Salivary Gland Pathology

DDx for Palatal Mass

Intact Mucosa - infection -pleomorphic adenoma -PLGA -Mucoepidermoid carcinoma low grade -Non-hodgkins lymphoma Ulcerated - SCC -Nectrotizing sialometaplasia -Mucoepidermoid CA high grade -PLGA -Adenoid Cystic Carcinoma

Mucocele Ranula (picture)

Ranula = sublingual mucocele

Pleomorphic Adenoma (benign mixed tumor)

-*most common salivary gland tumor* -derived from ductal and myoepithelial cells S/S: painless, slow growing, superficial lobe of parotid more frequent, can be ulcerated Histo: capsule, chondrocytes and keratin formation Treatment -palate: surgical excision - other sites: enucleation Prognosis: *malignant transformation*, facial nerve paralysis from tx

Polymorphous Low-Grade Adenocarinoma (PLGA)

-EXCLUSIVE to minor salivary glands also shows perineural invasion, but is good prognosis

Mucoepidermoid Carcinoma

-MOST COMMON malignant salivary gland tumor (all ages) -can looks like a mucocele -can have *intraosseous* presentation S/S: PALATE! other places too. painless, red/blue, rubbery swelling that may be ulcerated -if you see a *red/bluish* mucocele like lesion in *retromolar mucosa* it is a Mucoep unless proven otherwise Histo: mucoid cells AND epidermoid cells Prognosis: kids better than adults

Sjogren's Syndrome

-chronic autoimmune disease -rheumatoid arthritis like symptoms -15% of pts with rheumatoid arthritis also have SS -30% of pts with lupus may develop SS Primary: keratoconjunctivitis sicca and xerostomia Secondary: + other autoimmune disease Pt: FEMALE

Saladenosis (sialosis)

-enlargement of parotid gland *WITHOUT inflammation* -Many causes: endocrine or neurogenic medications common causes

Salivary Duct Cyst

-epithelium lined cavity -mucous retention phenomenon (gets blocked by sialolith) pt: adults S/S: *UPPER lip* most common

Sialorrhea

-excessive salivation Pt: GERD, heavy metal poisoning, CP, retardation, medications (cholinergic agonist), lithium, mandibulectomy -Idiopathic paroxysmal sialorrhea: prodrome followed by periods of excessive salivation Tx: antocholinergic agents, surigcal relocation of salivary ducts, section chorda tympani, parotid gland ligation

Sialadentis

-inflammation of a salivary gland Causes -viral: mumps -bacterial: most common -surgical mumps: acute parotitis following abdominal surgery -any medication that causes xerostomia Two non infectious types: 1. Subacute necrotizing 2. Chronic sclerosing S/S: swelling, pain, erytematous skin, low grade fever, trismus

Subacute Necrotizing Sialadentis

-minor glands esp in palate -young adults and teens -painful nodule -self-limiting

Adenoid Cystic Carcinoma (cylindroma)

-most common malignancy of submandibular gland -extremely aggressive and prognosis is NOT GOOD -can metastasize to multiple organs Histo -Cribriform pattern (most common, looks like swiss cheese. See picture) -perineural invasion (also seen in polymorphous low grade adenocarcinoma) Treatment - 5-year survival rate *70%* (GOOD) -20 year survival rate *20%* (long term is bad)

Sjogren Treatment

-no cure Supportive -artificial tears and saliva -protective eyewear -good OH Increased risk for *non-hodgkin B-cell lymphoma* (*40X HIGHER RISK*)

DDx for Parotid Mass

-pleomorphic adenoma -Warthins Tumor -Mucoepidermoid Carcinoma -Adenoid Cystic Carcinoma -Sjogren's -Sialadenosis

Xerostomia S/S

-reduction in salivary flow -saliva appears "ropey" or foamy -gloves stick in mouth -SFR low *risk of candidiasis and caries*

Tumor of the parotid

-right below ear lobes

Xerostomia Causes

-salivary gland aplasia: very rare -dehydration: MOST COMMON -vommiting -medication: also VERY common -Sjogren syndrome, diabetes, sarcoidosis, HIV, GVHD, psychogenic disorders -decreased mastication, smoking,m mouth breathing

Sialolithiasis

-salivary stones -deposition of calcium salts around a nidus -submandibular gland > parotid -tortuous duct, thicker saliva pt: young and middle aged adults R/F: well defined radiopacity DDx: tuberculosis if *multiple sialoliths*

Papillary Cystadenoma Lymphomatosum (Warthin's Tumor)

-second most common benign parotid tumor -smoker 8x more often -EXCLUSIVE in parotid (more in the tail of the gland) -*bilateral tumors* that are metachronous pt: elderly MALE Histo: heteroptopic salivary tissue within lymph tissue tx: supericial parotidectomy

Necrotizing Sialometaplasia (slide)

-squamous metaplasia of salivary ducts

Necrotizing Sialometaplasia

-uncommon -locally destructive -Cause: *ischemia* that leads to infarction -major glands affected -not a tumor but looks really malignant -self-limiting -*acute presentation* Pt: adults 2x M >F S/S: posterior palate and soft palate, unilateral MOST common -initially a non-ulcerated painful swelling-->ulcer formation-->necrosis--> portion of palatal tissue will fall off DDx: SCC (becuase it looks similar clinically AND microscopically), salivary gland malignancy

Mucocele

-very common! - rupture of duct and spillage of mucin (from trauma, bit tongue) -aka mucous extravasation cyst pt: children frequent S/S: *lower lip* most common, Tx: remove cyst AND associated salivary gland so it will not recur

Salivary Gland Tumor 10 Commandments

1. Benign salivary gland tumors are more frequent than malignant 2. Benign tumors occur more frequently in 4th to 5th decade. Malignant most common in 6th decade 3. Malignant tumors are more frequent in MINOR glands than parotid and submandibular gland. Most tumors of the sublingual gland are malignant. 4. Pain, hemorrhage, ulceration and necrosis characterize malignancy 5. Most tumors in parotid, most minor salivary glands occur in the palate 6. Upper lip 10X > lower lip for frequency 7. *Pleomorphic Adenoma* is the MOST COMMON epithelial tumor (benign and malignant) of major and minor salivary glands. Mucoepidermoid carcinoma is most common malignant tumor of minor glands. 8. Mucoepidermoid carcinoma is the MOST COMMON malignant salivary gland tumor in childhood and adolescence. 9. Pleomorphic adenoma, although benign, can occasionally recur 10. Perineural invasion in adenoid cystic and polymorphous low grade adenocarcinoma

Chronic Sclerosing Sialadentis

Acinar atrophy and fibrinosis is observed

Salivary Gland Tumors (list)

Benign -*Pleomorphic adenoma* (most common for major AND minor salivary glands, aka mixed tumor) -Basal cell adenoma -Canalicular adenoma -Papillary cystadenoma lymphomatosum (Wharthin's Tumor, excuslively MAJOR glands ) Malignant -*Mucoepidermoid carcinoma* (most common for children and adults in BOTH major and minor) -*Adenoid cystic carcinoma* (most AGGRESSIVE) -Polymorphous low-grade carcinoma

Other adenomas

Canalicular adenoma: exclusively in minor glands, mistaken for mucocele Basal cell adenoma: parotid Oncocytoma: parotid, cells show mitochondria

Sjogren Exclusion Criteria

Need to make sure pt doesn't have these which xerostomia is a symptom: -radiation tx -Hep C -AIDS -Lymphoma -Sarcoidosis -GVHD -Anticholinergic meds

Sjogren's Dx (new criteria)

New International Criteria -Ocular signs -Lip biopsy -salivary gland involvement -Autoantibodies: Ro(SS-A) or La(SS-B) or both