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Tumors of salivary gland

tumors of salivary glands

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Tumors of salivary gland

  1. 1. AZFAR NEYAZ, JUNIOR RESIDENT SGPGIMS, LUCKNOW
  2. 2.       
  3. 3. Serous-type acini of a parotid gland with dense secretory granules Histologic section of a submaxillary gland.
  4. 4. Portion of a parotid gland demonstrating multiple foci of sebaceous differentiation.
  5. 5. The intercalated ducts (arrows) (sectioned longitudinally) lie in contact with the acinus. The striated ducts (sectioned transversely) are lined with a oncocytic columnar cells.
  6. 6.        Malignant epithelial tumors
  7. 7.         Malignant epithelial tumors
  8. 8. Benign epithelial tumors
  9. 9. Soft tissue tumors  Hemangioma Haematolymphoid tumors Secondary tumors
  10. 10. General features of salivary gland tumors in adults and children
  11. 11. Major salivary gland Minor salivary gland Warthin tumor Polymorphous low grade adenocarcinoma (palate) Acinic cell carcinoma Canalicular adenoma (lip, buccal mucosa) Oncocytoma/oncocytic carcinoma Cystadenoma/cystadenocarcinoma Epithelial-myoepithelial carcinoma Inverted papilloma Basal cell adenoma/adenocarcinoma Intraductal papilloma Salivary duct carcinoma Lymphoepithelial carcinoma Sialadenoma papilliferum (palate)
  12. 12. architectural pleomorphism
  13. 13. Benign mixed tumor of the submandibular gland demonstrating a firm, whitish tan, well-encapsulated mass Gross specimen of pleomorphic adenoma. The external surfaces have been marked with blue dye. The cut surface of the tumor is tan- colored and interspersed with brown areas. Note the glistening quality of the tumor.
  14. 14. • Plasmacytoid hyaline cells :    Chondromyxoid stroma
  15. 15. There is a small satellite nodule immediately outside the thin capsule of the tumor. This represents a tumor protuberance . This finding is still compatible with a diagnosis of benign pleomorphic adenoma. Double-layered duct-like structures with a conspicuous abluminal layer of clear myoepithelial cells.
  16. 16. An intimate mixture of epithelial and stromal elements is seen in this mixed tumor. The stroma exhibits cartilaginous differentiation. Plasmacytoid cells
  17. 17. Cellular mixed tumor : Because of its extreme cellularity, this tumor may be mistaken for a malignant tumor Pleomorphic adenoma with a focus resembling adenoid cystic carcinoma. There are some cribriform structures and tubules sharply demarcated from the stroma.
  18. 18. Pleomorphic adenoma showing a focus of mucous metaplasia. Focal squamous differentiation with keratinization is seen amidst complex glandular structures.
  19. 19. Lipomatous pleomorphic adenoma. Pleomorphic adenoma showing bone forming by osseous metaplasia in stroma.
  20. 20. Spindly and stellate cells are disposed in a lattice-like fashion within the myxoid matrix. A myoepithelioma can show a similar appearance.
  21. 21. Recurrent pleomorphic adenoma Typical multinodular growth pattern.
  22. 22. Metastasizing pleomorphic adenoma
  23. 23. Signs of malignant transformation:  Rapid growth,     Malignant mixed tumor
  24. 24. Noninvasive carcinoma ex pleomorphic adenoma showing more extensive dysplastic change Noninvasive carcinoma ex pleomorphic adenoma showing dysplastic cells replacing the inner duct layer leaving a benign myoepithelial layer.
  25. 25. Perineural invasion next to remnant of scarred pleomorphic adenoma. Note the benign component with numerous small irregular ducts in a hyalinized stroma (upper left) and a focus of adenocarcinoma with associated necrosis (lower right).
  26. 26. Carcinosarcoma showing mixture of adenocarcinomatous and osteosarcomatous differentiation
  27. 27. basaloid
  28. 28. Cut surface of the parotid gland tumor shows well-circumscribed, grayish-white, solid mass.
  29. 29. Histologically subclassified according to their cellular growth pattern.  Solid  Trabecular  Tubular,  Membranous (dermal analogue) types
  30. 30. Trabecular type : Narrow epithelial islands forming an interconnecting cord-like architecture. Solid type : Large sheets & broad bands of basaloid cells with peripheral palisading. Detail of a squamous diff. frequently found in the solid variant (inset).
  31. 31. Tubular type. Prominent duct-like structures with intraluminal eosinophilic secretion. Membranous type. Thick, hyaline, basement membrane like material surrounds large lobules. This material is also present within the epithelial nests forming coalescing, hyaline droplets.
  32. 32. Basal cell adenocarcinoma. Islands of basaloid cells infiltrate a fibrous stroma. Distinction from basal cell adenoma is based on the presence of unequivocally infiltrative growth. As is typical of basal cell adenocarcinoma, some cells have darker nuclei and some have larger paler nuclei. A focus of perineural invasion is seen (right of center).
  33. 33. Basal cell adenocarcinoma. Solid nests of mildly atypical basaloid cells with peripheral palisading Basal cell adenocarcinoma. Focal squamous differentiation with keratin pearl formations.
  34. 34. Myoepithelioma. The cut surface of a tumor presents as a well-circumscribed, yellow-tan colored, solid mass in the parotid gland.
  35. 35. Spindle cell type. The spindle cells are arranged in an interlacing fascicular pattern. Plasmacytoid cell type. The plasmacytoid cells exhibiting eccentrically located nuclei and abundant eosinophilic cytoplasm are surrounded by a myxoid matrix.
  36. 36. Epithelioid cell type : Solid and trabecular growth patterns of polygonal epithelial cells with central nuclei and eosinophilic cytoplasm Clear cell type : Solid growth of polygonal shaped clear cells with intercellular hyaline depositions.
  37. 37. Spindle-shaped myoepithelial cell forming a neurilemmoma-like pattern. Myoepithelial cells forming a reticular pattern.
  38. 38. • Reactivity for cytokeratin and at least one of the other myoepithelial markers, including SMA , GFAP, CD10, calponin and smooth muscle actin is required for diagnosis.
  39. 39. Myoepithelial carcinoma. Low-power view showing multinodular architecture. Spindle cell type. The spindle cells arranged in a vaguely interlacing fascicular pattern.
  40. 40. Gross appearance of oxyphilic adenoma. The tumor is well circumscribed, solid, and light brown.
  41. 41. Oncocytoma consisting of characteristic light and dark cells. Oncocytoma with clear cell change.
  42. 42. Oncocytic carcinoma. This is a destructive infiltrating tumor. Oncocytic carcinoma showing neural invasion.
  43. 43. Canalicular adenoma is made up of double rows of interconnecting & branching cords of tumor composed of bland, basaloid, cuboidal to columnar cells. The surrounding stroma is acellular with very sparse collagen production
  44. 44. • 2nd mc tumor M>F Radiation smoking.
  45. 45. Gross appearance of Warthin tumor of parotid gland. The presence of multiple large cystic spaces is characteristic of this lesion. Warthin tumor is typically tannish brown, often with cystic spaces. In addition, this tumor demonstrates areas of degeneration and necrosis (yellowish foci).
  46. 46. Warthin’s tumor showing papillary cystic tumor with dense lymphoid stroma The papillae and glands are typically lined by columnar oncocytic luminal cells in which the nuclei are often polarized towards the lumen. Beneath the luminal cells is a layer of basal cells, which are sharply demarcated from the underlying lymphoid stroma.
  47. 47. Sebaceous adenoma showing nests of sebaceous cells with peripheral squamous differentiation. Sebaceous adenoma consisting solely of sebaceous cells of varying sizes.
  48. 48. Well-differentiated sebaceous carcinoma consisting of non-specific glandular cells and cells showing conspicuous sebaceous differentiation.
  49. 49. within a background of lymphocytes and lymphoid follicles
  50. 50. Sebaceous lymphadenoma : Variably shaped epithelial nests with multiple cystic formations, containing sebaceous cells ,in a lymphoid stroma. Sebaceous glands in a diffuse lymphoid background
  51. 51. Lymphadenoma. A well-circumscribed tumor in the parotid gland. Lymphadenoma, nonsebaceous type. There are multiple nests of basaloid tumor cells with focal ductal differentiation in a lymphoid background.
  52. 52. Cystadenoma. Well-circumscribed tumor composed of variably sized, multiple cysts with focal papillary configurations. The cyst lining epithelium consists of columnar or cuboidal cells. The cysts contain eosinophilic, proteinaceous material
  53. 53. Oncocytic cystadenoma. Papillary-cystic proliferation of oncocytic epithelium in the parotid gland. Note the absence of lymphoid infiltration in fibrous stroma separating cystic spaces. The cysts are lined by a double-layered oncocytic epithelium, resembling that seen in Warthin tumor.
  54. 54. Cystadenocarcinoma. Tumor with multiple papillary-cystic structures invades into the surrounding salivary gland parenchyma. Cyst formations accompanied by prominent intracystic papillary projections of columnar cells.
  55. 55. arising at the junction endophytic growth
  56. 56. Inverted ductal papilloma. This tumor is continuous with the overlying surface epithelium and grows in an inverting pattern, forming a smooth-edged, broad- based mass. It is composed of immature squamous or basaloid epithelium In addition, numerous mucinous goblet cells are often intermixed with the basaloid and squamous cells.
  57. 57. Intraductal papilloma
  58. 58. Intraductal papilloma. A cystically dilated duct with papillary epithelial projections into the cystic space. Extending into the lumen of the cystic space are fronds of columnar epithelium supported by a central fibrovasacular core.
  59. 59. Sialadenoma papilliferum demonstrating the typical exophytic papillary surface and deeper ductal components. The bland surface squamous epithelium communicates with the underlying columnar epithelium lining the ductal structures.
  60. 60. • Salivary gland anlage tumor manifests in newborns or within the first few weeks of life with respiratory distress. • The tumor is postulated to be a hamartoma because the histologic features are reminiscent of developing salivary gland in embryo. • Although some investigators favor a teratomatous interpretation. Salivary gland anlage tumor The surface is covered by nonkeratinizing squamous epithelium which extends downwards into the submucosal tissue, giving rise to squamous nests, branching ducts and cystic structures.
  61. 61. • Commonest childhood.
  62. 62. Cut surface of the intermediate-grade tumor shows gray white, solid mass accompanied by multiple small cystic structures and infiltrative borders. Low-grade mucoepidermoid carcinomas may have a distinctly cystic gross appearance.
  63. 63. Low-grade mucoepidermoid carcinoma: with a prominent cystic component. The tumor contains goblet, intermediate and squamous cells.
  64. 64. Intermediate grade mucoepidermoid carcinoma. Solid nests with focal cystic structures consisting of intermediate cells as well as epidermoid cells & a few mucous cells Low-grade mucoepidermoid carcinoma
  65. 65. Tumor is composed primarily of markedly pleomorphic epidermoid cells and a small proportion of mucous cells. Periodic acid–Schiff (PAS) stain showing scattered positive mucous cells in the solid nests.
  66. 66. Mucoepidermoid carcinoma. Clear cell variant Oncocytic variant.
  67. 67. Mucoepidermoid carcinoma. Abundant hyalinized stroma is evident. Extensive secondary lymphoid cell infiltration, referred to as tumor- associated lymphoid proliferation.
  68. 68. Differential diagnosis
  69. 69. perineural invasion.
  70. 70. Adenoid cystic carcinoma of the parotid gland has deceptively well- delineated outlines. Microscopically, the tumor extends well beyond the grossly apparent edges of the tumor. Tan, fleshy, firm, invasive tumor
  71. 71. The classic cribriform pattern of adenoid cystic carcinoma. At higher magnification, the cells are haphazardly arranged around the extracellular spaces
  72. 72. Adenoid cystic carcinoma. Tubular variant (20-30%) showing morphologically similar luminal and abluminal cells. Adenoid cystic carcinoma. Tubular variant showing morphologically clear abluminal cells.
  73. 73. Adenoid cystic carcinoma. Solid variant higher power showing scattered duct-like structures within the tumor sheet. Adenoid cystic carcinoma. Solid variant showing extensive comedo necrosis.
  74. 74. Adenoid cystic carcinoma with prominent perineurial invasion Adenoid cystic carcinoma showing bone invasion
  75. 75. Adenoid cystic carcinoma with hyalinization or myxoid change, mimicking pleomorphic adenoma. The cribriform island shows deposits of abundant hyaline material with strangulation" of the tumor cells. This pattern differs from the hyalinization seen in pleomorphic adenomq in that the process is confined to the cellular island, which itself is sharply delineated from the fibrous stroma.
  76. 76. Adenoid cystic carcinoma. P63 staining of myoepithelial component.
  77. 77. The left field depicts the pre-existing adenoid cystic carcinoma, comprising Basaloid cells with interspersed pseudocystics paces. The right field shows the poorly differentiated (dedifferentiated) solid tumor composed of much larger, pleomorphic and mitotically active cells, associated with coagulative necrosis
  78. 78. DIFFERENTIAL DIAGNOSIS:  PLG adenocarcinoma  Basaloid sq. cell carcinoma  Pleomorphic adenoma  BC adenocarcinoma
  79. 79. serous acinar cell differentiation
  80. 80. Sections through a superficial parotidectomy for an acinic cell carcinoma reveal a sharply demarcated tumor with a partially cystic appearance.
  81. 81. Acinic cell carcinoma. The cells have an abundant cytoplasm filled with basophilic zymogen granules Acinic cell carcinoma. Periodic acid Schiff stain highlighting zymogen granules on the luminal aspect
  82. 82. Some tumor cells contain basophilic granules (left lower field). Most cells are polygonal and many resemble intercalated duct cells. Note the bland appearances of the nuclei. Acinic cell carcinoma with extensive psammoma body formation
  83. 83. Microcystic variant. Follicular variant
  84. 84. Acinic cell carcinoma showing focal clear cell change. Papillary cystic variant. There are many hobnail cells and some vacuolated cell
  85. 85. Well-differentiated acinic cell carcinoma with abundant lymphoid stroma. favorable prognosis This otherwise typical acinic cell carcinoma shows an area (upper) of higher grade carcinoma with small-cell features. This phenomenon has been referred to as “dedifferentiation.”
  86. 86. Tumor invades into the minor salivary gland parenchyma. A malignant infiltrative tumor characterized by diverse architectural patterns but unified by bland-looking tumor cells.
  87. 87. Sheet-like solid growth of the tumor cells exhibiting uniform oval nuclei without any pleomorphism. Polymorphous low-grade adenocarcinoma. Low power view showing histologic diversity within the tumor. Mainly solid and tubular growth patterns with focal cribriform and papillary areas.
  88. 88. Tubular structures are predominantly lined by a single layer of small cuboidal cells. Multiple pseudocystic spaces with pale staining amphophilic mucoid contents resulting in a cribriform appearance
  89. 89. Papillary configurations of columnar or cuboidal cells Polymorphous low-grade adenocarcinoma ‘‘Indian-file’’ growth pattern.
  90. 90. Perineural invasion with concentric targetoid appearance. Fascicular growth pattern
  91. 91. • So variability of growth pattern is the most consistent architectural feature of the tumor.
  92. 92. The myoepithelial component is represented by the cells with clear cytoplasm The tumor characteristically invades in broad fronts (normal salivary gland tissue seen in right field)
  93. 93. Epithelial-myoepithelial carcinoma with trabecular arrangement & predominantly non-canalized ducts. Epithelial-myoepithelial carcinoma. Not uncommonly some glandular structures have dilated lumens or are thrown into papillary folds. This feature is practically never seen in adenoid cystic carcinoma.
  94. 94. A) Cytokeratin stain highlighting the luminal cells. (B) Calponin staining highlighting abluminal myoepithelial cells. Epithelial-myoepithelial carcinoma showing neural invasion
  95. 95. Cut surface of the tumor shows gray-white, solid mass with foci of necrosis
  96. 96. Intraductal component comprised of cribriform structures. Note that the central portion of the ductal cell nests undergoes comedo-like necrosis The invasive component consists of irregular glands and cords of cells that elicit a prominent desmoplastic reaction.
  97. 97. Carcinoma cells exhibiting large pleomorphic nuclei with coarse chromatin and prominent nucleoli. The cytoplasm is abundant and granularly eosinophilic Sarcomatoid salivary duct carcinoma. There are several nests of typical salivary duct carcinoma with a prominent cribriform pattern surrounded by a markedly pleomorphic, atypical spindle cell population of tumor cells
  98. 98. Mucin-rich variant. Mucin lakes containing islands of carcinoma cells (right) in addition to the typical salivary duct carcinoma component. Invasive micropapillary variant. Morula-like small cell clusters without fibrovascular cores, surrounded by a clear space.
  99. 99. Salivary duct carcinoma. Immunohistochemistry. Carcinoma cells are diffusely positive for androgen receptor in their nuclei. Diffuse and strong membranous staining for HER-2/neu.
  100. 100. • The majority of tumors with a predominant population of clear cells have been diagnosed as epithelial-myoepithelial carcinomas. • Other differentials: • clear cell oncocytoma • mucoepidermoid carcinoma • acinic cell carcinoma • sebaceous carcinoma • metastatic renal cell carcinoma are needed to be excluded. • It is a diagnosis by exclusion.
  101. 101. Hyalinizing clear cell carcinoma. Uniform population of cells with clear cytoplasm forming discrete nests in a dense fibrous stroma.
  102. 102. undifferentiated carcinoma non-neoplastic lymphoplasmacytic
  103. 103. Undifferentiated lymphoepithelioma-like carcinoma of the parotid gland. The tumor has sharply demarcated margins and grossly resembles a lymphoma.
  104. 104. Undifferentiated, lymphoepithelioma-like carcinoma. A large component of tumor (left) is surrounded by a brisk lymphoplasmacytic reaction (right). The neoplastic cells have large, vesicular, but relatively uniform nuclei. Mitotic figures are typically easily identified. Cell borders are indistinct. The epithelial cells are mixed in a complex fashion with the reactive lymphoplasmacytic elements
  105. 105. In situ hybridization for EBV-encoded small RNA (EBER). Almost all of the carcinoma cells express strong nuclear EBER hybridization signals. Note complete absence of signal in the surrounding lymphoid stroma.
  106. 106. Undifferentiated carcinoma • Rare tumors composed of primitive/anaplastic cells which exhibit no obvious line of differentiation. • Focal isolated glandular formation or squamous differentiation does not exclude this diagnosis. • Undifferentiated carcinoma can be further subclassified into: • small cell carcinoma • large cell undifferentiated carcinoma • lymphoepithelioma-like carcinoma
  107. 107. Small cell carcinoma. High-power view showing the tumor cells with scant cytoplasm and inconspicuous nucleoli. Mitotic figures are readily identified. Small cell carcinoma. Tumor cells are diffusely immunopositive for chromograninA.
  108. 108. Paranuclear dot-like pattern of immunoreactivity for cytokeratin 20. The tumor cell nuclei are round to oval, with pale, dispersed chromatin and a well- defined nuclear membrane
  109. 109. Large cell carcinoma. Sheet-like growth pattern of large pleomorphic cells with abundant eosinophilic cytoplasm and prominent nucleoli Solid growth with peripheral palisading and several rosette-like structures. The tumor cells have large and polygonal nuclei with vesicular chromatin and prominent nucleoli
  110. 110. Adenocarcinoma NOS: Low grade tumor. Prominent well-formed glandular formations. Intermediate-grade tumor. Fused glandular formations with focal solid areas.
  111. 111. High-grade tumor. Irregularly shaped islands and strands of anaplastic carcinoma cells.Glandular formations are inconspicuous.
  112. 112. Colloid carcinoma Composed of multiple pools of mucin in a delicate fibrous stroma that surrounds atypical pleomorphic carcinoma cells. Detail of carcinoma nests demonstrating prominent nucleoli and moderate amounts of eosinophilic cytoplasm
  113. 113. Low-power view showing multilocular cystic lesions filled with lamellar keratin material. Portion of the cyst wall consists of stratified squamous epithelium with keratinization through parakeratotic cells.
  114. 114. The tumor forms sheets of basaloid cells with focal ductal differentiation separated by fibromyxomatous stroma.. The tumor cells are uniform without mitotic figures or pleomorphism.
  115. 115. Tumor diffusely and uniformly involves the parotid gland lobules, leaving scattered striated ducts. Proliferation of the plump endothelial cells with mild nuclear atypia.
  116. 116. well-developed stage of MALT lymphoma showing scattered lymphoepithelial lesions in diffuse sheets of monocytoid cells Lymphoepithelial lesion formed by the infiltration of monocytoid cells in the proliferation of duct epithelial cells.
  117. 117. MALT lymphoma.Immunohistochemistry. (A) The lymphoid tumor cells at both inside and outside of the lymphoepithelial lesion diffusely express CD20 (left) but are negative for CD3 (right). Immunoglobulin light chain restriction. Many kappa light chain-positive cells are seen in the left, whereas only scattered lambda positive cells are identified in the right
  118. 118. Most important features taken into consideration before making a diagnosis are : • Tumor borders • Cellular composition • Architectural arrangement • Cytologic features • Stromal components Analytic approach to diagnosis of epithelial tumors of salivary glands
  119. 119. • Some acinic cell ca and ca-ex-PA have circumscribed borders. • Pushing type of infiltration – Epithelial myoepithelial carcinoma, Basal cell adenocarcinoma, acinic cell carcinoma. • Morphologically bland looking myoepithelial, basal cell, oncocytic neoplasm if having invasive borders : malignant. • Warthin's tumor complicated by infarction or inflammation can result in adhesions to the surrounding tissues, mimicking a -malignant neoplasm clinically or grossly. Invasive or not?
  120. 120. Cellular differentiation in various salivary gland neoplasms

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