The pathology of head and neck tumors: the lymphoepithelial lesion and Sjögren's syndrome, Part 16

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.

Sjögren's syndrome induced by estrogen therapy

OBJECTIVE

To describe a possible role for estrogen in the induction or acceleration of Sjögren's syndrome (SS).

METHOD

Two healthy young women who received estrogen-increasing therapy and then developed full-blown SS are described. The relationship between SS and estrogen therapy is discussed and the available literature reviewed.

RESULTS

Both women developed SS 3 years after starting estrogen-increasing treatment. The syndrome was severe in the first patient, who was treated with a high dosage of estrogen; the disease was moderate in the second patient, who received a lower estrogen dosage.

CONCLUSION

Estrogen may play a role in the pathogenesis of SS in some patients.

Salivary gland lesions with a prominent lymphoid component: cytologic findings and differential diagnosis by fine-needle aspiration biopsy

Fine-needle aspiration (FNA) is an accepted technique for the preoperative diagnosis of salivary gland nodules. The majority of salivary gland nodules are pleomorphic adenomas and offer little difficulty in diagnosis. Most diagnostically difficult lesions fall into one of four morphologic categories represented by squamous-cell-containing lesions, clear cell neoplasms, neoplasms with a prominence of stromal material, and lymphocyte-containing lesions. Herein, we describe our experience with a series of 61 histologically confirmed cases in which the smears contained a prominent or predominant number of lymphocytes. The differential diagnosis is discussed and points of diagnostic aid enumerated.

Immunoglobulin gene rearrangements in lymphoplasmacytic infiltrates of labial salivary glands in Sjögren's syndrome. A possible predictor of lymphoma development

OBJECTIVES

Sjögren's syndrome is an autoimmune disorder in which patients have a well-recognized risk of developing malignant lymphoma. Although some clinical parameters may herald the onset of lymphoma, few reliable histologic or molecular markers are available that predict progression to a malignant lymphoproliferative disorder. The purpose of this study was to identify the prevalence of immunoglobulin heavy chain monoclonality in labial gland biopsies of patients with Sjögren's syndrome and to compare this to clinical outcome.

STUDY DESIGN

The polymerase chain reaction was applied to 76 sequential labial salivary gland biopsies from patients under investigation for Sjögren's syndrome. A seminested polymerase chain reaction technique was used on DNA extracted from formalin-fixed, paraffin-embedded tissue to amplify the V-D-J region of the immunoglobulin heavy chain gene. Thirty-four randomly selected labial salivary glands that showed nonspecific sialadenitis from patients without Sjögren's syndrome were used as controls.

RESULTS

Monoclonality, as defined by a single band on polyacrylamide gel electrophoresis was detected in 11 cases (14.5%). Of cases that showed monoclonality, four patients were subsequently diagnosed with extrasalivary lymphoma. In each case the rearranged bands in the lip biopsy and the lymphoma were the same size. In one patient who later developed lymphoma, a monoclonal rearranged immunoglobulin band was not identified. In addition, no cases of the translocation t(14;18) were identified by polymerase chain reaction in any of the lip biopsies showing heavy chain monoclonality or in any of the extrasalivary gland lymphomas.

CONCLUSIONS

These results suggest that monoclonal immunoglobulin heavy chain gene rearrangements are a relatively common finding in patients with Sjögren's syndrome and may prove to be a useful marker for predicting the progression to, and early detection of malignant lymphoma.

Intraductal Tetracycline Therapy for the Treatment of Chronic Recurrent Parotitis

Chronic recurrent parotitis (CRP) is recurrent parotid inflammation with non-obstructive sialectasis. Therapies which produce acinar atrophy or remove the acini are effective in treating CRP. Parotidectomy, tympanic neurectomy, duct ligation, and radiation therapy have either a low success rate or a high risk of morbidity. Intraductal antibiotic instillation has been proposed as a possible method of treatment. We hypothesized that the cytotoxic effects of tetracycline could produce acinar atrophy. A double-blind experiment of intraductal tetracycline instillation was performed in ten rabbits. Acinar atrophy and acute inflammation were found in 40% of the tetracycline treated glands; controls had a complete absence of these histologic changes. These results support the use of tetracycline instillation to produce acinar atrophy and therefore, intraductal tetracycline may be an effective, low-risk therapy for CRP. The clinical features of CRP will be reviewed and therapeutic implications discussed.

Monotypic plasma cells in labial salivary glands of patients with Sjögren's syndrome: prognosticator for systemic lymphoproliferative disease

AIMS

To determine the prevalence of plasma cell monotypia in labial salivary gland tissue of patients with and without Sjögren's syndrome, and to evaluate its relation to the development of systemic monoclonal lymphoproliferative disorders.

METHODS

A quantitative immunohistological study was performed on labial salivary gland tissue of 45 patients with Sjögren's syndrome, 18 with rheumatoid arthritis without Sjögren's syndrome, and 80 healthy controls. In none of the patients with Sjögren's syndrome was there evidence of systemic monoclonal lymphoproliferative disease at the time of biopsy.

RESULTS

Monotypic plasma cell populations, defined by a kappa:lambda ratio of > or = 3, were only observed in older patients (above 43 years) with Sjögren's syndrome. In almost all these patients monotypic plasma cell populations were present in multiple labial salivary gland tissues and the IgM/kappa monotypia was observed most frequently. The prevalence of monotypic plasma cell populations in the group with Sjögren's syndrome was 22% (10/45) and there was no significant predilection for primary Sjögren's syndrome. Of special clinical interest was the observation that progression to systemic monoclonal lymphoproliferative disease had occurred exclusively in this subgroup of patients with Sjögren's syndrome, with a prevalence of 30% (3/10).

CONCLUSION

Quantitative immunohistological examination of labial salivary gland tissues provides pathologists with a simple method to select those patients with Sjögren's syndrome who have an increased relative risk at the time of biopsy to develop benign or malignant lymphoproliferative disorders.

Quantitative immunohistologic criteria are superior to the lymphocytic focus score criterion for the diagnosis of Sjögren's syndrome

OBJECTIVE

The aim of the present study was to evaluate the diagnostic value of quantitative immunohistologic criteria for Sjögren's syndrome (SS) in labial salivary gland biopsies.

METHODS

Quantitative immunohistologic examination was performed on labial salivary gland biopsy samples from 80 healthy controls, 32 patients with primary SS, 14 patients with secondary SS, 5 with "probable" SS, 36 with keratoconjunctivitis sicca (KCS) with a lymphocytic focus score less than 1 on the lip biopsy, and 18 with rheumatoid arthritis (RA) without clinical evidence of SS.

RESULTS

This is the first study to show that immunohistologic criteria for SS, based on the percentages of IgA-containing and IgG-containing plasma cells, are able to 1) confirm the diagnosis of SS in labial salivary glands of KCS patients in the absence of grade IV lymphocytic adenitis; and 2) distinguish between a grade IV focal lymphocytic adenitis in the labial salivary glands of SS patients and of RA patients without SS.

CONCLUSION

Quantitative immunohistologic criteria were shown to be much more sensitive and disease specific than the widely accepted grade IV lymphocytic adenitis criterion, which corresponds to a lymphocytic focus score greater than 1, and these criteria should be included in the international diagnostic criteria for Sjögren's syndrome.

Benign lymphoepithelial lesion with large cysts: case report

A case of benign lymphoepithelial lesion with two large cysts and many foci of duct dilatation is reported. Clinical features, except for absence of dry eyes, indicated the case was Sjögren's syndrome. The cysts were found in the left parotid gland of a 60-yr-old woman and were surgically removed. The size of each cyst was 20 mm in diameter and one of them was located in the lymph node. Because of the HLA-DR expression by the epithelium, the cysts are considered to have formed as a result of duct dilatation due to autoimmune response. As for one cyst, it is also possible that the pre-existing lymphoepithelial cyst might be involved in the autoimmune phenomenon because of its relation to the lymph node.

Immunocytochemical identification of HIV (p24) antigen in parotid lymphoid lesions

Antibodies to specific human immunodeficiency virus (HIV) polypeptides are important laboratory markers of HIV infection. We have used an antibody to the major structural gag protein p24 of HIV-1 virus to immunochemically localize this capsid antigen in lymphoid cells from seven of eight patients at risk for HIV infection and who presented with parotid lymphadenopathy and lymphoepithelial cysts of the parotid gland. A clinicopathological assessment of these two manifestations as they relate to HIV infection is also presented.

Benign nasopharyngeal lymphoid tumors, lymphoepithelial lesions, and lymphocytic interstitial pneumonitis

A clinico-pathologic and immunologic case study of a 57-year-old woman who has shown progressive lymphoid proliferations and lymphocyte dysfunction over the course of 10 years is presented. Early in the course of her disease, she presented with recurrent benign nasopharyngeal lymphoid tumors. She subsequently developed benign lymphoepithelial lesions involving both a submandibular and then a parotid salivary gland. She eventually underwent pneumonectomy for lymphocytic interstitial pneumonitis with marked cystic degeneration and lung destruction. Although frank malignancy has not been demonstrated review of her nasopharyngeal biopsies and of her pulmonary pathology shows a tendency toward distinct cellular uniformity with loss of follicles and germinal centers. Concurrently, immunologic studies have demonstrated abnormalities of cell mediated (T cell) function.

Clinicopathological study of myoepithelial sialadenitis and chronic sialadenitis (sialolithiasis)

To determine any overlap in pathological features between myoepithelial sialadenitis and chronic sialadenitis/sialolithiasis histological sections from 69 cases of myoepithelial sialadenitis (MESA) (n = 7) and chronic sialadenitis/sialolithiasis (n = 62) were reviewed over a 10 year period. Three of the cases with MESA contained calculi and four of those originally diagnosed as chronic sialadenitis/sialolithiasis showed epimyoepithelial island formation. The presence of calculi should not rule out a diagnosis of MESA, particularly in the parotid gland where calculi are uncommon; as the incidence of MESA may very well be underestimated and diagnosed as chronic sialadenitis, these patients, who are at increased risk of developing lymphoma, could be lost to follow up.

Familial occurrence of malignant lymphoepithelial lesion of the parotid gland in a Finnish family with dominantly inherited trichoepithelioma

A rare malignant lymphoepithelial lesion (MLEL) of the parotid gland is described in a mother and daughter within one Finnish family. Several cases of dominantly inherited trichoepithelioma were observed in the same family. This is the third published case of familial MLEL, and the first in whites. The simultaneous occurrence of MLEL with hereditary trichoepithelioma is a new finding and may suggest a common genetic background and/or etiology.

Malignant lymphoepithelial lesion of the salivary gland

Eight cases of malignant lymphoepithelial lesion (MLEL) of major salivary glands, seven of which occurred in Southern Chinese patients, are reported. All but two of the patients were older than 40 years of age; there were five male and three female patients. The parotid and submandibular glands were the sites of origin in equal numbers of cases. Six patients had elevated titers of serum IgA against Epstein-Barr virus capsid antigen. Seven remained well after surgery and local radiation therapy, and one died of miliary tuberculosis without evidence of residual neoplasm. Histologically, MLELs were characterized by syncytial clumps of large cells with vesicular nuclei and prominent nucleoli, admixed with abundant small lymphocytes and plasma cells. Two features not emphasized previously in the literature were the presence of reactive histiocytes in some epithelial islands, producing a starry sky pattern, and perineural invasion, which was identified in four cases. The tumor cells showed strong immunostaining for cytokeratin. The literature concerning this rare tumor is reviewed, and the differential diagnosis between MLEL and benign lymphoepithelial lesion, metastatic undifferentiated carcinoma, and malignant lymphoma is discussed.

Benign lymphoepithelial lesion: a less than benign disease

The precise clinical correlate of the benign lymphoepithelial lesion is unclear. Thirty-six cases of benign lymphoepithelial lesions (BLL), reported to the British Salivary Gland Tumour Panel between 1971 and 1984, have been reviewed. Eighty per cent arose in the parotid gland and 20% were bilateral; 83% were in females and the mean age at presentation was 55.26 years. Only 50% presented with, or developed, symptoms of sicca complex, Sjogren's syndrome or related autoimmune disease. Two cases of BLL had, or went on to develop, extra salivary lymphomas and 5 cases of BLL had lymphomatous change in the initial biopsy. A further case had carcinoma within the benign lymphoepithelial lesion. None of those who developed lymphoma had sicca or Sjogren's syndrome but 3 of them had rheumatoid arthritis. The incidence of lymphomas (salivary or extra-salivary) in this series is very much higher than that reported in Sjogren's patients and amounted to 20% overall.

Sjögren's syndrome in children

Sjögren's syndrome (SS) is a chronic autoimmune disease characterized by lymphocytic infiltration of the lacrimal and salivary glands; it eventually leads to keratoconjunctivitis sicca and xerostomia. The disease usually affects middle-aged women and is second to rheumatoid arthritis as the most commonly diagnosed connective tissue disorder. Surprisingly, only 31 cases have been reported in the pediatric population. The diagnosis should be considered, however, in children with a foreign body sensation in the eyes, chronic dryness of the eyes or mouth, or recurrent salivary gland enlargement. This has prompted us to describe our experience in treating five children with SS at Texas Children's Hospital, Houston. One 5-year-old child with no other evidence of connective tissue disease was diagnosed as having primary SS. The remaining four children either had juvenile rheumatoid arthritis or systemic lupus erythematosus in addition to SS, and the diagnosis of secondary SS was made. Other autoimmune disorders associated with SS include polyarteritis nodosa, scleroderma, and polymyositis. Interestingly, one child with secondary SS and chronic lymphocytic thyroiditis developed papillary carcinoma of the thyroid. Both forms of SS are probably more prevalent than the literature would suggest. Recognition of this fact is important if the immediate complications of corneal damage and severe dental decay are to be prevented. Symptomatic treatment with steroids, eyedrops, artificial saliva, and prophylactic fluoride treatments is available. With an adequate follow-up program the late morbidity associated with SS, such as malignant disease, can be minimized.