Warthin's tumour associated with autoimmune diseases and tobacco use

Pathogenesis of Warthin's Tumor: Neoplastic or Non-Neoplastic?

Warthin's tumor is the second most frequent neoplasm next to pleomorphic adenoma in the salivary gland, mostly in the parotid gland. The epithelial cells constituting a tumor are characterized by the presence of mitochondria that undergo structural and functional changes, resulting in the development of oncocytes. In addition to containing epithelial cells, Warthin's tumors contain abundant lymphocytes with lymph follicles (germinal centers) that are surrounded by epithelial cells. The pathogenesis of Warthin's tumor is not fully understood, and several hypotheses have been proposed. The risk factors for the development of Warthin's tumor, which predominantly occurs in males, include aging, smoking, and radiation exposure. Recently, it has been reported that chronic inflammation and aging cells promote the growth of Warthin's tumor. Several reports regarding the origin of the tumor have suggested that (1) Warthin's tumor is an IgG4-related disease, (2) epithelial cells that compose Warthin's tumor accumulate mitochondria, and (3) Warthin's tumor is a metaplastic lesion in the lymph nodes. It is possible that the pathogenesis of Warthin's tumor includes mitochondrial metabolic abnormalities, accumulation of aged cells, chronic inflammation, and senescence-associated secretory phenotype (SASP). In this short review, we propose that DNA damage, metabolic dysfunction of mitochondria, senescent cells, SASP, human papillomavirus, and IgG4 may be involved in the development of Warthin's tumor.

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.

A Case-Control Study of Risk Factors for Salivary Gland Cancer in Canada

Aim. To assess the effect of various lifestyle risk factors on the risk of salivary gland cancer in Canada using data from a population-based case-control study. Methods. Data from a population-based case-control study of 132 incident cases of salivary gland cancer and 3076 population controls were collected through self-administered questionnaire and analysed using unconditional logistic regression. Results. Four or more servings/week of processed meat product was associated with an adjusted odds ratio (OR) and corresponding 95% confidence interval (CI) of 1.62 (1.02–2.58). Nonsignificantly increased ORs were also related to obesity, >7 drinks/week of alcohol consumption, and occupational exposure to radiation. Furthermore, nonsignificantly decreased ORs were found to be associated with high education level (>12 years) (OR = 0.65), high consumption of spinach/squash (OR = 0.62) and all vegetables/vegetable juices (OR = 0.75), and >30 sessions/month of recreational physical activity (OR = 0.78). Conclusions. This study suggests positive associations with consumption of processed meat, smoking, obesity, alcohol drinking, and occupational exposure to radiation as well as negative associations with higher education, consumption of spinach/squash, and physical activity, which suggest a role of lifestyle factors in the etiology of salivary gland cancer. However, these findings were based on small number of cases and were nonsignificant. Further larger studies are warranted to confirm our findings.

Synchronous bilateral warthin tumors: a case report

Introduction Warthin tumor is described as papillary cystadenoma lymphomatosum and is the second most common tumor of the parotid glands. Bilateral synchronous incidence is rare, occurring in 7 to 10% of the cases. It is more common in males between 60 and 70 years of age and is closely related to smoking. There is slow growth and the condition is a delimited nodule of regular outlines; it has low rates of malignant progression and recurrence.

Objective Report a case of synchronous bilateral Warthin tumor occurring in an elderly patient, and review incidence and peculiarities of this tumor.

Case Report A 78-year-old man who used to smoke had a history of mild pain in the topography of right parotid three weeks ago. Patient with hypertension, diabetes and a longtime smoker (smoking a pack per day for 32 years) noticed a progressive bulging in the right parotid region for about 2.5 years ago, and noticed another progressive bulging (althought in the left parotid region), for about one year ago. Patient denied fever, redness, skin lesions and pain during this period until last three weeks, when he sought medical attention for a mild pain in the right facial region. The patient underwent cervical magnetic resonance imaging that showed tumor lesions in both parotids. Fine needle aspiration revealed a typical lesion of epithelial oxyphilic cells associated with reactive lymphoid proliferation, suggesting Warthin tumor. The patient underwent two superficial parotidectomies, and the histopathologic result from both tumors of parotid glands showed papillary cystadenoma lymphomatosum.

Conclusion The occurrence of synchronous bilateral Warthin tumor is extremely rare, and anamnesis and physical examination, as well as some complementary examinations, are important means for diagnostic evaluation. Confirmation of the diagnosis can only be obtained through a histopathologic study. A superficial or total parotidectomy is the recommended treatment for the disease.

Genetic polymorphisms in UDP-glucuronosyltransferase 1A6 and 1A7 and the risk for benign Warthin's tumors of the parotid gland

BACKGROUND

Warthin's tumors of the parotid gland are associated with smoking, whereas pleomorphic adenomas are not. Genetic polymorphisms in biotransformation enzymes, involved in detoxification of toxins and carcinogens in cigarette smoke, might modify the corresponding enzyme activity and influence detoxifying capacity. We hypothesize that these genetic polymorphisms may influence the individual risk for Warthin's tumor, but not for pleomorphic adenomas.

METHODS

Blood from 146 patients with benign parotid gland tumors and 437 controls were investigated for polymorphisms in several biotransformation enzymes. Based on these polymorphisms, patients and controls were divided according to predicted enzyme activity (low, intermediate, and high).

RESULTS

Prevalence of predicted intermediate and high activity UGT1A7 and UGT1A6 genotypes was significantly higher in the patients with Warthin's tumors, but not in patients with pleomorphic adenomas, compared with healthy controls.

CONCLUSION

Predicted intermediate and high activity UGT1A7 and UGT1A6 genotypes are associated with an increased risk for Warthin's tumor. © 2015 Wiley Periodicals, Inc. Head Neck 38: E717-E723, 2016.

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.

Oncocytic mania: a review of oncocytic lesions throughout the body

Oncocytic lesions are characterized pathologically by an abundance of oncocytes, that is by enlarged, eosinophilic, and finely granular cells enriched in mitochondria. They can arise in numerous organs and tissues, often in endocrine glands, and have been associated with hyperplasia, autoimmunity, and neoplasia. The causes and mechanisms that transform a normal cell into an oncocyte remain to be elucidated. Aim of this article is to review the most common oncocytic lesions, highlighting their key pathological features and clinical significance.

Using time-dependent covariate analysis to elucidate the relation of smoking history to Warthin's tumor risk

The authors aimed to elucidate the relation of the time-dependent smoking history parameters--age at smoking initiation and smoking intensity, duration, and latency--to the risk of Warthin's tumor, a benign tumor of the salivary gland for which cigarette smoking is a strong risk factor. They studied 117 cases of Warthin's tumor and 336 matched controls included in an Israeli nationwide case-control study of parotid gland tumors conducted from 2002 to 2003 by using the Cox regression model with time-dependent covariates, with age as the time axis. When current age and smoking duration were included in the statistical model, the authors show that the coefficient of a latency variable does not represent latency as such, but a balancing of the effects of age at initiation and time since cessation. They found a strong positive linear effect of duration of smoking, together with a positive nonlinear effect of intensity that levels off at higher intensities, and a negative effect of latency from 25 years onward. The latter finding implies that the effect of time since cessation dominates the effect of age at initiation, with risk decreasing sharply after smoking cessation. The relation of smoking variables to Warthin's tumor agrees with the patterns reported for lung cancer.

Smoking and risk of parotid gland tumors: a nationwide case-control study

BACKGROUND

Because existing data regarding the relation between smoking and salivary gland tumors are sparse, tobacco is currently not classified as a salivary gland carcinogen. The objective of the current study was to assess the association between smoking and benign and malignant parotid gland tumors (PGTs) in a nationwide study.

METHODS

The sample included 459 patients with incident PGT, aged > or =18 years, who were diagnosed between 2001 and 2003 and a group of 1265 individually matched, population-based controls. Analyses of the risk of PGT associated with various smoking variables were performed by using conditional logistic regression. Data also were stratified by histologic type; statistical significance tests were 2-sided.

RESULTS

Ever smoking cigarettes was associated with an odds ratio (OR) of 1.66 (95% confidence interval [95% CI], 1.31-2.11) for developing a PGT. The risk was strongest for early ages at smoking initiation, and trends of increasing risk were observed with increasing smoking intensity, pack-years, latent period, and smoking duration (P for trend <.001 for each). Analysis by histologic type indicated remarkably high risks for Warthin tumor (OR for ever cigarette smokers: 15.3; 95% CI, 6.1-38.5). For pleomorphic adenomas and malignant tumors, the risks associated with ever smoking were 1.01 (95% CI, 0.75-1.37) and 1.69 (95% CI, 0.81-3.51), respectively.

CONCLUSIONS

Smoking plays an important role in the development of Warthin tumor. Although no association was observed for pleomorphic adenoma, the possible indication of increased risk of malignant tumors requires further investigation in larger studies.

Clinical features of cystadenolymphoma (Warthin’s tumor) of the parotid gland: A retrospective comparative study of 96 cases

The details of the etiopathogenesis of cystadenolymphoma (Warthin's tumor) are still unclear. To explore the possible risk factors for the development of this tumor, medical records of 81 patients with 96 Warthin's tumors of the parotid glands were compared retrospectively with those of 91 patients with pleomorphic adenoma. The medical history and clinical tumor characteristics of all patients were similar. There were no significant differences between these two patient groups with respect to concomitant diseases, regular medications, and preoperative laboratory findings. However, a significant male predominance of patients with Warthin's tumor could be noted (P<0.05). The male to female ratio was 3.3:1 in patients with Warthin's tumor. Multifocal Warthin's tumor were detected in five cases (6.2%), and 10 patients (12.3%) had bilateral lesions. The odds ratio for the incidence of Warthin's tumor among current smokers compared with never smokers was 8.3 (P<0.0001). Compared with never smokers, clearly higher odds of Warthin's tumor was observed in heavy smokers (more than 30 pack-years) (odds ratio=24.1, P<0.0001) than patients who smoked less than 30 pack-years (odds ratio=4.9, P<0.0001).

Tissue that has lost its track: Warthin's tumour

The origin of cystadenolymphoma (Warthin's tumour) of the parotid gland is unknown. According to the most favoured hypothesis, Warthin's tumour results from the proliferation of salivary gland ductal cells that were entrapped in parotid lymph nodes during embryonal life. If this is correct, and the almost total lack of recurrence and malignant transformation of this lesion lends credence to this view, Warthin's tumour is correctly classified in the group of tumour-like lesions and should not be considered to be a monomorphic adenoma.

Warthin's tumour: a study of 78 cases with emphasis on bilaterality, multifocality and association with other malignancies

The authors reviewed the clinical records and the histopathological preparations of 78 cases of Warthin's tumours (WTs), treated at the Department of Dental Sciences, Centre for the Study of Oral Tumours, of the University of Bari. All the surgical specimens had been fixed in neutral buffered formalin, sampled according to the step-serial, whole-specimen sectioning technique, embedded in paraffin and stained with haematoxylin-eosin, periodic acid Schiff and Gomori's reticulin. The results showed that Warthin's tumours characteristically affect the parotid gland, and most frequently arise in adults (mean age=57 years) and in males (95%). Multiple tumours were detected in 16 cases (20.5%), and five of these were bilateral (6.5%). One of the multifocal tumours involved an intra-parotideal lymph node and the laryngeal piriform sinus. In addition, 13 cases (16.6%) were associated with other malignancies. These data indicate that multiple (synchronous or metachronous) WTs may occur more frequently than previously reported. The high rate of multiple WTs detected in the current study may result from extensive and accurate sampling of these neoplasms for histopathological evaluation. Consequently, complete preoperative work-up of patients harbouring parotideal tumours consistent with or suspicious for WT is necessary. The work-up should include CT scans and/or magnetic resonance imaging of both parotid glands, to exclude the occurrence of multiple tumours, which may be clinically undetectable. Also, fine needle aspiration biopsy may be an accurate tool for excluding malignant neoplasms and for better planning subsequent surgical procedures. These usually consist in (bilateral) superficial parotidectomy and should be followed by long term follow up of the patients, in view of possible metachronous WTs, even after prolonged time intervals.

Steroid hormone receptors in parotid gland cystadenolymphoma (Warthin's tumour)

The aetiopathogenesis of cystadenolymphoma is mostly unknown. Cystadenolymphomas have a significantly higher incidence in the male than the female population. This might be as a result of endocrine dependency in this kind of tumour. The purpose of the present study was to determine the sex hormone receptor status in cystadenolymphoma. Tissue samples of cystadenolymphoma, pleomorphic adenoma and normal samples of the parotid gland were examined immunohistochemically for oestrogen and progesterone receptors. Progesterone-positive cells could be found in the salivary duct system of normal glands and in the epithelial components of cystadenolymphomas. There was no evidence for the presence of oestrogen receptor in any sample studied. The evidence of progesterone receptors in cystadenolymphoma may implicate a potential role of endocrine factors in the development of this tumour.

Epidemiology of Warthin's tumour of the parotid gland in an Asian population

BACKGROUND

Recent studies have documented a number of changing demographic features in the occurrence of Warthin's tumour (adenolymphoma) of the parotid gland. In order to analyse its epidemiology in an Asian population, a retrospective study was performed on all parotid neoplasms (n = 289) operated on between 1988 and 1998.

PATIENTS AND METHODS

A total of 209 consecutive patients were selected for study, 136 with pleomorphic adenomas (one bilateral) and 73 with Warthin's tumours (seven bilateral). Patients were analysed with regard to tumour incidence, age, sex and race. Smoking as an aetiological factor in the development of Warthin's tumour was also studied.

RESULTS

Warthin's tumour formed 25 per cent of parotid tumours and its ratio to pleomorphic adenomas was 1 : 1.9. Multicentricity was found in 14 patients (19 per cent). The male : female ratio for Warthin's tumours was 4.6 : 1. The proportion of Warthin's tumours did not show any increasing trend relative to pleomorphic adenomas. The racial distribution of Warthin's tumours showed an increased incidence among Chinese and a reduced incidence among Malays and Indians. The adjusted odds ratio for sex and age favouring an association between smoking and Warthin's tumour was 39.5 (95 per cent confidence interval 10.5-149. 0; P < 0.0001).

CONCLUSION

The incidence of Warthin's tumour is considerable among Asians although there is still male predominance. There is no rising incidence of Warthin's tumour; the trend parallels the declining smoking rate in the population. The lower incidence among ethnic groups with dark skin seems to suggest concomitant genetic factors other than environmental factors alone in histogenesis. Smokers have a 40-fold greater risk than non-smokers of developing a Warthin's tumour.