Slide 15 Diseases of Salivary Glands II

8/3/2019 Slide 15 Diseases of Salivary Glands II

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Dent 356-11Diseases of Salivary Glands II

SialadenosisHIV-Associated Salivary Gland DiseaseSalivary Gland TumorsAge Changes

Dr. Rima Safadi


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Sialadenosis (Sialosis)

Non-inflammatory, non-neoplastic,recurrent bilateral swelling of salivaryglands.

Parotid glands most commonly.

Probably due to abnormalities ofneurosecretory control.


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Has been reported with:

1.Hormonal disturbances.2.Malnutrition.

3.Liver cirrhosis.4.Chronic alcoholism.5.Various drugs.


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Histopathology:

1. Hypertrophy of serous acinar cells toabout twice their normal size.

2. Cytoplasm is densely packed withsecretory granules.


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HIV-Associated Salivary Gland Disease

May be a feature in a small number of adults with HIVinfection.

Prevalence may be higher in children.

Xerostomia and/or swelling of major glands, especiallyparotid.

Xerostomia may be caused by a Sjgren syndrome-like

process associated with myoepithelial sialadenitis.

However, there is no autoantibody profile as seen withSjgren syndrome.


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HIV-Associated Salivary Gland Disease

HIV-related parotidenlargement may be

due to:

1. Persistent glandularlymphadenopathy.

2. Multiplelymphoepithelialcysts.


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Salivary Gland Tumors

Uncommon.

Geographical variation.

Tumors of major glands more common

than minor (15-20%).


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In major glands , parotid tumors comprise~90%.

55% of minor gland tumors affect palate,20% upper lip.

Tumors of sublingual gland and lower lipglands are rare.


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Proportion of malignant tumors in minor glandsis higher than benign.

Opposite is true for major glands.

Rare salivary gland tumors occur as centralintraosseous lesions of the jaws, either fromentrapped salivary tissue or from lining ofodontogenic cysts.


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Salivary Gland Tumors: Classification


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Pleomorphic Adenoma (Mixed Tumor)

Commonest SG tumor, 60-65% of parotidtumors, 45% of minor gland tumors.

7% originate in minor glands, especially palatal.

Predilection to old age and females.

Usually solitary, recurrences may be multifocal.


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Pleomorphic Adenoma: Clinical Features

Slowly growing, painless, rubbery swelling with intactoverlying skin or mucosa.

Patient may be aware of lesion for several years.


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Pleomorphic Adenoma: Histopathologic Features

Composed of cells ofepithelial andmyoepithelial origin.

Great variety withcomplex intermingling ofcomponents &mesenchyme-like areas,hence the 2 names.


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Although benign, CT capsuleis not always complete.

Clearly demarcated , butapparently isolated nodulesmay be seen within or evenoutside the capsule giving theimpression of invasive growth.

Serial sections show that theserepresent outgrowths of themain mass.

These islands explain the needfor excision with a margin toavoid recurrence.


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Considerable variation inarrangement of epithelial andstromal components betweendifferent tumors and withindifferent areas of same tumor.


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Epithelial component may bearranged in duct-like structures,sheets, clumps, and interlacingstrands.


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Epithelial-duct cells and myoepithelial-type cells.

Polygonal, spindle, stellate, or plasmacytoid cells thought to be derived frommyoepithelium.


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Areas of squamous metaplasia and keratin pearl formation may be present.


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Intercellular material varies inquantity and quality: fibrous,hyalinized, myxoid, chondroid, ormyxochondroid.


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Tumors rich in mucoidmaterial(glycosaminoglycans)tend to rupture during

surgical removal allowingspillage and implantationof tumor and multiplerecurrences.

Malignant transformationcan occur, usually intumors present for many

years.


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Warthin Tumor(Papillary Cystadenoma Lymphomatosum)

Occurs almost exclusively in the parotid.

Slow-growing.

May be multifocal.

May bilateral (5-10%).

Predilection for old age.

Most likely arises from residual salivary duct epitheliumentrapped within lymph nodes during development.


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Warthin Tumor: Gross Appearance

Multiple, irregular cysticspaces ( C ) of variablesize containing mucoid

material.

The lining of the cystshas small projections that

represent the papillarystructures.


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Warthin Tumor: Histopathologic Features

Multiple, irregularcystic spaces

containing mucoidmaterial separatedby papillaryprojections of tumortissue.


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Warthin Tumor: Histopathologic Features

Tumor consists of:1. Epithelial component:

double-layered epitheliumlining cystic spaces inpapillary arrangement.

2. Lymphoid component withinstroma, may containgerminal centers.

Epithelial cells have granularcytoplasm rich in abnormalmitochondria, resemblingoncocytes.


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Basal Cell Adenoma: Clinical Features

1-2% of all SGtumors.

70% in parotid, 20%in upper lip.

Peak incidence in 7th

decade.


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Basal Cell Adenoma: Histopathologic Features

Consists of cytologicallyuniform basaloid cellsarranged in a variety ofpatterns.

Well-encapsulated.


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Oncocytoma

Rare tumor.

Usually arises in parotid.

>60 years of age.

Thin capsule.

Consists of oncocytes; large cells with granulareosinophilc cytoplasm rich in mitochondria.

D/D oncocytic hyperplasia.


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Canalicular Adenoma

> 50 years of age.

Almost all cases in upperlip.

Consists of anastomosingstrands of basaloidepithelial cells arrangedin canalicular structures.

May be partly or grosslycystic due todegeneration of loose

vascular stroma.


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Canalicular Adenoma

In some cases, multiplemicroscpic foci

multicentric) seen insurrounding minorsalivary gland tissue.

Do not appear to be ofclinical significance anddo not represent invasivegrowth.


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Ductal Papillomas

Rare tumors.

Papillary structure projecting into theductal system.

Several subtypes.


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Mucoepidermoid Carcinoma

~10% of all salivary gland tumors.

Most arise in parotid.

In minor glands, the palate is the mostcommon site.

Highest incidence in 4th & 5th decades.


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Mucoepidermoid Carcinoma: Clinical Features

Often presents clinicallyin a similar manner topleomorphic adenoma.

Grossly cystic tumorsmay be fluctuant.

More aggressive tumorsmay cause pain andulceration.


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Mucoepidermoid Carcinoma: Histopathologic Features

Characterized bypresence of 3 celltypes: squamous(epidermoid), mucous,

and intermediate.

Relative proportionsand arrangements of

cell types are used todistinguish between:

1. High grade MEC.

2. Low grade MEC.


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Low grade MEC:

1. Well-differentiated.

2. Mucous and epidermoidcells predominate.

3. No cellularpleomorphism.

4. Often cystic, cysts beinglined by mucus-secretingcells.


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Low grade MEC:

5. Epidermoid cells presentin strands or clumps, may

show keratinization.

6. Rupture of mucin-containing cysts may leadto inflammation.

7. Advance on a broad,pushing front.


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High grade MEC:

1. Poorly differentiated.

2. Epidermoid and intermediatecells predominate.

3. Nuclear & cellularpleomorphism and atypia.

4. Cystic spaces not prominent.


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High grade MEC:

5. Differentiation fromSCC may be difficult.

6. Ill-defined and highlyinfiltrative.


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Mucoepidermoid Carcinoma: Prognosis

Low grade tumors rarely metastasize.

However, behavior cannot be accurately predicted fromhistopathology.

Overall 5-year survival rate ~70%.

Low grade tumors 5-year survival rate ~95%, localrecurrence


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Acinic Cell Carcinoma

Uncommon.

Accounts for 2-3% ofparotid tumors.

Regarded as a low grademalignancy.

80-100% 5-year survival

rates reported for well-differentiated tumors,65% for poorlydifferentiated ones.


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Acinic cell adenocarcinoma


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Acinic Cell Carcinoma: Histopathologic Features

Spectrum ofhistopathologicalappearances.

The most commonvariants consist of sheetsor acinar groupings oflarge, polyhedral cellswith basophilic, granularcytoplasm, similar toserous acinar cells.


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Adenoid Cystic Carcinoma

Middle-aged &elderly.

Up to 30% of minorSG tumors, but only~6% of parotid

tumors.
http://images.google.com/imgres?imgurl=http://www.health-pictures.com/oral/images/Adenoid.jpg&imgrefurl=http://www.health-pictures.com/oral/Adenoid-cystic-carcinoma.htm&h=203&w=300&sz=5&tbnid=EyTuWdjGyWwJ:&tbnh=75&tbnw=111&hl=en&start=22&prev=/images%3Fq%3Dadenoid%2Bcystic%2Bcarcinoma%26start%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN


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Adenoid Cystic Carcinoma: Clinical Features

May present as slowlyenlarging tumors likepleomorphic adenoma,but pain and ulcerationare much more common.

Parotid tumors maypresent with facial palsy.

Neurologicalmanifestations reflectpredilection to infiltrateand spread along nerves.
http://images.google.com/imgres?imgurl=http://www.health-pictures.com/oral/images/Adenoid.jpg&imgrefurl=http://www.health-pictures.com/oral/Adenoid-cystic-carcinoma.htm&h=203&w=300&sz=5&tbnid=EyTuWdjGyWwJ:&tbnh=75&tbnw=111&hl=en&start=22&prev=/images%3Fq%3Dadenoid%2Bcystic%2Bcarcinoma%26start%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN


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Adenoid Cystic Carcinoma: Histopathologic Features

Wide spectrum ofappearances.

Most commonly, epithelium isarranged as ovoid & irregularlyshaped islands oranastomosing cords andstrands in scanty CT stroma.

Numerous microscopic cyst-like spaces within epithelialislands produce a cribriform orSwiss cheese pattern.

Epithelium consists of small,uniform, basophilic cells.

Rare mitoses.


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Adenoid Cystic Carcinoma: Histopathologic Features

Perineural invasion. Less commonlyepithelium is arranged ina tubular or solid pattern.

Prominent infiltration andinvasion of adjacenttissues, and spreadaround and along nerves.

In the maxilla, tumor mayinfiltrate along marrowspaces with no evidenceof bone destruction.


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Adenoid Cystic Carcinoma: Prognosis

Radiotherapy may be used for inoperable cases, butdoes not result in permanent cure.

Runs a prolonged clinical course and metastases arelate, usually to lungs.

Long term prognosis is poor.

5-year survival rates for parotid tumors are 75%, 10-yearrates are 40%, 20-year are


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Carcinoma Arising in Pleomorphic Adenoma

Also known as carcinoma expleomorphic adenoma.

~3% of SG tumors.

Almost all arise in parotid orsubmandibular tumors thathave been present for manyyears.

Histological diagnosis requiresevidence of pre-existingpleomorphic adenoma.


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Carcinoma Arising in Pleomorphic Adenoma

Malignant component may bean adenocarcinoma orundifferentiated carcinoma, orother types of SG malignancy.

When the malignant part isconfined within pre-existingtumor, prognosis is excellent.

When there is infiltration ofsurrounding tissues there is

poor prognosis.

Some mixed tumors arise asmalignant de novo*.


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Polymorphous Low Grade Adenocarcinoma

Occurs almost exclusivelyin minor glands.

Most arise in the palate.

Good prognosis.

Unpredictable potential tometastasize in ~15% ofcases.

Polymorphous Low Grade Adenocarcinoma:


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Polymorphous Low Grade Adenocarcinoma:

Histopathologic Features

Shows a variety of growthpatterns within the samelesion, including solid, tubular,

papillary, & cribriform.

Cytologically uniform andbland with infrequent mitosesand lack of atypia.

D/D adenoid cystic carcinoma,both show perineural invasion.

Histologic patterns: linearsingle cells (Indian file) (A);tubular (B); solid (C); fascicular(streaming) (D).

P l h L G d Ad i


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Polymorphous Low Grade Adenocarcinoma:Histopathologic Features

Additional histologicpatterns: myxoid (A);

cribriform(pseudoadenoid) (B);

jigsaw (C); cystic (D).


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Other Salivary Carcinomas

Epithelial myoepithelial carcinoma

Basal cell adenocarcinoma

Adenocarcinoma; not otherwise specified

(NOS)


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Age Changes in Salivary Glands

Reduction in weight of parotid andsubmandibular glands related to atrophy ofsecretory tissue & replacement by fibrofattytissue.

Similar changes in labial minor glands.

Oncocytic change in ductal epithelium.

Reduction in flow rate in submandibular gland.

Slide 15 Diseases of Salivary Glands II

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