High grade transformation in adenoid cystic carcinoma of the parotid: report of a case with cytologic, histologic and immunohistochemical study

Abstract

Adenoid cystic carcinoma (ACC) constitutes about 4% of salivary epithelial tumors and is the second common malignant epithelial salivary gland tumor involving both the major and minor salivary glands. High grade transformation in ACC is a recently recognized entity with only a few cases reported in literature. We report the first case of ACC with high grade transformation involving the parotid. A 54-year-old man with a history of right parotid painful swelling from 1.5 years presented with recent increase in size of the swelling and facial paresis of 2 months duration. The locally invasive salivary neoplasm was composed predominantly of an undifferentiated carcinoma with foci of conventional ACC occupying less than 10% of tumor area. Immunohistochemical study of the undifferentiated component as compared to conventional ACC showed greater over-expression of p53 and Ki-67. Her-2/Neu was negative in both components. Recognition of occasional clusters of basaloid cells and hyaline globules in association with larger poorly differentiated malignant cell population in aspiration smears can help in cytological diagnosis. The acquisition of high proliferation index and over-expression of p53 may be the probable factors involved in the pathogenesis of high grade transformation in a conventional ACC.

Keywords: Adenoid cystic; Carcinoma; Cytology; Ki-67; Parotid; Pathology; p53.

Fig. 1

FNA smears showing dispersed population of highly pleomorphic cells with a small cluster of isomorphic basaloid cells surrounding a hyaline globule (arrow) (MGG)

Fig. 2

High grade ACC component showing pleomorphic undifferentiated cells with frequent mitoses (arrows)

Fig. 3

Conventional ACC component with isomorphic basaloid cells in cribriform pattern (upper left) and high-grade undifferentiated ACC component (lower right)

Fig. 4

Nuclear positivity for Ki67 (arrows) in greater proportion of cells in high-grade component (lower right) as compared to conventional component (upper left) (DAB)