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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 6  |  Page : 1418-1421

Mucoepidermoid carcinoma of the minor salivary gland: Presenting as ranula


1 Department of Oral Medicine and Radiology, Y.C.M.M. and R.D.F's Dental College, Ahmednagar, Maharashtra, India
2 Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Narketpally, Telangana, India
3 Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Hyderabad, Telangana, India

Date of Web Publication28-Nov-2018

Correspondence Address:
Pavani Donempudi
Department of Oral Medicine and Radiology, Y.C.M.M. and R.D.F's Dental College, Ahmednagar, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.204884

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 > Abstract 


Malignant tumors of the salivary gland are rare, clinically diverse group of neoplasms, among which mucoepidermoid carcinomas (MECs) are reported to be most frequently occurring epithelial carcinomas. MEC at times misleads the clinician because of its atypical location and innocent appearance. Here, we report a case of low-grade MEC in a 70-year-old female patient in the floor of the mouth mimicking as ranula clinically. Individuals with a history of malignancy are at risk for the development of additional malignant tumors; hence, follow-up of 2 years did not show any recurrence or additional tumors.

Keywords: Carcinomas, mucoepidermoid carcinoma, ranula, salivary gland neoplasm


How to cite this article:
Donempudi P, Bhayya H, Venkateswarlu M, Avinash Tejasvi M L, Paramkusam G. Mucoepidermoid carcinoma of the minor salivary gland: Presenting as ranula. J Can Res Ther 2018;14:1418-21

How to cite this URL:
Donempudi P, Bhayya H, Venkateswarlu M, Avinash Tejasvi M L, Paramkusam G. Mucoepidermoid carcinoma of the minor salivary gland: Presenting as ranula. J Can Res Ther [serial online] 2018 [cited 2020 Jul 8];14:1418-21. Available from: http://www.cancerjournal.net/text.asp?2018/14/6/1418/204884




 > Introduction Top


Mucoepidermoid carcinoma (MEC) is the most common malignant neoplasm of major and minor salivary glands and can also occur as an intraosseous tumor frequently called as central MEC.[1] In 1895, Volkman described these tumors for first time; later, it was elaborated by Stewart et al. in 1945 as mucoepidermoid tumor. In 1953, Foot and Frazell named these tumors as MEC. About two-third arise within the parotid gland, and one-third arise within the minor salivary glands. When MEC arises in the minor salivary glands, it can be located in different areas such as palate, retromolar area, floor of the mouth, buccal mucosa, lips, and tongue. Low-grade MEC at times misleads the clinician because of its atypical location and innocent appearance. In the present paper, we describe a case of a low-grade MEC in a 70-year-old female patient, arising from the minor salivary gland located in the floor of the mouth which is very rare in occurrence.


 > Case Report Top


A 70-year-old female patient came to the Department of Oral Diagnosis with a chief complaint of swelling on the left side of floor of the mouth for 1 year, which was associated with mild pain for 1 month. The patient noticed a small swelling in floor of the mouth, which was initially smaller and gradually increased to the present size. Intraoral soft tissue examination revealed a solitary diffuse swelling seen on floor of the mouth on left side which is roughly oval and measuring about 2 cm × 3 cm extending anteriorly from lingual frenum and posteriorly till mesial aspect of 36, medially ventral aspect of tongue, and laterally extending into lingual vestibule in relation to 32–36. Surface color of the swelling appears to be same as that of normal mucosa [Figure 1] with bluish tinge on the lateral aspect of swelling [Figure 2]. On palpation, swelling was slightly tender and consistency was variable with cystic consistency at the center and hard at the periphery. Extraoral examination revealed a single palpable submandibular lymph node on the left side, measuring approximately 1 cm × 1 cm in size, roughly spherical, freely mobile, firm in consistency, and tender on palpation. Based on the history and clinical examination, it was provisionally diagnosed as ranula.
Figure 1: Diffuse swelling in floor of the mouth on the left side

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Figure 2: Clinical picture showing bluish hue on the surface of lateral aspect of swelling

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Orthopantomogram [Figure 3] and occlusal radiographs [Figure 4] did not show any changes. Ultrasonography revealed evidence of solid hypoechoic mass on the left side anterosuperior to submandibular gland, suggestive of malignancy.
Figure 3: Orthopantomogram did not show any periapical pathology and bone invasion

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Figure 4: Occlusal radiograph showed no calcified calculi

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Gross specimen of excisional biopsy performed under local anesthesia [Figure 5], subjected to histopathological evaluation. Based on the histological features [Figure 6] and [Figure 7], a diagnosis of low-grade MEC was made. Adjuvant therapy of surgical excision of palpable left submandibular lymph node was offered. Follow-up of 2 years did not show any recurrence.
Figure 5: Excised gross surgical specimen

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Figure 6: Histopathological section under low power (×10) showing prominent mucin-filled cystic spaces, minimal cellular atypia and a high proportion of mucous cells along with well-formed glandular structures. There is also presence of epidermoid and intermediate cells arrange in the form of sheets separated by thin connective tissue septa

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Figure 7: Histopathological section under high power (×40) showing cellular atypia. High proportion of mucous cells along with epidermoid and intermediate cells

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 > Discussion Top


MEC is a malignant glandular epithelial neoplasm characterized by mucous, intermediate and epidermoid cells, with columnar, clear cells and oncocytoid features.[2] According to Eversole, incidence of MEC was found to be 89.6% in parotid, 8.4% submandibular, and 0.4% sublingual gland.[3] Tumors of the minor salivary glands account for 10%–15% of all salivary gland neoplasms. The palate is the most common site for all tumors of minor salivary gland origin (55%) and more than 60% of these are malignant. About 3.5% of MEC of minor salivary gland occur in floor of the mouth.[4] The mean age of occurrence of MEC is 48 years (range 12–82 years) with peaks in the fifth and sixth decades of life although it may occur at any age[5] and affects women more often than men (3:2).[6] The present case was seen in a 70-year-old female patient in floor of the mouth which is a rare entity.

The MEC in minor salivary glands are usually slowly developing lesions which are asymptomatic with a history lasting from 1½ to 10 years. The most common complaint is a painless swelling in the mouth (60%). Clinically, MEC may manifest as a lesion of color ranging from blue to red or purple. The tumor of low-grade malignancy usually appears as a slowly enlarging painless mass which simulates the pleomorphic adenoma. Because of their tendency to develop cystic areas, these intraoral lesions may bear close clinical resemblance to the mucous retention phenomenon or mucocele.[7] The tumor of high-grade malignancy grows rapidly and does produce pain as an early symptom; they are not encapsulated and they tend to infiltrate the surrounding tissue.[2] In the present reported case, the swelling was diffuse and was arising from the minor salivary gland with blue tinge and partially encapsulate with a mild tenderness on palpation, which had classical appearance of ranula of the floor of the mouth.

The diagnosis of MEC and its grading can however be achieved only after histological examination. These tumors are classified as either a high grade or a low grade, depending on the ratio of epidermal cells to mucous cells.[8] The low-grade tumor has a higher ratio and is a less aggressive lesion. The high-grade form is considered to be a more malignant tumor and has a poorer prognosis.

Treatment of MEC includes surgery which remains the main modality of treatment. For loco-regional control of the disease a wide surgical resection, selective cervical lymphadenectomy and adjuvant postoperative radiotherapy is recommended.[9] Currently, surgery followed by radiation is the recommended treatment for high-grade tumor and intermediate-grade tumors; low-grade tumors can be managed by surgery alone. Elective lymph node dissection is not necessary in patients with low-grade and intermediate-grade tumors.[10] The present reported case was treated by complete surgical excision along with adjuvant therapy of surgical excision of palpable left submandibular lymph node, and after 2 years follow-up, there was no history of recurrence.


 > Conclusion Top


At times, atypical locations and innocent appearance of the tumor such as the one reported in the present case can mislead the clinician and can lead to an erroneous diagnosis. Routine investigations may at times be inconclusive, pressing the need for more specific and advanced investigatory procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Jansisyanont P, Blanchaert RH Jr., Ord RA. Intraoral minor salivary gland neoplasm: A single institution experience of 80 cases. Int J Oral Maxillofac Surg 2002;31:257-61.  Back to cited text no. 1
    
2.
Barnes L, Eveson JW, Reichart P, Sidransky D, editors. WHO Classification of Tumours. Pathology and Genetics of Head and Neck Tumours. Lyon: IARC Press; 2005. p. 209-82.  Back to cited text no. 2
    
3.
Eversole LR. Mucoepidermoid carcinoma: Review of 815 reported cases. Oral Surg Oral Med Oral Pathol 1970;28:490-4.  Back to cited text no. 3
    
4.
Pires FR, de Almeida OP, de Araújo VC, Kowalski LP. Prognostic factors in head and neck mucoepidermoid carcinoma. Arch Otolaryngol Head Neck Surg 2004;130:174-80.  Back to cited text no. 4
    
5.
Triantafillidou K, Dimitrakopoulos J, Iordanidis F, Koufogiannis D. Mucoepidermoid carcinoma of minor salivary glands: A clinical study of 16 cases and review of the literature. Oral Dis 2006;12:364-70.  Back to cited text no. 5
    
6.
Auclair PL, Goode RK, Ellis GL. Mucoepidermoid carcinoma of intraoral salivary glands. Evaluation and application of grading criteria in 143 cases. Cancer 1992;69:2021-30.  Back to cited text no. 6
    
7.
Spiro RH. Management of malignant tumors of the salivary glands. Oncology (Williston Park) 1998;12:671-80.  Back to cited text no. 7
    
8.
Clarós P, Dominte G, Clarós A, Castillo M, Cardesa A, Clarós A. Parotid gland mucoepidermoid carcinoma in a 4-year-old child. Int J Pediatr Otorhinolaryngol 2002;63:67-72.  Back to cited text no. 8
    
9.
Ozawa H, Tomita T, Sakamoto K, Tagawa T, Fujii R, Kanzaki S, et al. Mucoepidermoid carcinoma of the head and neck: Clinical analysis of 43 patients. Jpn J Clin Oncol 2008;38:414-8.  Back to cited text no. 9
    
10.
Rajendran R, Shivapathasundhram B. Shafer's Textbook of Oral Pathology. 5th ed. New Delhi: Elsevier Publication; 2006. p. 1223-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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