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European Journal of Radiology 66 (2008) 419–436
Imaging of salivary gland tumours
Y.Y.P. Lee, K.T. Wong, A.D. King, A.T. Ahuja
∗
 Department of Diagnostic Radiology & Organ Imaging, The Chinese University of Hong Kong,Prince of Wales Hospital, Shatin NT, Hong Kong SAR
Received 11 January 2008; received in revised form 11 January 2008; accepted 14 January 2008
Abstract
Salivary gland neoplasms account for <3% of all tumors. Most of them are benign and parotid gland is the commonest site. As a general rule,the smaller the involved salivary gland, the higher is the possibility of the tumor being malignant. The role of imaging in assessment of salivarygland tumour is to define intra-glandular vs. extra-glandular location, detect malignant features, assess local extension and invasion, detect nodalmetastases and systemic involvement. Image guided fine needle aspiration cytology provides a safe means to obtain cytological confirmation.For lesions in the superficial parotid and submandibular gland, ultrasound is an ideal tool for initial assessment. These are superficial structuresaccessible by high resolution ultrasound and FNAC which provides excellent resolution and tissue characterization without a radiation hazard.Nodal involvement can also be assessed. If deep tissue extension is suspected or malignancy confirmed on cytology, an MRI or CT is mandatoryto evaluate tumour extent, local invasion and perineural spread. For all tumours in the sublingual gland, MRI should be performed as the risk of malignancy is high.For lesions of the deep lobe of parotid gland and the minor salivary glands, MRI and CT are the modalities of choice. Ultrasound has limitedvisualization of the deep lobe of parotid gland which is obscured by the mandible. Minor salivary gland lesions in the mucosa of oral cavity,pharynx and tracheo-bronchial tree, are also not accessible by conventional ultrasound.Recent study suggests that MR spectroscopy may differentiate malignant and benign salivary gland tumours as well as distinguishing Warthin’stumorfrompleomorphicadenoma.However,itsroleinclinicalpracticeisnotwellestablished.Similarly,theroleofnuclearmedicineandPETscan,inimagingofparotidmassesislimited.Sialographyisusedtodelineatethesalivaryductalsystemandhaslimitedroleinassessmentoftumourextent.© 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Salivary gland tumours; Imaging; Ultrasound; CT; MR
1. Introduction
Salivary gland neoplasms account for <3% of all tumours[1].Most of them are benign and parotid gland is the common-estsite.Asageneralrule,thesmallertheinvolvedsalivarygland,the higher is the possibility of the tumour being malignant. Thepercentage of malignant salivary gland tumours are: 20–30% inparotidgland,45–60%insubmandibulargland,70–85%insub-lingual gland and 49–80% in other minor salivary gland[2–4].Imaging of salivary gland tumour serves to define malignantfeatures, differentiate it from benign mimics, assess local inva-sion and regional spread. Image guided fine needle aspirationcytology provides a safe means to obtain cytological confirma-tion and to differentiate benign salivary gland tumour from itslow-grade malignant counterpart.
∗
Corresponding author. Fax: +852 2648 7269.
 E-mail address:
aniltahuja@cuhk.edu.hk (A.T. Ahuja).
2. Clinical presentation
Adenoidcysticcarcinomaisseeninadultswithslightfemalepredominance while mucoepidermoid carcinoma has no age orsexpredeliction.Theothermalignantsalivaryglandtumoursareseen in adults with slight male-predominance[5,6].Most patients presented with a painless, progressive enlarg-ing mass in the region of salivary gland or in mucosal spaceof oral cavity in the case of minor salivary gland tumour. Themasses are firm to hard on palpation, mobile if within the sali-vary gland and fixed when there is local invasion. The higherthe histological grade, the faster the tumour enlargement. Minorsalivary gland malignancies may present as mucosal ulceration.Pain is experienced in 5.1% of patients with benign sali-vary gland tumours and 6.5% of patients with its malignantcounterpart[7].Therefore, pain is not a good indicator of  benignity or malignancy. However, in patients with provensalivary gland carcinoma, the prognosis is worse in those pre-senting with constant pain. The 5-year-survival drops from
0720-048X/$ – see front matter © 2008 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.ejrad.2008.01.027
 
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Y.Y.P. Lee et al. / European Journal of Radiology 66 (2008) 419–436 
68% to 35% in patients without and with pain at presentation[8].Neurological symptoms involving cranial nerves are seen inpatients with perineural spread, local neural invasion or irri-tation. The commonest symptoms are those involving facialnerve (CN VII) as most of the carcinomas occur in the parotidgland. The symptoms include facial pain, facial itchiness, otal-gia and facial nerve paralysis. Facial nerve paralysis correlateswithpoorprognosisandincreasedincidenceofnodalmetastases(66–77%) with a 5-year-survival rate of 9–14%.[8]The third branch (CN V3) of the trigeminal nerve may beinvolved if the tumour is in the deep lobe of parotid gland. Theglossopharyngealnerve(CNIX),vagusnerve(CNX),accessorynerve (XI) and hypoglossal nerve (CN XII) may be involved bytumourextensiontothedeeptissueofupperneckorbyperineu-ralspread.Hoarsenessofvoice,aspiration,shoulderdysfunctionand atrophy of hemitongue are the related symptoms.
Fig. 1. Gadolinium enhanced T1W axial (a) and fat suppressed coronal scan(b) show the internal necrosis, thick, ill-defined enhancing walls of a malignantparotid lesion (arrows) although ultrasound, CT, MR can identify malignantlesions, they are unable to distinguish between the types of malignancies.
Lymph node metastases may be clinically detected as a firmneck lump. The parotid and submandibular glands first drain tothe deep cervical chain while sublingual gland drains to sub-mental and submandibular nodes. Retropharyngeal nodes arethe first station of nodal drainage from oropharyngeal mucosa.The presence of metastatic node in patients with malignant sali-vary gland tumour is associated with poorer prognosis. The10-year-survival of those without nodal metastasis is 63% whilethose with nodal metastasis are 33%. In patients with parotidgland carcinoma, nodal metastasis is most commonly seen inmucoepidermoid carcinoma, followed by squamous cell car-cinoma. In patients with submandibular, sublingual and minorsalivary gland cancer, nodal spread is most commonly seen incarcinoma-ex-pleomorphic adenoma.Distantmetastasisisanindicatorofpoorprognosis.Itisseenin 20% of the parotid cancers, most commonly from adenoidcystic carcinoma, followed by undifferentiated carcinoma[8].
3. The use and choice of imaging
The role of imaging in assessment of salivary gland tumouris to define intra-glandular vs. extra-glandular location, detectmalignant features, assess local extension and invasion anddetect nodal metastases and systemic involvement.For lesions in the parotid, submandibular and sublingualglands, ultrasound is an ideal tool for initial assessment.These are relatively superficial structures accessible by high-resolution ultrasound, which provides excellent resolution andtissuecharacterizationwithoutaradiationhazard.Cervicalnodeinvolvement can also be assessed. It is readily combined with
Fig. 2. Grey-scale ultrasound shows an infiltrative, ill-defined, solid, hypoe-choic mass (arrows) overlying the ramus of the mandibular (arrowheads). Theappearances are typical of a malignant parotid mass.
 
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fineneedleaspirationcytology(FNAC)andifthereisadeeptis-sue extension suspected or malignancy confirmed on cytology,an MRI or CT is mandatory to evaluate the complete tumourextent, local invasion and perineural spread. For all tumoursdetected in the sublingual gland, an MRI should be performedas the risk of malignancy is high.For lesions of the deep lobe of parotid gland and the minorsalivaryglands,MRIandCTarethemodalitiesofchoice.Ultra-soundhaslimitedvisualizationofthedeeplobeofparotidgland,which is also partially obscured by the body of the mandible.Minor salivary gland lesions are seen in the mucosa of oral cav-ity,pharynxandtracheo-bronchialtree,whicharenotaccessibleby conventional ultrasound. Moreover, the first station nodaldrainage from oral cavity and pharyngeal mucosal space isretropharyngeal nodes, which is also not accessible by conven-tional ultrasound.High-resolution ultrasound provides excellent tissue charac-terization, multi-planar information and vascular pattern withDoppler technique. It is also an optimal tool to guide fine nee-dle aspiration cytology with its ready availability and ability toproviderealtimeimageguidance.Theuseofultrasoundis,how-ever,limitedtosuperficialstructuresandtheaccuracydependanton specialistexpertise. Minor salivary gland lesions, deep tissueinvolvement, perineural spread, bony invasion and oropharyn-geal/retropharyngeal nodes are not accessed by conventionalultrasound technique[7].MRIandCTareoptimaltodelineatecompletetumourextentand regional lymphadenopathy. MRI is superior in its soft tissuedifferentiation. It is particularly helpful in detecting deep tis-sue extension, marrow infiltration/edema, perineural spread andthe parotid portion of facial nerve using high-resolution tech-niques. It also detects signal change and extra-capsular spreadinregionallymphnodesanddoesnotinvolvetheuseofionizingradiation.
Fig. 3. Corresponding CECT demonstrates enhancement within the mass(arrow), its location and extent and infiltration into the overlying subcutaneoustissue, which is thickened. Ultrasound readily identifies a malignant mass in thesuperficiallobeandhelpstoguideabiopsy.However,CT/MRaremuchbetterinidentifying the exact location of the lesion, its adjacent and distant involvement,particularly perineural extension.
The disadvantage of MRI is the relative high cost, suscep-tibility to motion artifacts and poorer cortical bone delineationcompared to CT. When bony erosion is a concern, such as inpalatal minor salivary gland malignancy, CT may be required.The role of nuclear medicine and PET scan, in imagingof parotid masses has not yet been established[9].Warthin’s tumour and oncocytoma are the only salivary gland tumoursthat accumulate Tc99m Pertechnetate. Sialography is used todelineate the salivary ductal system and has a limited role inassessment of tumour extent.At our center, if a patient presents with signs and symp-toms suggestive of a malignant tumour, or tumour of minorsalivary glands, MR is the initial investigation of choice. Ultra-
Fig. 4. Axial grey-scale ultrasound (a) shows an ill-defined, hypoechoic, het-erogeneous mass (arrows) in the superficial lobe of the parotid gland. Notethe internal areas of necrosis and prominent vessels on Doppler ultrasound (b).Although it demonstrates posterior enhancement similar to pleomorphic ade-noma, the presence of ill-defined edges and internal necrosis makes the lesionssuspicious. A biopsy confirmed its malignant nature.
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