FNA biopsy of secondary nonlymphomatous malignancies in salivary glands: A multi-institutional study of 184 cases

Metastases to the parotid glands: An institutional experience

BACKGROUND

Metastatic lesions to the salivary gland are rare and mostly affect the parotids. Metastases represent 8% of all malignant lesions of the parotid gland. Around 80% originate from squamous cell carcinomas (SCC) of the head and neck region. Fine needle aspiration (FNA) plays a crucial role in distinguishing primary salivary gland lesions from metastases. Herein we describe our series of metastases to the parotid glands.

MATERIALS AND METHODS

We analysed 630 parotid gland FNAs over a decade including conventional and liquid-based cytology specimens. Ancillary techniques such as immunocytochemistry (ICC) were conducted on cell blocks.

RESULTS

Eighty (12.4%) cases were malignant lesions, of which 53 (63.75%) were metastases including 24% melanoma, 22.6% SCC, 19% renal carcinomas, 7.5% breast carcinomas, 11.3% lung, 9% intestinal and 1.8% testicular, malignant solitary fibrous tumour and Merkel cell carcinoma. The 53 cases, classified according to the Milan system for salivary cytopathology, belonged to 5 Suspicious for malignancy (SFM) and 48 malignant (M) categories. Forty had a known history of primary malignancy (75.4%), while 13 were suspicious to be a metastatic localisation (24.5%), distributed as 5SFM (2SCC and 3Melanoma) and 8 M. A combination of clinical history, cytomorphology and ICC identified 100% of them.

CONCLUSIONS

Fine needle aspiration plays a central role in the diagnostic workup of patients with metastatic lesions to their parotid glands, thereby defining the correct management. Diagnostic accuracy may be enhanced by applying ICC. Although melanoma and SCC are the most common histological types, several other malignancies may also metastasize to the parotid glands and should be kept into consideration.

Intraparotid Recurrence of Papillary Thyroid Carcinoma After Thyroidectomy Coincident With Declining Thyroglobulin Levels: A Case Report and Review of the Literature

Papillary thyroid carcinoma (PTC) is the most frequent thyroid malignancy. Intraparotid recurrence of PTC is, however, rare. Most parotid malignancies are either primary or metastatic from cancer outside the head and neck. We report a case of a 71-year-old man who had undergone lobectomy and completion thyroidectomy for PTC and presented to our clinic with an insidious intraparotid recurrence, for which he underwent a superficial parotidectomy and radioactive iodine therapy. We also present a review of the literature on similar cases. Intraparotid metastasis of PTC should be considered in the differential diagnosis of a parotid mass.

Primary leiomyosarcoma of the parotid gland: Aspiration cytology with emphasis on differential diagnosis

Most salivary gland neoplasms are of epithelial origin. Sarcomas of the parotid gland, including leiomyosarcoma, are exceedingly rare mesenchymal tumours. A definitive diagnosis of leiomyosarcoma is challenging on cytomorphology alone. We herein describe a case of a 41-year-old woman who presented with parotid gland swelling. The patient was previously diagnosed with leiomyosarcoma of the parotid gland on histopathology. Fine needle aspiration cytology was done from this recurrent swelling. Cytomorphology combined with cell block immunocytochemistry was fruitful in confirming the tumour recurrence. Primary and recurrent/metastatic leiomyosarcoma of the parotid gland is a rarity and cannot be distinguished on cytology. Such a distinction is based on the known history of prior malignancy, which was forthcoming in the present case, or after an exhaustive work-up. Pertinent clinical history and radiology provide leads for the cytopathologist. They must be sought so that immunocytochemistry can be applied judiciously and a precise/nearly precise cytological diagnosis rendered, as it guides patient management. The diagnosis is challenging on cytology as the spindle cell lesions of the parotid gland range from reactive to benign to malignant tumours.

Advanced magnetic resonance imaging findings in salivary gland tumors

Salivary gland tumors (SGTs) make up a small portion (approximately 5%) of all head and neck tumors. Most of them are located in the parotid glands, while they are less frequently located in the submandibular glands, minor salivary glands or sublingual gland. The incidence of malignant or benign tumors (BTs) in the salivary glands varies according to the salivary gland from which they originate. While most of those detected in the parotid gland tend to be benign, the incidence of malignancy increases in other glands. The use of magnetic resonance imaging (MRI) in the diagnosis of SGTs is increasing every day. While conventional sequences provide sufficient data on the presence, localization, extent and number of the tumor, they are insufficient for tumor specification. With the widespread use of advanced techniques such as diffusion-weighted imaging, semi-quantitative and quantitative perfusion MRI, studies and data have been published on the differentiation of malignant or BTs and the specificity of their subtypes. With diffusion MRI, differentiation can be made by utilizing the cellularity and microstructural properties of tumors. For example, SGTs such as high cellular Warthin’s tumor (WT) or lymphoma on diffusion MRI have been reported to have significantly lower apparent diffusion values than other tumors. Contrast agent uptake and wash-out levels of tumors can be detected with semi-quantitative perfusion MRI. For example, it is reported that almost all of the pleomorphic adenomas show an increasing enhancement time intensity curve and do not wash-out. On quantitative perfusion MRI studies using perfusion parameters such as Ktrans, Kep, and Ve, it is reported that WTs can show higher Kep and lower Ve values than other tumors. In this study, the contribution of advanced MRI to the diagnosis and differential diagnosis of SGTs will be reviewed.

Parotid metastases from primary lung cancer: Case series and systematic review of the features

Most parotid metastases have been reported to come from the head and neck; however, cases metastasized from the lung are extremely rare. Missed diagnoses and misdiagnoses occurred quite a few times. Thus, accurately identifying the clinical features of parotid metastasis of lung cancer is important. However, current studies about this issue are mostly case reports, and little is known about the detailed and systematic aspects. We reported three cases of parotid metastases from lung cancer and then systematically searched similar cases through “Pub-Med” and “Web of Science”. Finally, twenty-three patients were included in the study. Eighty-three percent of which were males, and 19 patients were over 50 years old. In all cases with smoking history mentioned, 93% were smokers. The predominant pathological type was small cell lung cancer (SCLC, 13 patients, 56%). Seventeen combined with other site metastasis, while more than half of which were brain metastases. The survival time ranged from 3months-17years, and as for SCLCs, it was only 3months-40months. It can be concluded that clinical features, such as sex, age, smoking history, pathological types, and metastasis patterns, could provide valuable evidence for diagnosis. The lung seems to be the most common primary site of parotid metastases except for head and neck tumors. The two circumstances, SCLC coexisting with Warthin’s tumor and parotid small cell carcinoma with lung metastasis, should be differentiated from parotid metastasis of lung cancer with caution For cases presented as SCLC, more aggressive strategies, such as chemotherapy with immunotherapy and maintenance therapy, may be more suitable. Due to the greater tendency of brain metastasis in such diseases, whole-brain radiation therapy, stereotactic radiosurgery or prophylactic cranial irradiation should be applied to corresponding patients in time. Additionally, lung cancer parotid metastases may be a marker of poor prognosis.

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.

Mesenchymal neoplasms of the parotid gland and parapharyngeal space: an FNA cytologic study of 22 nonlipomatous tumors

BACKGROUND

Mesenchymal neoplasms of the parotid gland (PG) and para-pharyngeal (PP) space are distinctly uncommon. Fine-needle aspiration (FNA) biopsy experience with nonlipomatous neoplasms from this site is reviewed.

METHODS

Cytopathology and surgical pathology files were examined for mesenchymal PG and PP space neoplasms. FNA biopsy was performed using standard technique.

RESULTS

Twenty-two PG and/or PP aspirates from 20 adults (male:female = 1.1:1; age range, 19-84 years, mean age, 50 years) and a 10-week-old infant met inclusion criteria. Biopsy sites included PG (17, 77%) or PP space (5, 23%). Five of 6 malignant neoplasms (83%) were called malignant cytologically. Only 7 of 11 (63%) benign neoplasms were recognized as a benign neoplasm. None of 5 solitary fibrous tumor (SFT) cases were correctly recognized. Conversion to the Milan classification showed 8 (36%) FNA cases diagnosed as benign neoplasm, 6 (27%) malignant neoplasm, 4 (18%) neoplasm of uncertain malignant potential, 2 (9%) nondiagnostic, and single cases of suspicious for malignancy and nonneoplastic. There was 1 false-positive and no false-negative FNA diagnoses. Ancillary testing in 10 (45%) aspirates helped substantiate a correct specific diagnosis in 3 malignant and 3 benign cases.

CONCLUSIONS

FNA biopsy of nonlipomatous mesenchymal SG neoplasms is particularly challenging. Less than half (9 of 11, 41%) had specific FNA diagnoses that correctly matched the tissue diagnoses or clinical outcome. Accurate Milan categorization was superior for malignant neoplasms (5 of 6, 83%) in contrast to benign neoplasms (7 of 11, 63%), or neoplasms of uncertain malignant potential (SFT) (2 of 5, 40%).

Lymphoepithelial Carcinoma of Salivary Glands

Lymphoepithelial carcinoma of salivary glands (LECSG) is an uncommon neoplasm. This article summarizes the findings of 438 cases in a review of the literature. Concurrent lymphoepithelial lesions may suggest a primary tumor. The tumor shows a nonkeratinizing carcinoma intimately associated with a rich lymphohistiocytic infiltrate, destroying adjacent salivary gland tissue. Irrespective of race or ethnicity, the tumors usually express Epstein-Barr virus, with Epstein-Barr virus encoded small RNA (EBER) and/or latent membrane protein-1 (LMP-1), although a subset does not. There is an overall good prognosis of about 80% at 5 years.

FNA diagnostics of secondary malignancies in the salivary gland: Bi-institutional experience of 36 cases

OBJECTIVE

Fine-needle aspiration (FNA) is a key diagnostic method in the evaluation of salivary gland lesions. Secondary tumors of salivary glands represent only 5% of all malignancies of major salivary glands. The goal of our study was to examine the cytological and clinical features of secondary tumors sampled by FNA.

MATERIALS AND METHODS

A series of 36 secondary tumors from the pathology departments of two university hospitals are presented. Clinical referrals to FNA, cytological features, immunohistochemical results, and histopathological diagnoses were reviewed in all cases.

RESULTS

The study population consisted of 36 cases (19 males and 17 females) with mean age 70.9 ± 13.0 years (range 41-96 years). The most common site of the metastasis was parotid gland (n = 26). The primary malignancy was known in 17 cases at the time of FNA diagnosis. The most common primary site was skin of head and neck area (11 cases) followed by lungs (n = 5) and tonsils (n = 5), kidney (n = 2) and breast (n = 2) and thyroid gland, gastrointestinal tract and soft tissue, 1 case of each. In 8 cases, the primary site remained unknown. The diagnostic or confirmatory immunocytochemistry was performed on cell blocks in 21 cases.

CONCLUSIONS

FNA is a reliable technique in the diagnosis of salivary gland secondary malignancies. The knowledge of the personal history of malignancy is essential for the successful immunocytochemical targeted diagnosis without any delay.

Lymphoepithelial Carcinoma of Salivary Gland EBV-association in Endemic versus Non-Endemic Patients: A Report of 16 Cases

Lymphoepithelial carcinoma of salivary glands (LECSG) are rare neoplasms, reported in endemic populations (southeastern Chinese) with a strong Epstein-Barr virus (EBV) association. A retrospective series comparing EBV status within an ethnically diverse population (endemic vs. non-endemic patients) has not been reported. Sixteen LECSG were equally distributed between males (n = 8) and females (n = 8) with a median age of 54 years (range 18 to 85 years) at initial diagnosis. Ten patients were white, 4 Asian, and 2 black. The patients typically presented with swelling or mass for an average of 11.6 months. Tumors affected only major salivary glands: parotid (n = 13); submandibular (n = 3). Tumors were an average of 2.9 cm (range 1.5 to 5.8 cm). Nine of 16 (56%) patients had cervical lymph node metastases at presentation. No patients had nasopharyngeal or oropharyngeal tumors. Microscopically, the tumors were widely infiltrative, characterized by large polygonal to spindled cells arranged in a syncytial, lattice-like network in a background of lymphoplasmacytic cells. The neoplastic cells showed an open-vesicular nuclear chromatin to a more basaloid-morphology, the latter showing hyperchromatic nuclei and less cytoplasm, while nearly all of the cases had associated lymphoepithelial lesions/sialadenitis. By in situ hybridization, 8 of 16 cases had a strong, diffuse EBER expression (4 of 4 Asians; 4 of 12 non-Asians), while with immunohistochemistry all cases tested were pan-cytokeratin, CK5/6 and p63 reactive; none of the cases tested were p16 reactive. All patients were managed with wide or radical excision, 4 with concurrent chemoradiation, and 6 with radiation alone. Distant metastasis (lung, brain, and bone) developed in 2 patients. Overall follow-up (mean 3.8 years) revealed 12 patients alive and 2 dead, none with evidence of disease (mean 4.3 years); one white male alive with disease at 1.9 years, and one Asian female dead of disease at 4.2 years; both of these latter patients had Group IV stage disease. High stage (Group IV) patients had a shorter mean survival than lower stage patients: 3.1 versus 4.8 years, respectively. In conclusion, LECSG are uncommon primary neoplasms. Concurrent lymphoepithelial lesions may help suggest a primary tumor. The tumors, irrespective of race or ethnicity, may express EBER. There is an overall good survival, perhaps better for EBV-negative patients and for those with lower stage disease.

Thyroid carcinoma metastasizing to the submandibular gland: Sonographic findings

Metastases to the submandibular gland are extremely rare; a literature search retuned only three previously reported cases from a thyroid gland primary site. Herein, we report two cases of metastatic thyroid carcinoma to the submandibular gland in a 64-year-old woman with PTC and a 70-year-old-woman with medullary thyroid carcinoma (MTC). The metastases were identified on CT and PET/CT in one case and on CT in the other case, but both were diagnosed with ultrasound-guided fine-needle aspiration. Our cases highlight that while rare, both PTC and MTC can metastasize to the submandibular gland.

A 4-Year Retrospective Analysis of Salivary Gland Cytopathology Using the Milan System for Reporting Salivary Gland Cytology and Ancillary Studies

The cytopathology of salivary glands presents major challenges due to the heterogeneity of benign and malignant neoplasms, which is reflected in the large range of WHO 2017 Classifications. Fine needle aspiration (FNA) of salivary gland tumours is still the favoured initial approach as it results in good sensitivity and specificity. The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) was published in 2018 and comprises seven categories. We report results from a 4-year retrospective analysis of 328 salivary gland FNAs which were reviewed and classified according to the MSRSGC. We assess the risk of neoplasm, the risk of malignancy and the contribution of ancillary studies to the diagnosis. Benign neoplasms were the most frequent diagnosis (44.2%). Malignant and suspicious for malignancy were identified in 11.3% and 4.9% of diagnosed cases, respectively. Histopathological analysis after surgery was available for 216 (65.8%) of the cases. All malignant cases were confirmed post-surgery, and 68.8% of suspicious for malignancy were confirmed as malignant tumours. Immunocytochemistry was informative in 72.3% of cases. Immunocytochemistry and FISH provided the definitive diagnosis in 23.7% and 33% of cases, respectively. In conclusion, the MSRSGC is more effective when specific features of neoplasms can be identified. Ancillary studies help to further characterise salivary gland tumours and thereby increase the accuracy of MSRSGC.

Cytopathology approach to rare salivary gland lesions with oncocytic features

Salivary glands located in the head and neck area are known to have different lesions with prominent oncocytic features. Fine needle aspiration is usually the initial approach in the management of these lesions, whether they represent neoplastic or non-neoplastic processes. Owing to the limited material present upon cytopathologic examination, knowledge of variants and subtypes of various oncocytic lesions that can occur in this area is of major importance to provide the most accurate interpretation to the patients and clinicians. In this article, we selected rare lesions of the salivary glands that may exhibit oncocytic changes, and provided a brief discussion of each one of them, with emphasis on challenges in navigating the differential diagnosis that these cases may pose, from the cytopathology standpoint.

Non-primary salivary malignancies: A 22-year retrospective study

PURPOSE

Most salivary gland malignancies are primary tumors, but in our medical center one of six is non-primary. The relative scarcity of such reports justifies studying them.

SUBJECTS & METHODS

We studied patients' demographic and clinical parameters, salivary tumors/metastasis, diagnosis and treatment, and survival rates.

RESULTS

Of all our salivary malignancy patients over the last 22 years, 15% (18/119) had non-primary malignant tumors, all located in the parotid glands. Of these, nine had skin cancer (SCC), 3 malignant solid tumors and 6 hematological systemic malignancies. Four had concomitant second malignancy. Mean age was 70.2 ± 13.8 years, 66.7% of the patients were males, 27.8% were smokers, none reported alcohol use. The most prevalent diagnostic tools used were CT (16 patients), FNA (13) and PET-CT (12). Eleven of 18 patients died from the disease despite receiving therapy: 6 SCC patients, 2 CLL patients and all 3 with solid tumors. All four lymphoma patients survived as did another three SCC patients.

CONCLUSIONS

Chemotherapy and radiotherapy for systemic disease prolonged life rather than surgery. Patients with poor prognosis non-primary salivary tumors should be treated conservatively; surgery should be for those without widespread metastases or systemic disease. Sometimes a palliative patient may benefit from tumor debulking.

The key radiologic and cytomorphologic features of oncocytic and oncocytoid lesions of the salivary gland

Oncocytic and oncocytoid lesions represent a distinct subset of salivary gland lesions. True oncocytic lesions of the salivary gland are entirely composed of oncocytes. These are characterized by the presence of abundant eosinophilic granules due to the presence of abundant cytoplasmic mitochondria. Oncocytic lesions of the salivary gland include oncocytosis, oncocytoma, and oncocytic carcinoma. In addition to the true oncocytic lesion, there exists another group of salivary gland lesions, which demonstrate cells with abundant and occasionally granular cytoplasm. These are often termed as "oncocytoid" lesions. The recently proposed Milan System for reporting salivary gland cytology clearly states that fine-needle aspiration specimens representing oncocytic/oncocytoid lesions of salivary gland cannot effectively distinguish between a nonneoplastic lesion, benign and malignant neoplasms. Therefore, most lesions lacking classic cytomorphologic features will be classified under the umbrella diagnostic term of "Salivary Gland Neoplasm of Uncertain Malignant Potential" (SUMP). In this review, we discuss and illustrate key clinicopathologic and radiologic features that can help the practicing cytopathologist narrow down the differential and provide the best management based diagnosis.

Contemporary Management of Benign and Malignant Parotid Tumors

To report the standard of care, interesting new findings and controversies about the treatment of parotid tumors. Relevant and actual studies were searched in PubMed and reviewed for diagnostics, treatment and outcome of both benign and malignant tumors. Prospective trials are lacking due to rarity of the disease and high variety of tumor subtypes. The establishment of reliable non-invasive diagnostics tools for the differentiation between benign and malignant tumors is desirable. Prospective studies clarifying the association between different surgical techniques for benign parotid tumors and morbidity are needed. The role of adjuvant or definitive radiotherapy in securing loco-regional control and improving survival in malignant disease is established. Prospective clinical trials addressing the role of chemotherapy/molecular targeted therapy for parotid cancer are needed. An international consensus on the classification of parotid surgery techniques would facilitate the comparison of different trials. Such efforts should lead into a clinical guideline.

Parotid gland metastasis from carcinoma of the breast detected by PET/CT: Case report and review

RATIONALE

The parotid gland is an unusual site for metastatic disease from breast cancer, and it usually has a poor prognosis.

PATIENT CONCERNS

A 36-year-old woman presented to our department with a swelling in her left parotid gland. The patient did not receive any other treatment after breast conserving surgery.

DIAGNOSES

Multifocal metastases in the bones, lymph nodes, left parotid and contralateral mammary gland were proved by PET/CT.

INTERVENTIONS

Eight cycles of first-line rescue chemotherapy, combining with zoledronic acid in treatment of bone metastasis, followed by the combination of endocrine therapy and ovarian function suppression after chemotherapy.

OUTCOMES

The patient obtained clinical complete response in the metastasis tumor of parotid gland, lymph nodes, and bones.

LESSONS

It is necessary for patient to receive comprehensive treatment after receiving surgery. Through this case, we present the appropriate management of advanced breast cancer accompanying with the parotid gland metastasis. PET/CT is a useful method to diagnose and evaluate the metastasis lesions.