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Table of Content - Volume 21 Issue 2 - February 2022


 

Cytological study of salivary gland lesions at tertiary care hospital, Rajkot

 

Vrutika Khunt1, Amit Agravat2*, Gauravi Dhruva3

 

1IIIrd Year Resident, 2Associate Professor, 3Professor & HOD, Department of Pathology, P.D.U Medical College, Rajkot-36001, INDIA.

Email: khuntvrutika29595@gmail.com

 

Abstract                                             Background: Fine-needle aspiration cytology (FNAC) is the first tissue-based procedure applied before any surgical intervention. A nodule or diffuse enlargement of the salivary glands may be caused by inflammation, cystic lesion, degenerative, or benign/malignant neoplasm. Salivary gland neoplasms account for 2%–6.5% of all the head and neck neoplasms. FNA renders specific diagnosis in the majority of cases, thus helps the surgeon to appropriately plan treatment. Aims and Objectives: To study the prevalence, age at the occurrence and sex ratio among the patient with salivary gland lesions. Materials and Methods: This was a prospective study over a period of 1 year (from January2020 to December 2020) comprising 161 patients with salivary gland lesions who underwent FNAC in our Department. The clinical data pertaining to patients' age, sex and anatomical site were recorded and consent was taken before the procedure. The air-dried and ethanol fixed smears were stained with May Grunwald's Giemsa, Papanicolaou and Hematoxylin -Eosin respectively. Results and Conclusions: In the present study, out of 161 cases are taken, majority were males 110 cases (67%). 84 (52%) were diagnosed non-neoplastic, 58(36%) benign, while 19(12%) malignant. Pleomorphic adenoma was the most common benign tumor and mucoepidermoid carcinoma was the most common malignant tumor. FNAC is a reliable tool in distinguishing benign and malignant salivary gland lesions and helps the surgeon to appropriately plan treatment.

Keywords: Cytology, Salivary Gland, Diagnosis.

 

INTRODUCTION

FNAC is a well-known safe diagnostic procedure. It has been used for the investigation of various organs for many years. FNAC is very useful as early diagnosis, treatment and management of the patient. In recent years it is so much popular – those clinicians and pathologists prefer it due to its simplicity, rapidity, safety, low cost, relatively good accuracy and effectiveness. Wide applicability of FNAC during recent years has reduced unnecessary ‘surgical procedure and traumatic biopsy.’ Salivary glands neoplasms are characterized by their wide variety as well as histologic diversity within same tumor. Standard FNA technique is suitable and applicable not only for the parotid and submandibular glands but also for the sublingual and minor salivary glands. It is very useful for distinguishing between salivary and other non salivary pathology.2 Although salivary glands tumor accounts for 2-6.5% of all head and neck tumor, their superficial location, easy accessibility and high diagnostic accuracy makes FNAC a popular method for evaluating salivary glands lesions.3

 

MATERIALS AND METHODS

The present study was carried out at the Cytopathology Laboratory, Civil Hospital, Rajkot during the period of January 2020 to December 2020. All the patients with suspected of salivary glands lesions were investigated with fine needle aspiration cytology.

METHODS: Written consent was taken before the procedure. The clinical data pertaining to patients' age, sex and anatomical site detailed clinical history were recorded and doing detailed physical examination.

FNAC procedure: Aspiration was done with standard precautions using 22-gauge needle. Smears were immediately fixed in 95% alcohol. Four to five smears of each case were stained with Hematoxylin and eosin stain (HandE) and May Graunwald Geimsa (MGG). MGG, air dried smears were used. Cytopathological diagnosis had been recorded in each case.

 

RESULTS

The present study of 161 patients was carried out at Cytopathology laboratory, Department of Pathology, PDU Medical College, Rajkot during the period of January 2020 to December 2020. All the 161 aspiration cytology smears were stained by HandE Stain and Geimsa Stain.

 

Table 1: Distribution of various Salivary glands lesions by FNAC

Salivary glands lesions

No. of cases (%)

Inflammatory

84(52%)

Benign

58(36%)

Malignant

19(12%)

Total

161(100%)

Table 1 shows the distribution of various salivary glands lesions consisting of benign lesions, inflammatory lesions and malignant lesions.

 

Graph 1: Location of salivary glands lesions

Graph 1 shows most common site of involvement of salivary glands lesions was parotid gland (55%), followed by submandibular gland 40%. Sublingual glands show 2.5% of all lesions. In minor salivary glands 2.5% cases were seen.


 

Table 2: Various salivary glands lesions

Diagnosis

Total

Percentages (%)

Acute siladenitis

9

6

Chronic Siladenitis

47

29

Acute on Chronic Siladenitis

17

11

Cystic Salivary Lesion

7

4

Warthin Tumor

19

12

Pleomorphic Adenoma

39

24

Koch’s Parotitis

4

2.5

Carcinoma ex Pleomorphic Adenoma

2

1.24

Adenocarcinoma Salivary Gland

1

0.6

Adenoid Cystic Carcinoma

4

2.5

Metastatic Carcinoma

2

1.24

Mucoepidermoid Carcinoma

7

4

Acinic Cell Carcinoma

1

0.6

Non Hodgkin Lymphoma

2

1.24

Total

161

100

Table 2 shows benign lesions were common than malignant lesions. Among the benign lesions, Pleomorphic adenoma was the most common tumor (24%), followed by Warthin tumor (12%) in present study. Among malignant lesions Mucoepidermoid carcinoma was most common (4%) and Adeoid cystic carcinoma was second most malignant lesions (2.5%).

Table 3: Age-wise distribution of salivary gland lesion

Age in years

Inflammatory Lesions

Benign Lesions

Malignant Lesions

Total

1-10

5

0

0

5

11-20

8

4

0

12

21-30

18

12

0

30

31-40

19

10

3

32

41-50

11

17

5

33

51-60

11

9

6

26

61-70

10

6

4

20

71-80

2

0

1

3

Total

84

58

19

161

Table 3 Most of the cases were presented between the 5th and 6th decades of life. Benign lesions were common during the 4th decades of life while inflammatory were more common during the 3nd decades of life. Malignant tumors were encountered in the 5th decades of life.

Graph 2: Incidence of salivary glands lesions according to sex distribution

 

Table 4: Sex incidence of various salivary glands Lesions

Diagnosis

Female

Male

Total

Acute siladenitis

6

3

9

Chronic Siladenitis

11

36

47

Acute on Chronic Siladenitis

6

11

17

Cystic Salivary Lesion

2

5

7

Warthin Tumor

0

19

19

Pleomorphic Adenoma

14

25

39

Koch’s Parotitis

2

2

4

Carcinoma ex Pleomorphic Adenoma

0

2

2

Adenocarcinoma Salivary Gland

1

0

1

Adenoid Cystic Carcinoma

2

2

4

Metastatic Carcinoma

1

1

2

Mucoepidermoid Carcinoma

5

2

7

Acinic Cell Carcinoma

0

1

1

Non Hodgkin Lymphoma

1

1

2

TOTAL

51

110

161

 

        Figure 1                                                    Figure 2

          Figure 3                                                 Figure 4

Figure 1: Pleomorphic adenoma. Poorly cohesive epithelial like cells associated with fibromyxoid stroma (HandE 40X); Figure 2: Mucoepidermoid carcinoma. Moderately cellular smear of scattered intermediate cells resembling squamous metaplasia. (HandE40X); Figure 3: Adenoid cystic carcinoma. Small uniform epithelial cells with hyperchromatic nuclei with hyperchromatic nuclei and coarse chromatin, dispersed and adhering to a large, hyaline stromal globule. (HandE40X); Figure 4: Acinic cell carcinoma. Cells mainly in clusters and micro acinar groupings with rounded, medium-sized nuclei, abundant, fragile, oncocyte-like cytoplasm. (HandE40X)

 


DISCUSSION

In the present study, it was observed that the frequency of salivary glands lesions was highest during 5th decades of life. The mean age of patients was around 48 years. Non-neoplastic (52%) lesions were more reported then neoplastic lesions (48%). Most of the cases were presented between the 5th and 6th decades of life. Benign lesions were more common during the 4th decades of life while inflammatory were more common during the 3nd decades of life. Malignant tumors were encountered in the 5th decades of life. In present study male predominance was seen with M: F ratio was 1.7: 1, as in the study conducted by Das DK et al. with M: F ratio was 1.28:1 and Lukas J. et al. with M: F ratio was 1.06:1, but unlike other studies were female predominance were noticed. Mainly aspiration were done from parotid glands (55%) followed by submandibular glands (40%). Most of the other workers have also observed high incidence of parotid gland lesions. For present study 58 benign tumors and 19 malignant tumors of salivary gland were aspirated and observed. The most common benign neoplasm was Pleomorphic adenoma, which were comparable with Stewart CJR et al., Jesus Sousa at el, Sudarat Nguansangiam. 15 cases of pleomorphic adenoma exhibiting squamous cell metaplasia and 22 cases with plasmacytoid differentiation and two case which had hyaline globule in addition to chondromyxoid stroma. Warthin tumor were second most common benign neoplasm. Affecting only males. The similar results were obtained by Stewart CJR et al., Jesus Sousa at el, Sudarat Nguansangiam. Oncocytes, lymphocytes and dirty fluid background are three main components that characterize the cytological smears of Warthin's tumor. Warthin’s tumors differential diagnosis are lymphoepithelial cysts of salivary gland, chronic inflammatory and obstructive duct lesions exhibiting oncocytic metaplasia and lymphocytes. Its needs to be differentiated from oncocytoma which has oncocytes and variable number of lymphocytes however cells clusters in oncocytoma are bigger and three dimensional.  Mucoepidermoid carcinoma were most common malignant neoplasm in our study which were comparable with Stewart CJR et al. Jesus Sousa at el Sudarat Nguansangiam Akhter J. Presence of mucus producing cells and intermediate cells were shown from MEC of cytological smears. The cells exhibit varying degree of atypia according to which the tumor is categorized as low, intermediate and high grade. Low-grade tumor accounts for 80% of all MECs and is characterized by cystic growth pattern. The aspiration of low-grade MEC usually yields mucoid fluid and smears are typically hypocellular having bland cytologic features. A low-grade tumor has to be differentiated from Warthin’s tumor, benign salivary gland cyst, branchial cleft cyst, sialolithiasis and pleomorphic adenoma with excess of mucoid stroma. An extensive search for mucus producing goblet cells is required in these cases. Adenoid cystic carcinoma were second most common malignant neoplasm in our study which is comparable with other studies, except in Souza Lima S et al. The aspirates from adenoid cystic carcinoma usually had two components: epithelial cells and acellular basement membrane material seen as homogenous spherical structure. The hyaline globules are not unique for adenoid cystic carcinoma, it may be found in cases of polymorphous low-grade adenocarcinoma, basal cell adenomas, and pleomorphic adenoma and even in epithelial-myoepithelial carcinoma and basal cell adenocarcinoma.

 We reported two cases of metastatic deposits from larynx in our analysis. Nguansangiam et al. reported 2.2% salivary gland aspirates as metastasis. It is important to differentiate a primary neoplasm from a secondary malignant neoplasm to avoid unnecessary surgery and to guide subsequent radiotherapy and chemotherapy. Two case of lymphoma was diagnosed in our work. Das et al. reported almost similar incidence of 3.5% salivary gland aspirates as lymphoma. In the current work, nonneoplastic lesions constituted 52% of adequate salivary gland aspirates as shown in a studies conducted by Singh Nanda et al. and Rajwanshi et al. revealed the presence of nonneoplastic lesions as 55.9% and 66.8%, respectively. Chronic sialadenitis was seen in 29% followed by acute on chronic sialadenitis in 11%, acute sialadenitis in 6% and tuberculosis in 2.5% in the present analysis. Similar results were obtained by Singh Nanda et al., s. Gupta et al.25 Quoted that out of 74 patients of salivary gland aspirates 57.4% had chronic sialadenitis, 12.7% had acute sialadenitis and 2% had granulomatous sialadenitis and 1.8% presented with sialadenosis. A higher incidence was seen in males that was seen in study conducted by Gupta et al. 25 The age range for nonneoplastic lesions was from 7 to 80 years. The parotid gland was most commonly involved followed by submandibular and minor salivary glands. The cytological smears of chronic sialadenitis comprised clusters of ductal epithelial cells along with the presence of lymphomononuclear cells in the background. The cases diagnosed as acute sialadenitis showed numerous polymorphonuclear neutrophils and cell debris. The four cases were reported as tuberculosis of major salivary gland, which on microscopic examination showed the presence of epitheloid cell granuloma and exhibited acid-fast bacilli on ZN staining.

 

CONCLUSION

Along with clinical examination and other non-invasive investigations FNAC has an immense significance in detecting and differentiation salivary glands lesions. FNAC is a very useful, time saving procedure, which have a great relevance to our patients who often come to institutes from remote places. It is cost effective process. It cuts down the waiting period between the patient’s first visit to the clinicians and establishment of definite diagnosis and specific line of therapy. FNAC is highly accurate in the diagnosis of neoplastic lesions as well as non-neoplastic lesions. By that it is proved that FNAC is a primary and most effective screening test for the salivary glands lesions. Present study included aspiration and observation of 58 benign tumors and 19 malignant tumors of salivary gland. The study’s conclusion findings were that salivary glands lesions frequency were higher in people who were in 5th decade of their lives with average age of patient being 47.8 years. Benign lesions were more common during the 4th decades of life while inflammatory were more common during the 3nd decades of life. Malignant tumors were encountered in the 5th decades of life. The study also concludes that Non-neoplastic (52%) lesions were more reported then neoplastic lesions (48%). Also worth noting was that male predominance was higher with M:F ratio being 1.7: 1. 55% of aspiration were mainly done from parotid glands and 40% were done by submandibular glands.

 

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