Cytologic diagnosis of salivary duct carcinoma: a review of seven cases

Mucoepidermoid carcinoma: Analysis of 76 cytologic cases and correlation with histologic grade

BACKGROUND

Mucoepidermoid carcinoma (MEC) is the most common salivary gland (SG) malignancy. In this study, the author undertook analysis of a large collection of MEC cytologic cases.

MATERIALS AND METHODS

Cytopathology files were searched for MEC cases with histopathologic confirmation. Fine-needle aspiration (FNA) smears used standard technique.

RESULTS

Seventy-six cases (63 patients [M:F = 1:1; age range, 23-87 years; mean age, 58 years]) met inclusion criteria. Aspirates were primary (54 [71%]), metastatic (18 [24%]), and locally recurrent (4 [5%]). FNA sites included parotid gland (49 [64%]), regional lymph nodes (11 [14%]), submandibular gland (5 [7%]), inner canthus of eye (2 [3%]), and lung (2 [3%]); and single specimens from palate, jaw, shoulder, paranasal sinus, floor of mouth, ear canal, and effusion. Cytologic diagnoses included MEC (30 cases [39%]), suspicious for MEC (16 [21%]), non-MEC carcinoma (9 [12%]), suspicious for malignancy (SM) (2 [3%], malignant (M) (1 [1%]), SG and/or suspicious SG neoplasm (7 [8%]), atypical (3 [5%]), nonneoplastic (5 [6%]), nondiagnostic (2 [3%]), and benign SG neoplasm (1 [1%]). A total of 26% of low-grade (LG) cases were diagnosed as malignant in contrast to 87% malignant in high-grade (HG) cases. Cytomorphology depended on tumor grade. LG MEC contained intra- and/or extra-cellular mucin and more uniform cell and/or nuclear morphology, whereas cytologic atypia, anisonucleosis, and keratotic cells were more typical of HG tumors.

CONCLUSION

A malignant (M) or suspicious for malignancy (SM) cytologic interpretation was made in 76% of mucoepidermoid carcinoma (MEC) cases. In contrast to high-grade MEC (97% identified as M/SM), only 59% of low-grade (LG) MEC cases were interpreted as such, illustrating the continued diagnostic challenge posed by LG MEC using fine-needle aspiration biopsy.

Salivary duct carcinoma: A report of 70 FNA cases and review of the literature

BACKGROUND

Although usually recognized as malignant, fine-needle aspiration (FNA) biopsy of salivary duct carcinoma (SDC) has been confused with other primary salivary gland (SG) neoplasms. This article undertook an analysis of a large collection of SDC FNA cases to assess diagnostic accuracy, specificity, and cytopathology.

METHODS

Cytopathology files were searched for SDC with histopathologic validation. FNA biopsy smears were performed using standard techniques.

RESULTS

Seventy cases from 56 patients (M:F, 1.9:1; age range, 26-92 years; mean age, 65 years) met inclusion criteria. All had tissue confirmation of SDC. FNA sites included: parotid gland (42, 60% cases), neck (10), submandibular gland (7), pre-/post-auricular area (5), face/cheek (3), mediastinal lymph nodes (2), and clavicle (1). Aspirates were from primary (52, 74%), metastatic (12, 17%), and locally recurrent (6, 9%) neoplasms. FNA diagnoses included: SDC (19, 27%), favor/suspicious for SDC (7, 10%), high-grade carcinoma (11), adenocarcinoma (9), carcinoma (6), malignant (6), SG neoplasm (5), atypia (3), SDC versus another malignancy (2), and pleomorphic adenoma (2). Large polygonal cells in groups and single forms showed cribriforming, variable necrosis, pseudopapillae, and oncocytic change. Androgen receptor staining was positive in all cases.

CONCLUSIONS

FNA biopsy is accurate and reliable in classifying SDC as a malignant neoplasm, but much less so for identification as a specific tumor type. Using the Milan system, 86% of aspirates were classified as either malignant or suspicious for malignancy. A recurring pitfall includes sampling error in cases of SDC ex pleomorphic adenoma.

Oncocytic features in salivary duct carcinoma, a potential pitfall for misdiagnosis as Warthin tumor in fine needle aspiration specimens: A cytomorphologic analysis of 14 cases

BACKGROUND

Salivary duct carcinoma (SDC) is an uncommon and highly aggressive primary salivary gland neoplasm. Cytomorphologic features of SDC include cellular smears, nuclear atypia, prominent nucleoli, cribriform and papillary architecture, and background necrosis. The presence of oncocytic features has been described but not adequately characterized in the current literature.

METHOD

This study cohort consisted of 14 cases of histologically proven SDC with previous salivary gland fine needle aspiration (FNA). The cytologic material of each case was semi-quantitatively analyzed and evaluated for various cytomorphologic, architectural, and background features.

RESULTS

Twelve SDCs were located in the parotid gland and two in the submandibular gland. In two cases the initial cytologic diagnoses was Warthin tumor or favor Warthin tumor. Moderate to marked degree of oncocytic changes were noted in all cases except one case. Nuclear atypia was variable with most cases exhibiting moderate to high-grade nuclear features, while four cases demonstrated low-grade nuclear cytomorphology. Cytoplasmic vacuolation was seen in nine cases and variable amount of background necrosis was observed in eight cases. Cribriform and papillary architecture was recognized in only six cases. Background lymphocytes were absent in all but one case.

CONCLUSIONS

Precise diagnosis of SDC based on cytomorphologic features alone can be challenging. Oncocytic change is one of the most consistent features observed in this case series and when associated with less pronounced cytologic atypia, can potentially lead to misdiagnosis as Warthin tumor. SDC should be considered in the differential diagnosis of oncocytic salivary gland neoplasms where precise diagnosis is not possible.

Clinicopathological Behavior and Treatment-related Outcome of Rare Salivary Duct Carcinoma: The Shaukat Khanum Memorial Cancer Hospital Experience

Background

Salivary gland tumors are rare salivary gland malignancies with resemblance to ductal breast carcinoma. We have described clinicopathological behavior and treatment outcomes of this rare malignancy.

Methods

Salivary duct carcinoma patients treated from 2010 to 2015 were retrospectively analyzed for clinicopathological characteristics and treatment-related outcomes of the disease.

Results

A total of 12 patients with salivary duct carcinoma were included in the study. All were males with mean age of 52.58 ± 13.43. Parotid gland was the most commonly involved major salivary gland while buccal mucosa and anterior tongue were most common oral cavity sub-sites involving minor salivary glands. The disease-free survival was 75% at 10 months and 25% at 20 months. The mean follow-up time was 12 months. There were three local recurrences and one distant metastasis.

Conclusion

Salivary duct carcinoma is a locally aggressive tumor with tendency for local recurrence and distant metastasis. Adverse features such as perineural invasion, extra-capsular spread and advanced nodal disease may worsen prognosis.

A rare tumor of salivary gland: Diagnostic Dilemma on fine needle aspiration cytology

Salivary gland cytopathology is a diagnostically challenging area with overlapping cytomorphological features between benign, malignant, and metastatic tumors. We report the case of 45-year-old male who presented with two swellings in right retroauricular and infraauricular region along with a palpable single right cervical lymph node. On ultrasonography of the neck, a possibility of malignant lesion was given. Contrast enhanced computed tomography of the head showed a large well-defined space occupying lesion in right temporooccipital region eroding the skull bone with both extra and intracranial extension. Fine needle aspiration was performed from both swellings and cervical lymph node. Based on cytological features and clinicoradiological examination, a possibility of metastasis from epithelial malignancy (adenocarcinoma) was suggested. The retroauricular region swelling was excised, and a diagnosis of salivary duct carcinoma was given on histopathology. In this article, we discuss the diverse presentation, cytomorphological features, and differential diagnosis of this rare salivary gland tumor.

Salivary Duct Carcinoma of the Parotid: Outcomes with a Contemporary Multidisciplinary Treatment Approach

OBJECTIVE

Salivary duct carcinoma (SDC) is a rare and aggressive malignancy for which an optimal treatment algorithm is lacking. We endeavored to assess the current treatment outcomes for SDC with a multimodality treatment approach combining surgery with adjuvant radiotherapy ± concurrent chemotherapy.

STUDY DESIGN

Case series with chart review.

SETTING

A National Cancer Institute-designated comprehensive cancer center.

SUBJECTS AND METHODS

The clinical record of 17 patients with salivary duct carcinoma were analyzed to assess locoregional control, recurrence-free survival, and overall survival.

RESULTS

All SDC cases (n = 17) were managed with surgical resection, followed by adjuvant radiotherapy (47.1%) or concurrent chemotherapy and radiotherapy (52.9%). Median patient follow up was 37 months. An aggressive disease course was generally observed, with 3-year recurrence-free survival and overall survival of 34.4% and 35.5%, respectively. The majority of recurrences were distant. Intensification with adjuvant concurrent chemotherapy was not associated with improved outcomes on univariate survival analysis.

CONCLUSION

For salivary duct carcinoma, a multimodality treatment approach is associated with acceptable locoregional control rates but poor distant control and overall survival. Novel systemic therapies may be needed to optimize clinical outcomes.

Salivary gland tumor fine-needle aspiration cytology: a proposal for a risk stratification classification

OBJECTIVES

Fine-needle aspiration (FNA) is useful in the evaluation of salivary gland tumors, but currently no standard terminology or risk stratification model exists.

METHODS

FNA smears were reviewed and categorized based on cytonuclear features, stromal characteristics, and background characteristics. Risk of malignancy was calculated for each category. Classifications as benign, neoplasm of uncertain malignant potential (NUMP), suspicious for malignancy, and positive for malignancy were used to aggregate categories into similar risk groups.

RESULTS

Categorization of salivary gland aspirates into morphologic categories resulted in the expected risk stratification. Grouping of categories maintained risk stratification, providing classes with malignancy risk as follows: benign, 2%; NUMP, 18%; suspicious for malignancy, 76%; and positive for malignancy, 100%.

CONCLUSIONS

Salivary gland FNA categorization into commonly encountered morphologic categories provides risk stratification, which translates to a simplified classification scheme of benign, NUMP, suspicious, and positive for malignancy similar to the paradigm in other organ systems.

Invasive salivary duct carcinoma ex pleomorphic adenoma of the parotid gland: a teaching case giving rise to the genuine diagnostic difficulty on an inadequate cytology specimen

Abstract

A history of a recent rapid increase in long-standing swelling mass was presented in the right parotid gland of an 85-year-old male. The inadequate cytologic specimens contained few small clusters of three-dimensional malignant epithelial cells having hyperchromatic pleomorphic nuclei and prominent nucleoli, adjacent to a cluster of benign monomorphic myoepithelial cells. We first interpreted it merely as an adenocarcinoma, not otherwise specified. A radical parotidectomy was performed, and gross examination revealed an encapsulated and firm tumor lesion, looking grayish-blue to yellowish-white, focally associated with extracapsular invasion. On microscopic examination, the tumor was predominantly composed of a proliferation of highly atypical epithelial cells having abundant eosinophilic cytoplasm, often arranged in a Roman-bridge appearance with foci of comedo necrosis, alternating with extensive infiltration to adjacent stroma in a trabecular or alveolar fashion with severe vessel permeation. Within the background of pleomorphic adenoma, the carcinoma cells sometimes replaced ductal luminal cells while retaining an intact-like myoepithelial layer. Therefore, we finally made a diagnosis of invasive salivary duct carcinoma ex pleomorphic adenoma. We should be aware that owing to its characteristic features, cytopathologists might be able to determine correct diagnosis, based on multiple and adequate samplings.

Virtual slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2126158270695815

Salivary duct carcinoma: what is already known, and can we improve survival?

Salivary duct carcinoma is an aggressive malignancy with a high mortality rate, which phenotypically resembles high-grade breast ductal carcinoma. The parotid gland is the most common location. Standard treatment is surgery to the primary tumour together with post-operative radiotherapy. Despite this, there is a high rate of local recurrence, cervical nodal involvement and distant metastasis. Chemotherapy is currently considered only for end-stage, disseminated disease; however, current evidence indicates that chemotherapy used with radiotherapy may result in improved disease control and survival.Human epidermal growth factor receptor-2 is a proto-oncogene which is over-expressed in both breast ductal carcinoma and salivary duct carcinoma. Clinical studies of patients with metastatic breast cancer, using trastuzumab, a monoclonal antibody directed against human epidermal growth factor receptor-2, have shown significant efficacy in tumour response, resulting in improved survival. Such advances in immunohistochemistry, and in targeted immunotherapy for breast ductal carcinoma, should be applied to the treatment of salivary duct carcinoma.

Salivary duct carcinoma of parotid gland

A 40-year old male presented with rapidly growing swelling in the right parotid region. Based on the fine needle aspiration cytology report of adenocarcinoma not otherwise specified, superficial parotidectomy was performed, which showed the features of salivary duct carcinoma by histopathological examination. The smears were reviewed to identify the potential pitfalls in the cytological diagnosis of salivary duct carcinoma.

Salivary duct carcinoma metastatic to inguinal lymph node: A case report of salivary duct carcinoma with distant metastasis diagnosed by fine-needle aspiration

Salivary duct carcinoma (SDC) is a high-grade malignant tumor exhibiting aggressive growth with early regional and distant metastasis. We report a case of SDC in a 53-yr-old male with distant metastasis to an inguinal lymph node. The diagnosis of the primary tumor as well as the metastatic lesion was accomplished by fine-needle aspiration (FNA). Aggressive clinical management appears to be the main therapeutic option for long-term survival. Therefore, establishing an accurate preoperative diagnosis by FNA can have both clinical and prognostic relevance.

Salivary duct carcinoma with neuroendocrine features: Report of a case with cytological and immunohistochemical study

We report a salivary duct carcinoma (SDC) of parotid gland in a 75-year-old male. Initially, it was studied by fine-needle aspiration, which disclosed features of malignancy consistent with a high-grade carcinoma. Histologically, the tumor showed typical features of SDC, predominantly with a solid and apocrine pattern. The aggressive behavior of this tumor was documented by facial palsy and the presence of 12 regional lymph node metastases. Immunohistochemical study showed positivity for cytokeratins (AE1/AE3), cytokeratin 7, GCDFP-15, C-erbB-2, Mib-1, topoisomerase II alpha, p53, and androgen receptors. Diffuse positivity with chromogranin-A, synaptophysin, and Grimelius stains was also observed, suggesting endocrine features. Phosphotungstic acid hematoxylin, antimitochondrial antigen, progesterone and estrogen receptors, cytokeratin 20, and S-100 stains were negative. To our knowledge, this is the first case reported of SDC exhibiting neuroendocrine differentiation.

Salivary duct carcinoma: cytologic characteristics and application of androgen receptor immunostaining for diagnosis

BACKGROUND

Although there have been several reports of cytologic features for salivary duct carcinoma (SDC), it still can be difficult to diagnose patients with these tumor accurately at the time of fine-needle aspiration (FNA). Review of the literature indicates that, immunohistochemically, SDC expresses androgen receptor (AR) in the majority of patients. The authors investigated the cytologic characteristics and utility of AR immunostaining on cytologic smears for the diagnosis of patients with SDC.

METHODS

FNA and imprint smears from four patients with SDC were stained with Papanicolaou and periodic acid-Schiff (PAS). Immunostaining for AR on paraffin sections and imprint smears of SDC was performed, including 51 benign and other malignant salivary gland tumors.

RESULTS

The smears were cellular and contained three-dimensional clusters, flat sheets, and scattered epithelial cells with necrotic backgrounds. A cribriform architectural pattern was noted in many of the tumor sheets. The tumor cells were large polygonal, spindle, and round to oval, and had abundant, finely granular, or vacuolated cytoplasm. Intracytoplasmic vacuoles were PAS negative. The nuclei were hyperchromatic, medium to large in size, round to oval in shape, and often had prominent nucleoli. All SDC tumors expressed AR. Two patients with carcinoma in (pleomorphic adenoma) showed a focal, comedo carcinoma pattern in which AR positive nuclei were observed. Other salivary gland tumors were completely negative for AR.

CONCLUSIONS

The cytologic features of high-grade adenocarcinoma with a variety of cell morphologies, flat sheets of tumor cells with a cribriform pattern, and necrotic backgrounds are characteristic findings in patients with SDC. Immunostaining for AR on cytologic smears is useful for the diagnosis of these patients.

Carcinosarcoma of the parotid gland: cytological, clinicopathological and immunohistochemical study of a case

Manifesting a putative origin from a pleomorphic adenoma, carcinosarcoma of the salivary gland is a heterologous neoplasm in which a sarcomatous and a carcinomatous component coexist. We present a parotid gland carcinosarcoma in a 77-year-old man with peculiar morphological findings. Fine-needle aspiration cytology allowed a preoperative diagnosis of poorly differentiated carcinoma. At histologic examination, the tumor showed biphasic differentiation with an epithelial component made up of well-differentiated keratinizing squamous carcinoma and ductal-type adenocarcinoma, and a mesenchymal component, revealing focal areas of osteosarcoma and myoepithelial malignant proliferation. Carcinosarcoma is a very rare malignant neoplasm, accounting for 0.16% of malignant salivary gland tumors: only 60 cases have been reported, some of which arose "de novo", i.e., without clinico-pathologic evidence of a pre- or co-existing pleomorphic adenoma.