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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
What is this clinical finding?
MUCOEPIDERMOID CARCINOMA
26
What is this radiographical finding?
**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
27
**ACINIC CELL ADENOCARCINOMA**
*  Occurs **predominantly in major SGs,** *  Found in **all age group**s, 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
What is the clinical finding?
**ACINIC CELL ADENOCARCINOMA**
29
What is the clinical finding?
ACINIC CELL ADENOCARCINOMA blue‐ish tint
30
What is this clinical finding?
Untreated acinic cell adenocarcinoma ## Footnote  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
Adenoid Cystic Carcinoma
 **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
**Adenoid Cystic Carcinoma** Location Growth rate Clinical presentation Treatment Prognosis
**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
What is this clinical finding?
Adenoid Cystic Carcinoma
34
What are these clinical findings?
Adenoid Cystic Carcinoma
35
What are these clinical findings?
Adenoid Cystic Carcinoma
36
Adenoid Cystic Carcinoma
Swiss cheese appearance, cribriform pattern (full of holes aka cystic spaces)
37
Perineural invasion Histology
Perineural invasion: nerve nuble in the center and is wrapped by tumor
38
Polymorphous Adenocarcinoma _Location_ _Gender_ _Appearance_ _growth patterns_ _Treatment_
* **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
What is this clinical presentation?
Polymorphous Adenocarcinoma
40
What is this clinical presentation?
Polymorphous Adenocarcinoma
41
**Carcinoma Ex Pleomorphic Adenoma** _What is it?_ _Mean age?_ _Growth pattern_ _Treatment?_ _Prognosis_
**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
What is this clinical finding?
Carcinoma Ex Pleomorphic Adenoma
43
What are the **FREQUENCY OF SALIVARY GLAND TUMORS BY LOCATION** _Palate_
**o Pleomorphic adenoma o Adenoid cystic ca o Mucoepidermoid ca o PLGA o Monomorphic adenoma**
44
What are the **FREQUENCY OF SALIVARY GLAND TUMORS BY LOCATION** _Parotid_
**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
What are the **FREQUENCY OF SALIVARY GLAND TUMORS BY LOCATION** _upper lip_
**o Canalicular Adenoma o Salivary Duct Cyst\* o Pleomorphic Adenoma**
46
What are the **FREQUENCY OF SALIVARY GLAND TUMORS BY LOCATION** _Lower lip_
**o Mucocele o Mucoepidermoid Ca o Pleomorphic Adenoma**
47
**SG Tumors: Summary of Key Points**
 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
Inflammatory/Reactive Lesions of the Salivary Glands List 5
* mucocele/mucous cyst * ranula * necrotizing sialometaplasia * sialolithiasis * sialadentitis
49
**Mucocele** _Definition_ _Clinical features_ _Location_ _Histological features_ _Treatment_
**• 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
What is this clinical finding?
**Mucocele**
51
**Mucous Cyst** _Definition_ _Clinical features_ _Histological features_ _Treatment_
•_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
What is this clinical finding?
**Mucous Cyst**
53
**Ranula** Definition Associated with Clinical features Treatment
• **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
What is this clinical finding?
Ranula * Notice how it's unilateral* * on the floor of the mouth*
55
What is this clinical finding?
**Ranula** Notice how it's unilateral on the floor of the mouth
56
**Necrotizing Sialometaplasia** _Definition_ _Predisposing factors_ _Clinical features_ _Histologic features_ _Treatment_
**• 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
What is this clinical finding?
Necrotizing Sialometaplasia
58
**Sialolithiasis** Definition Location Origin Clinical features Radiological features Histological features Treatment
**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
What is this clinical finding?
Sialolithiasis
60
What is this clinical finding?
**Sialolithiasis** Notice how it can appear radiographically as a well defined radiolucency
61
What is this Radiographical finding?
**Sialolithiasis**
62
**Sialadenitis** _definition_ _causes:_ _clinical features:_ _histologic features:_ _Treatment:_
• **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
What is this clinical finding?
**Sialadenitis** Acute: parotid papilla purulent discharge
64
What is this clinical finding?
Sialadenitis Chronic: caused fibrosis
65
Summery of inflmattory salivaory conditions
**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

Oral Path (23 decks)

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