CASE 2

GROUP 2
MD 1-C
PATIENT PROFILE
50 year old patient
Female
Chief Complaint
Slow, painless swelling on left side of face
for 5 years
- swelling was initially small in size and
progressively increased with time to attain
present size
PATIENT PROFILE

Past medical and surgical history was

noncontributory
Extra-oral clinical exam: Marked Facial
Symmetry
 PATIENT PROFILE
Swelling was seen on the left side of the
side
- Well-defined, ovoid, multilobular
- It had a superioinferior extent from
mid body region to posterior border of the
mandible
- Firm, non-tender, warm on
palpitation
- Fixed to the underlying structures
and overlying skin
PATIENT PROFILE

Left ear lobule was slightly everted

Loss of wrinkling of the skin
Engorged veins was also seen

Normal facial and eye movements

Intraoral clinical exam was unremarkable
EXCISED TUMOR MASS
Gross Exam
- 5.0 x 2.0 cm
- Encapsulated, lobulated, pale
gray surface
- Occasionally multicystic with
mucinous/serous secretion
 EXCISED TUMOR MASS
Histopathology
Double layer of epithelial cells resting on
dense lymphoid stroma with variable
germinal centers

Cystic spaces are seen, narrowed by

polypoid projections of lymphoepithelial
elements
 EXCISED TUMOR MASS
Histopathology
There is surface palisading of
oncocytic columnar cells with
underlying discontinuous basal cells
DIAGNOSIS
WARTHIN’S TUMOR

picture
GUIDE QUESTIONS
1. Describe the normal histology of the parotid gland
Serous Intercalate Arteriole
acini d Duct

Striated
Duct

Interlobula
r
Connective
Tissue
Parotid Gland
Serous
Compound tubuloacinar gland
The secretory acini of the principal salivary gland are drained by ducts
Secretory Ducts: Simple Epithelium
Intralobular Ducts: Tall Columnar Epithelium
Intercalted Portion: Low Cuboidal Epithelium
Enclosed by a capsule
Arteriole, venule, and interlobular excretory ducts are located in the connective
tissue septa between the lobules.
Parotid Gland
Secretory cells forming the serous acini and arranged
around a lumen with pyramid-shaped cells

Serous’ spherical nuclei at the base of the slightly

basophilic cytoplasm

Small secretory granules

Intercellular secretory canaliculi

All serous acini are surrounded by means of slender

myoepithelial contractile cells situated between the serous
cells and the basement membrane

Some lobules of the parotid gland could comprise of

various adipose tissue
Parotid Gland
From the intercalated ducts
- Secretory products empty into bigger striated ducts
- These striated ducts have larger lumina
- Lined with simple columnar cells that display basal
STRIATIONS
Parotid Gland
The intercalated ducts
- Narrow channels where secretory serous acini empty
their product
- These ducts have tiny lumina
- Lined with either a simple squamous or low cuboidal
epithelium that are usually enclosed by myoepithelial cells
Striations
Membrane’s deep infoldings = Striations

Infoldings of the basolateral plasmalemma = Increase the surface

area

Mitochondria in the infoldings = Provide energy

Striated ducts  discharge product  intralobular excretory ducts
Intralobular excretory ducts join bigger interlobular excretory ducts
Lamina
Gradually widens
Epithelium becoming taller  Increased duct size
Epithelial tissue
Columnar to pseudostratified
Stratified columnar in big lobular excretory ducts
 2. What is a Warthin’s Tumor? What are its
characteristic histopathologic features?
- aka lymphomatous papillary
cystadenomas
- benign, sharply demarcated tumors of
the salivary gland
- 2nd most common benign parotid tumor
- typically occur in the elderly
- patients typically present with painless
parotid swelling
Histologic Description
Lining epithelium: Multiple Papillary Infoldings.

Papillary formations: Tall columnar cells enclosing a dense

lymphoid population with or without lymphoid follicles.

Epithelium: Oncocytic in nature

Double layer of epithelial cells resting on dense lymphoid
stroma with variable germinal centers

Inner cells = tall columnar cells with centrally placed, slightly

hyperchromatic nuclei
Second layer = polygonal cell having more vesicular nuclei
Epithelium is supported by lymphoid stroma

Focal areas of squamous metaplasia may be seen

Lymphoid aggregates in connective tissue stroma

Papillary Cystadenoma Lymphomatosum
Cystic space contains eosinophilic coagulum

Cystic spaces narrowed by polypoid projections of

lymphoepithelial elements

Surface palisading of oncocytic columnar cells with

underlying discontinuous basal cells
Occasional features are:
Cilia
Squamous metaplasia associated with infarct-like necrosis
Mast cells
Dendritic cells
Mucin secreting cells
Sebaceous cells
• Very rarely signet ring cells
• No myoepithelial component
 3. Compare the histology of the parotid gland to a pleomorphic
adenoma
  Parotid Gland Pleomorphic Adenoma
● Intralobular: Compound acinar serous ● Presence of chondromyxoid foci
gland surrounded by contractile ● Glanduloductal differentiation: Tubular and
myoepithelial cells gland-like structures surround myoepithelial
● Acinar cells are fairly uniform in size, cells
Key structure, and staining ● Lack of infiltrative growth pattern
characteristics ● Perineural invasion
● Pseudopodia or satellite nodules
● Biphasic population of epithelial,
myoepithelial, and mesenchymal cells

Cytoplasm Basophilic zymogen granules Eosinophilic

Stromal Myxoid, chondroid, hyaline, or osseous

Glandular with adipocytes
component differentiation
 3. Compare the histology of the parotid gland to a pleomorphic
adenoma
  Parotid Gland Pleomorphic Adenoma

Epithelial tissue Intralobular ducts: pseudostratified columnar Stratified squamous epithelium

epithelium
Interlobular ducts: cuboidal epithelium

Capsule Parotid sheath Fibrous capsule with variable thickness

Myoepithelial morphology Stellate-shaped Plasmacytoid or spindle

Myoepithelial description Thin layer above the basement membrane beneath Myoepithelial cells form random
the luminal cells clusters or dense fascicles which mimics
myoepithelioma or nerve-sheath tumor

Other descriptions Interlobular: presence of blood vessels, nerves and Punctuated with myxochondroid areas
large excretory ducts embedded in myxoid
4. Identify common causes of the condition.
Cigarette smoking
irritation of the ductal epithelium
by tobacco smoke --> initiates the
tumorigenesis
trigger ductal hyperplasia and
oncocytic metaplasia in
preexisting lymph nodes
Cigarette smoking
Mitochondria-rich oncocytic cells may show structural
abnormalities and reduced metabolic function.
Smoking may potentiate this damage due to development of
reactive oxygen species
Cigarette smoking
Studies have detected high rates of deleted mitochondrial DNA
in oncocytic cells of WT
Atomic Bomb Survivors
Saku et al (1997)
radiation may also be implicated
in the Warthin’s tumorigenesis
role for ionizing radiation in
salivary gland tumorigenesis
Epstein–Barr virus
Santucci et al.
EBV: frequently present in the
cytoplasm of neoplastic cells of
multiple/bilateral Warthin’s tumor
occasionally: solitary Warthin’s
tumor
Auto-immune Reaction
Orabona et al (2015)
 autoimmune thyroiditis
5. How was the biopsies tissue processed in the laboratory?
Briefly describe the processing technique that was used.

FIXATION
 preserve the morphological and chemical integrity of the cells
 harden and protect the tissue from trauma of further handling
Fixative: 10% Neutral Buffered Formaldehyde
FIXATION

 Rate of penetration:
1mm/hour
Duration of fixation: 5 hours
(minimum)
Amount of fixative: 10-20
times the volume of the tissue
specimen
Thickness of specimen: NMT 5
mm
DEHYDRATION
 removing fixative and
intercellular and extracellular
water from the tissue prior to
impregnations
 Ethyl alcohol
ascending concentrations (70%,
95%, 100%)
CLEARING (DE-ALCOHOLIZATION)
 Dehydrating agent is replaced with
a substance that will dissolve the
paraffin wax
facilitate the penetration of the
embedding medium
translucent appearance
CLEARING (DE-ALCOHOLIZATION)
 Xylene
– most rapid clearing agent
- biopsies
- clears within 15-30 minutes.
IMPREGNATION (INFILTRATION)
 completely removing the clearing agent from the tissue
replacing it with a medium that will fill all tissue cavities
firm consistency to the specimen
easier handling and cutting of suitably thin sections
IMPREGNATION (INFILTRATION)
 Impregnating medium: Paraffin
wax
 Melting point of paraffin wax:
54-60˚C
Volume of wax: 25-30 times
volume of specimen
Duration of impregnation: 3-4
hours
EMBEDDING
impregnated tissues:
placed in a mold
precisely arranged
position
mold containing a
medium --> solidify
EMBEDDING

surface of the tissue section to be cut: placed parallel to the

bottom of the mold
plastic ice trays, paper boats , disposable, compound embedding
units
TRIMMING
removal of excess wax
expose tissue surface
preparation for
cutting/microtomy/sectioning
thickness of wax: 2 mm surrounding
the tissue
SECTIONING/CUTTING/MICROTOMY
cutting of tissue into uniformly thin slices or sections
microtome: rotary microtome
floated out on a water bath
- 45 to 50 deg C
flatten out the sections before mounting them into the slides
SECTIONING/CUTTING/MICROTOMY
 sections are fished out from the water
bath
slide with an adhesive (Mayer's Egg
albumin)
sections: fixed in a hot plate
STAINING
 H&E stain
 routine procedure:
• deparaffinization (2
xylene baths)
• rehydration (descending
grade of alcohol)
• hematoxylin staining
STAINING
 routine procedure:
• differentiation (acid alcohol)
• blueing
• counterstaining (eosin staining)
• dehydration (increasing grade of alcohol)
• clearing (xylene)
• mounting
• slide examination
 MOUNTING
 mounting medium is applied between the
stained section and the coverslip
setting the section firmly
improves the clarity of the section
Canada balsam
6. What tissue stain was used in this case? Justify your
answer. Describe this staining process.
EOSIN AND HEMATOXYLIN
-first stain used
-recognizing various tissue types and the
morphological changes for CANCER DIAGNOSIS
-The tumor is then evaluated by
immunohistochemical (IHC) staining to
confirm the diagnosis of Warthin’s tumor.
-IHC staining is widely used in the diagnosis of
abnormal cells such as those found in
cancerous tumors. 
 EOSIN AND HEMATOXYLIN

Staining process:
Hematoxylin is oxidized →HEMATEIN (active staining component of the hematoxylin stain)
Hematoxylin stains must 'ripen' by oxidation before they can be used.
requires the use of a mordant → nuclear components of cells a dark blue.
used with EOSIN stains the cytoplasmic organelles varying shades of pink, red or orange.
The combination of the two stains provides a broad range of morphological information about
the section.
EOSIN AND HEMATOXYLIN
H & E Stain with Harris' Hematoxylin
1. Stain rehydrated sections in Hematoxylin solution for 20-40 minutes.
2. Wash in tap water for 1-5 minutes, until sections turn blue ("bluing").
3. Differentiate sections in 70% ethanol—containing 1% HCl—for 5 seconds. This removes
excess dye, allowing nuclear details to emerge.
4. Wash 1-5 minutes in tap water until blue.
5. Stain in Eosin solution for 10 minutes.
6. Wash 1-5 minutes in tap water.
7. Dehydrate, clear and mount.
7. Are special stains necessary in this case? Why or why not?
If yes, give example of such stains.
Special stains are not necessary for this case.
FINE-NEEDLE ASPIRATION (FNA) BIOPSY ALONG WITH HEMATOXYLIN-EOSIN STAINING
- gold standard method diagnosis of this benign type of tumor
IMMUNOHISTOCHEMISTRY (IHC)
- will be used if it is a malignant Warthin’s tumor
- but this type of tumor rarely progress into its malignant form
 
 
References: