J Oral Pathol Med (2009) 38: 145–149
doi: 10.1111/j.1600-0714.2008.00676.x
New insights into the nature of Warthin’s tumour
Iain David O’Neill
Centre D’Affaires Poincare, 3 Rue Poincare Nice, France
Warthin’s tumour is considered heterogeneous as to its
pathogenesis with some data supporting a polyclonal
origin for the epithelium, implying a non-neoplastic nat-
ure. After inconsistent reports, current information from
molecular studies suggests that a recurrent t(11;19) and
associated CRTC1-MAML2 fusion oncogene character-
izes a subset of Warthin’s tumours and supports a clonal
origin in such cases. CRTC1-MAML2 is also a frequent
feature of mucoepidermoid carcinoma. These findings,
and the recent reports of Warthin’s tumour and
co-existent mucoepidermoid carcinoma with common
CRTC1-MAML2 expression, provide a morphological and
molecular framework for future studies as a basis for a
fresh appraisal of the pathogenesis of Warthin’s tumour.
The underlying molecular basis and the pivotal studies
defining such events are discussed.
J Oral Pathol Med (2009) 38: 145–149
Keywords: fusion oncogene; mucoepidermoid; pathogenesis;
t(11;19); translocation; Warthin’s tumour
Introduction
Warthin’s tumour (WT) or papillary cystadenoma
lymphomatosum’ is the second most common salivary
gland neoplasm, after pleomorphic adenoma, represent-
ing 4–11% of all salivary gland tumours (1, 2). The great
majority occur in the parotid gland, and less commonly
within peri-parotid lymph nodes, although presence at
other sites is reported (1, 3–5). Multifocal, often bilateral
involvement may be seen, which may be either synchro-
nous or metachronous (4, 6–8). Although a male
predilection is reported, a strong association with
tobacco use (8) and changing patterns are such that an
increasing proportion of females now also present (6, 9).
An association with Epstein–Barr virus infection has
also been noted, although the relationship remains
unclear (10, 11).
Morphologically, WT comprise both an oncocytic
double-layered epithelial component, typically arranged
Correspondence: Iain David O’Neill, Centre d’Affaires Poincaré – de
l’immeuble 3, 3 Rue Poincaré Nice 06000, France. Tel: +33 4 93 96 74
29, Fax: +33 497 07 10 01, E-mail: iain.oneill@hotmail.com
Accepted for publication March 11, 2008
ª 2008 The Author. Journal compilation ª 2008 Blackwell Munksgaard Æ All rights reserved
www.blackwellmunksgaard.com/jopm
as papillary projections lining cystic spaces, and an
associated follicular lymphoid stroma. These features
suggest a developmental relationship between the
tissues, with two mechanisms considered. One is that
WT develops from heterotopic salivary ductal ele-
ments trapped within intra- or peri-parotid lymph
nodes, with an alternative proposal being that WT
represents a ductal cell proliferation arising within
salivary gland tissue which induces an intense lym-
phocytic infiltration (12, 13). Whatever developmental
origins are valid, the lymphoid component to WT is
polyclonal (14).
Nevertheless it is the nature of the epithelial compo-
nent that is of greater interest, i.e. it is truly neoplastic or
simply proliferative. Until recently, available data from
molecular studies strongly suggested that the epithelial
component of WT is also polyclonal. The use of the
HUMARA assay for the X-linked human androgen
receptor in one series of WT demonstrated a polyclonal
inactivation pattern within the epithelial component
(15). A subsequent molecular study of WT found a near
total absence of clonal allelic losses across a wide
number of tumour suppressor genes supporting a non-
clonal epithelial proliferation (16). At this time, a
supporting basis for a genuine clonal nature for WT
was restricted to a less number of cytogenetic studies in
which chromosomal translocations have been demon-
strated. The presence of a t(11;19) translocation, either
as the sole abnormality (17) or as part of a more
complex abnormal karyotype was of particular interest
(18, 19). However, the rarity of such events and the more
robust data for a polyclonal origin supported the
hypothesis that although WT as a group may be
heterogeneous regarding pathogenesis, the majority of
WT were non-clonal in origin (20). Although some
consider that such polyclonal features are indicative of a
reactive or hyperplastic process (15, 16, 20), it should be
noted that other lesions have also been similarily
characterized as being both polyclonal and neoplastic.
X-linked polyclonality has recently been demonstrated
in sacral chordoma (21), whereas others have recognized
that certain breast carcinomas also have a polyclonal
origin (22).
Now, recent studies on the nature of the t(11;19)
translocation, and its associated novel CRTC1- MAML2
fusion oncogene, increasingly recognized as having a role
 The nature of Warthin’s tumour
O’Neill
146
in mucoepidermoid carcinoma (MEC) of the salivary
glands and lung, have revealed that such events are also
a feature of certain WT (23). The information derived
from such studies and its implications, allows a fresh
consideration as to the nature of WT.
t(11;19) and the CRTC1- MAML2 fusion
oncogene
Initial cytogenetic studies on MEC arising from salivary
glands demonstrated a recurrent t(11;19) reciprocal
translocation, either as part of a more complex abnor-
mal karyotype or as the sole chromosomal abnormality,
with similar observations reported in MEC arising
within the lung (23, 24). Positional cloning of the
t(11;19) translocation identified in primary tumour
samples from salivary gland and lung and also MEC-
derived cell lines found that this translocation results in
the fusion of exon 1 of the CTRC1 gene (also known as
MECT1, TORC1, or WAMTP1) on chromosome 19p13
with exons 2–5 of the MAML2 gene on chromosome
11q21 to generate a novel CRTC1-MAML2 fusion
oncogene (25, 26). Both constituent genes in this
translocation have roles in cell-cycle control in their
normal state, with CRTC1 acting as a cAMP response
element-binding protein (CREB) co-activator, and
MAML2 involved in Notch receptor signalling. In the
novel CRTC1-MAML2 oncogene, the CREB binding
domain from CRTC1 replaces the free intracellular
Notch binding domain from MAML2, to produce a
chimeric gene with novel transformation properties
(Fig. 1). CRTC1-MAML2 is oncogenic in vitro and
in vivo, as shown by the induction of foci within an
immortalized rat RK3E cell-line (25) and tumour
formation in nude mice injected with CRTC1-MAML2
transfected RK3E cells, with sustained ectopic expres-
Figure 1 Schematic illustration of the CRTC1 and MAML2 genes and the resulting CRTC1-MAML2 fusion oncogene associated with t(11;19).
The Notch-binding domain of MAML2 is replaced by the CREB binding domain of CRTC1 which is fused to exons 2–5 of the MAML2 gene. This
fusion oncogene remains under the control of the CRTC1 promoter.
J Oral Pathol Med
sion of the fusion transcript required for tumourigenesis
(27).
The identification and cloning of the CRTC1-
MAML2 oncogene has allowed the development of
molecular probes which may detect the fusion transcript
in both archival and fresh tumour tissue, allowing the
study of transcript expression in both MEC and WT.
CRTC1-MAML2 in salivary gland tumours
Before discussing the role of CRTC1-MAML2 in WT, a
brief summation of its association with MEC may be
helpful. Clinico-pathological studies have shown that
CRTC1-MAML2 is important in MEC, and is present
in 38–81% of tumours (28–31), with expression seen in
mucous, epidermoid and intermediate cells (29). Such
tumour transcript expression is not tissue-specific being
detected in MEC arising in both minor and major
salivary glands, lung and thyroid gland (31). These
findings suggest that in this tumour, CRTC1-MAML2
acts at an early stage in tumour initiation. The recently
reported example of MEC characterized by a t(11;15)
translocation and associated variant fusion oncogene,
CRTC3-MAML2, in which a CRTC1-related CREB,
CRTC3 present on chromosome 15, acts as an alter-
native fusion partner with MAML2, provides further
support for such a mechanism (32).
Despite initial results suggesting a restricted presence in
low and intermediate grade tumours, this fusion has been
demonstrated in all histological grades and may be
present in all clinical stages. However, limited data
does suggest that there may be inherent biological
differences between fusion-positive and fusion-negative
tumours with the former showing improved clinical out-
come as measured by significantly lower presence of dis-
tant metastases and greater disease-free survival (29–31).

The relationship between WT and CRTC1-MAML2
was initially less certain. Studies that demonstrated
transcript expression in 70% and 38% of MEC failed to
show expression in seven and 26 cases respectively of
WT (28, 30). Indeed, there was some debate as to the
validity of any such association with the belief being that
in the salivary glands, transcript expression was limited
to MEC (33, 34). However, a subsequent study which
found that 81% of MEC was fusion positive also
showed that 36% (4 out of 11 cases) of WT also
harboured the CRTC1-MAML2 oncogene (31) con-
firming that in the salivary glands, CRTC1-MAML2 is
not restricted to MEC, and may also be expressed by an,
albeit small subset of WT. That WT as a group that
have a more limited prevalence of oncogene expression
is supported by another recent study, which reports that
only 4% (2 out of 48 cases) of WT analysed were fusion
positive (35). Furthermore, both cases carrying this
transcript were characterized histologically by squa-
mous metaplasia and necrosis within the epithelial
component. Very recently, an intriguing investigation
further documents the relationship between WT, MEC
and CRTC1-MAML2 (36). In this investigation, three
cases of WT with co-existent MEC were analysed for
CRTC1-MAML2 transcript expression, as well as a WT
with co-existent metastatic melanoma and also a case of
primary malignant WT. The authors reported that all
the five cases studied were fusion positive. Specifically,
all benign elements of WT, the malignant WT and the
co-existent MEC were fusion positive whereas, as may
be expected, the melanoma was negative for the tran-
script. In the three cases of WT with co-existent MEC,
squamous metaplastic changes were noted in the onco-
cytic epithelium juxtaposed between the WT and MEC.
Implications for Warthin’s tumour
The data outlined above suggests that, for a subset of
WT, a chromosomal translocation with the generation
of a novel fusion-oncogene is an important feature. As
such an event is by necessity, clonal in nature then the
implication is that a corresponding subset of WT is truly
clonal, consistent with a neoplastic process. Other
studies have shown that WT is polyclonal in origin,
with some arguing that this implies a reactive non-
neoplastic nature. Leaving such distinctions aside, with
the data now available, it would now seem that WT as a
group are heterogeneous regarding their pathogenesis,
with morphologically similar lesions being either poly-
clonal, and possibly reactive in nature or clonal, and
unquestionably neoplastic.
The distinction of pathogenetically diverse tumour
subsets by the presence of the CRTC1-MAML2 tran-
script has also been considered for another benign
epithelial neoplasm, clear cell hidradenoma, a benign
sweat gland tumour. This tumour has also been asso-
ciated with a t(11;19) and a recent study found the
transcript was present in 50% of such cases, with
expression being restricted to clear cell variants of this
tumour (37). As it has been proposed that such variants
are of apocrine derivation while poroid forms have an
The nature of Warthin’s tumour
O’Neill
147
eccrine origin (38), this provides an interesting parallel
to WT regarding tumour sub-type heterogeneity depen-
dant upon the underlying initiating factors. This and the
guarded understanding that in MEC, fusion expression
confers an improved clinical outcome, with an inherent
difference in biological behaviour from MEC lacking
the CRTC1-MAML2 oncogene, suggests a common
molecular basis across three distinct tumour types. In
part, this is consistent with the concept that molecular
events are as important as conventional histogenetic-
based models of tumour development (39).
The molecular consequences of the CRTC1-MAML2
in WT are not well documented. Limited data suggest
that transcript expression is associated with altered
expression of cAMP⁄ CREB and Notch-responsive genes
in WT in a similar manner to that seen in MEC (29) but
the significance of this remains unclear. The cell biology
of WT is poorly understood. The oncocytic epithelium is
rich in mitochondria which show mitochondrial DNA
deletions which may be a response to smoking (40, 41).
Indeed, it has been suggested that this is the fundamen-
tal event in all WT, with such a mechanism also seen in
oncocytic (Hurthle cell) tumours of the thyroid (20, 42,
43).
Although the great majority of WT are benign, with
an excellent clinical outcome, malignant transformation
is occasionally reported, including that to MEC (44). As
such, the recent study demonstrating the co-existence
and evolution of WT and MEC is of particular interest
(36). In all cases, both benign and malignant elements
expressed the CRTC1-MAML2 as did a case of malig-
nant WT. In response to these findings, the authors
proposed a model for the pathogenesis of WT. In this,
the initial step was mitochondrial dysfunction within
salivary duct cells resulting in oncocytic change. This
tissue may either proliferate in a reactive polyclonal
fashion, or following a t(11;19) and CRTC1-MAML2
generation, undergo a truly neoplastic clonal expansion.
In this latter group, as a third step, such cells undergo
further, as of yet undefined genetic alterations which
could predispose to malignant transformation. Such a
model would account for the clonal heterogeneity seen
in WT as described above.
However, the speculation that clonal expansion driven
by CRTC1-MAML2 may predispose per se to malig-
nant change in WT may be ambitious. Given the high
frequency of this oncogene in MEC, and that, although
the data are limited, CRTC1-MAML2 is a feature of a
significant minority of WT, the common finding in
co-existing tumours may be coincidental. It should be
remembered that WT is a relatively common salivary
gland tumour and that malignant transformation remains
rarely reported. Thus, although highly interesting, at
present it remains as speculation. Further investigation
of larger series of both conventional WT and those with
any associated malignancy, including that of non-MEC
or oncocytic histology would be of great value. How-
ever, the efforts of this group and others who have
contributed to our understanding of this particular
fusion oncogene in both WT and other tumours, and
extended our knowledge of such events in epithelial
J Oral Pathol Med
 The nature of Warthin’s tumour
O’Neill
148
neoplasia in general, have certainly provided a sound
foundation for future studies.
Concluding remarks
Although until recently, studies suggested that the
epithelial component of WT was polyclonal, with some
considering this to imply a non-neoplastic, reactive
nature, it is clear that a subset of WT are characterized
by a recurrent t(11;19) with its associated CRTC1-
MAML fusion oncogene, a feature also shared by MEC.
Such WT are clonal and truly neoplastic, supporting the
view that this tumour has a genuinely heterogeneous
pathogenesis. It is also speculated that WT carrying this
oncogene may be predisposed to malignant transforma-
tion, although this is inferred from limited data. Such
events may serve as a morphological and molecular
framework for future studies as a basis for a fresh
appraisal of the pathogenesis of this tumour.
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Acknowledgements
The author would like to thank the anonymous reviewer(s) for the helpful
comments and suggestions prior to the final publication of this article.
J Oral Pathol Med