Benign and malignant lesions of salivary gland

1. By
Dr. Lakshmi Unnikrishnan
JR3, Unit 1
Dept of ENT

2.  Major salivary glands
Parotid
Submandibular
Sublingual
 Minor salivary glands

4.  Distribution: 80%-parotid, 10%- submandibular, minor

5. Radiation
Radn- Warthin’s
HPV16- benign
Chernobyl- ↑ Warthin’s, pleomorphic adenoma
↑ mucoepidermoid Ca
Smokers- 2x: Warthin’s- multicentric
EBV- b/l Warthin’s undifferentiated parotid ca
CMV- mucoepiermoid Ca
Dietary PUFA- 1/α salivary cancers
Aspergillus mycotoxins- livestock feed processing unit workers- salivary cancers

6. Grow slowly over a long period of time, no symptoms
Sympt- obstruct salivary flow
Benign: smooth, relatively mobile, non tender
? Malignant transformation:
Pain
Paraesthesia {adenoid cystic Ca}
Rapid growth
Skin involvement, ulceration
Fixity
Irregularity
Age – considered: ↑younger, submandibular trs(40%) malignant

7. Parotid tr: firm mass, getting bigger
behind < of jaw in retromandib reg,
in front of tragus/ in cheek
Parotid deep lobe, p-ph space trs tonsil, palate – med displaced: not
palpable from outside
Large p-ph saliv trs stertor, sleep dis breathing, affect voice qlty, ET fn
Bimanual palpation of floor of mouth: submandibular ∆le swellings
Minor saliv gl trs: firm submucosal swellings

12. • Benign mixed tumors
• m/c neoplasm of salivary gland
• m/c – major salivary glands
• Origin: from uncommitted reserve cell of intercalated
duct epith, myoepith cells
• Parotid: Dumbbell appearance
• Minor : m/c- palate> upper lip
• Solitary, firm, round trs

13. • Major- capsulated
• Myxoid / chondroid stroma
• Mucoid nature- fragile, rupture @ Sx seeds operative
field  recurrence
• HPE: sq metaplasia, calcification, cartil, oxyphillic cells,
Tyr- Ca oxalate cryst, palisading- stroma, lipomatous &
osseous changes(+)
• Focally thin capsule, potential spillage during Sx
• Satellite nodules/ psuedopodia -25%[Surrounding cuff
of normal tissue]

14. • Submandib- preserve marginal mandibular nerve
• Parotid: tr removal- adeq margin, VII preservn [superficial parotidectomy]
• Recurrent: multicentric pattern[surgical excision]
• Postoperative RT- gross residual dis, LT local ctrl
• Malignant transformation- 0.15%
• Metastasizing Pleomorphic Adenoma- benign PA- mets
regionally/ distantly
Aggressive clinical behaviour
After multiple recurrences
m/c : lungs, bones- sites of mets

19. <1%- saliv gl trs, oncophilic adenoma
m/c- parotid
H/o radiation (+)
50-60 yrs, F=M
painless, slowly enlarging, enhance- radioNT scan
Oncocytes: large epithelial cells- granular Eilic cytoplasm (mitoch hyperplasia)
D/D
Minor: irregular, locally invasive pattern
IHC
Rx: surgical excision

20. 2nd m/c benign saliv gl neoplasm
60s
20%- of all benign parotid trs
Papillary cystadenoma lymphomatosum / adenolymphoma
M>F, 1.6:1, Caucasians↑, rare- Africo Carribeans
cigarette smoking (irritation of ductal epith- tobacco
smoketumorigenesis
10% all parotid trs, excl parotid gl / periparotid l.n (rare –
submandib- no lymphoid tissue)
Origin: from saliv tissue entrapped in ln

21. 10%- B/L
Asymptomatic, slow growing mass, often- tail
Ovoid masses, encapsulated with smooth / lobulated
surface
Papillary cysts- mucoid brown fluid
µsc- papillae of Eilic epithelia- project into cystic spaces,
lymphoid matrix
Double layered cytic lining, oncocytic epithelium
Radn malign transformation [adenoca, SCC or undiff]
Surgical excision {parotidectomy- VII N preservation}

22. Variant of pleomorphic adenoma
Myoepithelial Xn
40s, ch, eld
Any sex, any gland
Carcinomatous variant- id
Mx- excision

23. Epithelial trs- 95%
Mesenchymal trs (<20%)
Haematolymphoid trs (lymphoma & plasmacytoma
70%- parotid
1-3% of H&N ca- parotid Ca
10- 25% salivary Ca- minor

25.  Multi cellular theory
 Reserve cell theory

26. m/c saliv gl malign, major
Minor- oral cavity: hard palate, buccal mucosa, lip, retromolar trigone
Intraosseously- in mandible, maxilla- odontogenic, less aggressive
F,45 yrs
m/c pediatric saliv gl ca
Painless, slow growing mass
Both solid, cystic components- mucinous material- bluish colour

27. µsc: 3 cell types:
mucous
squamoid/ epidermoid
intermediate
Mucin stains- PAS, mucicarmine, Alcian blue
True keratinization rare: ?adenosq ca

28. -Low grade: prominent cystic comp, abundant well
differentiated mucous cells- little cytologic atypia, mitotic
activity
-High grade: solid, predomin- squamoid, intermediate cells
: cytologic atypia, mitotic activity, necrosis,
infiltrative growth
• T(11;19)(q21;p13)->1/2 MECs fusion of CRTC1,
MAML2 genes- can be used for confirmation of Dx,
good Px

30. More common
More recognizable trs
Infltrative growth, slow progressive behaviour, recurrences
Any gl
Solid, light tan, firm, well circumscribed, unencapsulated
µsc: 3 growth patterns
• Tubular
• Solid
• Cribriform

31. 70- 75%- perineural invasion, worse Px- major N trunk
Recurrence
Distant mets- m/c lungs
Grade 3 trs- regional ln mets
Distant bone mets- poor outcome
D/D: polymoprhous adenocarcinoma,
epithelial myoepithelial ca,
basaloid SCC,
high grade NE Ca
T(6;9), inv MYB,NF1B genes

32. Pleomorphic adenoma with carcinoma
m/c- parotid
50s, 60s
Long standing mass, sudden rapid growth over several m,
freq VII paralysis(+)
Malignant component classif:
non invasive
minimally invasive
invasive
Wide resection, LND, RT- widely invasive trs/ cervical ln mets(+)