The differential diagnosis of lymphoepithelial lesion of the salivary gland.

The differential diagnosis of salivary gland lesions with epithelial components and lymphoid stroma is often challenging. Salivary gland carcinoma with tumor-associated lymphoid proliferation, tumors composed of both epithelial and lymphoid components, lymphoid neoplasms in the salivary gland, and inflammatory lesions are all included in this category. It encompasses inflammatory lesions and neoplastic lesions. With the exception of Warthin tumors, these lesions are rare, making them more difficult to diagnose. Carcinoma showing thymus-like elements has recently been reported in the salivary gland. Similar to thymic carcinoma, tumor cells are positive for CD5 and are accompanied by T lymphocytes.

Warthin-like papillary carcinoma: Case report.

Warthin-like papillary thyroid carcinoma is a rare variant of papillary carcinoma with a very good prognosis. It is often associated with lymphocytic thyroiditis. Due to its typical histological picture resembling Warthin's salivary gland tumor, the histological diagnosis is not difficult, usually does not require an accompanying immunohistochemical examination and is based on the presence of nuclear features typical of papillary carcinoma and the presence of oncocytes in a background of rich lymphocyte infiltrate. The preoperative cytologic examination is challenging, as many other lesions may have a similar picture. Women are more likely to get affected. It appears a decade earlier than the classic variant. Clinically, it presents similarly to a conventional papillary carcinoma. In our case report, we would like to present the case of a 56-year-old woman with non-toxic multinodular goiter, in whom the presence of this rare variant of papillary carcinoma was revealed by histological examination.

A rare case of sebaceous lymphadenoma: Cytohistological correlation of preoperative cytomorphologic findings.

We are presenting a case of a 74-year-old female with a parotid gland mass. Fine-needle aspiration (FNA) of the mass demonstrated cohesive groups of epithelial cells with overall bland-appearing nuclei and abundant vacuolated cytoplasm, consistent with sebaceous cells, in a background of polymorphous lymphocytes, scattered histiocytes, and adipose tissue. Immunostains showed that the epithelial cells stain positive for p63, but negative for CD117 and DOG-1. CD3 and CD20 showed a mixture of T- and B-cells. On the PAP-stained slides, there were numerous sac-like structures, consistent with myospherules. These findings were suggestive of neoplasm with sebaceous differentiation. The main differential diagnosis included sebaceous adenoma, sebaceous lymphadenoma, and other benign lesions with sebaceous differentiation. The parotid mass was resected. Histology sections demonstrated a well-circumscribed neoplasm with multicystic epithelial component and surrounding lymphoid infiltrate, consistent with sebaceous lymphadenoma. Sebaceous lymphadenoma (SLA) is a rare benign salivary gland neoplasm that is most commonly seen in the parotid gland. Preoperative FNA diagnosis of sebaceous neoplasms is challenging. To the best of our knowledge, this is the third case of sebaceous lymphadenoma diagnosed preoperatively. In this manuscript, we detail the epidemiological characteristics and histogenesis of sebaceous salivary gland neoplasms, and the cytomorphologic differential diagnosis of SLA with key diagnostic features of each entity.

Cytomorphology of Warthin-like variant of papillary thyroid carcinoma: A diagnosis not to be missed.

The authors have elaborated the cytological features of Warthin-like variant of papillary thyroid carcinoma (WLPTC) presenting unusually with nodal metastasis in a 43-year-old lady, and which was reported on cytology as papillary thyroid carcinoma (PTC) with lymphocytic thyroiditis.

Imaging quality of PROPELLER diffusion-weighted MR imaging and its diagnostic performance in distinguishing pleomorphic adenomas from Warthin tumors of the parotid gland.

The aim of this study was to evaluate the imaging quality and diagnostic performance of fast spin echo diffusion-weighted imaging with periodically rotated overlapping parallel lines with enhanced reconstruction (FSE-PROP-DWI) in distinguishing parotid pleomorphic adenoma (PMA) from Warthin tumor (WT). This retrospective study enrolled 44 parotid gland tumors from 34 patients, including 15 PMAs and 29 WTs with waived written informed consent. All participants underwent 1.5 T diffusion-weighted imaging including FSE-PROP-DWI and single-shot echo-planar diffusion-weighted imaging (SS-EP-DWI). After imaging resizing and registration among T2WI, FSE-PROP-DWI and SS-EP-DWI, imaging distortion was quantitatively analyzed by using the Dice coefficient. Signal-to-noise ratio and contrast-to-noise ratio were qualitatively evaluated. The mean apparent diffusion coefficient (ADC) of parotid gland tumors was calculated. Wilcoxon signed-rank test was used for paired comparison between FSE-PROP-DWI versus SS-EP-DWI. Mann-Whitney U test was used for independent group comparison between PMAs versus WTs. Diagnostic performance was evaluated by receiver operating characteristics curve analysis. P < 0.05 was considered statistically significant. The Dice coefficient was statistically significantly higher on FSE-PROP-DWI than SS-EP-DWI for both tumors (P < 0.005). Mean ADC was statistically significantly higher in PMAs than WTs on both FSE-PROP-DWI and SS-EP-DWI (P < 0.005). FSE-PROP-DWI and SS-EP-DWI successfully distinguished PMAs from WTs with an AUC of 0.880 and 0.945, respectively (P < 0.05). Sensitivity, specificity, positive predictive value, negative predictive value and accuracy in diagnosing PMAs were 100%, 69.0%, 62.5%, 100% and 79.5% for FSE-PROP-DWI, and 100%, 82.8%, 75%, 100% and 88.6% for SS-EP-DWI, respectively. FSE-PROP-DWI is useful to distinguish parotid PMAs from WTs with less distortion of tumors but lower AUC than SS-EP-DWI.

Cytopathology and diagnostics of Warthin's tumour.

Warthin's tumour (WT) is a benign epithelial salivary tumour, one type of salivary adenoma. Histologically, WT is structured of two components, epithelial tissue that often lines cystic formations and lymphoid tissue in the tumour stroma. FNA is a reliable diagnostic approach in the diagnosis of salivary gland lesions allowing a highly accurate categorization of benign tumour-like lesions, benign tumours and malignant tumours. In the proposed Milan reporting system of salivary gland lesions, WT is categorized in the IVA group of benign neoplasms. Accurate cytological diagnosis is straightforward when three characteristic components are present: oncocytes, either isolated or associated in clusters, lymphocytes and lymphoid cells and often an inflammatory/necrotic-like substance. Also, specific features of scintigraphy and radiological imaging contribute to the diagnosis of WT. WT is categorized according to Seifert G. et al in 4 types, depending on the proportions of the epithelial component and lymphoid stroma. Differential cytopathological and pathohistological diagnosis include other salivary gland lesions with lymphoid, oncocytic epithelial and cystic components. In some cases, such as the metaplastic WT variant, there are additional cytopathological and histological diagnostic difficulties. Moreover, bilateral, multicentric or multiple and infrequently seen extra-salivary localizations of WT are associated with further cytopathological diagnostic difficulties. Also, a rare possibility of malignant transformation of the epithelial or lymphoid component of WT as well as possible association with other primary tumours remains a challenge in accurate cytopathological and histological diagnosis of WT.

Clinicopathological analysis of parotid masses: six-year experience of a tertiary center.

OBJECTIVE: To analyse the clinical and histopathological characteristics of parotid gland masses at a tertiary referral centre and to compare the results with those cited in literature. METHODS: The retrospective study was conducted at Adana Numune Training and Research Hospital, Adana, Turkey, and comprised data of patients undergoing parotid surgery between January 2011 and December 2016. They were evaluated in terms of age, gender, surgery method, fine-needle aspiration biopsy results, specimen reports and complications after the surgery for one year. SPSS 20 was used for data analysis. RESULTS: Of 170 parotidectomies, 97(57.1%) had been performed on males and 73(42.9%) on females. There were 145(85.3%) benign and 25(14.7%) malignant tumours. Pleomorphic adenoma 67(39.4%) and Warthin's tumour 56(32.9%) were the two most common benign tumours. Mucoepidermoid carcinoma 7(4.1%) and adenoid cystic carcinoma 6(3.5%) were the two most prevalent malignant tumours. Superficial parotidectomy 133(78.2%) was the main type of surgical intervention. The sensitivity of fine needle aspiration cytology for identifying malignant tumours was 64.71%, the specificity was 100% and overall accuracy of the procedure was 94.92%. CONCLUSIONS: Repeated aspirations for sampling different parts of the lesion should be performed on suspicion of malignancy, especially if fine needle aspiration cytology reported pleomorphic adenoma.

The extent of surgery for benign parotid pathology and its influence on complications: A prospective cohort analysis.

BACKGROUND: The surgical management of benign parotid tumors is aimed at complete extirpation of the mass with preservation of facial nerve function. There is a relative paucity of literature pertaining to complications after benign parotid surgery and related risk factors. We aim to critically review the outcomes following treatment of benign parotid pathology when surgery entailed either complete superficial parotidectomy (CSP), partial superficial parotidectomy (PSP) or extracapsular dissection (ECD). MATERIAL AND METHODS: This is a review of prospectively collected data of all parotidectomies performed between June 2006 to June 2016 for histologically-proven benign pathology of the parotid. Median follow-up time was 31.6weeks. RESULTS: A total of 101 parotidectomies were carried out on 97 patients (40 CSP, 56 PSP and 5 ECD). Pleomorphic adenoma (48.4%) and Warthin's tumors (32.7%) were the most common pathologies. Temporary facial weakness occurred after 7 operations (6.9%). Facial weakness was permanent in 4 cases (3.9%). The rates of sialocele and salivary fistula were 4.9% and 0.9%, respectively. Only one patient (0.9%) developed Frey Syndrome postoperatively. No significant associations between extent of parotid surgery and postoperative facial nerve dysfunction (p=0.674) or wound complications (p=0.433) were observed. Univariate analyses for potential contributing factors such as advanced age, smoking status, tumor location or histology did not demonstrate any increased risk with developing postoperative complications. CONCLUSION: Partial superficial parotidectomy was associated with low rates of morbidity to the facial nerve and surgical wound. The results were comparable to complete superficial parotidectomy. We recommend offering patient partial superficial parotidectomy where appropriate and this is in line with the current trend of minimising surgical dissection, thereby potentially decreasing the risk of short-term and long-term complications.

Increased incidence of Warthin tumours of the parotid gland: a 42-year evaluation.

AIM: To evaluate the frequency of Warthin tumours among parotid neoplasms over the past 42 years in a population in rural Germany and to identify potential risk factors. METHODS: We conducted a retrospective case note evaluation from all patients who underwent parotid surgery between 1975 and 2017. The 42-year time period was evenly split into four quartiles. RESULTS: A Warthin tumour was diagnosed in 265 out of 806 patients (32.9%). The frequency of Warthin tumour increased steadily from 20.6% in the first decade between 1975 and 1986 to 44.9% in the fourth decade between 2008 and 2017. The age of the patients decreased from 68 years in the first to 62 years in the fourth decade. The male-to-female ratio in Warthin tumour was reduced from 1:5.3 in the first to 1:2.1 in the fourth decade. CONCLUSION: A Warthin tumour was the most common histological tumour type in the period from 1997 to 2017. We also found a high incidence of multiple tumours, a growing incidence in women and a decreasing age of patients. We propose a re-evaluation of the existing view of the epidemiology of benign parotid tumours, which proposes that pleomorphic adenoma is the most common benign parotid tumour.

Diagnostic pitfalls of infarcted Warthin tumor in frozen section evaluation.

Warthin tumor (WT) is the second most common benign salivary gland neoplasm and has characteristic cytologic and histologic findings. Fine-needle aspiration is a common and useful preoperative diagnostic technique, which sometimes leads to ischemic injury resulting in the infarction of these lesions. Infarcted WT may demonstrate variable gross and histologic alterations that may render the diagnosis challenging, particularly during intraoperative frozen section evaluation. In this study, we collected 11 resection specimens from 9 patients with infarcted WT. Seven patients were men and 2 were women, ranging from 49 to 85 years (mean, 69). All the patients had fine-needle aspiration before the resection. Macroscopically, the tumors were tan-white and contained soft, yellow, exudative material. The histologic findings were variable and included necrosis, ghosts of papillae, squamous metaplasia, cholesterol clefts, foamy macrophages, multinucleated giant cell reaction, necrotizing granulomas, and fibrosis. Each case predominantly demonstrated 1 or 2 of these histomorphologic features. In the permanent sections, additional sampling revealed foci of residual viable WT in 8 cases. Three cases were completely infarcted; however, they all had ghost-like papillae in which the architecture of WT was evident. Infarcted WT may present a diagnostic challenge during intraoperative frozen section evaluation. Associated morphologic alterations may preclude a definitive diagnosis of WT and may mimic malignancy. Awareness of the gross and microscopic features associated with infarcted WT is important, particularly for accurate frozen section evaluation of these salivary gland tumors.

Renal Cell Carcinoma: Delayed Metachronous Metastases to Parotid and Cerebellum.

PURPOSE: The purpose of this report is to describe a rare case of delayed metachronous isolated metastases of renal cell carcinoma (RCC) to the parotid gland and the cerebellum. The metastases occurred more than a decade after treatment of the primary tumor without any other systemic involvement. In addition, the potential differential diagnosis of the parotid mass based on presentation and imaging is discussed. MATERIALS AND METHODS: An 83-year-old man presented for evaluation and treatment of a rapidly growing mass at the right parotid region. He had a history of RCC resection 10 years before this presentation and had no evidence of persistent disease at the primary site. The diagnosis of metastatic RCC was made after fine-needle aspiration biopsy examination of the mass. The patient underwent superficial parotidectomy for resection of the tumor. Approximately 1.5 years later, he complained of loss of balance. Further investigation disclosed a cerebellar mass that at biopsy examination was found to represent RCC. He underwent stereotactic ablation of the mass. He currently remains free of disease at the primary site and the parotid and without further known brain metastases. RESULTS: This report presents the 29th case of a solitary parotid mass consistent with metastatic RCC 10 years after successful treatment of the primary RCC. Approximately 1.5 years later, the patient presented with new-onset loss of balance. Further investigation disclosed a mass to the cerebellum consistent with metastatic RCC. This case is unique because the brain involvement occurred extremely late, 11.5 years after successful treatment of primary RCC and 1.5 years after resection of a metastatic RCC to the parotid, and without any evidence of other metastases. CONCLUSIONS: Late distant metastases of RCC are not uncommon and patients require life surveillance follow-up, but such late presentation of metachronous metastases without systemic disease progression is unique. The patterns of metastases of RCC are not clearly defined and this diagnosis should be considered, especially in patients with relevant history.

Positron emission tomography in Warthin's tumor mimicking malignancy impacts the evaluation of head and neck patients.

PURPOSE: 1) To determine SUVs and PET/CT characteristics of Warthin's tumors in patients presenting to a head and neck cancer clinic. 2) To analyze the impact of PET/CT on the clinical course of these patients. MATERIALS AND METHODS: This is a single-institution retrospective analysis of patients with proven Warthin's tumors who underwent PET/CT done at or near the time of diagnosis and presented to a head and neck cancer practice. Data were obtained from the electronic medical records of these patients and the imaging and pathology databases. RESULTS: Six patients with Warthin's tumor met the criteria for and form the study cohort. Three patients had bilateral tumors. The SUVs for Warthin's varied from 3.4 to 16.1 in these patients, with an average of 7.8 and these SUVs were higher for Warthin's than for the cancers. These findings on PET/CT in this group required additional workup of all patients and required FNA, surgery or SPECT-CT to confirm the diagnosis. CONCLUSION: Although it is known that Warthin's tumor may be hypermetabolic on PET, this finding in the parotid or neck on PET/CT alters the evaluation and treatment of head and neck cancer patients and patients with cancers outside the head and neck by raising the concern about metastatic disease or multiple primary cancers. In other patients, PET/CT obtained for other reasons may prompt concern about incidental malignancy. This series specifically characterizes clinical features, SPECT-CT and FNA findings that can help reinforce the diagnosis of Warthin's and facilitate management.

Contemporary diagnosis and management of Warthin's tumor.

OBJECTIVE: Determine if the pathophysiology of Warthin's tumor, clinical presentation, cytology, and frozen section analysis signal an opportunity for less invasive parotid surgery and reduced morbidity. STUDY DESIGN: Retrospective review of 120 human parotidectomies identified 50 consecutive Warthin's tumors. SETTING: Single surgeon, single institutional study. SUBJECTS AND METHODS: Surgeon performed ultrasound guided Fine Needle Aspiration (FNA) and intra-operative frozen section with nerve integrity monitoring were used in all cases. Partial superficial parotidectomy was performed in the initial 25 patients and extracapsular dissection in the subsequent 25 patients. RESULTs: Smoking history was acknowledged in 45/50 (90 percent) of patients. The mean age was 63. Lower parotid pain and cellulitis occurred 23/50 (46 percent) and 11/50 (22 percent), respectively. Tumor in the lower parotid pole occurred in 48/50 (96 percent). Frozen section diagnosis for Warthin's tumor was confirmed by final pathology in all 50/50 (100 percent) patients. Two of 50 patients (8 percent) in the partial superficial parotidectomy group and no patient in the extracapsular dissection group had transient facial nerve dysfunction (p > 0.05). CONCLUSIONS: Warthin's tumor presents with a high rate of symptomatic inflammation, overwhelmingly in the lower parotid pole. Cytology largely excludes malignancy. Frozen section analysis diagnosing Warthin's tumor is highly specific in predicting final diagnosis. Minimally invasive approaches can be performed with confidence with extracapsular dissection or partial superficial parotidectomy resulting in potentially reduced morbidity.

MRI criteria for the diagnosis of pleomorphic adenoma: a validation study.

OBJECTIVES: To validate an MRI algorithm characteristic of pleomorphic adenoma (PA). STUDY DESIGN: Cross-sectional analysis. SETTING: Academic tertiary-care medical center. METHODS: A radiologic algorithm for the MRI diagnosis of PA was developed on the basis of five "high probability" criteria that all must be fulfilled for the MRI to qualify as a positive test result: bright T2-signal, sharp margins, heterogeneous nodular enhancement, lobulated contours, T2-dark rim. We then identified MRI images from our institutional database to test the diagnostic accuracy of the proposed algorithm. RESULTS: A total of 103 parotidectomy cases with adequate MRI studies were identified (pleomorphic adenoma n=41, mucoepidermoid carcinoma n=11, Warthin's tumor n=8, adenoid cystic carcinoma n=6, oncocytoma n=6, acinic cell carcinoma n=5, salivary duct carcinoma n=5, and other n=21). Eighteen of 21 cases that met all five "high probability" MRI criteria were consistent with PA on final histopathology; 3 were consistent with carcinoma. MRI had a specificity of 95.1% [95% confidence interval: 85.6-98.7%] and sensitivity of 43.9% [95% C.I.: 28.8-60.1%] for PA. The positive predictive value was 85.7% [95% C.I.: 70.4-100%] and the negative predictive value was 71.9% [95% C. I.: 62.0-81.9%]. The overall diagnostic accuracy was 74.8% [95% C.I.: 66.2-83.3%]. CONCLUSION: A "high probability" MRI is about 95% specific for pleomorphic adenoma. A subset of patients with MRI imaging that is highly suggestive of PA may reliably avoid further workup. The value of MRI in this setting is especially useful if preoperative fine needle aspiration is not readily available. A significant proportion of PAs, however, have indeterminate imaging features that overlap considerably with other benign and malignant lesions.

[Patterns of xanthogranulomatous reaction in salivary glands. Histomorphological spectrum and differential diagnosis]. / Xanthogranulomatöses Reaktionsmuster in Speicheldrüsen. Histomorphologisches Spektrum und Differenzialdiagnose.

Xanthogranulomatous inflammation is an uncommon subtype of chronic inflammatory processes that has been mainly reported in the kidneys, gallbladder and other less common sites. Due to the presence of tumefactive mixed inflammatory infiltrates with variable involvement of surrounding soft tissues, this benign condition is often mistaken for a malignancy on clinical examination. In the salivary glands xanthogranulomatous inflammation is rare and mainly represents reactive changes secondary to a preexisting lesion, in particular infarcted Warthin tumors as well as ruptured ductal cysts and other sialectatic ductal changes. A special type of xanthogranulomatous salivary gland disease is represented by the rare primary (idiopathic) xanthogranulomatous sialadenitis without identifiable predisposing parenchymal or ductal lesions. The histological differential diagnosis is mainly based on the dominant histological pattern and encompasses among others inflammatory pseudotumors of various etiologies (e.g. inflammatory myofibroblastic tumor, IgG4-related disease and sarcoidosis), neoplastic and paraneoplastic xanthogranulomatosis, malignant lymphoma and carcinoma with secondary xanthogranulomatous reactions. Thus, identification of the underlying lesion is necessary for correct classification and to avoid overlooking more serious neoplastic or autoimmune diseases.

[Nasopharyngeal space-occupying lesion with middle ear effusion. Malignant or benign?]. / Nasopharyngeale Raumforderung mit assoziiertem Paukenerguss. Ein maligner Prozess?

Warthin tumors (cystadenolymphoma, cystadenoma lymphomatosum papilliferum) account for approximately 10-15 % of all benign salivary gland tumors and are bilateral in approximately 10-15 %, as well as extraparotideal in approximately 8 % of cases. Nasopharyngeal Warthin tumors are extremely rare; however they should be borne in mind as a consideration of differential diagnostics. Furthermore, parotid glands and cervical lymph nodes should be examined as associated synchronous or metachronous manifestations are possible. Palpation, sonography and other radiological imaging of the cervical region, if applicable, might be required.

Warthin's tumor with superimposed mycobacterium tuberculosis infection.

We report a case of atypical mycobacterium infection in a Warthin's tumor which occurred in a 79-year-old man. The patient had along history of a left parotid mass that underwent rapid growth, became painful, and fistulized. The patient underwent left parotidectomy and neck dissection which showed a Warthin's tumor with areas of necrotizing granulomas. Subsequent culture showed the growth of acid fast bacilli. Consideration of an underlying mycobacterium infection, although rare, is important due to the public health concerns and other treatment needs that such a diagnosis raises.

Primary intranodal Warthin-like variant of mucoepidermoid carcinoma.

This report describes a rare case of primary intranodal Warthin-like mucoepidermoid carcinoma (WL-MEC) presenting as a left level II lymph node mass in a 48-year-old man. Warthin-like mucoepidermoid carcinoma is a recently defined variant of MEC that bears a close histologic resemblance to Warthin tumor. Whereas MEC has readily identifiable key histologic features that render diagnosis relatively straightforward, WL-MEC is a challenging diagnosis due to overlapping histologic features and only limited case reports in the literature. This case was initially diagnosed as primary intranodal MEC after the exclusion of metastasis by imaging. It was not until years later, upon review of historic cases, that the diagnosis of WL-MEC was established. This diagnosis was further supported by molecular testing that was not available at the time of the original diagnosis.

Bilateral intra-lymph node Warthin's tumor as a potential diagnostic pitfall mimicking metastatic carcinoma.

Warthin's tumor (WT) is a benign and frequent salivary gland tumor primarily affecting the parotid gland. In some cases, this tumor can involve the extra parotid region and affect cervical lymph nodes. Fine-needle aspiration can be the first step in the diagnostic approach to lymphadenopathy; however, specimens from intra-nodal WT can present a potential pitfall, leading to a misdiagnosis of metastasis. Here, we report an unusual case of a patient with bilateral WT in parotid lymph nodes misdiagnosed as metastases. In addition, we highlight the cytopathological aspects of WT to alert cytopathologists about this challenging diagnosis.