Clin Neuro: Neoplams of SalivaryGlands, Neck (Exam 2)

What is an oncocytoma and when will it present?

-Rare tumors that constitute only 2.3% of benign epithelial salivary gland neoplasms. -Sixth decade of life with a nearly equal male-to-female ratio of occurrence.

When and where will warthin's tumor occur?

6-10% of cases of parotid tumors and has only rarely been described as occurring outside the parotid gland. 4th to 7th decades of life and occurring with a male-to-female ratio of approximately 5:1. Bilateral or multicentric 10% of cases. Three percent are associated with other benign or malignant tumors.

What is shown in the following?

MRI of parotid malignancy

What is seen microscopically in oncocytomas?

Microscopically, there are sheets, nests or cords of uniform oncocytes. These cells are large with distinct borders and filled with an acidophilic granular cytoplasm.

Where are invasions and metastasis seen in adenoid cystic carcinoma?

Perineural invasion Metastatic to the lung

What is shown in the following?

Pleomorphic Adenoma

How will warthin's tumor present?

Slowly enlarging, painless mass. They tend to be firm or rubbery in texture and may be nodular. A minority of patients may report rapid enlargement of the tumor with associated pain or pressure. Aspirate straw colored fluid May demonstrate uptake on technetium-99m pertechnetate scintigraphy

What is shown in the following?

Squamous cell carcinoma

What tumors are included in monomorphic adenoma?

The term "monomorphic adenoma" refers to a group of rare salivary tumors that includes the -basal cell (Most common) -canalicular -sebaceous, -glycogen-rich -clear cell adenoma. Myoepithelioma

What procedure is shown in the following?

parotid biopsy

What is shown in the following?

parotid malignancy

What are the major salivary glands?

parotid, submandibular, sublingual

According tot he bicellular theory, what kind of cancer will be found in the intercalated duct?

pleomorphic adenoma, Warthin's tumor, oncocytoma, acinic cell carcinoma and adenoid cystic carcinoma. think POW youre IN AA

What is a pleomorphic adenoma, and when will it appear?

-"benign mixed tumor" is the most common of all salivary gland neoplasms. -4th to 6th decades of life and are uncommon in children although they are second only to hemangiomas in this population. -Female-to-male ratio of 3-4:1.

Describe he clinical presentation of adenoid cystic carcinoma

-Clinical presentation is often an asymptomatic mass, however, this tumor is more likely than others to present with pain or paresthesias

What is believe to be associated with recurrence in pleomorphic adenoma?

-Enucleation of these tumors is what is believed to have led to high local recurrence rates in the past and should be avoided. Rupture of the capsule and tumor spillage believed to increase the risk of recurrence.

Describe the gross inspection of a mucoepidermoid carcinoma

-Gross inspection may be well circumscribed/partially invasive or poorly defined and infiltrative.

Describe the cells seen in Intermediate-grade mucoepidermoid carcinomas

-Intermediate-grade tumors display fewer and smaller cysts and occasional solid islands of epidermoid tumor cells. Although mucus cells are still present, there is an increasing proportion of epidermoid cells and occasional keratin pearl formation.

What glands are affected by oncocytoma?

-Majority of these tumors affect the parotid gland (78%), few affect the submandibular gland (9%), none are reported in the sublingual gland and minor salivary gland involvement is most often in the palate, buccal mucosa or tongue.

What is a mucoepidermoid carcinoma?

-Most common salivary gland malignancy and makes up between 5 and 9% of all salivary gland neoplasms. - This tumor displays a uniform age distribution between the ages of 20 and 70 years, with a slight peak in occurrence in the 5th decade. -Most common salivary gland malignancy in the pediatric and adolescent populations. -More frequently in women than in men and in Caucasians than in African Americans

What glands are most affected by mucoepidermoid carcinoma?

-Most often the parotid (45-70%). S -Second most common site of occurrence is the palate (18%). This tumor displays a uniform age distribution between the ages of 20 and 70 years, with a slight peak in occurrence in the 5th decade.

Describe the cut surface and microscopic appearance of mucoepidermoid carcinoma

-The cut surface of the tumor may contain solid areas, cystic areas or both. The cystic spaces contain viscous or mucoid material. -Microscopically, both mucus cells and the epidermoid cells, the proportion of which helps to define the grade of the tumor.

Describe the eptihelium seen in Warthin's tumor

-The epithelium is a double cell layer with tall columnar cells lining the cystic spaces and cuboidal cells along the basement membrane. The nuclei of the columnar cells is oriented toward the cystic space while the cuboidal cell nuclei is oriented toward the basement membrane.

What is the most common location for pleomorphic adenoma?

-The most common location of occurrence is the parotid (85%) followed by the minor salivary glands (10%), in which the palate, upper lip and buccal mucosa are most commonly affected.

What is the pathognomonic microscopic feature of warthin's tumor?

-The pathognomonic microscopic features are epithelial cells forming papillary projections into cystic spaces in a background of a lymphoid stroma.

What is the treatment for acinic cell carcinoma?

-Treatment of acinic cell carcinoma includes surgical excision. distant metastasis many years after initial treatment (1,2,3,5).

What is the treatment for pleomorphic adenoma?

-Treatment superficial parotidectomy with facial nerve preservation, submandibular gland excision or wide local excision for a minor salivary gland.

Describe the H&P portion of a parotid tumor diagnosis

-Typically present as painless masses on examination -Facial nerve paralysis or numbness -Trismus -History of skin cancer

What is the clinical presentation of acinic cell carcinoma?

-Usually excellent survival for low grade, -Second most common parotid malignancy in children -3% bilateral tumors -Clinical presentation is similar to other neoplasms—often an asymptomatic enlarging mass.

What is the treatment for warthin's tumor?

-superficial parotidectomy with facial nerve preservation is the standard management

Answer the following

Adenoid Cystic Carcinoma Parotidectomy and radiation

How will benign and malignant parotid tumors present?

Benign - painless mass Malignant tumors 75% present as painless mass -Pain -Facial nerve paralysis or numbness -Trismus

What are the benign and malignant neoplasms of the salivary glands?

Benign: Parotid 80%, Submandibular 50%, Sublingual/Minor 40% Malignant neoplasms: Minor SGs > SLG > SMG > PG

What is shown in the following?

CT of parotid malignancy

What tests can be used for diagnosis of parotid malignancies?

CT or MRI Fine needle aspirate

Describe the gross appearance of acinic cell carcinoma

Gross appearance demonstrates a mass that is well circumscribed but lacks a true capsule.

What are the gross pathology findings of oncocytoma?

Gross pathology findings include a homogenous tumor with a smooth surface that may be divided into lobules by fibrous tissue septae.

What is shown in the following?

High grade mucoepidermoid carcinoma

Describe the cells in high-grade mucoepidermoid carcinomas

High-grade carcinomas are hypercellular, solid tumors with noticeable cellular atypia and frequent mitotic figures LESS MUCIN MORE EPITHELIAL TISSUE. These tumors will often be mistaken for a squamous cell carcinoma and the differentiation between the two can be quite difficult. Positive immunohistochemical staining for mucin indicates a high-grade mucoepidermoid carcinoma rather than a squamous cell carcinoma.

How will pleomorphic adenoma appear microscopically?

Microscopically, these tumors are composed of varying proportions of gland-like epithelium and mesenchymal stroma. The stroma is just as variable and may be myxoid, chondroid, fibroid or osteoid. The incomplete encapsulation and transcapsular growth of tumor pseudopods characteristic of pleomorphic adenoma are demonstrated

What is shown in the following?

Oncocytoma: Uniform plump oncocytes with granular eosinophilic cytoplasm arranged in glandular pattern.

What is the treatment for the different stages of mucoepidermoid carcinoma?

Stage I and II disease can often be treated by surgical excision alone—parotidectomy with facial nerve preservation Stage III and IV disease often require more radical excision and may warrant additional intervention such as a neck dissection or postoperative radiation therapy

What do the divisions of the parotid compartment contain?

Superior - Zygoma Posterior - EAC Inferior - Styloid, ICA, Jugular Veins

What symptoms will increase suspicion of a high grade tumor?

Symptoms such as pain, fixation to the surrounding tissues or skin or facial paralysis are uncommon and should increase suspicion for a high-grade tumor.

Describe the cut surface of acinic cell carcinoma

The cut surface is grayish, friable, and displays solid and cystic areas.

What causes the granularity of the cytoplasm in oncocytoma, and what stains use this feature?

The granularity of the cytoplasm is due to the presence of large numbers of mitochondria that may constitute up to 60% of the cell volume. Special staining procedures such as the phosphotungstic acid hematoxylin stain, Bensley's aniline-acid fuchsin or Luxol-fast-blue reaction take advantage of this unique characteristic and can help to make the diagnosis of oncocytoma, as can electron microscopy.

Describe the gross pathologic appearance of pleomorphic adenoma

The gross pathologic appearance of a pleomorphic adenoma is a smooth or lobulated, well-encapsulated tumor that is clearly demarcated from the surrounding normal salivary gland. Typically solid tumors and may have areas of gelationous myxoid stroma.

What are the hypotheses of tumorigenesis of salivary gland neoplasms?

These hypotheses, the bicellular and multicellular theories, propose that certain cells that make up the salivary gland unit are responsible not only for normal gland cell turnover and maintenance, but also for the development of different salivary gland tumors.

What is the bicellular theory?

This hypothesis states that neoplastic development within salivary glands originates from the basal cells seen in the excretory and intercalated ducts.

Answer the following

Warthin's tumor

What is shown in the following?

Warthin's tumor

What is the only neoplasm of the salivary glands associated with tobacco and ethanol?

Warthin's tumor think soldiers smoke and drink during war

Describe the shape and processes of the parotic gland

Wedge shaped with 5 processes -3 Superficial -2 Deep

What is shown in the following?

acinic cell carcinoma

What is shown in the following?

adenoid cystic carcinoma

What is the second most common salivary gland neoplasm?

adenoid cystic carcinoma

What type of carcinoma is indicated by immunohistochemical staining for mucin?

high grade mucoepidermoid carcinoma rather than a squamous cell carcinoma

What is shown in the following?

low grade mucoepidermoid carcinoma

What cells are found in low-grade mucoepidermoid carcinomas?

more mucus cells and fewer epidermoid cells

According to the bicellular theory what kind of cancers will be found in the excretory ducts?

squamous cell carcinoma and mucopeidermoid carcinoma think: suck my ex duct

What is the multicellular theory?

states that neoplasm development occurs from differentiated cells within the salivary gland unit.

What will different cells give rise to according to the multicellular theory?

striated duct cells give rise to oncocytic tumors acinar cells give rise to acinic cell carcinoma excretory duct cells give rise to squamous cell carcinoma and mucoepidermoid carcinoma intercalated duct cells and myopeithelial cells give rise to pleomorphic tumors

What technique is shown in the following?

superficial parotidectomy

Describe the microscopic appearance of acinic cell carcinomas

vMicroscopic appearance has been categorized as solid, microcystic, papillary cystic and follicular. Tumor cells are dark staining and have granular or honeycomb cytoplasm. The surrounding stroma often demonstrates a lymphoid infiltrate.

Describe the appearance of Warthin's tumor

vSmooth lobulated surface and a thin but tough capsule. The diagnosis is often obvious just by the appearance of the cut surface of the tumor. Multiple cysts of varying diameter and containing variably viscous fluid are seen. The lining of the cysts appears shaggy and irregular. The lymphoid component makes up the solid areas of the tumor and lymphoid follicles can occasionally be seen.

What is the treatment for oncocytoma?

vStandard treatment of oncocytomas is surgical excision with a margin of normal tissue

What is another term for Warthin's tumor?

vThe second most common benign parotid neoplasm is Warthin's tumor, also known as papillary cystadenoma lymphomatosum.