Salivary Glands tumors. Pr Cécile Badoual Service Pr Cécile d anatomo-pathologie Hôpital HEGP, Européen Paris G Pompidou

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1 Salivary Glands tumors Pr Cécile Badoual Service Pr Cécile d anatomo-pathologie Badoual Hôpital HEGP, Européen Paris G Pompidou

2 Tumours of the salivary glands Huge number of histological subtype : OMS classification 2017 contains 11 subtypes of benign lesion and 19 subtypes of carcinomas. 2/3 are benign 1/3 are malignant. Salivary glands carcinoma are rare and represent a range of 3 to 5 % of the head and neck carcinoma, with a incidence <1/ habitants. Peak incidence at years, and a mean around 45 years. Female predominance. Carcinoma generally classified in 3 groups : low grade, intermediate grade and high grade of malignancy.

3 Tumours of the salivary glands The etiology of salivary gland neoplasms remains unknown. Growing evidence that certain environmental factors such as radiation, viruses, diet could be envolved Certain occupational exposures may increase the risk of developing tumors of the salivary glands. Specific genetic abnormalities have recently been well characterized. Su YX, Ann Surg Oncol. 2015; Spiro RH. Head Neck Surg. 1986; Who classification 2005

4 Tumours of the salivary glands HPV infection role still debated Epstein-Barr virus (EBV) associated with lymphoepithelial carcinoma of the salivary gland in the Asian population. No evidence of a causal role of EBV in other primary salivary gland neoplasms. No positive signal by in situ hybridization for EBV RNA in 42 benign salivary gland neoplasms. Other viruses including human herpesvirus-8, and cytomegalovirus do not appear to have any etiologic role in salivary gland neoplasms. Hühns M, Biomed Res Int. 2015; Veit JA, Anticancer Res. 2015; Pollock AM, J Laryngol Otol. 1999

5 What s up? Clinical strategy for diagnosis WHO classification. New one? Molecular/genetics and histochemical findings Salivary glands tumor and chilwood Place of new therapeutics

6 Methods to detect a salivary gland lesion Ponction with needle Frozen section Definitive histology The radiologists can give a diffusion and perfusion coefficient to help the diagnosis

7 Frozen section Methods Frozen tissue quick staining Answer in less than 10 minutes Problems Orientation diagnose Alteration of the tissue sample examination Indications Control of one of the surgical border Guidance of the surgery Modification of the surgery

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9 Fine needle aspiration Useful for small tumors First orientation for the diagnosis Expert ++

10 Fine needle aspiration cytology and frozen section in the diagnosis of malignant parotid tumours? Evaluation of frozen section diagnosis in 721 parotid gland lesions Badoual C, Histopathology 2006

11 Fine needle aspiration cytology and frozen section in the diagnosis of malignant parotid tumours? Badoual C, Evaluation of frozen section diagnosis in 721 parotid gland lesions. Histopathology 2006 Fakhary N, J Oral Maxillofac Surg (138 tumors)

12 Macroscopy

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14 07h3226 parotid

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18 Immunohistological profile cytokératin Smooth muscle actin Caldesmon/ calponin S100 Epithelial cells Myoepithelial cells Ki67, cerb2, ckit (ADK), ER, PR, AR (ductal carcinoma) CK19 (acinic), Dog-1(acinic), mammaglobin (secretory carcinoma)

19 CK7/CAM5.2 (+/-) Acinar cells Vimentin (+/-) CK7/CAM5.2 CK7/CAM5.2 CK7/CAM5.2 Claponin/SMA/myosin, CK7/CAM5.2, P63,S100, vimentin

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21 Cases 2C and 2L

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25 Pleomorphic adenoma Clinical characteristics Most frequent benign tumor, 80% over benign lesions Mean age 45 yo. Slow development Childhood, 5-15 yo. During childhood boys >girls conversely adult age. Incidence 2,4 to 3,5 for Main salivary glands and all the others glands like palate, lachrymal, laryngeal, bronchus.

26 Pleomorphic adenoma Clinical features and macroscopy : Parotid: under skin well circumscribed mass, mobile, painless, no facial nerve weakness or dysesthesia. round or oval shape, surrounded by a capsule. others sites: not well delimited, no capsule. Surface light tan to grey. Cystic changes can been seen. Haemorrhage and infarction can been seen.

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28 Pleomorphic adenoma Histological description: Typically, two types of tumor cells Epithelial cells, tubes, glands, isolated, mucinous, sebaceous or oncocytic metaplasia Myoepithelial spindle cells, epithelioïd, clear cells, plasmocytoïd. Atypias mostly for hypercellular adenoma. Foci of squamous metaplasia secondary to ischemic necrosis General architecture, mixture of different aspects avec with solid nests, tubes but also epithelialmyoepithelial or pseudo cylindromatous.

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33 Pseudo cylindromatous shape

34 Epithelial-myoepithelial

35 Pleomorphic adenoma Histological feature: Mostly abondant stroma, chondroïd, myxoïd, osteoïd, adipocyte like, even fibrous. Not abondant, if hypercellular adenoma. Calcifications and cristalloïds rich in tyrosine. Rarely, adipocytes with stroma adipocytic metaplasia. Vascular emboli, capsular effractions, are not necessary associated with malignant transformation.

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37 squamous metaplasia Tyrosine cristalloïd Adipocytic metaplasia

38 CD34

39 Pleomorphic adenoma Immunohisstochemistry Molecular biology 70% : chromosomic aberrations : 8q12 rearrangement (targeted gene PLAG1), rearrangement 12q13-15 (targeted gene HMGA2) coding for chromatine protein. Not well circonscribed pleomorphic adenomas and well delimited adenoid cystic carcinomas! Minor salivary glands biopsies ( no interface between tumor tissu /sane tissu ) Cytological Ponctions

40 Nasale cavity

41 Nasal cavity

42 AE1/AE3 S100

43 inferior lip

44 Inferior lip GEPSO External auditory canal

45 Pleomorphic adenoma Histological description: Typically, two types of tumor cells Epithelial cells, tubes, glands, isolated or in. Mucinous, sebaceous or oncocytic metaplasia Myoepithelial spindle cells, epithelioïd, clear cells, plasmocytoïd. Atypies surtout si adénome hypercellulaire. Zones de métaplasie malpighienne. Foyers de nécrose ischémique à l origine. L architecture générale, mélange d aspect divers et variés, avec des massifs, des tubes mais aussi des aspects épithélio-myoépithéliaux ou pseudo cylindromateux.

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50 Architecture pseudo cylindromateuse

51 Architecture épithéliale-myoépithéliale

52 Adénome pléomorphe Aspects histologiques : Stroma le plus souvent abondant, chondroïde, myxoïde, ostéoïde, adipocyte like, fibreux, voire squirreux. Peu abondant, si adénome hypercellulaire. Calcifications et cristalloïdes riches de tyrosine. Plus rarement, adipocytes avec métaplasie lipomateuse du stroma. Des emboles vasculaires, ainsi que effractions de capsule, ne préjugent pas nécessairement d une transformation maligne.

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54 Métaplasie malpighienne Cristalloïdes riches en tyrosine Métaplasie adipocytaire

55 CD34

56 Pleomorphic adenoma Immunohisstochemistry Molecular biology 70% : chromosomic aberrations : 8q12 rearrangement (targeted gene PLAG1), rearrangement 12q13-15 (targeted gene HMGA2) coding for chromatine protein. Not well circonscribed pleomorphic adenomas and well delimited adenoid cystic carcinomas! Minor salivary glands biopsies ( no interface between tumor tissu /sane tissu ) Cytological Ponctions

57 Cloison nasale

58 Fosse nasale

59 AE1/AE3 S100

60 inferior lip

61 Inferior lip GEPSO External auditory canal

62 Pleomorphic adenoma Evolution : The two major risks are recurrences or transformation Frequent recurrences. Multiple nodules and of very variable size. Complete surgical excision, if this is possible. Radiation therapy may be offered. Increased volume, appearance of pain, facial paralysis, will lead to a diagnosis of malignancy. Notion of metastatic pleomorphic adenoma discussed

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67 Biopsie de rein

68 PLAG1 (1) gene fusions involving the PLAG1 and HMGA2 oncogenes are specific for benign pleomorphic adenomas. PLAG1 encodes a developmentally regulated DNAbinding zinc finger protein that is part of a family of cell cycle progression-related proteins. Rearrangement of PLAG1 in aproximatively 50 % of the pleomorphic adenomas Prognosis++

69 Usefulness of MYB/PLAG Not well circonscribed pleomorphic adenoma / well delimited adenoid cystic carcinoma! PLAG1 persistant after a transformation of a pleomorphic adenoma Fine needle aspiration Prognostic implication

70 A translocation-generated network of oncogenic gene fusions in salivary gland tumors. The multiple translocation target genes MYB,HMGA2, and PLAG1 are indicated in red. ACC adenoid cystic carcinoma, MEC mucoepidermoid carcinoma, HCCC hyalinizing clear Stenman G, Head Neck Pathol. 2013

71 Cases 2D and 2D.. Woman19 yo parotid lesions since the childhood with recent increase of the volume

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80 Pleomorphic adenoma Evolution : Pleomorphous ex-adenoma carcinoma: pleomorphic adenoma with transformed tumor zones. Aggressiveness: infiltration of the capsule, of the glandular parenchyma, adipocytic tissue or peri-nervous sheaths + cytological criteria Most often high-grade (ductal) carcinoma but, all histological types of carcinomas described. The tumor type and grade of the carcinomatous contingent must be specified because they also participate in the evaluation of the prognosis.

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89 pleomorphic ex-adenoma carcinomas Capsular invasion determinant for the prognosis Clearly proved that according to the extensions pleomorphic ex-adenoma carcinomas have a totally different prognosis: New 2017 WHO classification Strictly enclosed excellent prognosis almost comparable to the pleomorphic adenoma one. Capsular invasion, minimal invasion (invasion outside the capsule <4-6 mm) more favorable prognosis, Invasion out of the capsule> 4-6 mm, prognosis more reserved. Massively invasive> 8 mm prognosis consistently pejorative

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91 Cas 2A Woman lesion superficial lobule of the left parotid since 2 ans

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96 Basal cell adenoma (tubulo-trabecular) Morphologically monotonic proliferation of small basaloid cells with occasional inner ductal epithelial cells forming nests and cords From a phenotypic point of view these cells are of essentially basal type (P63) but also show myoepithelial (AML) and luminal (ACE) differentiation. 6% of benign tumors of the salivary glands Sixth decade Parotid 80%> oral mucosa> under maxillary Firm tumor well limited usually <3 cm

97 Histopathology Tumour mixture of solid, tubular, trabecular and membranous patterns Basaloïd cells with scant cytoplasm, indistinct cell borders, and round to oval nuclei and may show peripheral palissading Pas d implication clinique sauf pour le type membraneux (recurrence 25%) Transformation in basal cell adenocarcinoma rare but can occur Often multi-nodular.so recurrence are likely to be more frequente

98 Small cells with pale cytoplasm P63 +, Pancytokeratin + More or less basophilic nuclei according to tumors interface with the stroma: palisade arrangement of the nuclei Squamous differenciation

99 Solid subtype: Nest with varyious size and shape Scarce stroma (never chondromatous nor myxoid) Palisadic arrangement

100 Tubular and trabecular pattern

101 Membranous basal cells adenoma Membranous mostly associated with recurrent and is sometimes associated with skin tumors

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103 Basal cells adenocarcinoma? Rare ++, yo Same distribution as adenoma: parotid Diagnosis especially because of infiltration and invasion Beware of the often multinodular membranous adenoma) Atypia, inconstant mitosis Low grade lesion: 37% recurrence and lymph node metastasis 8%, distant metastases 4%

104 Cases 2B

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108 Canalicular adenoma Benign tumor composed of monomorphous epithelial ductal cells Well delineated and lobulated Correlation with basal cell adenomas? Special clinical behaviour: upper lip in almost 80% of cases from phenotypic point of view pure epithelial tumor: no positive myoepithelial AML contingent

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110 Cases 2E Man 46 yo parotid lesion since 8 months, retracted skin

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112 07H3126 parotid

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116 Mucoepidermoid Carcinoma (MEC) Localisation : parotid et minor salivary glands Histology : 3 types of cells mostly assembled in nest: mucus producing, squamoid and intermediate cells. Differential diagnosis : pleomorphic adenoma, acinic carcinoma, myoepithelial carcinoma, metastases of renal cell carcinoma Prognosis : uncertain, with recurrence of 25% and 10% of metastasis Molecular genetics: t(11;19) fusion gene MECT1-MAML2 for 60-70% MEC. Inactivation pathway Notch, favorable outcome Evolution : slow (recurrence after 7 to 10 years)

117 Mucoepidermoid Carcinoma (CME) Grading (OMS 2005) Aspect histologique Score Cystic component < 20% 2 Neural invasion 2 Necrosis 3 4 mitoses or more /10 hpf 3 Anaplasia 4 Grade Low 0-4 Intermediate 5-6 High > No OMS 2005 grading

118 Mucoepidermoid Carcinoma (MEC) - CME low grade : Cystic, mucinous cell-rich and well circonscribe -CME intermediate grade :More solid and less circonscribe, diversity of appearances including mucin extravasation - CME high grade : One or more of the features : nuclear anaplasia, necrosis, increased mitotic rate, and perineural, lymphovascular and bony invasion -

119 MECT1-MAML2 translocation associated with favorable prognosis MECT1: CREB mediated transcription MAML2:mastermind-like gene family: voie Notch normal FISH MAML2 «split» Behboudi and coll. (Cancer 2006) Translocation MECT1- MAML2 No translocation Survival mean > 10 years 1,6 years Mean age 48 years 76 years apparition Tumor size 1 3 Tumor grade low and intermediate grade High and intermediate grade High grade associated with low survival CDKN2A methylation or deletion Sethala Am J Surg Pathol 2010

120 A translocation-generated network of oncogenic gene fusions in salivary gland tumors. The multiple translocation target genes MYB,HMGA2, and PLAG1 are indicated in red. ACC adenoid cystic carcinoma, MEC mucoepidermoid carcinoma, HCCC hyalinizing clear Stenman G, Head Neck Pathol. 2013

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124 Low grade mucoepidermoid carcinoma

125 intermediate grade mucoepidermoid carcinoma

126 High grade mucoepidermoid carcinoma

127 Alcian Blue PAS

128 CK5/6 CK5/6 Cerb2 P63 CK7

129 Cases 2M woman 63 yo painless parotid lesion

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133 Oncocytic mucoepidermoïd carcinoma MEC very close the oncocytoma features Infiltration and mucinous cells

134 KI67

135 Oncocytoma Benign tumor proliferation consitued exclusively of oncocytic cells Parotid 95% > 70 years Single nodule, well limited, +/- encapsulated, red brown, from 1 to 7 cm Single nodule, well limited, +/- encapsulated, red brown, from 1 to 7 cm Sometimes, main nodule in a multinodular context

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138 Case 2F

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142 (ex cylindrome in french) Frequently painful Adenoid cystic carcinoma Localisation : parotid, submandibular gland, minor salivary glands (palate, tongue, lip, lachrymal glands, lip, buccal mucosa..) Microscopy: well circumscribed but not encapsulated, invariably infiltrative Histopathology : Two main cell types : epithelial and myoepithelial. No atypia. Rare mitosis. Perineural invasion+++. Stroma hyalinized or myxoid Diagnostic différentiel : adenocarcinoma, pleomporphic adenoma, basal cell adenoma, basal cell adenocarcinoma

143 Adenoid cystic carcinoma - patterns 3 mains patterns Tubular well formed ducts and tubules. Inner epithelial cells and outer myoepithelial Cribriform, most frequent nests of cells with cylindromatous microcystic spaces. Solid or basaloid type sheets of uniform basaloid cells Tumors can be composite or present a predominant pattern.

144 Adenoid cystic carcinoma Prognostic: influenced by numerous clinical considerations (size, localisation, pattern..), slow evolution, Recurrences after 7-8 years. Late mestastases. No official grading but some authors propose : - grade 1 : Tubular or cribriform pattern - grade 2 : less than 30%solid pattern - grade 3 : solid predominant pattern Szanto PA Cancer 1984 No grade in the 2017 WHO classification

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148 PAS CK7 AML S100 SMA

149 Ckit RO REGF RP

150 Molecular biology of the acinic carcinoma Translocation between Chromosomes 6q and 9q with the creation of a MYB-NFIB chimeric fusion in about 50% cases

151 Wysocki PT Oncotarget 2016

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153 A translocation-generated network of oncogenic gene fusions in salivary gland tumors. The multiple translocation target genes MYB,HMGA2, and PLAG1 are indicated in red. ACC adenoid cystic carcinoma, MEC mucoepidermoid carcinoma, HCCC hyalinizing clear Stenman G, Head Neck Pathol. 2013

154 Conclusion interesting +++ for mucoepidermoid carcinomas: diagnosis (difficult variants, fine needle biopsies) prognosis (intermediate grades) Differential diagnosis :pleomorphic adenomas and adenoid cystic carcinomas +++ Help to define malignancy

155 Cases 2G Man 47 yo parotid lesion

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158 Cases 2N woman 63 yo smoker oral cavity

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162 Epithelial-myoepithelial carcinoma (clear cell adenoma, cell clear ductal adenocarcinoma= Parotid ++ (80%) Macroscopy: usually plurinodular with incomplete capsule. Often necrosis Histology: double cellular population layering numerous glandular formations - epithelial: internal (cytokeratin +) - myoepithelial: external (S100 +, AML)

163 Epithelial-myoepithelial carcinoma (clear cell adenoma, cell clear ductal adenocarcinoma= Differential diagnosis: acinic cell carcinoma, mucoepidermoid carcinoma, sebaceous carcinoma, metastasis of renal clear cell carcinoma Prognosis: low grade of malignancy, recurrence, rare metastases

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174 Acinic cell carcinoma 6 % of the salivary glands tumor and 5-15 % among malignant salivary glands tumor. Most often in parotid Histology :large, polygonal cells, few atypia. Cytoplasm contain granules (PAS-diastase+) vacuolated cells contain clear cytoplasm with vacuoles numerous pattern (acinar, ductal, inflammatory infiltration) Hyalinization associated with a bad prognosis Rarely mimic thyroid pattern

175 4 different cells Vacuolated Clear Oncocytic Hobnail 3 different patterns: Microcystic Solid Follicular Acinic cell carcinoma Prognosis: dependant on the size, the surgery. No grading Recurrence in 25% cases but metastasis are rare (10%).

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181 Dog1 and SOX10: cellules acinic cell apical staining and cells coming from the intercalar duct Head Neck Pathol Dec;10(4):

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184 Case 2I

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189 Secretory carcinoma (MASC) Recently described, rare salivary gland tumor that relates the morphology and genetics of an equally rare malignancy of the breast, secretory carcinoma (SC) Previously classified as acinic cell carcinoma ("zymogen poor", intercalated cell predominant variant), mucoepidermoid carcinoma and adenocarcinoma, NOS Specific cytogenetic characteristic: t(12; 15)(q13;q25): ETV6-NTRK3 translocation, demonstrated by either FISH or PCR

190 Secretory carcinoma (MASC) Typically it is a disease of young male patients but occurs in a wide age range (21-75), with a mean of 46 years Pediatric cases have been Sex ration :1 Parotid gland (up to 70%); lips, hard palate, submandibular glands. More frequent in nonparotid sites compared to acinic cell carcinoma

191 Secretory carcinoma (MASC) Overall slowly growing, painless tumor, occasional extracapsular extension and perineural invasion Infrequent local recurrences Rare metastatic dissemination to cervical lymph nodes, pleura, pericardium and lungs Broad range of clinical behaviours, from indolent to aggressive Currently there is no way to predict which tumours will behave aggressively Higher incidence of regional lymph node involvement than acinic cell carcinomas Treatment Local excision, radiation therapy in select cases Molecular targeted gene therapy currently investigated

192 Secretory carcinoma (MASC) Gross description Most frequently solitary, well circumscribed, nonencapsulated or multinodular mass Brown or gray in color and rubbery in texture Variable sizes, from 0.2 cm to 5.5 cm Histologic)description Prominent "bubbly" low power aspect Cystic, tubular, solid or papillary architecture Intermediate size cells with eosinophilic / amphophilic vacuolated cytoplasm; absence of zymogen granules Low grade, bland and pale nuclei, some with prominent nucleoli Intraluminal or intracellular colloid-like material with a "bubbly" appearance May have mucinous differentiation May have perineural invasion No extensive necrosis and very low mitotic activity Unusual feature: foci of high grade / dedifferentiation with large nests and comedonecrosis

193 Lame 32: tumeur de la parotide, femme de 42 ans

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195 Lame 32

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200 Lame 34

201 Case 2J

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209 Polymorphous adenocarcinoma Oral cavity ++, (26% of carcinomas of the oral cavity) Macroscopy: firm mass, fairly well limited, unencapsulated, yellowish, multi-lobed, nodules of different size (mean size = 2.1 cm) Histology: ++ Feature: cellular -monomorphism: (small to medium cells) architectural polymorphism, - infiltrating cells, (lobules, islets, columns) in adjacent tissue or salivary parenchyma

210 Immunohistochemistry: CK7+, ps100+,bcl2+, Mammaglobin+, p63+, p40-, DOG1+/-. Pronostic : low grade of malignancy, but recurrent, rare metastases

211 CATS : Cribriform Adenocarcinoma of the Tongue and other minor Salivary glands posterior third of the tongue Synchronous local node metastases: 70% of cases. No distant metastasis excellent prognosis. average age 54 years (5 to 85 years)

212 One other new entity? Tongue Cytology very close the papillary carcinoma of the thyroid (thyroglobulin and TTF1-) lymph node metastases +++ gene Fusion PRKD1, 2 ou 3

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218 Salivary duct carcinoma Aggressiveness ++ High level of malignancy 9% of the salivary glands tumor 4M /1F Parotid, submandibular, minor salivary gland Similar to intraductal and infiltrating mammary duct carcinoma Cribriform growth pattern, comedonecrosis, atypia++mitosis. De novo (53%) or ex pleomorphic adenoma (47%) AE1/AE3+, S100-, Ki67++, RA+, CerB2+

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221 RA CK7 RA KI67 CerB2

222 GCDFP15 P63 Mamaglobin

223 Dalin M Cancers 2017,9:17