Chronic sclerosing sialadenitis

Chronic sclerosing sialadenitis
Classification and external resources
Specialty	Dentistry
ICD-10	Xxx.x
ICD-9-CM	xxx

Chronic sclerosing sialadenitis is a chronic (long-lasting) inflammatory condition affecting the salivary gland. Relatively rare in occurrence, this condition is benign, but presents as hard, indurated and enlarged masses that are clinically indistinguishable from salivary gland neoplasms or tumors. It is now regarded as a manifestation of IgG4-related disease.^[1]

Involvement of the submandibular glands is also known as Küttner's tumor, named after Hermann Küttner (1870–1932), a German Oral and Maxillofacial Surgeon, who reported four cases of submandibular gland lesions for the first time in 1896.^[2]

Presentation

The inflammatory lesions in Küttner's tumor may occur on one side (unilateral) or both sides (bilateral), predominantly involving the submandibular gland,^[3] but is also known to occur in other major and minor salivary glands,^[4] including the parotid gland.^[5][6] Overall, salivary gland tumors are relatively rare, with approximately 2.5–3 cases per 100,000 people per year seen in the Western world; however, salivary gland malignancies account for 3–5% of all head and neck cancers.^[7] However, salivary tumors show a great deal of morphological diversity, as well as variations in the nature of the lesion (malignant vs. benign): approximately 20% to 25% of parotid tumors, 35% to 40% of submandibular tumors, and more than 90% of sublingual gland tumors are malignant.^[8] This situation underscores the diagnostic challenges in respect of Küttner's tumor; despite being benign, this condition mimics the clinical appearance of malignancy in the salivary gland.

The swollen masses of Küttner's tumor are generally painful, and patients are advised surgical resection (known as 'sialadenectomy') of a part or whole of the glandular tissue upon suspicion of possible malignancy. It is only upon post-surgical histopathology of the excised mass that the diagnosis of Küttner's tumor is definitively made.

Histological features

The histopathological features that characterize Küttner's tumor^[9] include:

• Heavy infiltration of the glandular tissue by lymphocytes (predominantly activated B-cells and helper T-cells) as well as plasma cells (collectively known as 'Lymphoplasmacytic Infiltrate').
• Presence of reactive lymphoid follicles in the infiltrate, marked by a lack of atypical lymphoid cells (this is in sharp contrast to the presentations in lymphoma).
• Atrophy and loss of acini (groups of secretory cells found in the salivary glands).
• Encasement of the glandular ducts in thick fibrous tissues, as a result of chronic presence of inflammatory infiltrate in that area - a condition known as periductal fibrosis.
• Eventual periductal and interlobular (inside the gland) sclerosis (replacement of regular tissue with hard connective tissue).

Diagnosis

Given the difficulties of a definitive pre-operative diagnosis, the clinical entity of Küttner's tumor has so far remained significantly under-reported and under-recognized. In recent times, armed with a better understanding of the occurrences and observable features of this condition, surgeons are increasingly depending upon pre-operative ultrasonography along with Fine-needle aspiration cytological (FNAC) examinations to make an accurate presumptive diagnosis,^[10] and according to one estimate, about 44% of patients undergoing submandibular resection are found to have this condition.^[10] In the ultrasonogram, Küttner's tumor is characterized by a diffuse, heterogeneous zone of echo-shadows.^[11] The FNAC finds cells greatly reduced in number (called 'paucicellularity') along with scattered tubular ducts against a backdrop of lymphoplasmacytic infiltration and fibrous depositions.^[11] There may be a reduced but moderate number of cells and ducts enveloped in fibrous sheaths, as well as fibrous proliferation of the gland's septa.^[12] The cytologic findings by themselves may not be specific, and the diagnosis requires adjunct consideration of both the ultrasonogram and clinical presentation. Application of magnetic resonance imaging (MRI) has been tried to non-invasively examine the morphological variations in Küttner's tumor and differentiate them from those seen in malignant tumors;^[13] while MRI findings of the affected tissue and the pattern of cellular infiltration may offer some diagnostic clues for this condition, so far the results have been inconclusive.^[13]

Pathogenesis

The etiology and pathogenesis of this chronic condition are not very well understood. Several factors have been postulated:

• Formation of a hard salivary calculus or sialolith by accumulation of calcium salts in the duct of the salivary gland (a process known as Sialolithiasis). This has been proposed as the most common etiology for Küttner's tumor of the submandibular gland, with sialoliths observed in an appreciable proportion of cases.^[14][15] However, sialolith involvement may not be found in many cases.
• Abnormalities of the salivary gland ducts leading to excessive accumulation or retention of ductal secretions, which can excite chronic inflammations.^[6]
• Immune, especially autoimmune, etiology^[16] - which has gained steam, given the observation that the tissue of the glands is overrun with lymphoid immune cells^[17] and fibrous connective tissue, as well as corroboration from markedly similar lesions (with histologic and immunohistochemical findings) seen elsewhere in the body.^[18][19] The presence of abundant Immunoglobulin G4 (IgG4) associated with Plasma cells infiltrating into the salivary glands, as well as increased serum IgG4 concentration, has been noted with patients with Küttner's tumor.^[20][21][22]

This chronic condition is primarily observed in adult (40–70 years) patients. However, Küttner's tumor, with prominent immunopathological features, has been described in an 11-year-old boy in Brazil in 2012.^[23]

Existing treatment options

Standard, and most effective, therapy to date is glandular sialadenectomy, which is associated with fairly low operative morbidity; however, in recent times, the administration of steroid (which can shrink the inflammatory lesion and is known to reduce serum IgG4 values) has been considered favorably,^[20][21] and may be useful in younger patients or those who refuse surgery.

See also

• Sialadenitis

References

1. John H. Stone; Arezou Khosroshahi; Vikram Deshpande; et al. (October 2012). "Recommendations for the nomenclature of IgG4-related disease and its individual organ system manifestations". Arthritis & Rheumatism. 64 (10): 3061–3067. doi:10.1002/art.34593. PMID 22736240.
2. Küttner, H (1896). "Ueber entzündliche Tumoren der submaxillar-speicheldrüse". Beiträge zur Klinischen Chirurgie. 15: 815–828. Retrieved 15 November 2013.
3. Kiverniti, E; Singh A; Clarke P (2008). "Küttner's tumour: an unusual cause of salivary gland enlargement". Hippokratia. 12 (1): 56–58. PMC 2532958. PMID 18923750.
4. Blanco, Mario; Mesko T; Cura M; Cabello-Inchausti B (2003). "Chronic sclerosing sialadenitis (Kuttner's tumor): unusual presentation with bilateral involvement of major and minor salivary glands". Annals of Diagnostic Pathology. 7 (1): 25–30. doi:10.1053/adpa.2003.50004. PMID 12616471. Retrieved 15 November 2013.
5. Beriat, GK; Akmansu SH; Kocatürk S; Ataoğlu O (2010). "Chronic Sclerosing Sialadenitis (Küttner's tumour) of the Parotid Gland". Malaysian Journal of Medical Sciences. 17 (4): 57–61. PMC 3216182. PMID 22135562.
6. de Vicente, JC; López-Arranz E; García J; López-Arranz JS (2003). "Chronic sclerosing sialadenitis of the parotid gland". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 96 (1): 77–80. doi:10.1067/moe.2003.S1079210403000969. PMID 12847448. Retrieved 15 November 2013.
7. Speight, PM; Barrett AW (2002). "Salivary gland tumours". Oral Diseases. 8 (5): 229–240. doi:10.1034/j.1601-0825.2002.02870.x. PMID 12363107.
8. National Cancer Institute (NCI/NIH) (2012-07-20). "General Information About Salivary Gland Cancer". cancer.gov. Retrieved 15 November 2013.
9. Chan ACL; Chan JKC; Abbondanzo SL (2005). "Chapter 5. Tumours of the Salivary Glands". In Leon Barnes; John W. Eveson; Peter Reichart; David Sidransky. World Health Organization Classification of Tumours: Pathology and Genetics of Head and Neck Tumours (PDF). Lyon, France: WHO/IARC Press. p. 278. ISBN 92 83 22417 5. Retrieved 15 November 2013.
10. Chow, TL; Chan TT; Choi CY; Lam SH (2008). "Kuttner's tumour (chronic sclerosing sialadenitis) of the submandibular gland: a clinical perspective" (PDF). Hong Kong Medical Journal. 14 (1): 46–9. PMID 18239243. Retrieved 15 November 2013.
11. Chou, YH; Tiu CM; Li WY; Liu CY; Cheng YC; Chiou HJ; Chiou SY; Wang HK; Hung GS (2005). "Chronic sclerosing sialadenitis of the parotid gland: diagnosis using color Doppler sonography and sonographically guided needle biopsy". Journal of Ultrasound Medicine. 24 (4): 551–555. PMID 15784774. Retrieved 17 November 2013.
12. Cheuk, W; Chan, JKC (2002). "Kuttner Tumor of the Submandibular Gland: Fine-Needle Aspiration Cytologic Findings of Seven Case" (PDF). American Journal of Clinical Pathology. American Society for Clinical Pathology (117): 103–108. Retrieved 5 December 2013.
13. Abu, A; Motoori K; Yamamoto S; Hanazawa T; Nagai Y; Kaneoya K; Ito H (2008). "MRI of chronic sclerosing sialoadenitis". British Journal of Radiology. 81 (967): 531–536. doi:10.1259/bjr/38960620. PMID 18316344. Retrieved 17 November 2013.
14. Epivatianos, A; Harrison JD; Dimitriou T (2006). "Ultrastructural and histochemical observations on microcalculi in chronic submandibular sialadenitis". Journal of Oral Pathology and Medicine. 16 (10): 514–517. doi:10.1111/j.1600-0714.1987.tb00683.x. PMID 3127566.
15. Chan, JKC (1998). "Kuttner tumor (chronic sclerosing sialadenitis) of the submandibular gland: an underrecognized entity". Advances in Anatomic Pathology. 5 (4): 239–51. doi:10.1097/00125480-199807000-00004. PMID 9859756.
16. Ikeda, M; Ikui A; Tanaka M; Omori H; Tomita H (1994). "Immunohistopathological investigation on unspecific chronic sclerosing sialadenitis of the submandibular gland (Kuttner tumor)". Auris Nasus Larynx. 21 (2): 103–110. doi:10.1016/s0385-8146(12)80028-9. PMID 7993223.
17. Tiemann, M; Teymoortash A; Schrader C; Werner JA; Parwaresch R; Seifert G; Klöppel G (2002). "Chronic sclerosing sialadenitis of the submandibular gland is mainly due to a T lymphocyte immune reaction" (PDF). Modern Pathology. 15 (8): 845–852. doi:10.1097/01.MP.0000022280.72359.04. PMID 12181270. Retrieved 15 November 2013.
18. Tsuneyama, K; Saito K; Ruebner BH; Konishi I; Nakanuma Y; Gershwin ME (2000). "Immunological similarities between primary sclerosing cholangitis and chronic sclerosing sialadenitisreport of the overlapping of these two autoimmune diseases". Digestive Diseases and Sciences. 45 (2): 366–372. doi:10.1023/A:1005429130150. PMID 10711453.
19. Sekine, S; Nagata M; Watanabe T (1999). "Chronic sclerosing sialadenitis of the submandibular gland associated with idiopathic retroperitoneal fibrosis". Pathology International. 49 (7): 663–667. doi:10.1046/j.1440-1827.1999.00926.x. PMID 10504530.
20. Kamisawa, T; Nakajima H; Hishima T (2006). "Close correlation between chronic sclerosing sialadenitis and immunoglobulin G4". Internal Medicine Journal. 36 (8): 527–529. doi:10.1111/j.1445-5994.2006.01119.x. PMID 16866659. Retrieved 15 November 2013.
21. Nagai, K; Andoh K; Ogata A; Aoki N; Nakamura N; Hosaka H; Kurihara R (2010). "A new category for chronic sclerosing sialadenitis as an IgG4 related syndrome". BMJ Case Reports. 2010: bcr1020092412. doi:10.1136/bcr.10.2009.2412. PMC 3028012. PMID 22448185.
22. Cheuk, W; Yuen HK; Chu SY; Chiu EK; Lam LK; Chan JK (2008). "Lymphadenopathy of IgG4-related sclerosing disease". Am J Surg Pathol. 32 (5): 671–681. doi:10.1097/PAS.0b013e318157c068. PMID 18344866.
23. Melo, JC; Kitsko D; Reyes-Múgica M (2012). "Pediatric chronic sclerosing sialadenitis: Küttner tumor". Pediatric and Developmental Pathology. 15 (2): 165–169. doi:10.2350/11-04-1023-OA.1. PMID 21985393.

External links

• Salivary glands: Inflammation: Sialadenitis (with images) from Pathology Outlines.com