All tumors (benign and malignant) have two basic components. Proliferating neoplastic cells that constitute their parenchyma, and suppertime stroma made up of connective tissue and blood vessels.

Microscopic apperance of cancer cells 4 degrees of severity

Grade: GX Grade cannot be assessed

(Undetermined grade) G1 Well-differentiated (Low grade) G2 Moderately differentiated (Intermediate

grade) G3 Poorly differentiated (High grade) G4 Undifferentiated (High grade)

Most common (accepted by UICC, AICC)

Based on : T extent of the tumor N extent of spread to the lymph

nodes M presence of metastasis

Number indicates size or extent of the prim. tumor and the extent of spread of metastasis

Primary Tumor (T) TX Primary tumor cannot be evaluated T0 No evidence of primary tumor Tis Carcinoma in situ (has not spread) T1, T2, T3, T4 Size and/or extent of the primary tumor

Regional Lymph Nodes (N) NX Regional lymph nodes cannot be evaluated N0 No regional lymph node involvement N1, N2, N3 Involvement of regional lymph nodes (number and/or extent of spread)

Distant Metastasis (M) MX Distant metastasis cannot be evaluated M0 No distant metastasis M1 Distant metastasis (cancer has spread to distant parts of the body)

Ann Arbour lymphomas

Duke’s classification colon cancer

Breslow scale and Clark’s level melanoma

Physical exams examination, looking, listening

Imaging studies X-ray, US, CT, MRI, PET

Laboratory tests blood, urine, AST/ALT, tumor markers (CA19-9,CA19-5….)

Pathology reports biopsy, cytology

Surgical reports

Lung cancer,PET scan

1. Principle of nomenclature (1) Benign tumors Attaching the suffix-oma to the cell

origin of the name of organ and derived tissue cell + oma i. g. adenoma of thyroid.

More detail: The name of organ and derived

tissue/ cell + morphologic character + oma i. g. skin pailloma, ovarian cyst adenoma

(2) Malignant tumors (cancers)

① Carcinoma: Malignant tumors of epithelial cell origin

The name of organ and derived tissue/ cell + carcinoma.

i. g. adenocarcinoma of thyroid.More details: The name of organ and derived tissue/

cell + morphologic futures + carcinoma i. g. papillary carcinoma of skin, ovarian

cytadenocarcinoma, oat cell carcinoma of long, signet ring cell carcinoma of stomach

② Sarcoma: malignant tumors arising in mesenchymal tissue or its derivatives

The name of organ and derived tissue/ cell + sarcoma i. g. leiomyosarcoma of uterus

(3) Special nomenclature

① Blastoma: tumors rigging in immature tissue or nervous tissue, most of them are malignant

i.g. medulloblastoma retinoblastoma, nephroblastoma

② Some tumors attaching the suffix-oma. But malignant

i. g. seminoma, lymphoma, melanoma, dysgerminoma, endodermal sinus tumor

③ Some malignant tumors, but called disease.

i. g. leukemias, paget’s disease

④ Some malignant tumors nominated by

scientists’ name

i. g. Hodgkin’s disease, Ewing’s tumor

⑤ Mixed tumors: tumors which derived from one germ layer may undergo divergent defferentiation creating

i. g. mixed tumor of salivery gland

⑥ Teratomas: tumors containing mature or immature cells or tissues representative of more than one germ layer and sometimes all the three layers.

⑦ Hamartoma: tumor-like malformation composed of a haphazard arrangement of tissues indigenous to the particular site, which is totally benign.

Tissue of Origin Benign Malignant

Composed of One parenchymal cell TypeMesenchymal tumors

Connective tissue and

derivatives

 

 

FibromaLipomaChondromaOsteoma

 

 

FibrosarcomaLiposarcomaChondrosarcomaOsteogenic sarcoma

Endothelial and related tissues Blood vessels Lymph vessels Synovium Mesothelium Brain coverings

 

HemangiomaLymphangioma 

 

Meningioma

AngiosarcomaLymphangiosarcomaSynovial sarcomaMesotheliomaInvasive meningioma

Tissue of Origin Benign Malignant

Blood cells and related cells Hematopoietic cells Lymphoid tissueMuscle Smooth Striated

Leiomyoma

Rhabdomyoma

Leiomyosarcoma

Rhabdomyosarcoma

Epihelial tumors Stratified squamous Basal cells of skin or adnexa Epithelial lining Glands or ducts

 Squamous cell papilloma 

 

AdenomaPapillomaCystadenoma

Tissue of Origin Benign Malignant

Epihelial tumors Stratified squamous Basal cells of skin or adnexa Epithelial lining Glands or ducts

 Squamous cell papilloma 

 

AdenomaPapillomaCystadenoma

Squamous cell or epidermoid carcinoma Basal cell carcinoma

AdenocarcinomaPapillary carcinomaCystadenocarcinoma

Tissue of Origin Benign Malignant

Respiratory passages

NeuroectodermRenal epitheliumLiver cellsUrinary tract epithelium (transitional)Placental epithelium (trophoblast)Testicular epithelium (germ cells)

Nevus Renal tubular adenoma Liver cell adenomaTransitional cell papilloma

Hydatidiform mole

Bronchogenic carcinomaBronchial adenoma (carcinoid)Malignant melanoma Renal cell carcinomaHepatocellular carcinomaTransitional cell carcinomaChoriocarcinomaSeminoma Embryonal carcinoma

Tissue of Origin Benign Malignant

More Than One Neoplastic Cell Type- Mixed Tumors, Usually Derived From One Germ Layer

Salivary glands Pleomorphic adenoma (mixed tumor of salivary origin)

Malignant mixed tumor of salivary gland origin

BreastRenal anlage

Fibroadenoma Malignant cystosarcoma phyllodes Wilms tumor

Tissue of Origin Benign Malignant

More Than One Neoplastic Cell Type Derived From More Than One Germ Layer- Tera- fogenous

Totipotential cells in gonads or in embryonic rests

Mature teratoma, dermoid cyst

Immature teratoma, teratocarcinoma

Most bone tumors are classified according to the normal cell or tissue of origin. Lesions that do not have normal tissue counterparts are grouped according to their distinct clinicopathologic features.

Overall, matrix-producing and fibrous tumors are the most common. Among the benign tumors, osteochondroma and fibrous cortical defect are most frequent. Excluding malignant neoplasms of marrow origin, osteosarcoma is the most common primary cancer of bone, followed by chondrosarcoma and Ewing sarcoma.

Clinically, bone tumors present in various ways. The more common benign lesions are frequently asymptomatic and are detected as incidental findings. Many tumors, however, produce pain or are noticed as a slow-growing mass. Sometimes, the first hint of a tumor's presence is a sudden pathologic fracture.

Radiographic analysis plays an important role in diagnosing bone tumors. In addition to providing the exact location and extent of the tumor, imaging studies can detect features that help limit the differential diagnosis and give clues to the aggressiveness of the tumor. Ultimately, in most instances, biopsy and histologic study are necessary.

There are variety of cysts and tumors that affect the osseous marrow and cortex of the jaw

bones, which are uniquely derived from the tissues of developing

teeth.

A cyst is a pathologic cavity filled with fluid, lined by epithelium and surrounded by a definite connective tissue wall.

Odontogenic cysts arise from tooth development epithelium.

Odontogenic cysts are true cysts occurring in the jaws. They arise from stimulation of epithelium left over from tooth development.

Odontogenic cysts include:

Radicular (Apical) Cyst Residual cysts Dentigerous Cyst Odontogenic Keratocyst Lateral Periodontal cyst

A radicular cyst is a cyst that most likely results when rests of epthielial cells in the periodontal ligament are stimulated by inflammatory products from a non vital tooth.

A Residual cyst is a cyst that develops after incomplete removal of the original cyst.

It is a radicular cyst remaining after the tooth has been extracted.

Usually asymptomatic. Usually small size (less than 1 cm in diameter).

Unilocular, round or oval, well-defined, usually well-corticated.

It can cause bone expansion and displacement of the adjacent teeth.

A Dentigerous cyst is a cyst that forms around the crown of an unerupted tooth.

It arises in the follicular region of unerupted permanent tooth.

It develops after fluid accumulates between the remnants of enamel organ and the tooth crown.

Usually adolescents, 20-40 years old.

Most common sites: mandibular third molar, maxillary canine, maxillary third molar.

Unilocular radiolucency, well-defined, often corticated, associated with the crown of an unerupted and displaced tooth.

Large cysts tend to expand the outer plate (usually buccally)

This is a non-inflammatory odontogenic cyst that arises from the dental lamina.

Features

It is lined by keratinizing epithelium.

It is usually located in the

mandible (posterior body and ramus region).

most develop during the second and third decade.

It can become very large. It extends along the body of the mandible causing minimal mediolateral expansion.

Features

Unilocular (often with scalloped margins) or multilocular (more often in larger lesions)

Smooth margins, well-defined, often well-corticated.

Tendency for recurrence after inadequate surgery.

Adjacent teeth: vital, rarely resorbed.

Lateral Periodontal Cyst are thought to arise from Epithelial rests in periodontum lateral to the tooth root.

It is a developmental odontogenic cyst. It arises from remnants of the dental lamina or from the reduced enamel epithelium.

Common site: Along the lateral surface of the root of vital tooth. Usually in mandibular premolar/canine region.

Usually asymptomatic.

Small size (less than 1 cm in diameter).

Unilocular, round or oval, well-defined, usually well corticated radiolucency.

OdontogenicOdontogenic TumorsTumors

EpithelialEpithelial MixedMixed MesodermalMesodermal

EpithelialEpithelialOdontogenicOdontogenic

TumorsTumors

AmeloblastomaAmeloblastomaAdenomatoidAdenomatoid odontogenicodontogenic

tumortumor

CalcifyingCalcifying epithelial epithelial

odontogenic odontogenic tumortumor

This a true neoplasm of odontogenic epithelium

It is an aggressive neoplasm the arises from the remnants of the dental lamina and dental organ( odontogenic epithelium)

Benign, locally aggressive odontogenic tumor. Usually it slowly grows as painless swelling of the affected site.

It can occur at any age.

Localized invasion into the surrounding bone.

80-95% in the mandible (posterior body, ramus region). In the maxilla mostly in the premolar-molar region.

Unilocular (small lesions). Multilocular (large discrete areas or honeycomb appearance)

Smooth, well-defined, well-corticated margins

Adjacent teeth are often displaced and resorbed.

It causes extensive bone

expansion.

Incomplete removal can result in recurrence.

These are uncommon , nonaggressive tumors of odontoginc epthilum.

Features

Benign. Relatively rare.

It occurs in young patients (70% of cases in patients younger than 20 years).

Most common site: anterior maxilla.

Often surrounds an entire unerupted tooth (most commonly the canine).

Usually well defined, well corticated. Some tumors are totally radiolucent; others show evidence of internal classification.

CALCIFYING EPITHELIAL ODONTOGENIC TUMOR (PINDBORG TUMOR

These are rare neoplasms of the tooth – producing apparuts.

CALCIFYING EPITHELIAL ODONTOGENIC TUMOR (PINDBORG

TUMOR Rare benign neoplasm.

It occurs more often in middle-aged patients.

Usually in mandible. Small lesions may be

radiolucent. In advanced stages irregularly sized calcifications may be scattered in the radiolucency.

It can cause displacement and impaction of teeth.

Mixed Mixed OdontogenicOdontogenic

TumorsTumors

Odontomas AmeloblasticAmeloblastic fibro-odontomafibro-odontoma

AmeloblasticAmeloblastic fibromafibroma AmeloblasticAmeloblastic

odontomaodontomaOdontomasOdontomas

It is a tumor that is radiogrphically and histologically characterized by the production of mature enamel , dentin , cementum and pulp tissue .

Compound # complex

Features

Relatively common lesion. It usually occurs in young

patients. Usually asymptomatic.

Failure of eruption of a permanent tooth may be the first presenting symptom.It is commonly found occlusal to the involved tooth.

Features

Two types: complex and compound odontoma.

Complex odontoma is composed of haphazardly arranged dental hard and soft tissues.

Compound odontoma is composed of many small "denticles" .

Well defined. The internal aspect is very radiopaque in comparison to bone.

CEMENTOBLASTOMA Features

Benign neoplasm. Most commonly in the second and third decade.

Site: usually mandibular premolar and molar regions.

Attached to the root of the affected tooth. Tooth displacement, resorption are common.

Pain in 50% of the cases, swelling.

When radiopaque is usually surrounded by a thin radiolucent halo.

Location:

Periphery: well defined RO with RL hallo surrounding the calcified mass.

Internal structure: mixed RL-RO leseions may be amorphous

Effect on surrounding tissues:

expansion, external root resorption

CEMENTOBLASTOMA

ODONTOGENIC FIBROMA Features

Rare neoplasm. More often between the ages 10 and 40 years.

Asymptomatic or swelling and tooth mobility

More common sites: mandible (premolar-molar region), maxilla (anterior region)

Small lesions are usually unilocular, and larger lesions multilocular.

Well-defined margins.

Adjacent teeth: often displaced, impaction, root resorption.

Osteosarcoma is defined as a malignant mesenchymal tumor in which the cancerous cells produce bone matrix. Osteosarcomas occur in all age groups but have a bimodal age distribution; 75% occur in patients younger than age 20.

In adolescence, and about half of them arise in the metaphysis around the knee, either in the distal femur or proximal tibia. These are the sites of greatest skeletal growth activity. In persons over age 25, the incidence in flat bones and long bones is almost equal.

RIOLAN 1648: Identified the glandular substance of parotid

NIELS STENSON 1660: Identified the parotid duct in sheep

THOMAS WARTON 1656 – Identified the submandibular gland and duct

HEYFELDER 1825: Avoided the facial nerve after parotidectomy

VELPEAU 1830: Identified trunk of facial nerve BELL AND VELPEAU: Determined the facial

nerve was responsible for facial animation. Determined facial sensation was from CN V.

Largest salivary gland The parotid duct lies on an

imaginary line between the external nares and the tragus of the ear.

Boundaries: external auditory canal, ramus of mandible, & mastoid process

Gland is encased in a sheath Stensen’s duct – courses

anterior to masseter muscle, transverses Buccinator, and exits orally along maxillary second molar.

Artificial division between the deep and superficial lobes by facial nerve.

Exits from stylomastoid foramen

Divides into temporofacial and cervicofacial

Terminal Branches: Temporal/Frontal Zygomatico-orbital Buccal Mandibular Cervical

Tympanomastoid suture Bisects angle between

post belly of digastric and ear canal

Tragal Pointer 1cm deep and inferior

Nerve lateral to styloid process

Superficial to retromandibular vein

Retrograde dissection

Malignant salivary gland neoplasms represent 3-4% of malignant head and neck disorders

Incidence of 1-2 per 100,000 individuals Neoplasms arising in the minor salivary

glands have a poorer prognosis than those primary in the parotids.

20-25% of parotid gland tumors are malignant

Average age of presentation is 56.6 years

Present with an incidentally noted mass Pain Nerve palsy, commonly CN VII, but

lingual and hypoglossal nerves may be affected.

Presence of lymphadenopathy Trismus, numbness, fixation may also

be present

MRI Does not require

iodination or radiation

Excellent soft tissue detail

Superior in defining the tumor boundaries

Useful to determine if nerve involvement present

T1, low signal intensity

T2, high signal intensity

Fine-Needle Aspiration Biopsy

Efficacy is well

established Accuracy = 84-97% Sensitivity = 54-95% Specificity = 86-100% Safe, well tolerated

Pleomorphic Adenoma- FNA

Increased risk: Radiation exposure Full-mouth dental x-rays Rubber industry Nickel compound/alloy Hair dye Silica dust Kerosene cooking fuels Vegetables preserved in salt

Decreased risk: High intake liver High intake dark yellow vegetables

Mucoepidermoid Carcinoma 34%

Adenoid Cystic Carcinoma 22%

Adenocarcinoma 18%

Carcinoma ex pleomorphic adenoma 13%

Acinic cell carcinoma 7%

Squamous cell carcinoma 4%

Most common type 80-90% occur in the parotid gland Female to male ratio of 4:1 Highest prevalence in 5th decade of life Characterized histologically by a mixed

population of cell, mucin-producing cells, epithelial cells, and intermediate cells.

Stain positive with Mucicarmine stain Classified as low, intermediate, high grade

based on clinical behavior and tumor differentiation.

Low-grade tumors have a higher proportion of mucous cells to epidermoid cells.

High-grade mucoepidermoid carcinomas have a higher proportion of epidermoid cells difficult to differentiate from scca.

Mucicarmine stainCharacterized by islands having squamous cells as well as clear cells containing mucin and

intermediate cells.

Survival rates:5 yr.

survival15 yr.

survival

Low Grade

70% 50%

High Grade

47% 25%

More common in submandibular, sublingual and in minor salivary glands

Presents equally frequent in women and men Asymptomatic mass Clinical course is indolent and protracted Perineural spread, including discontinuous

spreading can occur along a nerve in 80% Therefore adjuvant radiation to regional

named nerves is recommended Lymphatic spread is uncommon

Microscopically, adenoid cystic carcinoma has a basaloid epithelium arranged in cylindric formations in an eosinophilic hyaline stroma.

Subtype % Characteristics

Cribiform 44%Swiss cheese pattern of vacuolated area (best prognosis)

Tubular 35%Cords & nests of malignant cells

Solid 21%Solid sheets of cells (worst prognosis)

Cribiform subtype

Aggressive behavior 25-60% nodal metastases 50% recur locally Originates from excretory or striated ducts. Histologically identified by mucicarmine

stain for mucus & negative keratin stain Polymorphous low-grade adenocarcinoma is

a more benign subtype Prognosis: 5 yr survival is 25-70% Poor prognostic indicators: advanced stage,

infiltrative growth pattern, abnormal DNA

75% occur in parotid gland Arise from/in pleomorphic adenomas (a

benign mixed tumor) Associated with a rapid change in size of a

previously stable tumor. Histologically: mixture of epithelial and

mesenchymal cells Malignant component is purely epithelial Classified as high grade Prognosis: if treated prior to invasion, good. 5 yr. survival is <10%.

Treatment is surgical resection with facial nerve preservation, neck dissection for nodal disease, and adjuvant radiotherapy.

Ductal structures (D) are randomly scattered and lined by cuboidal or columnar epithelium which usually surrounded by myoepithelial cells (M). Islands of well-differentiated squamous cells with keratin (S) are seen.

80-90% occur in parotid gland Presents in 5th decade of life Higher incidence in women Low-grade malignancy Two cell types: serous acinar cells (explains

parotid gland preference) & clear-cytoplasm cells

Four histologic types: Solid, microcystic, papillary, & follicular

Prognosis at 5, 10 & 15 yrs is 78%, 63%, 44%

Round cells with abundant granular, blue cytoplasm

Existence of true primary SCC of salivary glands debated

Present in elderly males Commonly present in advanced stage 20% facial paralysis 40-70% nodal metastases 15-20% distant metastases Must distinguish from mucoepidermoid

carcinoma with immunohistochemical staining for mucin.

Must exclude extension from skin primary or mucosal primary

Neck dissection is indicated

Less than 10% of malignant salivary disorders are metastases from other sites

Most are lymphatic metastases from skin cancer of face, ear, scalp.

Most commonly SCC or Melanoma.

Elective superficial parotidectomy and neck dissection should be performed for primary melanoma of intermediate depth (1.5-4mm) located within periparotid drainage area.