Clinical, Cytological and Histopathological Study of

DOI: 10.21276/aimdr.2018.4.3.PT6 Original Article ISSN (O):2395-2822; ISSN (P):2395-2814 Clinical, Cytological and Histopathological Study of Salivary Gland Lesions. Akansha Agarwal 1, Ramesh Kumar Kundal 2, Harpal Singh 3, Ashwani Kumar 4, Yasmeen Singh 1, Anika Mittal 1 1 Junior Resident, Department of Pathology, Government Medical College, Patiala, Punjab, India. 2 Professor & Head, Department of Pathology, Government Medical College, Patiala, Punjab, India. 3 Associate Professor, Department of Pathology, Government Medical College, Patiala, Punjab, India. 4 Professor & Head, Department of Surgery, Government Medical College, Patiala, Punjab, India. Received: March 2018 Accepted: March 2018 Copyright: the author(s), publisher. Annals of International Medical and Dental Research (AIMDR) is an Official Publication of Society for Health Care & Research Development. It is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: A prospective study was conducted in the Department of Pathology, GMC Patiala for two years on 60 patients with swellings of jaw seeking consultation in Rajindra Hospital, Patiala. Methods: Fine Needle Aspiration Cytology (FNAC) was done on all these patients followed by microscopic examination of the prepared slides and relevant clinical information was collected. The data was compiled and analysed statistically. In lesions where surgery followed FNAC, the comparison was done with histopathology and statistical values were calculated. Results: The results of the study were: non-neoplastic cases were 51.7% and neoplastic cases were 48.3%. Maximum cases were of chronic sialadenitis (30%) followed by pleomorphic adenoma (23.3%). Parotid gland was involved in maximum cases (60%). Biopsies or specimens for histopathological examination were received for 30 cases; maximum cases of which were diagnosed as pleomorphic adenoma on histopathology. Among malignant tumors, mucoepidermoid carcinoma was the most common. Conclusion: On correlating the cytological and histopathological nature of salivary gland lesions, sensitivity of FNAC came out to be 75%, specificity 100% and accuracy was calculated as 93.3%. Keywords: FNAC, cytological, histopathological, sensitivity, specificity, accuracy. INTRODUCTION Salivary glands are compound, tubuloacinar exocrine glands whose ducts open into the oral cavity. The major salivary glands are the paired parotid, submandibular and sublingual glands. In addition, there are numerous minor salivary glands scattered throughout the oral mucosa and submucosa. [1] Salivary gland lesions form about 2-6.5% of all head and neck neoplasm in adults, [2] and present as enlarged masses which are usually accessible for FNAC. Fine-needle aspiration (FNA) cytology has been used in the investigation of salivary gland lesions for many years. [3,4] The technique is safe and simple and well-tolerated by patients, so that repeat sampling may be performed if required. The use of quick staining methods also allows a rapid provisional diagnosis to be achieved in many cases, guiding further management. [5] Name & Address of Corresponding Author Dr Ramesh Kumar Kundal Professor & Head Department of Pathology, Government Medical College, Sangrur Road, Patiala, Punjab, India. Fine needle aspiration cytology (FNAC) is a popular method for diagnostic evaluation of salivary gland masses due to their superficial nature and easy accessibility for the procedure. This technique assumes greater importance considering the lack of characteristic clinical or radiologic features that may suggest a particular diagnosis. Though, few symptoms and signs may suggest malignancy, most malignant salivary gland lesions cannot be differentiated from their benign counterparts on clinical criteria alone. [6] They are not generally subjected to incisional or needle biopsy techniques because of the risks of fistula formation, or in the case of neoplasm, of tumour implantation. There is no evidence that these complications occur with FNAC. [7] The present study evaluates and analyzes salivary gland lesions by FNAC and correlates the cytological findings with histopathology wherever possible. Aims and Objectives 1. To assess the incidence of various salivary gland neoplasms during two years of study. 2. To assess the incidence of neoplastic and nonneoplastic salivary gland lesions. 3. To observe the cytological findings of salivary gland lesions in relation to age, sex and site. Annals of International Medical and Dental Research, Vol (4), Issue (3) Page 24

4. To study correlation between cytological and histopathological diagnosis in cases of salivary gland lesions wherever subsequent surgery is done to calculate overall accuracy of FNAC for salivary gland lesions. MATERIALS AND METHODS After a detailed history and clinical examination, the patients referred to the Department of Pathology of Government Medical College, Patiala were explained the procedure and an informed consent was taken. The present study consisted of FNAC of salivary gland swellings in 60 patients irrespective of their age, sex and site of the lesion. In all the cases, pertinent clinical information like age of the patient, detailed clinical and relevant personal history and physical findings were recorded. The histopathological examination of the salivary gland biopsies and the resected specimens of the patients was done whereever surgery was done by the Department of Surgery. The findings thus obtained were correlated and statistical evaluation was done. RESULTS Table 1: Frequency Of Salivary Gland Lesions In Various Age Groups. Age Group Frequency Percentage (in years) 20 7 11.7 21-40 22 36.6 41-60 24 40.0 >60 7 11.7 Total 60 100.0 Table 2: Frequency of salivary gland lesions according to sex Gender Frequency Percent Male 27 45.0 Female 33 55.0 Total 60 100.0 Table 3: Frequency of Various Non-Neoplastic And Neoplastic Lesions On Cytological Basis Cytological Diagnosis Frequency Percent A. Non-Neoplastic 31 51.7 1. Acute Sialadenitis 5 8.3 2. Chronic Sialadenitis 18 30.0 3. Cystic Lesion 4 6.7 4. Sialadenosis 2 3.30 5. Granulomatous Pathology 2 3.30 B. Neoplastic 29 48.3 I Benign neoplasms 21 35 1. Pleomorphic Adenoma 14 23.3 2. Monomorphic Adenoma 2 3.3 3. Oncocytoma 1 1.7 4. Warthin s Tumor 4 6.7 II Malignant neoplasms 8 13.3 1. Acinic Cell 1 1.7 2. Adenoid Cystic 1 1.7 3. Mucoepidermoid 5 8.2 4. Ex Pleomorphic 1 1.7 Adenoma Total 60 100.0 Swelling was found in all the 60 cases of salivary gland lesions (100%) included in the study followed by pain in 36.7% cases. In this study, among non-neoplastic lesions, chronic sialadenitis has the maximum incidence. Pleomorphic adenoma is the most common lesion among benign neoplasms followed by warthin s tumor. Mucoepidermoid carcinoma is the most common malignant neoplastic salivary gland lesion. Table 4: Incidence of various salivary gland lesions on the basis of cytological nature in parotid, submandibular and sublingual glands Site Cytological Diagnosis Non-Neoplastic Benign Neoplastic Malignant Neoplastic Total cases in each gland Parotid Number 14 16 6 36 (60%) %age 45.2% 76.2% 75% Sublingual Number 0 0 1 1 (1.7%) %age.0%.0% 12.5% Submandibular Number 17 5 1 23 (38.3%) %age 54.8% 23.8% 12.5% Total Number 31 21 8 60 (100%) %age 100% 100% 100% Table 5: Frequency distribution of various salivary gland lesions whose specimens were received on histopathological basis (n=30) Histopathological Diagnosis Frequency Percentage Chronic Sialadenitis 4 13.4 Pleomorphic Adenoma 13 43.4 Adenoid cystic 1 3.4 Warthin s Tumor 5 16.6 Mucoepidermoid 7 23.4 Total 30 100.0 In this study, all the cases of warthin s tumor are in parotid gland. All the cases of mucoepidermoid carcinoma are in parotid gland except one which is in submandibular gland. There is one case of adenoid cystic carcinoma which is in sublingual gland. All the four cases of chronic sialadenitis are in submandibular gland. There were two cases in this study which were underdiagnosed as pleomorphic adenoma on cytological examination and they came out to be mucoepidermoid carcinoma on histopathological examination. This could be due to selective sampling of the tumor One case of warthin s tumor was misdiagnosed as oncocytoma on cytological examination which could be due to the cystic nature of both the tumors. There is one case of monomorphic adenoma on cytological examination Annals of International Medical and Dental Research, Vol (4), Issue (3) Page 25

which came out to be pleomorphic adenoma on histopathological examination. This could be due to selective sampling from highly cellular areas with scant stroma. On correlating the cytological diagnosis with histopathological diagnosis of the received specimens after surgery, highly significant correlation was found with p-value < 0.05. Statistical evaluation was done between cytological nature and histopathological nature of salivary gland lesions. 90% cases of benign neoplasms diagnosed cytologically correlated histopathologically but 10% cases turned out to be malignant. In the nonneoplastic and malignant neoplastic cases, 100% correlation was found between the two variables. Overall, correlation between the two was found to be highly significant. Sensitivity of FNAC came out to be 75%, specificity 100% and accuracy was calculated as 93.3%. Table 6: Correlation Of Cytological Diagnosis With Histopathological Diagnosis Of Salivary Gland Lesions (N=30) Cytological Diagnosis Histopathological Diagnosis Total Chronic Sialadenitis Pleom- Orphic Adenoma Adenoid Cystic Warthin s Tumor Mucoepi- Dermoid Adenoid Cystic No. 0 0 1 0 0 1 %Age 0 0 100 0 0 100 Chronic Sialadenitis No. 4 0 0 0 0 4 %Age 100 0 0 0 0 100 Monomorphic Adenoma No. 0 1 0 0 0 1 %Age 0 100 0 0 0 100 Mucoepidermoid No. 0 0 0 0 5 5 %Age 0 0 0 0 100 100 Oncocytoma No. 0 0 0 1 0 1 %Age 0 0 0 100 0 100 Pleomorphic Adenoma No. 0 12 0 0 2 14 %Age 0 85.7 0 0 14.3 100 Warthin s Tumor No. 0 0 0 4 0 4 %Age 0 0 0 100 0 100 Total No. 4 13 1 5 7 30 %Age 13.3 43.3 3.3 16.7 23.3 100 Figure 1: Monomorphic adenoma showing cluster of small basaloid epithelial cells with scanty cytoplasm and bland rounded nuclei, scanty stroma MGG 400x Figure 3: Pleomorphic adenoma showing epithelial proliferation and chondromyxoid stroma H&E 40X. Figure 2: Pleomorphic adenoma showing clusters of epithelial cells in the background of chondromyxoid stroma MGG 40X Figure 4: Warthin s tumor showing monolayered sheets of uniform oncocytic cells, lymphocytes in proteinaceous background; MGG 100x Annals of International Medical and Dental Research, Vol (4), Issue (3) Page 26

Figure 5: Photomicrograph of Warthin s tumor showing double layered oncocytic epithelial cells along with lymphocytic stroma, H and E,400x Figure 8: Photomicrograph of Mucoepidermoid showing islands of squamous cells along with clear cells and mucin H and E 40x Figure 9: Adenoid cystic carcinoma showing hyaline spherical globules with adherent tumor cells along with finger-like or beaded cords of hyaline stroma MGG 100x Figure 6: Mucoepidermoid carcinoma showing cohesive sheets of epithelial cells in a dirty background of mucus and debris, MGG, 40x Figure 10: Photomicrograph of Adenoid cystic carcinoma showing pseudocysts forming the cribriform pattern H and E 400x DISCUSSION Figure 7: Mucoepidermoid carcinoma showing pleomorphic malignant cells, some with squamous differentiation, MGG 400x The most common age-group for salivary gland lesions was 41-60 years in this study which is in accordance with study done by Verma (2016).[8] In the present study, male to female ratio came out to be 1:1.2 which is in accordance with studies conducted by Nguansangiam et al and Todase et al Annals of International Medical and Dental Research, Vol (4), Issue (3) Page 27

indicating that salivary gland lesions are more common in females. [9,10] In the present study, parotid gland was involved in 60% cases, submandibular gland in 38.3% and sublingual gland in 1.7% cases. Parotid gland is the maximum involved gland by salivary gland lesions followed by submandibular gland which is in accordance with studies conducted by Ashraf et al (2010), [11] Nanda et al (2012) and Verma (2016). [8,12] Table 7: Comparative Analysis Of Incidence Of Non- Neoplastic And Neoplastic Lesions In Various Studies. Author and year of study Nonneoplastic Benign neoplasm Malignant neoplasm Omhare et al [13] 53.2% 31.5% 15.3% (2014) Verma [8] (2016) 55.56% 31.72% 12.72% Todase et al [10] (2017) 56% 33% 11% Present study (2017) 51.7% 35% 13.3% In the studies conducted by Shetty and Geethamani (2016), [14] Verma (2016) and Todase et al (2017), [8,10] incidence of pleomorphic adenoma among all salivary gland tumors is 68%, 58.3% and 54.7% respectively. In the present study, the incidence of pleomorphic adenoma is 48.3% among all salivary gland tumors which is in accordance with these studies indicating that pleomorphic adenoma has the highest incidence among all salivary gland tumors. In a study conducted by Eveson and cawson (1986), [15] it was seen that warthin s tumor occurs only in parotid gland. In the present study also, all the cases of warthin s tumor are in parotid gland (100%). In the studies conducted by Shafkat et al (2002), [16] Jain et al (2013) and Fernandes et al (2014), [17,18] it was concluded that mucoepidermoid carcinoma is the most common malignant salivary gland neoplasm. In the present study also, it was found that mucoepidermoid carcinoma was the most common malignant salivary gland neoplasm. Table 8: Comparative Analysis Of Sensitivity, Specificity And Accuracy Of Fnac In Various Studies Author and year of Sensitivity Specificity Accuracy study Lurie et al [19] (2002) 66% 100% 69.2% Nguansangiam et al [9] (2012) 81.3% 99.1% 97% Naz et al[20] (2015) 77.7% 86.3% 83.8% Shetty and Geethamani [14] 94.4% 100% 94.6% (2016) Todase et al [10] (2017) 90.2% 97.6% 90.2% Present study(2017) 75% 100% 93.3% Discrepancy in the results from the studies done by Lurie et al, [19] (2002) and Todase et al, [10] (2017) can be due to the low sample size and sampling error [Table 8]. CONCLUSION Salivary gland lesions present with nonspecific clinical symptoms. This study establishes that nonneoplastic lesions are more common than neoplasms. FNAC of the salivary gland lesions is a safe, quick and affordable investigative procedure. 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