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Zubair Baloch, MD, PhD
Professor of Pathology & Laboratory Medicine
Algorithmic Approach to Everyday Salivary Gland Cytology Faculty Disclosure
X No, nothing to disclose
Yes, please specify:
Question #1
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Question #1The name “American Society of Cytology” was adapted in year?
Correct Answer ‐ #1
• The 1st Annual Scientific Meeting of the Inter‐Society Cytology Council was held in Philadelphia, Pennsylvania, November 19‐20, 1953, and the tradition has continued each succeeding year.
• At the 9th Annual Scientific Meeting held in Memphis in 1961, the name American Society of Cytology was adopted by unanimous vote of the membership.
Let’s Make Sense of Present & Predict Future
In Light of Past
“Study the past if you would define the future” ~Confucius
Fine‐Needle Aspiration Salivary Gland lesions
What We Know
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American Cancer Society Info for Patients w Salivary Gland Lumps
• Doctors may use FNA if they are not sure whether a lump is a salivary gland cancer. The FNA might show the lump is due to an infection, a benign (non‐cancerous) salivary tumor, or a salivary gland cancer. In some cases this type of biopsy can help a person avoid unnecessary surgery.
• An FNA biopsy is only helpful if enough cells are taken out to be able to tell for certain what a tumor is made of. But sometimes not enough cells are removed, or the biopsy is read as negative (normal) even when the tumor is cancer.
• If the doctor is not sure about the FNA results, a more extensive type of biopsy might be needed.
Advantages of Salivary Gland FNA
1.Differentiation of inflammatory from neoplastic disease1. Especially important in immunosuppressed
2.Culture for suspected infectious masses
3.Differentiation of benign from malignant disease
4.Differentiation of the specific tumor cell type
5.Determination of site of origin, primary vs. metastatic
6.Squamous cell carcinoma diagnosis: 1. Squamous cell carcinoma can be accurately diagnosed, and treatment can be planned based on fine‐needle
aspiration (FNA) findings.
2. A highly cellular muco‐epidermoid carcinoma may appear to be squamous cell carcinoma by fine‐needle aspiration (FNA) cytology.
3. This difference is purely academic and does not change the treatment.
Complications of Salivary Gland FNA• Needle track contamination by lesional cells:
– Rare complication despite thousands of fine‐needle aspirations (FNAs) performed worldwide.
– A positive correlation exists with number of passes and needle size.
• Local hemorrhage: – Major salivary glands are in close proximity to the great vessels of the head and neck, local hemorrhage due to piercing of these
vessels is possible but very unlikely.
– Hematoma formation can be prevented by applying firm pressure in the area of aspiration immediately after the procedure.
• Infection: – This risk is no greater than that of veni‐puncture and is closely correlated with the patient's immune status.
– Adherence to sterile techniques and cleaning the skin with alcohol minimizes this risk.
• Warthin tumor (papillary cystadenoma lymphomatosum or adenolymphoma) has a high predisposition for parotitis from FNA due to a combination of cystic spaces surrounded by oncocytic cells and poor blood supply.
• Syncope: – Some patients are prone to vasovagal reactions.
– Perform aspiration while the patient is lying down or sitting.
• Dissemination of the dislodged tumor cells through lymphatics and blood vessels: – Risk is certainly lower in fine‐needle aspiration (FNA) than in incisional biopsy.
Salivary Gland FNA
Literature Review
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Salivary Gland Lesions Reported in Cytology Literature
Inflammatory/ Non-neoplastic Benign Neoplasms Malignant
Sialadenitis (acute & chronic) Pleomorphic Adenoma Mucoepidermoid carcinoma
Sialadenosis Warthins Tumor Adenoid cystic carcinoma
Lymphoepithelial sialadenitis (LESA) Basal cell adenoma Acinic cell carcinoma
Lymphoepithelial cyst Monomorphic adenoma Basal cell adenocarcinoma
Mucocele Oncocytoma Carcinoma ex-pleomorphic adenoma
Reactive lymph node Myoepithelioma Epithelial-myoepithelial Carcinoma
Lipoma Salivary Duct Carcinoma
Secretory Carcinoma
Amyloidosis Lymphoma
The list of lesions diagnosed on FNA is still expanding to keep up with Surgical Pathology Literature
The Gold StandardHistologic Follow‐up
WHO Classification of Salivary Gland TumorsThen & Now
2017 WHO Classification of Salivary Gland Tumors1972 WHO Classification of Salivary Gland Tumors
Salivary Gland Tumors – Diagnostic Paradigm
MalignantBenign
Invasion Present• Macroscopic• Microscopic
• Perineural• Into surrounding normal parenchyma• Angioinvasion
Invasion Absent, BUT Benign Tumors can show• Multinodular and Irregular growth• Lack of encapsulation• Capsular violation • Outpouching into surrounding normal parenchyma• Vascular invasion?• Fatty metaplasia within the tumor mimicking invasion
into fat• Invasion absent but still Malignant
• Intraductal Carcinoma Cytologic Features of Malignancy• Marked Nuclear Pleomorphism• Atypical Mitoses• Tumor Necrosis
Benign Tumors (especially Pleomorphic Adenoma) can show / mimic Cytologic Features of Malignancy:• Increased Cellularity• Nuclear Pleomorphism• Mitoses• Infarction mistaken for Tumor Necrosis• Post FNA tumor necrosis• Atypical Architecture
But some Malignant Tumors May Not show Cytologic Features of Malignancy• Monotonous basaloid cells and low grade nuclear cytology of
“Adenoid Cystic Carcinoma”
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Histogenesis of Salivary Gland TumorsReason for Morphologic Heterogeneity
www. pocketdentistry.com Redder et al. Clin Can Invest J 2013;2:101‐105
Myoepithelial Cell Differentiation in in salivary gland tumors
Histogenesis of Salivary Gland TumorsReason for Morphologic Heterogeneity
DIAGNOSTIC REPORTING & MANAGEMENT
Salivary Gland FNA Literature Review
The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC): implied risk of malignancy and recommended clinical management
Diagnostic Category % ROM
(ROM range)
Management
Non‐Diagnostic c 25
(0‐67%)
Clinical and radiologic correlation/ repeat
FNAC
Non‐Neoplastic 10.2%
(0‐20%)
Clinical follow‐up and radiologic correlation
Atypia of Undetermined Significance (AUS) TBD Repeat FNAC or surgery
Neoplasm
i. Benign 3.4%
(0‐13%)
Surgery or
clinical follow‐up
i. Salivary Gland Neoplasm of Uncertain Malignant Potential (SUMP)e 37%
(0‐100%)
Suspicious for Malignancy 57%
(0‐100%)
Surgery
Malignant 92%
(57‐100%)
Surgery
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Milan System for Reporting Salivary Gland CytopathologyOnline Presence
Milan System for Reporting Salivary Gland CytopathologyOnline Presence, > 90 National & International Publications
Question #2
Question # 260‐year‐old man underwent FNA by palpation of a 1.5 cm mobile mass in left parotid gland.
This specimen should be classified as per “Milan System for Reporting Salivary Gland Cytopathology”
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Correct Answer for Question #2
• #3
Must know
Normal Salivary Gland Cytology
Normal Salivary Gland Histology
The Major Salivary Glands1. Parotid2. Submandibular3. Sublingual
The Minor Salivary Glands
• Acinus has acinar cells – Grape like clusters
• Myoepithelial cells constrict intercalated duct and squirt saliva into striated duct.
• Acinar epithelium secretes proteins and isotonic filtrate
Salivary Gland Histology
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Normal Salivary GlandHistology‐Cytology Correlation
Normal Salivary GlandHistology‐Cytology Correlation
Question #3
Question #3:The current name “American Society of Cytopathology” was adapted in year?
1. 1963
2. 1961
3. 1994
4. 1970
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Correct Answer ‐ #3
• The current name, American Society of Cytopathology, was voted on during the 42nd Annual Scientific Meeting held in Chicago in 1994. This change was made to express the evolution of the profession.
Salivary Gland FNA Components
• Cells• Epithelial cells• Inflammatory cells
• Background• Stroma
• Basement membrane type material
• Mucous
• Proteinaceous
Cells
– Epithelial cells
Plasmacytoid
Basaloid
Oncocytic
Granular
Clear/Vacuolated
Background
– StromaFibrillary, solid
Relationship to cells
– MucousLook for intracytoplasmic mucin
– Proteinaceous
Salivary Gland Tumors: Pattern Recognition
Salivary Gland Tumors: Pattern Recognition
• Architecture – cytology-radiology correlation• Cystic (includes microcystic), solid, cribriform, papillary, acinar, tubular, trabecular
• Cell type• Ductal cells, myoepithelial cell and variants
• Stroma and basement membrane type material• Association with lesional cells
• Background• Mucin, inflammatory cells, macrophages
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60‐year‐old man with history of lung adenocarcinoma presented with a superficial left parotid mass.
The mass measured 1.5 cm and appeared solid and lobulated on ultrasound.
Cytology Diagnosis: Basaloid Neoplasm with Differential
60‐year‐old man with history of lung adenocarcinoma presented with a superficial left parotid mass. FNA Followed by Superficial Parotidectomy
Surgical Pathology Diagnosis: Pleomorphic Adenoma
Discussion: Tumors with:Matrix/Stroma & Basaloid Cells
1. Benign Mixed Tumor / Pleomorphic Adenoma
2. Adenoid Cystic Carcinoma
3. Basal cell adenoma
4. Basal cell adenocarcinoma
5. Polymorphous Adenocarcinoma (Location)
Benign Mixed Tumor / Pleomorphic Adenoma
Clinical Features
• Most common tumor of salivary glands in children and adults
• Two-thirds of parotid tumors
• 50% of all salivary gland tumors
• PE: Circumscribed; firm; rubbery
Cytomorphology
• Cells• Epithelial cells arranged in cohesive, honeycomb groups
• Myoepithelial cells arranged singly or loosely arranged groups
• Plasmacytoid, epitheloid, spindled or clear cells
• Chondromyxoid matrix• Fibrillar with frayed edges
• Embedded myoepithelial cells
• Surrounding individual tumor cells
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Many of BMT
Sharma G et al. Radiology 2011;259:471-478 2011 by Radiological Society of North America
The Classic Case of BMT
Parapharyngeal mass. Benign Mixed Tumor
Air‐dried smear
Alcohol fixed Pap‐stained smear ThinPrep® Cell Block
Variations on Classic “BMT”
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Sharma G et al. Radiology 2011;259:471-478
BMT w Cystic Change
Sharma G et al. Radiology 2011;259:471-478
BMT w Cystic Change
Cellular BMT with Increased Plasmacytoid Cells“SUMP” with a Differential Including Cellular BMT
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Pleomorphic Adenoma w Extensive Squamous & LipomatousMetaplasia
Pleomorphic AdenomaWith
Atypical Nuclei
1. Benign cellular atypia – Ancient change2. Atypia – Carcinoma ex-pleomorphic adenoma
55‐year old woman with 4.0 cm painless parotid mass, been present for 10+ years 55‐year old woman with 4.0 cm painless parotid mass, been present for 10+ years
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63‐year old man with 5.0 cm parotid mass, been present for 11+ years, currently enlarging rapidly. US shows solid & cystic mass.
63‐year old man with 5.0 cm parotid mass, been present for 11+ years, currently enlarging rapidly. US shows solid & cystic mass.
63‐year old man with 5.0 cm parotid mass, been present for 11+ years, currently enlarging rapidly. US shows solid & cystic mass.
Carcinoma ex‐pleomorphic adenoma
Pleomorphic AdenomaMimicking
Basaloid Tumors
The Story of Sampling A Heterogeneous Tumor
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Cellular BMT with Stromal Cores Mimicking Basaloid Neoplasms
Cellular BMT with Stromal Arrangements Mimicking Adenoid Cystic Carcinoma
. Look for spindle shaped and/or plasmacytoid cells
. Classic features of Pleomorphic Adenoma will be evident in other areas of the slide
. Process the entire specimen
. Immunostains can be helpful – Cell block
Adenoid Cystic Carcinoma (ADCC)
• 3rd most common malignancy
• Higher frequency in submandibular gland
• Poor long-term survival
Painful – due to invasion of the nerves
• Cytomorphology• Variably sized three dimensional Acellular Hyaline Matrix Globules surrounded by monotonous Basaloid Cells
• Cellular atypia – not frequent
D C Howlett, Br J of Radiology 2003
Hypoechoic tumorIrregular margins
Infiltration / Extension (into deep lobe of parotid gland)
Ultrasound Features of Adenoid Cystic Carcinoma (ADCC)
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ADCC – Classic Cytomorphology55‐year‐old man with history smoking and leukoplakia presented with a right sub‐mandibular mass slowly enlarging
for 5‐years. Patient complains of fullness without pain or paresthesia.
ThinPrep Preparation OnlyLightly staining Hyaline Globules
55‐year‐old man with history smoking and leukoplakia presented with a right sub‐mandibular mass slowly enlarging for 5‐years. Patient complains of fullness without pain or paresthesia.
Adenoid Cystic Carcinoma
ADCCa – ThinPrep SpecimenLook at the structure / shape of stroma
devoid of cells
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ADCCa – Thin-Prep Specimen. Look at the structure / shape of stroma devoid of cells Summary
Diagnostic Scenarios – Basaloid Cells
• Diagnosable as:• Neoplasm‐Benign: Pleomorphic Adenoma. Basal cell adenoma
• Malignant: ADCCa
• If morphology not typical:• Salivary gland neoplasm of uncertain malignant potential
• Basaloid features with differential
• Atypical nuclei
Differential Diagnosis of Tumors with Salivary Gland Neoplasm w Basaloid Features ‐ Based On Amount & Type of Stroma
1. FibrillaryPleomorphic Adenoma
Epithelial‐myoepithelial carcinomaBasal cell adenoma / Adenocarcinoma
2. HyalinizedBasal cell adenoma / Adenocarcinoma
Adenoid cystic carcinomaEpithelial‐myoepithelial carcinoma
Polymorphous adenocarcinoma (location)
3. Mixed or Other Types (globular structures) Adenoid cystic carcinomaPolymorphous adenocarcinoma
4. Scant to None Pleomorphic adenomaBasal cell adenoma (usually canalicular type)
MyoepitheliomaMyoepthelial carcinoma
Question #4
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Question # 445‐year‐old woman underwent ultrasound guided FNA of a 2.0 cm solid and painless right parotid gland mass.
This specimen should be classified as per “Milan System for Reporting Salivary Gland Cytopathology”
Question # 245‐year‐old man underwent ultrasound guided FNA of a 2.0 cm solid and painless right parotid gland mass.
This specimen should be classified as per “Milan System for Reporting Salivary Gland Cytopathology”
Question # 445‐year‐old woman underwent ultrasound guided FNA of a 2.0 cm solid and painless right parotid gland mass.
This specimen should be classified as per “Milan System for Reporting Salivary Gland Cytopathology”
Correct Answer
• #1
26‐year‐old man with 2.8 cm ill‐defined mass bridging superficial and deep lobes of parotid gland
Malignant – Mucoepidermoid Carcinoma
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26‐year‐old man with 2.8 cm ill‐defined mass bridging superficial and deep lobes of parotid gland
Malignant – Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma - Classic Case
• Background• Mucinous (low grade tumors), extracellular mucin, easily detected strings of mucin• Lymphocytes
• Cells• Clear / foamy macrophage type cells (mucous glandular cells)• Ductal appearing intermediate cells. • Glandular cells, singly or gland formation.• Squamous cells. Lymphocytes
Mucoepidermoid Carcinoma – Not so Classic CasesThe Tumors Failed To Read the Atlas Low Cellularity Specimens
Mucoepidermoid Carcinoma – Not so Classic CasesThe Tumors Failed To Read the Atlas Low Cellularity Specimens
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Lymphocytes in Salivary Gland FNA Specimens
• Intraparotid LN• Lymphoepithelial cyst• Chronic Sialadenitis• Warthin Tumor
• Acinic cell carcinoma
• Mucoepidermoid Carcinoma
• Lymphoma
Low Grade Mucoepidermoid Carcinoma FNADifferential Diagnosis
• Benign tumors with focal mucinous or clear cell change• Pleomorphic adenoma
• Benign cysts
• Chronic sialadenitis with mucinous metaplasia
• Low grade salivary duct carcinoma
• Squamous cell carcinoma
• Acinic cell carcinoma
• Carcinoma with clear cell features
Chronic Sialadenitis• Scant cellularity. Ductal epithelium (sheets & tubules). Paucity of acinar elements.
• Background debris & inflammation. Fragments of mesenchymal tissue.
• Squamous & mucinous Metaplasia. Cell atypia ?
23 Year‐old‐man with Right Parotid Mass
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23 Year‐old‐man with Right Parotid Mass
Atypical cells Suspicious for Mucoepidermoid Carcinoma – Mucicarmine stain positive on the smearSurgical Pathology Diagnosis:
Chronic Sialadenitis
23 Year‐old‐man with Right Parotid Mass
45 year‐old man with 2.5 cm submandibular/sub‐mental space mass Oncocytic Mucoepidermoid Carcinoma vs. Just Mucinous Cells in Warthin-Tumor
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Differential Diagnosis of Tumors with Oncocytic Features Based On Cytomorphologic Features
1. Background
• Cystic
• Mucinous
• Blood or Non‐specific
• Warthin Tumor, Cystadenoma
• Oncocytic Mucoepidermoid Carcinoma, Warthintumor w mucinous metaplasia?
• Oncocytoma, Pleomorphic Adenoma
2. Cytoplasm
‐ not so dense but variably vacuolated
• Acinic Cell Carcinoma• Secretory Carcinoma (MASC)
• Metastatic Renal Cell Carcinoma
3. Nuclear Atypia • Salivary Duct Carcinoma• High Grade Mucoepidermoid Carcinoma
• Metastatic Renal Cell Carcinoma
Question #5
Question #5In which year the cytotechnologists were voted onto the ASC executive board?
Correct Answer ‐ #4
• The cytotechnologist role in the ASC has evolved over the years. Originally, the cytotechnologists were welcomed into the Society as Associate members in 1954.
• In 1981, a new category was established setting criteria for a voting cytotechnologist in the Society. That same year, three cytotechnologists were voted onto the Executive Board.
• Later in 1995, the membership category was changed to Cytotechnologists members and Voting Cytotechnologists members.
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50 year old woman with a slow growing right parotid mass, present size 5.0 cm
Malignant: Acinic Cell Carcinoma
50 year old woman with a slow growing right parotid mass, present size 5.0 cm
Malignant: Acinic Cell Carcinoma
Acinic Cell Carcinoma – Radiologic FeaturesLi et al. Eur J Radiol 2014;83:1152‐1156
Irregular bordersWell‐definedHypoechoic
Plain CT: Regular defined homogeneous lesionContrast: Moderate homogeneous enhancement
Acinic Cell Carcinoma – Cytomorphologic Features
1. Sheets of large cells with abundant foamy vacuolated and granular cytoplasm2. Eccentrically placed nuclei with small, inconspicuous nucleoli, naked nuclei in the background (delicate cytoplasm)
3. Lymphocytes
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Acinic Cell Carcinoma –Differentiate from Benign Acinar Tissue (BAT)
BAT – Low power “Rosette” pattern or “Clustered Ball‐like” strructures Acinic Cell CarcinomaDifferential Diagnosis
• Granular cytoplasm• Oncocytic / Oncocytoid Tumors
• Secretory Carcinoma
• Clear or vacuolated cytoplasm• Myoepithelial differentiation
• Metastatic tumors
• Granular Cytoplasm + Lymphocytes• Warthin Tumor
Warthin Tumor
• Primarily occurs within parotid gland• Second most common salivary gland neoplasm – 5‐10%
• Believed to originate from salivary duct remnants entrapped within glandular lymphoid tissue
• Clinical features:• 50‐79 year‐old
• Common in men
• Bilateral
• PET and TC‐99 positive
Cyto-morphology: Lymphocytes & Oncocytes• Mixed population of lymphocytes in the background and intimately associated
with oncocytic cells• Background debris ( grossly mobile oil consistency)• Rarely Mucous cells (think of oncocytic mucoepidermoid carcinoma)
Warthin TumorCyto-morphology: Lymphocytes & Oncocytes
• Mixed population of lymphocytes in the background and intimately associated with oncocytic cells
• Background debris ( grossly mobile oil consistency)
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Warthin TumorCyto-morphology: Lymphocytes & Oncocytes
• Mixed population of lymphocytes in the background and intimately associated with oncocytic cells• Background debris ( grossly mobile oil consistency)
45-old-woman with 2.5 cm right parotid mass
Oncocytic Neoplasm vs. Secretory Carcinoma
45-old-woman with 2.5 cm right parotid mass
Oncocytoma
E
F
45‐year‐old man with right parotid gland mass
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E
F
45‐year‐old man with right parotid gland mass
FISH ‐ ETV6 Rearrangement
Recent Case: 71‐year old with <1.0 cm left submandibular gland mass
Recent Case: 71‐year old with <1.0 cm left submandibular gland mass
MAML2 FISH +ve, DOG‐1 negative
Poster # 1294 –USCAP 2019. Bundele et al. Mucoacinar carcinoma: A rare intercalated duct/acinar variant of mucoepidermoid carcinoma, hybrid tumor or distinct entity
Recent Case: 71‐year old with <1.0 cm left submandibular gland mass
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Question #6
Question # 665‐year‐old man underwent ultrasound guided FNA of a 4.0 cm cystic and solid right parotid gland mass. This specimen should be classified as per “Milan System for Reporting Salivary Gland Cytopathology”
Question # 665‐year‐old man underwent ultrasound guided FNA of a 4.0 cm cystic and solid right parotid gland mass. This specimen should be classified as per “Milan System for Reporting Salivary Gland Cytopathology” Correct Answer
• #4
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Ancillary Studies
Special Stains and Immunostains
Molecular Targets
PanCK p63 &
p40
SOX10 S100 DOG1 Mammoglobin Androgen
Receptor
GATA3 CD117 PLAG1
Tumor Type
Pleomorphic Adenoma + + + + ‐ ‐ ‐ v v +
Basal Cell
Adenoma/Adenoca
+ + + + ‐ ‐ ‐ v v v
Mucoepidermoid Ca + + +/‐ ‐ ‐ ‐ ‐ v v ‐
Acinic Cell Ca + ‐ + ‐ + ‐ ‐ ‐ ‐ ‐
Secretory Ca (MASC) + ‐ + + ‐ + ‐ + (n) ‐ ‐
Adenoid Cystic Ca + + + + + ‐ ‐ ‐ +
(luminal)
‐
Oncocytoma + + ‐ ‐ ? ‐ ‐ ‐ ? ?
Ancillary Studies - Immunohistochemistry
Caution should be applied when using these in cytology preparations ‐ validation
Ancillary Studies - Molecular Targets
• Mucoepidermoid Carcinoma
• CRTC1‐MAML2 ‐ t(11;19)(q21;p13)
• CRTC3‐MAML2 ‐ t(11;15)(q21;q26)
Adenoid Cystic Carcinoma• MYB‐NFIB‐T(6:9) ‐ t(6;9)(q22‐23;p23‐24)rarely t(8;9)
• Pleomorphic Adenoma & CA ex PA
• PLAG1 ‐ t(3;8)(p21;112), t(5;8)(p13;q12)
• HMGA2‐t(3:12) ‐ t(3;12)(p14.2;q14‐5), ins(9;12)(p23;q12‐15)
• Secretory Carcinoma (MASC)ETV6‐NKRT: t(12:15)(p13q25)
• Acinic Cell CA
mTOR Pathway, PTEN, BRAF, NF1
• Polymorphous Adenocarcinoma
• PRKD1 E710D
Summary
My Two Cents
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Diagnosing Salivary Gland Lesions on Fine‐needle Aspiration Cytology
• Clinical History
• Radiologic features (if available)
• Architectural pattern
• Cellular elements & their distribution• Background
• Differential diagnosis
• If specific diagnosis cannot be provided – Grouping based on: • Cellular elements – everything counts (background, cell, stroma, other)
• Differential
•Warthin’s Tumor
• Cystadenocarcinoma
•Mucoepidermoid carcinoma
• Acinic cell carcinoma
Cystic• Acinic cell carcinoma
• Polymorphous adenocarcinoma
•Mucoepidermoid carcinoma
• Secretory CarcinomaMicrocystic
• Pleomorphic adenoma
• Adenoid cystic carcinoma
• Salivary duct carcinoma
• Polymorphous adenocarcinoma
• Cribriform adenocarcinoma
Cribriform• Pleomorphic adenoma
• Adenoid cystic carcinoma
• Polymorphous adenocarcinoma
• Epithelial‐myoepithelial carcinoma
• Cystadenoma / cystadenocarcinoma
• Salivary duct carcinoma
Tubular
•Warthin’s Tumor
• Cystadenocarcinoma
• Acinic cell carcinoma
• Adenocarcinoma, NOSPapillary
Tumor Grouping Based on Architectural Pattern
Basaloid Neoplasm
• Pleomorphic adenoma
• Basal cell adenoma
• Adenoid cystic Ca*
• Polymorphous adenocarcinoma*
• Basal cell adenocarcinoma
Oncocytic / OncocytoidNeoplasm
• Warthin Tumor
• Oncocytoma
• Cystadenoma
• Acinic cell carcinoma
• Secretory carcinoma
• Oncocytic carcinoma
• Sebaceous adenocarcinoma (rare)
Neoplasm with
Clear Cell Features
• Clear cell carcinoma*
• Epithelial myoepithelialcarcinoma
• Acinic cell carcinoma
• Metastatic tumor
• Clear cell oncocytoma(rare)
• Sebaceous adenocarcinoma (rare)
Tumor Grouping Based on Cellular Elements
*Tumor location Salivary Gland Fine Needle Aspiration Reporting – Milan System
Benign Neoplasm SUMP Suspicious‐Malignancy Malignant
BMT/PA BMT/PA
Warthin T Acinic Cell Ca
Adenoid Cystic Ca
Basaloid Neoplasm
Secretory Carcinoma
Susp‐MEC
BMT/PA w Atypia
Oncocytic / Oncocytoid Neoplasm
Necrotic Tumor Susp SCCA
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SUMMARIZING TO …Based on:
Morphologic heterogeneity
Literature Review &
Ever expanding list of salivary gland lesions
Milan System for Reporting Salivary Gland Cytopathology