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Dec76dc4293ede47e9f0f3977e8 07/01/2012 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Salivary Glands Intro • Salivary glands are exocrine SALIVARY glands • 3 pairs of large glands GLAND located extra-orally • Major salivary glands – Parotid (serous) TUMOURS – Submandibular (mixed) – Sublingual (mucous) Prof R V SUBRAMANYAM • Minor salivary glands – Labial, lingual, palatal, Oral & Maxillofacial Pathology buccal, glossopalatine & retro molar glands • Function: Production of saliva 4/20/2008 2 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Salivary Glands Intro Normal Salivary Gland Structure 4/20/2008 R V SUBRAMANYAM 3 4/20/2008 R V SUBRAMANYAM 4 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Cells in Salivary Glands and Ducts CLASSIFICATION (Foote & Frazell, 1954) BENIGN MALIGNANT • Pleomorphic adenoma • Malignant mixed tumor (mixed tumor) • Mucoepidermoid tumor • Papillary cystadenoma • Squamous cell carcinoma lymphomatosa • Adenocarcinoma • Oxyphil adenoma – Adenoid cystic • Sebaceous cell – Trabecular or solid adenoma – Anaplastic – Mucous cell • Benign lymphoepithelial – Pseudoadamantine lesion – Acinic cell • Unclassified – Unlassified 4/20/2008 R V SUBRAMANYAM 5 4/20/2008 R V SUBRAMANYAM 6 1 07/01/2012 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours CLASSIFICATION (Thackray & Lucas, 1974) CLASSIFICATION (AFIP, Ellis & Auclair, 1990) BENIGN MALIGNANT BENIGN MALIGNANT • Pleomorphic adenoma • Pleomorphic adenoma • Adenocarcinomas • Mucoepidermoid tumor • Warthin’s tumor • Acinic cell adenocarcinoma (mixed tumor) • Acinic cell tumor • Basal cell adenoma • Basal cell adenocarcinoma • Monomorphic adenoma • Myoepithelioma • Clear cell adenocarcinoma – Adenolymphoma • Carcinomas • Canalicular adenoma • Cystadenocarcinoma – Oxyphil adenoma – Adenoid cystic • Oncocytoma • Sebaceous adenocarcinoma • Cystadenoma • Lymphadenocarcinoma – Tubular adenoma – Adenoid cystic carcinoma – Clear cell adenoma • Sebaceous adenoma • Adenoid cystic carcinoma – Epidermoid carcinoma • Sialadenoma • Mucinous adenocarcinoma – Basal cell adenoma – Undifferentiated • Ductal papillomas • Malignant mixed tumor – Trabecular adenoma – Sialadenoma papilliferum – Carcinoma ex mixed tumor – Sebaceous adenoma • Connective tissue and – Inverted ductal papilloma – Metastasizing mixed tumor – Sebaceous lymphadenoma metastatic tumors – Lymphadenoma – Carcinosarcoma – Intraductal papilloma 4/20/2008 R V SUBRAMANYAM 7 4/20/2008 R V SUBRAMANYAM 8 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours CLASSIFICATION (AFIP) Salivary gland tumours: Introduction • Carcinomas • Uncommon: 2 - 4% of head & neck tumours – Squamous cell carcinoma • Distribution – Mucoepidermoid carcinoma – Adenosquamous carcinoma – Parotid: 70% overall; 75% benign – Epithelial-myoepithelial carcinoma – Submandibular: 10% overall; 50% benign – Oncocytic carcinoma – Sublingual / Minor: 20% overall; 25% benign; – Salivary duct carcinoma – Most common site for minor: Palate – Myoepithelial carcinoma – Others • Age predilection: – Mesenchymal tumors – Benign: > 40 yrs – Lymphomas – Malignant: > 60 yrs – Metastatic tumors • Gender predilection: – Benign: Females – Malignant: Men=Women • Most common benign tumour: Pleomorphic adenoma 4/20/2008 R V SUBRAMANYAM 4/20/2008 R V SUBRAMANYAM 10 9 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Salivary gland tumours: Introduction Aetiology of salivary gland tumours in general • Most common malignant tumour: Mucoepidermoid • Viruses: EBV, CMV carcinoma • Ionizing Radiation – >>Frequency in submandibular gland than parotid – Most common malignancy in Submandibular gland: – A dose of ≥ 140 rad increases risk of tumour Adenoid cystic carcinoma development – Minor sg tumours of retromolar area, floor of the mouth • Occupation & tongue are more likely to be malignant – Asbestos mining, shoe manufacturing, plumbing • In Children – 65% of tumours are benign – most common • Hormones Haemangioma, followed by pleomorphic adenoma – Role of hormones like oestrogen still controversial – 35% of tumours are malignant – most common Mucoepidermoid carcinoma 4/20/2008 R V SUBRAMANYAM 11 4/20/2008 R V SUBRAMANYAM 12 2 07/01/2012 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Pathogenesis of SGT Origin of Salivary Gland Tumors • Bicellular stem cell theory: tumours arise from 1 of 2 undifferentiated stem cells: – the excretory duct reserve cell: squamous cell and MEC – the intercalated duct reserve cell: pleomorphic adenomas, oncocytomas, adenoid cystic carcinomas, adenocarcinomas, and acinic cell carcinomas. • Multicellular theory: Each tumour type is associated with a specific differentiated cell of origin within the salivary gland – Squamous cell carcinomas arise from excretory duct cells – pleomorphic adenomas arise from the intercalated duct cells – oncocytomas arise from the striated duct cells – acinic cell carcinomas arise from acinar cell 4/20/2008 R V SUBRAMANYAM 13 4/20/2008 R V SUBRAMANYAM 14 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Origin of Salivary Gland Tumors Origin of Salivary Gland Tumors Normal Structure Cell of Origin Tumour Excretory Duct Excretory Duct Reserve Squamous Cell Carcinoma Cells Mucoepidermoid Carcinoma Striated Duct Intercalated Duct Oncocytoma Reserve Cell Intercalated duct Intercalated Duct Adenoid Cystic Carcinoma Reserve Cell Acinus Intercalated Duct Pleomorphic adenoma Reserve Cell Monomorphic adenoma Myoepithelioma Acinic cell carcinoma Adenocarcinoma Myoepithelial cell Intercalated Duct Adenocarcinoma Reserve Cell 4/20/2008 R V SUBRAMANYAM 15 4/20/2008 R V SUBRAMANYAM 16 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours SALIVARY GLAND TUMOURS Pleomorphic Adenoma: Definition • Pleomorphic adenoma • Also called mixed tumour (Minssen, 1874) • Warthin’s tumour • Both are misnomers • Mucoepidermoid carcinoma – Not mixed – not derived from 2 germ layers – Not pleomorphic – no pleomorphism of cells • Adenoid cystic carcinoma • The term pleomorphic adenoma was suggested • Polymorphous low grade adenocarcinoma by Willis, 1948 • Acinic cell carcinoma • A benign tumor of the salivary gland composed of variable admixture of epithelial (ductal, and non-ductal) elements and mesenchymal (chondroid, myxoid and osseous) components. 4/20/2008 R V SUBRAMANYAM 17 4/20/2008 R V SUBRAMANYAM 18 3 07/01/2012 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Pleomorphic Adenoma: Pathogenesis Pleomorphic Adenoma: Demographics • Myoepithelial cell (Hubner et al, 1971) • Most common neoplasm of salivary glands – 70% of parotid tumors • Intercalated duct reserve cell (Regezi & – 50% of submandibular tumors Batsakis, 1977) – 45% of minor salivary gland tumors • Both (Batsakis, 1980) – 6% of sublingual tumors • Age predilection • Neoplastically altered epithelial cell (Dardick et – 4th- 6th decade; Average 43 years al, 1982) • Gender predilection – Females • Site predilection – Parotid – lower pole of superficial lobe – Palate 4/20/2008 R V SUBRAMANYAM 19 4/20/2008 R V SUBRAMANYAM 20 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Pleomorphic Adenoma: Clinical features Pleomorphic Adenoma: Clinical features • Painless & slow growing • Single nodular, firm, slightly compressible mass • Not fixed • Palatal tumors – posterolateral aspect • Recurrent lesions appear to be multinodular and are less mobile than the original tumor 4/20/2008 R V SUBRAMANYAM 21 4/20/2008 R V SUBRAMANYAM 22 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Pleomorphic Adenoma: Gross features Histologic classification (Foote & Frazell, 1954) • Irregular, round to ovoid mass • Principally myxoid → • Well defined borders Most common • Major salivary glands: • Myxoid & cellular Incomplete fibrous capsule or components equal unencapsulated • Predominantly cellular • Minor salivary glands: Unencapsulated • Extremely cellular → • Homogeneous tan to white Least common; More cut surface aggressive • Occasionally Haemorrhage and infarction 4/20/2008 R V SUBRAMANYAM 23 4/20/2008 R V SUBRAMANYAM 24 4 07/01/2012 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology Lecture Series :: Salivary Gland Tumours Pleomorphic Adenoma: Histopathology Pleomorphic Adenoma: Histopathology • Morphologic diversity is the hallmark of • Myoepithelial cells forming pleomorphic adenoma – Spindle cells, plasmacytoid cells • Glandular epithelial cells forming • Connective tissue stroma exhibits – anastomosing trabeculae – Fibrous interlacing bundles – Sheets & islands – sometimes with keratin pearls – Myxoid, Chondroid, Chondromyxoid, & Osseous – ducts – tubular pattern areas – Cystic spaces lined by squamous epithelium – Eosinophilic hyaline areas – basement lamina – Proliferating papillae material – Presence of tyrosine crystals – unique to this tumour 4/20/2008 R V SUBRAMANYAM 25 4/20/2008 R V SUBRAMANYAM 26 Oral Pathology Lecture Series :: Salivary Gland Tumours Oral Pathology
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