European Journal of Cardiovascular Medicine

Salivary glands are exocrine organs that secrete components of saliva that both break down carbohydrates and lubricate the passage of food. There are three major paired salivary glands: the parotid, the submandibular, and the sublingual. There are also numerous minor salivary glands located in the Submucosa of the entire upper aerodigestive tract, from the lips and nasal cavity to the major bronchi.

Salivary gland lesions constitute 0.4-13 cases per one lakh population.They constitute about 2-6% of all head and neck tumors. Major salivary glands are the common site of involvement. Among them Parotid gland(60-80%) are the most common site of involvement, followed by submandibular gland(7-10%), sublingual gland(less than1%), and minor salivary glands(7-22%). Among the minor salivary glands hard palate is the common site involved.[1,2]

Pleomorphic adenoma is the most common benign neoplasm accounting for 52% of all salivary gland tumors and 80% of pleomorphic adenomas are seen in the parotid gland. Mucoepidermoid carcinoma is the most common malignant tumor accounting for 4% of salivary gland tumors and parotid gland is the common site of involvement ( 50% of mucoepidermoid carcinomas). Adenoid cystic carcinoma is the second common malignant tumor accounting for 1.4% of all salivary gland tumors and is seen commonly in the minor salivary glands( 50-70% of adenoid cystic carcinomas).[3,4]

In this study the HPE was done for 34 surgically resected specimens . Statistical analysis like sensitivity, specificity and diagnostic accuracy was done.

Study design and setting

This was a prospective observational study carried out in the Department of Pathology, Maharajah’s Institute of Medical Sciences (MIMS), Nellimarla, Vizianagaram, Andhra Pradesh, India. The study was conducted over a period of four years, from June 2010 to June 2014. Patients presenting with suspected salivary gland lesions to the departments of Otorhinolaryngology (ENT) and General Surgery were evaluated, and surgically excised specimens were submitted to the Department of Pathology for further analysis.

 Study population

A total of 34 patients were included in the study. These patients were clinically diagnosed with salivary gland swellings and subsequently underwent surgical excision. Both major salivary glands (parotid, submandibular, and sublingual) and minor salivary glands were included in the study.

 Inclusion criteria

Patients of all age groups and both sexes with clinically or radiologically suspected salivary gland lesions.

Patients who underwent surgical excision of the lesion.

 Adequate specimen quality for histopathological processing.

 Exclusion criteria

Patients with incomplete clinical data or inadequate biopsy material.

Poorly preserved or autolyzed specimens.

Patients who declined surgical excision or consent for study inclusion.

Ethical considerations: The study protocol was reviewed and approved by the Institutional Ethics Committee of MIMS, Vizianagaram. All procedures conformed to the ethical standards of the Declaration of Helsinki (2008 revision). Written informed consent was obtained from each patient prior to specimen collection and inclusion in the study.

Clinical evaluation

For each patient, a detailed clinical history was recorded, including:

Demographic profile (age, sex, occupation).

Presenting complaints (duration and progression of swelling, pain, facial nerve involvement, dysphagia, xerostomia, or other symptoms).

Relevant past history (previous surgery, radiation exposure, or systemic illness).

Clinical examination findings, including site, size, consistency, mobility, and fixation of the lesion, along with regional lymphadenopathy.

Preoperative cytological assessment

Fine-Needle Aspiration Cytology (FNAC) was performed in cases where it was clinically indicated. Smears were prepared, air-dried and stained with Giemsa, as well as fixed in 95% ethanol and stained with Papanicolaou stain. FNAC findings were documented and later compared with histopathological diagnosis for cytohistological correlation.

Specimen collection and processing

Surgically resected specimens were received fresh in the Department of Pathology and fixed in 10% neutral buffered formalin for 24–48 hours. Gross examination included:

 Measurement of size and weight of the specimen.

Description of external surface (smooth, nodular, encapsulated, infiltrative).

Cut surface findings (cystic areas, necrosis, hemorrhage, or calcification).

Identification of surgical margins and relationship of lesion to glandular capsule.

Representative tissue sections were taken from different areas of the tumor, adjacent salivary gland tissue, and, where necessary, from resection margins.

Histopathological techniques

The tissue sections were routinely processed by paraffin embedding. Blocks were cut into 3–5 µm thick sections using a rotary microtome. Sections were mounted on glass slides and stained with Hematoxylin and Eosin (H\&E) for microscopic examination.

Special stains such as Periodic Acid-Schiff (PAS), Mucicarmine, and Alcian Blue were employed when required to demonstrate mucin and other tissue elements.

Cytohistological correlation

Where FNAC results were available, they were compared with final histopathological diagnoses. Parameters analyzed included:

 Concordance rate between cytology and histopathology.

 Diagnostic accuracy of FNAC in differentiating benign from malignant lesions.

Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of FNAC.

Data collection and analysis

All patient data, including demographic details, clinical features, cytological findings, and histopathological diagnoses, were entered into a structured proforma. Results were tabulated and analyzed to assess. Distribution of salivary gland lesions according to age, sex, and anatomical site. Proportion of benign versus malignant lesions. Accuracy of FNAC compared with histopathology.

Statistical analysis was performed using descriptive statistics (percentages, mean, range). Where applicable, Chi-square test and Fisher’s exact test were used to compare categorical variables. A p-value <0.05 was considered statistically significant.

A total of 34 patients with salivary gland lesions were studied. Of these, 20 were males (58.82%) and 14 were females (41.18%), giving a male-to-female ratio of 1.4:1. The age of patients ranged from the second to seventh decade, with a peak incidence in the third (25%) and fifth decades (25%).

Table 1: Age and gender distribution of patients with salivary gland lesions (n=34)

A total of 34 patients with salivary gland lesions were evaluated in this study. Of these, 20 were males (58.82%) and 14 were females (41.18%), giving a male-to-female ratio of 1.4:1. The age of patients ranged from the second to seventh decade of life, with the third (21–30 years, 25%) and fifth decades (41–50 years, 25%) showing the highest incidence (Table 1).

Figure-1: Histopathological spectrum in present study

Table -2: Histopathological spectrum of salivary gland lesions (n=34)

Histopathological analysis revealed that benign tumors formed the majority (70.5%), followed by malignant tumors (17.6%), and non-neoplastic lesions (11.76%). Among benign neoplasms, pleomorphic adenoma was the most common lesion (19 cases, 55.88%), followed by Warthin’s tumor (1 case, 2.94%), myoepithelioma (1 case, 2.94%), oncocytoma (1 case, 2.94%), and basal cell adenoma (1 case, 2.94%). Non-neoplastic conditions comprised chronic sialadenitis (2 cases, 5.88%).) and benign cystic lesions (2 cases, 5.88%). Malignant lesions included adenoid cystic carcinoma (2 cases, 5.88%), mucoepidermoid carcinoma (1 case, 2.94%), epithelial-myoepithelial carcinoma (1 case, 2.94%), and squamous cell carcinoma (1 case, 2.94%) (Table -2).

Table -3: Site distribution of lesions (n=34)

The parotid gland was the most frequently involved site, accounting for 24 cases (70.59%), followed by the submandibular gland (6 cases, 17.65%) and minor salivary glands (4 cases, 11.76%). Pleomorphic adenoma was predominantly seen in the parotid gland, while malignant lesions were distributed across both major and minor salivary glands.

Table 4: FNAC and histopathological correlation (n=34)

Fine-needle aspiration cytology (FNAC) was performed in all patients and compared with histopathological diagnosis. Out of 34 cases, 28 were true positive, 2 true negative, and 4 false negative, with no false-positive results. Based on this, the sensitivity of FNAC was 87.5%, specificity 100%, and the overall diagnostic accuracy 88.24% (Table 4).

Table 5: Mean age distribution according to lesion type

The mean age of patients with benign lesions was 35 years, whereas malignant tumors presented at a higher mean age of 50 years, demonstrating a clear age-related difference between benign and malignant conditions.

Diagnostic accuracy of FNAC:

Sensitivity = 87.5%

Specificity = 100%

Overall accuracy = 88.24%

The present study comprised 34 cases of salivary gland lesions diagnosed over a period of four years. The analysis focused on clinicopathological features, histomorphology, site distribution, and cytohistological correlation. In our study, the age of patients ranged from the second to the seventh decade, with a peak incidence in the third and fifth decades (23.53% each). Benign tumors were common in younger patients (mean age 35 years), while malignant tumors showed a higher incidence in older patients (mean age 50 years). These findings are consistent with the observations of Seifert and Sobin, who reported that benign salivary gland tumors commonly present in the 3rd–4th decade, while malignant lesions are more frequent in the 5th–6th decade (5). A slight male predominance (M\:F = 1.4:1) was observed in our study. Similar male predominance has been documented by Eveson and Cawson (6) and Tilak et al. (7). However, some studies such as Nagarkar et al. reported a female preponderance (8). This variation may reflect regional and demographic differences.

The parotid gland was the most commonly affected site (70.59%), followed by the submandibular gland (17.65%) and minor salivary glands (11.76%). This distribution aligns with the established literature, as parotid lesions account for the majority of salivary gland pathology (7,8). Minor salivary gland tumors, though less frequent, carried a higher proportion of malignancy, which was also noted by Nagarkar et al. (8) and Vaidya et al. (9).

The most frequent lesion encountered in our study was pleomorphic adenoma (55.88%), followed by chronic sialadenitis (11.76%) and adenoid cystic carcinoma (5.88%). This predominance of pleomorphic adenoma is universally reported in most series (3,6,8). Other benign lesions included Warthin’s tumor, oncocytoma, basal cell adenoma, and myoepithelioma, all of which are relatively rare entities. Among malignant tumors, adenoid cystic carcinoma and mucoepidermoid carcinoma were the leading histological subtypes, which is consistent with findings from Spiro et al. (10) and Pinkston & Cole (11). The presence of squamous cell carcinoma and epithelial-myoepithelial carcinoma, though less common, highlights the histological diversity of salivary gland neoplasms.

Fine needle aspiration cytology (FNAC) demonstrated high diagnostic utility with a sensitivity of 87.5%, specificity of 100%, and overall accuracy of 88.24% in our study. These values are comparable to the diagnostic accuracy rates of 80–95% reported in previous studies (11,12). False negative results (11.76% in our study) were mainly attributed to sampling error and overlapping cytological features between pleomorphic adenoma and low-grade mucoepidermoid carcinoma. This limitation of FNAC has been highlighted by Klijanienko et al. (14). The absence of false positives in our series emphasizes FNAC’s reliability in ruling out malignancy. However, histopathology remains the gold standard, particularly for rare or morphologically complex lesions.

Our study reinforces the role of FNAC as a minimally invasive, cost-effective, and reliable preoperative diagnostic tool, particularly in differentiating neoplastic from non-neoplastic lesions. However, reliance solely on FNAC may lead to under-diagnosis in cases of low-grade malignancies. Histopathology not only confirms the diagnosis but also provides insights into tumor grade and prognostic parameters.

Limitations

The small sample size (34 cases) is a limitation of our study. Larger, multicentric studies with ancillary techniques such as immunohistochemistry and molecular analysis are recommended to better characterize rare salivary gland tumors and improve diagnostic accuracy.

Pleomorphic adenoma remains the most common benign lesion, while adenoid cystic carcinoma and mucoepidermoid carcinoma are the predominant malignant tumors. Parotid gland is the most commonly affected site. FNAC is highly accurate, though histopathology continues to be the gold standard for final diagnosis. Our findings are largely in agreement with existing literature, thereby supporting the continued use of FNAC in routine evaluation of salivary gland swellings, while emphasizing the irreplaceable role of histopathology in definitive diagnosis and management

1. Barnes L, Eveson JW, Reichart P, Sidransky D, editors. World Health Organization Classification of Tumours. Pathology and Genetics of Head and Neck Tumours. Lyon: IARC Press; 2005.
2. Speight PM, Barrett AW. Salivary gland tumours. Oral Dis. 2002;8(5):229–40.
3. Seethala RR. An update on grading of salivary gland carcinomas. Head Neck Pathol. 2009;3(1):69–77.
4. Rosai J. Rosai and Ackerman’s Surgical Pathology. 11th ed. Philadelphia: Elsevier; 2018.
5. Seifert G. Tumours of the salivary glands: histological classification and clinical relevance. Eur J Cancer B Oral Oncol. 1992;28B(1):49–56.
6. Eveson JW, Auclair PL, Gnepp DR, El-Naggar A, Nagao T. Tumours of the salivary glands. In: Barnes L, Eveson JW, Reichart P, Sidransky D, editors. WHO Classification of Head and Neck Tumours. Lyon: IARC; 2017. p. 159–202.
7. Tilak V, Nageshwar V, Reddy BVR. Cytology of salivary gland lesions with histopathological correlation. J Cytol. 2011;28(4):178–83.
8. Nagarkar NM, Bansal S, Dass A, Singhal SK, Mohan C, Singhal S. Salivary gland tumors—our experience. Indian J Otolaryngol Head Neck Surg. 2004;56(1):31–4.
9. Vaidya S, Vaidya SA. Cytology of salivary gland lesions with histopathological correlation: A study of 81 cases. J Pathol Nepal. 2011;1(2):118–21.
10. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head Neck Surg. 1986;8(3):177–84.
11. Pinkston JA, Cole P. Incidence rates of salivary gland tumors: results from a population-based study. Otolaryngol Head Neck Surg. 1999;120(6):834–40.
12. Chauhan S, Dhingra S, Gulati A, Arora R. Diagnostic role of FNAC in salivary gland lesions and its histopathological correlation. J Cytol. 2020;37(1):21–5.
13. Batsakis JG. Salivary gland neoplasia: an outcome of modified morphogenesis and cytodifferentiation. Oral Surg Oral Med Oral Pathol. 1980;49(3):229–32.
14. Klijanienko J, Vielh P. Fine-needle sampling of salivary gland lesions IV. Review of 50 cases diagnosed as malignant: accuracy, limits and pitfalls. Diagn Cytopathol. 1997;17(1):36–44.