Salivary Gland Tumors Flashcards
ADENOMA
benign tumor
of glandular origin
Characteristics of a Benign Tumor:
Encapsulated ‐ distinguishable from surrounding tissues
Freely movable ‐ not fixed
Slow growing
Non tender ‐ patients do not complain of pain
BENIGN SALIVARY GLAND
TUMORS
(list 3)
Pleomorphic adenoma aka mixed tumor
Monomorphic adenomas
o Canalicular adenoma
o Basal cell adenoma
Warthin tumor (papillary cystadenoma lymphomatosum)
PLEOMORPHIC ADENOMA
(MIXED TUMOR)
- 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
What is this clinical finding?
PLEOMORPHIC ADENOMA
(MIXED TUMOR)
What is this clinical finding?
PLEOMORPHIC ADENOMA
Classic presentation: includes swelling in the parotid region
(MIXED TUMOR)
What is this clinical finding?
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)
What is this clinical finding?
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)
What is this clinical finding?
Untreated pleomorphic adenoma
slow growing, but can grow to enormous sizes
Pleomorphic adenoma
histology
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
Monomorphic Adenomas
What is it?
Types?
Treatment?
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
Canalicular Adenoma
- 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.
What is this clinical finding?
Canalicular Adenoma
What is this clinical finding?
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.
Basal Cell Adenoma
- 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,
What is this clinical finding?
Basal Cell Adenoma
PAPILLARY
CYSTADENOMA
LYMPHOMATOSUM
(WARTHIN TUMOR)
- 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
What is this clinical finding?
PAPILLARY
CYSTADENOMA
LYMPHOMATOSUM
(WARTHIN TUMOR)
Summary for benign
tumors
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
MALIGNANT SALIVARY
GLAND TUMORS
List 5
Mucoepidermoid carcinoma
Acinic cell carcinoma
Adenoid cystic carcinoma
Carcinoma ex‐mixed tumor/malignant mixed tumor
Polymorphous adenocarcinoma
CLINICAL FEATURES OF
ADENOCARCINOMAS
(malignant gland tumors)
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
MUCOEPIDERMOID
CARCINOMA
Charcterstics?
Location
Clinical appearance in minor gland
Can be mistaken for
Histopahtology
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
MUCOEPIDERMOID
CARCINOMA
What are its compoenents?
Within jaw prognosis
Treatment
Prognosis
Therapy by gene?
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)
What is this clinical finding?
MUCOEPIDERMOID
CARCINOMA
Request all for biopsies!
What is this clinical finding?
MUCOEPIDERMOID
CARCINOMA
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
ACINIC CELL
ADENOCARCINOMA
- 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
What is the clinical finding?
ACINIC CELL
ADENOCARCINOMA
What is the clinical finding?
ACINIC CELL
ADENOCARCINOMA
blue‐ish tint
What is this clinical finding?
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.
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
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
What is this clinical finding?
Adenoid Cystic Carcinoma
What are these clinical findings?
Adenoid Cystic Carcinoma
What are these clinical findings?
Adenoid Cystic Carcinoma
Adenoid Cystic Carcinoma
Swiss cheese appearance, cribriform pattern (full of holes aka cystic spaces)
Perineural invasion Histology
Perineural invasion: nerve nuble in the
center and is wrapped by tumor
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
What is this clinical presentation?
Polymorphous
Adenocarcinoma
What is this clinical presentation?
Polymorphous
Adenocarcinoma
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
What is this clinical finding?
Carcinoma Ex Pleomorphic
Adenoma
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
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
What are the FREQUENCY OF SALIVARY
GLAND TUMORS BY
LOCATION
upper lip
o Canalicular Adenoma
o Salivary Duct Cyst*
o Pleomorphic Adenoma
What are the FREQUENCY OF SALIVARY
GLAND TUMORS BY
LOCATION
Lower lip
o Mucocele
o Mucoepidermoid Ca
o Pleomorphic Adenoma
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
Inflammatory/Reactive Lesions of the Salivary Glands
List 5
- mucocele/mucous cyst
- ranula
- necrotizing sialometaplasia
- sialolithiasis
- sialadentitis
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
What is this clinical finding?
Mucocele
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
What is this clinical finding?
Mucous Cyst
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
What is this clinical finding?
Ranula
- Notice how it’s unilateral*
- on the floor of the mouth*
What is this clinical finding?
Ranula
Notice how it’s unilateral
on the floor of the mouth
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
What is this clinical finding?
Necrotizing Sialometaplasia
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
What is this clinical finding?
Sialolithiasis
What is this clinical finding?
Sialolithiasis
Notice how it can appear radiographically as a well defined radiolucency
What is this Radiographical finding?
Sialolithiasis
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
What is this clinical finding?
Sialadenitis
Acute: parotid papilla purulent discharge
What is this clinical finding?
Sialadenitis
Chronic: caused fibrosis
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
