Kuttner tumor of the submandibular gland: fine-needle aspiration cytologic findings of seven cases

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.

Is Milan for kids?: The Milan System for Reporting Salivary Gland Cytology in pediatric patients at an academic children's hospital with cytologic-histologic correlation

BACKGROUND

The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) provides a useful framework for the diagnosis of salivary gland fine-needle aspiration (FNA) biopsies. In this study, the MSRSGC was applied to salivary gland FNAs in pediatric patients to assess its usefulness and look at pitfalls.

METHODS

The laboratory information system was queried over a 15-year period for all salivary gland FNAs in patients 18 years old or younger. Patient demographics, FNA diagnosis categorized according to the MSRSGC, and follow-up surgical pathology diagnoses were examined and correlated.

RESULTS

Thirty-two cases were identified, with an average age of 12 years (range, 0.6-18 years). A majority of the cases (84.4%) were from the parotid region. Twenty of 32 cases (62.5%) had follow-up resection. MSRSGC recategorization diagnoses of the 32 FNA cases were 34% benign neoplasm, 31% nonneoplastic, 16% nondiagnostic, 9% atypia of undetermined significance, 3% salivary neoplasm of uncertain malignant potential, 3% suspicious for malignancy, and 3% malignant. Overall, the sensitivity and specificity were 100% and 80%, respectively. On follow-up resection, 55% were neoplastic: pleomorphic adenomas (n = 6; 55%), pilomatricoma (n = 3; 28%), mucoepidermoid carcinoma (n = 1; 9%), schwannoma (n = 1; 9%), and myofibroma (n = 1; 9%).

CONCLUSIONS

The MSRSGC performed fairly well in the pediatric population with a low overall risk of malignancy (6%) and high sensitivity. Although the majority of pediatric salivary gland FNAs were benign, 55% of resected cases were positive for a neoplasm, with benign neoplasms outnumbering malignancy. Challenging entities included inflammatory conditions, like immunoglobulin G4-related sialadenitis, and skin and soft tissue lesions near the salivary gland.

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.

Warthins tumor: Cyto histological spectrum with emphasis on diagnostic difficulties

Warthins tumour is characterized by the presence of epithelial proliferation in a lymphoid stroma. It has been categorized as Sieferts types: 1-4, depending on the proportions of the 2 components. Although FNA is fairly accurate in establishing the diagnosis, the cytologic diagnosis of this tumor has potential sources of error. This retrospective study was conducted in the Department of Pathology and Lab Medicine, of a tertiary care hospital. Cytology and surgical pathology records of past 15 years were screened. A total of 1200 FNAC cases of salivary gland lesions in the past 15 years were retrieved. 36 cases with presumptive cytodiagnosis of WT were identified and histopathological correlation was done. Histopathological correlation could be done in 24 cases. 19 out of 24 cases, were confirmed as WT. The 5 cases with discordance were analyzed for potential diagnostic pitfalls. The most common discordance was in the category of papillary proliferation with minimal lymphoid infiltrate. One case proved as oncocytoma and the other was papillary oncocyticcystadenoma. The other major pitfalls, were the interpretation of atypical squamoid cells. Their presence in a lymphoid background needs consideration of cytologic diagnosis of WT, mucoepidermoid carcinoma and metastatic squamous carcinoma. FNA showed an accuracy of 79% for WT. Cytological misinterpretation can thus occur in presence of morphology other than classical Siefert type1. An awareness of these potential pitfalls should push the need for avoiding single cytologic interpretation.

Clinicopathology of Immunoglobulin G4–Related Chronic Sclerosing Sialadenitis

Objectives

To investigate the clinicopathologic characteristics of patients with immunoglobulin G4–related chronic sclerosing sialadenitis (IgG4-RCSS), a recently recognized disease.

Study Design

Case series with chart review and pathology study.

Settings

Tertiary care hospital.

Subjects and Methods

We evaluated chronic sialadenitis specimens obtained over 11 years using pathologic examination and IgG4 immunohistochemistry staining. The specimens were assigned a revised diagnosis of IgG4-RCSS or chronic sialadenitis not otherwise specified, and clinicopathologic data from each group were compared.

Results

Of the 84 patients, 21 were diagnosed with IgG4-RCSS and 63 with chronic sialadenitis not otherwise specified. IgG4-RCSS patients were older (68.2 ± 13.9 vs 54.2 ± 15.8 years, P = .001), predominantly male (85.7% vs 61.9%, P = .036), and more likely to present with painless swelling (75% vs 44.3%, P = .001) and bilateral involvement (52.4% vs 6.3%, P < .001). Ratio of IgG4-positive plasma cells to IgG-positive plasma cells in IgG4-RCSS tissues was 0.81 ± 0.14. The mean value of serum IgG4 in IgG4-RCSS patients was 918.8 mg/dL.

Conclusion

IgG4-RCSS is more common in older male patients and frequently presents with bilateral involvement. Informing head and neck surgeons of the clinical features of IgG4-RCSS and promoting a combined approach of clinical evaluation, imaging, and biopsy can improve the accuracy of preoperative diagnoses.

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 (CSS) is a benign chronic inflammatory condition of the salivary gland. Clinically, CSS patients may present with a neck mass, often suggesting a neoplastic process. Fine-needle aspiration (FNA) is frequently used to evaluate these lesions. We present a series of 4 patients with CSS, in whom all but one had history of squamous cell carcinoma. The previous diagnosis of malignancy appeared to influence the interpretation of the cytologic preparations. Four patients who had undergone resection of a neck nodule that eventually was diagnosed as CSS were identified. FNA was performed in all 4 cases, and the final cytologic diagnosis in these cases included squamous cell carcinoma, basaloid neoplasm, and salivary gland neoplasm. During intraoperative consultation, the lesions were identified as benign, atrophic salivary gland with chronic inflammation, or sialadenitis with atypical glands. All resected specimens were submitted for histopathological examination and were considered diagnostic for CSS. CSS is a potential pitfall in the FNA interpretation of salivary gland lesions, especially if there is a previous history of head and neck malignancy. Awareness of this entity, adherence to strict cytologic criteria, and careful clinicopathologic correlation are helpful in preventing misinterpretation and unnecessary surgical intervention.

IgG4-related disease of the head and neck

IgG4-related disease is an uncommon sclerosing and inflammatory mass-forming disease that may affect a single organ or be systemic. The prototypical example of the disease is type 1 autoimmune pancreatitis. After the pancreatobiliary system, the head and neck is the next most common site for involvement by IgG4-related disease. Here, we describe the clinicopathologic features of the head and neck involvement by this disease process with particular attention to involvement of the major salivary glands, the lacrimal glands and periorbital tissues, the upper aerodigestive tract, the thyroid gland, lymph nodes, the ear, and the skin and soft tissues.

Pediatric chronic sclerosing sialadenitis: Küttner tumor

Chronic sclerosing sialadenitis is an uncommon cause of salivary gland enlargement mainly occurring in the fifth and seventh decade of life. In the Western population, chronic sclerosing sialadenitis has been characterized as an IgG4-related disease. Although rare, this lesion occurs in children. To increase awareness about this entity in the pediatric age group, we report the case of an 11-year-old boy with a hard, 4.0-cm circumscribed mass in the right submandibular gland. Histologically there was marked distortion of the gland architecture by a dense lymphocytic infiltrate and extensive fibrosis with septa that crossed and distorted the gland, leaving atrophic acini and dilated, irregular ducts. The lymphoid infiltrate formed multiple follicles with active germinal centers, numerous plasma cells, and areas with diffuse arrangement. Immunophenotyping showed abundant CD20- and CD3-positive lymphocytes; cytokeratin AE1/AE3 highlighted the distorted architectural pattern; IgG staining showed large numbers of positive cells infiltrating the interstitium and surrounding the atrophic acini and ducts. IgG4 staining revealed a large proportion of positive infiltrating elements. Küttner tumor belongs to the group of IgG4-related sclerosing diseases. The differential diagnosis includes pleomorphic adenoma and other salivary gland neoplasms. Its recognition in children is important clinically because this entity is amenable to steroid treatment, and additional work up and follow up is warranted to stave off other IgG4-related diseases/complications.

IgG4-related sclerosing disease, an emerging entity: a review of a multi-system disease

Immunoglobulin G4-related systemic disease (IgG4-RSD) is a recently defined emerging entity characterized by a diffuse or mass forming inflammatory reaction rich in IgG4-positive plasma cells associated with fibrosclerosis and obliterative phlebitis. IgG4-RSD usually affects middle aged and elderly patients, with a male predominance. It is associated with an elevated serum titer of IgG4, which acts as a marker for this recently characterized entity. The prototype is IgG4-related sclerosing pancreatitis or autoimmune pancreatitis (AIP). Other common sites of involvement are the hepatobiliary tract, salivary gland, orbit, and lymph node, however practically any organ can be involved, including upper aerodigestive tract, lung, aorta, mediastinum, retroperitoneum, soft tissue, skin, central nervous system, breast, kidney, and prostate. Fever or constitutional symptoms usually do not comprise part of the clinical picture. Laboratory findings detected include raised serum globulin, IgG and IgG4. An association with autoantibody detection (such as antinuclear antibodies and rheumatoid factor) is seen in some cases. Steroid therapy comprises the mainstay of treatment. Disease progression with involvement of multiple organ-sites may be encountered in a subset of cases and may follow a relapsing-remitting course. The principal histopathologic findings in several extranodal sites include lymphoplasmacytic infiltration, lymphoid follicle formation, sclerosis and obliterative phlebitis, along with atrophy and destruction of tissues. Immunohistochemical staining shows increased IgG4+ cells in the involved tissues (>50 per high-power field, with IgG4/IgG ratio >40%). IgG4-RSD may potentially be rarely associated with the development of lymphoma and carcinoma. However, the nature and pathogenesis of IgG4-RSD are yet to be fully elucidated and provide immense scope for further studies.

Bilateral Kuttner tumours of the lacrimal glands

Kuttner Tumour is a chronic inflammatory disease diagnosed histologically. It is under-diagnosed due to lack of awareness of the disease. We present a case of a 40-year old female with recurrent upper lid swelling. Biopsy revealed the diagnosis of Kuttner Tumours of the lacrimal glands. Although surgical excision is a treatment option, it can be treated with a course of steroids. Our patient opted for conservative management. We describe the presentation and course of the case, with an emphasis on the histological features of the tumour.

IgG4-related sclerosing disease: a critical appraisal of an evolving clinicopathologic entity

An elevated serum titer of immunoglobulin G4 (IgG4), the least common (3% to 6%) of the 4 subclasses of IgG, is a surrogate marker for the recently characterized IgG4-related sclerosing disease. The syndrome affects predominantly middle-aged and elderly patients, with male predominance. The patients present with symptoms referable to the involvement of 1 or more sites, usually in the form of mass lesions. The prototype is IgG4-related sclerosing pancreatitis (also known as autoimmune pancreatitis), most commonly presenting as painless obstructive jaundice with or without a pancreatic mass. Other common sites of involvement are the hepatobiliary tract, salivary gland, orbit, and lymph node, but practically any organ-site can be affected, such as retroperitoneum, aorta, mediastinum, soft tissue, skin, central nervous system, breast, kidney, prostate, upper aerodigestive tract, and lung. The patients usually have a good general condition, with no fever or constitutional symptoms. Common laboratory findings include raised serum globulin, IgG, IgG4, and IgE, whereas lactate dehydrogenase is usually not raised. Some patients have low titers of autoantibodies (such as antinuclear antibodies and rheumatoid factor). The disease often shows excellent response to steroid therapy. The natural history is characterized by the development of multiple sites of involvement with time, sometimes after many years. However, the disease can remain localized to 1 site in occasional patients. The main pathologic findings in various extranodal sites include lymphoplasmacytic infiltration, lymphoid follicle formation, sclerosis and obliterative phlebitis, accompanied by atrophy and loss of the specialized structures of the involved tissue (such as secretory acini in pancreas, salivary gland, or lacrimal gland). The relative predominance of the lymphoplasmacytic and sclerotic components results in 3 histologic patterns: pseudolymphomatous, mixed, and sclerosing. Immunostaining shows increased IgG4+ cells in the involved tissues (>50 per high-power field, with IgG4/IgG ratio >40%). The lymph nodes show multicentric Castleman disease-like features, reactive follicular hyperplasia, interfollicular expansion, or progressive transformation of germinal centers, with the unifying feature being an increase in IgG4+ plasma cells on immunostaining. The nature and pathogenesis of IgG4-related sclerosing disease are still elusive. Occasionally, the disease can be complicated by the development of malignant lymphoma and possibly carcinoma.

Epithelioid Cell Clusters With an Extensive Lymphoid Background

Context.—Fine-needle aspiration of salivary gland lesions can be particularly challenging for pathologists. There are numerous neoplasms that occur in this area and several cytologic variations of each specific lesion.

Objective.—To present and discuss a practical pattern recognition approach to fine-needle aspiration diagnosis, which includes categorizing lesions that share a certain overall cytologic architectural pattern, followed by identifying unique cellular characteristics that are specific to a certain lesion. An extensive discussion of one cytologic common pattern of salivary gland lesions, “epithelioid cell clusters with an extensive lymphoid background,” is presented. The pathologic entities that fall under this architectural pattern group are discussed, with an emphasis on neoplasms.

Data Sources.—Published literature and personal experience.

Conclusions.—A practical cytologic architectural pattern method can aid the pathologist in rendering a correct diagnosis when evaluating salivary gland lesions. One common pattern in salivary gland cytopathology is epithelioid cell clusters with an extensive lymphoid background. This pattern is often associated with Warthin tumor; however, other benign and malignant entities fall under this diagnostic group. Unique cytologic features separate these lesions into their respective diagnostic category.

Küttner's tumor of the submandibular glands: Report of five cases with fine-needle aspiration cytology

Küttner's tumor (KT) is a benign tumor-like lesion of the salivary gland that mimics neoplasm clinically because of presentation as a hard mass. Recently, the histomorphological and immunohistochemical findings of this lesion have been analyzed, and differential diagnostic problems relating to salivary gland lymphoma have been discussed. However, currently there is little information on the cytological findings of those lesions. We present cytological findings from five such cases using fine-needle aspiration cytology (FNAC). FNAC of this lesion may present a diagnostic challenge to the cytologist as lesions share some cytologic features with inflammatory process containing numerous lymphoid cells. Smears obtained from two cases contained moderate to large numbers of lymphoid cells without definite cytological atypia, scattered ductal structures, and acinar cell clusters. The remaining three cases showed low cellularity probably attributable to fibrosis that made it difficult to aspirate the cellular element. FNAC findings of scattered ductal structures surrounded by collagens and infiltrated by a mixed population of lymphoid cells, not specific for KT, are highly suggestive of the diagnosis with the appropriate clinical findings. However, a portion of cytological specimens of KT containing relatively large numbers of lymphoid cells should be differentiated from malignant lymphoma arising from the submandibular gland.

Abundant IgG4-positive plasma cell infiltration characterizes chronic sclerosing sialadenitis (Küttner's tumor)

Chronic sclerosing sialadenitis (CSS) is a cryptogenic tumor-like condition of the salivary gland(s). While immune-mediated processes are suspected in its pathogenesis, and CSS is occasionally reported to be associated with sclerosing pancreatitis, an IgG4-related disease, the exact immunopathologic processes of CSS remain speculative. In this study, we examined the clinicopathologic findings of CSS (12 cases) in comparison with sialolithiasis (8 cases) and Sjogren's syndrome (13 cases), and tried to clarify whether CSS is an IgG4-related disease or not. Submandibular gland(s) were affected in all cases of CSS. CSS cases could be divided into two types: 5 cases were associated with sclerosing lesions in extrasalivary glandular tissue (systemic type), while only salivary gland(s) were affected in the remaining 7 cases (localized type). In the former type, which showed male predominance, bilateral salivary glands were frequently affected, and eosinophilia and elevations of gamma-globulin and IgG in serum were frequently found. Histologically, all cases of CSS showed marked lymphoplasmacytic infiltration admixed with fibrosis and the destruction of glandular lobules. Obliterative phlebitis was found in the affected salivary glands in all cases of CSS. Immunohistochemically, the proportion of IgG4/IgG-positive plasma cells was more than 45% in CSS, while it was less than 5% in controls. The resemblance of the clinicopathologic features of CSS with those of sclerosing pancreatitis suggests the participation of a similar immunopathologic process with IgG4 disturbance in CSS. The abundance of IgG4-positive plasma cells in the lesions would be useful for distinguishing CSS from other forms of sialadenitis.

Küttner's tumor: unusual presentation with bilateral involvement of the lacrimal and submandibular glands

Chronic sclerosing sialadenitis, known as Küttner's tumor (KT), is a chronic inflammatory disease of the salivary gland characterized by progressive periductal fibrosis, dilated ducts with a dense lymphocyte infiltration and lymphoid follicle formation, and acinar atropy. We report a unique case of KT in a 30-year-old female who presented with time-serial involvement of the bilateral lacrimal and submandibular glands with reactive follicular hyperplasia of bilateral upper cervical lymph nodes. All tissue samples of the submandibular and lacrimal glands were typical of KT on pathologic examination. There was no evidence of lymphoepithelial lesions or intraepithelial lymphocytes. This is the first case of KT involving both lacrimal and submandibular glands, suggesting that KT is closely related to an active local immune process.