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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 : 361-363

Salivary amylase crystalloids in Warthin's tumor: An aspiration cytodiagnosis

Department of Pathology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission25-Aug-2020
Date of Decision08-Jun-2021
Date of Acceptance10-Jun-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
Subhransu Kumar Hota
Department of Pathology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-029X.325241

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Crystalloids may be seen in a variety of salivary gland lesions, but their presence is not common. Among various types of crystalloids, amylase crystalloids are usually found in benign lesions of the salivary gland. Here, we report a case of a 76-year-old male with swelling on the angle of the mandible left side for 15 days. Local examination showed a solitary soft-to-firm swelling of size 4.7 cm × 4.1 cm × 2.8 cm. Ultrasonography (USG) showed a well-defined cystic lesion with the solid component. Fine-needle aspiration cytology cytosmears showed predominantly mixed inflammatory cells; few epithelial cell clusters with numerous crystalloids which are rectangular to rhomboid shape with nonparallel sides. Cytological features are suggestive of benign cystic sialadenitis with amylase crystalloids. However, after 3 months of follow-up, as the swelling did not subside, excisional biopsy was done and histopathology showed features of Warthin's tumor with crystalloids. The presence of amylase crystalloids in any type of salivary gland lesion with cystic change; multiple aspirations followed by histopathological examination should be done to rule out neoplastic etiology.

Keywords: Excisional biopsy, fine-needle aspiration cytology, swelling angle of mandible

How to cite this article:
Hota SK, Giri R, Sharma T, Senapati U. Salivary amylase crystalloids in Warthin's tumor: An aspiration cytodiagnosis. J Oral Maxillofac Pathol 2021;25:361-3

How to cite this URL:
Hota SK, Giri R, Sharma T, Senapati U. Salivary amylase crystalloids in Warthin's tumor: An aspiration cytodiagnosis. J Oral Maxillofac Pathol [serial online] 2021 [cited 2021 Dec 8];25:361-3. Available from: https://www.jomfp.in/text.asp?2021/25/2/361/325241

   Introduction Top

Amylase type crystalloids (nontyrosine crystals) are angular, rectangular and nonbirefringent with geometric shapes ranging between 5 μ and 500 μ of size and stained orange with Papanicolaou (PAP), dark blue in diff quick and pink in hematoxylin-eosin (H & E) stain.[1] However, amylase crystalloids are commonly associated with inflammatory and benign lesions including chronic sialadenitis, lymphoepithelial cysts and Warthin's tumor.[2] Crystalloids in the salivary gland can be seen in fine-needle aspiration cytology (FNAC) of neoplastic and nonneoplastic lesions of salivary glands.[3] Here, we are describing a case of parotid gland swelling on aspiration showing few salivary gland epithelial cells and plenty of inflammatory cells with amylase crystalloids. Cytological diagnosis was benign cystic sialadenitis with amylase crystalloids subsequently diagnosed on histology as “Warthin's tumor” with crystalloids.

   Case report Top

A 76-year-old male presented with swelling in the left angle of the mandible for 15 days. USG showed a well-defined cystic lesion with solid component and smooth septation. His general and systemic examinations revealed no significant findings. Hematological and biochemical profiles were within normal limits except hemoglobin level was low. The local examination of the left neck revealed a solitary, soft-to-firm well-defined swelling measuring 4.7 cm × 4.1 cm × 2.8 cm [Figure 1]a. It was mildly tender. The overlying skin was unremarkable. The oral cavity, head and neck region showed no infective foci. The FNAC was performed with a 24G needle attached to a 10 ml syringe holder and yielded necrotic-like material. Cytological examination of the smear revealed moderately cellular smears composed of mixed inflammatory cells predominantly neutrophils, lymphocytes and few histiocytes. Few clusters of benign epithelial cells with some showing oncocytic change and many degenerated cells seen. In addition, the background showed many geometrical crystalline structures dispersed in a necrotic background. Their shape ranged from rectangular, rod-shaped to elongated rhomboid shape and nonbirefringent. They are bluish in Leishman stain [Figure 1]b, eosinophilic in H & E [Figure 1]c and reddish to orange color in PAP stain [Figure 1]d. Their structures morphologically resembled amylase crystalloids. No malignant cells, granuloma, or fungal elements were identified. Although oncocytic change seen in our cases as oncocytic metaplasia of epithelial cells usually occurs in this type of lesion, we could not think of it in the line of Warthin's tumor. A final cytological diagnosis of benign cystic sialadenitis with amylase crystalloid was made. Supportive treatment was given and asked for a follow-up. After 3 months, again the patient had come with swelling. Excisional biopsy was done followed by histopathology. It showed a feature of Warthin's tumor with a cystic cavity filled with similar crystalline structures [Figure 2]a and [Figure 2]b.
Figure 1: (a) Clinical picture shows swelling over the left side of neck. (b) Microphotograph shows rod and rectangular shape bluish color crystalloids (Leishman's stain [×400]). (c) Microphotograph shows rod and rectangular shape eosinophilic color crystalloids (H & E stain, [ ×400]). (d) Microphotograph shows rod-shaped orange color crystalloids. (PAP stain, [ ×400])

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Figure 2: (a and b) Histopathological picture shows Warthin's tumor having cyst lined by oncocytic cells and lumen contains rod shapes crystalloids and inflammatory cells. (a, H & E [×100], b, H & E [×400])

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   Discussion Top

There are a variety of causes of salivary gland enlargement which include both neoplastic and nonneoplastic conditions. FNAC plays a great role in the evaluation of these salivary gland lesions. Rarely, crystalloid structures can be found in FNAC of salivary gland lesions. These crystalloids have been described in association with various nonneoplastic and neoplastic entities. Different types of crystalloids include tyrosine-rich crystalloids, collagenous crystalloids and nontyrosine crystalloids.[4] Morphologically, these crystalloids are composed of radially arranged, needle-shaped fibers that are nonrefractile. Amylase crystalloids are nonbirefringent and very often associated with benign lesions such as sialadenitis, sialolithiasis, oncocytic metaplasia and oncocytic neoplasms (Warthin's tumor, oncocytoma, oncocytic cystadenoma and mixed tumor with oncocytic features).[2] They were originally considered a matter of nonneoplastic disease, but Gilcrease et al. identified them on oncocytic neoplasms.[5] Hence, rendering a specific diagnosis based on the presence of such crystalloids is very difficult. Nasuti et al. stated that the presence of amylase crystalloids should not be accepted as a marker of specific salivary gland pathology.[6]

Crystalloids seen in our case morphologically resembled amylase crystalloids described in the literature. The presence of very few clusters of epithelial cell clusters with the predominance of inflammatory cells and necrotic debris mislead our cytological diagnosis as inflammatory lesion which was subsequently diagnosed as Warthin's tumor on histopathology. A review of the literature showed that amylase crystalloids have been mostly encountered on FNA smears of salivary glands with sialadenitis and sialolithiasis. Nasuti et al. said that amylase crystalloids should not be accepted as a noncellular marker of specific salivary gland pathology because various reports show that crystalloids can be seen in various salivary gland lesions.[6] They described amylase crystalloids in Warthin's tumor and oncocytic cystadenoma.

   Conclusion Top

Although crystalloids in salivary gland lesion on fine-needle aspiration are an uncommon finding, amylase crystalloids are commonly associated with the inflammatory lesion. It is a well-known fact that the presence of amylase crystalloids in any salivary gland lesion having cystic change, multiple aspirations followed by histopathological examination should be done to rule out any neoplastic pathology.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Gupta RK, Green C, Fauck R, Lallu S, Naran S. Fine needle aspiration cytodiagnosis of sialadenitis with crystalloids. Acta Cytol 1999;43:390-2.  Back to cited text no. 1
López-Ríos F, Ballestín C, Martínez-González MA, Serrano R, de Agustín PP. Lymphoepithelial cyst with crystalloid formation. Cytologic features of two cases. Acta Cytol 1999;43:277-80.  Back to cited text no. 2
Paker I, Anlar M, Genel N, Alper M. Amylase crystalloids on the fine-needle aspiration of the salivary gland. Turk J Pathol 2010;26:153-5.  Back to cited text no. 3
Issac RM, Oommen AM, Mathai JM. Crystalloids in salivary gland lesions. J Cytol 2014;31:194-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
Gilcrease MZ, Nelson FS, Guzman-Paz M. Tyrosine-rich crystals associated with oncocytic salivary gland neoplasms. Arch Pathol Lab Med 1998;122:644-9.  Back to cited text no. 5
Nasuti JF, Gupta PK, Fleisher SR, LiVolsi VA. Nontyrosine crystalloids in salivary gland lesions: Report of seven cases with fine-needle aspiration cytology and follow-up surgical pathology. Diagn Cytopathol 2000;22:167-71.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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