Diagnostic Challenges in the Fine Needle Aspiration Biopsy of Chronic Sclerosing Sialadenitis (Küttner's Tumor) in the Context of Head and Neck Malignancy: A Series of 4 Cases

Chronic Sclerosing Sialadenitis of the Submandibular Gland and its Histopathological Spectrum in the IgG4-Related Disease: a Series of 17 Cases

PURPOSE

This study aimed to characterize the histopathological immunohistochemical features of chronic sclerosing sialadenitis, emphasizing the IgG4-related disease.

METHODS

Seventeen cases of chronic sclerosing sialoadenitis were examined for histopathological aspects, (inflammation, fibrosis, glandular parenchyma, and lymphoid follicles) and immunohistochemistry (BCL2, CD3, CD20, CD34, CD163, p63, cyclin D1, mast cell, SMA, S100A4, IgG, and IgG4) which were scored. IgG4-related disease features were investigated. Demographic and clinical data were also collected.

RESULTS

Males predominated (10:7), with an average lesion size of 3.9 cm. Common histopathological findings included reduced acinar parenchyma, lymphoid follicle formation, and ductular proliferation. CD3-positive T lymphocytes and CD34- and SMA-positive stromal fibroblasts were abundant. Nine cases (53%) showed sialoliths and three cases met the criteria for IgG4-related disease.

CONCLUSION

CSS of the submandibular gland represents a reactive pattern rather than IgG4-RD as only 3 cases seemed to be related to IgG4-RD. The immunohistochemical profile revealed an abundant population of CD3-positive T lymphocytes, as opposed to regulatory proteins such as cyclin D1, demonstrating that populations of CD34- and SMA-positive stromal fibroblasts contribute to the fibrosis characteristic of CSS. In addition, our results provide a comprehensive insight into the study of CSS and its relationship with IgG4-RD.

Chronic sclerosing sialadenitis of the bilateral submandibular glands in childhood - a diagnostic dilemma

Chronic sclerosing sialadenitis (CSS), currently included in the group of immunoglobulin G4 (IgG4)-related diseases, is an under-recognized inflammatory lesion that afflicts mostly the submandibular gland of 40-60 years adults. To our knowledge, only one case of CSS located in the submandibular gland has been reported in childhood to date. We present a case of CSS in a 5-year-old male child. He presented with bilateral submandibular swellings that clinically resembled discrete lumps, suspected to be tumors. The completely resected tumors composed predominantly of dense lymphoplasmacytic inflammatory infiltrate rich in IgG4-positive cells [77-90 IgG(+) cells per high-power field; IgG4(+)∕IgG(+) cells ratio of 42.77%]. We discuss the peculiarities of this case, and we also review the literature on CSS.

Polarized Microscopic Analysis of Picrosirius Red Stained Salivary Gland Pathologies: An Observational Study

OBJECTIVE

 Salivary gland diseases and their pathologies may affect the glandular structure including collagen, a major stromal component, in response to tissue damage or diseases. This study aimed to examine the changes in collagens in different salivary gland diseases using polarized picrosirius red staining.

MATERIALS AND METHODS

 The submandibular gland samples diagnosed as sialadenitis, chronic sclerosing sialadenitis, pleomorphic adenoma, adenoid cystic carcinoma, and mucoepidermoid carcinoma were stained with picrosirius red, Masson's trichrome, and anticollagen I staining. The quantity of collagens was examined and reported as a percentage of positive picrosirius red area. The maturity of collagens was studied with polarized light microscope and reported as a percentage of orange-red and yellow-green polarized collagens, representing the mature and immature collagens, respectively.

STATISTICAL ANALYSIS

 The % positive areas for picrosirius red representing the collagen amount among salivary gland diseases were analyzed by one-way analysis of variance with Tukey's test. The % orange-red and % yellow-green polarized areas representing the collagen maturity were analyzed by Kruskal-Wallis test and Mann-Whitney U test.

RESULTS

 The malignant tumors, adenoid cystic carcinoma (29.92) and mucoepidermoid carcinoma (26.59), had higher significant percentage of positive picrosirius red area, compared with the benign tumor (14.56), chronic sclerosing sialadenitis (10.61), and sialadenitis (7.22) (p < 0.05). The percentages of orange-red polarized areas are 48.07, 39.6, 62.67, 83.75, and 76.05 in sialadenitis, chronic sclerosing sialadenitis, pleomorphic adenoma, adenoid cystic carcinoma, and mucoepidermoid carcinoma, respectively. This percentage tended to increase in the benign and malignant lesions with statistical difference, compared with the inflammatory lesions (p < 0.05). There was no statistical difference in the percentages of yellow-green polarized areas among various salivary gland diseases. In addition, the results of Masson's trichrome and anticollagen I staining are corresponding to that of picrosirius red among various salivary gland diseases.

CONCLUSIONS

 Polarized picrosirius red demonstrated the most amounts of collagen in the malignant lesion, and represented the different maturity of collagens in each lesion group. Studying the amounts and maturity of collagen with picrosirius red for extracellular matrix alteration in salivary gland diseases along with routine hematoxylin and eosin, Masson's trichrome, and immunohistochemistry may provide a better understanding in different salivary gland pathologies.

Chronic sclerosing sialadenitis (Küttner's tumour) of the submandibular gland: a neoplastic mimic

A 74-year-old man was referred for a plastic surgery consultation for two previous acute episodes of right submandibular sialadenitis. Physical examination revealed a lump in the right submandibular region, painful on palpation. The initial impression on clinical examination was of sialolithiasis. The sonography demonstrated a structural heterogeneity of the submandibular gland with a hypoechogenic and vascularised nodular formation (1.5×1.2 cm), suggestive of a mixed tumour of the right maxillary gland, requiring histological evaluation. He underwent a right submandibulectomy and an IgG4-positive chronic sclerosing sialadenitis was diagnosed. The patient's condition evolved favourably, resulting in a full recovery. The clinical features and differential diagnosis of this entity are debated in light of relevant literature.

A case report of Kuttner tumor mimicking a malignant tumor, leading to overtreatment

Preoperative diagnosis with multimodal approaches might lead to overtreatment. Cautious understanding of cytology and dynamic contrast-enhanced magnetic resonance imaging is required when a Kuttner tumor is cited as differential diagnosis.

Mikulicz's disease and Küttner's tumor as manifestations of IgG4-related diseases: a review of the literature

According to a new concept for the classification and division of autoimmune diseases, Mikulicz's disease and Küttner's tumor belong to immunoglobulin G4-related diseases (IgG4-RD) and fulfil their diagnostic criteria. The aim of this study was to summarize the new classification concepts of IgG4-RD in the head and neck area and to review their clinical, histopathological and serologic criteria and the methods used in the diagnostic workup with respect to their advantages, limitations and differentiative value. The PubMed, Web of Science, Google Scholar, and Scopus databases were searched for articles published between 2009 and 2019 using the following key words: IgG4-related diseases, Mikulicz's disease, Küttner's tumor, salivary glands, xerostomia. Results of the review of the literature revealed that Mikulicz's disease and Küttner's tumor fulfil the same diagnostic criteria but may manifest different clinical symptoms which determine the choice of the different diagnostic tools.

Pediatric Parotid Chronic Sclerosing Sialadenitis in an African-American Female: A Rare Case and Review of the Literature

Chronic sclerosing sialadenitis (CSS) or Küttner tumor is an under-recognized, benign fibroinflammatory disease most commonly seen in the submandibular gland of older adult males. Sialolithiasis or bacterial infection was first suspected as an etiology, but CSS is now considered an immunoglobulin G4-related disease (IgG4-RD). IgG4-RD can affect almost every organ in the body, characterized by organ fibrosis with IgG4-positive plasmacytes. Numerous autoimmune-related diseases have been unified under IgG4-RD, including Mikulicz disease (MD), autoimmune pancreatitis, Reidel’s thyroiditis, and others. In any organ, IgG4-RD can present similar to malignancy. Due to the ability to mimic malignancy, it is crucial to be aware of this under-recognized clinical entity. CSS is currently of broad and high clinical interest due to increased understanding, multiorgan involvement, and more clearly defined criteria. To increase awareness of this disease, we describe a rare presentation of CSS with a literature review.

Arteriovenous vascular malformation of the submandibular gland masquerading as Küttner's tumour

Chronic sclerosing sialadenitis, also known as Küttner's tumour, is a chronic inflammatory condition affecting the salivary glands. We present the case of an arteriovenous vascular malformation (AVM) of the right submandibular gland mimicking a Küttner's tumour on ultrasound scan in a 63-year-old woman. Examination revealed a 2 cm firm, mobile, non-pulsatile, right-sided submandibular mass with no overlying skin changes but with mild tenderness to palpation. Histological appearances revealed an AVM associated with localised fatty metaplasia and glandular atrophy. Although rare, AVMs should be considered a differential diagnosis for a submandibular gland mass that gives unclear or unusual radiological appearances.

Chronic sclerosing sialadenitis (Küttner's tumor) of the submandibular salivary gland: Our experience of one case report

Surgical excision of the submandibular salivary gland in patients with chronic sclerosing sialadenitis can be complicated because of hyalinosis of the surrounding soft tissues. Patients with autoimmune diseases suspected of having salivary gland neoplasms or granulomatous disease should be carefully investigated for chronic sclerosing sialadenitis to prevent potential harm.