Received: 17 May 2017 | Revised: 13 June 2017 | Accepted: 29 June 2017

DOI: 10.1002/dc.23785

BRIEF REPORT

Cytological features of the Warthin-like variant

of salivary mucoepidermoid carcinoma

Jen-Fan Hang, M.D.1,2,3 | Chung H. Shum, M.D., Ph.D.4 | Syed Z. Ali, M.D.1,5 |
Justin A. Bishop, M.D.1

1
Department of Pathology, The Johns
Hopkins Hospital, Baltimore, Maryland
Abstract
2
Department of Pathology and Laboratory Warthin-like mucoepidermoid carcinoma is a recently proposed variant of musoepidermoid carci-
Medicine, Taipei Veterans General Hospital, noma. Histologically, it is characterized by its close resemblance to Warthin tumor, including dense
Taipei, Taiwan lymphocytic infiltration, flattened intermediate epithelium resembling squamous metaplasia, and
3
School of Medicine, National Yang-Ming cystic change. Given its histologic similarity to Warthin tumor, confirmatory testing for MAML2
University, Taipei, Taiwan
rearrangement is often required for this diagnosis. Here we present the first cytologic reports of
4
Dahl-Chase Diagnostic Services, Bangor,
two 53-year-old female patients with parotid masses. In both cases, the fine needle aspirations
Maine
5
showed fragments of bland epithelium with a squamous appearance, mucinous cyst content, and
Department of Radiology, The Johns
Hopkins Hospital, Baltimore, Maryland focal lymphocytic background. Neither frank keratinization nor mucinous cells were identified in
the smears. Fluorescence in situ hybridization (FISH) study confirmed MAML2 rearrangement on
Correspondence the resection specimens in both. Other cytologic differential diagnoses, including Warthin tumor
Dr. Justin A. Bishop, Department of
with metaplasia, lymphadenoma, and lymphoepithelial cyst, were briefly discussed.
Pathology, The Johns Hopkins Hospital,
401 N. Broadway, Weinberg Building 2249,
Baltimore, MD 21231. KEYWORDS
Email: jbishop@jhmi.edu fine needle aspiration, mucoepidermoid carcinoma, salivary gland, warthin tumor

1 | INTRODUCTION of this tumor.14 Recently, a new variant called Warthin-like mucoepider-

Fine needle aspiration (FNA) of salivary glands is a challenging field in
cytopathology due to a large variety of tumor types that can arise from
this organ. Mucoepidermoid carcinoma is the most common malignant
1 variable mucinous cells. However, the bilayered tall columnar oncocytic
tumor in salivary glands. Definite cytologic diagnosis of mucoepider-
moid carcinoma requires presence of all three tumor components,
including squamous cells, intermediate cells, and mucinous cells.2–4
However, it is not always possible to representatively sample all these
elements in cytologic specimens. Mucoepidermoid carcinoma may be
misdiagnosed as a benign cystic lesion when it presents exclusively with
cyst contents or as other benign salivary gland tumors when it shows
only bland intermediate cells. 2,5–11
Hence it is among the most common
salivary gland carcinomas that are missed on FNA (false-negative). In
moid carcinoma has been introduced.15 This variant is characterized by
prominent lymphocytic infiltration and cystic change, features that
closely resemble a Warthin tumor. The epithelium is composed of flat-
tened intermediate epithelium resembling squamous metaplasia and
epithelium that is typical for a Warthin tumor is absent. The main con-
sideration in the differential diagnosis of this variant is a metaplastic
Warthin tumor, and confirmatory testing for MAML2 rearrangement is
often needed to make the distinction. To the best of our knowledge,
there are no published cytologic reports of molecularly confirmed
Warthin-like mucoepidermoid carcinoma in the English literature. Here
we present the first two FNA cases with histologic confirmation and flu-
orescent in situ hybridization (FISH) study of MAML2 gene.

addition, benign salivary gland lesions, such as oncocytic tumors and epi-
thelial cysts, can also harbor squamous metaplasia that mimics the squa-
mous and intermediate components of a low-grade mucoepidermoid 2 | CASE REPORT
carcinoma.12 Therefore, mucoepidermoid carcinoma is also a frequent
2.1 | Case 1
false-positive diagnosis for benign conditions in salivary FNA.5,9–11,13
Several histologic variants of mucoepidermoid carcinoma have been This 53-year-old woman presented with a right facial mass at The
proposed and that may further complicate the cytologic interpretation Johns Hopkins head and neck surgery clinic. The mass was fixed,

Diagnostic Cytopathology. 2017;1–5. wileyonlinelibrary.com/journal/dc V

C 2017 Wiley Periodicals, Inc. | 1
2 |
FIGURE 1 Case 1. (A) Diff-Quik stained smears showed bland squamous-appearing epithelial fragments in a background of abundant
mucin (3200). (B) The epithelial cells had dense cytoplasm and cytoplasmic processes (3400). (C) In focal areas, lymphocytic infiltration
within the epithelial fragments was noted (3100). (D) Background lymphocytes, histiocytes, and scant multinucleated giant cells were seen
(3100) [Color figure can be viewed at wileyonlinelibrary.com]
rubbery, and not painful. Nonspecific headache was mentioned but she
denied dysphasia, odynophagia, or unintentional weight loss. Magnetic
resonance imaging revealed a solid nodule in the inferior aspect of the
right parotid gland, measuring 2.3 3 1.3 3 1.2 cm3. Fine-needle aspira-
tion biopsy was performed under sonographic guidance. Eight conven-
tional smears were made for cytopathology interpretation. The air-
dried smears were stained with Diff-Quik stain and the alcohol-fixed
smears were stained with Papanicolaou stain.
The cytologic smears were moderately cellular with scattered epi-
thelial fragments in a background of abundant mucin (Figure 1A). The
epithelial fragments were composed of bland squamous-appearing cells
with dense cytoplasm and cytoplasmic processes (Figure 1B). There
was no frank keratinization, cytoplasmic mucin, or unequivocal onco-
cytic epithelium identified. In focal areas, there were lymphocytic infil-
trates within the epithelial fragments. In these areas, the epithelial cells
were polygonal with abundant cytoplasm (Figure 1C). Background lym-
phocytes, histiocytes, and scant multinucleated giant cells were also
noted (Figure 1D). Based on the cytomorphology, the original diagnosis
was “suspicious for a low-grade mucoepidermoid carcinoma, but can-
not exclude a non-neoplastic cyst with reactive/metaplastic changes.”
The patient underwent superficial parotidectomy. The specimen
consisted of one encapsulated, pink-tan and soft nodule, measuring
3.3 3 2.3 3 1.5 cm3, with scant attached salivary tissue. On serial
sections, it grossly showed a multiloculated cystic lesion with markedly
viscous mucinous content and focal dark brown discoloration.
HANG ET AL.
Histologically, the tumor consisted of a multiloculated cystic epithelial
proliferation surrounded by a well-circumscribed cuff of prominent
lymphoid stroma. The cystic epithelial lining was predominantly attenu-
ated and squamoid with scattered mucinous cells. In some areas, how-
ever, it had a two cell layer arrangement but lacked the classic
bilayered oncocytic epithelium of Warthin tumor. The cystic spaces
were filled with proteinaceous material, and there was scarring with
cholesterol clefts in the stroma. There was a 0.2-cm area of smaller,
more infiltrative-appearing tumor nodules, with an appearance more
classic for mucoepidermoid carcinoma. The epithelial components were
cytologically bland. There was no perineural or lymphovascular invasion
and the surgical margin was negative for tumor. Break-apart FISH for
MAML2 identified split signals in both the Warthin-like and more con-
ventional mucoepidermoid elements of the tumor.
2.2 | Case 2
This 53-year-old white woman was referred to otolaryngology by her
primary care provider for evaluation of a left parotid mass. The lesion
had been present for 1 year and gradually enlarging, without any signif-
icant symptoms. She had a prior history of tobacco use but switched to
electronic cigarettes. Physical exam revealed a mass in the left parotid,
which was non-tender and deep. A contrasted computerized tomogra-
phy scan revealed a 2.4 3 2.0 3 1.4 cm3 hyperdense parotid mass,
which was interpreted as most consistent with an enlarged lymph
HANG ET AL. | 3

FIGURE 2 Case 2. (A) Papanicolaou stained smears showed a epithelial fragment in a proteinaceous background. The epithelial cells had
bland nuclei, dense cytoplasm, and cytoplasmic process (3400). (B) Background lymphocytic infiltrates and tangles were noted (3100)
[Color figure can be viewed at wileyonlinelibrary.com]

node. Fine needle aspiration was performed using a 22-gauge needle
and producing two alcohol-fixed conventional smears, which were pre-
pared with Papanicolaou stain. It was diagnosed as “few benign epithe-
lial cells in a myxoid background, suggesting a pleomorphic adenoma.”
After the procedure, the patient underwent left parotidectomy. The
cytologic smears along with the histologic slides were sent to us in
consultation.
On the cytologic smears, there were scattered epithelial fragments
in a proteinaceous background. The epithelial cells had a squamous
appearance with bland nuclei, dense cytoplasm, and cytoplasmic
process (Figure 2A). There was no frank keratinization, cytoplasmic
mucin, or unequivocal oncocytic epithelium identified. In focal areas,
lymphocytic infiltrates and tangles were noted (Figure 2B). Our FNA
diagnosis was “salivary neoplasm, suspicious for a mucoepidermoid car-
cinoma.” The tumor was resected and on gross examination there was
a 2.5 3 1.9 3 1.1 cm3 well circumscribed nodule with a granular, tan-
gray cut surface with vague papillations, and adjacent normal-
appearing parotid tissue. On the histologic sections, the tumor was
very similar to case 1. It consisted of a multicystic epithelial prolifera-
tion with a surrounding well-circumscribed chronic inflammatory

FIGURE 3 Case 2. (A) The hematoxylin and eosin-stained surgical pathology section revealed a well-circumscribed nodule of cystically
dilated glands and lymphoid stroma with germinal centers (320). (B) The squamoid epithelial lining of the cysts vaguely resembled that of
Warthin tumor, but never exhibited the bilayered oncocytic epithelium characteristic of Warthin tumor (3400). There were a few scattered,
smaller nests with an infiltrative appearance and a fibrotic stromal reaction (3100). All components of the tumor harbored MAML2 rear-
rangement as demonstrated by positive break-apart fluorescence in situ hybridization [Color figure can be viewed at wileyonlinelibrary.com]
4 |
infiltrate with germinal centers (Figure 3A). The cystic epithelial lining
was bland, eosinophilic, and squamoid with occasional, scattered muci-
nous cells (Figure 3B). Again, while there was a bilayered or multilay-
ered appearance, the classic bilayered oncocytic epithelium of Warthin
tumor was not identified. Between the large cysts were rare scattered
solid or microcystic nests with an infiltrative appearance and a fibrotic
reaction (Figure 3C). There was no perineural or lymphovascular inva-
sion, and the margins were negative for tumor. Break-apart FISH for
MAML2 revealed split signals in both the large cysts and smaller nests
(Figure 3D).
3 | DISCUSSION
Mucoepidermoid carcinoma can rarely arise from Warthin tumor 15–18
and the relationship between these two tumors has long been contro-
versial. Recent molecular studies have demonstrated chromosomal
rearrangements resulting in CRTC1/3-MAML2 fusion gene in the major-
ity of mucoepidermoid carcinomas, preferentially in low-grade tumors
with favorable prognosis.19–25 However, this genetic change was also
originally reported in a subset of Warthin tumors. 21,26–28
These
translocation-positive “Warthin tumors” were reported to harbor
squamous metaplasia, making the morphological distinction with a
mucoepidermoid carcinoma more ambiguous. However, Skalova, et al.
investigated metaplastic Warthin tumors (and pleomorphic adenomas)
but found no cases to harbor MAML2 fusions. 29
Garcia, et al. originally
used the term “Warthin-like” MEC to describe a subtype of the onco-
cytic variant of MEC.30 More recently, using whole slide digital imaging
of FISH sections, Ishibashi et al. demonstrated that MAML2 split signals
were present in the metaplastic epithelial cells in the fusion-positive
“Warthin tumors” but absent in the fusion-negative tumors. 15
Further
detailed histologic comparison shows that although the metaplastic
areas were morphologically indistinguishable between these two
groups, bilayered tall columnar oncocytic epithelium is virtually absent
in all fusion-positive tumors but always present in various portions in
the fusion-negative tumors. In addition, the age and sex distributions
of fusion-positive tumors were more concordant with that of mucoepi-
dermoid carcinomas than Warthin tumors. Based on these observa-
tions, the authors proposed that these fusion-positive metaplastic
Warthin tumors were, in fact, better classified as a separate subtype,
“Warthin-like” mucoepidermoid carcinomas.15
Histologically, Warthin-like mucoepidermoid carcinoma exhibits
dense lymphocytic infiltration and cystic change that resemble a
Warthin tumor on low power. The tumor epithelium has a metaplastic
appearance with squamoid and goblet cells that could be interpreted as
intermediate and mucinous cells as in mucoepidermoid carcinoma.
While Garcia et al. regarded Warthin-like MEC as a subtype of the
oncocytic variant of MEC,30 oncocytic change is generally focal in
Warthin-like MEC, and less striking than in true Warthin tumor.
Unequivocal bilayered tall columnar oncocytic epithelium that defined
Warthin tumor is absent. Molecular testing demonstrating MAML2
rearrangement is recommended for the confirmation of this variant
HANG ET AL.
and to distinguish it from a true Warthin tumor with metaplasia, which
is fusion-negative.
Both of our FNA biopsies of Warthin-like mucoepidermoid carci-
nomas showed fragments of bland epithelium with a metaplastic and
squamoid appearance, mucinous or proteinaceous cyst content, and
focal lymphocytic background. Without sampling of mucinous cells,
diagnosis of a Warthin-like mucoepidermoid carcinoma or a low-grade
mucoepidermoid carcinoma with lymphocytic infiltration cannot be
ascertained on FNA. The differential diagnoses should include other
benign salivary lesions. For Warthin tumor with metaplastic change,
the cystic content is usually more granular than mucinous. In addition
to metaplastic epithelium, tall columnar oncocytic epithelium is at least
focally present. The other less common diagnostic considerations
include lymphadenoma and lymphoepithelial cyst. Extravasated sebum
and sebaceocytes may be seen in sebaceous lymphadenoma.31,32 Basa-
loid type epithelium and basement membrane material are noted in
nonsebaceous lymphadenoma.33 Without the ultrasonographic findings
and history of HIV infection, the distinction with a lymphoepithelial
cyst on FNA would be very difficult.34
In conclusion, here we report the first cytologic illustration of two
molecularly confirmed Warthin-like mucoepidermoid carcinomas. Diag-
nosis of this mucoepidermoid carcinoma variant is difficult on FNA.
The differential diagnosis should include other benign salivary lesions
with metaplastic epithelium and lymphocytic infiltration. To request
more material for cell block and FISH study would be helpful for the
confirmation.
CONFLICT OF INTERE ST
The authors have no relevant disclosures. This study was conducted
without a funding source.
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How to cite this article: Hang J-F, Shum CH, Ali SZ, Bishop JA.
Cytological features of the Warthin-like variant of salivary
mucoepidermoid carcinoma. Diagnostic Cytopathology. 2017;00:
1–5. https://doi.org/10.1002/dc.23785