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Head & Neck Pathology > Salivary glands > Flashcards

Salivary glands Flashcards

1
Q

What are the salivary gland tumours with a myoepithelial cell component?

A
  1. Benign: myoepithelioma, pleomorphic adenoma, basaloid adenoma
  2. Malignant: epithelial-myoepithelial carcinoma, adenoid cystic carcinoma, polymorphous adenocarcinoma, basaloid carcinoma
  3. Congenital: sialoblastoma, salivary gland anlage tumour
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2
Q

What normal structure is epithelial-myoepithelial carcinoma said to be recapitulating/mimicking?

A

The intercalated duct

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3
Q

What are the various morphologic types of myoepithelial cells in salivary gland, and what tumours can they be seen in?

A
  1. Stellate/myxoid (PA)
  2. Spindled/myoid (PA, myoepithelioma)
  3. Hyaline/plasmacytoid (PA, myoepithelioma)
  4. Clear cells (many tumours - around ducts, epithelial-myoepithelial ca)
  5. Lipoid cells (PA with lipometaplasia)
  6. Oncocytic (epi-myoepi ca of oncocytic type, PA, oncocytic myoepithelioma)
  7. Osteoblastic (PA)
  8. Squamous (PA)
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4
Q

What is a possible significance of the presence of myoepithelial cells in a salivary gland tumour?

A

Better prognosis/less aggressive - may have anti-invasive properties e.g. inhibit angiogenesis, etc

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5
Q

What are some salivary gland tumours that can occur in heterotopic salivary gland tissue?

A
  1. PA
  2. MEC
  3. Adenoid cystic

*Problem - ddx is metatastic tumour to a lymph node vs primary in heterotopic tissue

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6
Q

What are some changes seen in aging in salivary glands?

A

Increased oncocytes, fatty infiltration

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7
Q

What are the patterns of oncocytes seen in salivary gland?

A

Occasional cells

Nodular hyperplasia (nodules, unencapsulated)

Oncocytosis (diffuse)

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8
Q

Oncocytes can be seen in which salivary gland tumours?

A

Warthin’s

Basal cell adenoma

PA

Myoepithelioma

Polymorphous

MEC

Acinic cell

Pure oncocytoma

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9
Q

What are the reactive changes that can occur in salivary gland?

A
  1. Metaplasia (squamous, mucous, necrotizing sialometaplasia)
  2. Hyperplasia (esp in minor glands - sialadenosis - endocrine/nutritional abnormalities)
  3. Atrophy (common -> obstruction of excretory duct + inflammation)
  4. Regeneration (embryonic, atypical but lobular architecture preserved)
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10
Q

What are the biphasic (epithelial and myoepithelial components) tumours of salivary gland?

A
  1. PA
  2. Adenoid cystic
  3. Basal cell adenoma
  4. Epithelial-myoepithelial carcinoma
  5. Polymorphous
  6. Basal cell carcinoma
  7. Embryonic tumours
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11
Q

What salivary gland tumour morphologically corresponds to the acinus?

A

Acinic cell carcinoma

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12
Q

What salivary gland tumour(s) morphologically correspond to the intercalated duct?

A

PA

Adenoid cystic

Monomorphic adenoma

Epithelial-myoepithelial carcinoma

Polymorphous

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13
Q

What salivary gland tumour(s) morphologically correspond to the striated duct?

A

Warthin’s tumour

Oncocytoma

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14
Q

What salivary gland tumours morphologically correspond to the excretory ducts?

A

MEC

Ductal adenocarcinoma

Epidermoid carcinoma

Papilloma

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15
Q

What are the similarities and differences between a mucocoele and a ranula?

A

Mucocoele: various sites, pseudocyst with denuded epithelial lining, granulation tissue

Ranula: similar but is from sublingual gland so only floor of mouth (can be plunging/cervical/extra-oral)

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16
Q

What is the pathogenesis of the lymphoepithelial cyst in salivary gland?

A

Cystic dilatation and squamous metaplasia of intranodal salivary gland inclusions

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17
Q

What are the histologic features of a lymphoepithelial cyst in salivary gland?

A

Cyst lined by flattened to stratified squamous epithelium surrounded by lymphoid stroma

Occasional - glandular epithelium

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18
Q

In what clinical situation are lymphoepithelial cysts of salivary gland more common?

A

HIV - “cystic lymphoid hyperplasia”

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19
Q

What are the histologic features of sclerosing polycystic adenosis of the parotid gland?

A

Mass-forming, mixture of sclerotic and cystic stroma with entrapped glands and inflammation

Apocrine metaplasia

Complex ductal hyperplasia (like UDH in breast)

Intraductal necrosis

Atypia

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20
Q

What is the differential diagnosis of a neck cyst?

A

Lymphoepithelial cyst

Thyroglossal duct cyst

Branchial cleft cyst

Ranula

Dermoid cyst

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21
Q

What are the histologic features of necrotizing sialometaplasia?

A

Early: infarction of seromucinous glands, extravasation of luminal contents, acute and chronic inflammation

Few days: squamous metaplastic cells in necrotic acini -> mitoses, atypia, can be mixed with residual non-infarcted mucous cells (ddx: MEC) -> stays lobular

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22
Q

What is the diagnosis?

A

Necrotizing sialometaplasia

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23
Q

What is the usual clinical setting for necrotizing sialometaplasia?

A

Prior surgery

Trauma

(Vascular compromise -> necrosis, inflammation, regeneration with squamous metaplastic cells)

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24
Q

What are the histologic features of radiation-related change in salivary gland?

A

Retained lobular architecture

Similar to necrotizing sialometaplasia

Radiation like atypia (smudged cells)

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25
Q

What is a mass-forming form of chronic sialadenitis?

A

Chronic sclerosing sialadenitis/Kuttner tumour

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26
Q

What are the histologic features of a Kuttner tumour?

A

Preserved lobular architecture

Periductal fibrosis

Periductal lymphoplasmacytic infiltrate

Progressive atrophy

Reactive lymphoid follicles

IgG4-related

(Can get MALToma)

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27
Q

What is the differential diagnosis of chronic inflammation in salivary gland?

A
  1. Chronic sialadenitis (obstruction, stone, etc)
  2. Kuttner tumour
  3. Sjogren syndrome
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28
Q

What are the histologic features of enlarged salivary glands in Sjogren syndrome?

A

Benign lymphoepithelial lesion/lymphoepithelial sialadenitis/Mikulicz disease

(increased risk of MALToma)

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29
Q

What are the diagnostic criteria for Sjogren syndrome in salivary gland?

A

At least 4 lobules with at least 2 foci of lymphocytes per 4mm2 (focus = cluster of 50 or more lymphocytes)

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30
Q

What clinical situations can result in sialadenitis?

A

Viral (EBV, coxsackie, etc)

Bacterial (staph aureus, etc)

Rheumatoid arthritis (chronic sial)

Dehydration

Malnutrition

Immunosuppression

Sialolithiasis

(Granulomatous - TB, fungi, sarcoid, duct obstruction)

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31
Q

What are the causes of granulomatous sialadenitis?

A

Infection (TB, fungi)

Sarcoidosis

Duct obstruction

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32
Q

What is the main differential diagnosis of benign lymphoepithelial lesion?

A

Malignant lymphoepithelial carcinoma (EBV assoc, undiff ca with lymphoid stroma)

MALT lymphoma

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33
Q

What is the characteristc pattern of metastasis in adenoid cystic carcinoma

A

Late met to lung (can be years)

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34
Q

Where do primary salivary gland tumours usually met to?

A

Local lymph nodes

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35
Q

What tumours can met to salivary glands?

A

SCC, melanoma, Merkel cell - beware met to intraparotid lymph node!

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36
Q

List the benign epithelial tumours of the salivary gland

A
  1. PA
  2. Myoepithelioma
  3. Basal cell adenoma
  4. Warthin tumour
  5. Oncocytoma
  6. Lymphadenoma
  7. Cystadenoma
  8. Sialadenoma papilliferum
  9. Ductal papillomas
  10. Sebaceous adenoma
  11. Canalicular adenoma (and other ductal adenomas)
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37
Q

What are the genes possibly translocated in PAs?

A

PLAG1 and HMGA2 (by FISH)

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38
Q

What are the indications to perform FISH testing in PAs?

A
  1. To establish diagnosis of PA in histologically difficult tumours
  2. To establish PA as basis for carcinoma ex PA (which has better prognosis compared to other ca)
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39
Q

What are the histologic features of myoepithelioma?

A

Monophasic

Myoepithelial cells with variable appearance (oncocytic, clear cell, spindled, stellate/myxoid, epithelioid, plasmacytoid)

Can have reticular or microcystic appearance

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40
Q

What is the immunoprofile of myoepithelioma?

A

S100+, CK7+, calponin +, GFAP+

*pitfall - plasmacytoid variant may be negative for myoepithelial markers

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41
Q

What is the differential diagnosis of myoepithelioma?

A

Depends on morphology:

Clear cell - metastatic RCC

Myoepithelial carcinoma - invasive

Spindle cell - schwannoma, nodular fasciitis, synovial sarcoma..

42
Q

What syndrome MAY be associated with basal cell adenoma of the parotid gland?

A

Brooke-Spiegler syndrome: multiple familial trichoepitheliomas

43
Q

What are the histologic features of basal cell adenoma?

A

cellular

monotonous

nests of basaloid cells

may have squamoid features

44
Q

What are the subtypes of basal cell adenoma?

A
  1. Trabecular: interlacing narrow bands of cells, may have ductal lumens, loose fibrous stroma
  2. Solid: nests with surrounding dense collagenous stroma, palisading, squamous whorls/eddies
  3. Tubular: lumens lined by cuboidal ductal cells (like canalicular adenoma)
  4. Membranous: prominent hyaline material or basal lamina surrounding nests of cells
45
Q

What are the histologic features of Warthin’s tumour/papillary cystadenoma lymphomatosum?

A

Thin capsule

Bilayered epithelium (columnar and basaloid oncocytic cells)

Cystic

Epithelium forms papillae

Surrounding lymphoid stroma +/- follicles

Cyst contents - cellular debris, corpora amylacea, calcs

+/- Squamous metaplasia

46
Q

What is the differential diagnosis of bilateral salivary gland lesions/lumps?

A
  1. Acute parotitis
  2. Chronic sialadenitis
  3. Lymphoma
  4. Warthin’s tumour (can be bilateral or multifocal)
  5. Sjogren’s
  6. Lymphoepithelial cysts in HIV patients
  7. Acinic cell carcinoma

I.e. Non-neoplastic (infection - viral or bacterial, obstruction, AI)

or neoplastic (Warthins, lymphoma)

47
Q

What is the differential diagnosis of Warthin’s tumour?

A

Oncocytoma - usually more solid, no lymphoid

Papillary oncocytic cystadenoma - no lymphoid

Lymphoepithelial cyst - no oncocytes

Lymphadenoma - no oncocytes

Parotid duct cyst - no lymphoid

48
Q

What are the two components of pleomorphic adenoma?

A

Epithelial (ductal structures with myoepithelial cells of variable appearance, squamous, bland)

Mesenchymal (myxoid, hyaline, cartilagenous, osseous)

49
Q

What are the other variants of pleomorphic adenoma (apart from usual)?

A
  1. Cellular (predominant epithelial component >80%)
  2. Myxoid (myxochondromatous element predominates)
50
Q

What is the differential diagnosis of pleomorphic adenoma?

A

Ca ex PA (look for malignant tumour - of any kind)

Polymorphous - esp in minor gland, PNI, infiltrative, single file, tubular

51
Q

How does a pleomorphic adenoma present in the superficial lobe and in the deep lobe?

A

Superficial - palpable mass

Deep - oral retrotonsillary mass or mass in parapharyngeal space

52
Q

What are the clinical features associated with malignant PA?

A

Older

Male

Multiple recurrences

In deep lobe

53
Q

What clinical risk factors are associated with Warthin’s tumour?

A

Male

Smoking

Older

54
Q

What are the histologic features of sebaceous lymphadenoma?

A

Epithelial component (basaloid with palisading and central sebaceous)

Lymphoid background

FB type reaction

+/- squamous metplasia

55
Q

What is the diagnosis?

A

Sebaceous lymphadenoma

56
Q

List the malignant salivary gland tumours

A
  1. MEC
  2. Adenoid cystic carcinoma
  3. Acinic cell carcinoma
  4. Secretory carcinoma
  5. Polymorphous adenocarcinoma
  6. Salivary duct carcinoma
  7. Epithelial-myoepithelial carcinoma
  8. Myoepithelial carcinoma
  9. Clear cell carcinoma
  10. Basal cell adenocarcinoma
  11. Intraductal carcinoma
  12. Sebaceous adenocarcinoma
  13. Carcinosarcoma
  14. Lymphoepithelial carcinoma
  15. Adenocarcinoma NOS
  16. SCC
  17. Poorly differentiated carcinoma
  18. Oncocytic carcinoma
  19. Sialoblastoma
57
Q

What is the diagnosis?

A

Cystadenoma

58
Q

What are the histologic features of cystadenoma of salivary gland?

A

Cystic (single or multiple)

Intraluminal papillary proliferation lined by columnar/cuboidal epithelium

Luminal contents - eosinophilic fluid, epithelial/inflamm cells

+/- rare glands

+/- squamous metplasia

+/- oncocytic metaplasia

59
Q

What is the differential diagnosis of salivary gland cystadenoma?

A

Warthin - bilayered oncocytic, lymphoid stroma

Congenital polycystic disease - developmental malformation of ductal system, multicystic, luminal spheroliths, apocrine-like lining, infants/kids

Duct ectasia w/ focal epi prolif secondary to obstruction - acinar atrophy, chronic inflammation, fibrosis

Intraductal papilloma - always unicystic, dilated salivary gland duct, more papillary fronds that are more complex

Low-grade papillary cystadenocarcinoma - invasive (exclude LG MEC)

60
Q

What is the diagnosis?

A

Sialadenoma papilliferum

61
Q

What is the diagnosis?

A

Ductal papilloma

62
Q

What is the diagnosis?

A

Canalicular adenoma

63
Q

What is the differential diagnosis of a “blue” (basaloid) salivary gland tumour?

A

Adenoid cystic

Basal cell adenoma/adenoca

Cellular PA

Polymorphous adenoca

64
Q

What is the differential diagnosis of a “pink” (oncocytic) salivary gland tumour?

A

Acinic cell ca

MEC

Oncocytoma/oncocytic ca

myoepithelioma/myoep ca

low-grade intraductal ca

PA

salivary duct ca

clear cell carcinoma

65
Q

What is the differential diagnosis of a clear cell neoplasm in salivary gland tumours?

A

clear cell ca

acinic cell ca

MEC

oncocytoma/ca

epi-myoepi ca

myoepithelioma/myoep ca

mets (RCC)

66
Q

What biomarker is important in salivary duct carcinoma?

A

HER2 amplification in 30%, predicts sensitivity to trastuzumab (herceptin)

67
Q

Describe the grading system for MEC

A

AFIP

Cystic <20% - 2

Neural invasion - 2

Necrosis - 3

>4/10HPF mites - 3

Anaplasia - 4

0-4 = LG, 5-6 = IG, >7 = HG

68
Q

Describe the ETV6-NTRK3 rearranged tumours

A

Secretory carcinoma (of SG and breast)

Infantile fibrosarcoma

Congenital mesoblastic nephroma

(targeted tx: larotrectinib)

69
Q

What benign salivary gland tumour can have isolated vascular invasion?

A

PA

70
Q

What benign salivary gland tumour can metastasize?

A

PA

71
Q

What is the most common bilateral salivary gland malignancy?

A

Acinic cell carcinoma

72
Q

What are the histologic features of acinic cell carcinoma?

A

Acinar cells with blue appearance due to granules

Also has ductal cells, clear cells

Various architecture: solid, microcystic, hobnail, papillary-cystic (macrocystic with papillae), follicular (looks like thyroid)

TALP (tumour-associated lymphoid proliferation)

+/- stromal hyalinisation/fibrosis

+/- poorly diff/dediff component

73
Q

What is the immunoprofile/stains of acinic cell carcinoma?

A

DOG1 (luminal) and SOX10 + (not specific)

PAS+ D-resistant granules - luminal accentuation (most helpful)

74
Q

What proportion of acinic cell carcinomas undergo high grade transformation?

A

15%

Undiff, small or large cell appearance, anaplastic

Comedonecrosis

75
Q

What is the differential diagnosis of a high grade NE tumour in salivary gland?

A
  1. Primary (e.g. primary NEC, high grade transformation of other salivary tumour e.g. acinic cell)
  2. Metastatic Merkel cell carcinoma (or other met NEC)
76
Q

What is the molecular alteration in secretory carcinoma?

A

ETV6-NTRK3 fusion

(with infantile fibrosarcoma and congenital mesoblastic nephroma)

77
Q

Apart from salivary gland, where else can secretory carcinoma can be seen?

A

Breast

Skin

GU

Thyroid

78
Q

What are the features of high grade transformation in secretory carcinoma?

A

Pleomorphism

Necrosis

Mitoses

79
Q

What are the histologic features of secretory carcinoma?

A
  1. Lobulated growth pattern with fibrous septae
  2. Variable architecture: microcystic/solid, papillary-cystic, tubular, follicular
  3. Distinctive luminal secretion
  4. Small/uniform nuclei
  5. Eosinophilic granular to vacuolated cytoplasm

+/- high grade transformation

80
Q

What is the differential diagnosis of secretory carcinoma?

A
  1. **Acinic cell carcinoma (has PAS+ granules, unlike secretory)
  2. MEC (epidermoid areas but has oncocytic and clear cell types, MAML2)
  3. Polymorphous adenocarcinoma (minor glands, variable architecture, S100+)
81
Q

What is the immunoprofile of secretory carcinoma?

A

S100+ diffuse

Mammaglobin+

Negative for PAS-D

82
Q

What is the most common malignancy of the submandibular gland?

A

Adenoid cystic carcinoma

83
Q

What are the 3 main histologic growth patterns of adenoid cystic carcinoma?

A
  1. Cribriform (classic)
  2. Tubular
  3. Solid
    - most have a mix
84
Q

Describe the histologic features of adenoid cystic carcinoma?

A
  1. Cribriform, tubular, solid
  2. Cribriform spaces contain BM-like material
  3. Angulated, hyperchromatic nuclei
  4. Hyalinised/collagenous stroma
  5. PNI common
  6. Biphasic (myoep component)
85
Q

What is the molecular alteration in adenoid cystic carcinoma?

A

MYB- or MYBL1-NFIB fusion

86
Q

What chromosomal alteration in adenoid cystic carcinoma is associated with a poorer prognosis?

A

Loss of 1p and/or 6q (often solid tumours)

87
Q

What is the immunoprofile of adenoid cystic carcinoma?

A

p63+ in myoep component

CD117+ (not specific)

88
Q

What is the differential diagnosis of adenoid cystic carcinoma?

A
  1. Polymorphous (minor glands, PNI common)
  2. Basaloid SCC (look for in situ)
  3. Epithelial-myoepithelial carcinoma (not cribriform, biphasic, outer cell is prominent with clear cytoplasm)
89
Q

Where does polymorphous adenocarcinoma usually occur?

A

Palate (60%)

Other minor glands (buccal, base of tongue, upper lip, etc)

90
Q

What are the histologic features of polymorphous adenocarcinoma?

A
  1. Cytologic uniformity (bland, small, mitoses/necrosis usually only in HG transformation, can have oncocytic/clear/squamous/mucous cells)
  2. Histologic diversity (lobular, trabecular, microcystic, cribriform, papillary-cystic, solid, mucinous or collagenous stroma)
  3. Infiltrative growth pattern (PNI common)
91
Q

What is an emerging variant of polymorphous adenocarcinoma, possibly a separate entity?

A

Cribriform adenocarcinoma of tongue

92
Q

What benign entity/ies can MEC mimic?

A
  1. Mucocoele (beware LG MEC!)
  2. Sialometaplasia (reactive squamous met, no cystic areas, no intermediate cells)
  3. PA
  4. Sclerosing polycystic adenosis
  5. Warthin’s (oncocytic variant with lymphoid component)
  6. Sclerosing sialadenitis (sclerosing variant)
93
Q

What is the molecular alteration in MEC?

A

CTRC1-MAML2 fusion

94
Q

What special stains can be of use in MEC?

A

Mucicarmine - identify mucous cells

95
Q

What are the histologic features of MEC?

A
  1. 3 populations of cells (mucous, epidermoid, intermediate-type)
  2. Cystic/papillary cystic with lumina filled with mucin
  3. Extravasated mucin
  4. Sclerosing variant (sclerotic stroma)
  5. Oncocytic variant
  6. Clear cell
96
Q

What are the histologic features of epi-myoep carcinoma?

A
  1. Multinodular
  2. Tubules with biphasic/bilayered inner ductal cells and outer clear myoep cells
  3. +/- solid
  4. +/- necrosis
  5. PNI common
  6. Vascular invasion rare
97
Q

What is the differential diagnosis of epithelial-myoep carcinoma?

A
  1. PA (mesenchymal element)
  2. Myoepithelial carcinoma (no ducts)
  3. Adenoid cystic (more angulated, hyperchromatic nuclei, more infiltrative)
  4. Polymorphous (minor glands, bland, infiltrative/single-file, myoep component not prominent)
98
Q

What the usual demographic for salivary duct carcinoma?

A

Older men

99
Q

What molecular alteration is sometimes seen in salivary duct carcinoma?

A

HER2 amplification (like breast)

100
Q

What does salivary duct carcinoma resemble?

A

IDC of breast/DCIS with comedonecrosis

101
Q

What is lymphoepithelial carcinoma of salivary gland associated with?

A

EBV infection (like NPC)

Head & Neck Pathology (6 decks)

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