BÀI TẬP BỔ TRỢ TIẾNG ANH 11 THEO ĐƠN VỊ BÀI HỌC - CẢ NĂM - CÓ FILE NGHE (GLOB...
Salivary gland pathology
1. Februray 29, 2009
Salivary Glands
Classification, General Considerations
&
Tumors Like Conditions
By Louay Jaber DDS, MSc, MSD, PhD
2. The Normal Salivary Gland
The system is comprised of
major & minor salivary glands
Major: Parotid, submandibular &
sublingual.
Minor:
They produce the fluid that
constitute oral saliva
Parotid: serous
Submandibular: serous & mucous
Sublingual: mucous & serous
Palate: mucous
Tongue: mucous & serous
Lip: mucous
Buccal mucosa: mucous
Oral
mucosa
Acinus
Intercalaetd-Striated-Excretory
“ducts”
3. The Normal Salivary Gland (Cont.)
“Parotid gland”
Lymph node
Serous Acini
& striated duct
Facial nerve
4. The Normal Salivary Gland (Cont.)
“Submandibular, sublingual & minor glands”
Submandibular
Sublingual
Minor
5. Mucocele
70% in the lower lip
The remainders
floor of the mouth, tongue & buccal
mucosa
Third decades of life
Men > women (slight)
Small dome-shaped swelling
Size 0.2-1.0 cm
Mucoceles of the floor of the
mouth can be a large size
(several centimeters-Ranula)
Mucocele
Ranula
6. Mucocele
Pts might report a
fluctuation in size related to
meals or rupture
They are generally soft &
fluctuant (older becomes
firmer)
They are painless
They develop rapidly within
hours to days
Ruptured mucocele
Mucocele
7. Mucocele
Microscopically
Pool of mucus
It is a rounded pool of mucus
within fibrous connective tissue
Inflammatory reaction
(Macrophages that contain
phagocytized mucus)
Phagocytic macrophages
8. Mucus Retention Cyst
Etiology:
It results from obstruction of salivary
flow because of sialolith, periductal
scar or impinging tumor
Clinical features:
it is commonly found in the upper lip,
palate, cheek and floor of the mouth.
It represents asymptomatic swelling
Microscopically
Retention cyst: Epithelial-lined
fibrous tissue wall surrounds the
mucus pool
Little or no inflammatory reaction (no
epithelial rupture
Cuboidal epithelium
9. Ranula
It is a clincial term that includes mucus extravasation
phenomenon and mucus retention cyst
Occur specifically in the floor of t he mouth
Etiology:
Trauma & ductal obstruction
Clinical features:
Sialolith: represents precipitation of calcium salts
around the central nidus of cellular debris
it is fluctuant, unilateral soft tissue mass in the floor of the mouth
Histopathology:
It is similar to mucus retention cyst
10. Necrotizing Sialometaplasia
Clinically
It is a reactive inflammatory
condition of the salivary glands
Average age is 46 years
Male predominence 2:1
Palatal location preference
Deep crater-like ulcer, develops
rapidly & slow to heal
Size 1-5 cm.
Unilateral ulcer of necrotizing sialometaplasia
11. Necrotizing Sialometaplasia
Pathogenesis: Ischemic
necrosis or infarction
Traumatic injury
Dental injection
Denture use
Adjacent tumor & cyst
Surgery
Upper respiratory
infection or allergy
Swelling but no ulceration of necrotizing sialometaplasia
14. Infectious Conditions
Mumps:
It is an infectious , acute viral sialadenitis primarily
affected the parotid glands
It is the most common salivary gland diseases
Etiology:
The causative agent is a paramyxovirus
2-3 weeks incubation period
Transmission by direct contact with salivary droplets
15. Mumps
Clinical features:
Fever
Malaise
Headache
Chills
Preauricular pain
Parotid swelling
Male = female
Young adults & children
18. Mumps
Treatment & Prognosis
Symptomatic therapy
Bed rest
Analgesics
Corticosteroids (variable success)
Vaccination is now available
19. Metabolic Conditions
Sialadenosis
It is non-neoplastic & non-inflammatory salivary gland
enlargement
It is related to metabotic factor or
secretory dysfunction
Painless bilateral swellings
Peak incidence: 5th & 6th decades of life
Slight female predominence
Swelling develops slowly, painless & accompanied by
decreasing salivary secretion
20. Metabolic Conditions
Sialadenosis
It is usually associated
with systemic
conditions:
Diabetes mellitus
Malnutrition
Liver cirrhosis (Chronic
Alcoholism)
Hyperlipidemia
Acromegaly
Enlargement of parotid associated with
chronic alcoholism & liver cirrhosis
21. Metabolic Conditions
Sialadenosis
Microscopically
As the disease persistsAtrophy of the paranchymal
tissue but compensatory
increase in the amount of
adipose tissue
Inflammatory cell infiltrates
are absent
Atrophy of parotid parenchymal tissue &
increase of intraglandular fat
22. Sjögren Syndrome
It is the expression of an autoimmune process that principally
results in
Rheumatoid arthritis
Dry eyes (keratoconjunctivitis sicca)
Dry mouth (xerostomia)
Lymphocytic replacement of lacrimal
and salivary glands
25. Mixed Tumors
“Pleomorphic Adenoma”
It is the most common benign neoplasm
of salivary glands origin
It represents 45-74% of all salivary gland
tumors
Slow growing & asymptomatic,
Average age is about 43 yo.
Recurrent lesion occurs as multiple
nodules & are less mobile than initial
lesion.
26. Mixed Tumors
“Pleomorphic Adenoma”
CT revealed a mixed tumor
medial to the mandibular
ramus
It has prominent cartilagenous
& osseous elements that led
initially to diagnosis of
osteochondroma
27. Mixed Tumors
“Pleomorphic Adenoma”
The most common intraoral site is
the palate followed by the upper
lip & buccal mucosa
Mobility is limited for palatal
tumors.
Large intraoral tumors are
susceptible to trauma
29. Mixed Tumors
“Pleomorphic Adenoma”
Gross findings
Translucent central zone
represents myxochondroid
tissue
The presence of multiple
individual nodules are typical
of recurrent mixed tumor
32. Mixed Tumors
“Pleomorphic Adenoma”
Microscopic findings
In the absence of surgical
intervention, viable epithelial cells
within necrotic tissue suggest a
malignant transformation
Rarely tumor cells are seen within
vascular spaces
33. Mixed Tumor
“Treatment”
Parotidectomy & excision of the scar tissue with
preservation of the facial nerve are recommended
(specially recurrent)
Long term follow up is recommended more than 5 years
The risk of malignant degeneration increases with time
Radiotherapy has been found by some investigators to be
useful in some recurrent mixed tumor
34. Carcinoma Ex-Mixed Tumor
“Clinical Features”
It arises from a benign mixed tumor (diagnosis requires
identification of mixed tumor)
20% of patients had previous operation for mixed tumor
The risk for malignant transformation correlates with the
duration of mixed tumor
Painless mass or sometimes associated with facial nerve
pain or palsy
Tumor is freely movable or sometime fixed to underlying
tissue (especially with recurrent tumors)
36. Carcinoma Ex-Mixed tumor
“Treatment”
38-53% develop recurrence
Distant metastasis to lung, bone, brain, liver &
subcutaneous tissue
Radiotherapy alone has proven ineffective, although
it may have a beneficial role when combined with
surgery
37. Basal Cell Adenoma
It is composed of cells
predominantly of one type
Basal cell adenoma:
Occurs mainly in parotid
Slow growing & painless
Can be multinodular
Age 35-80
Male predominence
Well circumscribed mass near
the inferior pole of the parotid
41. Basal Cell Adenoma
Treatment & prognosis:
Conservative surgical
excision including a margin
of normal uninvolved tissue
Prognosis is good and
recurrence rate is so low
Small cells in the periphery of the epithelial islands
And larger cells adjacent to the tumor islands
42. Malignant Epithelial Tumors
“Mucoepidermoid Carcinoma”
It is the most common
malignant salivary
glands tumor
It represents 15.5% of all
benign & malignant
tumors at all sites
resemble a mucoceles.
Size varies from 1-12cm
43. Mucoepidermoid Carcinoma
It is believed to arise from
salivary duct system
Normal duct-lining epithelium
Neoplastic transformation
44. Mucoepidermoid Carcinoma
Ionizing radiation increases the risk for its developing
Occurrence:
7% Submandibular gland
1% Sublingual gland
45% Parotid gland
21% in the palate and 19% for the rest of the minor
salivary glands.
Mean age is about 47 years with the age range between
8 to 92 yo.
Women > men
45. Mucoepidermoid Carcinoma
Typically, it is a solitary painless mass
2/3 of pts. are asymptomatic
if growing rapidly, usually accompanied with pain &
mucosal ulceration, and sometimes a discharge of fluid
resemble abscess.
6 years average between onset & diagnosis (high grade
lesions demonstrate a 1.5-year interval before diagnosis).
46. Mucoepidermoid Carcinoma
According to cytologic features, it is divided into:
- Low
- Intermediate
- High grade types.
All grades of this neoplasm are carcinomas and
have the potential to metastasize.
They are epithelial mucin-producing tumor
47. Mucoepidermoid Carcinoma (Central)
This lesion may also arise centrally within the mandible
(Differential diagnosis: giant cell granuloma & odontogenic tumors).
Asymptomatic radiolucencies
Mandibule > maxilla
Third molar region is the
most likely to be involved
48. Mucoepidermoid Carcinoma (Central)
It arises from either:
Ectopic salivary gland tissue
Neoplastic transformation of epithelial lining of odontogenic cysts
Glandular odontogenic cyst
Mayer’s mucicarmine stain
highlights numerous mucus
cells in a dentigerous cyst
49. Mucoepidermoid Carcinoma
Treatment & Prognosis:
low grade usually follow a benign course.
However, in several instances low grade lesions
have metastasize widely.
High grade metastasize widely (60% of cases).
Surgical, or surgery plus postoperative
radiotherapy (high grade)
Central mucoepidermoid carcinoma is usually of
low grade (40% recurrence rate).
50. Adenoid Cystic Carcinoma
Oral mucosa overlying this palatal mucosa is ulcerated
Clinical Features
50-70% starts in the
minor salivary glands.
If major salivary gland
(parotid is the most affected)
Age: 5th and 7th decades
This tumor appears
deceptively well circumscribed
51. Adenoid Cystic Carcinoma
No gender predilection
(slight female predominance).
Unilocular mass
Firm on palpation
Occasional pain or tenderness
Slow growth rate
Bone invasion occurs
Lung metastasis
Sublingual gland tumor.
52. Adenoid Cystic Carcinoma
Treatment & prognosis:
Surgery is the treatment of choice
Radical resection is justified to obtain surgical
margins that are free of tumor
Multiple-agent chemotherapy showed some
promise for postoperative treatment
High recurrence rate
53. Acinic Cell Carcinoma
Clinical features
Age: 5th to 6th decades of life
No gender predilection
It represents 14% of parotid
gland tumor
9% of total salivary gland
carcinoma of all sites
50% of cases, the clinical
appearance is a benign lesion
54. Acinic Cell Carcinoma
Usually less than 3 cm in
diameter
Pain
The interval between the
initial appearance &
treatment is 6 months to 5
years
The origin is the ductal cells
56. Polymorphous Low-Grade Adenocarcinoma
It is considered to be low grade malignancy and low risk
of metastasis
Age: 5th to 8th decades
No gender predilection
Occurs in minor salivary
glands (palate)
Firm, non-ulcerated &
non tender
Size between 1-4 cm
Slow growth
Well circumscribed mass at the junction of the hard &
soft palate
62. Mucoepidermoid Carcinoma
Microscopic features:
The name is a contraction of
epidermoid and mucus-secreting carcinoma
A close association of mucous
& epidermoid cells
Mayer’s mucicarmine
hightlights the extracellular &
Intracytoplasmic mucin
64. Mucoepidermoid Carcinoma
Low grade. Note
Intracystic spaces
Intermediate grade.
hyperchromatic nuclei
& several microcystic spaces
High grade
Focal necrosis
65. Epidermoid &
mucus cells
Epidermoid cells
solid & infiltrative
Central Mucoepidermoid
Carcinoma
Cyst
Solid & cystic
neoplastic area
Characteristic variety
of cell types
66. Adenoid Cystic Carcinoma
Tubular pattern in the top
& bottom. A cribriform pattern
in the center
Epithelial cells have a clear
Cytoplasm, poorly defined
border & irregular shaped nuclei
Immunoreactivity of the
tumor cells for cytokeratin
74. Connective Tissue Lesions
Fibrous lesions:
Reactive hyperplasia: Fibrous hyperplasia or exuberant
proliferation of granulation tissue
Peripheral fibroma
Generalized gingival hyperplasia
Denture induced fibrous hyperplasia
Neoplasms: heterogeneous that form complex collection of
disease
Myxoma
Fibrosarcoma
75. Connective Tissue Lesions
“Fibrous Lesions”
Peripheral fibroma
Etiology: Reactive (secondary to overexuberant repair)
Origin: Connective tissue of the submucosa
Clinical features:
Predilection for young adults
Female>male
Location: commonly at the gingiva anterior to molars
Similar in color to the surrounding tissue
80. Connective Tissue Lesions
“Fibrous Lesions”
Generalized gingival hyperplasia:
Definition: Overgrowth of the gingiva
Etiology:
Non-specific: Response to chronic inflammation
associated with local factor
Hormonal changes (imbalance)
Drugs (Phenytoin, Cyclosporine, Nifidipine)
Leukemia
81. Connective Tissue Lesions
“Fibrous Lesions”
Generalized gingival hyperplasia:
Clinical features: Increase in the bulk of free and attached gingiva.
Stippling is lost
Color: red to blue
Associated inflammation: non-specific factors & hormonal imbalance
appears more inflamed than drug induced hyperplasia
Histopathology:
Abundance in collagen
Increased number of fibroblasts
Various degree of chronic inflammation
Increased capillaries (hormonal)
Immature & atypical white blood cells with leukemic type
86. Connective Tissue Lesions
“Fibrous Lesions”
Neoplasms:
Myxoma: Benign proliferation of spindle cells
Clinical features: It is a soft neoplasms composed of
gelatinous material
Slow growing
Asymptomatic
Location: Palate
Occurs at any age
Soap bubble multilocular area
90. Connective Tissue Lesions
“Fibrous Lesions”
Fibrosarcoma: It is a malignant spindle
cell tumor showing interlacing fascicular
pattern
Clinical features
Can arise in bone
Young adults most commonly affected
It is considered as infiltrative neoplasms
92. Connective Tissue Lesions
“Fibrous Lesions”
Treatment of Fibrosarcoma
Wide surgical excision
Recurrence is not uncommon
Metastasis is infrequent
5 years survival rate is 3050%
93. Vascular Lesion
Reactive & Congenital Lesions
Lymphangioma
Etiology:
It is regarded as congenital lesion
Appears within the first 2 decades of life
Clinical features:
Painless nodular, vesicle like swelling
Crepitant sound
Tongue is the most common
intraoral site
94. Vascular Lesion
Histopathology:
Endothelium-lined lymphatic channels
Eosinophilic lymph that occasionally
include red blood cells
Lymphatic channels directly adjacent
to overlying epithelium
Treatment: Surgical removal but because
of lack of encapsulation, recurrences are
common
95. Vascular lesion
Neoplasms:
Angiosarcoma
It is a neoplasm of endothelial cell origin
Scalp is the usual location
The lesion consists of an unencapsulated
proliferation of endothelial cells enclosing
irregular luminal spaces
It has an aggressive clinical course and
poor prognosis
96. Neural lesions
Reactive lesion:
Traumatic neuroma:
Etiology: It is caused by injury of peripheral nerve
Oral surgery procedure
Local anesthetic injection
Accident
Clinical features:
Pain
Wide age range
Mental foramen is the most common location
98. Neural Lesion
Neoplasms:
Granular cell tumors
Etiology: It is an uncommon benign tumor of unknown cause
The granular cell that make this tumor is believed to originate
from Schwann cells
Clinical features:
Wide age range
Tongue is the most common location
Uninflamed asymptomatic mass
< 2 cm in diameter
Overlying epithelium is intact
99. Neural lesion
Neoplasms:
Granular cell tumors
Histopathologically:
Unencapsulated sheets of
large polygonal cells with pale
granular or grainy cytoplasm
Pseudoepitheliomatous hyperplasia
Treatment: Surgical removal
100. Neural lesion
Neoplasms:
Schwannoma:
Etiology: It is derived from schwann cells
Clinical features:
It is an encapsulated submucosal mass
Asymptomatic lump
Occurs at any age
Tongue is the most common location
Bony lesion produce a well-defined
radiolucent lesion
Slow growing but may undergoe
a sudden increase (hemorrhage)
102. Neural lesion
Neoplasms:
Neurofibroma:
It mat appear as solitary or multiple lesions
Etiology: - Solitary type is unknown
- Neurofibromatosis is inherited
Clinical features: Solitary type
Uniflamed asymptomatic submucosal mass
Location: Tongue, vestibule & buccal mucosa
104. Neural lesion
Neurofibroma:
Clinical features: Neurofibromatosis:
Multiple
Café-au-lait macules
Bone abnormalities (cortical erosion
or medullary resorption)
Central nervous system changes
Pain or parasthesia may be seen
Malignant degeneration into
neurogenic sarcoma is seen in
5% to 15%
106. Neural lesion
Neurofibroma:
Histopathology:
Spindle-shaped cells in connective
tissue matrix
It may be well circumscribed or blended
into surrounding connective tissue
Mast cells are scattered
Immunohistochemistry with S-100 is a
useful tool to confirm diagnosis
Treatment: Surgical excision for solitary lesion
Lack of encapsulation
107. Neural lesion
Malignant peripheral nerve sheet tumor
The cell of origin is believed to be the schwann cells and
possibly other nerve sheath cells
It appears as expansile mass (soft tissue)
Asymptomatic
Dilation of the mandibular canal (bone)
Pain or parasthesia
108. Neural lesion
Malignant peripheral nerve sheet tumor
Histopathologically:
Abundant spindle cells
Mitotic figures
Nuclear pleomorphism
Treatment: Wide surgical exicion
Recurrence is common
Metastases are frequently seen
109. Muscle Lesions
Neoplasms (Leiomyoma & leiomyosarcoma):
Smooth muscle neoplasms are relatively common
They may arise anywhere in the body
Leiomyoma
Leiomyomas are commonly arise in the
muscularis of the gut and uterus
Oral leiomyoma is slow growing &
asymptomatic submucosal masses
Appears in the tongue, hard palate
or buccal mucosa
Spindle cells
Appears at any age
Pterygo-mandibular space
110. Muscle Lesions
Leiomyoma
Histopathology:
Immunohistochemical demonstration of actin and
desmin protein expression can confirm diagnosis
Obvious vascular origin
Vascular leiomyoma
Limited & uniform proliferation
around each of the vascular spaces
111. Muscle Lesions
Neoplasms
Leiomyosarcoma
It is commonly arise in the retroperitoneum,
mesentery, or subcutaneous and deep tissue
of the limbs
It may appear at any age
Immunohistocemistry can be a valuable
diagnostic tool
Treatment: wide surgical excision
Metastasis is not uncommon
Blunt ended nuclei
112. Muscle Lesions
Rhabdomyoma:
Predilection for the soft tissues
of the head and neck
Floor of the mouth, soft palate,
tongue & buccal mucosa
Mean age: 50 years (children to older adults)
Asymptomatic
Well defined submucosal mass Well demarcated but
unencapsulated
The neoplastic cells mimic their
normal counterpart (adult)
Large eosinophilic granular cell
with peripheral nuclei
118. Fat Lesion
Lipomyosarcoma:
It is a lesion of adulthood
It may occur at any site
Slow growing (mistaken for a benign process)
Treatment: surgery or radiation
Prognosis is fair to good
Well differentiated
Myxoid type
119. Mumps
It is an acute viral sialadenitis affecting primarily the parotid
glands
Etiology & pathogenesis:
Paramyxovirus, incubation period is 2-3 weeks
Transmission is by direct contact with salivary droplets
