04.05.2017 Salivary gland cytology • It is a reliable diagnostic test – However, definitive subclassification may be difficult for some lesions • Diagnostic accuracy differs according to the entity (e.g. high for pleomorphic adenoma, low for basal Salivary Gland Cytology cell adenocarcinoma) Pınar Fırat, MD • Diagnostic accuracy is higher Professor of Pathology – for neoplastic vs non-neoplastic lesions İ.U. İstanbul Faculty of Medicine Çapa, İstanbul – for low-grade vs high-grade tumors • Sensitivity 77-97%, specificity 86-100% Salivary gland cytology Triage helps the clinician Triage • Is it a salivary gland lesion? • Non-neoplastic lesions: Surgery may not be – Or arising in the adjacent tissues, lymph required node? skin? soft tissue? • Systemic diseases: Different therapeutic • Is the lesion neoplastic? modalities • Benign tumors, low-grade malignancies: Limited • Benign or malignant ? surgery (superficial parotidectomy) • If possible, type of neoplasm? • High-grade malignancies: Extensive surgery (Facial nerve sacrifice, lymph node neck dissection may be necessary; neo-adjuvant therapy may be indicated) • Inoperable patients Diagnostic difficulties Salivary gland tumors • Wide spectrum of benign and malignant tumors • Benign • Malignant – Some are extremely rare – Pleomorphic adenoma – Acinic cell carcinoma – Some are diagnosed by architecture only-invasion – Myoepithelioma – Mucoepidermoid carcinoma • Overlaps in different conditions – Basal cell adenoma – Adenoid cystic carcinoma – Cystic lesions (neoplasic/ non-neoplasitic) – Warthin tumor – Epithelial-myoepithelial – Squamous cells – Oncocytoma carcinoma – Hyaline stromal globules – Polymorphous low grade – adenocarcinoma – Basaloid morphology – – Salivary duct carcinoma – Spindle cell lesions – – – – – 1 04.05.2017 Tükrük bezi tümörleri Pleomorphic adenoma • Benign • Malign – Pleomorfik adenom – Adenoid kistik karsinom • Myoepithelial cells, often plasmacytoid or – Myoepitelyoma – Epitelyal-myoepitelyal spindled – Bazal hücreliMyoepithelial adenom karsinom • Cohesive epithelial cells BlidBasaloid – Polimorfik düşük dereceli – Warthin tümörü • Chondromyxoid matrix - fibrillary and bright – OnkositomOncocytic adenokarsinom Others with poligonal/cuboidal cells magenta (Romanowsky stains) with indistinct – – Asinik hücreli karsinom Cystic (squamous, mucinous) margins – – Mukoepidermoid karsinom High grade • Myoepithelial cells embedded into the fibrillary – – Tükrük bezi duktus karsinomu matrix – – Fibrillary matrix 2 04.05.2017 Pleomorphic Adenoid cystic adenoma carcinoma Globuler matrix 3 04.05.2017 Cystic change Metaplasias: squamous / sebaceous Mucin in the background Atypia in pleomorphic adenoma Pitfalls in diagnosing pleomorphic adenomas : • Cellular specimens with sparse or absent matrix material • Lesions with focal hyaline globules/adenoid cystic-like areas • Lesions with cytologic atypia • Lesions with metaplastic changes, especially squamous or mucinous features Cellularity with scanty matrix 4 04.05.2017 67y F 2cm nodular mass in the hard palate Myoepithelioma • Myoepithelial cells – Epitheloid, plasmacytoid, spindle cell, clear cell patterns Differential dx – Pleomorphic adenoma – Soft tissue lesions • Leiomyoma, schwannoma, noduler fascitis – Clear cell tumors Plasmacytoid cells Elongated spindle cells • If nuclear atypia, necrosis and invasion is NO matrix present: Myoepithelial carcinoma Myoepitelioma - Collagenous crystals 5 04.05.2017 Spindle cell myoepithelioma Schwannom Irving Dardick, Sudha Kini, Salivary Gland Tumor Cytopathology, Pathology Images Inc., Canada, 2006 MithlilMyoepitehlial tumors Bazaloid tumors Histology: Myoepithelial carcinoma Basal cell adenoma • Basaloid cells – Round-oval uniform nuclei, scanty cytoplasm, regular chromatin • Varied cellularity • Peripheral palisading • Hyaline stroma – Stick to cells, globules, basement-memb.like material • Squamous metaplasia Bazal cell adenoma 6 04.05.2017 Basal cell adenoma Differential diagnosis: • Pleomorphic adenoma (Polymorphic, fibrillary matrix) • Basal cell adenocarcinoma (nuclear atypia, mitosis, necrosis) • Adenoid cystic carcinoma (Hyperchromatic irregular Basal cell adenoma nucleus, coarse chromatin) Adenoid cystic carcinoma • Painful mass or pain during the FNA • Basaloid cells with dark angulated nuclei (variable nuclear atypia) • Acellular hyaline matrix with sharp borders • Variably sized, often large, three-dimensional hyaline spheres Basal cell Adenocarcinoma May be identical to BA Nuclear atypia Mitotic figures Invasion Hyaline matrix Nuclear atypia is not always present 7 04.05.2017 Solid variant of adenoid cystic carcinoma do not show abundant matrix Naked nuclei are seen in the background May closely mimic basal cell tumors Epitelyal-myoepitelyal karsinom Adenoid kistik karsinom as the number of hyaline globules and their size increases, the diagnosis gets closer to adenoid cystic carcinoma Epithelial-myoepithelial carcinoma • Matrix producing basaloid looking tumor – Hyaline globules / myxoid matrix • Cellular smears, naked nuclei in the background • Dual cell population – One component may dominate Epitelyal myoepitelyal Ca. 8 04.05.2017 Dual cell population Epitelyal - myoepitelyal Epitelyal - myoepitelyal karsinom Polymorphous Low Grade Adenocarcinoma Minor salivary glands Branching papilla Larger amount of cytoplasm Irving Dardick, Sudha Kini, Salivary Gland Tumor Cytopathology, Matrix – hyaline / myxoid Pathology Images Inc., Canada, 2006 9 04.05.2017 Neoplasms with Neoplasms basaloid cells producing matrix . Basal cell adenoma . Basal cell adenoma . Basal cell adenoca. Basal cell adenoca. Adenoid cystic carcinoma . Adenoid cystic carcinoma . Epithelial-myoepithelial . Epithelial-myoepithelial carcinoma carcinoma . Pleomorphic adenoma . Polymorphous low-grade . Neoplasms of the skin adenocarcinoma – basal cell carcinoma . Pleomorphic adenoma – pilomatrixoma . Small cell carcinoma PA Basal cell Ad Basal cell adenoma Basal cell adenocarcinoma ACC Ep-Myo Ca Pleomorphic adenoma Adenoid cystic ca. Matrix producing, basaloid looking tumors PA BCA BCAC ACC Pattern sheets and cohesive clusters; cohesive clusters; 3-D cylinders and syncytia, cells + peripheral + peripheral branching groups embedded in matrix palisading; palisading; Cells plasmacytoid & Basaloid cells, Basaloid cells, Basaloid cells, spindled round to oval or round to oval or maybe some Nuclear myoepithelial cells elongated nuclei elongated nuclei; myoepithelial cells, and cuboidal +atypia oval to angulated atypia epithelial cells nuclei; mild to moderate atypia Matrix Fibrillar Intercellular hyaline Intercellular hyaline large acellular chondromyxoid matrix; matrix; cylinders and Clinical matrix-irregular circumferential circumferential globules of hyaline features edges hyaline bands hyaline bands matrix surrounded by cells- sharp edges Background Myoepithelial cells naked nuclei naked nuclei; naked nuclei; Adenoid cystic carcinoma + necrosis + necrosis Ki-67 Modified from William C. Faquin’s hand out, USCAP, 2005 10 04.05.2017 Histology: Basal cell adenoma .70 y, F .CT: 1cm spiculated mass in the right upper lobe of the lung. .PET/CT: increased FDG up-take in left parotid gland (Well circumscribed mass, 1.5cm in diameter) Never trust globules Ask the clinical features, see the nuclear atypia PET scan for salivary gland : .Limited value .Warthin’s tumors, pleomorphic adenomas, basal cell adenomas show increased FDG uptake Warthin’s tumor • Oncocytes with large polygonal granular cytoplasm forming clusters/ monolayers • Lymphocytes, like a lymph node Warthin Tümörü • Cystic background looking like necrosis May present only by one or two components 11 04.05.2017 Mast cell Onkositler Cystic lesions of the salivary glands Non-neoplastic Neoplastic • Lenfoepitelhial cyst Benign • Retantion cyst • Warthin’ tumor . 63 cases with histopathologic follow up • Mucocel • Pleomorphic adenoma . FNAC correctly diagnosed 25 of 36 neoplasms • Branchial cyst • Cystadenoma however...., •Dermoid cyst Malign . 5 Warthin’s tumors • Epidermoid cyst • Mucoepidermoid carcinoma . 2 squamous cell carcinomas • Acinic cell carcinoma . 2 mucoepidermoid carcinomas . 2 schwannomas yielded non-representative aspirates Sensitivity 70% Specificity 96% Gabrijela Kocjan, Clinical Cytopathology of the Head and Neck, 2001 12 04.05.2017 Well differentiated squamous cell carcinoma Branchial cyst 62y, F 2 cm mass in the left parotid Oncocytoma Oncocytoma Differential diagnosis: • Noduler oncocytic hyperplasia • Cellularity, isolated oncocytes – Hypocellularity • 3-dimentional oncocytic groups • Warthin tumor – Round uniform nucleus, prominent nucleoli, – Monolayyyers, cystic backg round, ly ypymphocytes Warthin large granuler eosinophilic cytoplasm • Oncocytic carcinoma – Dyscohesion, large nucleus, pleomorphism, mitosis, necrosis • Capillary fragments within the groups • Acinic cell carcinoma • NO cystic background, NO lymphocytes – Prominent asiner structures 13 04.05.2017 Oncocytic carcinoma Irving Dardick, Sudha Kini, Salivary Gland Tumor Cytopathology, Pathology Images Inc., Canada, 2006 Acinic cell carcinoma • Cellular smears of acinar cells • Sheets and dyshesive crowded 3-D clusters • Large polygonal cells with abundant finely vacuolated to granular cytoplasm • PASDitttlPAS+D resistant cytoplasm ic zymogen granu les • Bland nuclear cytologic features • Background naked nuclei + lymphocytes Acinic cell Oncocytoma 14 04.05.2017 Epithelial-myoepithelial carcinoma Acinic cell carcinoma Salivary gland tissue • Serous and mucinous acinar