Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contact Us Login 
An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists

  Table of Contents    
Year : 2016  |  Volume : 20  |  Issue : 2  |  Page : 224-229

Role of fine-needle aspiration cytology in the diagnosis of major salivary gland tumors: A study with histological and clinical correlation

1 Department of Pathology, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India
2 Department of Pathology, BGS Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India

Date of Submission22-May-2015
Date of Acceptance20-May-2016
Date of Web Publication11-Jul-2016

Correspondence Address:
Archana Shetty
Department of Pathology, Sapthagiri Institute of Medical Sciences and Research Center, Street No. 15, Hesaraghatta Main Road, Bengaluru - 560 090, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-029X.185899

Rights and Permissions



Introduction: Neoplastic lesions of salivary glands present an interesting subject because of their histologic diversification. Complex features exhibited by them have aroused considerable speculations concerning their histogenesis and continues to hold the interest of clinicians and pathologists. Major salivary glands are superficial and have easy accessibility for fine-needle aspiration cytology (FNAC). These glands are generally not subjected to incisional or core needle biopsy, because of the possible risks of fistula formation and tumor seedling. FNAC diagnosis of major salivary gland neoplasms aids in proper planning of required surgery and avoidance of the same in cases of non-neoplastic lesions.
Materials and Methods: Cytological features of major salivary gland tumors diagnosed on FNAC were studied over a period of one and a half years. Cytological and architectural patterns in smears were compared with histopathological features in cases where the specimens were available with a note on the age, sex and presenting complaints. Statistical Analysis: Analysis of variance (ANOVA) was used to find the significance of study parameters.Chi-square/Fisher Exact was used to find the significance of study parameters on categorical scale between two or more groups. P value of <0.05 was considered to be significant.
Results: A total of 114 salivary gland FNACs were done, 75 patients were clinically suspected to be neoplasms. The peak incidence was in the third to fourth decade of life with a female preponderance. Parotid was the most commonly affected gland (80%) with pleomorphic adenoma and mucoepidermoid carcinoma (10.7%) being the most common benign and malignant tumors respectively. The diagnostic accuracy of FNAC was 97.6%. Warthins tumor was misdiagnosed and was associated with a strong smoking history.
Conclusion: Salivary gland neoplasms constitute a small but significant percentage of head and neck tumors. FNAC is inexpensive, quick, and aids in the preoperative diagnosis and planning of surgery.

Keywords: Fine-needle aspiration cytology, histopathology, major salivary gland tumors, Warthin's tumor

How to cite this article:
Shetty A, Geethamani V. Role of fine-needle aspiration cytology in the diagnosis of major salivary gland tumors: A study with histological and clinical correlation. J Oral Maxillofac Pathol 2016;20:224-9

How to cite this URL:
Shetty A, Geethamani V. Role of fine-needle aspiration cytology in the diagnosis of major salivary gland tumors: A study with histological and clinical correlation. J Oral Maxillofac Pathol [serial online] 2016 [cited 2021 Nov 28];20:224-9. Available from: https://www.jomfp.in/text.asp?2016/20/2/224/185899

   Introduction Top

Salivary gland tumors, because of their diversity, till date continue to hold the interest of the surgeons and the pathologists. Although fine needle aspiration cytology (FNAC) is now part of routine clinical practice for the evaluation of thyroid tumors [1] and cervical lymph nodes, no consensus has been reached concerning the role of this procedure in the management of salivary glands lesions, as some authors consider that it has a low sensitivity for diagnosis of malignant salivary tumors.[2],[3]

The purpose of this study was to determine the diagnostic value of FNAC to define its place and its advantages in the diagnostic strategy. The study also adds a note on the clino-pathological details of the same.

   Materials and Methods Top

All patients presenting to the surgical and ENT outpatient departments, as cases of salivary gland swellings, were subjected to FNAC after obtaining consent. Nonneoplastic lesions were not included in the study. FNA was performed under aseptic precautions, after obtaining the patient details. Aspirates were stained with May-Grunwald-Giemsa (MGG), Papanicolaou (PAP) and haematoxylin and eosin (H and E) stains. Histopathological correlation was made in cases where the surgically resected specimens were available. The sensitivity, specificity and accuracy of FNA were calculated using appropriate statistical methods Analysis of variance (ANOVA) was used to find the significance of study parameters between three or more groups of patients. Post-Hoc Tukey test was used to find the pair wise significance. Chi-square/Fisher Exact was used to find the significance of study parameters on categorical scale between two or more groups. P value of <0.05 was considered to be significant.

   Results Top

During the study, a total of 2051 FNAC's were performed out of which salivary gland FNAC's constituted 114 in number (5.5%), of which 39 were nonneoplastic lesions.

The peak incidence of tumors was in the third to fourth decade, with the oldest patient being 68-year-old, with a slight female preponderance. The parotid was the most commonly affected gland as shown in [Table 1].
Table 1: Site distribution of salivary gland tumours

Click here to view

Swelling was the most common complaint (100%), followed by associated pain (21.3%). FNAC diagnosis of the tumors was as presented in [Table 2].
Table 2: Analysis of fine needle aspiration cytology of major salivary gland tumours

Click here to view

Cytological features of tumors on cytology correlated with histopathology in relation to plemorphic adenoma [Figure 1]a and [Figure 1]b, oncocytoma [Figure 2]a and [Figure 2]b, adenoid cystic carcinoma (ACC) [Figure 3]a and [Figure 3]b and Mucoepidermoid carcinoma [Figure 4]a and [Figure 4]b.
Figure 1: Plemorphic adenoma (a) cytology showing a mixture of myoepithelial and plasmacytoid cells against a chondromyxoid background black arrow (H&E stain, ×100). (b) Histopathology of pleomorphic adenoma (H&E stain, ×100)

Click here to view
Figure 2: Oncocytoma (a) cytology showing monolayered sheets of oncocytes (arrow) in a clean background (H&E stain, ×400). (b) Histopathology of oncocytoma showing Groups of benign oncocytes (H&E stain, ×100)

Click here to view
Figure 3: Adenoid cystic carcinoma (a) cytology showing scattered hyaline globules (arrow) with adherent hyperchromatic, small monotonous tumour cells (Pap stain, ×400) (b) histopathology of adenoid cystic carcinoma (H&E stain, ×40)

Click here to view
Figure 4: Mucoepidermoid carcinoma (a) cytology showing a mixture of epithelial, intermediate and mucin secreting cells with relatively bland nuclei (Pap stain, ×400) (b) histopathology of mucoepidermoid carcinoma (H&E stain, ×200)

Click here to view

The two non-diagnostic aspirates were from large swellings in the parotid region that yielded only necrotic material, posing a diagnostic dilemma. The histopathological correlation later proved both the cases to be Warthin's tumors with extensive cystic change [Figure 5]a,[Figure 5]b,[Figure 5]c.
Figure 5: (a) Huge swelling in the left parotid region. (b) Fine needle aspiration cytology smear showing only hemorrhage and necrotic debris on repeated aspirates (H&E stain, ×100). (c) Surgically resected specimen showing a solid tumor with large areas of cystic change, confirmed as Warthins tumor on histopathology

Click here to view

Postoperative correlation with histopathology

The histopathological correlation was available for 56 cases and was correlated with the FNAC diagnosis. The sensitivity and specificity along with P value for the various tumors is presented in [Table 3].
Table 3: Correlation of fine needle aspiration cytology with histopathological diagnosis - an evaluation

Click here to view

Two cases of Warthins tumors could not be diagnosed on FNAC, thus reducing the sensitivity.

   Discussion Top

The incidence of major salivary gland tumors is found to be 18.8 cases/year. This correlates with the study conducted by Fernandes and Pandit.[4] Majority of the major salivary gland neoplasms arise in the parotid gland. In this study, also the majority of the tumors were arising in the parotid gland (80%), which co-relates well with the studies till date.

Salivary gland neoplasms, present as asymptomatic slowly growing masses, with associated pain being the next most common symptom; pain and fixity to the overlying skin are ominous signs.[5],[6]

Pleomorphic adenoma was the most common benign tumour, with slight female preponderance occurring mainly in the third decade of life.[7],[8] It most commonly affects the parotid gland,[7],[9],[10] cytology of the tumour shows a combination of bland epithelial cell in aggregates and sheets and fragments of the fibrillary chondromyxoid stroma.[7] This tumor posed no cytological difficulties in our study.

Warthin's tumor, the second most common benign tumor occurs mainly in the fifth to sixth decade, with a male preponderance.[11],[12] Warthin's tumor is known to occur predominantly in smokers. The risk of developing Warthin's tumor is 8 times high in smokers as compared to nonsmokers.[13],[14] In this study also, all the patients who were diagnosed as cases of Warthin's tumor gave a smoking history. The present study reported 2 cases of nondiagnostic aspirates on FNAC. The smears from repeated aspirates showed only nonspecific findings such as scattered squamous cells, lymphocytes and inflammatory infiltrate in a hemorrhagic background. On histopathology, the tumors were diagnosed as Warthin's. Oncocytic tumors like the Warthin's tumors are known to undergo cystic change, misleading the diagnoses as in the present study, even after repeated aspirates.[15],[16],[17]

Cytological features of oncocytoma are described classically as sheets of monotonous looking epithelial cells with abundant granular eosinophilic cytoplasm and round to oval nuclei with minimal lymphoid infiltration in the background.[18] The smears of aspirated oncocytoma in the present study also showed similar features and the diagnosis on histopathology was also oncocytoma involving the parotid gland.

Shafkat et al.[5] and Paik et al.[19] reported mucoepidermoid carcinoma to be the commonest malignant tumor occurring in the major salivary glands, with parotid being the favoured site.[10] Cytological features suggestive of mucoepidermoid carcinoma which include intermediate cells, squamous cells and overlapping epithelial groups [20] were all seen in varying proportions in our study.

ACC was the 2nd most common malignant tumor in our study similar to other studies.[5],[21],[22] However, few studies also [10],[23] document it to be the most common salivary gland tumor. The hyaline globules are described as the most striking features of ACC's. Hyaline globules are also seen in cases of epithelial-myoepithelial carcinomas, basal cell adenomas and occasionally in cases of pleomorphic adenomas also. These globules are homogenous structures occurring either singly or surrounded by epithelial cells.[24] However, basal cell adenoma can be differentiated by the peripheral palisading of the tumor cells and presence of squamous morules on smears. Truly chondromyxoid matrix on FNA smears with spindle cells is a feature specific to pleomorphic adenoma. Epithelial myoepithelial carcinoma, a rare entity has cells with pale and indistinct cytoplasm which is so fragile, that it disperses in the background and most of the cells appear as naked nuclei. The chromatin in these cells is pale with a discrete central nucleoli.[9],[16]

Cytological features of salivary gland tumours can often overlap, hence the final diagnosis must always take into account cellular, stromal and clinical features into account.

Fine needle aspiration cytology as a diagnostic procedure

The accuracy of FNAC as correlated with the histopathological diagnosis was 94.6% in our case and correlates with other studies. FNAC is a reliable procedure for preoperative examination that provides valuable information for the preoperative diagnostic work-up. It alerts the surgeon to the possible presence of malignancy, helps in definition of a surgical plan regarding resection margins, assess the need for lymph node dissection and the degree of urgency of treatment.

The sensitivity and specificity of the FNA were calculated using appropriate methods, and the results of the present study were compared with the other studies as shown in [Table 4].
Table 4: Comparative analysis of comparison of sensitivity and specificity of fine needle aspiration cytology with other studies

Click here to view

FNAC is a reliable examination procedure that provides valuable information for the preoperative diagnostic work-up and alerts the surgeon to the possible presence of malignancy. As the complication rate logically increases with the degree of invasiveness of the surgical procedure, it is important to be able to characterize the tumor preoperatively to correctly inform the patient about the type of surgery that will be performed, the need for lymph node dissection and the possibility of nerve sacrifice.[25],[26]

   Conclusion Top

Major salivary gland neoplasms present with nonspecific clinical symptoms, needing a high degree of suspicion. This study reaffirms that FNAC of the major salivary gland neoplasms is a safe, quick and affordable investigative procedure. It also offers an invaluable and highly accurate initial diagnostic tool for the management of patients even in the era of the brown stain, immunohistochemistry. However, occasionally tumors like Warthin's have a tendency to undergo severe cystic degeneration leading to nondiagnostic aspirates, making histopathological diagnosis confirmatory in such cases.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Sellami M, Tababi S, Mamy J, Zainine R, Charfi A, Beltaief N, et al. Interest of fine-needle aspiration cytology in thyroid nodule. Eur Ann Otorhinolaryngol Head Neck Dis 2011;128:159-64.  Back to cited text no. 1
Fakhry N, Antonini F, Michel J, Penicaud M, Mancini J, Lagier A, et al. Fine-needle aspiration cytology in the management of parotid masses: Evaluation of 249 patients. Ann Otolaryngol Chir Cervicofac 2007;124:41-5.  Back to cited text no. 2
Zbären P, Guélat D, Loosli H, Stauffer E. Parotid tumors: Fine-needle aspiration and/or frozen section. Otolaryngol Head Neck Surg 2008;139:811-5.  Back to cited text no. 3
Fernandes GC, Pandit AA. Diagnosis of salivary gland tumours by FNAC. Bombay Hosp J 2002;4:201-6.  Back to cited text no. 4
Shafkat A, Mohhainmad L, Rouf A. Clinicopathological study of primary salivary gland tumours in Kashmir. JK Pract 2002;9:231-33.  Back to cited text no. 5
Nagarkar NM, Bansal S, Dass A, Singhal SK, Mohan H. Salivary gland tumors – Our experience. Indian J Otolaryngol Head Neck Surg 2004;56:31-4.  Back to cited text no. 6
Masanja MI, Kalyanyama BM, Simon EN. Salivary gland tumours in Tanzania. East Afr Med J 2003;80:429-34.  Back to cited text no. 7
Schneider AB, Lubin J, Ron E, Abrahams C, Stovall M, Goel A, et al. Salivary gland tumors after childhood radiation treatment for benign conditions of the head and neck: Dose-response relationships. Radiat Res 1998;149:625-30.  Back to cited text no. 8
Ito FA, Jorge J, Vargas PA, Lopes MA. Histopathological findings of pleomorphic adenomas of the salivary glands. Med Oral Patol Oral Cir Bucal 2009;14:E57-61.  Back to cited text no. 9
Schoeman BJ, Clifford SD. The incidence of malignancy in neoplasms of the submandibular salivary gland. S Afr J Surg 2007;45:134-5.  Back to cited text no. 10
Lima SS, Soares AF, de Amorim RF, Freitas Rde A. Epidemiologic profile of salivary gland neoplasms: Analysis of 245 cases. Braz J Otorhinolaryngol 2005;71:335-40.  Back to cited text no. 11
Faur A, Lazar E, Cornianu M, Dema A, Vidita CG, Galuscan A. Warthin tumor: A curious entity – Case reports and review of literature. Rom J Morphol Embryol 2009;50:269-73.  Back to cited text no. 12
Teymoortash A. Head and Neck: Salivary Gland Tumors: Warthin's tumours. Atlas Genet Cytogenet Oncol Haematol 2009;13(4):312-315.  Back to cited text no. 13
Mistry D, Sood S. Benign salivary gland tumours. CME bulletin otolaryngology. Head Neck Surg 2004;8:49-52.  Back to cited text no. 14
Javadi M, Asghari A, Hassannia F. Value of fine-needle aspiration cytology in the evaluation of parotid tumors. Indian J Otolaryngol Head Neck Surg 2012;64:257-60.  Back to cited text no. 15
Canan E, Aysun UH, Ulku T, Levent S, Mete K. Fine needle aspiration cytology of the salivary glands; a twelve years experience. Aegean Pathol J 2004;1:51-6.  Back to cited text no. 16
Lurie M, Misselevitch I, Fradis M. Diagnostic value of fine-needle aspiration from parotid gland lesions. Isr Med Assoc J 2002;4:681-3.  Back to cited text no. 17
Chakrabarti I, Basu A, Ghosh N. Oncocytic lesion of parotid gland: A dilemma for cytopathologists. Journal of Cytology/Indian Academy of Cytologists. 2012;29(1):80-82.  Back to cited text no. 18
Paik I, Lee HK, Lee YD. The role of fine needle aspiration cytology of salivary gland tumours. J Korean Surg Soc1999;57:533-40.  Back to cited text no. 19
Klijanienko J, Vielh P. Fine-needle sampling of salivary gland lesions. IV. Review of 50 cases of mucoepidermoid carcinoma with histologic correlation. Diagn Cytopathol 1997;17:92-8.  Back to cited text no. 20
Das DK, Petkar MA, Al-Mane NM, Sheikh ZA, Mallik MK, Anim JT. Role of fine needle aspiration cytology in the diagnosis of swellings in the salivary gland regions: A study of 712 cases. Med Princ Pract 2004;13:95-106.  Back to cited text no. 21
Seifert G, Donath K. The congenital basal cell adenoma of salivary glands. Contribution to the differential diagnosis of congenital salivary gland tumours. Virchows Arch 1997;430:311-9.  Back to cited text no. 22
Eglis K, Juris T, Gunars L. Treatment of parotid gland tumours in latvian oncological center. Stomatologija Baltic Dent Maxillofac J 2005;7:110-4.  Back to cited text no. 23
Holger N, Hermann HJ, Rainer L, Reinhard C, Manfred D. Cytologic diagnosis of adenoid cystic carcinoma of the salivary glands. Diagn Cytopathol 1999;20:358-66.  Back to cited text no. 24
Fakhry N, Antonini F, Michel J, Penicaud M, Mancini J, Lagier A, et al. Fine-needle aspiration cytology in the management of parotid masses: Evaluation of 249 patients. Eur Ann Otorhinolaryngol Head Neck Dis 2012;129:131-5.  Back to cited text no. 25
Jain R, Gupta R, Kudesia M, Singh S. Fine needle aspiration cytology in diagnosis of salivary gland lesions: A study with histologic comparison. Cytojournal 2013;10:5.  Back to cited text no. 26
[PUBMED]  Medknow Journal  


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Utility of the Milan system for reporting salivary gland cytopathology: A retrospective 5?years study
Jyoti Chirmade, Kanchan Kothari, Leena Naik, Mona Agnihotri
Diagnostic Cytopathology. 2021; 49(4): 500
[Pubmed] | [DOI]
2 Role of fine needle aspiration in malignant parotid tumors at a single-center experience: A retrospective cohort study
Ashwag Alwagdani, Mohammad Alhejaili, Abdulaziz Alanzi, Saif Alghamdi
Annals of Medicine and Surgery. 2021; 64: 102229
[Pubmed] | [DOI]
3 The Milan System for Reporting Salivary Gland Cytopathology: Assessment of Cytohistological Concordance and Risk of Malignancy
Shilpy Jha, Suvradeep Mitra, Suvendu Purkait, Amit Kumar Adhya
Acta Cytologica. 2021; 65(1): 27
[Pubmed] | [DOI]
Rifat Qureishi, M.H. Usmani, U.R. Singh, P.C. Kol
[Pubmed] | [DOI]
5 Change in Warthin’s tumor incidence: a 20-year joinpoint trend analysis
Orhan Tunç, Burhanettin Gönüldas, Yusuf Arslanhan, Muzaffer Kanlikama
European Archives of Oto-Rhino-Laryngology. 2020; 277(12): 3431
[Pubmed] | [DOI]


Print this article  Email this article


    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
  Related articles
    Article in PDF (2,247 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Materials and Me...
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded387    
    Comments [Add]    
    Cited by others 5    

Recommend this journal

© Journal of Oral and Maxillofacial Pathology | Published by Wolters Kluwer - Medknow
Online since 15th Aug, 2007