WHO classification salivary

tumours: What's new?

Alena Skalova, MD, PhD
Professor of Pathology
Charles University, Faculty of Medicine in Plzen,
Czech Republic

An update on Histopathology of Salivary Gland Tumors,

La Spezia, Italy, Oct 18-20, 2017
WHO classification of salivary
tumours 1972
Revised WHO classification
1991
WHO classification 2005
WHO Consensus Meeting 2016
WHO Classification of Salivary Gland
Tumors 2017
WHO Classification of Salivary Gland
Tumors 2017
• Mammary analogue
secretory carcinoma
(MASC)
• Intraductal carcinoma
• Cribriform
adenocarcinoma of
tongue (CATS/CASG)
• Sclerosing polycystic
adenoma (SPA)
• (Mammary Analogue) Secretory
Carcinoma (MASC)
 (Mammary analogue) Secretory
carcinoma (MASC)
• akin to secretory carcinoma of the breast,
MASC expresses CK7/S-100 protein, and
mammaglobin
• harbours t(12;15)(p13;q25) translocation
resulting in ETV6-NTRK3 fusion
• presence of t(12;15) was not demonstrated
in any other salivary gland tumor
o however, many fusion partners of ETV6 have been reported in a variety of
epithelial and hematological malignancies other than salivary
Secretory carcinoma (mammary analogue)
ETV6-NTRK3
ETV6-RET (ETV6-X)

Skalova et al. Am J Surg Pathol 2010; 34: 599-608

 Secretory Carcinoma (mammary
analogue) MASC

Low grade vesicular nuclei, centrally located nucleolus,

pink vacuolated cytoplasm
FISH for ETV6 gene break is positive
FISH analysis of ETV6 gene (12p13)
using break apart rearrangement
probe - Vysis ETV6 Break Apart FISH
Probe Kit (Abbott Molecular) in FFPE
tissue.
Nuclei with one fusion (yellow), one
orange, and one green (split) signal
pattern indicative of a rearrangement
of one copy of the ETV6 gene region.
 Less common and
unexpected features in
MASC
 „Masked“MASC of parotid
gland

Petersson et al. A New Hitherto Unreported Histopathologic Manifestation of Mammary Analogue Secretory
Carcinoma: “Masked MASC” Associated With Low-grade Mucinous Adenocarcinoma and Low-grade In Situ
Carcinoma Components. Appl Immunohistochem Mol Morphol, in press
 Less common and unexpected
features in MASC
• salivary gland tumor of the parotid gland in a 54-
year-old woman
• which contained a minor mammary analogue
secretory carcinoma (MASC) component (20%)
intermixed with a different mucinous
adenocarcinoma component (80%)
• morphologically nondescript low-grade intraductal
carcinoma (in situ) component
• Both of the components revealed ETV6
rearrangement, RT-PCR failed to reveal an ETV6-
NTRK3 fusion
 MASC with mucinous
adenocarcinoma component

S100 protein positive in MASC component

 „Mucinous“ MASC with with
macrocystic appearance
• “mucinous” MASC of parotid gland in 17-y old male
with a macrocystic appearance
• should not be mistaken for low-grade MEC
• the cells of MASC can have single cytoplasmic
vacuole thus mimicking mucous cells
• Macrocystic structures lined by single layer of
apocrine cells
• with only rare, multivacuolated cells more
characteristic of MASC
• S100/MMG stain and ETV6 gene rearrangement, RT-
PCR failed to reveal an ETV6-NTRK3 fusion
 „Mucinous“ MASC

MASC with prevailing macrocystic growth pattern

 „Mucinous MASC“

MASC with macrocystic appearance and apocrine

features
„Sclerotic“ MASC

MASC with ETV6-X fusion

 „Sclerotic“ MASC

MASC with ETV6-X fusion: prominent fibrosclerotic

stroma
 Mammary Analogue Secretory Carcinoma of
Salivary Glands with High-grade Transformation

HG-MASC with atypical ETV6/NTRK3 fusion

 Mammary Analogue Secretory Carcinoma of
Salivary Glands with High-grade Transformation

Skalova et al. Am J Surg Pathol 2014;38:23-33

Molecular Features of MASC
• most SCs harbor the recurrent balanced t(12;15)
(p13;q25) chromosomal rearrangement resulting in
the fusion of the ETV6 and NTRK3 genes
• the ETV6 gene split visualized by FISH
• the classical ETV6-NTRK3 fusion transcript (exon 5-
exon 15 junction) is in some cases not detected by
standard reverse-transcriptase polymerase chain
reaction (RT-PCR)
• atypical fusion transcripts (4-14 or 5-14 junctions)
• ETV6-RET fusion
• 25 cases FISH ETV6 positive, RT-PCR
negative
• Nested RT-PCR positive in 4
• 16/25 rearrangement of NTRK3
• 4 cases of MASC ETV6-X gene
fusion
 Secretory carcinoma (MASC)
with ETV6-X translocation

MASC with ETV6-X fusion, predominatly macrocystic

and papillary structures
 Secretory carcinoma (MASC)
with ETV6-X translocation

SC with prominent hyalinization and trabeculae of neoplastic

cells embedded in a completely hyalinized central part
 Molecular profiling of mammary analogue
secretory carcinoma revealed a subset of tumors
harboring a novel ETV6-RET translocation: report
of 10 cases

• The presence of ETV6-RET fusion in MASC was

proved by at least three independent tests, i.e. NGS,
FISH, RT-PCR
• Histomorphology is variable
• MASC patients with ETV6-RET fusions may benefit
from RET-targeted therapy
o Skalova et al. Am J Surg Pathol Aug 2017, in press
Secretory carcinoma (MASC) with
novel ETV6-RET translocation

SC with typical morphology and immunoprofile harboring a

novel ETV6-RET translocation (4 cases)
Secretory carcinoma (MASC) with
novel ETV6-RET translocation

predominantly multicystic growth pattern with multiple

mural nodules (3 cases)
Secretory carcinoma (MASC) with
novel ETV6-RET translocation

prominent fibrosclerotic stroma with isolated tumor cells

in small islands or trabeculae (3 cases)
Primary extrasalivary
MASC
Primary MASC of thyroid gland
• ETV6-NTRK3 fusion was found in about 14% of
radiation-induced well-differentiated papillary
thyroid carcinomas
• Leeman-Neil, et al. Cancer 2014;120:799-807

• In up to 2% of sporadic well-differentiated papillary

thyroid carcinomas
• Primary MASC of the thyroid masquerading as
papillary thyroid cancer
• Reynolds, et al. Head Neck Pathol 2016;10:405-413

• Primary thyroid MASC

• Stevens, et al. Modern Pathol 2015;28:1084-1100
• Dettloff, et al Head Neck Pathol 2017;11(2):124-130
 Primary MASC of the thyroid
gland
• two cases of papillary carcinoma of the thyroid,
which showed transitions to the MASC
• papillary carcinoma component of the thyroid was
TTF1 and thyroglobulin positive, MASC component
was negative on these thyroid markers and was
mammaglobin, S-100, p63, PAX8, GCDFP-15
positive
• Both of the components of this composite tumors
revealed ETV6 rearrangement

Dogan, et al. Mammary analogue secretory carcinoma of the thyroid gland: A primary
thyroid adenocarcinoma harboring ETV6-NTRK3 fusion. Modern Pathol 2016;29:985-995
Primary „composite“ MASC of
thyroid gland

Papillary thyroid carcinoma component of MASC

Primary „composite“ MASC of
thyroid gland

conventional MASC component

 Treatment of MASC
• treatment of MASC has varied, ranging from simple
excision to radical resection, neck dissection,
adjuvant radiotherapy, and/or adjuvant systemic
chemotherapy
• For patients presenting with a locally advanced,
recurrent or metastatic disease the treatment
options are currently limited and mainly palliative
• Testing for ETV6-NTRK3 translocation-pan TrK inhibitor
Entrectinib (Ignyta) targets NTRK, ROS1, and ALK
fusions
• ETV6-RET testing

Drilon et al. What hides behind MASC:…Ann Oncol 2016;27:920-6

 Targeted treatment of MASC

• Use of and response to tyrosine kinase

inhibitors in SC is limited, so far…
• recent study suggested that the inhibition of
ETV6-NTRK3 activation could be used for the
treatment of patients with this fusion

Drilon A, Li G, Dogan S, et al. What hides behind the MASC: clinical response and acquired resistance
to entrectinib after ETV6-NTRK3 identification in a mammary analogue secretory carcinoma (MASC).
Ann Oncol. 2016;27:920–926.
42
 Conclusions; Secretory carcinoma
• MASC has distinctive morphology and
immunoprofile in most cases
• Diagnosis of „classical“ MASC features could be
performed without molecular testing
• However, in cases that depart from the typical
features of MASC in some way
• Molecular testing in MASC is of potential value in
treatment of patients
Draft WHO classification 2017
 Cribriform Adenocarcinoma of
Tongue (CAT) and (other)
Salivary Glands (CASG)

Michal et al. Cribriform adenocarcinoma of the tongue. Histopathology 1999;35:495-501

Possible variant of PLGA is CAT/CASG, but it is not yet
clear whether this represents a genuine entity or just an
unusual growth pattern in PLGA……….

WHO Classification of Tumours: Pathology and Genetics

Head and Neck Tumours, IARC Press, 2005
 Polymorphous adenocarcinoma
(PAC)- WHO 2017
• Syn. Low-grade
polymorphous
adenocarcinoma
(PLGA); terminal duct
carcinoma; lobular
carcinoma

CATS/CAMSG considered as „cribriform

variant of PAC“

Fonseca I; Assaad A; Katabi N; Seethala R;

Simpson RHW; Skálová A;Weinreb I; Wenig B
 Polymorphous (low-grade)
adenocarcinoma (PLGA/PAC)

• Spindle shaped cells, streaming

• Perineural invasion
• Targetoid structures
• Regular nuclei
Cribriform Adenocarcinoma of
Tongue and Salivary Glands
(CATS/CASG)
CASG; solid and cribriform
structures
CASG
overlapping clear, grooved nuclei

Papillary growth pattern, ground-glass nuclei

Key Features distinguishing PLGA
versus CASG
• PLGA is a low-grade infiltrative malignancy with a
mixture of tubular, cribriform, papillary, and solid
growth, arranged in fascicles with targetoid
neurotropism
• CASG is a tumor with distinctive cribriform/papillary
glomeruloid patterns and highly vesicular papillary
thyroid carcinoma–like nuclei predominating in
base of tongue
• PLGAs are characterized by PRKD1 E710D
mutations, whereas CASGs are characterized by
PRKD1-3 translocations
• CASGs have a high capacity for nodal spread
 Conclusions; CASG
• Histologic and molecular overlap between CASG
and PLGA
• CASG is a distinct tumor entity, differs from PLGA by
location, cytology, histological architecture, and
behavior
• frequent lymph node metastasis at the time of
presentation
• Paradoxically, early metastatic disease is
associated with an indolent behavior
• It makes CASG a unique neoplasm among all low-
grade salivary gland tumors
Draft WHO classification 2017.
 Intraductal carcinoma
• Syn. cribriform
cystadenocarcinoma;
intraductal carcinoma,
low-grade; low-grade
SDC
• Solid, cystic, in situ
• Mostly parotid gland
• Excellent prognosis

Loening T; Leivo I; Simpson RHW;

Weinreb I CK14
 Intraductal carcinoma (IC)
• IC show a variety of growth patterns, both solid and
cystic, ranging from cribriform to solid to
micropapillary reminiscent of low-grade ductal
carcinoma in situ or atypical ductal hyperplasia of
the breast.
• Tumor cells are monomorphic and ovoid and
evenly spaced with round nuclei and scant
eosinophilic cytoplasm.
• Oncocytic and apocrine change and intermediate
grade cytonuclear features are uncommon.
p63
mammaglobin
S100 protein
S100 protein
 S100

Calponin AR
 S100

“Apocrine variant of IDC”

AR
 Intraductal carcinoma; conclusions
• Pure intraductal lesions with either intercalated
duct or mixed apocrine/intercalated duct
morphology and S100 positivity should be called
“intraductal carcinoma”

they rarely invade and are associated with good

outcome after excision

• Pure apocrine equivalents are generally invasive

and are likely more related to true SDC and are
better termed “SDC in-situ” or “in-situ and
microinvasive SDC”

these should be treated as if they could behave

like fully invasive SDC
Draft WHO classification 2017.
 Sclerosing Polycystic Adenosis/
Adenoma (SPA)

• Smith BC, Ellis GL, Slater LJ, Foss RD, Sclerosing polycystic adenosis of major salivary glands.
A clinicopathologic analysis of nine cases. Am J Surg Pathol 1996:20: 161–170.
 Sclerosing polycystic adenosis
(SPA)
• Synonymum: sclerosing polycystic adenoma
o Benign neoplasm
o Recurrences common
o Clonal by HUMARA
o Dysplasia, DCIS, carcinoma arising in
Sclerosing polycystic adenoma

Circumscribed lesion, embedded in parotid gland

Sclerosing polycystic adenoma

Well circumscribed, with multiple variably sized cystic ducts

• Ducts lined by flattened to cuboidal epithelium with apocrine and foamy
change
Dysplastic epithelium/“DCIS“like
Sclerosing polycystic adenoma

CK14
 Biological nature and behavior of
SPA
• All but one reported cases of SPA are benign
• recurrence occurs in about one-third of cases
• lesion may be multifocal, difficult treatment
• focal atypical hyperplasia and DCIS in most cases
• infiltrative foci mimicking intra-lesional invasive
adenocarcinoma
• invasive carcinoma arising in SPA

Manajlovic et al. Pathol Res Pract 2014; 342-345

Marques et al. Virchows Arch 2014;464:621-625
 Differential diagnosis and
management of patients with SPA
• Both benign and malignant conditions
• sclerosing sialadenitis, polycystic dysgenetic disease, PA, LG
cystadenocarcinoma, AciCCa, mucoepidermoid carcinoma

• management is surgical with conservative subtotal

parotidectomy
• prolonged surveillance
• High risk of recurrences
• very low risk of carcinomatous transformation
 Conclusions; SPA
• is a distinctive entity, rare neoplastic condition with
characteristic histologic features,
• Atypical hyperplasia, dysplasia, DCIS
• Evidence of clonality (HUMARA assay)
• Frequent recurrences, including multiple
• Report of invasive carcinoma ex SPA
• No metastases, no DOD so far

Skalova, et al. Virchows Arch 2002;440:29-35.

Skalova, et al. Am J Surg Pathol 2006;30:939-444.
 2017 WHO Classification of
salivary tumors; conclusions
• Useful summary of present knowledge
• Includes new entities, such as MASC/Secretory
carcinoma
• Good to include “Other epithelial lesions”
• Improves the section on „undifferentiated and
neuroendocrine carcinomas“
• Improves the section on „low-grade SDC“ by
including „intraductal carcinoma“
• “Polymorphous adenocarcinoma” is confusing
• I would have preferred to keep PLGA and
include CATS as a separate entity.
Thank you for attention

An update on Histopathology of Salivary Gland Tumors,

La Spezia, Italy, Oct 18-20, 2017