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An Official Publication of the Indian Association of Oral and Maxillofacial Pathologists

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Year : 2021  |  Volume : 25  |  Issue : 2  |  Page : 327-331

Secretory carcinoma of salivary gland – A systematic review of pediatric case reports and case series

1 Lecturer, Department of Oral Pathology and Microbiology, SRM Dental College, Chennai, Tamil Nadu, India
2 Professor, Department of Oral Pathology and Microbiology, Saveetha Dental College, Chennai, Tamil Nadu, India

Date of Submission30-Jun-2020
Date of Decision28-Jan-2021
Date of Acceptance18-May-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
V Vasanthi
Department of Oral Pathology and Microbiology, SRM Dental College, SRMIST, Ramapuram, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-029X.325236

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Aim: Mammary analog secretory carcinoma (MASC) is a new pathological entity of salivary gland origin recognized as Secretory Carcinoma (SC) in the WHO 2017 classification. Pediatric cases of MASC were reviewed systematically from 2010 to 2019.
Materials and Methods: Databases were searched from 2010 to 2019 for pediatric case reports and case series, excluding retrospective studies. A total of 12 manuscripts were reviewed for clinical, histological and immunohistochemical findings.
Results: A total of 13 pediatric cases (11 case reports and 1 case series of 2 cases) of MASC in pediatric patients were found. The youngest reported age was 5 years. The common site was parotid gland usually presenting as a slowly growing firm, painless mass.
Conclusion: MASC should be considered in the differential diagnosis of salivary gland tumors in pediatric population, especially from parotid gland. Extended research on such recent entities with more inputs from new cases reported in literature may outstretch the possibilities of therapeutic fusion inhibition in future.

Keywords: Mammary analog, pediatric case reports, pediatric case series, salivary gland, secretory carcinoma

How to cite this article:
Vasanthi V, Ramadoss R. Secretory carcinoma of salivary gland – A systematic review of pediatric case reports and case series. J Oral Maxillofac Pathol 2021;25:327-31

How to cite this URL:
Vasanthi V, Ramadoss R. Secretory carcinoma of salivary gland – A systematic review of pediatric case reports and case series. J Oral Maxillofac Pathol [serial online] 2021 [cited 2021 Dec 3];25:327-31. Available from: https://www.jomfp.in/text.asp?2021/25/2/327/325236

   Introduction Top

Mammary analog secretory carcinoma (MASC) is a neoteric salivary gland tumor with genetic, histologic and immunophenotypic equivalence to Secretory Carcinoma (SC) of the breast. This novel pathological entity was acknowledged in the WHO 2017 classification as SC.[1] Less than 300 cases have been published so far, more prevalent in parotid gland and minor salivary glands.[2]

SC of the breast, a variant of mammary ductal carcinoma, was described by McDivitt and Stewart. As the synchronous mention goes as juvenile breast cancer, it is predominant in 3–15 years and less frequent in the elderly. Studies reported that the molecular pathogenesis of SC of the breast is chromosomal translocation of t (12;15), (p13; q25), resulting in fusion of transcriptional regulator gene ETV6 with membrane receptor kinase NTRK3. Fusion gene promotes oncogenesis through activation of RAS-MAP pathway and phosphatidylinositol 3-kinase-protein kinase B pathway, by tyrosine kinase causing increased cell proliferation and survival of tumor cells. Identical translocations were documented in myelogenous leukemia, infantile fibrosarcoma and congenital mesoblastic nephroma in the past. At present, cases of MASC have been reported in thyroid gland.[3],[4],[5]

Skalova et al. in 2010 explored matching histological, immunohistochemical and genetic translocations from archives of salivary gland tumors by fluorescence in situ hybridization (FISH), reverse transcriptase-polymerase chain reaction (RT-PCR) and described them as MASC. They were earlier reported as zymogen-poor acinic cell carcinoma/adenocarcinoma NOS, low-grade cystadenocarcinoma. They reported 16 such cases, 13 from parotid and 3 from minor salivary glands of buccal mucosa, upper lip and palate, respectively.[3],[4],[5]

MASC clinically presents as a slow-growing, asymptomatic, non-aggressive mass, with male predominance in the age group of 21–75 years (mean – 46 years). Vast majority of cases were reported in parotid gland and minor salivary glands of buccal mucosa, palate and palate. Size of the slow-growing mass varies between 0.7 and 5.5 cm (mean-2.1 cm).[3],[4],[5]

Macroscopically, the tumor is, unencapsulated, well circumscribed, firm to rubbery in consistency, gray white to brown on cut surface with variable cystic component. The microscopic presentation is, heretogeneous with various patterns. Low-grade tumor cells with eosinophilic cytoplasm and vesicular, oval-to-round nuclei, central nucleoli and fine granular chromatin are most commonly reported. Various patterns include solid, microcystic, tubular, glandular and papillary–cystic. Microcysts and tubular spaces are filled with bubbly, colloid-like Periodic acid-Schiff (PAS) +ve secretion.[3],[4],[5],[6],[7]

Histochemical studies prove to be a confirmatory tool next to FISH and RT-PCR considering the economic resources for FISH. MASC shows positivity for S100, vimentin and mammaglobin. Other positive markers include pan-cytokeratin (AE1–AE3 and CAM5.2), EMA, CK7, CK8, CK18, CK19, GATA3, SOX10, Muc1, Muc4, STAT5A and GCDFP15. The cells show negative staining for basal cell and myoepithelial cell markers such as p63. Some cases have reported p63 positivity in areas of peripheral staining suggestive of intraductal component of MASC.[7]

Molecular detection by FISH remains the gold standard as fusion gene has not been reported so far in any other salivary gland tumor. Novel ETV6-non NTRK3 fusion and ETV6-X gene fusion other than exon5-exon15 have been delineated. These atypical junctions may correlate to densely hyalinized fibrous septa, thick fibrosclerotic stroma and infiltrative histologic features.[7]

MASC is reported to rarely metastasize, though lymphovascular, perineural, extraglandular invasion and necrosis may prevail. Cases of high-grade transformation have been documented.

Management ranges from excision to neck dissection based on aggressiveness. Surgical exploration through neck dissection with/without postoperative radiotherapy and chemotherapy is being followed as a treatment modality. Preoperative radiotherapy was not considered in the sequelae. ETV6 may serve as a therapeutic target in inhibition of gene fusion. In vitro studies suggest inhibitors of insulin-like growth factor-1 might block the translocation between ETV and NTRK.[8]

Thereby, behavior and presentation of MASC in an adult patient as reported in the literature have been abridged to analyze the distinguishing features of MASC in pediatric patients. This systematic review was put forward to address the clinical, histopathological and immunohistochemical presentation of pediatric cases of MASC.

   Materials and Methods Top

Data sources

Databases such as PubMed, Crossref, Cochrane, Science Direct and Google Scholar were searched for keywords, namely SC, mammary analog, pediatric cases using Boolean operators AND/OR in various combinations using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Search strategy

Case reports from 2010 to 2019 were extracted and duplicates were removed. Only case reports and case series were included, retrospective studies were excluded. Case reports of more than 18 years of age were excluded. Case reports of MASC of skin, nasal cavity, lungs and thyroid were excluded. Studies in language other than English were excluded.

   Results Top

Following the initial search using Medical Subject Headings (MeSH) terms, 18 articles from PubMed, 2 from Crossref, 3 from Cochrane, 3 from Science direct and 16 from Google Scholar were obtained [Figure 1]. The manuscripts were filtered based on the inclusion and exclusion criteria following which a total of 13 cases (11 case reports and 1 case series of 2 cases) were evaluated according to the objectives of the study [Table 1].
Figure 1: Data extraction as per PRISMA guidelines

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Table 1: Overview of reported pediatric cases of SC

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   Discussion Top

Salivary gland neoplasms constitute 2% to 6% of all head-and-neck cancers. Pediatric salivary gland malignancies are reported to be <5%.[20] Secondary salivary gland malignancies arising postradiation are the most common in children and constitute 6% of all secondary pediatric malignancies. Mucoepidermoid carcinoma is reported to be the most prevalent pediatric secondary salivary gland malignancy.[21]

SC of the salivary gland shares morphological, immunological and molecular profiles with SC of the breast which may be attributed to both having tubuloacinar exocrine glands. Despite these analogous criteria, difference in clinical behavior is observed as salivary gland SC is most common in 21–75-year-old male patients as compared to 3–15-year-old female cases in SC of the breast.[22]

Of the 13 pediatric cases evaluated, the mean age was 12.7 years ranging from 5 to 17 years, with a M: F ratio of 1:1.2. The sex predilection was not compatible with the published reports of adult cases. This may be attributed to the limited number of pediatric cases reported. Of 13 pediatric cases, 12 were from parotid and 1 from buccal mucosa. Vast majority of adult cases were also from parotid. The smallest size of SC among 13 cases was 1 cm and largest was 20 cm, both from parotid. The mean size of SC from adults is 0.7 to 5.5 cm. Location of the tumor may also contribute to the size. Clinical presentation was asymptomatic, painless mass with indolent course, also consistent with the adult literature. Only one pediatric case had SC arising as a secondary malignancy from treated atypical teratoid rhabdoid tumor.

Fine-needle aspiration cytology was performed in 6 cases of 13 and advanced imaging techniques were performed as a diagnostic aid in all 13 cases. Histologically, microcystic, tubular and solid patterns with eosinophilic bubbly secretions were the most common patterns in pediatric cases too. Lymph node metastasis and perineural invasion are also important features of SC with aggressive course. High-grade transformation of SC has not been reported in pediatric population though observed in adults.

Management of SC is yet to be well documented as most of the studies are retrospective. Parotidectomy was the treatment of choice in pediatric cases as compared to surgical management with/without postoperative chemotherapy and radiotherapy in the management of adult SC. Postoperative follow-up details were available for 7 cases. Sparsity of clinical data with respect to management and long-term follow-up of pediatric SC can add up to the need for therapeutic target in near future.

However, the review has certain limitations such as evidence selection bias where studies with statistically significant outcomes were only published and retrospective studies, studies with only abstracts were not included in the study.

   Conclusion Top

The diagnosis of SC in pediatric cases is challenging due to the paucity of cases reported. SC should be considered in the differential diagnosis of salivary gland tumors in pediatric population, especially from parotid gland. Although pediatric clinical, immunologic and histological presentation is similar to the adult literature published so far, extended research on such recent entities with more inputs from new cases reported in literature may outstretch the possibilities of therapeutic fusion inhibition in future.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Boon E, Valstar MH, van der Graaf WTA, Bloemena E, Willems SM, Meeuwis CA, et al. Clinicopathological characteristics and outcome of 31 patients with ETV6-NTRK3 fusion gene confirmed (mammary analogue) secretory carcinoma of salivary glands. Oral Oncol 2018;82:29-33.  Back to cited text no. 1
Boliere C, Murphy J, Qaisi M, Manosca F, Fung H. Mammary analogue secretory carcinoma of the palate: Case report and review of the literature. Case Rep Dent 2019;7416302.  Back to cited text no. 2
Skálová A, Vanecek T, Sima R, Laco J, Weinreb I, Perez-Ordonez B, et al. Mammary analogue secretory carcinoma of salivary glands, containing the ETV6-NTRK3 fusion gene: A hitherto undescribed salivary gland tumor entity. Am J Surg Pathol 2010;34:599-608.  Back to cited text no. 3
Balanzá R, Arrangoiz R, Cordera F, Muñoz M, Luque-de-León E, Moreno E, et al. Mammary analog secretory carcinoma of the parotid gland: A case report and literature review. Int J Surg Case Rep 2015;16:187-91.  Back to cited text no. 4
Salat H, Mumtaz R, Ikram M, Din NU. Mammary analogue secretory carcinoma of the parotid gland: A third world country perspective-a case series. Case Rep Otolaryngol 2015:697254.  Back to cited text no. 5
Inaba T, Fukumura Y, Saito T, Yokoyama J, Ohba S, Arakawa A, et al. Cytological features of mammary analogue secretory carcinoma of the parotid gland in a 15-year-old girl: A case report with review of the literature. Case Rep Pathol 2015:656107.  Back to cited text no. 6
Skalova A, Michal M, Simpson RH. Newly described salivary gland tumors. Mod Pathol 2017;30:S27-43.  Back to cited text no. 7
Inaki R, Abe M, Zong L, Abe T, Shinozaki-Ushiku A, Ushiku T, et al. Secretory carcinoma-Impact of translocation and gene fusions on salivary gland tumor. Chin J Cancer Res 2017;29:379-84.  Back to cited text no. 8
Rastatter JC, Jatana KR, Jennings LJ, Melin-Aldana H. Mammary analogue secretory carcinoma of the parotid gland in a pediatric patient. Otolaryngol Head Neck Surg 2012; 146:514-5.  Back to cited text no. 9
Hwang MJ, Wu PR, Chen CM, Chen CY, Chen CJ. A rare malignancy of the parotid gland in a 13-year-old Taiwanese boy: Case report of a mammary analogue secretory carcinoma of the salivary gland with molecular study. Med Mol Morphol 2014;47:57-61.  Back to cited text no. 10
Woo J, Seethala RR, Sirintrapun J. Mammary analogue secretory carcinoma of the parotid gland as a secondary malignancy in a childhood survivor of atypical teratoid rhabdoid tumor. Head and Neck Pathol 2014;8:194-7.  Back to cited text no. 11
Keisling M, Bianchi M, Pascasi JM. Mammary analog secretory carcinoma of salivary gland in a 5 year old: Case report. Int J Pediatric Otorhinolaryngol 2014;9:163-5.  Back to cited text no. 12
Quattlebaum SC, Roby B, Dishop MK, Said MS, Chan K. A pediatric case of mammary analogue secretory carcinoma within the parotid. Am J Otolaryngol 2015;36:741-3.  Back to cited text no. 13
Joshi P, Mridha AR, Singh S, Kinra P, Ray R, Thakar A. Large lipid-rich mammary analogue secretory carcinoma of parotid gland: An unusual case. Indian J Pathol Microbiol 2015;58:351-3.  Back to cited text no. 14
[PUBMED]  [Full text]  
Oza N, Sanghvi K, Shet T, Patil A, Menon S, Ramadwar M, et al. Mammary analogue secretory carcinoma of parotid: Is preoperative cytological diagnosis possible? Diagn Cytopathol 2016;44:519-25.  Back to cited text no. 15
Ngouajio AL, Drejet SM, Phillips DR, Summerlin DJ, Dahl JP. A systematic review including an additional pediatric case report: Pediatric cases of mammary analogue secretory carcinoma. Int J Pediatr Otorhinolaryngol 2017;100:187-93.  Back to cited text no. 16
Shukla S, Kashyap A, Sharma S, Kamal L. Mammary analogue secretory carcinoma-A salivary gland neoplasm: Case report of an exceptionally rare tumour. J Clin Diagn Res 2018;12:ED01-2.  Back to cited text no. 17
Chen YC, Hsua HT, Lin YH, Chena LC, Lina YF. Mammary analog secretory carcinoma of the parotid gland: A case of a 12-year-old Taiwanese girl. Int J Pediatric Otorhinolaryngol Case Rep 2018;20:14-7.  Back to cited text no. 18
Shigeta R, Orgun D, Mizuno H, Hayashi A. Mammary analogue secretory carcinoma arising in the parotid gland of child. Plast Reconstr Surg Glob Open 2018;6:e2059.  Back to cited text no. 19
Shapiro NL, Bhattacharyya N. Clinical characteristics and survival for major salivary gland malignancies in children. Otolaryngol Head Neck Surg 2006;134:631-4.  Back to cited text no. 20
Cheuk DK, Shek TW, Chan GC, Lau YL, Ha SY, Chiang AK. Parotid acinic cell carcinoma in a long-term survivor of childhood acute lymphoblastic leukemia. Pediatr Blood Cancer 2006;50:636-9.  Back to cited text no. 21
Murase R, Sumida T, Ishikawa A, Murase R, McAllister SD, Hamakawa H. Novel therapeutic strategies for malignant salivary gland tumors: lessons learned from breast cancer. Int J Otolaryngol 2011:187623.  Back to cited text no. 22


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