Salivary glands

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The salivary glands help digest food. ENT surgeons take 'em out and want you to diagnose 'em. Cytopathology of the salivary glands is covered in the Head and neck cytopathology article.

Normal salivary glands

Types of salivary glands

Types of glands:[1]

  1. Serrous - eosinophilic cytoplasmic granules, acinar arrangement - vaguely resembles the acinar morphology of the pancreas.
  2. Mucinous - light eosinophilic staining.

Identifying the glands

The three main glands:

  1. Parotid:
    • Serous glands - lower viscosity, acini (lobules).[2]
    • Most tumours in this gland are benign.
  2. Submandibular:
    • Serous and mucinous glands.
      • Serous ~90% of gland.
      • Mucinous ~10% of gland.
    • Serous demilunes = mucinous gland with "cap" consisting of a serous glandular component.
  1. Sublingual:
    • Mucinous glands.

Other:

  • Adipose tissue is found between the glands.
    • It increases with age.

Images:

Memory devices:

  • The parotid gland vaguely resembles the pancreas.
  • Submandibular = glands are mixed.

Overview

Benign tumours

Tabular form - adapted from Thompson[5]

Entity Architecture Morphology Cell borders Cytoplasm Nucleus DDx Other Image
Pleomorphic adenoma var. mixed pop.; must include: (1) myoepithelium, (2) mesenchymal stroma, and (3) epithelium (ductal cells) or chondromyxoid stroma var. var. (1) plasmacytoid adenoid cystic carcinoma occ. encapsulated,
mixed pop. of glandular,
myoepithelial and mesenchymal cells
PA. (WP)
Warthin tumour papillary,
bilayer 		cuboid (basal), columnar (apical) clearly seen eosinophilic, abundant unremarkable sebaceous lymphadenoma AKA papillary cystadenoma lymphomatosum
PCL. (WP/Nephron)
Basal cell adenoma var., islands surrounded
by hyaline bands, lesion encapsulated 		basaloid subtle scant,
hyperchromatic 		granular basal cell adenocarcinoma - -
Canalicular adenoma chains of cells cuboid or columnar subtle scant,
hyperchromatic 		granular basal cell adenoma exclusively oral cavity, 80% in upper lip; IHC: p63- (webpathology.com), (webpathology.com)
Sialoblastoma var., islands surrounded
by loose fibrous stroma 		basaloid subtle scant, hyperch. granular basal cell adenocarcinoma - -

Malignant tumours

Tabular form - adapted from Thompson[6]

Entity Architecture Morphology Cell borders Cytoplasm Nucleus DDx Other Image
Mucoepidermoid carcinoma cystic & solid epithelioid distinct fuffy, clear,
abundant 		nuclei sm. SCC (?) IHC: p63+
MEC. (WC)
Adenoid cystic carcinoma (AdCC) pseudocysts,
cribriform, solid,
hyaline stroma 		epithelioid subtle scant,
hyperchromatic 		small
+/-"carrot-shaped" 		pleomorphic adenoma, PLGA Stains: PAS+ (pseudocyst material), CD117+, cyclin D1+
AdCC. (WC/Nephron)
Acinic cell carcinoma (AcCC) sheets, acinar (islands) epithelioid clear granular abundant stippled, +/-occ. nucleoli adenocarcinoma not otherwise specified, oncocytoma of salivary gland Stains: PAS +ve, PAS-D +ve; IHC: S-100 -ve, p63 -ve
AcCC. (WC/Nephron)
Salivary duct carcinoma glandular, cribriform columnar subtle/clear hyperchromatic columnar metastatic breast carcinoma similar to ductal
breast carcinoma; male>female
SDC. (WC/Nephron)
Polymorphous low-grade adenocarcinoma variable, often small
nests, may be targetoid 		epithelioid indistinct eosinophilic ovoid & small with
small nucleoli 		AdCC minor salivary gland tumour,
often in palate,
cytologically monotonous; IHC: S100+, CK+, vim.+, GFAP+/-, BCL2+/-
PLGA. (WC/Nephron)
Epithelial-myoepithelial carcinoma nests (myoepithelial) with tubules (epithelial) epithelioid not distinct eosinophilic cytoplasm; epithelial: scant; myoepithelial: moderate focal clearing AdCC, pleomorphic adenoma rare
EMCa. (WC/Nephron)
Basal cell adenocarcinoma var., islands surrounded
by hyaline bands, lesion not encapsulated 		basaloid subtle scant,
hyperchromatic 		granular basal cell adenoma rare, usu. parotid gland, may arise from a basal cell adenoma
BCA. (WC/Nephron)

DDx

Palate

Benign parotid tumours

Oncocytic tumours

Clear cell tumours

IHC overview

General:

  • Usually has limited value.

Specifics:

  • Luminal markers: CK7, CK19, CAM5.2 (LMWK).
  • Basal markers: p63, HMWK, CK14.
  • Myoepithelial markers: calponin, actin.
  • Uncommitted: S-100.

Notes:

  • p63 and S-100 are sometimes call myoepithelial.

Benign

General DDx:

  • Inflammation.
  • Neoplasm.
  • Ductal obstrution.

Chronic sialadenitis

Chronic sailolithiasis redirects here.
Sialadenitis redirects here.

General

Etiology:[8]

Microscopic

Features:

  • Non-neoplastic mononuclear inflammatory infiltrate (lymphocytes, plasma cells).
  • Fibrosis.
  • +/-Calcifications.

Note:

  • If the infiltrate is predominantly lymphocytes Sjögren's is a possibility, and reporting a Focus score should be considered.

DDx:

Image

  • Chronic sialadenitis. (WC/Nephron)

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SUBMANDIBULAR GLAND, RIGHT, EXCISION:
- CHRONIC SIALOADENITIS.
- SIALOLITHIASIS.
- TWO BENIGN LYMPH NODES.
- NEGATIVE FOR MALIGNANCY.

Micro

The sections show submandibular salivary gland with a mild patchy mixed mononuclear cell infiltrate, fibrosis and a large benign calcification. No zonal necrosis is identified. Significant nuclear atypia is not identified.

Salivary gland mucocele

General

  • Benign.
  • Infected mucocele = mucopyocele.

Microscopic

Features:[10]

  • Granulation tissue-like and pseudocyst-like.
    • Granulation tissue-like:
      • Fibroblasts.
      • Small caliber blood vessels.
      • Histocytes.
      • Neutrophils.
    • Pseudocyst:
      • No epithelial lining.
      • Poorly circumscribed.
  • Pale pink extracellular material (mucous) - key feature.
  • +/-Granulomas.[11]

DDx:

Images

  • Mucocele - low mag. (WC/KGH)

  • Mucocele - high mag. (WC/KGH)

  • Mucocele - low mag. (WC/Nephron)

  • Mucocele - high mag. (WC/Nephron)

www:

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LESION, LEFT LOWER LIP, EXCISION:
- BENIGN MUCOCELE.

Micro

The sections show a stratified squamous epithelium with a thin layer of parakeratosis, minor salivary glands, and a well-circumscribed cystic lesion.

The cystic lesion has a mildly fibrotic appearing wall, is lined by histiocytes intermixed with rare lymphocytes, and contains mucous and macrophages. No significant nuclear atypia is identified. Mitotic activity is not readily apparent.

Pleomorphic adenoma

Main article: Pleomorphic adenoma

Myoepithelioma

General

  • Usually benign.
    • May be malignant.

Location - head and neck:[12]

  • Parotid gland ~50%.
  • Palate ~25%
  • Submandibular gland ~12%.

Notes:

  • First described in 1972.[13]
  • May be seen in the skin.[14]

Microsopic

Features:[15]

  • Myoepithelial cells - may be:
    • Spindled.
    • Plasmacytoid.
    • Epithelioid.
    • Clear (rare).
  • Lack tubules, i.e. epithelial component.
    • May be up to 10% (or 5%[16]).

DDx:

Images

  • Myoepithelioma - low mag. (WC/Nephron)

  • Myoepithelioma - intermed. mag. (WC/Nephron)

  • Myoepithelioma - high mag. (WC/Nephron)

  • Myoepithelioma - very high mag. (WC/Nephron)

IHC

Features:[15]

  • S100 +ve.
  • GFAP +ve.
  • CK14 +ve.

Others:[17]

  • SMA +ve.
  • Calponin +ve.

Basal cell adenoma

General

  • ~2% of salivary gland tumours.
  • May be multifocal.
  • Usually parotid gland, occasionally submandibular gland.
  • Female:male = ~2:1.
  • May be seen in association with dermal cylindromas in the context of a genetic mutation.[18]
  • Malignant transformation - rarely.

Microscopic

Features:

  1. Basal component.
    • Basophilic cells - key feature.
    • Usu. in nests.
    • Large basophilic nucleus.
    • Minimal-to-moderate eosinophilic cytoplasm.
  2. Stromal cells.
    • Plump spindle cells without significant nuclear atypia - distinguishing feature.
      • Stromal cell nuclei width ~= diameter RBC.
    • Dense hyaline stroma.
  3. Tubular component.
    • Within basal component, may be minimal.
  4. Lesion is encapsulated - key feature.

Notes:

  • No chondromyxoid stroma.
  • Neoplastic cells embedded in stroma ("stromal invasion") = basal cell adenocarcinoma.
    • Basal cell adenocarcinoma may be cytologically indistinguishable from basal cell adenoma, i.e. "bad" architecture makes it a basal cell adenocarcinoma.

DDx:

Images:

IHC

  • Luminal stains +ve: CK7 +ve, CAM5.2 +ve.
  • p63 +ve -- basal component.
  • S100 +ve -- spindle cells in the stroma.

Canalicular adenoma

General

  • Exclusively oral cavity.
    • 80% of lesions on upper lip.

Microscopic

Features:

  • Channels - "beading of cell".
  • Mucoid/hemorrhagic stroma.

DDx:

  • Basal cell adenoma.

Images:

IHC

  • p63 -ve.
    • Basal cell adenoma p63 +ve.

Warthin tumour

Main article: Warthin tumour

Sebaceous adenoma

Main article: Sebaceous adenoma

Sebaceous lymphadenoma

General

  • Rare salivary gland tumour.[20]
  • Benign.

Microscopic

Features:[20]

  • Sebaceous glands within lymphoid tissue - key feature.

DDx:[21]

Images

  • Sebaceous lymphadenoma - low mag. (WC/Nephron)

  • Sebaceous lymphadenoma - intermed. mag. (WC/Nephron)

  • Sebaceous lymphadenoma - high mag. (WC/Nephron)

  • Sebaceous lymphadenoma - very high mag. (WC/Nephron)

www:

Oncocytoma of the salivary gland

  • AKA salivary gland oncocytoma.

General

  • No risk of malignant transformation.
  • Rare ~20 reported in literature.[22]
  • Thought to be ~1% of all salivary gland tumours.
  • Typical age: 60s-80s.
  • Associated with radiation exposure.
  • Major salivary glands - usually parotid gland.[23]

Gross

  • Golden brown appearance.

Image

  • Salivary gland oncocytoma (WC/euthman)

Microscopic

Features:

  • Like oncocytomas elsewhere.
    • Eosinophilic cytoplasm (on H&E stain).
      • Due to increased number of mitochrondria.
    • Fine capillaries.
  • Architecture: solid sheets, trabeculae or duct-like structure.[23]

Notes:

  • May have clear cell change.
  • Multiple small incidental lesions = oncocytosis - not oncocytoma.

DDx:

Images

www:

  • Parotid gland oncocytoma - intermed. mag. (WC/Nephron)

  • Parotid gland oncocytoma - high mag. (WC/Nephron)

  • Parotid gland oncocytoma - very high mag. (WC/Nephron)

IHC

  • p63 +ve[24] focally in nucleus.

Malignant

One approach:

  • Differentiate -- luminal vs. myoepithelial vs. basal (mucoepideroid).

Mucoepidermoid carcinoma

Main article: Mucoepidermoid carcinoma

Acinic cell carcinoma

Main article: Acinic cell carcinoma

Adenoid cystic carcinoma

See: Adenoid cystic carcinoma of the breast for the breast tumour.
Main article: Adenoid cystic carcinoma

Salivary duct carcinoma

Main article: Salivary duct carcinoma

Polymorphous low-grade adenocarcinoma

  • Abbreviated PLGA.
Main article: Polymorphous low-grade adenocarcinoma

Carcinoma ex pleomorphic adenoma

  • Abbreviated Ca ex PA.
Main article: Carcinoma ex pleomorphic adenoma

Epithelial-myoepithelial carcinoma

Main article: Epithelial-myoepithelial carcinoma

Basal cell adenocarcinoma

Main article: Basal cell adenocarcinoma

Sebaceous carcinoma

Main article: Sebaceous carcinoma

It is similar to the tumour found in the skin.

Hyalinizing clear cell carcinoma

Main article: Hyalinizing clear cell carcinoma

See also

References

  1. ↑ http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/oral.htm#LABSALIVA
  2. ↑ http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Epithelia/Epithel.htm
  3. ↑ URL: http://dictionary.reference.com/browse/demilune. Accessed on: 19 August 2011.
  4. ↑ URL: http://pathology.mc.duke.edu/research/pth225.html. Accessed on: 19 August 2011.
  5. ↑ Thompson, Lester D. R. (2006). Head and Neck Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 295-319. ISBN 978-0443069604.
  6. ↑ Thompson, Lester D. R. (2006). Head and Neck Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 325-357. ISBN 978-0443069604.
  7. ↑ Hasegawa M, Cheng J, Maruyama S, et al. (June 2011). "Complication of adenoid cystic carcinoma and sialolithiasis in the submandibular gland: report of a case and its etiological background". Int J Oral Maxillofac Surg 40 (6): 647–50. doi:10.1016/j.ijom.2010.11.009. PMID 21159490.
  8. ↑ URL: http://emedicine.medscape.com/article/882358-overviewhttp://emedicine.medscape.com/article/882358-overview. Accessed on: 10 January 2011.
  9. ↑ Beasley, MJ. (Apr 2012). "Lymphoma of the Thyroid and Head and Neck.". Clin Oncol (R Coll Radiol). doi:10.1016/j.clon.2012.02.010. PMID 22475637.
  10. ↑ URL: http://emedicine.medscape.com/article/1076717-workup. Accessed on: 6 March 2012.
  11. ↑ Seifert, G.; Donath, K.; von Gumberz, C. (Jun 1981). "[Mucoceles of the minor salivary glands. Extravasation mucoceles (mucus granulomas) and retention mucoceles (mucus retention cysts) (author's transl)].". HNO 29 (6): 179-91. PMID 7251405.
  12. ↑ Barnes, L.; Appel, BN.; Perez, H.; El-Attar, AM. (Jan 1985). "Myoepithelioma of the head and neck: case report and review.". J Surg Oncol 28 (1): 21-8. PMID 2982059.
  13. ↑ Saksela, E.; Tarkkanen, J.; Wartiovaara, J. (Sep 1972). "Parotid clear-cell adenoma of possible myoepithelial origin.". Cancer 30 (3): 742-8. PMID 5075358.
  14. ↑ Kutzner, H.; Mentzel, T.; Kaddu, S.; Soares, LM.; Sangueza, OP.; Requena, L. (Mar 2001). "Cutaneous myoepithelioma: an under-recognized cutaneous neoplasm composed of myoepithelial cells.". Am J Surg Pathol 25 (3): 348-55. PMID 11224605.
  15. ↑ 15.0 15.1 Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 130. ISBN 978-0470519035.
  16. ↑ I. Weinreb. 24 October 2011.
  17. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 18. ISBN 978-0470519035.
  18. ↑ Choi, HR.; Batsakis, JG.; Callender, DL.; Prieto, VG.; Luna, MA.; El-Naggar, AK. (Jun 2002). "Molecular analysis of chromosome 16q regions in dermal analogue tumors of salivary glands: a genetic link to dermal cylindroma?". Am J Surg Pathol 26 (6): 778-83. PMID 12023583.
  19. ↑ URL: http://moon.ouhsc.edu/kfung/jty1/Com/Com304-3-Diss.htm. Accessed on: 25 October 2011.
  20. ↑ 20.0 20.1 Mishra, A.; Tripathi, K.; Mohanty, L.; Nayak, M.. "Sebaceous lymphadenoma of the parotid gland.". Indian J Pathol Microbiol 54 (1): 131-2. doi:10.4103/0377-4929.77364. PMID 21393895. http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2011;volume=54;issue=1;spage=131;epage=132;aulast=Mishra.
  21. ↑ While, B.; Whiteside, OJ.; Desai, V.; Gurr, P. (Aug 2010). "Sebaceous lymphadenoma: a case report and review of the literature.". Ear Nose Throat J 89 (8): E22-3. PMID 20737364.
  22. ↑ Uzunkulaoğlu H, Yazici H, Can IH, Doğan S, Uzunkulaoğlu T (May 2012). "Bilateral oncocytoma in the parotid gland". J Craniofac Surg 23 (3): e246–7. doi:10.1097/SCS.0b013e31824dfccd. PMID 22627459.
  23. ↑ 23.0 23.1 Zhou, CX.; Gao, Y. (Dec 2009). "Oncocytoma of the salivary glands: a clinicopathologic and immunohistochemical study.". Oral Oncol 45 (12): e232-8. doi:10.1016/j.oraloncology.2009.08.004. PMID 19796983.
  24. ↑ 24.0 24.1 McHugh, JB.; Hoschar, AP.; Dvorakova, M.; Parwani, AV.; Barnes, EL.; Seethala, RR. (Dec 2007). "p63 immunohistochemistry differentiates salivary gland oncocytoma and oncocytic carcinoma from metastatic renal cell carcinoma.". Head Neck Pathol 1 (2): 123-31. doi:10.1007/s12105-007-0031-4. PMC 2807526. PMID 20614263. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807526/.
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