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Year : 2014 | Volume : 2 | Issue : 1 | Page : 57 - 58  


Case Reports
FNAC diagnosis of Pleomorphic Adenoma of Palate

Sudhir Kumar Vujhini1, Kandukuri Mahesh Kumar2, Konduru Omkareshwar3, Sridhar Reddy4, Ganesh5

1Associate Professor, 2Assistant Professor, 3Associate Professor, Department of Pathology, Malla Reddy Institute of Medical Sciences, Hyderabad

4MDS PG, MNR Dental College, Sanga Reddy, Medak

5Assistant Professor, Malla Reddy Institue Of Dental Sciences, Suraram, Hyderabad.

Abstract:

Pleomorphic adenoma also called benign mixed tumor, is the most common salivary gland tumor. Most of these tumors occur in major salivary glands; Parotid gland happens to be the commonly involved one (about 90 %) and about 10 % of these occur in the minor salivary glands. The most common sites for pleomorphic adenoma of minor salivary glands are the palate, followed by the lips, the cheeks, floor of the mouth, tongue, tonsil, pharynx, the retromolar area and the nasal cavity. FNAC of intraoral swellings is rarely advised. Here, we are reporting a rare case of pleomorphic adenoma arising from the palate diagnosed on FNA Cytology. We conclude that FNAC is a useful diagnostic tool before surgery even in intraoral swellings.

Key words: FNAC, cytology, Pleomorphic Adenoma.

Corresponding Author: Dr. Sudhir Kumar Vujhini, Dept. of Pathology, MallaReddy Institute of Medical Sciences, Suraram Hyderabad Andhra Pradesh. E-mail: vujhini07@yahoo.com

Introduction:

We report a rare case of pleomorphic adenoma of palate diagnosed on FNAC. Generally such intra-oral lesions are rarely advised for FNAC. We describe the classical cytological features and also discuss the probable cytological differential diagnoses.

Case Report:

A 24–year old male presented to dental OPD with the chief complaint of a painless swelling over the palate since the last two months. There was no history of trauma, fever, cigarette smoking or tobacco chewing. His intra–oral examination revealed a single swelling over the plate. The swelling was approximately 1 x 1 cm and was soft. The overlying mucosa was not ulcerated. FNAC was performed with a five ml syringe and the aspirate was blood mixed; smears were made and fixed in alcohol and stained with routine H and E stain and Giemsa stain. Smears show rich cellularity comprising of cell clusters with dual population of cells with bland round and oval nuclei. Few plasmacytoid cells and fibromyxoid stromal fragments were also noted in the hemorrhagic background. Based on these cytological features, a diagnosis of pleomorphic adenoma was offered. Later, the tumor was excised and sent for histopathological examination.

Grossly, the tumor was measuring 1x1x0.8 cm. Cut-section was solid and grayish white. Histology showed a well encapsulated tumor comprising of benign epithelial cells arranged predominantly in diffuse fashion and focal acinar pattern. Other areas show benign cells with spindle to oval nuclei (myoepithelial cells). Stoma is fibromyxoid with focal chrondroid elements. Based on these findings, histological diagnosis of pleomorphic adenoma was given confirming the cytological diagnosis.

Discussion:

Pleomorphic adenomas are benign salivary gland tumors that represent about 3-10% of the neoplasms of head and neck region. [1] They are the most common tumors (60%) of the major and minor salivary glands.[2, 3] The palate is considered as the most common intra-oral site followed by upper lip and buccal mucosa.[4] Other rare sites include the throat, the retromolar region and floor of the mouth and alveolar mucosa. Pleomorphic adenoma usually presents as a mobile, slowly growing, painless firm swelling that does not cause ulceration of the overlying mucosa. Rapid increase in size of the mass should lead to suspicion of intra-lesional bleed or malignant transformation. [5]

FNAC is rarely advised for intra-oral swellings. But the cytological features are very characteristic of the tumor. Cytologically, smears are cellular and show epithelial and myoepithelial cell clusters and mesenchymal stromal fragments. Cells show moderate to abundant cytoplasm and round to oval and elongated bland spindle nuclei. Few singly scattered plasmacytoid cells are present along with fibromyxoid and chondromyxoid stromal fragments.

Pleomorphic adenoma has to be differentiated from mucoepidermoid carcinoma, Adenoid cystic carcinoma and carcinoma ex pleomorphic adenoma. PA can be extensively cystic with mucoid material and show squamous metaplasia (epidermoid). Careful sampling from solid areas and long history will rule out mucoepidermoid carcinoma. Mucoepidermoid ca will show intermediate cells resembling squamous metaplasia, mucin secreting cells and mucoid background. Adenoid cystic carcinoma shows characteristic hyaline spherical globules of varying sizes with adherent tumor cells, multilayered dense cell clusters and cup – shared fragments composed of tumor cells with increase N: C ratio, hyper chromatic nuclei along with naked nuclei in the background. Carcinoma ex pleomorphic adenoma shows dual population of malignant tumor cells and benign epithelial cells of pleomorphic adenoma. A history of recent sudden increase in size of long standing tumor favors the diagnosis of Carcinoma ex pleomorphic adenoma.

Grossly, the PA is a smooth or lobulated tumor often well en-capsulated tumor that is clearly demarcated from surrounding normal salivary gland. They are typically solid tumors and may have areas of gelatinous myxoid stroma.

Histologically, it is highly variable in appearance, even within individual tumors. Classically it is biphasic and is characterized by an admixture of polygonal epithelial and spindle-shaped myoepithelial elements in a variable background stroma that may be mucoid, myxoid, cartilaginous or hyaline. Epithelial elements may be arranged in duct-like structures, sheets, clumps and/or interlacing strands and consist of polygonal, spindle or stellate-shaped cells (hence pleiomorphism).

We conclude that FNAC is a useful diagnostic tool to arrive at a diagnosis prior to surgery even in intra-oral swellings as was in our case.

References:

  1. Amit Kumar Gothwal, Anagha Kamath, Rajdeep S. Pavaskar, Sujatha K. Satoskar. Pleomorphic Adenoma of the Palate: A Case Report. Journal of Clinical and Diagnostic Research. 2012 August, Vol-6(6): 1109-1111
  2. Amit Aggarwal, Ravinder Singh, Soheyl Sheikh, Shambulingappa Pallagati, Isha Singla. Pleomorphic adenoma of minor salivary gland: a case report. RSBO. 2012 Jan-Mar;9(1):97-101
  3. Sahoo NK, Rangan MN, Gadad RD. Pleomorphic adenoma palate: Major tumor in a minor gland. Ann Maxillofac Surg 2013;3:195-7.
  4. Toida M1, Shimokawa K, Makita H, Kato K, Kobayashi A, Kusunoki Y, Hatakeyama D, Fujitsuka H, Yamashita T, Shibata T.
  5. Thiagarajan B. Pleomorphic adenoma hard palate a case report and literature review. ENT SCHOLAR. 2013 Mar 18 [last modified: 2013 Mar 18]. Edition 1.

Figure1- Arrow pointing intra-oral swelling.

 

 

Figure 2 showing epithelial cluster with round to oval nuclei (left) and scattered plasmacytoid myoepithelial cells (right), high power.

 

 

Source of Support: Nil. Conflict of Interest: None.





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