Acinic cell carcinoma mimicking Warthin's tumor: A diagnostic challenge on fine-needle cytology

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.

Papillary thyroid carcinoma associated with non‑functioning parathyroid carcinoma with Warthin's tumor of the parotid gland: A case report and brief literature review

Multiple neck pathologies occurring simultaneously are a rare condition. The present study describes an extremely rare case of papillary thyroid carcinoma, non-functioning parathyroid carcinoma (PC) and Warthin's tumor of the parotid gland. A 59-year-old male presented with a 3-month history of anterior neck swelling. The neck ultrasound revealed a left-sided thyroid nodule associated with pathological lymph nodes. There was a parotid gland mass. A fine-needle aspiration of the left parotid mass was not diagnostic, although the left thyroid nodule revealed a malignancy with metastasis to the left cervical group lymph nodes. The patient underwent total thyroidectomy, left central and left lateral cervical lymph node dissection. A superficial parotidectomy was also performed. A histopathological examination revealed three different pathologies: Papillary thyroid microcarcinoma, PC and Warthin's tumor. The simultaneous occurrence of a Warthin's tumor, papillary thyroid microcarcinoma and PC is an unusual condition. The concurrent findings of these three pathologies have not yet been reported in the literature, at least to the best of our knowledge. The synchronous findings of PTC, non-functioning PC and Warthin's tumor are extremely rare, yet possible. Surgical intervention remains the most appropriate treatment strategy.

Validation of indications for enucleation for benign parotid gland tumors

BACKGROUND

Enucleation has been reported as a minimally invasive surgery for Warthin's tumor (WT). However, the definite indications for enucleation have not been clarified.

METHODS

Enucleation was indicated by the following findings: findings of WT, cystic fluid, or benign leukocytes by fine-needle aspiration cytology; a well-margined and homogeneous pattern on imaging; and a tumor location in the tail or preauricular area of the parotid gland. We reviewed 552 cases treated with parotid gland surgery in our hospital.

RESULTS

A total of 108 tumors were treated with enucleation and included no malignant solid tumors or pleomorphic adenoma. Enucleation demonstrated low invasiveness and complication rates. Revision surgery for WT reappearance after enucleation was rare and showed minimal scarring, with a lower risk of facial weakness.

CONCLUSIONS

The indication criteria for enucleation were validated. Such enucleation is useful, as it is associated with minimal invasiveness, low complication rates, and safety in revision surgery.

Synchronous Bilateral Multifocal Warthin's Tumor Mimicking Primary Malignancy on 18 F-FDG Whole Body PET/CT in a Case of Metastatic Cervical Lymph Nodes from Unknown Primary Malignancy

Warthin's tumor is a benign and frequently encountered salivary gland neoplasm. Bilaterality and multifocality are rare in Warthin's tumor. Synchronous cervical lymph nodal metastasis with unknown primary in a case of Warthin's tumor can raise a suspicion of primary malignancy of the parotid gland. We present a case of bilateral multifocal Warthin's tumor with synchronous squamous cell carcinoma metastasis to the cervical lymph node. ¹⁸ F-fluorodeoxyglucose whole body positron emission tomography/computed tomography imaging showed hypermetabolic bilateral multifocal parotid lesions and metastatic cervical lymph node with unknown primary malignancy.

Squamous Cell Carcinoma Arising in a Parotid Warthin's Tumor: A Case Report and Literature Review

Warthin's tumor is the second most common benign neoplasm of the parotid gland. Epithelial malignant transformation of Warthin's tumor, especially to squamous cell carcinoma, is a rare event. The authors present a case report of a 57-year-old male patient with a mass in the left parotid gland. This paper documents the appearance of squamous cell carcinoma within Warthin's tumor of the left parotid gland and reviews the other similar features of 12 cases.

Malignant transformation of Warthin's tumor into squamous cell carcinoma: A case report

Malignant transformation of Warthin's tumor into squamous cell carcinoma is rare. The present study reported on a case of a 67-year-old male patient diagnosed with this condition. Microscopically, the tumor was mainly composed of squamous cell carcinoma and lymphoid stroma. Furthermore, the squamous cell carcinoma cells were arranged in a solid flake-like, papillary and cystic shape. Local bleeding was observed in the mass and a large number of lymphoid stroma-associated centers were observed between the cancer cells. The expression of cytokeratin (CK)5/6, P40, CK7, CK18, CK8 and MutS protein homolog 2 was detected by immunohistochemistry, in addition to Epstein-Barr encoding region in situ hybridization (−), Ki-67 (epithelial 25% +) and p53 (wild-type). The diagnosis of malignant transformation of Warthin's tumor into squamous cell carcinoma depends on the histopathology. The microscopic diagnosis is based on the dynamic process of scaling, atypical hyperplasia and cancerization of the eosinophilic columnar epithelium. Of note, it is also necessary to differentiate it from cervical malignant tumors such as lymphoepithelial carcinoma. The main clinical treatment is surgical resection with negative margins.

Function-preserving surgery via single transverse cervical incision for Warthin's tumor in the parotid gland

BACKGROUND

This study evaluated functional and disease control outcomes after gland-preserving surgery via a single transverse cervical incision for Warthin's tumor of the parotid gland.

METHODS

One-hundred eleven patients with Warthin's tumor underwent the preservation of most normal parotid tissues and the facial nerve combined with the en-bloc resection of tumors. Postoperative complications, subjective satisfaction, salivary function, and metachronous tumor were assessed in each patient.

RESULTS

No patients had an extension to modified Blair or periauricular incision with the median operation time of 32 min. Temporary and permanent paralysis of the facial nerve was 5 (4.0%) and none of 125 tumor resection sides, respectively. Postoperative complications were minimal. The secretory functions between the affected and unaffected glands did not differ. One patient had metachronous tumor for a median follow-up of 72 months.

CONCLUSION

Functional gland-preserving surgery via single transverse cervical incision can safely treat Warthin's tumor in the parotid gland.

Parotid Warthin's tumor: novel MR imaging score as diagnostic indicator

OBJECTIVES

Despite known characteristic radiologic and clinical features, differentiation between Warthin's tumor (WT) and other parotid tumors remains challenging. The purpose of this study was to more precisely assess the MR imaging features of WT and to develop a scoring system combining the most specific characteristics.

METHODS

A total of 208 patients with parotid gland tumors and presurgical MRI were included. Tumors were divided into 5 histological subtypes, and different MRI features were compared between groups. An MRI scoring test was developed including MR parameters that contributed significantly in distinguishing WT from other tumors.

RESULTS

The best MRI features for differentiating between WTs from other tumors included bilaterality (P = 0.002), multifocality (P < 0.001), ADC values <905.1 (P < 0.001), and high signal intensity on T1-W images (P < 0.001). Six or more points on the 14-point scoring MRI scale was associated with an area under the curve of 0.99 (Accuracy of 98%), while a cut-off value of 7 indicated 100% specificity and 100% positive predictive value.

CONCLUSIONS

Ill-defined margins, low T1-W signal, and location in the upper 2/3 of the parotid gland excluded WTs in 100% of cases. The proposed scoring method allows WTs to be distinguished from other tumors with high accuracy.

KEY POINTS

Ultrasound-guided ethanol sclerotherapy for non-surgical treatment of Warthin's tumor

BACKGROUND

Currently, the first line treatment for Warthin's tumor (WT) is parotidectomy. There is a paucity of data evaluating the safety and efficacy of non-surgical treatments for patients not amenable to surgery. Ultrasound guided ethanol sclerotherapy (UGES) has been successfully used for the management of lymphangiomans of the head and neck, thyroid nodules, and thyroid cysts. This is the first study to implement and assess the success of UGES for management of WT.

METHODS

We report two patients with WT, with a total of 3 masses, who underwent UGES. All procedures were performed in the clinic. The primary outcome measured was the tumor volume reduction rate (VRR), patient satisfaction, and complications observed at follow-up.

RESULTS

Both patients experienced a significant reduction in tumor size upon follow up. VRR for the three treated tumors were 67.30%, 98.32%, and 55.73%. Patient were very satisfied with the results and noted significant cosmetic improvement. No complications were observed at follow-up.

CONCLUSIONS

Ultrasound guided ethanol sclerotherapy may be a viable option for conservative treatment of Warthin's tumor in patients unsuitable or unwilling to undergo surgical resection.

Perfusion Computed Tomography Scan Imaging in Differentiation of Benign from Malignant Parotid Lesions

Introduction  The most common site of salivary gland tumors is the parotid gland. Computed tomography (CT), magnetic resonance imaging (MRI), and sonography are imaging modalities to differentiate benign from malignant parotid tumors.

Objective  The aim of this study is the evaluation of the diagnostic value of perfusion CT for differentiating histological categorization of benign and malignant parotid tumors.

Methods  A total of 29 patients with parotid neoplasms were enrolled in this study. Mean age and all CT perfusion variables (gradient and permeability, blood flow [BF], blood volume [BV], mean transit time [MTT], permeability surface [PS], maximum intensity projection [MIP], time-density curve [TDC], and time to peak [TTP]) were compared among three groups (malignant tumors [MTs], Warthin's tumor [WT] and pleomorphic adenomas [PA]).

Results  The mean age of the patients was 55.9 ± 14.1 (26–77), and 15 of them were male (51.7%). Eleven lesions were PAs [37.9%], 8 lesions were WTs (27.6%0 and 10 lesions (34.5%) were MTs (6 acinic cell carcinomas [ACCs], 3 adenocystic carcinomas [AdCCs], and 1 mucoepidermoid carcinoma [MEC]). The mean age of the patients with WTs was 62 ± 7.5 years; 52 ± 14.2 for patients with Pas, and 55.2 ± 17.2 for those with MTs ( p  = 0.32). The mean MIP was 122.7 ± 12.2 in WT, while it was 80.5 ± 19.5 in PA, and 76.2 ± 27.1 in MTs ( p  < 0.001); The mean MIP for WT was higher than for PAs and MTs; the values of MTs and PAs were not statistically different. The average of BF, BV, and curve peak were higher in WTs in comparison with the other two groups, and curve time 2 and TTP were higher in PAs in comparison with MTs.

Conclusion  Based on this study, perfusion CT of the parotid gland and its parameters can distinguish between benign and malignant parotid masses.

The diagnostic value of cytology in parotid Warthin's tumors: international multicenter series

INTRODUCTION

Warthin's tumor (WT) is a common benign salivary gland neoplasm with a negligible risk of malignant transformation. However, there is a risk of malignant tumors being misdiagnosed as WT on cytology and inappropriately managed conservatively.

METHODS

Patients from nine centers in Italy and the United Kingdom undergoing parotid surgery for cytologically diagnosed WT were included in this multicenter retrospective series. Definitive histology was compared with preoperative cytological diagnoses. Surgical complications were recorded.

RESULTS

A total of 496 tumors were identified. In 88.9%, the final histological diagnosis was WT. In 21 cases (4.2%) a malignant neoplasm was diagnosed, which had been incorrectly labeled as WT on cytology.

CONCLUSIONS

The risk of undiagnosed malignancy should be balanced against surgical risks when considering the management of WT. Although nonsurgical management remains an appropriate option, there may be a rationale for serial clinical or radiological evaluation if surgical excision is not performed.

Classical Hodgkin lymphoma arising from heterotopic Warthin's tumor in the cervical lymph node: A case report

Heterotopic Warthin's tumor (WT) arising from the cervical lymph nodes is uncommon and WT presenting concomitantly with classical Hodgkin's lymphoma has only been previously reported three times in English literature. The current study presents an unusual case of classical Hodgkin lymphoma (CHL) involving the heterotopic WT in a 59-year-old male. Histopathologic examination revealied a WT with extensive expansion of mixed-cellularity CHL in a lymph node in the right of the neck. Clinical staging was determined as stage IA disease. The patient received four courses of chemotherapy and local consolidative radiotherapy, no evidence of disseminated lymphoma was observed over the 6-month follow-up. To the best of our knowledge, this is the first well documented collision tumor between CHL and heterotopic WT of the cervical lymph nodes. The present case also expands the anatomical site of malignant lymphomas associated with WT.

Warthin-like papillary renal cell carcinoma: Clinicopathologic, morphologic, immunohistochemical and molecular genetic analysis of 11 cases

Oncocytic papillary renal cell carcinoma (PRCC) is a distinct subtype of PRCC, listed as a possible new variant of PRCC in the 2016 WHO classification. It is composed of papillae aligned by large single-layered eosinophilic cells showing linearly arranged oncocytoma-like nuclei. We analyzed clinicopathologic, morphologic, immunohistochemical and molecular-genetic characteristics of 11 oncocytic PRCCs with prominent tumor lymphocytic infiltrate, morphologically resembling Warthin's tumor. The patients were predominantly males (8/11, 73%), with an average age of 59years (range 14-76), and a mean tumor size of 7cm (range 1-22cm). Tumors had the features of oncocytic PRCCs with focal pseudostratification in 8/11 cases and showed dense stromal inflammatory infiltration in all cases. Papillary growth pattern was predominant, comprising more than 60% of tumor volume. Tubular and solid components were present in 5 and 3 cases, respectively. Uniform immunohistochemical positivity was found for AMACR, PAX-8, MIA, vimentin, and OSCAR. Tumors were mostly negative for carboanhydrase 9, CD117, CK20, and TTF-1. Immunohistochemical stains for DNA mismatch repair proteins MLH1 and PMS2 were retained in all cases, while MSH2 and MSH6 were negative in 1 case. Tumor infiltrating lymphocytes (TILs) consisted of both B and T cells. Chromosomal copy number variation analysis showed great variability in 5 cases, ranging from a loss of one single chromosome to complex genome rearrangements. Only one case showed gains of chromosomes 7 and 17, among other aberrations. In 4 cases no numerical imbalance was found. Follow up data was available for 9 patients (median 47.6months, range 1-132). In 6 patients no lethal progression was noted, while 3 died of disease. In conclusion, Warthin-like PRCC is morphologically very close to oncocytic PRCC, from which it differs by the presence of dense lymphoid stroma. Chromosomal numerical aberration pattern of these tumors is variable; only one case showed gains of chromosomes 7 and 17. Warthin-like PRCC is a potentially aggressive tumor since a lethal outcome was recorded in 3/9 cases.

Role of fine-needle aspiration cytology in the diagnosis of major salivary gland tumors: A study with histological and clinical correlation

INTRODUCTION

Neoplastic lesions of salivary glands present an interesting subject because of their histologic diversification. Complex features exhibited by them have aroused considerable speculations concerning their histogenesis and continues to hold the interest of clinicians and pathologists. Major salivary glands are superficial and have easy accessibility for fine-needle aspiration cytology (FNAC). These glands are generally not subjected to incisional or core needle biopsy, because of the possible risks of fistula formation and tumor seedling. FNAC diagnosis of major salivary gland neoplasms aids in proper planning of required surgery and avoidance of the same in cases of non-neoplastic lesions.

MATERIALS AND METHODS

Cytological features of major salivary gland tumors diagnosed on FNAC were studied over a period of one and a half years. Cytological and architectural patterns in smears were compared with histopathological features in cases where the specimens were available with a note on the age, sex and presenting complaints.

STATISTICAL ANALYSIS

Analysis of variance (ANOVA) was used to find the significance of study parameters. Chi-square/Fisher Exact was used to find the significance of study parameters on categorical scale between two or more groups. P value of <0.05 was considered to be significant.

RESULTS

A total of 114 salivary gland FNACs were done, 75 patients were clinically suspected to be neoplasms. The peak incidence was in the third to fourth decade of life with a female preponderance. Parotid was the most commonly affected gland (80%) with pleomorphic adenoma and mucoepidermoid carcinoma (10.7%) being the most common benign and malignant tumors respectively. The diagnostic accuracy of FNAC was 97.6%. Warthins tumor was misdiagnosed and was associated with a strong smoking history.

CONCLUSION

Salivary gland neoplasms constitute a small but significant percentage of head and neck tumors. FNAC is inexpensive, quick, and aids in the preoperative diagnosis and planning of surgery.

Genetic polymorphisms in UDP-glucuronosyltransferase 1A6 and 1A7 and the risk for benign Warthin's tumors of the parotid gland

BACKGROUND

Warthin's tumors of the parotid gland are associated with smoking, whereas pleomorphic adenomas are not. Genetic polymorphisms in biotransformation enzymes, involved in detoxification of toxins and carcinogens in cigarette smoke, might modify the corresponding enzyme activity and influence detoxifying capacity. We hypothesize that these genetic polymorphisms may influence the individual risk for Warthin's tumor, but not for pleomorphic adenomas.

METHODS

Blood from 146 patients with benign parotid gland tumors and 437 controls were investigated for polymorphisms in several biotransformation enzymes. Based on these polymorphisms, patients and controls were divided according to predicted enzyme activity (low, intermediate, and high).

RESULTS

Prevalence of predicted intermediate and high activity UGT1A7 and UGT1A6 genotypes was significantly higher in the patients with Warthin's tumors, but not in patients with pleomorphic adenomas, compared with healthy controls.

CONCLUSION

Predicted intermediate and high activity UGT1A7 and UGT1A6 genotypes are associated with an increased risk for Warthin's tumor. © 2015 Wiley Periodicals, Inc. Head Neck 38: E717-E723, 2016.

Adenolymphoma: A probing entity: Case report and review

Warthin's tumor undoubtedly is the most frequent monomorphic adenoma of the major salivary glands. Clinically, it appears as a slow-growing tumor often fluctuant on palpation due to its cystic nature. The treatment of choice is complete excision with wide tumor-free margins. This article highlights a case of Warthin's tumor of the parotid gland in an elderly male patient along with a review of the literature on the aforementioned pathology.

Characterization of the lymphoid stroma in Warthin's tumor of salivary gland by immunohistochemistry, heavy chain gene and Bcl-2 gene rearrangement

Warthin's tumor is rarely associated with malignant lymphoma. Only 18 cases were reported in the literature so far. In most cases the latter is a low grade process, including Marginal zone/Mucosa associated lymphoid tissue (MALT) type lymphoma, follicular lymphoma, and rarely diffuse large cell lymphoma which may arise de novo or secondary to low grade lymphoma. This study was conducted to determine the prevalence of occult B cell monoclones and genetic alterations in Warthin's tumor. Fourteen cases of Warthin's tumor were stained with antibodies to CD3, CD20, kappa and lambda light chains. On six cases of randomly selected Warthin's tumor, polymerase chain reaction (PCR) of IgH gene rearrangement (IgH-GR) was performed on genomic DNA extracted from formalin-fixed paraffin embedded tissue. One case of primary salivary gland indolent B-cell lymphoma and 3 cases of sialadenitis were analyzed by the same methods for comparison. In all Warthin's tumor and sialadenitis cases most of lymphoid stroma was B cell phenotype and concentrated in germinal centers. T cells were mostly located between germinal centers. No light chain restriction was demonstrable by kappa and lambda immunostains. Molecular genetic studies failed to show IgH-GR by FISH and showed polyclonal by IgH PCR. In contrast, the lymphoma case showed a diffuse proliferation of small B cells with light chain restriction and a minor component of reactive T cells. FISH showed IgH-GR and bcl-2 gene translocation with monoclonality by IgH PCR. Our study concludes that the lymphoid stroma of Warthin's tumor is reactive.