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128 Cards in this Set

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what are the major inflammatory conditions of the oral cavity?
herpes
canker sores (aphthous ulcers)
thrush (oral candidiasis)
glossitis
xerostomia (dry mouth)
what strain of herpesvirus causes most of the herpes infections in the mouth?
HSV-1
herpes general information
most are HSV-1
presents as a common cold sore
primary infection usually 2-4 years old
10-20% present as gingivostomatitis
describe acute herpetic gingivostomatitis
HSV-1 infection that causes diffuse involvement of mouth, especially the gingiva and the tongue

pt may have fever, lymphadenopathy, and anorexia
gross morphology of herpes infection
vesicles form that range in size from millimeters to large bullae

the vesicles are initially filled with clear, serous fluid and they then rupture causing painful, red-rimmed, shallow ulcers
microscopic morphology of herpes infection
intracellular and extracellular edema, leading to acantholysis (separation of dermal cells) and clefts

epidermal cells at the margin of the vesicles have intranuclear viral (HSV-1) inclusions OR many of them are fused into multinucleate giant cells
acantholysis
loss of intercellular connections, such as desmosomes, resulting in loss of cohesion between keratinocytes
herpes clinical picture
primary infection (seen in 2-4 yo's) resolves in 3-4 weeks and the virus becomes dormant in local ganglia

if/when the virus is reactivated, usually in young adults, the cold sore is milder - the patient can get recurrent stomatitis at the primary site or in the adjacent mucosa (groups of 1-3mm vesicles resembling primary but milder) - and heals in 7-10 days
what is the technical name for canker sores?
aphthous ulcers
aphthous ulcers (general information)
aka canker sores

present in about 40% of the population, more commonly in the first two decades

painful, recurrent, shallow, hyperemic-rimmed ulcers covered with thin exudate that can heal in a week or linger for several weeks

some seem to be familial
gross morphology of aphthous ulcers
painful, recurrent, shallow, hyperemic-rimmed ulcers covered with thin exudate that can heal in a week or linger for several weeks

can be single or multiple
microscopic morphology of aphthous ulcers
initially has a mononuclear infiltrate

ulcer gets a secondary bacterial infection, which attracts neutrophils
what is the most common fungal infection of the oral cavity?
oral candidiasis (thrush)
oral candidiasis (general information)
presents as a grey-white superficial curdy membrane of candida organisms enmeshed in fibrinosuppurative exudate; the membrane is easily scraped off to show an erythematous base

candida is a normal mouth inhabitant that causes disease in immunosuppressed or diabetic pts, those with xerostomia (dry mouth), and those with antibiotic-altered oral flora
define xerostomia
dry mouth due to a lack of saliva
glossitis
usually implies inflammation of the tongue, but can be applied to a "beefy" red appearance of the tongue caused by some nutritional deficiency states (B12, riboflavin, niacin, pyridoxine, iron deficiencies)

caused by atrophy of papillae and thinning of mucosa, which makes underlying vasculature more prominent

can also be caused by real inflammation with ulcers (jagged carious teeth, bad dentures, syphilis)
what deficiencies can cause glossitis?
riboflavin (B2) deficiency
niacin (B3) deficiency
pyridoxine (B6) deficiency
pernicious anemia (B12)
sprue (gluten allergy)
iron-deficiency anemia
what is Plummer-Vinson syndrome?
aka paterson-brown-kelly syndrome

combination of Fe-deficiency anemia, glossitis, and dysphagia

chronic iron deficiency anemia causes the glossitis as well as esophageal webs (ledge-like projections from esophageal mucosa into the esophageal lumen and cause dysphagia)
what are the major manifestations of Sjogren syndrome?
xerostomia (dry mouth)**
keratoconjunctivitis sicca (dry eyes)

**major and sometimes only symptom**
what are the causes of xerostomia?
Sjogren syndrome
radiotherapy
anticholinergic drugs
what is the proposed autoantigen in Sjogren syndrome?
alpha-fodrin (a cytoskeletal protein)
Sjogren syndrome pathogenesis
lymphocytic infiltrate of activated CD4 helper T cells, with some B cells that secrete antibody to alpha-fodrin locally in the lacrimal and salivary glands

EBV, HCV, or HTLV-1 may be viral triggers in genetically susceptible individuals

75% have rheumatoid factor (w/ or w/o RA)
50-80% have ANAs
90% have anti-SS-A and anti-SS-B antibodies
various HLA associations
morphology of Sjogren syndrome
lacrimal and salivary glands are the main targets, but other exocrine glands can be involved

starts as periductal and perivascular lymphocytic infiltrate, which eventually becomes extensive and may develop germinal centers in the larger salivary glands (can be mistaken for a lymphoma)

eventually the gland atrophies, becomes fibrotic, and the parenchyma is replaced by fat
clinical features of Sjogren syndrome
- lack of tears leading to corneal erosions and ulcers
- lack of saliva leading to fissuring and inflammation of oral mucosa
- ulcerations and perforations of nasal septum can cause nosebleeds
- 1/2 of pts have parotid and/or lymph node enlargement
- 1/3 of pts have involvement of kidney, lung, CNS, skin, muscle
- more common in females 50-60 years old
- 60% of pts have other autoimmune diseases
what extraglandular organs are involved in Sjogren syndrome?
kidney, lung, CNS, skin, muscle

**in Sjogren syndrome glomerular lesions are rare, but in SLE glomerular lesions are common**
in what gender and age group is Sjogren syndrome most common?
females, 50-60 years old
define Mikulicz syndrome

how does it differ from Sjogren's syndrome?
Mikulicz syndrome is the combination of lacrimal gland and salivary gland enlargement of any cause

Sjogren's syndrome is a subclass of Mikulicz syndrome, where autoantibodies specifically destroy the salivary and lacrimal glands (lip biopsy to examine minor salivary glands is necessary to diagnose Sjogren's syndrome)
what type of cancer is more common in patients with Sjogren's syndrome than in normal patients?
marginal zone lymphomas

Sjogren's syndrome increases risk 40x
what is the other name for Sjogren's syndrome?
sicca syndrome
how are reactive lesions distinguished from more serious lesions?
biopsy
what are the reactive lesions of the oral cavity?
irritation fibroma
pyogenic granuloma
peripheral ossifying fibroma
peripheral giant cell granuloma
irritation fibroma
reactive lesion of the oral cavity

located along the buccal mucosa, along the biteline or at the gingivodental margin

fibrous tissue with few inflammatory cells, covered by squamous mucosa

remove surgically
pyogenic granuloma
reactive lesion of the oral cavity (not actually a granuloma)

most common in pregnancy (aka pregnancy tumor) and then subsequently regresses or has fibrous maturation; also seen in children and young adults

red-purple pedunculated lesion located in the gingiva that consists of a vascular proliferation resembling granulation tissue (variant of capillary hemangioma); may ulcerate

remove surgically

may turn into peripheral ossifying fibroma
peripheral ossifying fibroma
reactive lesion of the oral cavity

red-purple pedunculated lesion located in the gingiva that consists of a vascular proliferation resembling granulation tissue (resembles pyogenic granuloma grossly)

can be caused by maturation of a pyogenic granuloma or can arise de novo

most common in teenage or young adult females

surgical removal, but must excise all the way down to the periosteum, or there is a 15-20% recurrence rate
peripheral giant cell granuloma
reactive lesion of the oral cavity

nodular lesion that protrudes from the gingiva at a site of chronic inflammation (resembles a pyogenic granuloma, except that it has a bluer hue where a pyogenic granuloma tends to be purple-red); occasionally gingival mucosal covering ulcerates

consists of many multinucleate foreign body type giant cells separated by fibroangiomatous stroma

easily excised
in what patients are 80% of cases of hairy leukoplakia seen?
patients with HIV, but it can be seen in other immunosuppressed patients
hairy leukoplakia
white, confluent, hairy, hyperkeratotic thickening, usually on the lateral border of the tongue

hyperparakeratosis & acanthosis with balloon cells in the upper spinous epidermal layer

nuclei of underlying cells sometimes have koilocytosis, which indicates HPV infection, but EBV infection is the major cause

80% seen in HIV-infected pts but also seen in other immunosuppressed pts
what disease commonly develops within 2-3 years of a patient having hairy leukoplakia?
AIDS
leukoplakia
white precancerous plaque that cannot be removed by scraping, and cannot be diagnosed clinically or microscopically as something else

has sharp or indistinct borders (usually located on buccal mucosa, floor, undersurface of the tongue, palate, or gingiva; can be single or multiple)

ranges from benign thickenings to dysplasia that borders on carcinoma in situ

most common in males (2:1) between 40-70 years old

high association with tobacco (especially chew and pouches), alcohol, bad dentures, oral irritants, HPV 16
erythroplakia
red, velvety, possibly ulcerated, precancerous plaque, level with or slightly depressed from surrounding mucosa with sharp or indistinct borders (usually located on buccal mucosa, floor, undersurface of the tongue, palate, or gingiva; can be single or multiple)

more atypical histology than leukoplakia, with a higher rate of malignant transformation

most common in males (2:1) between 40-70 years old

high association with tobacco (especially chew and pouches), alcohol, bad dentures, oral irritants, HPV 16
microscopic morphology of leukoplakia
range from hyperkeratosis over an acanthotic but orderly epithelium to marked dysplasia or even to carcinoma in situ

the more dysplastic or anaplastic, the more likely there is to be underlying mononuclear inflammation with infiltrating lymphocytes and macrophages
what type of cancer accounts for 95% of head and neck cancers?
squamous cell carcinoma

(6th most common cancer globally)
what is the overall long-term survival of patients with squamous cell carcinoma?
<50% with no significant change in decades

with diagnosis in early stage, 5YS is 80%; with diagnosis in late stages, 5YS is 20%
what is field cancerization? how does it apply to squamous cell carcinoma?
once you have one oral cancer lesion, the whole oral mucosa is at risk for a second primary cancer lesion

in squamous cell carcinoma, 3-7% of patients develop a second primary every year; patients who survive the first five years have a 35% chance of developing at least 1 new primary during the first five years

these second primaries are the most common cause of death related to squamous cell head and neck cancer
pathogenesis of squamous cell carcinoma of oral mucosa
risk factors: alcohol & tobacco (together increase risk 5-15x), pipe smoking, HPV, family history, sunlight, chewing betel nuts, chronic irritation
what virus is found in more than 50% of oropharyngeal cancers?
HPV

especially found in tonsillar cancers and those at the base of the tongue

gives a better survival than those cancers without HPV
what are the steps in the molecular pathogenesis of squamous cell carcinoma?
1) loss of regions of 3p and 9p21
- inactivation of p16 (inhibitor of CDK)
- appearance of hyperplasia/hyperkeratosis
2) loss of heterozygosity at 17p
- mutation of p53
- appearance of dysplasia
3) amplification & overexpression of 11q13
- cyclinD1 gene amplified
- associated with invasiveness
what cytokine receptor is overexpressed in many head and neck squamous cell carcinomas?
epidermal growth factor receptor (EGFR)

useful in tx
what are the commonest sites of squamous cell carcinoma of the oral cavity?
lower lip
ventral surface/base of tongue
floor of mouth
lower gingiva
bucchal mucosa
upper gingiva & palate
gross morphology of squamous cell carcinoma of oral cavity
early, presents as raised, firm white plaques or warty thickenings that progress to protruding masses or irregular ulcers with firm, elevated, rolled borders

pt may have history of leukoplakia or erythroplakia
microscopic morphology of squamous cell carcinoma of the oral cavity
varies from well differentiated to sarcomatoid, but the histologic grade doesn't correlate well with behavior

tend to infiltrate locally before distant metastases
to what organs does oral squamous cell carcinoma metastasize?
lymph nodes (cervical, then mediastinal)
liver
lung
bone
oral squamous cell carcinoma has the best prognosis if diagnosed in what location?
lip
5 yr recurrence rate only 10%

on the floor of the mouth or on the base of the tongue, recurrence rate is 70-80%
dentigerous cyst
unilocular odontogenic cyst around the crown of an unerupted tooth, usually a wisdom tooth; a thin layer of stratified squamous epithelium lining with dense chronic inflammation in the stroma

surgical removal, but must remove entire lesion or risk recurrence

only rarely transforms into a neoplasm
odontogenic keratocyst
uni- or multilocular odontogenic cyst that can be aggressive; a thin layer of stratified squamous epithelium with prominent basal cell layer

incomplete surgical resection leads to 60% recurrence

if multiple lesions are present, think of Gorlin (nevoid basal cell carcinoma) syndrome
gorlin syndrome
aka nevoid basal cell carcinoma syndrome

inherited medical condition involving defects within multiple body systems such as the skin, nervous system, eyes, endocrine system, and bones

people with this syndrome are particularly prone to developing a common and usually non-life-threatening form of non-melanoma skin cancers

think about this syndrome if a person has multiple odontogenic keratocysts
periapical cyst
relatively common odontogenic cyst in the apex of a tooth that starts as long-standing inflammation of tooth pulp (pulpitis); necrosis of the pulp can exit the apex forming an abscess that eventually fill in with granulation tissue

Tx must include killing the infecting bacteria
ameloblastoma
odontogenic tumor that arises from odontogenic epithelium

usually cystic, slow-growing, locally invasive, and benign
odontoma
most common type of odontogenic tumor, but more likely a hamartoma rather than a neoplasm

arises from epithelium, but has extensive enamel and dentin components

cured by local excision
what is the most common type of odontogenic tumor?
odontoma
allergic rhinitis
sensitivity to allergens, mediated by IgE immune reaction with early and late phase responses

present in 20% of the US population
nasal polyps
protrusions in the nasal mucosa caused by recurrent attacks of rhinitis; reach 3-4cm and can impair sinus drainage
microscopic morphology of nasal polyps
edematous mucosa with loose stroma

often see hyperplasia or cystic mucous glands

neutrophils, eosinophils and plasma cells are usually present (as are occasional lymphocyte clusters)
chronic rhinitis
sequelae of repeated attack of allergic or microbial rhinitis

impairment of secretions by a deviated nasal septum or by nasal polyps contributes to microbial invasion

may have desquamation or ulceration of mucosal epithelium; variable amount of inflammation is present
sinusitis
inflammation of the sinuses, usually caused by oral organisms

usually preceded by acute or chronic rhinitis

impairment of drainage via inflammatory edema of mucosa contributes to empyema (pus collection) in the sinus

outflow obstruction may cause accumulation of mucous (mucocele) in absence of bacterial infection, usually in the frontal or anterior ethmoidal sinuses

complications: spread to orbit, septic thrombophlebitis of dural sinus, osteomyelitis
what type of sinusitis are diabetics particularly prone to? what are the complications of this?
chronic fungal sinusitis, especially mucormycosis

complications: spread to orbit, septic thrombophlebitis of dural sinus, osteomyelitis
what is kartagener syndrome?
rare, ciliopathic, autosomal recessive genetic disorder that causes a defect in the action of the cilia lining the respiratory tract (lower and upper, sinuses, Eustachian tube, middle ear) and fallopian tube, and also of the flagella of sperm in males

main consequence of impaired ciliary function is reduced or absent mucus clearance from the lungs, and susceptibility to chronic recurrent respiratory infections, including sinusitis, bronchitis, pneumonia, and otitis media
what type of sinusitis can be caused by periapical infection of a tooth?
maxillary sinusitis
what are the causes of necrotizing lesions in the nose and nasopharynx?
fungus, especially Mucor in diabetics

Wegener granulomatosis

lethal midline granuloma
lethal midline granuloma
non-Hodgkin lymphoma of NK cells; superimposed ulceration and bacterial infection produces granulomatous inflammation

no longer fatal since lymphoma can be treated
nasopharyngeal angiofibroma
benign tumor of the nose/nasopharynx

common in adolescent males

often presents with nosebleeds and can bleed profusely during surgery
nasopharyngeal papillomas
benign nasopharyngeal tumor of squamous or columnar epithelial origin

HPV 6 & 11 have been implicated

types: exophytic, inverted, cylindrical (a subtype of exophytic)
inverted nasopharyngeal papillomas
benign but locally aggressive (extend into mucosa) squamous epithelial tumors located in the nose and paranasal sinuses; can invade the orbit or cranial vault

papillomatous proliferation of squamous epithelium growing inward

has a high rate of recurrence with incomplete excision, but rarely develops into carcinoma
nasopharyngeal plasmacytoma
malignant plasma cell tumor growing within soft tissue or within the skeleton that arises in adjacent lymphoid tissue and protrudes into the nose or sinus

rarely progresses to multiple myeloma
olfactory neuroblastoma
uncommon, highly malignant tumor that arises from neuroendocrine cells (small, round, blue cells) in the olfactory mucosa; metastasizes widely

Tx: combination of surgery, Xray, and chemo (5 ys: 40-90%)
nasopharyngeal carcinoma
common in parts of Africa (most common childhood CA)
common CA in adults in south China

EBV is found in the tumor epithelial cells of most undifferentiated and nonkeratinizing squamous cell carcinomas

types:
1) keratinizing squamous cell
2) nonkeratinizing squamous cell
3) undifferentiated (lymphoepithelioma)

tend to grow silently (with few symptoms), so they are often metastatic and/or unresectable
- 70% present as cervical node masses

Tx: radiotherapy (3YS is 50-70%; most effective with (3))
undifferentiated nasopharyngeal carcinoma (lymphoepithelioma)
large epithelial cells admixed with abundant normal-appearing lymphocytes

tend to grow silently (with few symptoms), so they are often metastatic and/or unresectable
- 70% present as cervical node masses

most sensitive type of nasopharyngeal carcinoma to radiotherapy
what are the types of laryngitis?
allergic
viral
bacterial
chemical
croup
laryngotracheobronchitis in young children

inflammatory narrowing of passages creates inspiratory stridor
acute epiglottitis
infection of epiglottis by H. influenzae, S. pyogenes (beta-hemolytic strep), respiratory syncytial virus (RSV)

causes a medical emergency by creating a laryngeal obstruction

common in infancy and young children
vocal cord polyps
reactive nodules (smooth, round excresences of a few mm diameter) on the true vocal cords in people with strain on vocal cords (singers) or heavy smoking

by convention, singers' polyps are bilateral and smokers' polyps are unilateral

more often seen in males

polyps can be hyperkeratotic or even slightly dysplastic; stroma consists of loose, myxoid tissue, variable fibrosis, and variable vascularity

Sx: hoarseness

virtually never cause malignancy, but can cause damage/change a singer's voice
what are "singers' nodules"?
vocal cord polyps
where do laryngeal squamous papillomas usually occur?
usually on the true vocal cords and are a cm or less
laryngeal papillomas
finger-like projections of typical squamous epithelium with an central fibrovascular core

if on the free edge of the vocal cord, can ulcerate and cause hemoptysis; usually single in adults and multiple in kids

caused by HPV types 6 & 11

rare malignant transformation, but can recur
juvenile papillomatosis
presence of multiple 1cm finger-like projections of typical squamous epithelium with central fibrovascular cores on the true vocal cords

lesions often spontaneously regress at puberty

Sx: hemoptysis (caused by ulceration of papillomas on the free edge of vocal cords)
how quickly do laryngeal neoplasms transform to cancer?
neoplasms with mild dysplasia: 1-2% over 5-10 years

neoplasms with severe dysplasia: 5-10% over 5-10 years
what type of neoplasms make up the largest part (95%) of malignant laryngeal neoplasms?
squamous cell carcinoma
what factors contribute to development of cancer?
tobacco smoke
alcohol
asbestos
HPV
nutrition
irradiation
what is the most common location for malignant laryngeal cancers?
true vocal cords

can be above or below the cords, in the aryepiglottic folds, in the pyriform sinus, or on the epiglottis
development of malignant laryngeal cancers
start as carcinoma in situ, and then progress to plaque, and finally ulcerated and/or fungating lesions (grows in or out)
clinical features of malignant laryngeal neoplasms
hoarseness

60% are confined to larynx at the time of dx (gives a better px)

ulcerated lesions are often secondarily infected

1/3 of pts die from infection of the distal respiratory tract, metastases, or cachexia
tx for malignant laryngeal neoplasms
advanced lesions - total laryngectomy with permanent tracheostomy and feeding tube (lose defense of URT)

early lesions - radiotherapy
otitis media
middle ear infection in infants and children

usually a serous exudate and caused by viral infection; can have a suppurative secondary bacterial infection

chronic otitis media caused by P. aeruginosa, S. aureus, fungus
what cause of chronic otitis media is particularly problematic in diabetics?
P. aeruginosa

it is aggressive and spreads widely causing destructive necrosis
cholesteatoma
1-4cm cystic lesion with a squamous or mucus secreting epithelial lining and a lumen filled with amorphous debris and sometimes cholesterol spicules; surrounded by chronic inflammatory reaction

can rupture or can erode adjoining structures as it enlarges

associated with chronic otitis media
otosclerosis
bilateral abnormal bone deposition around the rim of the oval window into which the footplate of the stapes fits

starts as fibrous ankylosis of the footplate, eventually being replaced by bone; degree of immobility determines severity of hearing loss (minimal is common and severe is uncommon)

AD inherited disorder
what type of tumors of the ear are common in elderly men?
basal and squamous cell cancers on skin of external ear

usually related to sun exposure

begin as papules and undergo local invasion, but rarely spread
what type of tumors of the ear are common in elderly women?
squamous cell carcinoma in the ear canal

not related to sun exposure

begin as papules and can invade cranium or metastasize to regional nodes

5 year survival is 50%
branchial cyst
anterolateral 2-5cm cyst in the neck that arises from remnants of branchial arches, or from salivary inclusions within cervical lymph nodes

walls lined with stratified squamous or pseudostratified columnar epithelia; underlying intense lymphocytic infiltrate or well developed lymphoid tissue with reactive follicles; cyst contains watery to mucinous fluid or desquamated material

DDx: lymphoma (usually too superficial to be the case)
thyroglossal duct (tract) cyst
midline 1-4cm cyst lined by squamous epithelium if near the base of the tongue or by pseudostratified epithelium if lower; wall has lymphoid aggregates or recognizable thyroid tissue

may move if pt sticks their tongue in or out
paraganglioma
aka carotid body tumor

rare neuroendocrine tumor similar to pheochromocytoma

occur around great vessels along the aorticopulmonary chain (parasympathetic ennervation)

non-chromaffin lesions, so infrequently release catecholamines

usually occur in the 6th decade of life; usually single and sporadic though can be familial as a part of MENII

carotid body tumors are most frequent - cells sense O2 and CO2 in adjacent vessels (chemodectoma)
where are 70% of extra-adrenal paragangliomas located?
head and neck - generally around the great vessels along the aorticopulmonary chain of parasympathetic ennervation
what is a chemodectoma?
carotid body tumor (most frequent form of paraganglioma)

non-chromaffin neuroendocrine tumor of the carotid body

cells sense O2 and CO2 levels in adjacent vessels
morphology of paraganglioma
arises close to or envelops bifurcation of common carotid

pink-to-brown round to oval cells with abundant cytoplasm and uniform nuclei; arranged in zellballen (pattern of nests/balls unique to paraganglioma)

stain for neuroendocrine markers and spindle shaped stromal cells stain for S100
clinical course of paraganglioma
slow growing, painless tumor around the carotid body occuring in the 5-6th decade

difficult to resect b/c they are entangled with the carotid artery and b/c they are very infiltrative, and frequently recur if resection is incomplete

can metastasize

neither histology nor vascular invasion can predict clinical course (whether benign or malignant)

50% are fatal
what is the most common salivary lesion?
mucocele - blockage or rupture of a duct with leakage of saliva in the stroma
mucocele
most common salivary lesion

blockage or rupture of a duct with leakage of saliva in the stroma; seen as a bluish, translucent cyst-like space containing mucin and inflammatory cells and lined by granulation tissue or fibrous tissue

most often found on lower lip
ranula
mucocele from damage to duct of the sublingual gland
what is the most common infectious cause of sialadenitis?
mumps
what is the most common autoimmune cause of sialadenitis?
Sjogren syndrome
nonspecific sialadenitis
inflammation of salivary glands

particularly involves submandicular glands

bacteria can infect, usually secondary to ductal obstruction by stones
etiology of sialolithiasis
sialolithiasis = stones in salivary ducts

poorly understood etiology, but dehydration with decreased secretion may have a role
statistics for salivary neoplasms
<2% of human tumors overall

- 65-80% arise in the parotid gland (20% are malignant)
- 20% arise in submandibular gland (40% are malignant)
- 50% of minor salivary gland tumors and 70-90% of sublingual tumors are malignant
what is the rule of thumb for malignancy of tumors in salivary glands?
the smaller the salivary gland is, the more likely the tumor is to be malignant
when do salivary gland tumors generally present?
benign tumors in the 5th-7th decades of life

malignant tumors slightly older

malignant usually grow more rapidly
pleomorphic adenoma (mixed tumor of salivary glands)
60% of parotid tumors; less common in other salivary glands

benign tumor derived from a mix of ductal epithelial and myoepithelial cells (epithelial and mesenchymal differentiation, with either dominating)
morphology of pleomorphic adenoma
aka mixed tumor of salivary glands

grey-white tumor with myxoid or bluish areas; size rarely exceeds 6cm

capsule not fully developed and often small protrusions into surrounding gland

epithelial component can be ductal, acinar, sheets, myoepithelial cells
mesenchymal component is loose, often with areas of cartilage and occasionally bone
clinical course of pleomorphic adenoma
painless, slow growing tumor that can develop into a carcinoma (adenocarcinoma or undifferentiated carcinoma; 2% if pt has tumor <5 yrs; 10% if pt has tumor >15 yrs)

very aggressive (30-50% 5yr mortality)

4% recurrence with lobectomy; 25% recurrence with enucleation w/o lobectomy
warthin tumor
aka cystadenoma lymphomatosum

bilateral and/or multifocal benign 2-5cm encapsulated tumor in the superficial lobe

grey surface with narrow cystic or cleft-like spaces filled with mucinous or serous contents and lined by double layer of columnar epithelium with abundant fine granular eosinophilic cytoplasm; underlying stroma is dense and lymphoid and can have germinal centers

only found in parotid glands; more common in males and in smokers
what is the second most common tumor in salivary glands?
warthin tumor (aka cystadenoma lymphomatosum)
mucoepidermoid carcinoma
15% of all salivary tumors (60-70% occur in parotid, but accounts for a large number of minor salivary gland tumors)

up to 8cm circumscribed tumor with infiltrative margins

grey-white with small mucin containing cysts; cords, sheets or cysts of squamous or mucous epithelium or intermediates

range from low to high grade (low grade tends to have more mucin producing cells and high grade have a larger squamous component)
what is the most common malignancy of salivary glands?
mucoepidermoid carcinoma
what is the most common radiation induced neoplasm?
mucoepidermoid carcinoma
clinical course of mucoepidermoid carcinoma
low grade - recurrence/local invasion in 15%, but don't tend to metastasize (5 year survival is 90%)

high grade - 30% recurrence and tend to metastasize (5 year survival is only 50%)
molecular pathology of mucoepidermoid carcinoma
about 1/2 of pts have a t(11;19) creating fusion gene of portions of MECT1 and MAML2

(disturbs notch and cAMP dependent signaling pathways)
adenoid cystic carcinoma
50% occur in minor salivary glands, especially those in the palate; also occur in parotid and submandibular glands

small, poorly encapsulated, infiltrative lesions that consist of small cells (with dark nuclei and scant cytoplasm) with hyaline material between them; cribriform, solid or tubular patterns

adenoid cystic pattern (punched out holes)
clinical course of adenoid cystic carcinoma
recurrent, slow growing tumor that tends to invade perineural spaces (quite painful)

50% or more have wide dissemination, but it takes years to manifest

five year survival is 60-70%; fifteen year survival is 15%
acinic cell tumor
2-3% of salivary tumors (mostly occuring in parotid glands)

may be bilateral and/or multicentric

cells resemble normal serous cells of salivary glands, with cleared cytoplasm in sheets, glands, papillary formation

recurrence is uncommon but 10-15% metastasize to nodes

5 year survival is 90%; 20 year survival is 60%