Transcript wCQzES_182257

IMAGING CONTRIBUTION IN
CHARACTERIZATION OF PAROTID
GLAND WARTHIN’S TUMOR: ABOUT
THREE CASES.
K.KNAISSI, I.KECHAOU, R.DAOUD, F.JABNOUN, K. BOUZAID
Department of Radiology,
MT Maamouri Hospital, Nabeul, Tunisia
HN7
INTRODUCTION
• Warthin’s tumor (benign cystadenolymphoma) is the second
most common salivary gland tumor after pleomorphic salivary.
• The exact pre-operative diagnosis of Warthin’s tumor remains
a major challenge, it allows patients to avoid a total
parotidectomy.
• The purpose of our work is to illustrate the imaging features of
this tumor.
METHODS AND MATERIELS
• Retrospective study of 3 patients distributed in 2 men and 1
woman with a mean age of 60 years.
• The main reason for consultation was a painless parotid
swelling lasting for several months.
• Three patients underwent cervical ultrasonography.
• One had a CT imaging both pre- and post-contrast studies .
• One had MR imaging including axial , coronal T1 , T2 weighted
and contrast enhanced.
• The diagnosis of warthin’s tumor was mentioned in only one
case.
• All patients underwent parotidectomy with histological
confirmation of diagnosis of warthin’tumor.
RESULTATS
PATIENT 1:
An 69 –year-old women presented with mass of the inferior pole
of right parotid gland.
Parotid ultrasound demonstrating a
well circumscribed oval lesion with
heterogeneous appearanceand small
areas of kystisation.
RESULTATS
PATIENT 2:
An 62 year old man presented with right parotid mass.
Parotid ultrasound demonstrating a
well circumscribed oval lesion with
cystic (arrow) an solid portions
(large arrow).
Fig 3(A)
Fig3(B)
Fig 3(C)
Axial T1-weighted (A), axial T2-weighted (B) and axial T1-weighted (C) contrast
enhanced fat suppressed MR image.
A: multifocal hyperintense small cysts (arrow) and hypointense large cyst with solid
stroma (large arrow).
B: the solid stroma shows low signal intensity (arrow)and the cystic portion shows
high signal intensity (double arrow).
C: after gadolinium enhancement, the solid stroma shows faint enhancement
(arrow).
RESULTATS
PATIENT 3:
An 81 year old man , presnted with right parotid mass.
Parotid ultrasound
demonstrating a well
circumscribed oval lesion
with cystic (arrow) an
solid portions (large
arrow).
Cervical CT: axial slices pre- and post-contrast
well-circumscribed lesion with cystic and solid components.
Enhancement after contrast administration is relatively poor.
DISCUSSION
• Warthin tumor generally has been regarded as the second
most common benign tumor of the parotid gland after
pleomorphic adenoma.
• It occurs largely in middle-aged and older men and usually in
the parotid gland or periparotid region, mostly involving the
inferior pole of the gland.
• It is clinically important to determine preoperatively this
diagnosis because exofacial parotidectomy is recommended
in this case and only 2% recurrence is reported.
• Imaging (US, CT and MR imaging) provides a diagnostic
approach.
DISCUSSION
• the best arguments in favor of the diagnosis of Warthin’s
tumor are:
- location in the lower pole of the gland observed in three
patients of our series.
- bilaterality and multiplicity of lesions.
- the existence of a cystic portion.
DISCUSSION
Fig. 1. Classification of the shape of Warthin’s tumor is presented.
Type 1 tumors are entirely cystic masses (arrow) with a peripheral solid enhancing rim (A).
Type 2 tumors are solid and cystic masses; a solid mass with a large cystic portion (type 2A,
arrow) (B) and a mainly solid mass with small cysts (type 2B, arrow) (C).
Type 3 tumors are entirely solid enhancing masses (arrow) (D).
DISCUSSION
 Sonography is the first step, especially for lesions in
the superficial lobe of the parotid gland. It can be used to
distinguish solid from cystic, guide fine-needle aspiration.
three patients in our series had an ultrasound first
intension showing a single lesion of the right parotid in
three cases and cystic portion which is of variable size.
DISCUSSION
 CT is the method of choice in patients suspicious for
inflammatory disease (abscess, calculi, major salivary
duct dilatation, and acute inflammation) or in patients
with contraindication for MR imaging.
 For CT imaging, both pre- and post-contrast studies
must be performed .
 CT shows a double component of the tumor tissue
and cystic with enhancement of tissue portion
post contrast study.
DISCUSSION
 MR imaging (MRI) is the method of choice for
patients with palpable masses and a strong suspicion that
the lesion is neoplastic.
 MRI gives information on the exact localisation and
extent of the lesion, addresses neighbouring structures,
and allows perineural spread, bone invasion and
meningeal infiltration to be assessed.
DISCUSSION
MRI findings of Warthin’s tumor is related to the presence of a
double epithelial and lymphoid contingeant.
 Intermediate signal intensity of the stroma seen
on both T1 and T2 weighted (high cellular
epithelial components).
 High or heterogeneous signal intensity of the
stroma seen on T2 weignted ( mixed epithelial
tissue with lymphoid proliferation).
DISCUSSION
Focal hyperintense areas seen on T1 weighted
(semisolid cysts that contain proteinaceous fluids
with cholesterol crystals).
 Dense nodular enhancement at the peripheral
stroma (mitochondriarich oncocytes).
 High signal intensity on diffusion-weighted with
lower ADC value.
DISCUSSION
• Recently, a dynamic contrast-enhanced MRI (DCE-MRI) have
shown promising results in the differentiation between benign
and malignant salivary gland tumours.
• Malignant salivary gland tumours can be differentiated from
pleomorphic adenomas but not from Whartin tumours using
DCE-MRI at a time of peak enhancement of 120 s.
• A washout ratio of 30% enabled the additional differentiation
between malignant and Whartin tumours.
DISCUSSION
• Using time-signal intensity curves on the basis of time to
peak enhancement of 120 s and a washout ratio of 30% had
high sensitivity (91%) and specificity (91%) in the
differentiation between benign and malignant tumours.
Type A: Pleomorphic adenoma
Type B: Warthin’tumor
Type C: Malignant tumours
CONCLUSION
• warthin’s tumor is frequently seen in the parotid superficiel lobe
of older males with a higher bilateral and multiple tendency.
• Warthin’s tumor shows cystic portions with papillary projections
at the wall on CT images and focal high signal intensity on T1weighted images with dense nodular enhancement on MR
images.
• A dynamic contrast-enhanced MRI (DCE-MRI) show precocious
enhancement with fast washout.
BIBLIOGRAPHY
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