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Salivary gland; Non-neoplastic lesions

There are three major salivary glands; parotid, submandibular and sublingual. There are innumerable minor salivary glands. These glands can be involved by neoplastic as well as non-neoplastic lesions including inflammation, radiation induced and related to obstruction

    • Sialolithiasis:
      • Cause:  obstruction of orifices of salivary gland, may be due to impacted food debris or edema around orifices due to some injury. Frequently, no cause is detected.
      • Location: Three-fourths occur in major salivary gland. Half of these cases occur in salivary gland due to tortuous salivary duct and thick mucin-rich secretions.
      • Composition: calcium salts and cellular debris.
      • Histologically: chronic inflammatory cells, acinar atrophy and metaplasia.
    • Mucocele:
    •         Most common lesion.
      • Cause: blockage or rupture of salivary gland duct leading to leakage of saliva into surrounding stroma.
      • Location: Minor salivary glands. Lower lip, cheeks, floor of mouth and dorsal surface of tip of tongue
      • Clinical appearance: fluctuant swelling with a blue hue.
      • Gross appearance: well-circumscribed, blue-white cyst
      • Microscopic appearance: Pseudocyst with the cyst wall composed of compressed connective tissue with a denuded epithelial lining and granulation tissue. Chronic inflammatory cells are also present.
    • Ranula:
      • Cause: Exact etiology is not known but damage to the salivary gland duct is a cause.
      • Location: sub-lingual salivary gland
      • Clinical presentation: cyst on floor of mouth
      • Microscopic appearance: epithelial lined cyst with extravasated
    • Lymphoepithelial cyst:
    • Associated with HIV positive patients.
      • Location: parotid gland
      • Clinical presentation: single or multiple lesions.
      • Microscopic appearance: cysts are lined by flattened to stratified squamous epithelium surrounded by lymphoid stroma with germinal centers.
    • Sclerosing polycystic adenosis:
      • New entity added in the WHO classification of salivary gland lesion placed under other epithelial lesions.
      • Location: parotid gland
      • Age: broad but usually fourth decade
      • Gender: female predilection
      • Gross: mass with several centimetres in diameter
      • Microscopic appearance: well-circumscribed tubulocystic proliferation of glands in sclerotic stroma. Presence of acini with aberrant coarse red zymogen granules. Myoepithelial lining is present around the proliferating tubules helping to differentiate it from adenocarcinoma
    • Necrotizing sialometaplasia:
      • Infarctive, inflammatory and metaplastic error
      • Location: seromucinous glands, usually palatal minor salivary glands.
      • Cause: vascular compromise may be due to trauma or previous surgery
      • Microscopic appearance: Infarction of seromucinous gland with extravasation of luminal content, necrotic acini with metaplastic squamous cells. Acute and chronic inflammatory cells. Prominent mitotic activity and mild cytological atypia can also be seen.
      • Differential diagnosis: it can be confused with mucoepidermoid carcinoma. Differentiating points are:

Features

Mucoepidermoid ca

Necrotizing sialometaplasia

Pattern

infiltrative

Lobular

Inflammation

Not present esp neutrophils

Present,both  acute and chronic

Cells

Basal, intermediate, clear, squamous, mucus and oncocytic

Squamous,mucus and acinar cells

 

    • Radiation-related changes:
      • This non-neoplastic lesion is prone to be confused with the tumors of salivary gland
      • Salivary glands are sensitive to radiation therapy in head and neck area
      • Marked atrophy with variable degrees of chronic inflammation
      • Cells with enlarged, hyperchromatic, smudged nuclei with increased cytoplasm maintaining the nuclear to cytoplasmic ratio
      • The differential diagnosis includes the mucoepidermoid carcinoma or squamous cell carcinoma
      • Maintainence of lobular architecture, inflammation and lack of basal, intermediate and oncocytic cells helps to differentiate these entities.
    • Inflammatory lesions included in the non-neoplastic lesions of salivary glands are as follows
    • Acute sialadenitis:
      • Predisposing conditions: Trauma, immunosuppression, duct obstruction.
      • Causative agent: Bacteria: Staphylococcus or streptococcus , Viral: EBV,CMV, mumps virus and coxsackie virus
      • Microscopic appearance: dense chronic inflammation, interstitial edema and vacoulization of acinar cells.
    • Chronic sialadenitis:
      • Cause: chronic duct obstruction
      • Microscopic appearance: glandular atrophy and chronic inflammation with some fibrosis
    • Chronic sclerosing sialadenitis: (kuttner’s tumor)
      • Location: submandibular gland
      • Clinical presentation: palpable mass
      • Microscopic appearance: lobular architecture, lymphoplasmacytic inflammatory infiltrate, periductal fibrosis
      • It is member of IgG4 related disease
      • MALT type lymphoma can arise in this setting
    • Granulomatous sialadenitis:
      • caused by fungus, tuberculosis, cat-scratch disease and sarcoidosis
      • granulomas composed of epithelioid histiocytes, multinucleated histiocytes and lymphocytes
      • necrosis may or may not be present
    • Xerostomia:
      • of autoimmune disease and microscopic evidence of sjogren syndrome
      • Microscopic findings: Benign lymphoepithelial lesion: It is characterized by infiltration of ductal epithelium by lymphocytes forming epimyoepithelial islands.
      • In minor salivary gland, four lobules with at least two foci of lymphocytes with a focus containing 50 or more lymphocytes.
      • There is increased risk of lymphoma in patients with sjogren’s syndrome
    • Other epithelial lesions:
    • These are new entities in the nonneoplastic lesion of salivary gland added in new WHO classification of salivary gland
      • Intercalated duct hyperplasia:
        • Occur in parotid gland. Size is less than 1cm.the encapsulated lesion are called intercalated adenoma. These are precursor to basal cell adenoma and epithelial-myoepithelial carcinoma
      • Nodular oncocytic hyperplasia:
        • Parotid gland is involved. 5th and 6th Multiple unencapsulated solid to tubulo-trabecular pattern nodules of oncocytes. In contrast to oncocytosis no dominant encapsulated lesion is seen.
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