoid carcinoma showing islands having squamous cells as well as clear cells containing mucin. B, Mucicarmine stains the mucin reddish-pink. (Courtesy of Dr. James Gulizia, Brigham and Women's Hospital, Boston.)
  • 29. ADENOID CYSTIC CARCINOMA Adenoid 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.
  • 30. ADENOID CYSTIC CARCINOMA Nerve (N) invaded by adenoid cystic carcinoma (the blue area surrounding the nerve). Spread may occur by emboli along the nerve lymphatics
  • 31. ADENOID CYSTIC CARCINOMA Adenoid cystic carcinoma in a salivary gland. A, Low-power view. The tumor cells have created a cribriform pattern enclosing secretions. B, Perineural invasion by tumor cells.
  • 32. HODGKIN'S LYMPHOMA Hodgkin's disease involving the parotid gland. Note the Reed-Sternberg cell. (Fine needle aspiration, Pap, 630x)
  • 34. Habis Question?????????????? Q1. Mention the common types of salivary gland benign tumors with origin of each. Q2. Identify the histological feature for mucoepidermoid carcinoma

Hinweis der Redaktion

  1. Pleomorphic Adenomas: PAIM
  2. Batsakis- pg 6
  3. Figure 16-16 .
  4. Batsakis-Pg 6
  5. Figure 16-17 Pleomorphic adenoma.
  6. Batsakis-Pg 8
  7. Batsakis-Pg 8
  8. Warthins: WHALE = W arthins H as A bundant L ymphoid and E pithelial components
  9. Batsakis-Pg 8
  10. Figure 16-18 Warthin tumor.
  11. Figure 16-19
  12. Figure 16-20