Fine-needle aspiration biopsy of salivary duct carcinoma: report of five cases

Mucoepidermoid carcinoma: Analysis of 76 cytologic cases and correlation with histologic grade

BACKGROUND

Mucoepidermoid carcinoma (MEC) is the most common salivary gland (SG) malignancy. In this study, the author undertook analysis of a large collection of MEC cytologic cases.

MATERIALS AND METHODS

Cytopathology files were searched for MEC cases with histopathologic confirmation. Fine-needle aspiration (FNA) smears used standard technique.

RESULTS

Seventy-six cases (63 patients [M:F = 1:1; age range, 23-87 years; mean age, 58 years]) met inclusion criteria. Aspirates were primary (54 [71%]), metastatic (18 [24%]), and locally recurrent (4 [5%]). FNA sites included parotid gland (49 [64%]), regional lymph nodes (11 [14%]), submandibular gland (5 [7%]), inner canthus of eye (2 [3%]), and lung (2 [3%]); and single specimens from palate, jaw, shoulder, paranasal sinus, floor of mouth, ear canal, and effusion. Cytologic diagnoses included MEC (30 cases [39%]), suspicious for MEC (16 [21%]), non-MEC carcinoma (9 [12%]), suspicious for malignancy (SM) (2 [3%], malignant (M) (1 [1%]), SG and/or suspicious SG neoplasm (7 [8%]), atypical (3 [5%]), nonneoplastic (5 [6%]), nondiagnostic (2 [3%]), and benign SG neoplasm (1 [1%]). A total of 26% of low-grade (LG) cases were diagnosed as malignant in contrast to 87% malignant in high-grade (HG) cases. Cytomorphology depended on tumor grade. LG MEC contained intra- and/or extra-cellular mucin and more uniform cell and/or nuclear morphology, whereas cytologic atypia, anisonucleosis, and keratotic cells were more typical of HG tumors.

CONCLUSION

A malignant (M) or suspicious for malignancy (SM) cytologic interpretation was made in 76% of mucoepidermoid carcinoma (MEC) cases. In contrast to high-grade MEC (97% identified as M/SM), only 59% of low-grade (LG) MEC cases were interpreted as such, illustrating the continued diagnostic challenge posed by LG MEC using fine-needle aspiration biopsy.

Salivary duct carcinoma: A report of 70 FNA cases and review of the literature

BACKGROUND

Although usually recognized as malignant, fine-needle aspiration (FNA) biopsy of salivary duct carcinoma (SDC) has been confused with other primary salivary gland (SG) neoplasms. This article undertook an analysis of a large collection of SDC FNA cases to assess diagnostic accuracy, specificity, and cytopathology.

METHODS

Cytopathology files were searched for SDC with histopathologic validation. FNA biopsy smears were performed using standard techniques.

RESULTS

Seventy cases from 56 patients (M:F, 1.9:1; age range, 26-92 years; mean age, 65 years) met inclusion criteria. All had tissue confirmation of SDC. FNA sites included: parotid gland (42, 60% cases), neck (10), submandibular gland (7), pre-/post-auricular area (5), face/cheek (3), mediastinal lymph nodes (2), and clavicle (1). Aspirates were from primary (52, 74%), metastatic (12, 17%), and locally recurrent (6, 9%) neoplasms. FNA diagnoses included: SDC (19, 27%), favor/suspicious for SDC (7, 10%), high-grade carcinoma (11), adenocarcinoma (9), carcinoma (6), malignant (6), SG neoplasm (5), atypia (3), SDC versus another malignancy (2), and pleomorphic adenoma (2). Large polygonal cells in groups and single forms showed cribriforming, variable necrosis, pseudopapillae, and oncocytic change. Androgen receptor staining was positive in all cases.

CONCLUSIONS

FNA biopsy is accurate and reliable in classifying SDC as a malignant neoplasm, but much less so for identification as a specific tumor type. Using the Milan system, 86% of aspirates were classified as either malignant or suspicious for malignancy. A recurring pitfall includes sampling error in cases of SDC ex pleomorphic adenoma.

Oncocytic features in salivary duct carcinoma, a potential pitfall for misdiagnosis as Warthin tumor in fine needle aspiration specimens: A cytomorphologic analysis of 14 cases

BACKGROUND

Salivary duct carcinoma (SDC) is an uncommon and highly aggressive primary salivary gland neoplasm. Cytomorphologic features of SDC include cellular smears, nuclear atypia, prominent nucleoli, cribriform and papillary architecture, and background necrosis. The presence of oncocytic features has been described but not adequately characterized in the current literature.

METHOD

This study cohort consisted of 14 cases of histologically proven SDC with previous salivary gland fine needle aspiration (FNA). The cytologic material of each case was semi-quantitatively analyzed and evaluated for various cytomorphologic, architectural, and background features.

RESULTS

Twelve SDCs were located in the parotid gland and two in the submandibular gland. In two cases the initial cytologic diagnoses was Warthin tumor or favor Warthin tumor. Moderate to marked degree of oncocytic changes were noted in all cases except one case. Nuclear atypia was variable with most cases exhibiting moderate to high-grade nuclear features, while four cases demonstrated low-grade nuclear cytomorphology. Cytoplasmic vacuolation was seen in nine cases and variable amount of background necrosis was observed in eight cases. Cribriform and papillary architecture was recognized in only six cases. Background lymphocytes were absent in all but one case.

CONCLUSIONS

Precise diagnosis of SDC based on cytomorphologic features alone can be challenging. Oncocytic change is one of the most consistent features observed in this case series and when associated with less pronounced cytologic atypia, can potentially lead to misdiagnosis as Warthin tumor. SDC should be considered in the differential diagnosis of oncocytic salivary gland neoplasms where precise diagnosis is not possible.

Updates in Salivary Gland Fine Needle Aspiration Biopsy: The Use of the Milan System and Ancillary Testing

Salivary gland fine needle aspiration biopsies remain common specimens seen by most cytology services. The diagnostic diversity and overlap between many of the lesions seen with these biopsies impart many challenges for the cytopathologist, rendering most specific diagnoses impossible with cytology alone. Here, the use of the Milan System for the classification of salivary gland fine needle aspiration biopsy FNAB is discussed, together with the potential use of ancillary testing in arriving at definitive diagnoses.

Salivary gland tumor fine-needle aspiration cytology: a proposal for a risk stratification classification

OBJECTIVES

Fine-needle aspiration (FNA) is useful in the evaluation of salivary gland tumors, but currently no standard terminology or risk stratification model exists.

METHODS

FNA smears were reviewed and categorized based on cytonuclear features, stromal characteristics, and background characteristics. Risk of malignancy was calculated for each category. Classifications as benign, neoplasm of uncertain malignant potential (NUMP), suspicious for malignancy, and positive for malignancy were used to aggregate categories into similar risk groups.

RESULTS

Categorization of salivary gland aspirates into morphologic categories resulted in the expected risk stratification. Grouping of categories maintained risk stratification, providing classes with malignancy risk as follows: benign, 2%; NUMP, 18%; suspicious for malignancy, 76%; and positive for malignancy, 100%.

CONCLUSIONS

Salivary gland FNA categorization into commonly encountered morphologic categories provides risk stratification, which translates to a simplified classification scheme of benign, NUMP, suspicious, and positive for malignancy similar to the paradigm in other organ systems.

Fine-needle aspiration of dedifferentiated acinic cell carcinoma: Report of a case with cyto-histological correlation

Dedifferentiated Acinic Cell Carcinoma (DAcCC) is a rare salivary gland malignancy. It has a high tendency to recur and metastasize and thus has a poor prognosis. So far, to our knowledge, only one case of DAcCC has been reported in the cytology literature. Herein, we describe a second case of DAcCC from a fine-needle aspiration (FNA) along with its subsequent histological correlation.

Sarcomatoid salivary duct carcinoma

The so-called sarcomatoid salivary duct carcinoma (SSDC) is one of the variants of salivary duct carcinoma (SDC). This neoplasm is characterized by the presence of both a carcinomatous and a sarcomatoid tumor component. The histology and nomenclature of such neoplasms has been a matter of debate for many years. The histologic, immunohistochemical, and electron microscopic findings including those of 4 previously described cases of SSDC are defined and the different attitudes concerning their etiology will be discussed. In addition, the fine-needle aspiration biopsy of such a case is presented for the first time. In analogy to typical SDC there seems to be a predilection for elderly men and a location in major salivary glands. The resected SSDC tumors measured between 1.5 and 3.5 cm. Histologically, each case was a composite of SDC and sarcomatoid carcinoma. Immunohistochemical positivity for epithelial membrane antigen (EMA) and cytokeratins (AE1/AE3, CAM 5.2) was shown in the sarcomatoid tumor component. The important cytomorphologic feature of SSDC is the presence of cohesive clusters and flat sheets of cells with a cribriform pattern, in combination with an atypical spindle cell component. The use of the term SSDC seems more appropriate than the term carcinosarcoma , as the immunohistochemical, electron microscopic, and recent molecular findings in this and other biphasic neoplasms imply a monoclonal origin.

Salivary duct carcinoma metastatic to inguinal lymph node: A case report of salivary duct carcinoma with distant metastasis diagnosed by fine-needle aspiration

Salivary duct carcinoma (SDC) is a high-grade malignant tumor exhibiting aggressive growth with early regional and distant metastasis. We report a case of SDC in a 53-yr-old male with distant metastasis to an inguinal lymph node. The diagnosis of the primary tumor as well as the metastatic lesion was accomplished by fine-needle aspiration (FNA). Aggressive clinical management appears to be the main therapeutic option for long-term survival. Therefore, establishing an accurate preoperative diagnosis by FNA can have both clinical and prognostic relevance.

Salivary duct carcinoma with neuroendocrine features: Report of a case with cytological and immunohistochemical study

We report a salivary duct carcinoma (SDC) of parotid gland in a 75-year-old male. Initially, it was studied by fine-needle aspiration, which disclosed features of malignancy consistent with a high-grade carcinoma. Histologically, the tumor showed typical features of SDC, predominantly with a solid and apocrine pattern. The aggressive behavior of this tumor was documented by facial palsy and the presence of 12 regional lymph node metastases. Immunohistochemical study showed positivity for cytokeratins (AE1/AE3), cytokeratin 7, GCDFP-15, C-erbB-2, Mib-1, topoisomerase II alpha, p53, and androgen receptors. Diffuse positivity with chromogranin-A, synaptophysin, and Grimelius stains was also observed, suggesting endocrine features. Phosphotungstic acid hematoxylin, antimitochondrial antigen, progesterone and estrogen receptors, cytokeratin 20, and S-100 stains were negative. To our knowledge, this is the first case reported of SDC exhibiting neuroendocrine differentiation.

Salivary duct carcinoma: cytologic characteristics and application of androgen receptor immunostaining for diagnosis

BACKGROUND

Although there have been several reports of cytologic features for salivary duct carcinoma (SDC), it still can be difficult to diagnose patients with these tumor accurately at the time of fine-needle aspiration (FNA). Review of the literature indicates that, immunohistochemically, SDC expresses androgen receptor (AR) in the majority of patients. The authors investigated the cytologic characteristics and utility of AR immunostaining on cytologic smears for the diagnosis of patients with SDC.

METHODS

FNA and imprint smears from four patients with SDC were stained with Papanicolaou and periodic acid-Schiff (PAS). Immunostaining for AR on paraffin sections and imprint smears of SDC was performed, including 51 benign and other malignant salivary gland tumors.

RESULTS

The smears were cellular and contained three-dimensional clusters, flat sheets, and scattered epithelial cells with necrotic backgrounds. A cribriform architectural pattern was noted in many of the tumor sheets. The tumor cells were large polygonal, spindle, and round to oval, and had abundant, finely granular, or vacuolated cytoplasm. Intracytoplasmic vacuoles were PAS negative. The nuclei were hyperchromatic, medium to large in size, round to oval in shape, and often had prominent nucleoli. All SDC tumors expressed AR. Two patients with carcinoma in (pleomorphic adenoma) showed a focal, comedo carcinoma pattern in which AR positive nuclei were observed. Other salivary gland tumors were completely negative for AR.

CONCLUSIONS

The cytologic features of high-grade adenocarcinoma with a variety of cell morphologies, flat sheets of tumor cells with a cribriform pattern, and necrotic backgrounds are characteristic findings in patients with SDC. Immunostaining for AR on cytologic smears is useful for the diagnosis of these patients.

Carcinosarcoma of the parotid gland: cytological, clinicopathological and immunohistochemical study of a case

Manifesting a putative origin from a pleomorphic adenoma, carcinosarcoma of the salivary gland is a heterologous neoplasm in which a sarcomatous and a carcinomatous component coexist. We present a parotid gland carcinosarcoma in a 77-year-old man with peculiar morphological findings. Fine-needle aspiration cytology allowed a preoperative diagnosis of poorly differentiated carcinoma. At histologic examination, the tumor showed biphasic differentiation with an epithelial component made up of well-differentiated keratinizing squamous carcinoma and ductal-type adenocarcinoma, and a mesenchymal component, revealing focal areas of osteosarcoma and myoepithelial malignant proliferation. Carcinosarcoma is a very rare malignant neoplasm, accounting for 0.16% of malignant salivary gland tumors: only 60 cases have been reported, some of which arose "de novo", i.e., without clinico-pathologic evidence of a pre- or co-existing pleomorphic adenoma.

Fine-needle aspiration of secondary neoplasms involving the salivary glands. A report of 36 cases

Metastases or secondary deposits account for 16% of the malignant neoplasms involving the major salivary glands. A correct diagnosis of a secondary neoplasm is important to avoid unnecessary radical surgery and to guide further therapy. Fine-needle aspiration biopsy (FNAB) is an excellent noninvasive diagnostic tool for evaluating salivary gland lesions. We reviewed 36 secondary malignant salivary gland neoplasms evaluated by FNAB. Ancillary studies were performed in selected cases. Follow-up included clinical correlation and review of histologic material. For 4 adenocarcinomas, 4 squamous cell carcinomas, 1 undifferentiated carcinoma, 1 cutaneous basal cell carcinoma, 10 cutaneous melanomas including 1 desmoplastic variant, 3 osteosarcomas, 11 non-Hodgkin lymphomas, and 2 multiple myelomas, there was 1 false-negative FNAB result. The desmoplastic melanoma was interpreted as reactive lymphoid hyperplasia. A malignant diagnosis was given in all remaining cases except the secondary basal cell carcinoma, which was diagnosed as a neoplasm with basal cell features. FNAB is a reliable tool to differentiate hematologic malignant neoplasms and melanomas from other salivary gland neoplasms. A complete knowledge of the clinical history, review of previous pathologic materials, and, in some instances, the use of ancillary studies are crucial for recognizing solid malignant neoplasms secondarily involving the salivary glands.

Metastatic salivary duct carcinoma to the uterus: report of a case diagnosed by cervical smear

Metastasis to the uterus from extragenital sites is uncommon. We report on a rare case of salivary duct carcinoma (SDC) of the parotid gland with metastasis to the uterus, diagnosed by cervical smear. To the best of our knowledge, this is the first case reported in the literature. A 61-yr-old woman with a prior diagnosis of SDC was admitted to hospital with a fractured left humerus, back pain, and vaginal bleeding. A cervical smear and an endometrial aspiration were performed. The cervical smear showed numerous fragments and many isolated tumor cells in a clean background. The tumor cells were large and had abundant, granular/vacuolated cytoplasm. The nuclei were slightly pleomorphic, with fine chromatin and 1-2 small nucleoli. The malignant cells were morphologically identical to the primary tumor and correlated with the tumor in the endometrial aspiration. A diagnosis of metastatic salivary duct carcinoma was made. Although metastatic SDC to the uterus is rare, this possibility should be considered in the differential diagnosis of a positive cervical smear. This case also illustrates the importance of appropriate clinical history, including the knowledge of a primary tumor which may prevent unnecessary clinical investigations. Diagn. Cytopathol. 1999;21:271-275.

Utility of fine-needle aspiration in the diagnosis of salivary gland lesions in patients infected with human immunodeficiency virus

Fine-needle aspiration (FNA) has been increasingly utilized as a diagnostic tool in evaluating salivary gland masses, primarily to differentiate nonneoplastic from neoplastic lesions. Patients infected with human immunodeficiency virus (HIV) frequently present with salivary gland lesions. In this study, we reviewed the cytology of salivary gland lesions in HIV-infected patients and assessed the value of FNA in the diagnosis of salivary gland lesions in HIV-infected patients. One hundred and three FNAs of salivary gland lesions from 78 HIV-infected patients (63 males and 15 females) were included in our study. The patients' ages ranged from 7-65 yr, with a mean age of 40.9 yr. FNAs were classified into three categories: benign lymphoepithelial lesions (BLL) (77 cases or 74.8%), inflammatory processes (14 cases or 13.6%), including 3 reactive lymphoid hyperplasia, and neoplastic lesions (6 cases or 5.8%). The latter included three malignant lymphomas, a multiple myeloma, a metastatic adenocarcinoma from a lung primary, and a direct extension of basal-cell carcinoma. Six (5.8%) aspirates were nondiagnostic. No false-positive or false-negative cases were noted during follow-up of these patients. In conclusion, FNA is a simple and cost-effective procedure for the diagnosis of HIV-related salivary gland lesions. The majority of these lesions are cystic BLL and can be managed conservatively. Malignant lesions are rarely encountered and are readily recognized by FNA. Diagn. Cytopathol. 1999;21:260-264.

Cytomorphological features of salivary duct carcinoma ex pleomorphic adenoma: diagnosis by fine-needle aspiration biopsy with histologic correlation

We report a case of salivary duct carcinoma arising from a pleomorphic adenoma (ex pleomorphic adenoma) in a parotid salivary gland of a 70-yr-old man. Fine-needle aspiration biopsy showed two distinct subsets of cells. There was the typical biphasic pattern of pleomorphic adenoma consisting of bland epithelial cells admixed with uniform spindle-shaped cells and chondromyxoid stroma. In addition, there were features of salivary duct carcinoma best demonstrated by necrosis and the presence of large polygonal cells arranged either singly or in rosettes, clusters or sheets reminiscent of ductal carcinoma of the breast. This case illustrates that the presence of background large polygonal cells and necrosis in an otherwise typical pleomorphic adenoma may suggest the diagnosis of a high-grade carcinoma, namely salivary duct carcinoma, which portends poor prognosis and requires aggressive treatment. Differential diagnosis from other carcinomas known to arise in pleomorphic adenoma is discussed.

Cytologic characteristics and histomorphologic correlations of 21 salivary duct carcinomas

Fine-needle samplings (FNS) of 21 salivary duct carcinomas, histologically correlated, including 19 primaries, one local recurrence, and one lymph node metastasis from 19 patients, are reported. Cytologic diagnosis of high-grade adenocarcinoma was established in 15 (71%). Five (24%) cases were misclassified as high-grade mucoepidermoid carcinomas and one (5%) as squamous-cell carcinoma. The histologic evaluation in all cases showed cytomorphologic features resembling mammary duct carcinoma with marked cytonuclear atypia and occasional oncocytic appearance. Our cytohistologic correlations indicate that irregular clusters of high-grade adenocarcinoma cells with necrotic background and oncocytic features suggest a cytologic diagnosis of either primary salivary duct carcinoma or metastatic mammary carcinoma.

Salivary duct carcinoma ex pleomorphic adenoma: analysis of the findings in fine-needle aspiration cytology and histology

Salivary duct carcinoma (SDC) is an uncommon and highly aggressive neoplasm that reveals histopathologic features resembling infiltrating duct carcinoma of the breast and prostate. SDC arising on the basis of preexisting pleomorphic adenoma (PA) is very rare. This report describes the fine-needle aspiration (FNA) cytology of a case of SDC ex PA. FNA smears were cellular with cells with large, pleomorphic nuclei, some prominent nucleoli, and finely vacuolated cytoplasm. The neoplastic cells were forming groups, sheets, and papillary structures and a cribriform pattern was present in some sheets. Mitotic figures were frequently seen. Necrosis was prominent in the background. Histologic sections of the tumor revealed areas of comedo carcinoma, papillary carcinoma, and infiltrative carcinoma as well as multiple foci of PA. The presence of a cribriform pattern, tumor cells resembling breast ductal carcinoma cells, and a necrotic background are helpful features for an accurate cytodiagnosis of SDC.

Cytologic diagnosis of salivary duct carcinoma: a review of seven cases

The cytomorphologic findings in fine-needle aspirates from 7 cases of salivary duct carcinoma (SDC) are reviewed and correlated with the histologic features. Malignant cytologic characteristics are clear in this tumor, and no false-negative results were obtained. But the absence of cribriform or papillary groups suggests an inconclusive diagnosis and sometimes the need to establish a differential diagnosis with other salivary tumors, and in particular with adenocarcinoma not otherwise specified (ADC-NOS) and high-grade mucoepidermoid carcinoma (h-g MEC). The pitfalls in the cytologic diagnosis of this tumor are discussed. In addition, the literature on the subject is reviewed.

Fine-needle aspiration biopsy of large-cell undifferentiated carcinoma of the salivary glands: presentation of two cases, literature review, and differential cytodiagnosis of high-grade salivary gland malignancies

Primary undifferentiated carcinoma of the salivary glands is a rare, high-grade neoplasm which accounts for a very small number (1-5.5%) of malignant salivary gland tumors. The large-cell variant (LCU) is less well-characterized than the small-cell form. We report on the fine-needle aspiration (FNA) biopsy findings of 2 cases of LCU, one arising in the parotid gland, and the other in a buccal mucosa accessory salivary gland. The 2 cases were similar in composition: isolated and loosely cohesive large cells with abundant cytoplasm, and variability pleomorphic nuclei with prominent nucleoli. One case also featured multinucleated tumor giant cells and macrophage polykaryons; the latter has not previously been described in FNA biopsies of LCU. There was no evidence of squamous, myoepithelial, or widespread mucinous differentiation by morphological, cytochemical, or immunohistochemical analyses (focal rare mucin production identified on special stains in one case). The differential diagnosis is lengthy and consists of other high-grade primary salivary gland malignancies as well as metastatic lesions, including melanoma. The pattern of immunohistochemical reactivity (positive keratin, negative S-100, and HMB-45 antigens), and lack of conspicuous mucin production of significant lymphoidinfiltrate, were useful in establishing the correct diagnosis.

Aspiration and imprint cytopathology of salivary duct carcinoma

BACKGROUND

Salivary duct carcinoma (SDC) is a highly malignant primary epithelial neoplasm of the salivary glands. The histology of this lesion resembles that of cribriform and comedo-type intraductal carcinoma of the breast, yet the cytopathology of salivary duct carcinoma has been described in only a few instances in the past.

METHODS

The authors report two cases of SDC diagnosed by fine-needle aspiration biopsy and one case imprinted after resection. The cytologic features that may permit diagnosis of this entity are described.

RESULTS

Cytologic features include variably cellular smears containing loose clusters of cribriform and glandlike aggregates; monomorphic polygonal cells with round-to-oval nuclei; abundant, finely granular cytoplasm; indistinct nucleoli; and variable necrosis.

CONCLUSIONS

The cytologic findings for SDC are relatively unique and may allow for its specific diagnosis on aspiration cytopathology.