ORAL

SALIVARY GLAND TUMOUR

Major glands
• Parotid: so-called watery serous saliva rich in amylase, proline-rich
proteins
• Stenson’s duct
• Submandibular gland: more mucinous
• Wharton’s duct
• Sublingual: viscous saliva
• ducts of Rivinus; duct of Bartholin
Minor glands
• Minor salivary glands are not found within gingiva and anterior part
of the hard palate
• Serous minor glands=von Ebner below the sulci of the circumvallate
and folliate papillae of the tongue
• Glands of Blandin-Nuhn: ventral tongue
• Palatine, glossopalatine glands are pure mucus
• Weber glands
Histologic differences between the salivary glands rests with the composition of their respective acinar cells:
• parotid gland:
– entirely serous, although mucinous acini may be identified;
– sebaceous glands and/or scattered sebaceous cells may be identified: stains for mucin are negative;
• submandibular gland:
– mixed serous and mucous, with the majority of acinar cells being serous;
– serous cells typically arranged as crescent-shaped caps (referred to as demilunes) along the periphery of the
mucous acinar cells;
• sublingual gland:
– predominantly mucous with serous demilunes;
• minor salivary glands varies depending on site:
– most of the upper aerodigestive tract, including oral cavity, sinonasal tract, pharynx, and larynx, is
mucoserous;
Structural elements of the salivary gland unit.
• pleomorphic adenomas originate from the
intercalated duct cells and
myoepithelial cells
• oncocytic tumors originate from the
striated duct cells
• acinous cell tumors originate from the
acinar cells,
• Mucoepidermoid tumors and
squamous cell carcinomas develop in
the excretory duct cells.
Salivary Gland Neoplasms
• Diverse histopathology
• Relatively uncommon
• 2% of head and neck neoplasms
• Distribution
• Parotid: 80% overall; 80% benign
• Submandibular: 15% overall; 50% benign
• Sublingual/Minor: 5% overall; 40% benign
SALIVARY GLAND LESSIONS

Non-Neoplastic Disease Benign Tumors Malignant Tumors

Acute & Chronic Pleomorphic Adenoid Cystic

Non-Autoimmune Adenomas Carcinoma

Autoimmune Basal Cell Mucoepidermoid

Sialadenitis Adenomas Carcinoma

Necrotizing Myoepitheliomas
Sialametaplasia
Warthin’s Tumor

Sialadenosis Oncocytoma and

Oncocytosis
Salivary
Lymphoepithelial Sclerosing
Cysts Polycystic Adenosis
Pleomorphic Adenoma (60%)

• Benign mixed tumor (most common)

• 80% involve parotid gland
• Painless slowly growing mass
• Recurrence and malignant transformation
• Complete resection
Pleomorphic Adenoma
• Slow-growing, painless mass
• Parotid: 90% in superficial lobe, most in tail of gland
• Minor salivary gland: lateral palate, submucosal mass
• Solitary vs. synchronous/metachronous neoplasms
Pleomorphic Adenoma

• Most common of all salivary gland neoplasms

• 70% of parotid tumors
• 50% of submandibular tumors
• 45% of minor salivary gland tumors
• 6% of sublingual tumors
• 4th-6th decades
• F:M = 3-4:1
Pleomorphic Adenoma
Pleomorphic Adenoma
• Gross pathology
• Smooth
• Well-demarcated
• Solid
• Cystic changes
• Myxoid stroma
Pleomorphic Adenoma
• Histology
• Mixture of epithelial,
myopeithelial and
stromal components
• Epithelial cells: nests,
sheets, ducts,
trabeculae
• Stroma: myxoid,
chrondroid, fibroid,
osteoid
• No true capsule
• Tumor pseudopods
Pleomorphic Adenoma
• Epithelial Components
• Tubular and cord-like arrangements
• Cells contain a moderate amount of cytoplasm
• Mitoses are rare
• Stromal or “mesenchymal” Components
• Can be quite variable
• Attributable to the myoepithelial cells
• Most tumors show chondroid (cartilaginous) differentiation
• Osseous metaplasia not uncommon
• Relatively hypocellular and composed of pale blue to slightly eosinophilic
tissue.
Pleomorphic Adenoma
• The diverse microscopic pattern of this lesion is
one of its most characteristic features.
• Islands of cuboidal cells arranged in ductlike
structures is a common finding.
• Loose chondromyxoid stroma, hyalinized
connective tissue, cartilage(arrows) and even
osseous tissue are observed.
• This neoplasm is typically encapsulated, although
tumor islands may be found within the fibrous
capsule.
Pleomorphic Adenoma
Pleomorphic Adenoma
Pleomorphic Adenoma
• pleomorphic adenoma contains
both epithelial (E) and stromal
(S) components.
Pleomorphic Adenoma
• Treatment: complete surgical excision
• Parotidectomy with facial nerve preservation
• Submandibular gland excision
• Wide local excision of minor salivary gland

• Avoid enucleation and tumor spill

Warthin’s Tumor

• AKA: papillary cystadenoma lymphomatosum

• 6-10% of parotid neoplasms
• Older, Caucasian, males
• 10% bilateral or multicentric
• 3% with associated neoplasms
• Presentation: slow-growing, painless mass
Warthin's Tumor
• Warthin's tumor (benign papillary
cystadenoma lymphomatosum)
• the second most common benign
tumor of the parotid gland
• It accounts for 2-10% of all parotid
gland tumors
• Bilateral in 10% of the cases
• may contain mucoid brown fluid in
FNA
Warthin’s Tumor
• Gross pathology
• Encapsulated
• Smooth/lobulated
surface
• Cystic spaces of
variable size, with
viscous fluid, shaggy
epithelium
• Solid areas with white
nodules representing
lymphoid follicles
Warthin’s Tumor
• Histology
• Papillary projections
into cystic spaces
surrounded by
lymphoid stroma
• Epithelium: double cell
layer
• Luminal cells
• Basal cells
• Stroma: mature
lymphoid follicles with
germinal centers
Warthin’s Tumor
• Mid Power
• Thought to arise from salivary
gland inclusions within lymph
nodes.
Warthin’s Tumor
• Epithelial Component
• Consists of papillary fronds which demonstrate 2 layers of oncocytic epitheilal
cells
• Cytoplasm stains deep pink and shows granularity b/c of an abundance of
mitochondria
• Occasionally undergoes squamous metaplasia (may mistakenly diagnose SCCa
on FNA)
Warthin’s Tumor
• Lymphoid Component
• An abundance of this is present
• Occasional germinal centres will be seen
• Lymphoid tissue forms the core or papillary structures
• Both lymphoid and oncocytic epithelial elements must be present to
diagnose Warthin’s
Warthin’s Tumor
• High Power
• Lymphocytc infilterates.
• Bilayer of epithilium.
Warthin’s Tumor
• Electron microscopy shows a tremendous number
of mitochondria in the epithelial cells, which are
responsible for its granular eosinophilic
appearance.
• Mitochondria-rich oncocytes are found in
Warthin’s tumors .
• Oncocytes selectively incorporate technetium Tc
99m and appear as hot spots on a
radionucleotide scan.
Warthin’s Tumor
Warthin’s Tumor
Oncocytoma
• Rare: 2.3% of benign salivary tumors
• 6th decade
• M:F = 1:1
• Parotid: 78%
• Submandibular gland: 9%
• Minor salivary glands: palate, buccal mucosa, tongue
Oncocytoma
• Presentation
• Enlarging, painless mass

• Technetium-99m pertechnetate scintigraphy

• Mitochondrial hyperplasia
Oncocytoma
• Gross
• Encapsulated
• Homogeneous, smooth
• Orange/rust color
• Histology
• Cords of uniform cells and
thin fibrous stroma
• Large polyhedral cells
• Distinct cell membrane
• Granular, eosinophilic
cytoplasm
• Central, round, vesicular
nucleus
Oncocytoma
• Electron microscopy:
• Mitochondrial hyperplasia
• 60% of cell volume
Malignant Salivary Gland Tumors
Mucoepidermoid Carcinoma
• Most common salivary gland malignancy
• 5-9% of salivary neoplasms
• Parotid 45-70% of cases
• Palate 18%
• 3rd-8th decades, peak in 5th decade
• F>M
• Caucasian > African American
Mucoepidermoid Carcinoma
• Mucoepidermoid carcinoma (MEC) is the most common malignant
tumor of the parotid gland and the second-most common malignancy
(adenoid cystic carcinoma is more common) of the submandibular
and minor salivary glands.
• Stained +ve by musicarmine.
• MECs constitute approximately 35% of salivary gland malignancy, and
80% to 90% of MECs occur in the parotid gland.
Mucoepidermoid Carcinoma

• Presentation
• Low-grade: slow growing, painless mass
• High-grade: rapidly enlarging, +/- pain

• **Minor salivary glands: may be mistaken for benign or

inflammatory process
• Hemangioma
• Papilloma
• Tori
Mucoepidermoid Carcinoma
• Gross pathology
• Well-circumscribed to partially
encapsulated to unencapsulated
• Solid tumor with cystic spaces
Mucoepidermoid
Carcinoma
• MECs contain two major
elements:
• mucin-producing cells
and epithelial cells of the
epidermoid variety
• (Epidermoid and
Mucinous components).
• MEC is divided into low-
grade (well
differentiated).
• High-grade (poorly
differentiated).
Mucoepidermoid Carcinoma
• Histology—Low-grade
• Mucus cell > epidermoid
cells
• Prominent cysts
• Mature cellular elements
Mucoepidermoid Carcinoma
• Histology—Intermediate-
grade
• Mucus = epidermoid
• Fewer and smaller cysts
• Increasing pleomorphism
and mitotic figures
Mucoepidermoid Carcinoma
• Histology—High-grade
• Epidermoid > mucus
• Solid tumor cell
proliferation
• Mistaken for SCCA
• Mucin staining
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
• Treatment
• Influenced by site, stage, grade
• Stage I & II
• Wide local excision
• Stage III & IV
• Radical excision
• +/- neck dissection
• +/- postoperative radiation therapy
Adenoid Cystic Carcinoma

• Overall 2nd most common malignancy

• Most common in submandibular, sublingual and
minor salivary glands
•M=F
• 5th decade
• Presentation
• Asymptomatic enlarging mass
• Pain, paresthesias, facial weakness/paralysis
Adenoid Cystic Carcinoma
• Adenoid cystic carcinoma with Swiss
cheese pattern.
• It is the second-most common
malignant tumor of the salivary
glands.
• ACC is the most common malignant
tumor found in the submandibular,
sublingual, and minor salivary glands.
Adenoid Cystic Carcinoma
• Nerve (N) invaded by adenoid
cystic carcinoma
(the blue area surrounding the
nerve).
• Spread may occur by emboli
along the nerve lymphatics
Adenoid Cystic Carcinoma
Adenoid Cystic Carcinoma
• Gross pathology
• Well-circumscribed
• Solid, rarely with cystic spaces
• infiltrative
Adenoid Cystic Carcinoma
• Histology—cribriform pattern
• Most common
• “swiss cheese” appearance
Adenoid Cystic Carcinoma
• Histology—tubular pattern • Histology—solid pattern
• Layered cells forming duct-like • Solid nests of cells without cystic
structures or tubular spaces
• Basophilic mucinous substance
Adenoid Cystic Carcinoma

• Treatment
• Complete local excision
• Tendency for perineural invasion: facial nerve sacrifice
• Postoperative XRT
• Prognosis
• Local recurrence: 42%
• Distant metastasis: lung
• Indolent course: 5-year survival 75%, 20-year survival
13%
ODONTOGENIC TUMOUR
AMELOBLASTOMA
Odontoma
• The odontoma is the most common odontogenic tumor.
• It is not a true neoplasm but rather is considered to be a
developmental anomaly (hamartoma).
• Two types of odontomas are recognized:
• Compound: this type of odontoma is composed of multiple small tooth-like
structures.
• Complex: this lesion is composed of a conglomerate mass of enamel and
dentin, which bears no anatomic resemblance to a tooth.
Odontoma: Clinical Features
• Patient Age: Most cases are recognized during the second decade of
life with a mean of 14 years.
• Gender Predilection: Approximately equal.
• Location: Somewhat more common in the maxilla. The compound
type is more often in the anterior maxilla while the complex type
occurs more often in the posterior regions of either jaw.
Odontoma: Radiographic Features
• Early lesions are radiolucent with smooth, well-defined contours.
• Later a well-defined radiopaque appearance develops.
• The compound type shows apparent tooth shapes while the complex
type appears as a uniform opaque mass with no apparent tooth
shapes present.
Odontoma: Additional Features
• Most odontomas are small and do not exceed the size of a normal
tooth in the region.
• However, large ones do occur and these may cause expansion of the
jaw.
• Most odontomas are asymptomatic and as a result are discovered
upon routine radiographic examination.
• Odontomas may block the eruption of a permanent tooth and in
these cases are often discovered when “searching for” the “missing”
tooth radiographically.
Odontoma: Histologic Features
• The compound odontoma is composed of enamel, dentin and
cementum arrange in recognizable tooth forms; some enamel matrix
may be retained in immature and hypomineralized specimens.
• The complex odontoma is composed of enamel, dentin and
cementum but these tissues are arranged in a random manner that
bears no morphological resemblance to a tooth.
Odontoma: Treatment and Prognosis
• Odontomas are treated by simple local excision and the prognosis is
excellent.
ORAL CANCER
What is oral cancer?

• Usually squamous cell (epithethial)

• Abnormal neoplasm of the mouth
• Found in most cases by a dentist or the person themselves.
• The majority of oropharyngeal cancers originate from the base of the
tongue and the tonsils, and more than 90 percent are squamous-cell
carcinomas.
Who is at risk?

• People over the age of 40

• Men vs. Women
• Ethnicity
• Socioeconomic Status (SES)
• Being a heavy smoker and drinker
• People with HPV-16 and HPV-18 are at slightly higher risk
OSSIFYING FIBROMA
• Definition: Well-demarcated, slow-growing benign fibro-osseous neoplasm
composed of fibrocellular tissue admixed with varying amounts of
mineralized material (i.e. bone, cementum) of varying appearances.
• Most common site of occurrence is the mandible, especially the molar or
posterior area, followed by the premolar area, incisor area, and cuspid
area; may also occur in association with the maxilla, but much less often
than in the mandibular region.
• • Generally asymptomatic, unassociated with pain or swelling, and
diagnosed incidentally following radiographic examination; symptomatic
tumors manifest by displacement of teeth or as an expansile mass that may
include facial asymmetry.
PATHOLOGY
Gross
• Well-demarcated, tan-gray to white, gritty, firm lesion varying in size from 0.5 cm to as large as 10 cm.
Histology
• Well-delineated, demarcated, or encapsulated proliferation composed of randomly distributed mature
(lamellar) bone spicules rimmed by osteoblasts admixed with a fibrous stroma.
• Whereas the osseous component is generally described as mature, the central portions may be woven bone
with lamellar bone at the periphery.
• Complete bone maturation is seldom seen.
• The fibrous stroma may be densely cellular; mitotic figures are rare to absent.
• Secondary changes, including hemorrhage, inflammation, and giant cells, may be seen.
• Lesions with associated cementum are referred to as cementifying fibroma, and those with cementum and
bone are referred to as cemento-ossifying fibroma:
• cementum is mineralized material covering the surface of the roots of teeth;
• no clinical relevance in distinguishing cementum from bone.
FIBROUS DYSPLASIA
Definition: Idiopathic non-neoplastic bone disease in which normal
medullary bone is replaced by structurally weak fibroosseous tissue.
MONOSTOTIC FIBROUS DYSPLASIA
• Only a single osseous site is involved.
• Represents more than 75–80% of all cases of fibrous dysplasia.
• Frequently occurs in older children and young adults.
• Most commonly affects the ribs, femur, and tibia; involves head and neck
bones in up to 25% of cases:
• in the head and neck the most common sites of involvement include
maxilla (zygomatic process) > mandible (region of premolar and molar teeth)
> frontal bone > ethmoid and sphenoid bones > temporal bone.
Histology
• Fibrous tissue component is nondescript and of variable cellularity.
• Osseous component includes:
• irregularly shaped trabeculae of osteoid and immature (woven) bone arising
metaplastically from the fibrous stroma;
• poorly oriented with misshapen bony trabeculae, increased cellularity, and irregular
margins, and forms odd geometric patterns including ‘C’- or ‘S’-shaped configurations
(socalled Chinese characters);
• trabeculae typically lack osteoblastic rimming;
• Multinucleated giant cells, macrophages, increased vascularity, and calcification may be
seen.
• Under polarized light, bone appears woven rather than lamellar; however, lamellar bone
can be seen in fibrous dysplasia and its presence does not exclude the diagnosis.