Tumour Like Lesions

Salivary gland
lesions
 • Nonneoplas1c,
noninflammatory
enlargement of salivary
glands, par1cularly the
paro1d gland.
• The enlargement is usually
bilateral and may manifest
recurrence or pain, or both
• The condi1on is almost
always found in associa1on
with systemic disorders;

Sialadenosis
Clinical Features

• chronic, afebrile salivary gland

enlargement, usually of the parotid
gland
• Enlargement--slowly evolving, indolent,
undulating, and recurrent.
• Persons in the later decades of life (4th
decade or beyond) are most affected
• Decreased salivary secretion occurs, and
sialochemistry generally demonstrates
increased levels of potassium and
decreased levels of sodium. Hypertrophy
of acinar cells crowds and compresses
the finer terminal ducts, thereby yielding
the sialographic ‘leafless tree’ pattern
Classifica.on of Sialadenosis
Hepatogenic sialadenosis
• Hormonal sialadenosis Pancreatogenic
Sex hormonal sialadenosis (exocrine) sialadenosis
Diabe2c sialadenosis
Thyroid sialadenosis Nephrogenic sialadenosis
Hypophyseal and adrenal cor2cal Dysproteinemic
disorders sialadenosis
• Neurohumoral sialadenosis Malnutri2onal
Peripheral neurohumoral sialadenosis
sialadenosis Mucoviscidosis
• Central neurogenous sialadenosis Drug-induced
• Dysenzyma2c sialadenosis sialadenosis
Histologic Features

• paro1d swelling is due to acinar enlargement

• diameter of the acinar cell increases two to three 1mes
that of normal
• The nuclei tend to be basally situated, and the cytoplasm
tends to be packed with granules
• Inflammatory cells are absent but individual fat cells may
be seen in the inters11al 1ssue
• Treatment
• Treatment is generally unsa2sfactory and depends on correc2ng the
underlying cause. Subtotal paro2dectomy may be considered as a last
resort.
Necro0zing Sialometaplasia: (Salivary gland infarc0on)

• Necrotizing Sialometaplasia (NS) is

a non-neoplastic inflammatory
condition of the salivary glands.
• Abrams et al, first reported this
condition.
E0ology

appear to arise spontaneously

others are associated with a history of trauma,

radia5on therapy, or surgery.

vascular ischemia

Tobacco use is suggested as a possible e5ologic risk

factor for NS.
Clinical Features

• involve the minor salivary glands of the oral cavity, par2cularly those
of the palate
• in the minor glands of the retromolar pad area, buccal mucosa,
tongue, incisive canal, and labial mucosa have also been reported
• paro2d and submandibular salivary glands, minor mucous glands in
the lung, nasal cavity, larynx, trachea, nasopharynx, and maxillary
sinus.
• The male-to-female ra2o is approximately 2 : 1. The average age of
pa2ents with NS is 47.9 years, with a range of 17–80 years.
• painless;
• swelling with or without ulceration in anatomic sites that have
mucous or serous glandular tissue.
• crateriform ulcer of the palate that simulates a malignant process
• These ulcerated lesions are 1–3 cm and are usually unilateral, but
bilateral synchronous lesions and metachronous lesions can occur
• Some lesions--submucosal swelling, without ulceration of the
overlying mucosa
• Erosion of the palatal bone may occur in either ulcerated or
nonulcerated lesions.
• Biopsy specimen-- to exclude a malignant or infec2ous process or an
inflammatory condi2on such as Wegener granulomatosis, Extranodal
lymphoma

•
Histologic Features

• Coagula2ve necrosis of glandular acini and squamous metaplasia of

its ducts. Mucin pooling is present, and an associated inflammatory
infiltrate consists of macrophages, neutrophils, and less commonly,
lymphocytes, plasma cells, and eosinophils
• Squamous metaplasia of salivary ducts. Lobular architecture of the
glands is intact.
• Pseudoepitheliomatous hyperplasia of the overlying mucosa can also
be present, but the cytologic features of the epithelial atypia are
usually absent.
• Occasionally, isolated mucous cells may be entrapped within the
squamous islands;
• Treatment and Prognosis
resolves spontaneously. No treatment is necessary.
Spontaneous resolu2on usually occurs within weeks.
The average healing 2me for NS of the minor salivary glands of the hard
and so[ palates is approximately five weeks.
Benign Lymphoepithelial Lesion: (Mikulicz syndrome,
dacryosialoadenopathia, Mikulicz-Radecki syndrome, Mikulicz-Sjögren
syndrome, von Mikulicz syndrome)

• Mikulicz disease is a chronic condi1on characterized by the abnormal

enlargement of the salivary and lacrimal glands.
• The tonsils and other glands in the so; 1ssue of the face and neck may also
be involved.
• Johann Mikulicz, a German surgeon first reported a case of chronic bilateral
lacrimal gland enlargement associated with enlargement of the salivary
glands.
• were caused by tuberculosis, sarcoidosis or lymphoma,
• The exact cause of Mikulicz disease is not known, although it is suspected
to be an autoimmune disorder.
•
Clinical Features

• Mikulicz disease affects more females than males and most o;en presents
during the middle adult years.
• It o;en occurs in combina1on with Sjögren syndrome.
• Mikulicz disease is characterized by the sudden onset of xerostomia that
may lead to difficulty in swallowing and result in tooth decay. Other
symptoms include enlarged lacrimal glands, leading to absent or decreased
tears; painless swellings (tumefac1ons) of the salivary glands (paro1d,
submaxillary) are no1ced.
• may experience recurring fevers. The fever may be accompanied by dry
eyes, diminished lacrima1on, and uvei1s. Lacrimal gland enlargement,
paro1d gland enlargement, dry mouth and dry eyes are the classic signs.
Histologic Features

• The disease is characterized by an orderly lymphocy2c infiltra2on of

the salivary gland 2ssue, destroying or replacing the acini, with the
persistence of islands of epithelial cells which probably represent
residua of gland ducts
• the lymphoid element is usually diffuse, actual germinal centers are
occasionally present.
• The epithelium may consist of ducts showing cellular prolifera2on and
loss of polarity, or as the disease persists, solid nests or clumps of
poorly defined epithelial cells which Morgan and Castleman termed
‘epimyoepithelial islands’.
• It has been suggested that such islands arise as a result of
prolifera2on of both ductal cells and peripheral myoepithelial cells. A
characteris2c change also found in advanced lesions is the deposi2on
of eosinophilic, hyaline material in the epithelial islands.
Treatment and Prognosis

• Biopsy of one of the swollen glands is key to the diagnosis of Mikulicz

disease.
• Treatment of this disorder is symptoma2c.
Sjögren’s Syndrome: (Sicca syndrome, Gougerot-
Sjögren syndrome)

• Sjögren’s syndrome is a condi2on originally described by Henrik

Sjögren in 1933, as a triad consis2ng of keratoconjunc2vi2s sicca,
xerostomia and rheumatoid arthri2s.
• Subsequently, it has been found that some pa2ents present only with
dry eyes and dry mouth (sicca complex or primary Sjögren’s
syndrome), while others also develop systemic lupus erythematosus,
polyarteri2s nodosa, polymyosi2s or scleroderma, as well as
rheumatoid arthri2s (secondary Sjögren’s syndrome).
E.ology

• gene2c, hormonal, infec2ous and immunologic,

• altered immunologic response
• the sicca complex and Sjogren’s syndrome have been found to be
associated with the HLA system, specifically HLA-DR3 and HLA-B8
which are associated with primary form of the disease and HLA-
DRw52 seen to be associated with both the forms of Sjögren’s
syndrome.
• Cytomegalovirus, paramyxo virus and Epstein-Barr virus
Clinical Features

• predominantly in women over 40 years of age, although children or

young adults may be affected
• The typical features of the disease are dryness of the mouth and eyes
as a result of hypofunc2on of the salivary and lacrimal glands. This
o[en results in painful, burning sensa2ons of the oral mucosa. In
addi2on, various secretory glands of the nose, larynx, pharynx and
tracheobronchial tree (buccopharyngolaryngi2s sicca), as well as of
the vagina, are involved with this dryness.
• Lymph adenopathy is more than twice as common in the primary
form of the disease.
• Rheumatoid arthri2s, as men2oned, is an integral part of secondary
Sjögren’s syndrome.
• pa2ents without rheumatoid arthri2s, that is, sicca complex or
primary Sjögren’s syndrome, more frequently manifest paro2d gland
enlargement, lymphadenopathy, purpura, Raynaud’s phenomenon,
kidney involvement and myosi2s.
Histologic Features

• Three types of histologic altera2ons in the major salivary glands

• intense lymphocy2c infiltra2on of the gland replacing all acinar
structures although the lobular architecture is preserved.
qanother, there may be prolifera2on of ductal epithelium and
myoepithelium to form ‘epimyoepithelial islands.
• third altera2on may be simply an atrophy of the glands sequen2al to
the lymphocy2c infiltra2on.
Laboratory Findings

• Over 75% of pa2ents with primary Sjögren’s syndrome have a

polyclonal hyperglobulinemia and many develop cryoglobulins
• Mul2ple organ- or 2ssue-specific an2bodies are found, including
an2salivary duct an2bodies, rheumatoid factor and an2nuclear
an2bodies
Radiographic Features

• Sialography may be of diagnos2c value in Sjögren’s syndrome.

• Sialographs demonstrate the forma2on of punctate, cavitary defects
which are filled with radiopaque contrast media.
• These filling defects have been said to produce a ‘cherry blossom’ or
‘branchless fruit-laden tree’ effect radiographically
Treatment and Prognosis

• There is no sa2sfactory treatment for Sjögren’s syndrome.

• Most pa2ents are treated symptoma2cally.
• Keratoconjunc2vi2s is treated by ocular lubricants
• Xerostomia-saliva subs2tute
• Extensive dental caries is a complica2on -scrupulous oral hygiene and
frequent fluoride applica2on is indicated to reduce this problem
• Surgery has been employed

•
Complica.ons
• pseudo lymphoma
• malignant lymphoma
Chronic Sclerosing Sialadeni0s of Submandibular Gland:
(Kü:ner tumor)

• Kuhner tumor or chronic sclerosing sialadeni2s is a benign

inflammatory condi2on of the submandibular gland that mimics a
malignant neoplasm clinically because of presenta2on as a hard mass.
Histologic Features

• excised submandibular glands revealed preserved lobular

architecture, thickening of interlobular septa by sclero2c 2ssue, dense
lymphoplasmacy2c infiltrate, preserva2on of ducts with periductal
fibrosis, and variable loss of acini.
• Fine-needle aspira2on cytologic findings were characterized by
scahered tubular ductal structures o[en enveloped by collagen
bundles or lymphoplasmacy2c infiltrate, isolated fragments of fibrous
stroma, a background rich in lymphoid cells, and paucity or absence
of acini.
Treatment and Prognosis

• an2bio2c therapy and rehydra2on of the pa2ent to s2mulate salivary

flow. Surgical drainage may be needed if there is abscess forma2on.