Difference between revisions of "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.
[[Image:Blausen_0780_SalivaryGlands.png|thumb|300px|Schematic showing the major salivary glands. (WC)]]
The '''salivary glands''' help digest food.  ENT surgeons excise them if a malignancy is suspected.  


==Normal==
The [[cytopathology]] of the salivary glands is covered in the ''[[Head and neck cytopathology]]'' article.
===Types of salivary glands===
 
=Normal salivary glands=
==Types of salivary glands==
Types of glands:<ref>[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/oral.htm#LABSALIVA http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/oral.htm#LABSALIVA]</ref>
Types of glands:<ref>[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/oral.htm#LABSALIVA http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/oral.htm#LABSALIVA]</ref>
#Serrous - eosinophilic cytoplasmic granules, acinar arrangement - vaguely resembles the acinar morphology of the [[pancreas]].
#Serrous - eosinophilic cytoplasmic granules, acinar arrangement - vaguely resembles the acinar morphology of the [[pancreas]].
#Mucinous - light eosinophilic staining.
#Mucinous - light eosinophilic staining.


===Identifying the glands===
==Identifying the glands==
The three main glands:
The three main glands:
# Parotid:
# Parotid:
Line 14: Line 17:
# Submandibular:
# Submandibular:
#*Serous and mucinous glands.
#*Serous and mucinous glands.
#**Serous ~90% of gland.
#**Mucinous ~10% of gland.
#*Serous demilunes = mucinous gland with "cap" consisting of a serous glandular component.
#**Demilune = crescent.<ref>URL: [http://dictionary.reference.com/browse/demilune http://dictionary.reference.com/browse/demilune]. Accessed on: 19 August 2011.</ref>
#**Image: [http://pathology.mc.duke.edu/research/histo_course/demilunes.jpg Serous demilunes (duke.edu)].<ref>URL: [http://pathology.mc.duke.edu/research/pth225.html http://pathology.mc.duke.edu/research/pth225.html]. Accessed on: 19 August 2011.</ref>
# Sublingual:
# Sublingual:
#*Mucinous glands.
#*Mucinous glands.
Other:
*Adipose tissue is found between the glands.
**It increases with age.


Images:
Images:
*[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/oral.htm#LABSALIVA Salivary glands (normal) - uwa.edu.au.]
*[http://www.lab.anhb.uwa.edu.au/mb140/CorePages/Oral/oral.htm#LABSALIVA Salivary glands - normal (uwa.edu.au)].
*[http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/PQ-Images/E1N002-2b.gif Submandibular gland (ouhsc.edu)] - from a [http://moon.ouhsc.edu/kfung/jty1/opaq/PathQuiz/E1N002-PQ01-M.htm Pathology Quiz].


Memory devices:  
Memory devices:  
Line 24: Line 38:
*Sub'''m'''andibular = glands are '''m'''ixed.
*Sub'''m'''andibular = glands are '''m'''ixed.


==Overview==
=Overview=
===Benign tumours===
==Benign tumours==
'''Tabular form - adapted from Thompson<ref>HNP PP.295-319.</ref>'''
'''Tabular form - adapted from Thompson<ref>{{Ref HaNP|295-319}}</ref>'''
{| class="wikitable"
{| class="wikitable sortable"
|
! Entity
| '''Architecture'''
! Architecture
| '''Morphology'''
! Morphology
| '''Cell borders'''
! Cell borders
| '''Cytoplasm'''
! Cytoplasm
| '''Nucleus'''
! Nucleus  
| '''DDx'''
! DDx
| '''Other'''
! Other
! Image
|-
|-
|Pleomorphic adenoma || var. || '''mixed pop.'''; must include: (1) myoepithelium, (2) epithelium, (3) chondromyxoid stroma  || var. || var. || (1) plasmacytoid || adenoid cystic c. || occ. encapsulated, <br>mixed pop. of glandular, <br>myoepithelial and mesenchymal cells
|[[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, <br>mixed pop. of glandular, <br>myoepithelial and mesenchymal cells
| [[Image:Pleomorphic_adenoma_(1)_parotid_gland.jpg | thumb | center |150px| PA. (WP)]]
|-
|-
|Warthin tumour || papillary, <br>'''bilayer''' || cuboid (basal), columnar (apical) || clearly seen || '''eosinophilic, abundant''' || unremarkable || sebaceous lymphadenoma || AKA ''papillary cystadenoma lymphomatosum''
|[[Warthin tumour]]
| papillary, <br>'''bilayer'''  
| cuboid (basal), columnar (apical)  
| clearly seen  
| '''eosinophilic, abundant'''  
| unremarkable  
| [[sebaceous lymphadenoma]]
| AKA ''papillary cystadenoma lymphomatosum''
| [[Image:Papillary_cystadenoma_lymphomatosum2.jpg| thumb| center | 150px| PCL. (WP/Nephron)]]
|-
|-
|Basal cell adenoma || var., '''islands surrounded'''<br>'''by hyaline bands''' || basaloid || subtle || scant,<br>hyperchromatic || granular || basal cell adenoca || -
|[[Basal cell adenoma]]
| var., '''islands surrounded'''<br>'''by hyaline bands''', lesion encapsulated
| basaloid
| subtle
| scant,<br>hyperchromatic
| granular
| [[basal cell adenocarcinoma]]
| -
| -  
|-
|-
|Canalicular adenoma || '''chains of cells''' || cuboid or columnar || subtle || scant,<br>hyperchromatic || granular || basal cell adenoma || -
|[[Canalicular adenoma]]
| '''chains of cells'''
| cuboid or columnar
| subtle
| scant,<br>hyperchromatic  
| granular
| [[basal cell adenoma]]
| exclusively oral cavity, 80% in upper lip; IHC: p63-
| [[Image:Canalicular_adenoma_--_high_mag.jpg | thumb | center |150px| CA. (WC)]]
|-
|-
|Sialoblastoma || var., '''islands surrounded'''<br>'''by loose fibrous stroma''' || basaloid || subtle || scant, hyperch. || granular || basal cell adenoca || -
|[[Sialoblastoma]]
| var., '''islands surrounded'''<br>'''by loose fibrous stroma'''
| basaloid
| subtle
| scant, hyperch.
| granular
| [[basal cell adenocarcinoma]]
| -
| -
|-
|-
|}
|}


===Malignant tumours===
==Malignant tumours==
'''Tabular form - adapted from Thompson<ref>HNP PP.325-357.</ref>'''
'''Tabular form - adapted from Thompson<ref>{{Ref HaNP|325-357}}</ref>'''
{| class="wikitable"
{| class="wikitable sortable"
| || '''Architecture''' || '''Morphology''' || '''Cell borders''' || '''Cytoplasm''' || '''Nucleus''' || '''DDx''' || '''Other'''
! Entity
! Architecture
! Morphology
! Cell borders
! Cytoplasm
! Nucleus
! DDx
! Other
! Image
|-
|[[Mucoepidermoid carcinoma]]
| cystic & solid
| epithelioid
| distinct
| '''fuffy, clear,<br>abundant'''  
| nuclei sm.
| SCC (?)
| IHC: p63+
| [[Image:Mucoepidermoid_carcinoma_%282%29_HE_stain.jpg |thumb| center| 150px | MEC. (WC)]]
|-
|-
|Mucoepidermoid carcinoma || cystic & solid || epithelioid || distinct || '''fuffy, clear,<br>abundant''' || nuclei sm. || ? || ?
|[[Adenoid cystic carcinoma]] (AdCC)
| pseudocysts,<br>'''[[cribriform]]''', solid,<br>hyaline stroma
| epithelioid
| subtle
| '''scant''',<br>hyperchromatic
| '''small'''<br>+/-"carrot-shaped"
| [[pleomorphic adenoma]], [[PLGA]]
| Stains: PAS+ (pseudocyst material), CD117+, cyclin D1+
| [[Image:Adenoid_cystic_carcinoma_-_high_mag.jpg|thumb|center|150px| AdCC. (WC/Nephron)]]
|-
|-
|Acinic cell adenocarcinoma (AcCC) || acinar (islands) || epithelioid || clear || '''granular''', generous || stipled, +/-occ. nucleoli || ? || ?
|[[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
| [[Image:Acinic_cell_carcinoma_-_high_mag.jpg | thumb| center|150px| AcCC. (WC/Nephron)]]
|-
|-
|Adenoid cystic carcinoma (AdCC) || pseudocysts,<br>cribriform, solid,<br>hyaline stroma || epithelioid || subtle || scant,<br>hyperchromatic || '''small<br>"carrot-shaped"''' || ? || ?
|[[Salivary duct carcinoma]]
| glandular, [[cribriform]]
| columnar
| subtle/clear
| hyperchromatic
| columnar
| metastatic breast carcinoma
| similar to ductal<br>breast carcinoma; male>female
| [[Image:Salivary_duct_carcinoma_-a-_low_mag.jpg | thumb| center|150px | SDC. (WC/Nephron)]]
|-
|-
|Salivary duct carcinoma || glandular, cribriform || columnar || subtle/clear || hyperchromatic || columnar || metastatic breast ca || similar to ductal<br>breast carcinoma
|[[Polymorphous adenocarcinoma]] (previously polymorphous low-grade adenocarcinoma)
| variable, often small<br>nests, may be targetoid
| epithelioid
| indistinct
| '''eosinophilic'''
| ovoid & small with<br>small nucleoli
| AdCC
| minor salivary gland tumour,<br>often in palate,<br> cytologically monotonous; IHC: [[S-100]]+, CK+, vim.+, GFAP+/-, BCL2+/-
| [[Image:Polymorphous_low-grade_adenocarcinoma_-_very_low_mag.jpg|thumb|center|150px|PLGA. (WC/Nephron)]]
|-
|-
|Polymorphous low-grade adenocarcinoma || variable, often small<br>nests, may be targetoid || epithelioid || indistinct || '''eosinophilic''' || ovoid & small with<br>small nucleoli || ? || minor salivary gland tumour,<br>often in palate,<br> cytologically monotonous
| [[Epithelial-myoepithelial carcinoma]]
| '''nests (myoepithelial) with tubules (epithelial)'''
| epithelioid
| not distinct
| eosinophilic cytoplasm; epithelial: scant; myoepithelial: moderate
| focal clearing
| [[AdCC]], [[pleomorphic adenoma]]
| rare
| [[Image:Epithelial-myoepithelial_carcinoma_-_high_mag.jpg |thumb|center|150px|EMCa. (WC/Nephron)]]
|-
|-
| [[Basal cell adenocarcinoma]]
| var., '''islands surrounded'''<br>'''by hyaline bands''', lesion '''not''' encapsulated
| basaloid
| subtle
| scant,<br>hyperchromatic
| granular
| [[basal cell adenoma]]
| rare, usu. parotid gland, may arise from a basal cell adenoma
| [[Image:Basal_cell_adenocarcinoma_-_parotid_gland_-_high_mag.jpg|thumb|center|150px|BCA. (WC/Nephron)]]
|}
|}


===DDx by site===
==DDx==
Palate:
===Palate===
*Polymorphous low-grade adenocarcinoma.
*[[Polymorphous adenocarcinoma]].
*Adenoid cystic carcinoma.
*[[Adenoid cystic carcinoma]].
*Pleomorphic adenoma.
*[[Pleomorphic adenoma]].
 
===Benign parotid tumours===
*[[Pleomorphic adenoma]].
*[[Warthin tumour]].


=Benign=
===Oncocytic tumours===
==Mucocele==
*Benign:
*Mucous.
**Oncocytoma.
**[[Warthin tumour]].
*Malignant:
**[[Mucoepidermoid carcinoma]], oncocytic variant.
**[[Salivary duct carcinoma]].
**[[Carcinoma ex pleomorphic carcinoma]] with a salivary duct carcinoma component.
**[[Apocrine carcinoma]].
**Oncocytic carcinoma.
**[[Acinic cell carcinoma]], oncocytic variant.


==Pleomorphic adenoma==
===Clear cell tumours===
===Epidemiology===
*[[Mucoepidermoid carcinoma]], clear cell variant.
Features:<ref>HANP P.295.</ref>
*[[Acinic cell carcinoma]], clear cell variant.
*Very common - approx. 60% of parotid gland tumours
*[[Hyalinizing clear cell carcinoma]].
*[[Epithelial-myoepithelial carcinoma]].
*Metastatic [[clear cell carcinoma]].
**Metastatic [[clear cell renal cell carcinoma]].


===Histology===
===Basaloid neoplasms===
Features:<ref>HANP P.295.</ref>
*[[Basal cell adenoma]].
*Proliferation of myoepithelium and epithelium in mesenchymal stroma.
*[[Basal cell adenocarcinoma]]
*Mesenchymal stroma - key feature.
*[[Pleomorphic adenoma]].<ref name=pmi12478487/>
**May be any of following: myxoid, mucochondroid, hyalinized, osseous, fatty.
*[[Adenoid cystic carcinoma]].<ref name=pmi12478487/>
*Look for, i.e. rule-out, poorly differentiated carcinoma: ''carcinoma ex pleomorphic adenoma''.
*[[Small cell carcinoma]].<ref name=pmi12478487>{{Cite journal  | last1 = Chhieng | first1 = DC. | last2 = Paulino | first2 = AF. | title = Basaloid tumors of the salivary glands. | journal = Ann Diagn Pathol | volume = 6 | issue = 6 | pages = 364-72 | month = Dec | year = 2002 | doi = 10.1053/adpa.2002.37013 | PMID = 12478487 }}</ref>


IHC: S-100+, SMA+, GFAP+.
==IHC overview==
General:
*Usually has limited value. <!--as per Ilan Weinreb-->


==Basal cell adenoma==
Overview:
*Basophilic cells.
*Luminal markers: [[CK7]], [[CK19]], CAM5.2 (LMWK).
*Nests.
*Basal markers: p63, HMWK, CK14.
*Myoepithelial markers: calponin, actin.
*Uncommitted: S-100.


==Canalicular adenoma==
Notes:
*Channels.
*p63 and S-100 are sometimes call myoepithelial.


==Papillary cystadeoma lymphomatosum==
Specifics:
*AKA ''Warthin tumour''.
*Calponin, S-100, Ki-67 may be useful as per Nagao ''et al.''<ref>{{Cite journal  | last1 = Nagao | first1 = T. | last2 = Sato | first2 = E. | last3 = Inoue | first3 = R. | last4 = Oshiro | first4 = H. | last5 = H Takahashi | first5 = R. | last6 = Nagai | first6 = T. | last7 = Yoshida | first7 = M. | last8 = Suzuki | first8 = F. | last9 = Obikane | first9 = H. | title = Immunohistochemical analysis of salivary gland tumors: application for surgical pathology practice. | journal = Acta Histochem Cytochem | volume = 45 | issue = 5 | pages = 269-82 | month = Oct | year = 2012 | doi = 10.1267/ahc.12019 | PMID = 23209336 }}</ref>
*Papillae.
*Most salivary gland tumours are p40 positive and p63 positive; [[polymorphous adenocarcinoma]] is p63 positive and p40 negative.<ref name=pmid34518135>{{cite journal |authors=Sivakumar N, Narwal A, Pandiar D, Devi A, Anand R, Bansal D, Kamboj M |title=Diagnostic utility of p63/p40 in the histologic differentiation of salivary gland tumors: A systematic review |journal=Oral Surg Oral Med Oral Pathol Oral Radiol |volume=133 |issue=2 |pages=189–198 |date=February 2022 |pmid=34518135 |doi=10.1016/j.oooo.2021.07.010 |url=}}</ref>


===Microscopy===
=Benign=
* Papillae (nipple-shaped structures) with a two rows of pink (eosinophilic) epithelial cells (with cuboidal basal cells and columnar luminal cells) -- '''key feature'''.
General DDx:
* Fibrous capsule - pink & homogenous on H&E.
*Inflammation.
* Cystic space.
*Neoplasm.
* Lymphoid stroma.
*Ductal obstrution.


===DDx===
==Chronic sialadenitis==
*Lymphoepithelial cyst.
{{Main|Chronic sialadenitis}}
**Cyst within a lymph node.


==Sebaceous adenoma==
==Salivary gland mucocele==
*Benign counterpart of ''sebaceous carcinoma''.
{{Main|Salivary gland mucocele}}


==Oncocytoma==
==Pleomorphic adenoma==
*Like [[oncocytoma]]s elsewhere.
{{Main|Pleomorphic adenoma}}
**Eosinophilic cytoplasm (H&E) - due to increased number of mitochrondria.


=Malignant=
==Myoepithelioma==
Approach:
{{Main|Myoepithelioma}}
*Differentiate -- luminal vs. myoepithelial vs. basal.


==Mucoepidermoid carcinoma==
==Basal cell adenoma==
General:
===General===
*Most common malignant neoplasm of salivary gland.
*~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 cylindroma]]s in the context of a genetic mutation.<ref name=pmid12023583>{{Cite journal  | last1 = Choi | first1 = HR. | last2 = Batsakis | first2 = JG. | last3 = Callender | first3 = DL. | last4 = Prieto | first4 = VG. | last5 = Luna | first5 = MA. | last6 = El-Naggar | first6 = AK. | title = Molecular analysis of chromosome 16q regions in dermal analogue tumors of salivary glands: a genetic link to dermal cylindroma? | journal = Am J Surg Pathol | volume = 26 | issue = 6 | pages = 778-83 | month = Jun | year = 2002 | doi =  | PMID = 12023583 }}</ref>
*Malignant transformation - rarely.


===Microscopic===
Features:
Features:
*Abundant fluffy cytoplasm - with large mucin vacuole.
#Basal component.
*Nucleus distorted by mucin vacuole.
#*Basophilic cells - '''key feature'''.
#*Usu. in nests.
#**May be bilayered tubules ''or'' [[trabeculae]].
#*Large basophilic nucleus.
#*Minimal-to-moderate eosinophilic cytoplasm.
#Stromal cells.
#*Plump spindle cells without significant nuclear atypia - '''distinguishing feature'''.
#**Stromal cell nuclei width ~= diameter [[RBC]].
#*Dense hyaline stroma.
#Tubular component.
#*Within basal component, may be minimal.
#Lesion is encapsulated - '''key feature'''.
 
Notes:
*No chondromyxoid stroma.
**Chondromyxoid stroma present -> [[pleomorphic adenoma]].
*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:
*[[Adenoid cystic carcinoma]] - not encapsulated.
*[[Basal cell adenocarcinoma]] - not encapsulated.
*[[Canalicular adenoma]] - different site; canalicular adenoma is the in oral cavity, usually upper lip.


Images:
Images:
*[http://commons.wikimedia.org/wiki/File:Mucoepidermoid_carcinoma_%282%29_HE_stain.jpg Mucoepidermoid carcinoma 2 (WC)].
*[http://moon.ouhsc.edu/kfung/jty1/Com/ComImage/Com304-3-LM1.gif BCA (ouhsc.edu)].<ref>URL: [http://moon.ouhsc.edu/kfung/jty1/Com/Com304-3-Diss.htm http://moon.ouhsc.edu/kfung/jty1/Com/Com304-3-Diss.htm]. Accessed on: 25 October 2011.</ref>
*[http://commons.wikimedia.org/wiki/File:Mucoepidermoid_carcinoma_%283%29_HE_stain.jpg Mucoepidermoid carcinoma 3 (WC)].
*[http://www.webpathology.com/image.asp?n=1&Case=115 BCA (webpathology.com)].
*[http://www.webpathology.com/image.asp?n=4&Case=115 BCA (webpathology.com)].
*[http://www.flickr.com/photos/euthman/5691555734/in/set-72057594114099781/ BCA (flickr.com/euthman)].
 
===IHC===
*Luminal stains +ve: CK7 +ve, CAM5.2 +ve.
*p63 +ve -- basal component.
*[[S-100]] +ve -- spindle cells in the stroma.


==Acinic cell adenocarcinoma==
==Canalicular adenoma==
*Abbreviated ''AcCC''.
{{Main|Canalicular adenoma}}
*Common malignant neoplasm of salivary gland.


Features:
==Warthin tumour==
*Psammoma bodies(?).
{{Main|Warthin tumour}}
*Abundant cytoplasm.
*Stipled chromatin.
*Acinar architecture (islands of cells).


Memory device:
==Sebaceous adenoma==
*AcCC - lots of "C"s - '''c'''hromatin stipled, '''c'''ytoplasm generous.
{{Main|Sebaceous adenoma}}
*Benign counterpart of ''[[sebaceous carcinoma]]''.


==Adenoid cystic carcinoma==
==Sebaceous lymphadenoma==
*Common malignant neoplasm of salivary gland.
{{Main|Sebaceous lymphadenoma}}
*AKA ''cylindroma''.<ref>Chest. May 1957. Vol. 31. No. 5. PP. 493-511. [http://www.chestjournal.org/content/31/5/493.abstract http://www.chestjournal.org/content/31/5/493.abstract]</ref>
**Should ''not'' be confused with ''dermal cylindroma'' (a benign skin tumour).


Features:
==Oncocytoma of the salivary gland==
*Cribriform architecture.
*[[AKA]] ''salivary gland oncocytoma''.
*Scant cytoplasm.
{{Main|Oncocytoma of the salivary gland}}
*Carrot-shaped nucleus.
*Hyaline stroma.


Images: [http://www.nature.com/modpathol/journal/v16/n12/fig_tab/3880915f2.html Adenoid cystic carcinoma - Mod. Pathol.]
=Malignant=
One approach:
*Differentiate -- luminal vs. myoepithelial vs. basal (mucoepideroid).


Memory device:
==Mucoepidermoid carcinoma==
*A'''d'''CC - mostly '''D'''NA (scant cytoplasm), distinct nucleus (carrot-shaped).
{{Main|Mucoepidermoid carcinoma}}


==Salivary duct carcinoma==
==Acinic cell carcinoma==
Needs work.
{{Main|Acinic cell carcinoma}}


*Malignant counterpart of ''salivary duct adenoma''.
==Adenoid cystic carcinoma==
{{Main|Adenoid cystic carcinoma}}
Note: The [[breast]] tumour is dealt with in ''[[adenoid cystic carcinoma of the breast]]''.


==Polymorphous low-grade adenocarcinoma==
==Salivary duct carcinoma==
*Classically found in the palate.
{{Main|Salivary duct carcinoma}}
*Tumour of the minor salivary glands.


===Microscopy===
==Intraductal carcinoma of the salivary gland==
*Cytologically monotonous (uniform) with variable architecture - '''key feature'''.
{{Main|Intraductal carcinoma of the salivary gland}}
**Architecture: often small nests, may be targetoid.
*Nucleus: ovoid & small with small nucleoli.
*Indistinct cell borders.
*Eosinophilic cytoplasm.


===DDx===  
==Polymorphous adenocarcinoma==
*Pleomorphic adenoma.
*Abbreviated ''PAC''.
*Adenoid cystic carcinoma.
*Previously known as ''polymorphous low-grade adenocarcinoma'', abbreviated ''PLGA''.
{{Main|Polymorphous adenocarcinoma}}


==Carcinoma ex pleomorphic adenoma==
==Carcinoma ex pleomorphic adenoma==
*Malignant transformation of ''pleomorphic adenoma''.
*Abbreviated ''Ca ex PA''.
*Rare.
{{Main|Carcinoma ex pleomorphic adenoma}}
*May be subtle.


===Microscopy===
==Epithelial-myoepithelial carcinoma==
*Nests of cells, may from glands, single cells. (???)
{{Main|Epithelial-myoepithelial carcinoma}}


Note:
==Basal cell adenocarcinoma==
*Adenocarcinoma-like.
{{Main|Basal cell adenocarcinoma}}


==Sebaceous carcinoma==
==Sebaceous carcinoma==
*Arises from ''sebaceous glands''
{{Main|Sebaceous carcinoma}}
*Sebaceous glands are serous glands and clear on H&E.
It is similar to the tumour found in the skin.
 
==Hyalinizing clear cell carcinoma==
{{Main|Hyalinizing clear cell carcinoma}}


==See also==
=See also=
*[[Head and neck pathology]].
*[[Head and neck pathology]].
*[[Thyroid gland]].
*[[Thyroid gland]].
*[[Breast]].
*[[Breast]].
*[[Head and neck cytopathology]].
*[[Lacrimal gland]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


[[Category:Head and neck pathology]]
[[Category:Head and neck pathology]]
[[Category:Salivary gland|Salivary gland]]

Latest revision as of 20:36, 2 June 2024

Schematic showing the major salivary glands. (WC)

The salivary glands help digest food. ENT surgeons excise them if a malignancy is suspected.

The 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-
CA. (WC)
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 adenocarcinoma (previously 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: S-100+, 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

Basaloid neoplasms

IHC overview

General:

  • Usually has limited value.

Overview:

  • 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.

Specifics:

  • Calponin, S-100, Ki-67 may be useful as per Nagao et al.[8]
  • Most salivary gland tumours are p40 positive and p63 positive; polymorphous adenocarcinoma is p63 positive and p40 negative.[9]

Benign

General DDx:

  • Inflammation.
  • Neoplasm.
  • Ductal obstrution.

Chronic sialadenitis

Main article: Chronic sialadenitis

Salivary gland mucocele

Main article: Salivary gland mucocele

Pleomorphic adenoma

Main article: Pleomorphic adenoma

Myoepithelioma

Main article: Myoepithelioma

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.[10]
  • 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.
  • S-100 +ve -- spindle cells in the stroma.

Canalicular adenoma

Main article: Canalicular adenoma

Warthin tumour

Main article: Warthin tumour

Sebaceous adenoma

Main article: Sebaceous adenoma

Sebaceous lymphadenoma

Main article: Sebaceous lymphadenoma

Oncocytoma of the salivary gland

  • AKA salivary gland oncocytoma.
Main article: Oncocytoma of the salivary gland

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

Main article: Adenoid cystic carcinoma

Note: The breast tumour is dealt with in adenoid cystic carcinoma of the breast.

Salivary duct carcinoma

Main article: Salivary duct carcinoma

Intraductal carcinoma of the salivary gland

Main article: Intraductal carcinoma of the salivary gland

Polymorphous adenocarcinoma

  • Abbreviated PAC.
  • Previously known as polymorphous low-grade adenocarcinoma, abbreviated PLGA.
Main article: Polymorphous 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. ↑ 7.0 7.1 7.2 Chhieng, DC.; Paulino, AF. (Dec 2002). "Basaloid tumors of the salivary glands.". Ann Diagn Pathol 6 (6): 364-72. doi:10.1053/adpa.2002.37013. PMID 12478487.
  8. ↑ Nagao, T.; Sato, E.; Inoue, R.; Oshiro, H.; H Takahashi, R.; Nagai, T.; Yoshida, M.; Suzuki, F. et al. (Oct 2012). "Immunohistochemical analysis of salivary gland tumors: application for surgical pathology practice.". Acta Histochem Cytochem 45 (5): 269-82. doi:10.1267/ahc.12019. PMID 23209336.
  9. ↑ Sivakumar N, Narwal A, Pandiar D, Devi A, Anand R, Bansal D, Kamboj M (February 2022). "Diagnostic utility of p63/p40 in the histologic differentiation of salivary gland tumors: A systematic review". Oral Surg Oral Med Oral Pathol Oral Radiol 133 (2): 189–198. doi:10.1016/j.oooo.2021.07.010. PMID 34518135.
  10. ↑ 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.
  11. ↑ URL: http://moon.ouhsc.edu/kfung/jty1/Com/Com304-3-Diss.htm. Accessed on: 25 October 2011.
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