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Presented by Eric Burks, MD and prepared by Jeffrey T. Schowinsky, M.D.
Case 1: The patient is a 78-year-old woman with an enlarged right neck mass, in the region of the tail of the parotid gland.
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1. Question
Week 308: Case 1
The patient is a 78-year-old woman with an enlarged right neck mass, in the region of the tail of the parotid gland./images/041607EB1a.jpg
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/images/041607EB1d.jpgCorrect
Answer: Extranodal marginal zone B cell lymphoma, MALT type
Histology: The specimen is from a salivary gland which is hardly recognizable as a result of a dense lymphoid infiltrate. From low-power the infiltrate has a nodular architecture which is the result of expanded reactive germinal centers which have been colonized and disrupted by the neoplastic marginal zone cells. While the cytology of these cells vary, they characteristically have abundant clear cytoplasm producing a “monocytoid” appearance. As can bee seen in this case, these monocytoid B-cells form confluent sheets between the germinal centers and overrun epithelial structures producing lymphoepithelial lesions.
Discussion: The principle differential diagnosis in the salivary gland is myoepithelial sialadenitis (MESA) and MALT. Both conditions are characterized by a dense small lymphocytic infiltrate with reactive germinal centers and lymphoepithelial lesions. Similarly, monocytoid B-cells may be seen in both conditions, however in MESA the monocytoid B-cells form narrow zones around epithelial structures whereas in MALT, these zones form confluent sheets overrunning germinal centers as seen in this case. In difficult cases, either molecular of immunophenotypic evidence of clonality may be required to distinguish MALT from MESA. While other low grade lymphoproliferative disorders may secondarily involve the salivary gland, the histologic heterogeneity as well as the characteristic monocytoid cytology exclude these disorders.
Incorrect
Answer: Extranodal marginal zone B cell lymphoma, MALT type
Histology: The specimen is from a salivary gland which is hardly recognizable as a result of a dense lymphoid infiltrate. From low-power the infiltrate has a nodular architecture which is the result of expanded reactive germinal centers which have been colonized and disrupted by the neoplastic marginal zone cells. While the cytology of these cells vary, they characteristically have abundant clear cytoplasm producing a “monocytoid” appearance. As can bee seen in this case, these monocytoid B-cells form confluent sheets between the germinal centers and overrun epithelial structures producing lymphoepithelial lesions.
Discussion: The principle differential diagnosis in the salivary gland is myoepithelial sialadenitis (MESA) and MALT. Both conditions are characterized by a dense small lymphocytic infiltrate with reactive germinal centers and lymphoepithelial lesions. Similarly, monocytoid B-cells may be seen in both conditions, however in MESA the monocytoid B-cells form narrow zones around epithelial structures whereas in MALT, these zones form confluent sheets overrunning germinal centers as seen in this case. In difficult cases, either molecular of immunophenotypic evidence of clonality may be required to distinguish MALT from MESA. While other low grade lymphoproliferative disorders may secondarily involve the salivary gland, the histologic heterogeneity as well as the characteristic monocytoid cytology exclude these disorders.
