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Carillo AM, De Luca C, Pisapia P, Vigliar E, Ikenberg K, Freiberger SN, Troncone G, Rupp NJ, Bellevicine C. Molecular testing in salivary gland cytopathology: A practical overview in conjunction with the Milan system. Cytopathology 2024; 35:330-343. [PMID: 38308401 DOI: 10.1111/cyt.13363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/04/2024]
Abstract
Recently, significant advances in the molecular characterization of salivary gland neoplasms have facilitated the classification and diagnosis of specific diagnostic entities. In the highly challenging diagnostic scenario of salivary malignancies, molecular testing is increasingly being adopted in routine practice to refine the cytological diagnosis of salivary lesions. Here, we reviewed the most recent evidence in the field of salivary glands molecular cytopathology.
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Affiliation(s)
- Anna Maria Carillo
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Caterina De Luca
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Pasquale Pisapia
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Elena Vigliar
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Kristian Ikenberg
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Sandra N Freiberger
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Giancarlo Troncone
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Niels J Rupp
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Claudio Bellevicine
- Department of Public Health, University of Naples Federico II, Naples, Italy
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Saoud C, Bailey GE, Graham A, Bonilla LM, Sanchez SI, Maleki Z. Pitfalls in Salivary Gland Cytology. Acta Cytol 2024; 68:194-205. [PMID: 38417405 DOI: 10.1159/000538069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/26/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Salivary gland lesions possess diagnostic challenges on fine-needle aspiration (FNA) material. They are relatively uncommon, yet present with a wide spectrum of cytomorphology. Herein, we review common salivary gland neoplasms, their cytomorphologic features, their diagnostic pitfalls, and ancillary studies helpful in achieving an accurate diagnosis. SUMMARY There are many cytomorphologic overlaps between benign and malignant salivary gland entities. Moreover, metaplasia, cystic changes, and degenerative changes are common findings adding to diagnostic dilemmas. These complicating factors contribute to a minute risk of malignancy in salivary gland lesions that are interpreted as benign on FNA. In rare cases, even malignant salivary gland neoplasms are misinterpreted as benign on aspirated material due to the many cytomorphologic overlaps. For example, benign and malignant neoplasms containing stroma such as myoepithelioma and adenoid cystic carcinoma may be misinterpreted as pleomorphic adenoma. Moreover, diagnosis of salivary gland neoplasms with basal cell features can be confusing on FNA materials; for example, basal cell adenoma can be misinterpreted as adenoid cystic carcinoma. Mucoepidermoid carcinomas have many different appearances on aspirated material due to variable amounts of mucin, degree of nuclear atypia, cellular content, and squamous metaplasia. Acinic cell carcinoma exhibits large cells with abundant cytoplasm on FNA, which can be mistaken for oncocytic cells in oncocytoma or Warthin tumor. Salivary duct carcinoma shows distinct features of malignancy and thus can be mistaken for secondary tumors involving the salivary glands or other malignant salivary gland tumors. The presence of tumor-associated lymphocytes is another underlying cause of misdiagnosis, especially when considering the differential diagnosis of an intraparotid lymph node. Ancillary studies such as immunohistochemistry and molecular studies are gaining more attention to be utilized on FNA cases. PLAG1 immunostaining, CD117, DOG1, mammaglobin, and androgen receptor (AR) are examples of commonly used immunostains in diagnosis of salivary gland lesions. MYB gene fusion, rearrangements of the MAML2 gene, and ERBB2/HER2 are examples of molecular alterations useful in diagnosis of salivary gland neoplasms. In conclusion, the aim of salivary gland cytology is to differentiate benign entities from the malignant ones and to prevent unnecessary aggressive treatments. KEY MESSAGES The diagnostic pitfalls are enormous in salivary gland cytology. Familiarity with cytomorphology of different entities and their cytomorphologic overlaps, and application of ancillary studies improves the diagnostic yield, patient management and prevents unnecessary aggressive procedures.
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Affiliation(s)
- Carla Saoud
- Division of Cytopathology, Department of Pathology, The Johns Hopkins Medical Institution, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Gabrielle E Bailey
- Division of Cytopathology, Department of Pathology, The Johns Hopkins Medical Institution, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ashleigh Graham
- Division of Cytopathology, Department of Pathology, The Johns Hopkins Medical Institution, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Lorena Marcano Bonilla
- Division of Cytopathology, Department of Pathology, The Johns Hopkins Medical Institution, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sandra Ixchel Sanchez
- Division of Cytopathology, Department of Pathology, The Johns Hopkins Medical Institution, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Zahra Maleki
- Division of Cytopathology, Department of Pathology, The Johns Hopkins Medical Institution, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Yaprak Bayrak B, Ozturk M. Acinic cell carcinoma mimicking Warthin's tumor: A diagnostic challenge on fine-needle cytology. Diagn Cytopathol 2024; 52:E23-E29. [PMID: 37800395 DOI: 10.1002/dc.25233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
The cytologic diagnosis of acinic cell carcinoma (ACC) can be challenging due to its polymorphous appearance and sharing cytomorphologic characteristics with other benign and malignant neoplasms as well as non-neoplastic diseases, even though various histomorphological aspects of ACC have been documented. We presented a 39-year-old female patient applied with right pre-auricular parotid swelling spreading infra-auricular region which was gradually increased in size for 3 months. Ultrasonographic examination revealed hypoechoic well-circumscribed mass with 17 × 22 × 29 mm size. Magnetic resonance imaging revealed intra-parotid solid lesion with cystic areas, slightly hypointense on T1 and hyperintense on T2 weighted images. The mass was pushing the retromandibular vein medially, still lateral to it in the caudal images, but in dumbbell-shape spreading through parapharyngeal space in superiorly cranial images. Fine-needle aspiration cytology was also performed with guidance of ultrasonography. The cytological examination of the lesion was characterized by the predominance of heterogeneous lymphoid cells, clusters of epithelial cells with a variety of cytologic appearances, including granular, transparent, vacuolated, and oncocytic, and the presence of numerous naked nuclei with a protein-like foamy background. Due to intense lymphocytic inflammation, it was considered as benign primary parotid tumor such as Warthin's tumor. The excision material was examined histopathologically. Immunohistochemical analysis showed that this carcinoma was positive for DOG1, SOX10, cytokeratin 7 and negative for mammaglobin. This salivary gland tumor was reported as a rare variant of ACC with lymphoid-rich stroma. To improve the diagnostic accuracy, various morphological aspects of ACC should be considered in the pathological practice.
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Affiliation(s)
- Busra Yaprak Bayrak
- Department of Pathology, Faculty of Medicine Kocaeli University, Kocaeli, Turkey
| | - Murat Ozturk
- Department of Otorhinolaryngology, Faculty of Medicine Kocaeli University, Kocaeli, Turkey
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Cole GG, Salgado CM, Vargas de Stefano D, Zambrano EV, Gómez AM, Reyes-Múgica M, Wang Q. Morphologic and Ancillary Studies of Pediatric Acinic Cell Carcinoma: A Single Institute Experience. Head Neck Pathol 2023; 17:204-209. [PMID: 36169793 PMCID: PMC10063734 DOI: 10.1007/s12105-022-01492-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Acinic cell carcinoma (AciCC) is the second most common pediatric malignant salivary gland tumor. However, there are limited pathology publications about this tumor in the pediatric population. METHODS We describe four pediatric AciCC cases diagnosed between 2000 and 2021 in our institute. Reticulin histochemistry plus immunohistochemistry for NR4A3 and DOG1 were performed on all cases. RESULTS Histologically, all four cases featured a tumor-associated lymphoid proliferation and collagenous stroma, in which two formed central scars. The tumors were predominantly solid, with a lobular pattern and variably sized dilated spaces, including one case with focal microcysts. High-grade transformation was not observed in any of our cases. Reticulin stain and immunohistochemistry for NR4A3 showed distinct features between AciCC and non-neoplastic salivary gland parenchyma. DOG1 immunohistochemistry confirmed the acinar origin of AciCC. CONCLUSIONS Our study reveals that pediatric AciCCs often present with tumor-associated lymphoid proliferation (TALP) and sclerosis. Special stains such as reticulin histochemistry and NR4A3 immunohistochemistry are helpful to separate tumor from adjacent benign parenchyma. The ancillary study is helpful for the diagnosis of small specimens. Our study is limited by its low case number, but we hope that our results will promote more studies on this rare salivary gland tumor in the pediatric population.
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Affiliation(s)
- Grayson G. Cole
- Department of Diagnostic Sciences, Oral and Maxillofacial Pathology, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Cláudia M. Salgado
- Department of Pathology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 152240 USA
| | - Danielle Vargas de Stefano
- Department of Pathology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 152240 USA
| | - Eduardo V. Zambrano
- Department of Pathology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 152240 USA
| | - Ana M. Gómez
- Department of Pathology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 152240 USA
| | - Miguel Reyes-Múgica
- Department of Pathology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 152240 USA
| | - Qian Wang
- Department of Pathology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 152240 USA
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Millan N, Tjendra Y, Zuo Y, Jorda M, Garcia-Buitrago M, Velez-Torres JM, Gomez-Fernandez C. Utility of NR4A3 on FNA cytology smears and liquid-based preparations of salivary gland. Cancer Cytopathol 2022; 130:949-954. [PMID: 35913415 DOI: 10.1002/cncy.22632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/03/2022] [Accepted: 07/13/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Fine-needle aspiration cytology (FNAC) is generally the initial sampling method for salivary gland neoplasms. The cytomorphologic features of acinic cell carcinoma (AciCC) of salivary gland can overlap with other neoplastic and nonneoplastic entities. AciCCs harbor a recurrent t(4;9) rearrangement with upregulation of nuclear receptor subfamily 4 group A member 3 (NR4A3). NR4A3 protein overexpression has been shown to be highly sensitive and specific for the diagnosis of AciCC in histologic specimens and cell block preparations. However, data on NR4A3 immunocytochemistry (ICC) on conventional smears or liquid-based cytology are limited. METHODS The authors identified 18 FNAC of histologically proven AciCC cases between 2013 and 2019. FNAC samples of diagnostic mimickers were likewise retrieved and included in the study cohort for comparison. The NOR1/NR4A3 mouse monoclonal antibody was applied directly to FNAC slides using a standard ICC technique. RESULTS The cohort included ethanol-fixed Papanicolaou-stained cytologic smears and liquid-based preparations from 18 AciCC, one secretory carcinoma, four mucoepidermoid carcinomas, four salivary duct carcinomas, five pleomorphic adenomas (PA), five Warthin tumors, five oncocytomas, one oncocytic hyperplasia, and five nonneoplastic salivary gland cases. Strong nuclear staining for NR4A3 was present in all AciCC, weak nuclear staining was present in one PA, and all other non-AciCC were negative (sensitivity, 100%; specificity, 97%). CONCLUSIONS NR4A3 ICC can be used directly on FNAC conventional smears and liquid-based cytology to reliably distinguish AciCC from its mimickers. This marker may be useful in cases where a cell block preparation is unavailable or inadequate.
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Affiliation(s)
- Nicolas Millan
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Pathology and Laboratory Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Youley Tjendra
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA.,Department of Pathology and Laboratory Medicine, Jackson Memorial Hospital, Miami, Florida, USA
| | - Yiqin Zuo
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Merce Jorda
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Monica Garcia-Buitrago
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jaylou M Velez-Torres
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Carmen Gomez-Fernandez
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
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Krishnan V, Nguyen L, Shen R, Lieu D, De Peralta-Venturina M, Fan X. NOR-1 (NR4A3) immunostaining on cytologic preparations for the preoperative diagnosis of acinic cell carcinoma of the salivary gland. J Am Soc Cytopathol 2022; 11:352-358. [PMID: 36058827 DOI: 10.1016/j.jasc.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/06/2022] [Accepted: 07/06/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Acinic cell carcinoma of the salivary gland (ACC-SG) is characterized by recurrent rearrangements in the nuclear receptor subfamily 4 group A member 3 (NR4A3). Immunostaining using an antibody targeting this rearrangement, neuron-derived orphan receptor 1 (NOR-1), has been recently studied on surgical specimens and cell block material of fine-needle aspirates for the diagnosis of ACC-SG. Our goal was to evaluate whether NOR-1 immunostaining could reliably be performed on destained cytologic preparations. MATERIALS AND METHODS This was a retrospective multi-institutional study. Immunostaining with the NOR-1 antibody (sc-393902 [H-7], Santa Cruz Biotechnology Inc.) was performed at a titer of 1:30 on destained cytologic preparations. ACC-SG cases (n = 17) were represented by twelve cases with alcohol-fixed preparations (n = 12), including direct smears and SurePath preparations, as well as 5 cases with air-dried preparations (n = 5). These were compared to 27 mimicker lesions (n = 27): normal acini (4), chronic sialadenitis (3), oncocytoma (2), pleomorphic adenoma (6), Warthin tumor (8), mucoepidermoid carcinoma (1), secretory carcinoma (2), and salivary duct carcinoma (1). RESULTS The positivity of NOR-1 in ACC-SG cases was 100% on destained alcohol-fixed preparations (12/12) and 60% on air-dried preparations (3/5). All 27 mimicker lesions were negative for NOR-1 (0/27). Evaluation of 2 ACC-SG cases with both types of cytologic preparations showed that NOR-1 was positive on the alcohol-fixed slides but negative on the air-dried slides. CONCLUSIONS NOR-1 immunostaining can reliably be performed on alcohol-fixed direct smears and liquid-based preparations for the diagnosis of ACC-SG. Air-dried preparations show a lower positivity rate and may be less suitable for diagnostic immunostaining.
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Affiliation(s)
- Vimal Krishnan
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Luan Nguyen
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rulong Shen
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | - Xuemo Fan
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Wakely PE, Lott-Limbach AA. Cytopathology of acinic cell carcinoma: A study of 50 cases, including 9 with high-grade transformation. Cancer Cytopathol 2021; 129:973-983. [PMID: 34379894 DOI: 10.1002/cncy.22496] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although largely readily recognizable in tissue sections, acinic cell carcinoma (ACC) remains diagnostically problematic in fine-needle aspiration (FNA) cytopathology. The authors undertook an analysis of a large series of ACC aspirates, including acinic cell carcinoma with high-grade transformation (ACC-HGT). METHODS The authors searched their cytopathology files for ACC cases with histopathologic confirmation. FNA biopsy was performed according to standard techniques. RESULTS Fifty FNA biopsy cases of ACC (including 36 of parotid origin [72%]) from 41 patients (female to male ratio, 1.4:1; age range, 23-84 years; average, 54 years) met the study inclusion requirements. Primary neoplasm aspirates were most common (72%), and they were followed by recurrent tumors (16%) and metastases (12%). A precise cytologic diagnosis was made for 64%. Three of 9 ACC-HGT cases (33%) were correctly interpreted as such; 98% of conventional ACC cases were correctly graded as low-grade. With the Milan classification system, 74% fit into the malignant category. Ancillary testing was performed for only 36%. Conventional ACC had moderately to highly cellular smears; monotonous cells in aggregates and single forms; rounded nuclei; and microvacuolated, finely granular, oncocyte-like, or nonspecific cytoplasm. ACC-HGT smears contained larger nuclei, high nuclear to cytoplasmic ratios, coarse nuclear chromatin, and a loss of cytoplasmic granules/vacuoles. CONCLUSIONS A correct diagnosis of ACC via FNA biopsy was made in almost two-thirds of the cases. With the Milan classification, 84% of the cases would have been classified as malignant or suspicious for malignancy. An absence of conventional serous acinar cell morphology in some cases as well as an absence of ancillary immunohistochemistry testing in almost two-thirds of the cases prevented even better diagnostic performance.
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Affiliation(s)
- Paul E Wakely
- Department of Pathology, Ohio State University Wexner Medical Center/James Cancer Hospital/Richard Solove Research Institute, Columbus, Ohio
| | - Abberly A Lott-Limbach
- Department of Pathology, Ohio State University Wexner Medical Center/James Cancer Hospital/Richard Solove Research Institute, Columbus, Ohio
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