B. Hagmar

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Salivary gland tumorsCytology - Histopathology

• B. Hagmar

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SALIVARY GLAND FNAB

• High sensitivity - 80
• High specificity - 98
• But - correct typing is difficult and requires
  extensive experience (WHO)
• Giemsa for background
• Pap for nuclei

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Normal Salivary gland

• Strong cellular cohesion
• Acinar structures,
• Ducts
• Few myoepithelial cells (cf pleomorphic adenoma,
  where these cells are abundant)

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GIEMSA
Duct
Acini
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PAPANICOLAOU
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SIALOADENITIS

• Acini and inflammatory cells

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DNR17132-93
Cave Differenial diagnosis
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DNR17132-93
Cave Differenial diagnosis
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DNR17132-93
Obvious atypia
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DNR 1068-93
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DNR1068-93
Nasopharyngeal carcinoma, undifferentiated
(lympho- epithelial carcinoma)
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ADENOMAS

• Pleomorphic adenoma
• Myoepithelioma
• Basal cell adenoma
• Warthin tumor (adenolymphoma)
• Oncocytoma
• Canalicular adenoma
• Ductal papilloma
• Cystadenoma

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PLEOMORPHIC ADENOMA 

• Three components
• Epithelial cells - ducts, sheets or nests
• Myoepithelial cells - spindle shaped or
  plasmacytoid
• Chondromyxoid stroma

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Myoepithelial cells
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Myoepithelial cells
Papanicolaou
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C496-02
Myoepithelial cells and chondromyxoid background
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Epithelial cells
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PLEOMORPHIC ADENOMA

• Diagnostic elements
• Plasmacytoid cells and chondro-myxoid stroma

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PLEOMORPHIC ADENOMA

• 82 year old man with tumor in his left parotid
  gland
• FNAB - myxoma
• Parotidectomy

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PLEOMORPHIC ADENOMACHONDROMYXOID TYPE
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B9382/02
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B9382/02
Bone and bone marrow in pleomorphic adenoma
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B9277/02
CELLULAR PLEOMORPHIC ADENOMA
Atypical? Malignant?
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B9277/02
Mitoses
Atypia?
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B9277/02
Ki 67 labelling for mitotic activity
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Case 3

• 27 year old woman with slowly growing tumor in
  her left parotid glandATYPIA

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Case 3

• 27 year old woman with slowly growing tumor in
  the left parotid gland
• FNAC pleomorphic adenoma
• Parotidectomy pleomorphic adenoma with carcinoma
  in situ
• Recurrence after 1 year
• Multiple recurrencies for 4 years

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CA EX PLEOMORPHIC ADENOMA

• Multiple recurrencies for 4 years

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CA EX PLEOMORPHIC ADENOMA
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CA EX PLEOMORPHIC ADENOMA

• 4,5 of all mixed tumors
• Rapid growth, facial palsy
• Benign and malignant components vary greatly
• Epithelial atypia
• Practically all types of carcinoma represented
• Atypical mixed tumor/ carcinoma in situ, if
  malignancy criteria are not met

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PLEOMORPHIC ADENOMA

• Atypia must be evaluated in any p.a.
• Any type of carcinoma may arise in p.a.
• The stroma remains typically myxoid, the
  epithelial component is malignant
• Clinically, progression is heralded by rapid
  growth of the lesion

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DD Pleomorphic adenoma

• Adenoma - epithelium sharply delineated from
  stroma
• LGPCa - epithelium more variable and occurs in
  tubular/papillary structures

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DD Pleomorphic adenoma

• Carcinoma ex. Pleomorphic adenoma
• Adenoid cystic carcinoma - Alcian blue
• Basal cell adenoma, canalicular adenoma -
  epithelium sharply delineated from stroma
• Myoepithelioma epithelial-myoepithelial
  carcinoma - no ducts

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Pleomorphic adenoma

• 93.5 in parotis
• 6.3 in submand. Gland
• 0.2 in sublingual gland
• 60 of all salivary gland tumors

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ADENOMASwith basaloid cells

• Canalicular and basal cell adenomas
• Monomorphous small ovoid basal cells
• Small hyaline globules no chondromyxoid

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B9147/02
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B9147/02
S 100
Smooth Muscle Actin
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ADENOMAS WITH BASALOID CELLS

• Monotonous cohesive or dissociated small ovoid
  basal cells
• Bland nuclei no nucleolus
• Pseudopapillæ
• No chondromyxoid stroma

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DD ADENOMAS WITH BASALOID CELLS

• Basal cell adenocarcinoma
• Adenoid cystic carcinoma
• Epithelial-myoepithelial carcinoma
• PLGA
• Cellular pleomorphic adenoma

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BASAL CELL ADENOCARCINOMA
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B6953/02
BASAL CELL ADENOCARCINOMA
Solid type
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BASAL CELL ADENOCARCINOMATubular type
B7413/02
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BASAL CELL ADENOCARCINOMA

• 4 subtypes solid, trabecular, tubular and
  membraneous
• Three-dimensional clusters of basaloid cells with
  small hyaline globules
• Mild cellular pleomorphism

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WARTHINS TUMOR,adenolymphoma

• Fluid, oncocytes and lymphocytes

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WARTHINS TUMOR,adenolymphoma
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Squamous Metaplasia
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Cave DD Plateepitelcarcinom
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CAVE
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WARTHINS TUMOR,adenolymphoma
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WARTHINS TUMOR,adenolymphoma

• Murky, mucoid, cystic aspirate.
• Background amorphous with granular débris.
• Monolayered oncocytic cells and lymphoid cells.

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DD Warthin (cystadenolymphoma)

• Ductal carcinoma
• Sialoadenitis, lymphadenitis
• Acinic cell carcinoma
• Muco-epidermoid carcinoma (low-grade)
• Oncocytoma
• Acinic cell carcinoma
• Metastasis

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SALIVARY GLANDCARCINOMAS

• Basal cell adenocarcinoma
• Polymorphous low grade carcinoma
• Epithelial-myoepithelial carcinoma
• Salivary duct carcinoma
• Acinic carcinoma
• Mucoepidermoid carcinoma
• Adenoidcystic carcinoma

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PLGA (PLGA Polymorphous Low-Grade Carcinoma)

• Is an uncommon low-grade (terminal duct)
  adenocarcinoma occuring in minor salivary glands,
  preferably on the palate. The cells are
  clustering , small with scanty cytoplasm and may
  resemble adenoid cystic carcinoma especially
  since small hyaline globules may occur, but
  nuclear chromatin is bland.

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B 7149/02
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B 7149/02
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B 7149/02
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B7835/02
PLGA or Adenoidcystic ca?
72 year old woman
Tumores som vanskelig lar seg skille
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EPITHELIAL-MYOEPITHELIAL CARCINOMA

• Pseudopapillae with eosinophilic stroma cores
• Spindle-shaped cells with hyperchromatic nuclei

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EPITHELIAL-MYOEPITHELIAL CARCINOMA

• Small, ball-like or trabecular clusters. The
  cells are both basaloid with scanty cytoplasm and
  myoepithelial with abundant pale vacuolated
  cytoplasm. Nuclei are mildly atypical and show
  discrete central nucleoli. Hyaline stromal
  material is present occasionally with small
  hyaline stromal globules.

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EPITHELIAL-MYOEPITHELIAL CARCINOMA
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EPITHELIAL-MYOEPITHELIAL CARCINOMA

• DD
• Adenoidcystic carcinoma
• PLGA
• Pleomorphic adenoma
• Acinic cell cancer
• Metastatic cancer

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ACINIC CELL CARCINOMA

• Large acinar cells (oncocytelike), in clusters or
  dissociated
• Azurophilic cytoplasmic granulation
• Naked nuclei
• Monotonous smear
• Lymphoid back-ground

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ACINIC CELL CARCINOMA

• Ca 17 of all malignbant salivary gl. tumors
• Low grade malignancy
• Solid, microcystic, papillary-cystic and
  follicular
• Acinar, intercalated ductal, vacuolated and NOS
  glandular cells
• PAS positive cells and gland content

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ACINIC CELL CARCINOMA
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ACINIC CELL CARCINOMA
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ACINIC CELL CARCINOMA

• Woman born in 1928
• 3 year history of slowly growing in the parotid
  gland
• Primary diagnosis PLGA

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B6486/02
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B6486/02
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B6486/02
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ACC, Papillary, cystic variant

• Juan Rosai is a very nice example of.
• Abrahams et al. Cancer 181145, 1965
• It is largely, if not entirely composed of
  intercalated cells.but the intercalated portion
  of the ducts and the acinar cells is an
  anatomico-functional unit

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DD Acinic Cell Carcinoma

• Sialoadenitis normal gland
• Warthin tumor
• Epithelial-myoepithelial carcinoma
• Metastasis, e.g. Renal cell carcinoma
• Cave This tumor is easily overlooked because of
  the monomophic cellular picture!

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MUCOEPIDERMOIDCARCINOMA

• Dirty background
• 3 celltypes mucoid, sqamous and intermediate

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MUCOEPIDERMOIDCARCINOMA
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Mucoep. ca
vacuole
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Squamous differentiation
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MALIGNANCY GRADINGMucoepidermoid ca

• Intracystic component lt 20 2
• Neural invasion 2
• Necrosis 3
• 4 or more mitoses/10 HPF 3
• Anaplasia 4
• Low grade 0 - 4
• Intermediate 5 - 6
• High grade 7 or more

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DD MUCOEPIDERMOID CARCINOMA

• Squamous cell carcinoma
• Salivary duct carcinoma
• Warthins tumor
• Carcinoma ex pleomorphic adenoma

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SALIVARY DUCT CARCINOMA

• Cytology as in comedocarcinoma of the
  breastwith large cells,pleomorphism and
  oftennecrosis
• High grade carcinoma

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SALIVARY DUCT CARCINOMA
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SALIVARY DUCT CARCINOMA

• 70 year old man with longstanding infection in
  his right parotid gland
• FNAB by oncologist - oncocytoma
• FNAB by cytologist - oncocytic carcinoma
• Parotidectomy

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SALIVARY DUCT CARCINOMA
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SALIVARY DUCT CARCINOMA

• 62 year old woman
• Tumor in the right parotid gland
• Sialoadenitis?

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C87-02
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C87-02
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B1120-02
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B1120-02
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B6821/02
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B6966/02
Ductal carcinoma ex pleomorphic adenoma
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ADENOIDCYSTIC CARCINOMA

• Ovoid or round hyaline globules
• Tubular and cylindrical or fingerlike structures
• Basaloid cells

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ADENOIDCYSTIC CARCINOMA

• 4th most common (after mucoepidermoid, acinic
  cell and adenocarcinoma NOS)
• Pimarily in major salivary glands, but also in
  oral and tracheal glands breast
• Cribriform, tubular and solid subtypes

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ADENOIDCYSTIC CARCINOMA
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ADENOIDCYSTIC CARCINOMA
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ADENOIDCYSTIC CARCINOMA

• Ovoid or round hyaline globules surrounded by
  tumour cells (arrow). Tubular and cylindrical or
  fingerlike structures. Compact aggregates of
  basaloid cells with hyperchromatic nuclei with
  coarse chromatin and nucleoli.

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ADENOIDCYSTIC CARCINOMASolid type
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C2474-01
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C2474-01
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B11794-01
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B11794-01
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B11794-01
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AdenocarcinomaUndifferentiated carcinoma
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Immunocytochemistry, CK
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HistologyPoorly differentiated adenocarcinoma
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