Salivary Gland Tumors: Dr. Arsalan Malik Assistant Professor (Oral Pathology)

‫الر ِح ِيم‬
َّ ‫من‬
ِ ْ‫الرح‬
َّ ‫هللا‬
ِ ‫س ِم‬
ْ ِ‫ب‬
Salivary Gland Tumors
Dr. Arsalan Malik

Assistant Professor (Oral Pathology)
1
Anatomy of Salivary Glands
Three major salivary glands
• Parotid gland (Stensen’s duct)
• Submandibular gland (warthin’s duct)
• Sublingual gland (Bartholin’s duct)
• Innumerable minor salivary glands in mucosa and oral cavity
2
Functions of Saliva
• Protection
• Lubrication
• Buffering
• Digestion
• Taste
• Antimicrobial
• Tooth integrity
3
Normal histology of salivary gland
4
Acinar cells of Salivary Glands
Classified as either:
• Serous cells: produce a thin watery secretion
• Mucous cells: produce a more viscous secretion
5
Salivary gland secretory unit
• Composed of terminal acini
• Intercalated, striated and excretory ducts
• Myoepithelial cells
6
Major Glands/Secretions
• Major SG are paired structures and include the parotid, submandibular and
sublingual
• Parotid: serous
• Submandibular: mucous & serous

• Sublingual: mucous
7
Diseases of Salivary Glands
• Neoplastic
• Developmental
• Infectious
• Inflammatory
• Autoimmune
• Ischemic
8
9
Etiologic Factors
• Radiation exposure
• Genetic predisposition
• Tobacco
• Chemical carcinogens
• Viruses
10
• Incidence:
• 6 % of head & neck neoplasms
• Age: 6 – 7th decades - peak incidence
• Gender: female predilection
• Site:
• Parotid: 64 - 80%
• Minor glands (palate): 9 -23%
• Submandibular gland: 8 - 11%
• Sublingual gland: < 1%
11
Salivary gland Tumors
 Tumors of the salivary gland may arise from
-- the salivary epithelium (the parenchyma)
--or the supportive stroma (mesenchymal)
 Benign parenchymal tumors are known as

Adenomas
 Malignant tumors are known as adenocarcinomas .
Salivary gland tumors may arise form any cellular component including the
 basal cells
 ductal,
 striated
 intercalated ducts,
 acini and
 the myoepithelial cells.
12
• Benign
• Malignant
Relative proportion of malignancy increasing in the smaller glands

(rule of thumb is the 25/50/75 rule)
13
Benign Malignant
► Pleomorphic adenoma ►Mucoeidermoid
► Warthin`s tumor carcinoma
► Oncocytoma ►Acinic cell carcinoma
► Myoepithelioma ►Adenoid cystic

► Ductal papilomas carcinoma
► Monomorphic adenoma ►Polymorphous low
grade adenocarcinoma
1. Basal cell adenoma
►Carcinoma arising in
2. Canalicular adenoma
pleomorphic adenoma
14
BENIGN SAIVARY GLAND TUMORS
15
General Characteristics
• Grow slowly,
• Asymptomatic,
• Do not fluctuate in size
• Usually of long duration
• Present a single nodule
• Not fixed to overlying skin or mucous membrane
• Recurrent lesion may be multi- nodular

16
Benign Malignant

pleomorphic adenoma
17
Pleomorphic Adenoma
• Benign glandular neoplasm
• Incidence: common
• 70% of salivary tumors
• Gender: female > male
• Age: 3-6th decades
• Site: parotid, palate, upper lip, buccal mucosa
• Symptoms: slow growing painless mass

18
Pleomorphic Adenoma
 Gross Pathology:
- well circumscribed firm tan white solid
or partially cystic mass
 Histology:
- ductal epithelial cells
- myoepithelial cells
- stroma: myxoid, chondroid, fibrohyaline
19
Pleomorphic Adenoma
20
Pleomorphic Adenoma
Treatment:
• Surgical excision
• Superficial parotidectomy
• Prognosis: excellent
• Complications:
• recurrence – multifocal
• malignant transformation (5%)
21
Benign Malignant

pleomorphic adenoma
22
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
• Benign salivary gland tumor
• Incidence: common
• Gender: male > female
• Symptoms: painless mass
• Site: parotid, multi-focal/bilateral (14%)
• Etiology: smoking (8 fold risk)

23
Warthin’s Tumor
• Gross Pathology:
• Well circumscribed cystic mass
• Papillations
• “machine oil fluid”
Histology:
• Encapsulated cystic lesion
• Papillary fronds
• Oncocytic columnar cells
• Lymphoid stroma
24
Warthin’s Tumor
25
Warthin’s Tumor
Treatment:
• Superficial parotidectomy
• Prognosis: excellent
Complications:
• Recurrence – 6-12% (multicentric)
• Association with other salivary tumors
• Malignant transformation – extremely rare
26
Benign Malignant

pleomorphic adenoma
27
Oncocytoma
• Benign salivary gland neoplasm

• Incidence: rare (1% of salivary tumors)
• Site: parotid gland (85-90%)
• No gender predilection
• Symptoms: painless mass (<4 cm)
• Multifocal/bilateral
28
Oncocytoma
• Encapsulated
• Trabecular-organoid
• Oncocytic epithelial cells
• Fibrous septae
• Clear cells
29
Oncocytoma
Treatment
Prognosis
• Excellent
• Recurrence uncommon
• Oncocytic Adenocarcinoma - sinonasal tract
30
Oncocytoma
• Electron Microscopy:
-Mitochondrial hyperplasia
-60% of cell volume
31
Ductal Papillomas
Present in three forms
• 1-Simple ductal papilloma
• 2-Inverted ductal papilloma
• 3-Sialadenoma papilliferum
32
Simple ductal papilloma
-Exophytic lesion, papillary surface and

pedunculated base
-Reddish in color present on palate or buccal
mucosa
-It consist of non-keratinized epithelium,
columnar, supported by a core of vascular
fibrous connective tissue
33
Inverted ductal papilloma
-Present as a nodule of oral mucosa of adults. No

distinctive clinical features
-Histologically it consist of squamous, cuboidal,or

columnar cells which proliferate into duct to form a
bulbous masses.
Mucous cells and micro cyst with mucous may be

seen
34
Sialadenoma Papilliferum
-The lesion occurs in adults
-Exophitic papillary lesion of hard palate
-Luminal layer of columnar cells on cuboidal

basal layer.
-Connective tissue papillae contain plasma

cells
35
Benign Malignant

pleomorphic adenoma
36
Monomorphic adenoma
• Consists of single epithelial cells type
• Basal cell, canalicular, sebaceous, glycogen-rich, clear cell
• Most common types are
- Basal Cell Adenoma
- Canalicular Adenoma
37
Canalicular Adenoma
• Monomorphic adenoma
• Site: upper lip (75%)
• Age: 7th decade
• Gender: female predilection
• Symptoms: slow growing mass
• Multifocal
38
Canalicular Adenoma
39
Canalicular Adenoma
Treatment
• Conservative surgical excision
• Enucleation not recommended
Prognosis
• Excellent
• Rare recurrence
• Can be misdiagnosed as a malignancy

40
Basal Cell Adenoma
• Monomorphic adenoma
• Incidence: 2% of salivary gland tumors
• Site: parotid gland (75%)
• Gender: female predilection (2:1)
• Symptoms: slow growing mass (< 3cm)
41
Basal Cell Adenoma
• Solid
• Most common
• Solid nests of tumor cells
• Uniform, hyperchromatic, round nuclei,

indistinct cytoplasm
• Peripheral nuclear palisading
• Scant stroma
42
Basal Cell Adenoma
Trabecular pattern
`Elongated anastomosing cords of basal
cells, surrounded by connective
tissue stroma.
43
Basal Cell Adenoma
Tubular Pattern
`Basaloid cells surrounds the duct like
structure.
44
Basal Cell Adenoma
Membranous or dermal analogue

adenoma
`Tumor islands moulded in jig saw
puzzle fashion surrounded by
hylinized basal lamina
45
Basal Cell Adenoma
Treatment
• Complete surgical excision
Prognosis
• Excellent
• Recurrences may occur
• Malignant transformation is rare
• Hybrid tumor
46
Malignant Epithelial Tumors
47
Malignant Epithelial Tumors
Mucoepidermoid carcinoma – Basal cell adenocarcinoma

29% – 2.9%
Adenocarcinoma, NOS – Epithelial myoepithelial
27% carcinoma – 1%
Acinic cell carcinoma – Clear cell carcinoma
17% – 1%
Polymorphous low grade Salivary duct carcinoma –
carcinoma – 19.6% 0.5%
Adenoid cystic carcinoma – 7.5%
48
Malignant salivary gland tumors
• Shorter duration than benign
• Grow rapidly or history of slow growth with sudden rapid activity
• Fixed to surrounding tissues
• Overlying skin or mucous membrane may be ulcerated or inflamed
• Surface talengectasia
49
Malignant salivary gland tumors
• Parotid gland tumors associated with facial nerve paralysis or neurological

symptoms
• Regional lymph nodes may be enlarged
• Palate and retromolar gland tumors infiltrate bone,produce radiolucencies and

loosening of teeth
50
Salivary Gland Tumor Staging
• T1: tumor < 2 cm
• T2: tumor 2 - 4cm
• T3: tumor > 4 cm or extraparenchymal
• T4a: invades skin, mandible, ear canal or facial nerve
• T4b: tumor invades skull base, pterygoid plates or encases carotid artery
51
Benign Malignant

pleomorphic adenoma
52
Mucoepidermoid Carcinoma
• Malignant epithelial salivary gland tumor
• 2nd most common salivary gland tumor
• 30% of malignant salivary gland tumors
• Age: 2nd – 7th decades
• Gender: slight female predilection
• Site: parotid gland, palate
• Etiology: radiation exposure
• Asymptomatic swelling
53
• Gross pathology
• Well-circumscribed to partially
encapsulated to unencapsulated
• Solid tumor with cystic spaces
54
• Histology—Low-grade
• Mucus cell > epidermoid cells
• Prominent cysts
• Mature cellular elements
55
• Histology—Intermediate- grade
• Mucus = epidermoid
• Fewer and smaller cysts
• Increasing pleomorphism and mitotic
figures
56
• Histology—High-grade
• Epidermoid > mucus
• Solid tumor cell proliferation
• Mistaken for SCCA

• Mucin staining
57
• Histology—High-grade
• Epidermoid > mucus
• Solid tumor cell proliferation
• Mistaken for SCCA

• Mucin staining
58
59
Treatment
Influenced by site, stage, grade
Stage I & II
Wide local excision
Stage III & IV
Radical excision
+/- neck dissection
+/- postoperative radiation therapy
60
Prognosis
• Recurrence
• Metastasis – lymph nodes, lung, bone, skin
• Low to intermediate grades

• – good prognosis ( 90% 5 year survival )
• High grade
• – poor prognosis (40% 5 year survival)
• Site: submandibular, floor of mouth, tongue

61
Benign Malignant

pleomorphic adenoma
62
Acinic Cell Carcinoma
• 2nd most common parotid and pediatric malignancy
• 5th decade
• F>M
• Bilateral parotid disease in 3%
• Presentation
• Solitary, slow-growing, often painless mass
63
• Gross pathology
• Well-demarcated
• Most often homogeneous
64
Histopathology
• Circumscribed
• Variable growth patterns
• Variable cytology
• Low grade tumor
• Scant stroma
• Lymphoid infiltrate
65
Histopathology
• Histology
• Solid and microcystic patterns
• Most common
• Solid sheets
• Numerous small cysts
• Polyhedral cells
• Small, dark, eccentric nuclei
• Basophilic granular cytoplasm
66
 Treatment:
- surgical excision
 Prognosis:
 - low-grade malignancy
- 12% recur
 - 8% metastasize
 - 6% mortality
 - prognosis is better for minor gland tumors
 Undifferentiated carcinoma component (rare)
 Difficult diagnosis for pathologist
67
Adenoid Cystic Carcinoma
• Overall 2nd most common malignancy
• Most common in submandibular, sublingual and minor salivary glands
•M=F
• 5th decade
• Presentation
• Asymptomatic enlarging mass
• Pain, paresthesias, facial weakness/paralysis
68
• Gross Pathology:
• - uncapsulated firm solid tan mass
• Histology:
highly infiltrative
small hyperchromatic cells
cribriform (“Swiss cheese”), tubular, solid
mucohyaline stroma
Perineural invasion
69
• Gross pathology
• Well-circumscribed
• Solid, rarely with cystic spaces
• infiltrative
70
• Histology—
• cribriform pattern
• Most common
• “swiss cheese” appearance
71
• Histology—tubular pattern • Histology—solid pattern
• Layered cells forming duct- • Solid nests of cells without
like structures cystic or tubular spaces
• Basophilic mucinous
substance
72
Treatment
Complete local excision
Tendency for perineural invasion: facial nerve sacrifice
Postoperative Radiations
Prognosis
Local recurrence: 42%
Distant metastasis: lung
Indolent course: 5-year survival 75%, 20-year survival 13% 73
Benign Malignant

pleomorphic adenoma
74
Polymorphous low grade adenocarcinoma
• Malignant epithelial neoplasm
• Oral cavity - minor glands
• Age: wide range – 6-8th decades
• Female gender predilection
• Site: palate (65%), lip, buccal mucosa
• Symptoms: painless swelling
• Duration: weeks to years

75
• Malignant epithelial neoplasm
• Oral cavity - minor glands
• Age: wide range – 6-8th decades
• Female gender predilection
• Site: palate (65%), lip, buccal mucosa
• Symptoms: painless swelling
• Duration: weeks to years

76
• 2nd most common malignancy in

minor salivary glands
• 7th decade
• F>M
• Painless, submucosal mass
• Morphologic diversity
• Solid, glandular, cribriform, ductular,
tubular, trabecular, cystic
77
• Histology
• Isomorphic cells, indistinct borders,
uniform nuclei
• Peripheral “Indian-file” pattern
• Treatment
• Complete yet conservative excision
78
Lymphoepithelial Carcinoma
• Rare
• High grade/poorly differentiated carcinoma
• Lymphoid stroma
• Asians, Greenlanders
• Epstein-Barr virus
• Prognosis - guarded
79
Lymphoepithelial Carcinoma
• undifferentiated tumor associated with
a dense lymphoid stroma
80
Salivary Adenocarcinoma NOS
• Some tumours still defy the current classification of salivary gland
tumours
• These are labelled as Salivary Adenocarcinoma Not Otherwise
Specified (NOS)
81
Treatment & Prognosis
• Early stage, well differentiated tumours appear to have a better
prognosis
• The survival rate is better for tumours of oral cavity as compared to
tumours of major salivary gland.
82

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‫الر ِح ِيم‬

Salivary Gland Tumors

Dr. Arsalan Malik

Three major salivary glands

• Parotid gland (Stensen’s duct)

• Submandibular gland (warthin’s duct)

• Sublingual gland (Bartholin’s duct)

• Innumerable minor salivary glands in mucosa and oral cavity

• Serous cells: produce a thin watery secretion

• Mucous cells: produce a more viscous secretion

• Composed of terminal acini

• Intercalated, striated and excretory ducts

• Submandibular: mucous & serous

 Benign parenchymal tumors are known as

Relative proportion of malignancy increasing in the smaller glands

► Myoepithelioma ►Adenoid cystic

• Do not fluctuate in size

• Usually of long duration

• Present a single nodule

• Not fixed to overlying skin or mucous membrane

• Recurrent lesion may be multi- nodular

► Myoepithelioma ►Adenoid cystic

• 70% of salivary tumors

• Gender: female > male

• Age: 3-6th decades

• Site: parotid, palate, upper lip, buccal mucosa

• Symptoms: slow growing painless mass

► Myoepithelioma ►Adenoid cystic

• Gender: male > female

• Age: 5-7th decades

• Symptoms: painless mass

• Site: parotid, multi-focal/bilateral (14%)

• Etiology: smoking (8 fold risk)

► Myoepithelioma ►Adenoid cystic

• Benign salivary gland neoplasm

• Oncocytic epithelial cells

• Oncocytic Adenocarcinoma - sinonasal tract

-60% of cell volume

Present in three forms

• 1-Simple ductal papilloma

• 2-Inverted ductal papilloma

-Exophytic lesion, papillary surface and

-Present as a nodule of oral mucosa of adults. No

-Histologically it consist of squamous, cuboidal,or

Mucous cells and micro cyst with mucous may be

-The lesion occurs in adults

-Exophitic papillary lesion of hard palate

-Luminal layer of columnar cells on cuboidal

-Connective tissue papillae contain plasma

► Myoepithelioma ►Adenoid cystic

• Consists of single epithelial cells type

• Basal cell, canalicular, sebaceous, glycogen-rich, clear cell

• Most common types are

- Basal Cell Adenoma

• Benign salivary gland neoplasm

• Site: upper lip (75%)

• Age: 7th decade

• Gender: female predilection

• Symptoms: slow growing mass

• Conservative surgical excision

• Enucleation not recommended

• Can be misdiagnosed as a malignancy

• Solid nests of tumor cells