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Salivary Gland Pathology

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Title: Salivary Gland Pathology


1
Salivary Gland Pathology
2
Mucocele
  • Mucus Extravasation Phenomenon Mucus Escape
    Reaction

3
Mucocele Clinical Features
  • Mucoceles typically appear as bluish, dome-shaped
    swellings if superficial or of normal color if
    deep in the tissues.
  • They are typically covered by an intact
    epithelium.
  • They may be slightly painful due to an
    accompanying acute inflammatory reaction

4
Mucocele Clinical Features
  • Mucoceles are most common on the lower lip
    (approx. 81 ), floor of the mouth, ventral
    tongue and buccal mucosa (in order of decreasing
    frequency)
  • They rarely occur in the upper lip
  • Mucoceles are more common in children and
    adolescents
  • They are a common oral lesion

5
Location of Mucoceles
  • Location Number of Cases of All Cases
  • Lower lip 1477 81.0
  • Floor of mouth 106 5.8
  • Ventral tongue 106 5.8
  • Buccal mucosa 87 4.8
  • Palate 26 1.4
  • Retromolar 10 0.5
  • Unknown 12 0.7
  • Upper lip 0 0.0
  • Total 1824 100.0
  • From Neville, et al., Third Edition

6
Mucocele Cause and Treatment
  • They are typically caused by traumatic severance
    of the salivary gland excretory duct.
  • Occasionally, mucoceles will rupture
    spontaneously and heal without treatment.
  • Surgical excision, if needed, is the treatment of
    choice. Removal of the adjacent minor salivary
    gland helps prevent recurrence.

7
Mucocele VS Mucus Retention Cyst VS Salivary Duct
Cyst
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Mucocele Prognosis and Significance
  • The prognosis is excellent, although occasional
    mucoceles will recur, necessitating re-excision,
    especially if the feeding glands are not removed.

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Ranula Clinical Features
  • A ranula is the term used for mucoceles that
    occur in the floor of the mouth.
  • The term ranula is derived from the Latin word
    for frog.
  • They appear as dome-shaped, fluctuant swellings
    unless they are deep in the tissue.
  • Typically, they are lateral to the midline.
  • Plunging or cervical ranulas dissect through
    the myohyoid muscle to produce swelling in the
    neck.

16
Ranula Cause
  • The cause is usually severance of the sublingual
    gland duct although severance of the
    submandibular duct may be the cause.
  • Blockage of the duct with a salivary gland stone
    (sialolith) may produce a ranula which, in this
    case, would be a true mucous cyst.

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Ranula Treatment and Significance
  • Treatment may consist of marsupalization and/or
    surgical removal.
  • Marsupalization is often unsuccessful
    necessitating removal.
  • The unilateral, lateral location may help
    distinguish the ranula from a midline dermoid
    cyst as well as color and consistency of the
    lesion.

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Salivary Duct Cyst
  • Mucus Retention Cyst
  • Mucus Duct Cyst
  • Sialocyst

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Salivary Duct Cyst Clinical Features
  • These lesions typically appear as solitary,
    asymptomatic, mobile, non-tender swellings
    covered by an intact epithelium.
  • They are usually the same color as the
    surrounding tissue.

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Salivary Duct Cyst Clinical Features
  • Salivary duct cysts are more common in adults
    over the age of 50 years.
  • The palate, cheek, floor of the mouth are the
    more common locations. They are uncommon in the
    upper lip and rare in the lower lip.
  • They may occur in the major glands with the
    parotid being the most common major gland site.

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Salivary Duct Cyst Cause, Treatment and
Significance
  • Salivary duct cysts are caused by blockage of the
    salivary gland excretory duct by a sialolith.
  • They are treated by conservative surgical
    excision.
  • Recurrence is not anticipated if the associated
    gland is removed.
  • Rarely, patients may have multiple mucus
    retention cysts then surgical excision is
    performed only on the more problematic lesions.

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Sialolithiasis
  • Salivary Calculi
  • Salivary Stones

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Sialolithiasis Clinical Features
  • Salivary gland stones occur most often in the
    submandibular gland ducts but they may also occur
    in the minor glands particularly of the upper lip
    and buccal mucosa.
  • Young and middle-aged adults are most frequently
    affected.
  • Patients frequently present with episodic pain
    and swelling particularly around mealtime.

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Sialolithiasis Clinical Features
  • Stones in the terminal ducts can usually be
    palpated.
  • If the sialolith is well calcified, it may appear
    on radiograph as a radipaque mass.
  • Minor gland stones are often asymptomatic.

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Sialolithiasis Cause, Treatment and Significance
  • Deposition of calcium salts around a nidus of
    debris in the duct lumen occurs but the exact
    cause of this is unknown.
  • The blockage of the duct and resultant
    inflammation can cause significant damage to the
    gland.
  • Small sialoliths can sometimes be removed by
    gentle message, sialagogues, moist heat, or
    increased fluid intake. Larger stones are
    removed surgically.
  • Stones in minor glands/ducts are best treated by
    surgical removal including the associated gland.

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Sialadenitis
  • Inflammation of the salivary glands can arise
    from various infectious and non-infectious
    causes.
  • The most common viral infection is mumps.
  • Most bacterial infections arise as a result of
    ductal obstruction or decreased salivary flow.
  • One of the more common causes of sialadenitis is
    recent surgery.

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Sialadenitis Clinical Features
  • Acute bacterial sialadenitis is most common in
    the parotid where it produces a painful swelling.
    The overlying skin may be erythematous and the
    patient may have low-grade fever, trismus and
    purulent discharge.
  • Chronic sialadenitis is associated with periodic
    swelling and pain.
  • Subacute necrotizing sialadenitis is more common
    in young (males?) adults. The lesion usually
    involves the minor glands of the hard or soft
    palate. It appears as a painful nodule, which
    does not ulcerate or slough like necrotizing
    sialometaplasia.

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Sialadenitis Cause
  • The inflammation of the glands can arise for
    various causes as noted previously. While mumps
    is the most common viral cause, other viruses
    such as Coxsackie A, ECHO, choriomeningitis,
    parainfluenza and cytomegalovirus may be the
    cause.
  • The most common cause of acute bacterial
    sialadenitis is Staphylococcus aureus but
    streptococci and a host of other bacteria have
    been implicated at different times.
  • Medications that can induce xerostomia can
    predispose the patient to infection.
  • Non-infectious causes include Sjögren syndrome,
    radiation therapy, sarcoidosis and some allergens.

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Sialadenitis Treatment, Prognosis and
Significance
  • Acute sialadenitis is treated by antibiotic
    therapy and rehydration to stimulate salivary
    flow.
  • Surgical drainage may be required if abscesses
    occur.
  • Management of chronic sialadenitis depends upon
    the severity and duration of the condition.
  • Subacute necrotizing sialadenitis is
    self-limiting and usually resolves in 2 weeks.
  • Significant inflammatory destruction of the
    salivary gland can occur requiring its surgical
    removal.

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Cheilitis Glandularis Clinical Features
  • This uncommon inflammatory condition
    characteristically affects the minor glands of
    the lower lip producing swelling and eversion.
  • The duct openings are dilated and inflamed and
    digital pressure often produces a mucopurulent
    secretion.
  • This entity is most common in middle-aged and
    older males but can affect any population.
  • Superficial suppurative (Baelz disease) and deep
    suppurative (cheilitis glandularis apostematosa)
    are more progressive stages with greater
    swelling, inflammation, suppuration and
    ulceration.

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Cheilitis Glandularis Cause, Treatment and
Significance
  • The cause is uncertain but it is associated with
    actinic damage, tobacco, syphilis, poor hygiene
    and heredity.
  • The treatment of choice for persistent cases is
    vermilionectomy (lip shave), which usually gives
    satisfactory results.
  • A significant percentage of cases (18-35 ) have
    been associated with the development of squamous
    cell carcinoma.

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Sialorrhea
  • Overproduction of saliva can produce drooling and
    chocking.
  • Patients with idiopathic paroxysmal sialorrhea
    may have short episodes of excessive salivation
    associated with prodromal nausea or epigastric
    pain.

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Sialorrhea Cause
  • Minor sialorrhea is associated with aphthous
    ulcers and ill-fitting dentures.
  • It is also associated with rabies, heavy metal
    poisoning, gastroesophageal reflux disease and
    certain drugs such as lithium and cholinergic
    agonists as well as neurologic disorders such as
    cerebral palsy.

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Sialorrhea Treatment, Prognosis and Significance
  • In cases which are mild and/or transitory, no
    treatment is needed.
  • In persistent severe case, therapeutic
    intervention may be required.
  • Anticholinergic medications, surgical correction
    and speech therapy have all been used in
    appropriate situations.
  • Social embarrassment, soiling of clothes and bed
    linens can be significant problems.

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Xerostomia Clinical Features
  • Xerostomia, dry mouth, is more common in females
    and the elderly.
  • With decreased salivary flow, the saliva becomes
    foamy or thick and ropey. There is a lack of
    polling of saliva in the floor or the mouth and
    the mucosa appears dry.
  • The dorsal tongue is often fissured with atrophy
    of the filiform papilla.

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Xerostomia Clinical Features
  • Mastication and swallowing may be difficult.
  • The clinical findings do not always correspond to
    the degree of salivary flow.
  • The incidence of oral candidiasis increases as
    does dental decay, especially cervical and root
    caries radiation caries (xerostomia-related
    caries).

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Xerostomia Cause, Treatment and Significance
  • Xerostomia can result from a variety of causes
    including salivary gland aplasia, aging,
    smoking, mouth breathing, local radiation
    therapy, Sjögren syndrome, HIV infection and some
    medications. Causes are highlighted in a later
    slide.

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Xerostomia Cause, Treatment and Significance
  • Xerostomia is difficult to treat. Treatments
    have included use of artificial salivas,
    surgarless candy and gum, sialagogues such as
    pilocarpine and changing the patients
    medication.
  • Xerostomia predisposes to increased dental caries
    and oral candidiasis.

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Benign Lymphoepithelial Lesion
  • Myoepithelial Sialadenitis
  • Other Terms Which Were Formerly Used Mikulicz
    Disease and Mikulicz Syndrome

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Benign Lymphoepithelial Lesion Clinical
Features
  • Most cases develop as a component of Sjögren
    syndrome and present as bilateral salivary gland
    swelling although other cases are unilateral.
  • This entity has a predilection for adults with a
    mean age of 50 years.
  • It has a female gender predilection (60-80 of
    cases).
  • Eight-five percent of the cases occur in the
    parotid gland.
  • It usually appears as a firm, diffuse swelling
    and the lesions may be asymptomatic or present
    with mild pain.

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Benign Lymphoepithelial Lesion Cause
  • Mikulicz disease (clinical presentation of
    painless swelling of the lacrimal and salivary
    glands due to a lesion histologically diagnosed
    as benign lymphoepithelial lesion.
  • Mikulicz syndrome (clinical presentation of
    lacrimal and salivary glands secondary to other
    disease entities such as TB, sarcoid and
    lymphoma.
  • Many case of so-called Mikulicz disease may be
    examples of Sjögren syndrome.
  • Role of autoimmunity

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Benign Lymphoepithelial Lesion Treatment,
Prognosis Significance
  • Benign lymphoepithelial lesions frequently
    necessitate surgical removal of the involved
    gland.
  • The prognosis in most cases is good.
  • However, patients with this entity have an
    increased risk for developing a lymphoma (?40
    times?). There is also a malignant counterpart
    termed malignant lymphoepithelial lesion or
    lymphoepithelial carcinoma. This is more common
    in Inuits and Asian populations.
  • Some cases originally diagnosed as benign
    lymphoepithelial lesion are actually early-stage
    MALT lymphomas, which are low-grade tumors.

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Sjögren Syndrome Clinical Features
  • Sjögren syndrome is a chronic, systemic
    autoimmune disorder that principally involves the
    salivary and lacrimal glands.
  • It predominantly affects middle-aged and older
    adults with 80-90 of them being women.
  • The principal oral symptom is xerostomia.
  • A third to a half of all patients have diffuse,
    firm enlargement of the major salivary glands,
    usually bilaterally.

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Sjögren Syndrome Clinical Features
  • The swelling may be painful or just slightly
    tender and these sensations may be intermittent
    or persistent.
  • The patient may have dry skin and nasal and
    vaginal dryness as well.
  • Fatigue is a common symptom and many patients are
    depressed.
  • Sialography often reveals punctate sialectasia
    with a fruit-laden, branchless tree pattern.

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Sjögren Syndrome Clinical Features
  • Two forms of Sjögren syndrome are recognized
  • Primary (sicca syndrome sicca means dry) with
    dry eyes and dry mouth and no other autoimmune
    disorder.
  • Secondary where the patient manifest dry eyes and
    mouth plus another associated autoimmune disease
    such as rheumatoid arthritis, SLE, scleroderma

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Sjögren Syndrome Cause, Treatment and
Significance
  • It is an autoimmune disease with increased ESR,
    elevated serum immunoglobulin levels,
    autoantibodies especially anti-SS-A and
    anti-SS-B. About 75 of patients are positive
    for rheumatoid factor.
  • Treatment is mostly supportive. Artificial tears
    and saliva, sugarless gum and candy, sialagogues
    (pilocarpine) fluoride applications to prevent
    caries and antifungals if candidiasis is a
    problem.
  • Sjögren syndrome patients have up to a 40 times
    increased risk for developing a lymphoma, which
    are usually a non-Hodgkin B-cell lymphoma, and
    for developing caries and oral candidiasis.

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Box 11-2 Revised International Classification
Criteria for Sjögren Syndrome
  • I. Ocular symptoms A positive response to at
    least one of the following questions
  • A. Have you had daily, persistent, troublesome
    dry eyes for more than 3 months?
  • B. Do you have a recurrent sensation of sand or
    gravel in the eyes?
  • C. Do you use tear substitutes more than three
    times a day?
  • II. Oral symptoms A positive response to at
    least one of the following questions
  • A. Have you had a daily feeling of dry mouth for
    more than 3 months?
  • B. Have you had recurrently or persistently
    swollen salivary glands as an adult?
  • C. Do you frequently drink liquids to aid in
    swallowing dry food?
  • III. Ocular signs Objective evidence of ocular
    involvement defined as a positive result for at
    least one of the following two tests
  • A. Schirmer I test, performed without anesthesia
    (5 mm in 5 minutes)
  • B. Rose bengal score or other ocular dye score
    (4 according to van Bijsterveld's scoring
    system)
  • IV. Histopathology
  • In minor salivary glands (obtained through
    normal-appearing mucosa) focal lymphocytic
    sialadenitis, evaluated by an expert
    histopathologist, with a focus score 1, defined
    as a number of lymphocytic foci (which are
    adjacent to normal-appearing mucous acini and
    contain more than 50 lymphocytes) per 4 mm2 of
    glandular tissue

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Box 11-2 Revised International Classification
Criteria for Sjögren Syndrome (CONTINUED)
  • V. Salivary gland involvement Objective
    evidence of salivary gland involvement defined by
    a positive result for at least one of the
    following diagnostic tests
  • A. Unstimulated whole salivary flow (1.5 ml in
    15 minutes)
  • B. Parotid sialography showing the presence of
    diffuse sialectasias (punctate, cavitary, or
    destructive pattern), without evidence of
    obstruction in the major ducts
  • C. Salivary scintigraphy showing delayed uptake,
    reduced concentration, and/or delayed excretion
    of tracer
  • VI. Autoantibodies Presence in the serum of the
    following autoantibodies
  • A. Antibodies to Ro(SS-A) or La(SS-B) antigens,
    or both

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Box 11-2 Revised International Classification
Criteria for Sjögren Syndrome (CONTINUED)
  • RULES FOR CLASSIFICATION
  • Primary Sjögren Syndrome
  • In patients without any potentially associated
    disease, primary Sjögren syndrome is defined as
    follows
  • I. Presence of any four of the six items is
    indicative of primary Sjögren syndrome, as long
    as either item IV (histopathology) or VI
    (serology) is positive
  • II. Presence of any three of the four objective
    criteria items (items III, IV, V, and VI)
  • Secondary Sjögren Syndrome
  • In patients with a potentially associated disease
    (e.g., another well-defined connective tissue
    disease), presence of item I or item II plus any
    two from among items III, IV, and V considered
    indicative of secondary Sjögren syndrome
  • Exclusion Criteria
  • Past head and neck radiation treatment
  • Hepatitis C infection
  • Acquired immunodeficiency syndrome (AIDS)
  • Preexisting lymphoma
  • Sarcoidosis
  • Graft-versus-host disease (GVHD)

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Sialadenosis (Sialosis) Clinical Features
  • Sialadenosis is a non-inflammatory disorder
    characterized by salivary gland enlargement, most
    common of the parotid.
  • Most cases present as a slowly developing,
    painless swelling of the parotids.
  • Most cases present with bilateral involvement.
  • Decreased salivary secretion may occur.
  • Sialography demonstrates a leafless tree
    pattern.

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Sialadenosis Causes
  • This condition is frequently associated with an
    underlying systemic problem, which may endocrine,
    nutritional or neurogenic as seen in the
    accompanying slide.
  • The best known conditions include diabetes
    mellitus, general malnutrition, alcoholism and
    bulimia.
  • It is thought that these conditions cause a
    dysregulation of the autonomic innervation of the
    salivary acini producing the enlargement.

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Sialadenosis Treatment and Significance
  • Clinical management is often unsatisfactory
    because it may be difficult or impossible to
    control the underlying condition.
  • Mild cases present few problems and are not
    treated. If swelling presents cosmetic concerns,
    surgery may be used to correct the problem.
  • Observation of the enlargement may lead to the
    diagnosis of the underlying systemic problem.

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Adenomatoid Hyperplasia of the Minor Salivary
Glands
  • Uncommon lesion that is characterized by
    localized swelling that mimics a neoplasm.
  • Its pathogenesis is uncertain while local trauma
    has been considered.
  • The palatal minor salivary glands are most
    commonly affected.
  • Most cases have occur in the fourth to sixth
    decades of life and the lesion presents as a
    sessile, painless swelling that may either soft
    or firm in consistency and is usually the color
    of the surrounding tissue.
  • Biopsy is necessary to establish the diagnosis.
    Once the diagnosis is established no further
    treatment is necessary and the lesion should not
    recur.

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Necrotizing Sialometaplasia
  • This lesion is an uncommon, locally destructive
    inflammatory condition of salivary glands.
  • Because of its worrisome clinical presentation,
    biopsy usually is indicated to rule out the
    possibility of malignancy.

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Necrotizing Sialometaplasia Clinical Features
  • The palatal salivary glands are most commonly
    affected with 2/3 of the cases being unilateral.
  • It is more common in adults with a mean age of 46
    years.
  • Males are more commonly affected.
  • Initially the lesion presents as a non-ulcerated
    swelling often associated with pain or
    paresthesia.
  • Within 2-3 weeks the tissue becomes necrotic and
    sloughs leaving a crater-like ulcer. The pain
    typically subsides when the tissue sloughs.

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Necrotizing Sialometaplasia Cause
  • The cause of necrotizing sialometaplasia is
    uncertain but most authorities believe it is
    related to ischemia leading to tissue infarction.
  • Predisposing factors may include traumatic
    injury, dental injections, ill-fitting dentures,
    upper respiratory tract infections, adjacent
    tumors and previous surgery.

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Necrotizing Sialometaplasia Treatment,
Prognosis Significance
  • As noted previously biopsy is usually necessary
    to rule out malignancy. Once the diagnosis is
    made, no specific treatment is necessary.
  • The lesion typically resolves on its own accord
    in 5-6 weeks.
  • The significance of this lesion comes from the
    fact that it mimics a malignant process, both
    clinically and microscopically.

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Sites of Occurrence of Primary Epithelial
Salivary Gland Tumors
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Frequency of Malignancy for Salivary Tumors at
Different Sites
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Parotid Tumors
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Submandibular Tumors
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Minor Salivary Gland Tumors
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Location of Minor Salivary Gland Tumors
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Palatal Salivary Gland Tumors
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Location of Labial Salivary Gland Tumors
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Intraoral Minor Salivary Gland Tumors Percentage
Malignant by Site
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Salivary Gland Tumors
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Pleomorphic Adenoma (Benign Mixed Tumor)
Introduction
  • This tumor is easily the most common salivary
    neoplasm.
  • Pleomorphic adenomas are derived from a mixture
    of ductal and myoepithelial elements.
  • This mixture gives rise to a remarkable diversity
    of microscopic appearances both among different
    pleomorphic adenomas and within any one tumor.

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Pleomorphic Adenoma (Benign Mixed Tumor)
Introduction
  • Neither the term pleomorphic nor mixed are
    entirely accurate in describing this neoplasm.
  • The basic pattern of the neoplasm is highly
    variable but rarely are individual cells actually
    pleomorphic.

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Pleomorphic Adenoma (Benign Mixed Tumor)
Introduction
  • Although the tumor often has prominent
    mesenchymal appearing stroma, it is not truly a
    mixed neoplasm that is derived from more than one
    germ layer. These stromal changes are believed
    to be produced by the myoepithelial cells.
  • Occasionally, salivary tumors are seen that are
    composed almost entirely of myoepithelial cells
    with no ductal elements. These tumors are called
    myoepitheliomas.

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Pleomorphic Adenoma Clinical Features
  • As indicated, this lesion is the most common
    salivary gland neoplasm representing from 53-77
    of all parotid tumors, 44-68 of submandibular
    tumors and from 38-43 of all minor gland
    tumors.
  • Benign mixed tumors are most commonly diagnosed
    between the ages of 30-50 years and there is a
    slight female gender predilection.
  • They typically appear as slow growing, painless
    masses.

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Pleomorphic Adenoma Clinical Features
  • In the parotid, they occur more commonly in the
    superficial lobe and initially the lesion is
    movable.
  • Intraorally, they are most common in the palate
    (posterior-lateral) followed by the upper lip and
    buccal mucosa.
  • The intraoral lesion is typically
    smooth-surfaced, dome-shaped and non-ulcerated
    (if traumatized the pleomorphic adenoma can be
    ulcerated).
  • In the hard palate, pleomorphic adenomas will be
    non-mobile due to the mucosa being tightly bound
    to the underlying bone.

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Pleomorphic Adenoma Cause, Treatment, Prognosis
Significance
  • The cause of this tumor is unknown.
  • Pleomorphic adenomas are best treated by surgical
    excision.
  • With adequate surgery, there is a 95 cure rate.
  • With inadequate surgery, multifocal seeding
    occurs. In such cases multiple recurrences are
    not unusual.
  • Malignant transformation is a potential
    complication but the rate is lt 5 of all cases.
    Transformation typically occurs many years
    (10-15) after the tumor is originally recognized.

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Oncocytoma (Oxyphilic Adenoma) Clinical Features
  • The oncoytoma is more common in older adults with
    a peak prevalence in the 8th decade.
  • This neoplasm has a slight female predilection
  • It is most commonly seen in the major salivary
    glands where it appears as a slow-growing firm,
    painless swelling.

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Oncocytoma Cause and Treatment
  • The cause of this rare neoplasm is not known.
  • The treatment of choice is surgical excision and
    in the parotid gland usually consists of a
    partial parotidectomy to avoid violation of the
    tumor capsule along with preservation of the
    facial nerve if possible.

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Oncocytoma Prognosis and Significance
  • The prognosis is usually good with a low rate of
    recurrence. However sinonasal oncocytomas can be
    locally aggressive and are usually managed as
    low-grade malignancies.
  • Oncocytomas should not be confused with
    Oncocytosis (nodular oncocytic hyperplasia),
    which is a metaplastic transformation of ductal
    and acinar cells to oncocytes. This benign
    condition is found primarily in the parotid gland
    in older adults and requires no treatment.

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Warthin Tumor (Papillary Cystadenoma
Lymphomatosum)
  • Warthin Tumor occurs as a slow-growing, painless,
    firm to fluctuant nodular mass.
  • It is found almost exclusively in the parotid
    gland.
  • Between 5-14 of the cases are bilateral.
  • Warthin tumor is more common in older adults with
    a peak in the 6th to 8th decades.
  • Early literature indicated the lesion was almost
    exclusively seen in males but recent reports
    indicated a more equal gender presentation.

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Warthin Tumor Cause, Treatment, Prognosis and
Significance
  • The cause is unknown. Some authors have
    suggested it results from heterotopic salivary
    gland tissue occurring within the parotid lymph
    nodal tissue. Smokers are said to have an
    eightfold greater risk than non-smokers.
  • Treatment consists of surgical removal and there
    is a 6-12 recurrence rate.
  • Since some tumors are multicentric in nature, is
    it a recurrence or a proliferation of another
    nodule.
  • Malignant Warthin tumors do occur but these are
    exceedingly rare.

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Canalicular Adenoma Clinical Features
  • This tumor typically presents as a slow-growing,
    painless, firm to somewhat fluctuant mass, which
    may or many not be blue in color.
  • It occurs most frequently in older adults (7th
    decade) and has a female gender predilection
    (1.2-1.8 1).
  • The most common site for this tumor, which occurs
    almost exclusively in the minor salivary glands,
    is the upper lip (75 ) followed by the buccal
    mucosa.

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Canalicular Adenoma Cause, Treatment, Prognosis
Significance
  • The cause of canalicular adenomas is unknown.
  • Local surgical excision is the treatment of
    choice.
  • There is a low rate of recurrence but again since
    this lesion is often multifocal in nature, the
    lesion may not be a recurrence per se.

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Basal Cell Adenoma
  • This benign salivary gland tumor is so named
    because of the basaloid appearance of its tumor
    cells.
  • The basal cell adenoma has a parotid site
    predilection although cases have occurred in the
    upper lip and buccal mucosa.
  • It has a peak prevalence in the 7th decade and is
    more common in females.

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Basal Cell Adenoma
  • Clinically, it appears as a slow-growing, freely
    movable mass similar to the pleomorphic adenoma.
  • The membranous subtype appears to be hereditary
    and is often seen in conjunction with skin
    appendage tumors.
  • Treatment consists of complete surgical removal
    and recurrence is rare except for the membranous
    subtype.
  • There is a malignant counterpart termed a basal
    cell adenocarcinoma.

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Ductal Papillomas
  • Sialadenoma Papilliferum
  • Intraductal Papilloma
  • Inverted Ductal Papilloma

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Ductal Papillomas Clinical Features
  • All 3 lesions are uncommon to rare.
  • All are more common in adults.
  • Sialdenoma papilliferum is an exophytic papillary
    growth which occurs more commonly on the palate
    and has a female predilection (21).

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Ductal Papillomas Clinical Features
  • Intraductal papilloma is more common on the lips
    where it appears as submucosal swelling.
  • The inverted ductal papilloma is seen on the
    lip/mandibular vestibule area, where it appears
    as an asymptomatic submucosal nodule.

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Ductal Papillomas Cause, Treatment, Prognosis
Significance
  • What causes the ductal papillomas is unknown.
  • Treatment consists of conservative surgical
    excision in each case and recurrence is rare.
  • The pathologist should be aware of these lesions
    to prevent misdiagnosis and treatment.

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Mucoepidermoid Carcinoma Clinical Features
  • This is the most common malignant salivary gland
    neoplasm in the United States.
  • It is seen over a wide age range (1st-7th
    decades).
  • There is a slight female gender predilection.
  • It occurs most commonly in the parotid gland
    where it often appears as an asymptomatic
    swelling. High grade tumors may cause pain or
    facial nerve palsy.

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Mucoepidermoid Carcinoma Clinical Features
  • Minor salivary glands represent the second most
    common location of occurrence with the palate
    being the most common site among these.
  • Mucoepidermoid carcinomas of the minor glands
    tend to appear as asymptomatic swellings, which
    may be fluctuant and have a blue/red color.
  • Although uncommon, other oral sites include the
    lower lip, floor of mouth, tongue and retromolar
    pad areas. The lesion can also occur
    intraosseously.

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Mucoepidermoid Carcinoma Cause and Treatment
  • The cause of mucoepidermoid carcinoma is unknown.
  • The treatment is predicated by location,
    histopathologic grade and clinical stage.
  • The treatment of choice is surgical excision with
    high grade tumors requiring a wider resection.
    Radical neck dissection is carried out on
    patients with clinical evidence of metastatic
    disease and considered for those with large or
    high-grade tumors.
  • Postoperative radiation therapy is used with
    aggressive tumors.

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Mucoepidermoid Carcinoma Prognosis and
Significance
  • Low-grade tumors may clinically resemble
    mucoceles.
  • Prognosis depends upon the grade and stage of the
    tumor.
  • Low-grade lesions have approximately a 90 cure
    rate.
  • High-grade tumors have approximately a 30 cure
    rate.
  • Prognosis is better in children overall.
  • Prognosis is poorer with tumors occurring in the
    submandibular glands or at the base of the tongue.

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Mucoepidermoid Carcinoma Comparing Two Grading
Systems
  • AUCLAIR ET AL. (1992)
  • Parameter Point Value
  • Intracystic component lt 20
  • 2
  • Neural invasion present
  • 2
  • Necrosis present
  • 3
  • Four or more mitoses per 10 high-power fields
  • 3
  • Anaplasia present
  • 4
  • Grade Total Point Score
  • Low 04
  • Intermediate 56
  • High 714
  • BRANDWEIN ET AL. (2001)
  • Parameter Point Value
  • Intracystic component lt25
  • 2
  • Tumor front invades in small nests and islands
  • 2
  • Pronounced nuclear atypia
  • 2
  • Lymphatic or vascular invasion
  • 3
  • Bony invasion
  • 3
  • Greater than four mitoses per 10 high- power
    fields
  • 3
  • Perineural spread
  • 3
  • Necrosis
  • 3

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Intraosseous Mucoepidermoid Carcinoma (Central)
  • This malignant neoplasm is more common in
    middle-aged adults and has a female gender
    predilection.
  • It occurs more commonly in the mandible (31) in
    the molar-ramus region.
  • Most often presents as a cortical swelling
    although some are discovered incidentally.

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Intraosseous Mucoepidermoid Carcinoma (Central)
  • Pain, trismus and paresthesia may occur.
  • On x-ray the lesion usually presents as a
    unilocular or multilocular radiolucency with
    well-defined borders.
  • Occasionally, it is associated with an unerupted
    tooth.

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Central Mucoepidermoid Carcinoma Cause,
Treatment Significance
  • The cause is unknown. Does it arise in ectopic
    salivary gland, from maxillary sinus lining or
    odontogenic epithelium?
  • Radical surgery offers the best chance for cure.
  • Most central mucoepidermoid carcinomas are
    low-grade tumors.
  • Approximately, 10 of the patients die as the
    result of the disease, most due to local
    recurrence.
  • Some tumors are misdiagnosed.

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Acinic Cell Adenocarcinoma Clinical Features
  • This malignant tumor is most common in the
    parotid gland it accounts for from 2-4 of all
    minor salivary gland tumors.
  • The buccal mucosa, lips and palate are the most
    common minor salivary gland sites.
  • There is a wide age range with a mean in the 40s.

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Acinic Cell Adenocarcinoma Clinical Features
  • Sixty percent of the patients are females.
  • The tumor typically presents as an asymptomatic,
    slow-growing mass.
  • Occasionally, pain and tenderness are presenting
    features.
  • Facial nerve paralysis is infrequent but an
    ominous sign for these malignant parotid tumors.

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Acinic Cell Adenocarcinoma Cause and Treatment
  • The cause is unknown.
  • In the parotid, it is best treated by lobectomy
    while at other sites surgical excision is the
    method of choice.
  • Lymph node dissection is only carried out if
    tumor is present.
  • Radiation therapy is used for uncontrolled
    disease.

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Acinic Cell Adenocarcinoma Prognosis and
Significance
  • This tumor has one of the better prognoses
    overall of any malignant salivary gland tumor.
  • Tumors of the minor glands have a better
    prognosis than those of the major glands.
  • 6-26 of the patients die as the result of their
    tumor.
  • It is considered a low-grade malignancy.

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Malignant Mixed Tumors
  • Carcinoma Ex Pleomorphic Adenoma
  • Carcinoma Ex Mixed Tumor
  • Carcinosarcoma
  • Metastasizing Mixed Tumor

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Malignant Mixed Tumors
  • The most common of these is the carcinoma ex
    pleomorphic adenoma, which is characterized by
    malignant transformation of the epithelial
    component of a previously benign pleomorphic
    adenoma.
  • The carcinosarcoma is a rare mixed tumor in
    which both carcinomatous and sarcomatous elements
    are present.
  • The metastasizing mixed tumor has histopathologic
    features that are identical to the common
    pleomorphic adenoma but the lesion metastasizes.

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Malignant Mixed Tumors Clinical Features
  • Carcinoma ex pleomorphic adenoma arises in a
    pleomorphic adenoma.
  • It occurs in patients about 15 years older than
    those with a pleomorphic adenoma.
  • Eighty percent occur in the major glands while
    2/3 of the intraoral tumors arise in the palate.

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Malignant Mixed Tumors Clinical Features
  • There is a slight female gender predilection.
  • Pain, recent rapid growth, ulceration, fixation
    and facial nerve palsy are common features of
    those tumors arising in the parotid gland.
  • Some intraoral tumors remain indistinguishable
    from their benign counterparts.
  • Carcinosarcomas and metastasizing mixed tumors
    are quite rare and thus there is little reliable
    clinical data.

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Malignant Mixed Tumors Cause, Treatment,
Prognosis Significance
  • The cause is unknown for these tumors.
  • Treatment consists of wide surgical excision
    often with lymph node dissection and adjunctive
    radiation therapy.
  • The overall prognosis for these tumors is roughly
    50-50.

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Adenoid Cystic Carcinoma
  • This is one of the more common and best
    recognized salivary gland malignancies.
  • An old term for this lesion is cylindroma. It
    should be avoided today because a skin adnexal
    tumor has been given the same terminology.

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Adenoid Cystic Carcinoma Clinical Features
  • Approximately, 50 of these tumors develop in
    the minor salivary glands with the palate being
    the most common site.
  • It is more common in middle-aged patients and has
    a slight female gender predilection.
  • Adenoid cystic carcinoma usually presents as a
    slow-growing mass and pain is a common feature.
    The pain is often described as constant,
    low-grade and dull.

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Adenoid Cystic Carcinoma Clinical Features
  • In parotid tumors facial nerve paralysis may
    occur.
  • Palatal tumors may be smooth or ulcerated.
  • Palatal tumors or those of the maxillary sinus
    may show radiographic evidence of bony
    destruction.

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Adenoid Cystic Carcinoma Cause and Treatment
  • The cause is unknown.
  • Surgical excision is usually the treatment of
    choice and adjunct radiation therapy may slightly
    improve prognosis.

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Adenoid Cystic Carcinoma Prognosis and
Significance
  • Perineural invasion is highly characteristic but
    said to have little effect on prognosis.
  • Late recurrence and metastasis make 5-year
    survival rates of little significance.
  • Tumors with a solid histopathologic pattern have
    the worst prognosis all other things being equal.
  • Tumors of the maxillary sinus and submandibular
    gland have poor prognoses relative to site.
  • Death, if it results from tumor, occurs because
    of local recurrence or distant metastases.

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Polymorphous Low-Grade Adenocarcinoma
  • Lobular Carcinoma
  • Terminal Duct Carcinoma

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Polymorphous Low-Grade Adenocarcinoma Clinical
Features
  • This malignant salivary gland neoplasm occurs
    almost exclusively in the minor salivary glands,
    where it is one of the more common malignancies.
  • Sixty percent of the cases occur on the hard or
    soft palates following in frequency by the upper
    lip and buccal mucosa.
  • Most commonly occurs in older adults (6-8th
    decades) and there is a female gender
    predilection ( two thirds of cases).
  • Most commonly presents as a slow-growing mass
    occasionally accompanied by bleeding or
    discomfort.

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Polymorphous Low-Grade AdenocarcinomaCause
Treatment
  • The cause of this tumor is unknown.
  • Treatment consists of wide surgical excision
    sometimes including resection of the underlying
    bone.
  • It is a low-grade malignancy which uncommonly
    metastizes.
  • Radical neck surgery is usually unwarranted.

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Polymorphous Low-Grade Adenocarcinoma Prognosis
  • Eighty percent of the patients are tumor free
    after treatment and most of the rest are
    controlled with re-excision.
  • Death due to the tumor is rare.
  • Perineural invasion, like adenoid cystic
    carcinoma, occurs frequently and does not appear
    to affect prognosis if it occurs.
  • This tumor must be differentiated from adenoid
    cystic carcinoma.
  • The histopathology of this tumor is deceptively
    uniform and can be mistaken for a benign lesion.

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Salivary Adenocarcinoma, NOS
  • These tumors are malignant salivary gland
    neoplasms that cannot be further classified as
    one in the existing classification schemes, hence
    NOS (not otherwise specified)
  • Since these adenocarcinomas represent such a
    diverse group it is difficult to generalize
    either about their clinical or microscopic
    features.

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Salivary Adenocarcinoma, NOS
  • They may present as asymptomatic masses or cause
    pain and nerve paralysis.
  • Their prognosis is guarded by patients with
    early-stage, well-differentiated tumors have a
    better outcome. Oral tumors generally have a
    better prognosis than those occurring in the
    major glands.
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