Optimizing preoperative assessment of salivary gland lesions: updates and practical implications in the Milan System 2nd edition

Salivary gland lesions encompass a broad clinicopathologic spectrum and remain challenging in the preoperative setting because tumor heterogeneity, cystic change, and cytomorphologic overlap may limit confident classification on fine-needle aspiration alone. The Milan System for Reporting Salivary Gland Cytopathology has standardized reporting by linking diagnostic categories to risk of malignancy and clinical management, while its second edition places greater emphasis on integration with imaging and ancillary testing. This narrative review discusses how these updated principles can be translated into daily practice through rapid on-site evaluation or telecytology, cell-block preparation, focused immunohistochemical and molecular studies, and selective use of ultrasound-guided core needle biopsy. The available evidence indicates that cell blocks improve diagnostic yield and facilitate ancillary testing, whereas non-contributory cell blocks should alert the pathologist to possible suboptimal sampling. Comparative studies and meta-analyses further show that core needle biopsy yields higher sensitivity and lower non-diagnostic rates than fine-needle aspiration, with uncommon and usually minor complications. Overall, an integrated, imaging-informed preoperative pathway can reduce indeterminate reporting, increase specific diagnoses, and support more timely and clinically actionable management of salivary gland lesions.