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next speaker:Christian Czerny

Diagnostic approach of large salivary gland nodules

C. CzernyDivision of Neuro-/Msk-Radiology

Department of Biomedical Imaging and Image-guidedTherapy

University Hospital AKH Vienna

Pathologies

• Stone• Inflammation acute – chronic• Tumor benign – malignant• Posttherapie

Introduction

US/CT/MRI characteristics:• Position: Deep/superficial part• Echogenity/Density/Signalintensity• Borders: Smooth/irregular

• Capsule/lobulated• Perilesional reaction• E.g. Lnn

Problem

• Exact localisation

• Differentiation benign-malignant

• Imaging not always characteristic

• Differentiation to other processes (e.g. inflammation-abscess)

• Lnn benign-malignant

Often correct diagnosis

Therapyplanning

Technique US

• High resolution US 7-15mHz• Linear transducer• Doppler• transversal/longitudinal• US guided Bx

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Technique CT and MRISCT/MDCT• Skullbase-Jugulum

• Spiral

• Axial/coronal (Recon)

• 3/3/1mm Xx0,6/Xx0,5mm

• 100-120ml CM i.v.

• Matrix 5122/7682

• Softtissue/Bone-WL

• PET-CT

MR• Skullbase-Jugulum

• Headcoil/Surfacecoils

• Axial/coronal

• STIR/TIRM/T2wFSE+FS

• T1wSE -/+ CM i.v., FS

• Diffusion

• Thk 3-4 mm

• Matrix 512x512/256x256

• MR-Sialography

• PET-MR

Anatomy

Anatomy

2. Molar

Anatomy

Glandula parotis

D

S

D S

Anatomy Anatomy

Glandula submandibularis

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Anatomic Variant

Accessory lobe

Pathology Tumor

Localisation Frequency Benign Malign.

Parotid 75% 80% 20%

Submandibular 15% 50% 50%

Sublingual 1% 10% 90%

Small glands 9% 40% 60%

Benign Tumors

Pleomorphic adenoma-polycyclic-heterogenous-++ echogenicity

Pleomorphic adenoma

Benign Tumors

Pleomorphic adenoma

Benign Tumors

Pleomorphic adenoma(Icebergtumor)

Benign Tumors

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Pleomorphic adenoma(Icebergtumor)

Benign Tumors

Pleomorphicadenoma

Benign Tumors

PerfusionNormale Parotis

PerfusionPleo Parotis

MR-Perfusion/DWI

Habermann CR et al. Diffusion-weighted echo-planar MR imaging of primary parotid gland tumors: is a prediction of different histologic subtypes possible?AJNR Am J Neuroradiol. 2009 Mar;30(3):591-6.

Espinoza S et al. Warthin's tumor of parotid gland : Surgery or follow-up? Diagnostic value of a decisional algorithm with functional MRI.Diagn Interv Imaging. 2014 Dec 17

Pleomorphic adenomaGl. submandibularis

Pleomorphic adenomaSmall salivary glands

Benign Tumors

Benign Tumors DD

CystCyst 2. 2. branchialbranchial cleftcleft

Harnsberger

Whartin-Tumor(Cystadenolymphoma)

Benign Tumors

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CystCyst 1. 1. branchialbranchial cleftcleft

Benign Tumors DD

Harnsberger

Benign Tumors DD

CystCyst 2. 2. branchialbranchial cleftcleft

Harnsberger

Mucoepidermoid-Ca

Malignant Tumors

Pleomorphic Carcinoma

Malignant Tumors

Adenocarcinoma with skininfiltration

Malignant Tumors

Carcinoma SCC

DWI

Frühwald, Czerny et alEur J Nucl 2011

Malignant Tumors

Fruehwald-Pallamar J, Czerny C et al. Functional imaging in head and neck squamouscell carcinoma: correlation of PET/CT anddiffusion-weighted imaging at 3 Tesla. Eur J Nucl Med Mol Imaging 2011;38:1009–19.

Varoquaux A, Becker M et al. Functionalimaging of head and neck squamous cellcarcinoma with diffusion-weighted MRI andFDG PET/CT: quantitative analysis of ADC andSUV. Eur J Nucl Med Mol Imaging 2013; Jun;40(6):842-52

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Frühwald, Czerny et alEur J Nucl 2011

Cystic LNN-Meta SCC

Malignant Tumors

Adenoidcyst. Ca. Parotidperineural VII

Malignant tumor with perineural infiltration

Malignant Tumors

Azinuscellcarcinoma

Juan CJ et al. Perusion characteristics of late radiation injury of parotid glands: quantitative evaluation with contrast-enhanced MRI. Eur Radiol. 2009 Jan;19(1):94-102

Bisdas S et al. Differentiation of bening and malignant parotid tumors using deconvolution-based perfusion CT imaging: feasibility of the method and initial results. Eur J Radiol. 2007 Nov;64(2):258-65

MALT-Lymphoma

Malignant Tumors

SarcomaFrühwald, Czerny et alEur J Nucl 2011

Fruehwald-Pallamar J, Czerny C et al. Functional imaging in head and neck squamous cell carcinoma: correlation of PET/CT and diffusion-weighted imaging at 3 Tesla. Eur J Nucl Med Mol Imaging 2011;38:1009–19.

Varoquaux A, Becker M et al. Functional imaging of head and neck squamous cell carcinoma with diffusion-weighted MRI and FDG PET/CT: quantitative analysis of ADC and SUV.Eur J Nucl Med Mol Imaging 2013; Jun;40(6):842-52.

Malignant Tumors

St.p. ParotidectomySBL in Parotid region

Malignant Tumors

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SBL Melanoma in Parotid

Frühwald, CzernyEur J Nucl 2011

Malignant Tumors

Kubissa K et al. Initial clinical results ofsimultaneous 18F-FDG PET/MRI in comparison to 18F-FDG PET/CT in patientswith head and neck cancer. Eur J Nucl MedMol Imaging 2014 Apr;41(4):639-48

Becker M, Zaidi H. Imaging in head and neck squamous cell carcinoma: the potentialrole of PET/MRI. Br J Radiol 2014 Apr;87(1036):20130677

Malignant TumorsPET-MR

Malignant extraparotideal Tumor

PlasmocytomaRhabdomysarcomaParapharyngeal space

Malignant extraparotideal Tumor

Lymphangioma

DD‘sDD‘sMalformationMalformation DD MalformationDD Malformation

AVM

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Venous Malformation Parotid

DD MalformationDD Malformation RetentioncystRanula

Retentioncyst„diving“ Ranula

Macdonald AJ et al. Giant ranula of the neck: differentiation from cystic hygroma. AJNR Am J Neuroradiol. 2003 Apr;24(4):757-761

DD DD HerniationHerniation

DD inflammation

Parotid Viral

Bacterial

Autoimmune

Submandibularis Viral

Bacterial

Autoimmune

Inflammation

Sialadenitis viral

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Sono-CT Abscess

Inflammation

DuctectasyMicroabscess

Abscess

Inflammation

Sjögren ParotidHigher Incidence Lymphoma

Nocturne G, Mariette X. Sjögren Syndrome-associatedlymphomas: an update on pathogenesis andmanagement. Br J Haematol. 2015 Feb;168(3)317-327

Inflammation DD Stone

DD Stone

Stone Whartonduct

Cellulitis MR

Inflammation

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StoneComplication

Abscess

Take home

• US, CT and MRI important tools• Analyse imaging characteristics• Localisation• Surrounding structures (e.g. Lnn)• Differentialdiagnosis

Diagnosis often possiblepotentailly US-FNABimportant for therapy planning

Communication with clinician!!!

Unilateral swelling of the face

MasseterhypertrophyChewing