Salivary Gland Tumors Flashcards

1
Q

ADENOMA

A

benign tumor
of glandular origin

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2
Q

Characteristics of a Benign Tumor:

A

 Encapsulated ‐ distinguishable from surrounding tissues
 Freely movable ‐ not fixed
 Slow growing
 Non tender ‐ patients do not complain of pain

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3
Q

BENIGN SALIVARY GLAND
TUMORS

(list 3)

A

Pleomorphic adenoma aka mixed tumor
Monomorphic adenomas
o Canalicular adenoma
o Basal cell adenoma
Warthin tumor (papillary cystadenoma lymphomatosum)

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4
Q

PLEOMORPHIC ADENOMA

(MIXED TUMOR)

A
  • This tumor comes in many forms/shapes
  • Most common salivary gland tumor
  • Painless, slowly growing, firm mass
  • Adults (30‐50 years old) ; slight female predilection
  • Sites:
    • 50% to 77% of parotid tumors (most commonly found in parotid-2/3rd to 3/4th of parotid tumors)
    • Minor SG: palate>upper lip>buccal mucosa> other site (most common intraoral site is the palate)
  • Malignant transformation possible in long standing lesions (about 5% cases) ‐> called Ca ex PA
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5
Q

What is this clinical finding?

A

PLEOMORPHIC ADENOMA

(MIXED TUMOR)

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6
Q

What is this clinical finding?

A

PLEOMORPHIC ADENOMA

Classic presentation: includes swelling in the parotid region

(MIXED TUMOR)

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7
Q

What is this clinical finding?

A

PLEOMORPHIC ADENOMA

Palatal presentation: since salivary glands are only in lateral sides of the palate, usually
swellings are in one side and not the midline.
Lateral swelling is a clue that you are
looking at a salivary gland lesion (left pics)
On the right pic, it involved midline and crossed over to other side, so there are
exceptions. But more commonly found in lateral side of the palate.

(MIXED TUMOR)

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8
Q

What is this clinical finding?

A

PLEOMORPHIC ADENOMA

  • Upper lip presentation: sometimes swelling can be seen extra orally and intraorally.
  • Remember the swelling will be movable, not tender, not fixed to underlying structures.

(MIXED TUMOR)

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9
Q

What is this clinical finding?

A

Untreated pleomorphic adenoma

slow growing, but can grow to enormous sizes

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10
Q

Pleomorphic adenoma
histology

A

This is a mixed tumor with myxoid component (right) and
fibrous/epithelial component(left)

This type of tumor can produce a lot of different tissues, since the origin is from myoepithelial cells aka plasmacytoid cells, which are pluripotent cells which means they can differentiate into many different lineages of cells such as

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11
Q

Monomorphic Adenomas

What is it?

Types?

Treatment?

A

What is it?

Proliferation of 1 type of cell makes up the tumor.

Types? Includes:
o Canalicular Adenoma
o Basal Cell Adenoma
Treatment for all monomorphic adenomas is surgical excision & diagnosis is done with biopsy

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12
Q

Canalicular Adenoma

A
  • Almost exclusively in minor SG
  • Striking predilection for upper lip (>75%)
  • Nearly always occurs in older adults
  • Slowly growing, painless mass
  • One clue for visualization of soft tissue swellings is increased vascularity with blue‐ish tint in the area.
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13
Q

What is this clinical finding?

A

Canalicular Adenoma

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14
Q

What is this clinical finding?

A

Canalicular Adenoma

  • Mucocele might look this way, but what would make it lower on
  • differential diagnosis is the location of the swelling. Mucocele is mostly seen on lower lip and this pic shows upper lip. Salivary gland tumors and mucoceles
  • can have the same clinical presentation, so always do a biopsy for formal histopathology diagnosis.
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15
Q

Basal Cell Adenoma

A
  • Basaloid appearance of the tumor cells
  • Primarily parotid lesion
  • predominantly in women over 50 years of age. It is uncommon in young adults.

 (Basal cells are located in epithelium that is adjacent to interface with the connective tissue and they are separated from the CT by a basement membrane, stem cells of epithelium are located in basal cell layer)
 Basal cells are typically Blue in appearance and cuboidal,

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16
Q

What is this clinical finding?

A

Basal Cell Adenoma

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17
Q

PAPILLARY
CYSTADENOMA
LYMPHOMATOSUM
(WARTHIN TUMOR)

A
  • finger‐like projections, benign, cystic spaces, aggregates oflymphocytes)
  • Vast majority occur within the parotid gland
  • Very rare intraorally
  • Predominantly in men
  • Typically between 5th and 8th decades
  • Strong correlation with cigarette smoking
  • Most common SG tumor to occur bilaterally (bilateral parotid swelling), but can be unilateral
  • Etiology: Thought to arise within lymph nodes as a result of entrapment of
  • salivary gland elements early in development
  • Clinical Features:
    • swelling that has more subtle presentation
    • Doughy to cystic mass
    • In the inferior pole of the gland, adjacent and posterior to the angle of the mandible
  • Treatment: surgical excision, responds very well to it
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18
Q

What is this clinical finding?

A

PAPILLARY
CYSTADENOMA
LYMPHOMATOSUM
(WARTHIN TUMOR)

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19
Q

Summary for benign
tumors

A

Encapsulated, freely movable, not fixed to underlying structure, not tender, patients do not complain of pain, slow growing
 There is one tumor of the ones discussed that does have a risk of malignant transformation (only 5% and will take many, many years) and that is Pleomorphic adenoma

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20
Q

MALIGNANT SALIVARY
GLAND TUMORS

List 5

A

 Mucoepidermoid carcinoma
 Acinic cell carcinoma
 Adenoid cystic carcinoma
 Carcinoma ex‐mixed tumor/malignant mixed tumor
 Polymorphous adenocarcinoma

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21
Q

CLINICAL FEATURES OF
ADENOCARCINOMAS
(malignant gland tumors)

A

 Infiltrative
 Fixed to underlying structures, not moveable
 Rapid or slow growth, depending on grade and type of malignant salivary
gland tumor
 Larger, rapidly growing lesions may cause pain and/or paresthesia
 Ulcerated overlying mucosa

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22
Q

MUCOEPIDERMOID
CARCINOMA

Charcterstics?

Location

Clinical appearance in minor gland

Can be mistaken for

Histopahtology

A

 Most common malignancy of salivary glands
 Most common malignant SG tumor in children

Locations
Palate, most common intraoral site
 Rare primary intrabony (jaws) tumors
 Most common in parotid
Minor SG: palate 2nd
Clinical appearance in minor gland: asymptomatic fluctuant swelling; blue or red colored
 Can be mistaken for mucocele
Histopathology: note the cells growing into adjacent tissue, showing infiltration

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23
Q

MUCOEPIDERMOID
CARCINOMA

What are its compoenents?

Within jaw prognosis

Treatment

Prognosis

Therapy by gene?

A

What are its compoenents? Mixture of mucus‐producing cells and epidermoid or squamous cells

May arise within jaws from odontogenic epithelium of dentigerous cysts
• More common in the mandible than maxilla
• Molar‐ramus area

Treatment: Usually treated by surgical excision

Prognosis:

• Overall prognosis is fairly good
• 10% of patients die, due to local recurrence or metastasis
 Low‐grade tumors have good prognosis (>90% are cured)
 High‐grade tumors the prognosis is guarded (Only 30% survive)
Therapy by gene?

CRTC1–MAML2, CRTC3‐MAML2 gene fusions (targeted therapy)

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24
Q

What is this clinical finding?

A

MUCOEPIDERMOID
CARCINOMA

Request all for biopsies!

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25
Q

What is this clinical finding?

A

MUCOEPIDERMOID
CARCINOMA

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26
Q

What is this radiographical finding?

A

CENTRAL
MUCOEPIDERMOID
CARCINOMA

  • Intrabony presentations, may have extraoral swelling depending on the stage
  • Started as small swelling and progressed rapidly:, need to pick it up early!
  • Patient recovered, but might need radiation, lost salivary glands, needed reconstruction of palate
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27
Q

ACINIC CELL
ADENOCARCINOMA

A
  •  Occurs predominantly in major SGs,
  •  Found in all age groups, peak incidence in 5th and 6th grade
  • No gender predilection
  • Malignancy with serous acinar differentiation
  • Most common in the parotid (since 90% serous acini)
  •  Variable microscopic appearance
  •  May even appear encapsulated, since it is SLOW growing
  • Better prognosis than salivary gland malignancies
28
Q

What is the clinical finding?

A

ACINIC CELL
ADENOCARCINOMA

29
Q

What is the clinical finding?

A

ACINIC CELL
ADENOCARCINOMA

blue‐ish tint

30
Q

What is this clinical finding?

A

Untreated acinic cell adenocarcinoma

 Because it is slow growing, and a low grade tumor, the
patient is alive and not dead with a tumor this size.
 Similar presentation to pleomorphic adenomas, but there is a lot of ulceration on the surface and prominent vascularization in acinic cell
adenocarcinoma.

31
Q

Adenoid Cystic Carcinoma

A

High grade salivary gland malignancy ( very bad cancer to get)
 Adults
Palatal mass; ulcerations
 Spread through perineural invasion ‐ tumor wraps itself around nerves and spreads through perineural spaces
Grows slowly in the beginning and then picks up speed
Histology: Duct like proliferation with cystic spaces

32
Q

Adenoid Cystic Carcinoma

Location

Growth rate

Clinical presentation

Treatment

Prognosis

A

Location:

 Approx. 50% occur within the minor SG ‐ palate most common site

Growth rate
 Usually a slowly growing mass

Clinical presentation
 Pain is a common and important early finding, occasionally occurring before there is noticeable swelling (described at annoying pain)
 Tendency to show perineural invasion, corresponds to pain

Treatment
 Excision usually the treatment of choice ‐ but edges of tumor may have perineural invasion and remain undetected ‐ makes tumor dangerous

Prognosis
 5‐year survival rate as high as 70% (maybe 90%)
 By 20 years, only 20% ‐ poor long term prognosis

33
Q

What is this clinical finding?

A

Adenoid Cystic Carcinoma

34
Q

What are these clinical findings?

A

Adenoid Cystic Carcinoma

35
Q

What are these clinical findings?

A

Adenoid Cystic Carcinoma

36
Q

Adenoid Cystic Carcinoma

A

Swiss cheese appearance, cribriform pattern (full of holes aka cystic spaces)

37
Q

Perineural invasion Histology

A

Perineural invasion: nerve nuble in the
center and is wrapped by tumor

38
Q

Polymorphous
Adenocarcinoma

Location

Gender

Appearance

growth patterns

Treatment

A
  • Location:
  • Almost exclusively in the minor SG
  • 60% on the hard or soft palate
  • Gender”
  • 2/3rds in females
  • Appearance:
  • Tumor cells have deceptively uniform appearance
  • Growth patterns:
  • Different growth patterns – polymorphous
  • Perineural invasion ‐ common ‐ but considered low grade tumor
  • Treatment: Wide surgical excision; overall prognosis relatively good, with 80% cure rate
39
Q

What is this clinical presentation?

A

Polymorphous
Adenocarcinoma

40
Q

What is this clinical presentation?

A

Polymorphous
Adenocarcinoma

41
Q

Carcinoma Ex Pleomorphic
Adenoma

What is it?

Mean age?

Growth pattern

Treatment?

Prognosis

A

What is it? (benign tumors that have underwent malignant transformation‐ takes a lot time, 15 to 20 years)

Mean age about 15 years greater than benign counterpart

Growth patterns: Mass present for many years with recent rapid growth with associated pain or ulceration

Treatment: Best treated by wide excision, with local node dissection and radiation

Prognosis: guarded, with 50% local recurrence or metastases and dying Prognosis is case to case scenario, may transform to high grade tumor

42
Q

What is this clinical finding?

A

Carcinoma Ex Pleomorphic
Adenoma

43
Q

What are the FREQUENCY OF SALIVARY
GLAND TUMORS BY
LOCATION

Palate

A

o Pleomorphic adenoma
o Adenoid cystic ca
o Mucoepidermoid ca
o PLGA
o Monomorphic adenoma

44
Q

What are the FREQUENCY OF SALIVARY
GLAND TUMORS BY
LOCATION

Parotid

A

o Pleomorphic adenoma
o Warthin’s tumor
o Basal cell adenoma
o Mucoepidermoid ca
o Acinic cell ca
o Adenoid cystic ca
o Ca ex mixed tumor

45
Q

What are the FREQUENCY OF SALIVARY
GLAND TUMORS BY
LOCATION

upper lip

A

o Canalicular Adenoma
o Salivary Duct Cyst*
o Pleomorphic Adenoma

46
Q

What are the FREQUENCY OF SALIVARY
GLAND TUMORS BY
LOCATION

Lower lip

A

o Mucocele
o Mucoepidermoid Ca
o Pleomorphic Adenoma

47
Q

SG Tumors: Summary of
Key Points

A

 Involve both major and minor glands
 Benign and malignant tumors both have similar
clinical presentation

 Most malignant salivary gland tumors do not show histopathologic
characteristics associated with malignancy
 Most occur in adults
 Warthin Tumor seen in parotid, may be bilateral
 Mucoepidermoid carcinoma
o Can occur in children
o May occur centrally in bone

48
Q

Inflammatory/Reactive Lesions of the Salivary Glands

List 5

A
  • mucocele/mucous cyst
  • ranula
  • necrotizing sialometaplasia
  • sialolithiasis
  • sialadentitis
49
Q

Mucocele

Definition

Clinical features

Location

Histological features

Treatment

A

• definition: a lesion that forms when a salivary gland duct is severed & secretion spills into the adjacent CT
a pseudocyst (not lined by epithelium) — mucous builds up in the CT & causes a bump
• clinical features:

  • swelling in the tissue that may increase & decrease in size
  • may have a bluish hue, fluctuant on palpation — fluid filled, soft, compressible

location: lower lip most common site, but may form in any area where there are minor salivary glands

• histologic features:
- a cyst-like space in soft tissue
- lined by compressed granulation tissue
- lumen filled with mucin, foamy macrophages & inflammatory cells
• treatment: surgical excision, removal of associated minor salivary glands
• may recur if don’t remove all associated injured minor salivary glands

50
Q

What is this clinical finding?

A

Mucocele

51
Q

Mucous Cyst

Definition

Clinical features

Histological features

Treatment

A

Definition: a pseudocyst
• microscopicallly appears as an epithelial lined cystic structure that is actually a dilated duct
clinically you CANNOT tell the difference between a mucocele & mucous cyst
• clinical features:
- same as a mucocele
• histologic features:
- same as mucocele but will see an epithelial lining (but actually a dilated duct)
treatment: same as mucocele; surgical excision

52
Q

What is this clinical finding?

A

Mucous Cyst

53
Q

Ranula

Definition

Associated with

Clinical features

Treatment

A

Definition: mucocele-like lesion that forms unilaterally on the floor of the mouth
• may break through the mylohyoid muscle & enter neck space = “plunging ranula”
associated with: the ducts of the sublingual & submandibular glands
• clinical features:
- must be on floor of the mouth for it to be considered a ranula
- big & have deep blue color if exophytic
- sometimes can grow downward/deep & won’t see blue as much
• treatment: surgical excision

54
Q

What is this clinical finding?

A

Ranula

  • Notice how it’s unilateral*
  • on the floor of the mouth*
55
Q

What is this clinical finding?

A

Ranula

Notice how it’s unilateral

on the floor of the mouth

56
Q

Necrotizing Sialometaplasia

Definition

Predisposing factors

Clinical features

Histologic features

Treatment

A

• Definition: locally destructive inflammatory condition — looks malignant but is benign
• salivary gland ischemia — “heart attack of the palate”; blood flow is interrupted
• predisposing factors:
- local trauma
- palatal injection of local anesthesia
- previous surgery
- many are idiopathic..
• usually a clinical diagnosis based on history & how fast — palate uncommon for SCC
• clinical features:
- initially appears as a non-ulcerated swelling of the palate
- often associated with pain or paresthesia
- within 2-3 weeks, necrotic tissue sloughs off & becomes a crater-like ulcer
- patient may say: “a chunk of the roof of my mouth fell out”
• histologic features:
- necrosis of the salivary glands — coagulative necrosis (green circles in histology —>)
- salivary gland duct epithelium is replaced by squamous epithelium — appear as islands of squamous epithelium deep in the CT & resembles SCC (arrows in histology —>)
Treatment: no treatment, spontaneously resolves within 6 to 10 weeks
irrigating & debriding the area can reintroduce vascularity & help healing

57
Q

What is this clinical finding?

A

Necrotizing Sialometaplasia

58
Q

Sialolithiasis

Definition

Location

Origin

Clinical features

Radiological features

Histological features

Treatment

A

Definition: lith = stone ;; sialolith: a salivary gland stone

Location: occur in both major & minor salivary glands

• floor of the mouth is most common location (Wharton’s duct is a common place)

• often causes obstruction of the duct

Origin: arise from desposition of calcium salts around nidus of debris within the duct lumen

  • *clinical features:**- minor glands: hard yellowish structure in soft tissue
  • may be visible on a radiograph
  • recurrent swelling (due to the obstruction)
  • episodic pain & swelling during times of increased salivation
  • can be palpated if the stone is located toward the terminal portion of the duct
  • *Radiological features** : may be viewed as a radiopacity on an occlusal x-ray–well defined radiopacity
  • *Histological features-** concentric rings of calcification, color of it in stain depends on level of calcificatio
  • *Treatment**: promote passage of stone (massage, sialogogues, increase fluid intake) or surgical removal
59
Q

What is this clinical finding?

A

Sialolithiasis

60
Q

What is this clinical finding?

A

Sialolithiasis

Notice how it can appear radiographically as a well defined radiolucency

61
Q

What is this Radiographical finding?

A

Sialolithiasis

62
Q

Sialadenitis

definition

causes:

clinical features:

histologic features:

Treatment:

A

definition: acute or chronic inflammation in major or minor salivary glands
• causes:
• obstruction of a salivary gland duct (sialolith)
• infection (mumps [viral], staph aureus [bacterial, most common], candida [fungal])
• decreased salivary flow (Sjogren’s, sarcoidosis)
• parotid gland = parotitis
• clinical features:
- acute: most common in parotid, swollen & painful gland, erythematous & warm overlying mucosa/skin, purulent discharge, low-grade fever
- chronic: caused by recurrent or persistent ductal obstruction, periodic swelling & pain
• histologic features:
- acute or chronic inflammatory cell infiltrate in the salivary gland
- in chronic cases = salivary gland replaced by fibrous CT & fat
- cells: acute = neutrophils ;; chronic = lymphocytes, plasma cells, macrophages
• Treatment: antibiotics, rehydration, surgical drainage, or surgical removal of gland

63
Q

What is this clinical finding?

A

Sialadenitis

Acute: parotid papilla purulent discharge

64
Q

What is this clinical finding?

A

Sialadenitis

Chronic: caused fibrosis

65
Q

Summery

of inflmattory salivaory conditions

A

Mucocele

  • fluctuant swelling
  • bluish hue
  • lower lip most common

Ranula

  • fluctuant swelling
  • floor of mouth

Sialolithisis

• major glands: episodic pain &
swelling of affected gland
• minor glands: asymptomatic/
local swelling or tenderness
• if superficial - firm to palpation
& yellowish color

Necrotizing
Sialometaplasia

• initial painful swelling
• later necrotic ulcer
• posterior lateral hard
palate & soft palate

Sialadenitis

• painful swelling of
affected gland
• purulent discharge if
acute infection