Salivary Gland Neoplasms Sam J. Cunningham, MD, PhD Faculty - - PowerPoint PPT Presentation

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Salivary Gland Neoplasms Sam J. Cunningham, MD, PhD Faculty - - PowerPoint PPT Presentation

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Histopathology of Major Salivary Gland Neoplasms Sam J. Cunningham, MD, PhD Faculty Advisor: Shawn D. Newlands, MD, PhD Faculty Advisor: David C. Teller, MD The University of Texas Medical Branch, Department of Otolaryngology Grand Rounds

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SLIDE 1

Histopathology of Major Salivary Gland Neoplasms

Sam J. Cunningham, MD, PhD Faculty Advisor: Shawn D. Newlands, MD, PhD Faculty Advisor: David C. Teller, MD The University of Texas Medical Branch, Department of Otolaryngology Grand Rounds Presentation November 16, 2005

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SLIDE 2

Introduction

 Neoplasms of the major salivary

glands constitute minor portion of head and neck neoplasms

 Less than 2% are malignant  Most neoplasms in parotid 75%,

0.8% in sublingual glands

 Remainder equally distributed

between submandibular gland and minor salivary glands

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SLIDE 3

Introduction

 Incidence rises at age 15 and peaks

at 65-75.

 Incidence of malignant neoplasms

increases after 4th and 5th decades and peaks 65-75 years.

 Benign neoplasms present slightly

earlier

 Malignant neoplasms occur most

  • ften in men.
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SLIDE 4

Introduction

 Cancers of the salivary glands

account for only 6% of H&N cancers

 Only 0.3% of all cancers  Proportion of malignant and benign

varies with the gland of origin.

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SLIDE 5

Introduction

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SLIDE 6

Salivary Gland Microanatomy

 Saliva transported from central structure

(acini) in complex ductal system to the

  • ral cavity

 System is a bilayer with internal luminal

layer and external reserve layer.

 Internal layer forms acini and ductal

epithelium

 External layer forms myoepithelium and

reserve cells

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SLIDE 7

Salivary Gland Microanatomy

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SLIDE 8
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SLIDE 9

Bicellular Theory

 Intercalated Ducts

  • Pleomorphic

adenoma

  • Warthin’s tumor
  • Oncocytoma
  • Acinic cell
  • Adenoid cystic

 Excretory Ducts

  • Squamous cell
  • Mucoepidermoid
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SLIDE 10

Multicellular Theory

 Striated duct—oncocytic tumors  Acinar cells—acinic cell carcinoma  Excretory Duct—squamous cell and

mucoepidermoid carcinoma

 Intercalated duct and myoepithelial

cells—pleomorphic tumors

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SLIDE 11

Classification of Salivary Gland Neoplasms

 WHO

  • Adenomas
  • Carcinomas
  • Nonepithelial Tumors
  • Malignant lymphomas
  • Secondary tumors
  • Unclassified tumors
  • Tumor-like lesions
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SLIDE 12

Classification of Salivary Gland Neoplasms

 Armed Forces Institute of Pathology

  • Benign Epithelial Neoplasms
  • Malignant Epithelial Neoplasms
  • Mesenchymal Neoplasms
  • Malignant Lymphomas
  • Metastatic Tumors
  • Nonneoplastic Tumor-like Conditions
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SLIDE 13

Benign Neoplasms

 Pleomorphic Adenoma  Warthin’s Tumor  Basal Cell Adenoma  Oncocytoma  Canalicular Adenoma  Myoepithelioma

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SLIDE 14

Pleomorphic Adenoma

 Histology

  • Mixture of

epithelial, myopeithelial and stromal components

  • Epithelial cells:

nests, sheets, ducts, trabeculae

  • Stroma: myxoid,

chrondroid, fibroid, osteoid

  • No true capsule
  • Tumor

pseudopods

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SLIDE 15

Pleomorphic Adenoma

 Necrosis and mitosis

rare

 IHC profile consistent

with dual architecture

 Glandular areas stain

with CEA and S-100, actin, epithelial membrane antigen

 Mesemchymal areas

stain with S-100 and actin only

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SLIDE 16

Warthin’s Tumor

 Histology

  • Papillary

projections into cystic spaces surrounded by lymphoid stroma

  • Epithelium:

double cell layer

 Luminal cells  Basal cells

  • Stroma: mature

lymphoid follicles with germinal centers

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SLIDE 17

Warthin’s Tumor

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SLIDE 18

Basal Cell Adenoma

 Solid nests of

cells with scant cytoplasm and hyperchromatic nuclei

 Tendency for

peripheral pallisading.

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SLIDE 19

Basal Cell Adenoma

 Solid

  • Most common
  • Solid nests of

tumor cells

  • Uniform,

hyperchromatic, round nuclei, indistinct cytoplasm

  • Peripheral nuclear

palisading

  • Scant stroma
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SLIDE 20

Basal Cell Adenoma

 Trabecular

  • Cells in elongated

trabecular pattern

  • Vascular stroma
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SLIDE 21

Basal Cell Adenoma

 Tubular

  • Multiple duct-like

structures

  • Columnar cell lining
  • Vascular stroma
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SLIDE 22

Basal Cell Adenoma

 Membranous

  • Thick eosinophilic

hyaline membranes surrounding nests

  • f tumor cells
  • “jigsaw-puzzle”

appearance

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SLIDE 23

Basal Cell Adenoma

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SLIDE 24

Oncocytoma

 Histology

  • Cords of uniform cells

and thin fibrous stroma

  • Large polyhedral cells
  • Distinct cell

membrane

  • Granular, eosinophilic

cytoplasm

  • Central, round,

vesicular nucleus

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SLIDE 25

Oncocytoma

 Positive staining

for phosphotungstic acid:hematoxylin, cytokeratin, epithelial membrane antigen

 Negative for S-100

glial fibrillary, smooth muscle actin

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SLIDE 26

Canalicular Adenoma

 Histology

  • Well-circumscribed
  • Multiple foci
  • Tubular structures

line by columnar or cuboidal cells

  • Vascular stroma
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SLIDE 27

Myoepithelioma

 Histology

  • Spindle cell

 More common  Parotid  Uniform, central

nuclei

 Eosinophilic granular

  • r fibrillar cytoplasm
  • Plasmacytoid cell

 Polygonal  Eccentric oval nuclei

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SLIDE 28

Myoepithelioma

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SLIDE 29

Malignant Neoplasms

 Mucoepidermoid Carcinoma  Adenoid Cystic Carcinoma  Polymorphous Low-Grade Adenocarcinoma  Acinic Cell Carcinoma  Adenocarcinoma  Malignant Mixed Tumor  Epithelial-Myoepithelial Carcinoma  Salivary Duct Carcinoma  Squamous Cell Carcinoma  Undifferentiated Carcinoma

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SLIDE 30

Mucoepidermoid Carcinoma

 Histology—Low-

grade

  • Mucus cell >

epidermoid cells

  • Prominent cysts
  • Mature cellular

elements

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SLIDE 31

Mucoepidermoid Carcinoma

 Histology—

Intermediate- grade

  • Mucus = epidermoid
  • Fewer and smaller

cysts

  • Increasing

pleomorphism and mitotic figures

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SLIDE 32

Mucoepidermoid Carcinoma

 Histology—High-

grade

  • Epidermoid >

mucus

  • Solid tumor cell

proliferation

  • Mistaken for SCCA

 Mucin staining

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SLIDE 33

Low Grade Mucoepidermoid Carcinoma

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SLIDE 34

High Grade Mucoepidermoid Carcinoma

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SLIDE 35

Adenoid Cystic Carcinoma

 Histology—

cribriform pattern

  • Most common
  • “swiss cheese”

appearance

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SLIDE 36

Adenoid Cystic Carcinoma

 Histology—tubular

pattern

  • Layered cells

forming duct-like structures

  • Basophilic mucinous

substance

 Histology—solid

pattern

  • Solid nests of cells

without cystic or tubular spaces

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SLIDE 37

Adenoid Cystic Carcinoma

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SLIDE 38

Polymorphous Low-Grade Adenocarcinoma

 Histology

  • Isomorphic cells,

indistinct borders, uniform nuclei

  • Peripheral “Indian-

file” pattern

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SLIDE 39

Polymorphous Low-Grade Adenocarcinoma

 Markedly positive

staining for S-100, epithelial membrane antigen, and

  • cytokeratins. Less

predictable with CEA and muscle- specific actin

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SLIDE 40

Acinic Cell Carcinoma

 Histology

  • Solid and

microcystic patterns

 Most common  Solid sheets  Numerous small

cysts

  • Polyhedral cells
  • Small, dark,

eccentric nuclei

  • Basophilic granular

cytoplasm

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SLIDE 41

Acinic Cell Carcinoma

 Positive staining

with cytokeratins and CEA, mixed results with others

 Vacuolated cells

with eccentrically located nuclei and granular, basophilic cytoplasm, scant stroma

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SLIDE 42

Adenocarcinoma

 Histology

  • Heterogeneity
  • Presence of

glandular structures and absence of epidermoid component

  • Requires exclusion
  • f other specific

salivary gland carcinomas

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SLIDE 43

Adenocarcinoma

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SLIDE 44

Malignant Mixed Tumors

 Carcinoma ex-pleomorphic

adenoma

 Carcinoma developing in the epithelial

component of preexisting pleomorphic adenoma

 Carcinosarcoma

 True malignant mixed tumor—

carcinomatous and sarcomatous components

 Metastatic mixed tumor

 Metastatic deposits of otherwise typical

pleomorphic adenoma

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SLIDE 45

Carcinoma Ex-Pleomorphic Adenoma

 Histology

  • Malignant cellular

change adjacent to typical pleomorphic adenoma

  • Carcinomatous

component

 Adenocarcinoma  Undifferentiated

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SLIDE 46

Carcinosarcoma

 Histology

  • Biphasic appearance
  • Sarcomatous

component

 Dominant  chondrosarcoma

  • Carinomatous

component

 Moderately to poorly

differentiated ductal carcinoma

 Undifferentiated

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SLIDE 47

Malignant Mixed Tumor

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SLIDE 48

Epithelial-Myoepithelial Carcinoma

 Dual epithelial

component

 Irregular, eccentric

nuclei w vacuolated cytoplasm

 IHC reveals dual cell

  • rigin

 epithelial:cytokeratins  Myoep:S-100, actin

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SLIDE 49

Epithelial-Myoepithelial Carcinoma

 Tumor cell nests  Two cell types  Thickened basement

membrane

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SLIDE 50

Salivary Duct Carcinoma

 Large polygonal cells

w well defined borders

 Pleomorphic nuclei w

prominent nucleoli and granular, eosinophilic cytoplasm

 IHC patterns similar to

breast CA except neg for estrogen

 CEA, epithelial

membrane +

 S-100, cytokeratins -

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SLIDE 51

Squamous Cell Carcinoma

 Histology

  • Infiltrating
  • Nests of tumor cells
  • Well differentiated

 Keratinization

  • Moderately-well

differentiated

  • Poorly

differentiated

 No keratinization

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SLIDE 52

Squamous Cell Carcinoma

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SLIDE 53

Undifferentiated Carcinoma

 High grade, high

mitotic activity, scant cytoplasm, hyperchromatic nuclei

 IHC:cytokeratins,

epithelial membrane antigen

 +/-

neuroendocrine

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SLIDE 54

References

Seifert, Diseases of the Salivary Glands. Thieme Publishers,

  • NY. 1986

Otolaryngologic clinics of North America. Salivary Gland

  • Disorders. WB Saunders, Phila, PA Oct. 1999.

Ellis, Surgerical Pathology of the Salivary Glands. WB Saunders, Phila PA, 1991. Salivary Gland Neoplasms: A Clinicopathologic Approach to

  • Treatment. 3rd ed. American Academy of Otolaryngology,

Head and Neck Surgery Foundation Inc. 2003. Bailey, Head and Neck Surgery-Otolaryngology. Lippencott, Williams, Wilkins. 3rd ed. 2001. Rosen, Salivary Gland Neoplasms. Dr. Quinns online textbook

  • f Otolaryngology. 2002.

Cummings, Otolaryngology Head and Neck Surgery. Elsiever and Mosby. 2005.

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SLIDE 55

Question 1

The highlighted area represents:

  • a. the acini
  • b. the intercalated duct
  • c. the striated duct
  • d. the excretory duct
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SLIDE 56

Question 2

The highlighted area represents:

  • a. the acini
  • b. the intercalated duct
  • c. the striated duct
  • d. the excretory duct
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SLIDE 57

Question 3

The highlighted area represents:

  • a. the acini
  • b. the intercalated duct
  • c. the striated duct
  • d. the excretory duct
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SLIDE 58

Question 4

The highlighted area represents:

  • a. the acini
  • b. the intercalated duct
  • c. the striated duct
  • d. the excretory duct
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SLIDE 59

Question 5

The parotid gland neoplasms are: a.) Mostly Benign b.) Mostly Malignant c.) About equal distribution, benign=malignant

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SLIDE 60

Question 6

The submandibular gland neoplasms are: a.) Mostly Benign b.) Mostly Malignant c.) About equal distribution, benign=malignant

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SLIDE 61

Question 7

The sublingual gland neoplasms are: a.) Mostly Benign b.) Mostly Malignant c.) About equal distribution, benign=malignant

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SLIDE 62

Question 8

Identify the neoplasm:

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SLIDE 63

Question 9

Identify the neoplasm:

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SLIDE 64

Question 10

Identify the neoplasm: