Cutaneous Lymphadenoma Is a Distinct Trichoblastoma-like Lymphoepithelial Tumor With Diffuse Androgen Receptor Immunoreactivity, Notch1 Ligand in Reed-Sternberg-like Cells, and Common EGFR Somatic Mutations.

The term "cutaneous lymphadenoma" was coined in this journal for an unusual lymphoepithelial cutaneous adnexal neoplasm, possibly with immature pilosebaceous differentiation. Some authors further proposed that cutaneous lymphadenoma was an adamantinoid trichoblastoma. However, although a hair follicle differentiation is widely accepted, the fact that this is a lymphoepithelial tumor is not appropriately explained by the trichoblastoma hypothesis. Our goal was to further clarify the phenotypic and genotypic features of cutaneous lymphadenoma in a series of 11 cases. Histologically, a lobular architecture surrounded by a dense fibrous stroma was present in all cases. The lobules were composed of epithelial cells admixtured with small lymphocytes and isolated or clustered large Reed-Sternberg-like (RS-L) cells. The epithelial cells were diffusely positive for the hair follicle stem cell markers CK15, PHLDA1, and for androgen receptor. No immunostaining for markers of sebaceous differentiation was found. Intraepithelial lymphocytes were predominantly CD3+, CD4+, FoxP3+ T cells. RS-L cells showed both strong Jagged-1 and Notch1 cytoplasmic immunostaining. Androgen-regulated NKX3.1 nuclear immunostaining was present in a subset of large intralobular cells in all cases. Double immunostaining showed coexpression of NKX3.1 and CD30 in a subset of RS-L cells. No immunostaining for lymphocytic or epithelial markers was present in RS-L cells. EGFR, PIK3CA, and FGFR3 somatic mutations were found by next-generation sequencing in 56% of the cases. We consider that cutaneous lymphadenoma is a distinct benign lymphoepithelial tumor with androgen receptor and hair follicle bulge stem cell marker expression, RS-L cell-derived Notch1 ligand, and common EGFR gene mutations.

Expressions of CXCL12, CXCL10 and CCL18 in Warthin tumors characterized pathologically by having a lymphoid stroma with germinal centers.

The Warthin tumor is a benign neoplasm of the salivary glands, histologically, the tumor has an oncocytic epithelial component forming uniform rows of cells surrounded by cystic spaces associated with a lymphoid stroma often showing the presence of germinal centers. The lymphoid stroma is a representative microscopic finding. If this lymphocytic accumulation is active, some sort of transmitter should exist between the Warthin tumor cells and lymphocytes. C-X-C motif chemokine ligand (CXCL12) 12, CXCL10 and C-C motif chemokine ligand 18 (CCL18) are a chemoattractant for lymphocytes in vivo. There is no report on the relationship between these chemokines and Warthin tumors. In this study, we investigated these chemokines expressions in 20 Warthin tumors using immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR). For comparison, we also enrolled samples of pleomorphic adenoma, which is another benign salivary gland tumor type without prominent lymphocytic infiltration. All Warthin tumors were immunopositive for CXCL12 and CXCL10, and these reactivities were diffuse. Meanwhile, the majority of pleomorphic adenomas were immunonegative for CXCL12 (95%), CXCL10 (80%) and CCL18 (85%). Warthin tumor and pleomorphic adenoma cases were significantly different in these immunostaining expressions (CXCL12, p<0.001; CXCL10, p<0.001; CCL18, p=0.024). We examined CXCL12, CXCL10 and CCL18 mRNA expressions of 3 representative Warthin tumor samples, each having these chemokines immunopositive areas detected by RT-PCR. Finding CXCL12 and CXCL10 expressions indicate that these chemokines may play a part in the formation of a lymphoid stroma within Warthin tumors. In regards to this phenomenon, the participation of CCL18 might be restrictive compared to CXCL12 and CXCL10.

The potential role of follicular helper T cells and helper T cells type 1 in Warthin tumour.

Warthin tumour (WT) is a benign tumour of the salivary gland that proliferates in both glandular epithelial and lymphoid tissue components, and rarely exhibits cystic changes. T follicular helper cells (Tfh) are involved in the formation and maintenance of germinal centres, the differentiation of B cells into plasma cells, and the maintenance of helper T cell type 2 (Th2)-dominant humoral immune responses. T-bet induces differentiation into helper T cell type 1 (Th1) by suppressing differentiation into Tfh and enhances cellular immune responses. The objective of this study was to enhance our understanding of the immune responses and relationship between Tfh and Th1 cells in patients with WTs. In this study, we classified WTs (n = 64) into solid-type (n = 25) and cyst-type (n = 39). We also performed immunostaining of the Tfh markers CXCR5 and CD40 L, and the Th1 marker T-bet for statistical analysis. The cyst-type exhibited significant atrophy of the germinal centre area (P = 0.0019), significantly fewer Tfh-positive lymphocytes in germinal centres (P < 0.0001), and significantly more T-bet-positive lymphocytes in the epithelium (P = 0.0017). We observed that Tfh were involved in the formation and maintenance of lymphoid follicles in WTs. In the cyst-type, Th2-dominant humoral immune responses were suppressed, and Th1-dominant cellular immune responses may have caused damage to tumour tissue.

Warthin's tumour: Aetiopathogenesis dilemma, ten years of our experience.

Despite the volume of studies written after the initial report by Hildebrand (1895) on Warthin's tumour (WT), its aetiopathogenesis continues to be an unresolved and controversial question. Many different genetic and/or environmental aetiological factors seem to act on heterotopic ductal inclusions and may give rise to WT following an unknown tumorigenic event. Recent studies discussed the importance of immunological reactions during the formation of the tumour. A hypersensitive/allergic reaction may play a role in epithelial proliferation and may stimulate the reactivity of the germinal centres in the lymphoid stroma as showed at histological examination. The aim of this study was to inform readers of the current understanding of possible risk factors with a suggested aetiological role in Warthin's tumorigenesis. From 2001 to 2011, a total of 342 patients with benign salivary neoplasm were admitted in the Department of Maxillofacial Surgery of the University of Naples "Federico II". A histological diagnosis of WT was made in 115 of the patients (33.6%); these were retrospectively investigated in our study. Correlation between the onset of WT and positivity for autoimmune diseases and smoking habits was calculated. The incidence rate of autoimmune thyroiditis in our series (9.5%) was significantly greater than that of the general population (0.58%) (p < 0.001). Analysis of our series and review of the literature support the hypothesis that this tumour is the result of an autoimmune reaction. Further studies and larger series are required to confirm this hypothesis and investigate the role of other aetiological factors in WT genesis.

Immunoglobulin class switching to IgG4 in Warthin tumor and analysis of serum IgG4 levels and IgG4-positive plasma cells in the tumor.

We previously reported a case of immunoglobulin (Ig)G4-related immune inflammation in Warthin tumor. Increased serum IgG4 levels and tissue infiltration of IgG4-positive plasma cells are characteristics of IgG4-related disease (IgG4-RD), a newly emerging clinicopathological entity. However, the relationship between IgG4-RD and Warthin tumor remains to be elucidated. We aimed to investigate the involvement of systemic and local IgG4 production and class-switch recombination in Warthin tumor. We examined serum IgG4 levels and also analyzed the involvement of IgG4-positive plasma cells in Warthin tumors (18 cases) compared with those of pleomorphic adenomas (19 cases) as controls. Furthermore, in specimens of Warthin tumors (3 cases), pleomorphic adenomas (2 cases), and IgG4-RDs (2 cases), we examined messenger RNA expression of activation-induced cytidine deaminase, IgG4 germline transcripts and productive IgG4 by reverse transcription polymerase chain reaction. Serum IgG4 levels were increased in 5 of 18 Warthin tumors and not in any of the 19 pleomorphic adenomas. Infiltration of IgG4-positive plasma cells was detected in 4 Warthin tumors and none in the pleomorphic adenomas. Moreover, activation-induced cytidine deaminase, IgG4 germline transcripts, and productive IgG4 messenger RNA were found to be expressed in 2 of 3 Warthin tumors as well as IgG4-RDs by reverse transcription polymerase chain reaction, but not in pleomorphic adenomas. In conclusion, immunoglobulin class switching to IgG4 may be involved in the pathogenesis of Warthin tumor, and it is possible that certain inflammatory background with an immune reaction is involved in the pathogenesis of Warthin tumor.

Warthin's tumor associated with IgG4-related disease.

Immunoglobulin G4-related disease (IgG4-RD) is an inflammatory condition associated with elevated serum IgG4 levels and tissue infiltration by IgG4-expressing plasma cells. Several inflammatory conditions associated with IgG4-RD have been reported. Warthin's tumor is a benign parotid gland tumor consisting of oncocytic epithelial cells and lymphoid stroma containing lymphoid follicles with reactive germinal centers. This is the first report describing a case of Warthin's tumor with possible involvement of IgG4-RD. The patient was a 71-year-old man presenting with swollen right parotid and bilateral submandibular glands. He had a history of a Warthin's tumor of the left parotid gland, autoimmune pancreatitis, and an inflammatory abdominal aortic aneurysm. Laboratory tests revealed a high serum IgG4 level. Histological examination of the resected parotid gland showed a Warthin's tumor and a nodule showing severe lymphocytic infiltration containing many IgG4-positive plasma cells. This case shows the possible involvement of Warthin's tumor with IgG4-RD.

Lymphadenoma of the salivary gland: clinicopathological and immunohistochemical analysis of 33 tumors.

Lymphadenomas (LADs) are rare salivary gland tumors. Their clinicopathologic characteristics and etiopathogenesis are poorly understood. We examined 33 LADs in 31 patients (17 women and 14 men) aged 11-79 years (median 65 years). There were 22 sebaceous LADs in 21 patients (9 women and 12 men) and 11 non-sebaceous LADs in 10 patients (8 women and 2 men). Two patients had synchronous double tumors. Twenty-six tumors (79%) arose in parotid, three in the neck, and two each in submandibular gland and oral cavity. Extraparotid tumors were seen in 2 of 21 (10%) patients with sebaceous and 4 of 10 (40%) patients with non-sebaceous LADs. Seven of twenty-three (30%) patients had immunosuppressive therapy for unrelated diseases. The tumors were well circumscribed, encapsulated (n=28, 84%) painless masses, varying in size from 0.6 to 6 cm (median 2.2). The cut surfaces were gray-tan to yellow, homogeneous and multicystic (n=24, 72%). The epithelial cells were basaloid, squamous and glandular, forming solid nests, cords, tubules, and cysts. Sebaceous differentiation was restricted to sebaceous lymphadenoma. The epithelial cells expressed basal cell markers (p63, 34BE12, and/or CK5/6, 18/18, 100%) and the luminal glandular cells expressed CK7 (12/12, 100%). Myoepithelial cells were absent (n=10/16, 63%) or focal. The lymphoid stroma was reactive, with germinal centers in 28 (84%). There was no evidence of HPV (0/11), EBV (0/7), and HHV-8 (0/8). Malignant transformation to sebaceous and basal cell adenocarcinoma was seen in one patient each. None of the 11 patients with follow-up (1-8 years) recurred. In summary, sebaceous and non-sebaceous LADs are benign, encapsulated, solid and cystic tumors affecting older adults. Non-sebaceous LADs affect women and extraparotid sites more frequently than sebaceous LADs. Altered immune status may have a role in their etiopathogenesis. Multiple synchronous tumors, origin in buccal mucosa, and malignant transformation may rarely occur.

Simultaneous occurrence of IgG4-related chronic sclerosing dacryoadenitis and chronic sclerosing sialadenitis associated with lymph node involvement and Warthin's tumor.

Chronic sclerosing dacryoadenitis and chronic sclerosing sialadenitis have been shown to belong to the group of diseases referred to as IgG4-related sclerosing disease. The authors report a case of the simultaneous occurrence of IgG4-related sclerosing disease in both lacrimal and submandibular glands, clinically simulating malignant lymphoma. A cervical lymph node and a Warthin's tumor were also involved. This unique case of multiple organ involvement in IgG4-related sclerosing disease is documented.

Warthin tumor: a curious entity--case reports and review of literature.

Warthin tumor was first described in the American literature, by Aldred Warthin, in 1929, the pathologist who named this tumor papillary cystadenoma lymphomatosum, but since than it was also knew as adenolymphoma, cystadenolymphoma, and Warthin tumor. Because of its microscopically appearance and unknown origin, this tumor entity is still fascinating head and neck surgeons and pathologist. We evaluate the histopathological aspect of Warthin tumors using Hematoxylin-Eosin stain, and immunohistochemical and histological techniques. We reviewed the medical record of patients with salivary gland tumors diagnosed at County Hospital of Timisoara from 2002-2008. In six years, 22 cases with Warthin tumor were diagnosed and among them 17 men and five women, with average age 58.47. The analysis showed that 77.27% of Warthin tumors occurred in men, and the main histopathological aspect was with 50% epithelial component. The stromal component showed a prominent B-cell population by staining with CD20, and histological techniques for mucin were positive, and reticulin fibers were revealed while using Gordon-Sweets stain. The standard and the histological and immunohistochemical techniques highlighted the complex and variable microscopical appearance of Warthin tumor that the pathologist should consider when a diagnosis for this tumor is to be considered.

Expression of CD44 standard and variant isoforms in parotid gland and parotid gland tumours.

In this study, we investigated the distribution of the standard form of the CD44 (CD44s) cell adhesion molecule and of its v3 and v6 isoforms in samples of foetal and adult parotid gland tissue, in comparison with samples of parotid gland adenomas and carcinoma ex pleomorphic adenoma. Foetal parotid gland showed CD44s and CD44v3 expression in the peripheral small primordial ducts and acini, while CD44v6 was only focally expressed. Adult parotid gland tissue showed a similar distribution of CD44s and variants, with a predominant expression in acinar structures and a weaker expression at duct level. In parotid gland adenomas, a diffuse and intense expression of CD44s and variants 3 and 6 was observed only in pleomorphic adenomas, while expression of CD44s was prevalent in Warthin's tumour, myoepithelioma and oncocytoma. The malignant areas of carcinoma ex pleomorphic adenoma showed a markedly decreased expression of CD44v3 and CD44v6 in comparison with the adjacent pleomorphic adenoma component. In conclusion, the prevalent expression of CD44s and variants in pleomorphic adenoma in comparison with other adenomas may be related to the abundant extracellular matrix production present in these tumours, while loss of CD44v3 and CD44v6 associated with the onset of carcinoma ex pleomorphic adenoma could promote stromal invasion, eventually contributing to the development of distant metastases.

Comparison of integrin alpha chain expression in benign and malignant salivary gland tumors.

OBJECTIVE: This study investigates the distribution of the alpha chain of the integrin family of extracellular matrix receptors in a series of adenomas and carcinomas of salivary gland origin to determine if the malignant phenotype is associated with modification of the expression of these receptors. STUDY DESIGN: Cryostat sections of 36 tumor specimens were stained by a standard streptavidin-biotin-peroxidase technique using primary monoclonal antibodies against alpha 1-6 and alpha v integrin chains. The immunohistochemical reaction was scored using a three-point scale and the results were analyzed using Fisher's exact test. RESULTS: In salivary adenomas, alpha 2, alpha 3, alpha 4, alpha 6, and alpha v chains were widely expressed in most of the cases studied. The alpha 1 subunit was prominently expressed by the epithelial cells of Warthin's tumor, whereas a minority of pleomorphic adenomas showed immunoreactivity for this antigen. We observed alpha 5 subunit expression only in the mesenchymal-like component of pleomorphic adenomas. In salivary carcinomas, integrin alpha chain expression was heterogeneous, varying greatly between different histotypes and within the same histotype. The distribution of the antigens was similar to that of adenomas, except for the alpha 6 chain, which localized not only at the interface between cell and matrix, but also at sites of cell-cell contact. When the immunohistochemical levels of integrin alpha chain expression were compared in adenomas and carcinomas, expression significantly decreased for the alpha 6 and alpha v chains (p = 0.0007; p = 0.002, respectively). CONCLUSIONS: Loss of alpha 6 and alpha v integrin subunits occurring in salivary gland carcinomas could modify the adhesive properties of malignant cells, contributing to the invasive potential of these tumors.

Adhesion molecules and lymphocyte recruitment in lymphocytic thyroiditis, thyroid papillary carcinoma and parotid adenolymphoma.

Lymphocytic infiltrates are usually present in chronic lymphocytic thyroiditis, thyroid papillary carcinoma and parotid adenolymphoma. We selected these conditions to investigate the mechanisms of recruitment and organization of lymphocytic infiltrates in extranodal tissues. MoAbs in immunoperoxidase were used to identify the expression of ICAM-1 and VCAM-1 on endothelial cells (EC), and of their ligands LFA-1 and VLA-4 on lymphocytes and accessory cells. VCAM-1 positive EC were rarely observed in thyroids devoid of lymphocyte infiltration. Conversely, EC in chronic lymphocytic thyroiditis and in papillary carcinoma showed positive immunostaining for VCAM-1 and ICAM-1. These findings were associated with the presence of lymphocytes positive for the ligands VLA-4 and LFA-1. The upregulated expression of VCAM-1 on perifollicular capillaries was co-distributed with an accumulation of VLA-4 positive lymphocytes. In adenolymphoma, all EC were ICAM-1 positive, whereas the majority of vessels were VCAM-1 negative. Consequently the majority of lymphoid cells were LFA-1 positive and VLA-4 negative. We suggest that ICAM-1 and VCAM-1 expression on EC play a role in the recruitment of lymphocyte infiltration in chronic lymphocytic thyroiditis and papillary carcinoma. Furthermore, the upregulation of VCAM-1 and VLA-4 in thyroid reactive and neoplastic conditions may be linked to an immune response possibly related to thyroid tissue antigens.

False aneuploidy in benign tumors with a high lymphocyte content: a study of Warthin's tumor and benign thymoma.

The quality of results of flow cytometric DNA content analysis of formalin-fixed, paraffin-embedded tissue may be affected by a number of preanalytical variables. We performed flow cytometric DNA content analysis on two types of benign tumors to investigate the effect of a prominent lymphocytic component: Warthin's tumor (N = 20) and benign thymoma (N = 8). Malignant tumors (N = 23) were included as DNA aneuploid controls. All tissues studied were archival material processed using Hedley's technique either without prolonged rehydration in water (day 0 samples) or with 24- or 48-hour rehydration (day 1 and day 2 samples, respectively). Image cytometric DNA ploidy analysis was also performed on most cases. Eight cases (40%) of Warthin's tumor and five cases (63%) of benign thymoma showed either hyperdiploid peaks or marked asymmetry on the day 0 DNA histograms; nine of the malignant tumors were aneuploid. The DNA histogram abnormalities of the benign tumors could be gated out by excluding the lymphocyte nuclei. None of the DNA indices of the benign tumors corresponded with expected deviations based on published chromosomal studies. All of the DNA histogram abnormalities of the benign tumors disappeared and/or fused with the main peaks on the day 1 or day 2 samples, except for one case of benign thymoma. All the DNA aneuploid peaks on the malignant tumors persisted with prolonged rehydration. Image cytometric DNA analysis showed a diploid pattern in all benign tumors. We conclude that a high lymphocyte content may be a cause of false aneuploidy in these benign tumors. Furthermore, the degree of rehydration appears to be an important factor in achieving optimum fluorochrome staining of DNA.

[Detection of Epstein-Barr virus DNA in salivary gland tumors].

To evaluate the relations between salivary gland tumors and Epstein-Barr virus (EBV), the levels of EBV-related antibodies were examined, and detection of EBV nuclear antigen (EBNA) and EBVDNA in tumor tissue was attempted by the anti-complement immunofluorescence technique and polymerase chain reaction, respectively. The mean VCA-IgG antibody level was increased to 925 (80-2560) in Warthin's tumor, 496 (40-2560) in mucoepidermoid tumor, and 206 (40-640) in pleomorphic adenoma. The positive rate of EA-IgG was high in Warthin's and mucoepidermoid tumors. VCA-IgA antibody was positive in 2 of the 7 cases of Warthin's tumor. EA-IgA antibody was negative in all cases. EBVDNA was detected in 7 of the 7 cases of Warthin's tumor, 3 of the 5 cases of mucoepidermoid tumor, and 2 of the 26 cases of pleomorphic adenoma. A relationship between Warthin's tumor and EBV was suggested by the 100% detection rate of the viral DNA.

[Salivary gland adenolymphomas as seen in current histochemical and immunomorphological research]. / Adenolimfomy sliunnykh zhelez v aspekte sovremennykh gistokhimicheskikh i immunomorfologicheskikh issledovanii.

Samples of 32 adenolymphomas and 10 intact salivary glands were studied using histological, histochemical (Grimelius and congo red staining), microscopic and immunohistochemical methods employing polyclonal antibodies to myosin, human carboanhydrase III and monoclonal antibodies to cytokeratin polypeptides No. 8 and 17, epithelial membrane antigen and T- and B-lymphocytes as well as peroxidase--antiperoxidase reaction. Binding of monoclonal antibodies to cytokeratin No. 8 and epithelial membrane antigen was observed in glandular cells of cysts whereas proliferating cells forming "Sandersen's cushions" showed binding of polyclonal antibodies to myosin, carboanhydrase III and monoclonal antibodies to cytokeratin No. 17. Tumor stroma revealed T- and B-lymphocytes incretory granulocytes and amyloid spaced along the fiber structures. It is inferred that adenolymphoma is a tumor arising exactly in salivary glands. The epithelial component of this tumor forms following tumor transformation of epithelial and myoepithelial cells of the distal part of salivary gland ducts. T- and B-lymphocytes contribute to formation of tumor stroma. Epithelial membrane antigen is an effective marker of the epithelial component of tumor.

Expression of major histocompatibility complex class II antigens and interleukin-1 by epithelial cells of Warthin's tumor.

The immunoreactivity for class II antigens of the major histocompatibility complex and interleukin-1 (IL-1) in Warthin's tumor (WT) cells was studied. In addition to macrophages, dendritic cells, and capillary endothelia, the luminal tumor cells and some keratinocytes in the metaplastic squamous foci exhibited immunoreactivity for both class II antigens and IL-1. The distribution of the class II antigens in the luminal tumor cells was limited to their basolateral membrane. These data, together with previous findings, strongly suggest that the luminal tumor cells of WT introduce the luminal antigen to the underlying lymphoid tissue and, thus, act as an antigen-presenting cell.

Malignant lymphoma involving a Warthin's tumor: a case with immunophenotypic and gene rearrangement analysis.

We describe a Warthin's tumor which was involved by malignant lymphoma. The lymphoma was classified in the Working Formulation as follicular and diffuse, mixed small cleaved and large cell type. Frozen section immunohistochemical studies revealed an abnormal immunophenotype: immunoglobulin-negative and B-lineage. Gene rearrangement analysis confirmed the diagnosis by demonstrating rearrangements of both the immunoglobulin heavy and kappa light chain genes. The bcl-2 gene was also rearranged, consistent with the presence of the t(14;18) (q32;q21) translocation which is typically seen in follicular lymphomas. The T-cell receptor beta chain gene retained the germline configuration. The results in this case highlight an advantage of molecular techniques as compared with immunophenotypic analysis: gene expression is not required to demonstrate clonality.

[An immunohistochemical evaluation of Warthin's tumor using the monoclonal anti-human lung adenocarcinoma antibody KM-93 and the anti-human gastric carcinoma antibody KM-231].

An immunohistochemical identification of a human lung adenocarcinoma antigen and a gastric carcinoma antigen, detected by means of the monoclonal antibodies (MoAbs) KM-93 and KM-231, respectively, has been investigated in cases of a Warthin's tumor and in normal salivary glands. The ductal basal cells of the excretory duct epithelium in normal salivary glands are characterized by their positive staining to MoAb KM-231, whereas MoAb KM-231 staining is confined to basal tumor cells in cases of Warthin's tumor. Further, MoAb KM-93 staining is slightly positive when luminal tumor cells are present. These results suggest that the histogenesis of Warthin's basal tumor cells might originate in the excretory duct epithelium.