Background: Salivary gland tumors comprise a heterogeneous group of lesions exhibiting diverse cytomorphological patterns. Fine-needle aspiration cytology (FNAC) is widely employed as a first-line diagnostic tool due to its simplicity, rapidity, and minimally invasive nature. Nevertheless, considerable overlap exists between benign and malignant salivary gland neoplasms, making accurate diagnosis challenging. Recognition of specific cytomorphological characteristics associated with malignancy can significantly enhance diagnostic confidence and improve patient management.

Objective: To evaluate cytomorphological features predictive of malignancy in salivary gland aspirates and determine their diagnostic significance.

Materials and Methods: A retrospective observational study involving 180 salivary gland FNAC specimens collected over five years was conducted. Cytological smears were reviewed for cellularity, nuclear pleomorphism, chromatin characteristics, nucleoli, mitotic activity, necrosis, background inflammation, mucin, extracellular matrix, and cellular architecture. Histopathological diagnosis served as the gold standard wherever available. Statistical analysis included sensitivity, specificity, predictive values, and logistic regression.

Results: Of 180 aspirates, 126 (70%) were benign and 54 (30%) were malignant. Significant predictors of malignancy included marked nuclear pleomorphism (94.4%), irregular nuclear membranes (90.7%), coarse chromatin (88.9%), prominent nucleoli (87.0%), necrosis (74.1%), increased mitotic figures (72.2%), and discohesive cellular arrangement (68.5%). FNAC demonstrated a sensitivity of 92.6%, specificity of 96.0%, positive predictive value of 91.0%, negative predictive value of 96.8%, and overall diagnostic accuracy of 94.8%.

Conclusion: Careful assessment of multiple cytomorphological parameters substantially improves the diagnostic accuracy of salivary gland FNAC. Nuclear atypia combined with necrosis and mitotic activity represents the strongest predictor of malignancy.