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Salivary Gland Disease

There are 3 pairs of large salivary glands - parotid, submandibular and sublingual, lying outside the mucous membrane of the oral cavity, but opening their excretory ducts into this cavity. In addition, in the thickness of the mucous membrane of the oral cavity are numerous small salivary glands - labial, lingual, buccal and palatine. All these glands, especially the large ones, undergo various inflammatory and tumor lesions.

Sialadenitis. It is an inflammation of any salivary gland. It may be of a viral, bacterial or autoimmune nature. The most common form of viral sialadenitis is mumps, which usually affects the parotid glands (mumps). Other glands, such as the pancreas or testicles, may also be involved. Inflammatory autoimmune changes occur in the salivary glands in Sjögren’s syndrome (see chapter 5). In this disease, widespread lesions of the salivary glands and glands of the nasal mucosa secreting mucus lead to xerostomia. A similar process in the lacrimal glands causes filamentous keratitis (dry keratoconjunctivitis), in which threads 1–5 mm long, consisting of dying epithelial cells, hang freely from the surface of the dried cornea. The combination of inflammatory enlargement of the salivary and lacrimal glands with xerostomia is called Mikulich syndrome (J. von Radecki Mikulicz). Xerostomia sometimes develops secondary to atrophic changes in the salivary glands after irradiation or the action of certain drugs (antihistamines, phenothiazine derivatives, etc.).

Sialolithiasis and nonspecific sialadenitis. Nonspecific bacterial sialadenitis, which is usually found in large, in particular submandibular salivary glands, is a rather rare disease. As a rule, it accompanies sialolithiasis, i.e. obstruction of the excretory ducts of the glands with stones. Among the causative agents of this disease, Staphylococcus aureus and Strep streptococcus predominate. The formation of stones (stones), the diameter of which varies from 0.1 mm to 2.0 cm, is associated with dyskinesia of the excretory ducts or their blockage by foreign bodies. Stagnation of saliva is accompanied by an increase in its viscosity and a shift in pH to the alkaline side. At the same time, calcium salts begin to be deposited on desquamated epithelial cells and masses of mucus contained in saliva. They form the basis of calculi. Inflammation occurs first in the ducts and then in the parenchyma of the gland. In the presence of these pathogens, it is purulent. If untreated, chronic sialadenitis and glandular sclerosis develop in the outcome.

Tumors of the salivary glands. They make up only about 2% of all neoplasms in humans. These tumors are very diverse in structure and clinical course.

We give a histological classification and indicators of the incidence of certain forms of benign and malignant tumors of the salivary glands.

More than 90% of salivary gland tumors are represented by epithelial neoplasms. From 65 to 80% of such tumors occur in the parotid salivary glands, about 10% - in the submandibular, the rest - in the sublingual and small glands. Only about 15% of tumors are malignant in the parotid glands, about 40% in the sublingual and more than 50% in small ones. Thus, there is a certain inversely proportional dependence of the frequency of malignancy on the size of the organ. Salivary gland epithelial neoplasms usually occur in adults, more often in women, although a Worthin tumor (ASWarthin) often affects men. Benign epitheliomas, as a rule, are found at the age of 50-70 years, and malignant - later. Tumors of the parotid glands, up to the moment of clinical recognition, reaching 4-6 cm in diameter, lead to an increase in the affected organ, determined directly under the auricle. Primary benign and malignant neoplasms form nodes that are equally easily displaced by palpation, and upon the initial recognition of any reliable clinical criteria to establish the benign or malignant nature of the tumor, no. A morphological study is required.

Pleomorphic adenoma (polymorphic adenoma, mixed tumor). It accounts for about 60% of neoplasms of the parotid salivary glands, but it occurs much less frequently in the submandibular, sublingual and small glands. Most pleomorphic adenomas are rounded, clearly bounded nodes, rarely rarely exceeding 6 cm in diameter. The capsule surrounding such nodes is not always developed. Where it is almost absent, one can find expansively advancing cords of tumor tissue that extend far into the surrounding tissue of the organ. Such features make it preferable not to hatch the tumor during surgery, but limited parotidectomy. A grayish-white tissue with variegated zones of mucus and bluish areas of cartilage density is visible in the section of the tumor node.

Under the microscope, it is seen that the tissue of the neoplasm consists of three main components: epithelial, stromal with mucoid or myxoid transformation (mucus) and cartilage-like (chondroid) (Fig. 16.7, A, B, C). Epithelial elements resembling ductal epithelial cells or myoepithelial cells form structures similar to ducts, acini, irregular tubes, cords or solid nests. These structures are located in a mesenchym-like, friable and mucous stroma containing islets of cartilaginous tissue (chondroid) and, occasionally, fossils of ossification. Sometimes tumor epithelial cells form

Fig. 16.7.

Pleomorphic adenoma

(mixed swelling) of the parotid salivary gland.

Epithelial (A)

, myxoid (B) and chondroid

(B) components of tumor tissue

(preparations of I.V. Antonova).

Fig. 16.7. To be continued.

explicit duct ducts lined with cubic or cylindrical cells that are located on a layer of small and hyperchromic myoepithelial elements. In the vast majority of patients in the tumor parenchyma, neither cellular atypia nor increased mitotic activity is detected. There was no difference in the biological behavior of neoplasms built primarily from epithelial components and those that consist mainly of mesenchymal structures.
Relapses after parotidectomy occur after several years (sometimes months) in 4% of patients, and after enucleation of the tumor in 25% of the operated patients. Malignancy occurs only in 2-3% of affected individuals. In the case of malignancy, emerging forms of cancer are the most aggressive of all malignant neoplasms of the salivary glands and cause a 30–50% mortality rate over 5 years.

Uortin's tumor (adenolymphoma, monomorphic adenoma, papillary lymphomatous cystadenoma). This is an unusual structure of the tumor, which in frequency of occurrence takes second place among tumors of the salivary glands. It occurs almost exclusively in the parotid glands in 50–70-year-old men (5 times more often than in women). About 10% of such tumors have multiple nodes in one gland and approximately the same number of them have a bilateral nature of the lesion.

In most cases, the Uortin tumor is a round encapsulated node with a diameter of 2-5 cm, is easily felt in the superficial parts of the parotid salivary gland. The incision has a pale gray surface on which multiple dotted or small slit-like cysts filled with mucous or serous contents are visible. Under the microscope, you can see that these cystic spaces are lined with a double layer of cells similar to salivary tube epithelial cells. The outer layer is represented by cylindrical cells, the cytoplasm of which is very plentiful, characterized by a noticeable oxyphilicity and weak granularity. These features, as well as a large number of mitochondria, give these cells a resemblance to special epithelial elements - oncocytes. The inner layer is made up of cubic or polygonal cells. Under the two layers of the lining, a stroma with developed lymphoid tissue is visible, sometimes forming follicles with germinal centers. Often, cystic cavities are filled with polypoid outgrowths of lymphoepithelial tumor tissue. In these cases, mucus-secreting elements are found among the cells of the double-row lining. In addition, solid epithelial nests constructed from cells of the inner layers of the double-row lining are found outside the cysts. Foci of squamous metaplasia are found. In the vast majority of cases, a Uortine tumor has a benign course.

Mucoepidermoid cancer. This form accounts for 10-15% of observations of all tumors of the salivary glands. Despite the fact that in more than 50% of cases this cancer develops in the parotid salivary glands, nevertheless in other salivary glands it is also a common form of malignant tumor growth. Mucoepidermoid cancer often occurs shortly after radiation therapy and reaches a maximum diameter of 8 cm. In the marginal zones, signs of invasion are often found. On the incision, the tumor tissue looks pale, whitish-gray with small cysts containing mucus. Parenchyma of mucoepidermoid cancer is almost always represented by both mucus-forming and squamous (epidermoid) complexes. Epidermoid cells can line the cystic cavities. Slime-forming cells are either located inside the epidermoid complexes, or they themselves form complexes containing mucus inside and outside the cells. In the first case, cells with optically empty cytoplasm are considered the most typical elements, and in the latter case, goblet cells. Secreted mucus gives a positive PAS response. Depending on the varying degrees of atypia and polymorphism of tumor cells, high, moderate and low-differentiated forms of cancer are distinguished.

Fig. 16.8.

Adenoid cystic carcinoma

(cylindrome) sublingual salivary gland.

The prognosis is closely related to the degree of histological differentiation of the neoplasm. Highly differentiated carcinomas recur in 15% of patients undergoing surgery. They rarely metastasize and therefore are characterized by 90% 5-year patient survival. Low-differentiated forms are characterized by relapses in 25-30% of cases, and they metastasize in 30% of patients, which determines a lower, 50%, 5-year survival rate.

Other salivary gland tumors. Adenoid cystic carcinoma (cylindroma, cystadenoid cancer, adenocystic cancer) is not as characteristic of the parotid glands as all the previous ones, but very often occurs in other salivary glands. Similar neoplasms appear in the nasal cavity, bronchi, pharynx, skin and mammary glands. Externally, adenoid cystic cancer is a small, fuzzy limited site of grayish-pink tissue. Under the microscope, the complexes of the tumor parenchyma formed by small cells with dark, compact nuclei and scanty cytoplasm are clearly visible. These complexes form cribrotic structures (similar to a sieve or sieve) (Fig. 16.8), as well as solid or tubular complexes. The spaces between the cells and the epithelial complexes are filled with hyaline-like material, which, according to ultrastructural studies, is a reduplicated matrix of the basement membrane. Despite its relatively slow growth, adenoid cystic cancer has unpredictable biological behavior. In particular, it is characterized by rapid perineural invasion, which makes this tumor the most painful among the neoplasms of the salivary glands.

An acinous cell tumor occurs in no more than 3% of all cases of salivary gland tumors and usually affects the parotid glands, sometimes submandibular. Like a Uortin tumor (see above), this neoplasm can have both multicentric growth and a bilateral nature of the lesion. As a rule, the tumor node is small, has clear boundaries. The most common histological variant is represented by rounded or polygonal cells with abundant, moderately basophilic or light, sometimes vacuolated cytoplasm and a compact nucleus. Cells form solid layers, sometimes glandular, follicular and even papillary structures. Cellular atypism and polymorphism are expressed differently, but the number of mitoses is usually small. In 10-15% of patients, such neoplasms metastasize to regional lymph nodes. The 5- and 20-year survival rates for patients undergoing surgical removal of the tumor are 90% and 60%, respectively.

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Salivary Gland Disease

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