l22 salivary & esophagus

8/3/2019 L22 Salivary & esophagus

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GIT ModuleGIT Module PathologyPathology

Salivary Gland & Esophageal Diseases

Proffessor. Fadwa J. Altaf.

Dr. Osama Nassif

Dr. Ali Sawan

Dr. Rana Bokary


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Salivary Glands

There are three major salivary glands:

parotid

submandibular

sublingual

as well as minor salivary glands distributed throughout the mucosa of the

oral cavity.

All these glands, particularly the major ones, are subject to inflammation

or to the development of neoplasms.


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Here is the normal appearance of a submandibular salivary gland at high

power, with both serous and mucinous acini. The serous cells contain dark

granules from which enzymes such as amylase and maltase are released. The

mucinous cells contain pale mucin. The secretions drain into ducts.


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At high magnification, the normal parotid gland has acini

composed of serous cells with abundant darkly staining granules.

There are admixed fat cells, and some ducts are present.


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Inflammation (Sialadenitis)

Sialadenitis may be of viral, bacterial, or autoimmune

origin.

The most common form of viral sialadenitis is mumps

(epidemic parotitis).

Nonspecific bacterial sialadenitis uncommoncondition, usually secondary to ductal obstruction

produced by stones (sialolithiasis).

Autoimmune disease underlies the inflammatory

salivary changes of Sjgrens syndrome


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A parotid gland has been sectioned serially to reveal the

presence of a tan-yellow stone in the duct, seen here at the

lower right. The salivary gland duct lithiasis led to

obstruction with pain and swelling and chronic

inflammation of the parotid gland.


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Obstruction of salivary gland ducts from lithiasis or

inspissated secretions predisposes to infection.An acute

parotitis is seen here, with neutrophils infiltrating the parotid

gland and an abscess around a duct at the upper right. The

elderly are more prone to develop this problem


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Obstruction of a salivary gland duct can lead to inflammation. Seenhere at low power are chronic inflammatory cell infiltrates along

with fibrosis and acinar atrophy. The sialadenitis here is due to

ductal obstruction. Bilateral inflammation of salivary glands can

occur acutely with mumps infection and chronically with Sjogren's

syndrome.


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Sjgrens syndrom

widespread involvement of the SG and the

mucus-secreting glands of the nasal mucosa

induces xerostomiadry mouth

associated involvement of the lacrimal glandsproduces dry eyeskeratoconjunctivitis sicca.

The combination of salivary and lacrimal gland

inflammatory enlargement with xerostomia is

sometimes called Mikuliczs syndrome


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Neoplasms of salivary glands

A classification tumors are shown in (Table)

Overall, relatively uncommon & represent


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Neoplasms of salivary glands


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Neoplasms

Malignant neoplasm represent

only 15% of tumors in the parotid glands

40% of tumors in the submandibular glands

> half of tumors in the minor SG

The likelihood then of a SG tumor being malignant isinversely proportional to the size of the gland.

usually occur in adults, with a slight female

predominance

about 5% occur in children younger than 16 years of age.

For unknown reasons, Warthins tumors occur much

more often in males.


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Neoplasms

Main tumors

Pleomorphic Adenoma

Warthins Tumor (Papillary

Cystadenoma Lymphomatosum)

Mucoepidermoid Carcinoma


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Pleomorphic Adenoma

also been called mixed tumors.

They represent about 60% of tumors in the parotid

less common in the submandibular glands, and are relativelyrare in the minor salivary glands.

composed of epithelial elements dispersed throughout a

matrix of mucoid, myxoid, and chondroid tissue.

In some tumors the epithelial elements predominate, and in

others they are present only in widely dispersed foci.


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Pleomorphic Adenoma

pathogenesis

? Radiation exposure increases the risk.

Equally uncertain is the histogenesis of the various components, but

favored today is the myoepithelial or ductal reserve cell origin


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Pleomorphic Adenoma

Morphology

Gross

rounded, well-demarcated masses rarely > 6 cm in

greatest dimension

encapsulated, with expansile growth produces tongue-

like protrusions into the surrounding gland

The cut surface is gray-white with variegated myxoid

and blue translucent areas of chondroid.


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Pleomorphic Adenoma

Micro:

The dominant histologic feature is the greatheterogeneity mentioned.

The epithelial elements form duct, acini, irregulartubules, strands, or sheets.

mesenchyme-like background of loose myxoid tissuecontaining islands of chondroid and, rarely, foci ofbone

a carcinoma arises in PA, referred to variously as acarcinoma ex pleomorphic adenoma or a malignantmixed tumor (rare)


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A pleomorphic adenoma of parotid gland is seen here at high magnification

next to a portion of adjacent normal parenchyma at the upper right. The

neoplasm is a mixed proliferation of both ductal epithelium, myoepithelial

cells, and a hyaline/chondroid/myxomatous stroma.

Pleomorphic Adenoma


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Warthins Tumor

Also called (Papillary Cystadenoma Lymphomatosum)

benign neoplasm

the second most common salivary gland neoplasm.

It arises almost always in the parotid gland (the only tumor

virtually restricted to the parotid)

occurs five times more commonly in males than in females

usually in the fifth to seventh decades of life.

About 10% are multifocal, and 10% bilateral.

The histogenesis

arise from the aberrant incorporation of inclusion-bearing

lymphoid tissue in the parotids.


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Warthins Tumor

Morphology

round to oval, encapsulated masses, 2 to 5 cm indiameter,

usualy in the superficial parotid gland

pale gray surface with cystic or cleft-li

ke spaces filledwith a mucinous or serous secretion.

Microscopically, these spaces are lined by a double layerof epithelial cells resting on a dense lymphoid stroma

polypoid projections of the lymphoepithelial elements.

Oncocytes are epithelial cells stuffed with mitochondriathat impart to the cytoplasm the granular appearance.


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Here is a "purple cow" or a lesion with a very distinctive histologic appearance. This isthe low power microscopic pattern of a benign papillary cystadenoma lymphomatosum,

or Warthin's tumor, of salivary gland.A rim of compressed normal parenchyma is seen

at the left. This is the second most common salivary gland tumor. It is almost always

found in the parotid gland, is much more common in males, and in some cases can be

multifocal or bilateral.


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The microscopic pattern of a Warthin's tumor is shown here. There are cystic to cleft-like spaces filled

with pale pink mucinous to serous secretions. The spaces are lined by a double layer of pink (oncocytic)

cuboidal to columnar epithelial cells over papillary fronds. The fronds beneath the epithelium are filled

with lymphocytes, sometimes with germinal centers.


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Mucoepidermoid Carcinoma

These neoplasms are composed of variable mixturesof squamous cells, mucus-secreting cells, and

intermediate hybrids.

They represent about 10 to 15% of all salivary gland

tumors

Overall they are the most common form of

malignant tumor primary in the salivary glands

the most common radiation-induced neoplasm.


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EsophagusEsophagus

Esophagitis

Barretts Esophagus

Esophageal Carcinoma


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EsophagitisEsophagitis Definition &Definition &

IncidenceIncidence It is inflammation of the esophageal mucosa

2ry to injury

Is a common disorder worldwide

In Northern Iran, the prevalence of esophagitis

is > 80%

It is also extremely high in regions of China

This has unknown basis In USA& other western countries it is 10 -

20% mainly reflux esophagitis


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EsophagitisEsophagitis -- CausesCauses

Reflux esophagitis, due to reflux of gastric contents Prolonged gastric intubation Ingestion of irritants e.g. alcohol, corrosive acids

Cytotoxic anticancer therapy = chemotherary Infection 2ry to bacteremia, vireamia or fungalinfection e.g. HSV, CMV, Candida

Uremia R

adiotherapy directed to thorax Graft-versus-host disease Systemic conditions such as hypothyroidism LES

tone


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Tan-yellow plaques are seen in the lower esophagus, along

with mucosal hyperemia. The same lesions are also seen at

the upper right in the stomach

Candida EsophagitisCandida Esophagitis


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The lower esophagus here shows sharply demarcated

punched-out ulcerations that have a brown-red base,

contrasted with the normal pale white esophageal

mucosa surrounding them

Herpes Simplex Viral EsophagitisHerpes Simplex Viral Esophagitis


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RefluxReflux EsophagitisEsophagitis

DefinitionDefinition:: Inflammation of the esophagus 2ry toreflux of gastric contents into esophagus

It is the most common cause of esophagitis in

western countries affects ~ 0.5% of US adults PathogenesisPathogenesis:: Many causative factors are implicated:

Decreased efficacy of esophageal anti-reflux mechanisms Inadequate or slowed esophageal clearance of refluxed

material

Presence of sliding hiatal hernia

Increased gastric volume Impaired reparative capacity of esophageal mucosa by

prolonged exposure to gastric juices


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Reflux EsophagitisReflux Esophagitis

Clinical features:Clinical features: Largely limited to adults > 40 years of age Occasionally seen in infants and children Manifestations:

Mainly heartburn & sometimes regurgitation of a sourbrash Rarely results in severe chest pain mimicking a heart attack

Complications:Complications: Bleeding Development of stricture Barretts esophagus


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Depends on causative agent & on duration &severity of the exposure

Mild esophagitis: Simple hyperemia

Severe esophagitis: Confluent erosions to totalmucosal ulceration

RefluxReflux EsophagitisEsophagitis GrossGross

MorphologyMorphology


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In uncomplicated reflux esophagitis, threemicroscopicmicroscopic features are present:

1) Eosinophils, with or without neutrophils withinthe surface epithelial layer

2) Basal zone hyperplasia

3) Elongation of lamina propria papillae

RefluxReflux EsophagitisEsophagitis MicroscopicMicroscopic

MorphologyMorphology


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BarrettsEsophagusBarrettsEsophagus

Definition & IncidenceDefinition & Incidence Is the replacement of normal distal stratifiedsquamous mucosa by metaplastic columnarepithelium containing goblet cells

It is a complication of long-standing GE refluxGE reflux,occurring in 5-15% of patients withpersistentpersistentreflux disease

M:F = 4:1 & occurring mainly in whiteindividuals


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BarrettsEsophagusBarrettsEsophagus GrossGross

MorphologyMorphology Appears as dark pink, velvetydark pink, velvety mucosa betweenthe smooth, pale pink esophageal squamousmucosa and the more lush, light brown gastric

mucosa

It may exist as tonguestongues extending up from theGEJ, as an irregularcircumferential bandcircumferential band

displacing the squamocolumnar junctionupwards, or as isolatedpatches (islandsisolatedpatches (islands)) in thedistal esophagus


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Microscopic MorphologyMicroscopic Morphology The esophageal squamous epithelium is replaced

by metaplastic columnarmetaplastic columnarepithelium

May be quite focal

Pathologists have to look fordysplasiadysplasia in every

case as it is precursor of malignancy

Dysplasia: Neoplastic epithelial change limited

to basement membrane


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Microscopic MorphologyMicroscopic Morphology Dysplasia is classified as low-grade or high-grade

Basal orientation of all nuclei low-grade

dysplasia

Nuclei reaching up to the apex of epithelial

cells high-grade dysplasia

Persistent highhigh--grade dysplasiagrade dysplasia demandsclinical intervention


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LowLow--Grade DysplasiaGrade Dysplasia


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HighHigh--Grade DysplasiaGrade Dysplasia


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Esophageal Benign TumorsEsophageal Benign Tumors

Epithelial:Epithelial:Squamous papillomas

Mesenchymal:Mesenchymal:Leiomyoma, fibroma, lipoma, hemangioma,

neurofibroma & lymphangioma

Both are uncommon


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Esophageal CarcinomaEsophageal Carcinoma

Two major types: Squamous cell carcinoma

(SCC) & adenocarcinoma

In USA there is continuous increase in incidence

of adenocarcinoma 2ry to Barrett esophagus(> SCC)

But WorldwideWorldwide, SCCSCC constitute 90% of

esophageal cancers


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Esophageal CarcinomaEsophageal Carcinoma

EpidemiologyEpidemiology Striking geographic differences Areas of high incidence include China & Iran

(20% of all cancer deaths, affect ~ 100 / 100,000

yearly) mainly SCC In USA, it affects ~ 6 / 100,000 yearly. Blacks>

whites (1-2% of all cancer deaths) Adenocarcinoma is more common in whites

while SCC is more common in blacks


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Esophageal Squamous cellEsophageal Squamous cell

CarcinomaCarcinoma Risk FactorsRisk Factors Esophagealdisorders:Esophagealdisorders:Long standing eosophagitisAchalasiaPlummer-Vinson syndrome esophageal web,

microcytic hypochromic anemia & atrophicglossitis

Dietary factors:Dietary factors:Fungal contamination of foodstuffsH

igh content of nitrosamine/nitrites ChinaVitamin deficiencies A& C, pyridoxine,riboflavinDeficiency of trace metals Zinc


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CarcinomaCarcinoma Risk FactorsRisk Factors LifeLife--style:style:Smoking tobaccoAlcohol consumption

Genetic predispositionGenetic predispositionTylosis hyperkearatosis of palms & soles


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CarcinomaCarcinoma MorphologyMorphology Like squamous cell carcinomas arising in otherlocations, those of the esophagus begin asepithelial dysplasia carcinoma in-situ

invasive cancer

Site:Site:20% of these tumors are located in the upper

third50% in the middle thirdmiddle third30% in the lower third of the esophagus


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Esophageal Squamous cell CarcinomaEsophageal Squamous cell Carcinoma

Gross MorphologyGross Morphology Early lesions appear as small, thickening or elevation ofmucosa,

Advanced lesion may take one of three forms:(1) Polypoid exophytic mass protruding into the lumen

(60%)(2) Diffuse, infiltrative form thickening & rigidity ofthe wall with narrowing of the lumen (15%)(3) Necrotizing cancerous ulceration (25%) that mayerode into:

A. Respiratory tree (causing pneumonia)B. Aorta (with catastrophic exsanguination)C. May permeate the mediastinum & pericardium


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Esophageal Squamous Cell CarcinomaEsophageal Squamous Cell Carcinoma

Exophytic Pattern of GrowthExophytic Pattern of Growth


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Esophageal Squamous Cell CarcinomaEsophageal Squamous Cell Carcinoma

Ulcerative Pattern of GrowthUlcerative Pattern of Growth


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Esophageal Squamous Cell CarcinomaEsophageal Squamous Cell Carcinoma DiffuseDiffuse

Pattern of GrowthPattern of Growth


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MorphologyMorphology Local extension into adjacent mediastinal structuresoccurs early and limits the chance of curativeresection

Tumors located in:Upper 1/3 metastasize to cervical lymph nodesMiddle 1/3 spread to the mediastinal, paratracheal,

tracheobronchial lymph nodesLower 1/3 often spread to the gastric and celiac groups

of nodes

Microscopic Features:Microscopic Features:Most squamous cell carcinomas are moderately towell differentiated malignant tumors


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Microscopic MorphologyMicroscopic Morphology


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Clinical FeaturesClinical Features Remain asymptomatic, often discovered too lateto permit cure

Gradual dysphagia & obstruction appear late

Weight loss, anorexia, fatigue & weakness Pain on swallowing

Hemorrhage & sepsis from ulceration of tumor

Aspiration pneumonia via a cancerous

tracheoesophegeal fistula


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PrognosisPrognosis Generally poor Resectability improves (from less than 50% to

more than 80%) with endoscopic screening of

individuals at risk The five-year survival rate in patients with:Superficial carcinoma limited to mucosa &

submucosa is amenable to curative surgery: 75%,A

dvanced lesions : 25% Local and distant recurrence after surgery arecommon

The presence of lymph node metastases indicate

bad prognosis


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Esophageal AdenocarcinomaEsophageal Adenocarcinoma EpidemiologyEpidemiology & Risk Factors& Risk Factors

They represent > half of cancers in the distalthird of the esophagus

More common in whites

Occur in individuals >40 years of age Males > females Barrett esophagus is the only recognized

precursor lesion

May be discovered early during course ofendoscopic screening

Poor prognosis,


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BarrettsEsophagus Is A Risk Factor forBarrettsEsophagus Is A Risk Factor for

Esophageal AdenocarcinomaEsophageal Adenocarcinoma


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Esophageal AdenocarcinomaEsophageal Adenocarcinoma GrossGross

MorphologyMorphology Usually located in the distal esophagusdistal esophagus & may

invade the adjacent gastric cardia Gross Features:Gross Features:

Initially they look like flat or raised patchesLarge nodular massesDiffusely infiltrative orUlcerative lesion

At the time of diagnosis, most tumors haveinvaded through the wall of the esophagusinto serosa


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Most are mucin-producing glandular tumors

May exhibit intestinal-type features or less

often are made up of diffusely infiltrative

signet-ring cells of gastric type


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