The Egyptian Journal of Radiology and Nuclear Medicine (2012) 43, 165–172

Egyptian Society of Radiology and Nuclear Medicine

The Egyptian Journal of Radiology and Nuclear Medicine

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ORIGINAL ARTICLE

Lacrimal gland lesions: Can addition of diffusion-weighted

MR imaging improve diagnostic accuracy in
characterization?
Sahar M. Elkhamary *

Mansoura Faculty of Medicine, Diagnostic Radiology Department, Mansoura University, Mansoura, Egypt

Received 2 January 2012; accepted 12 February 2012

Available online 12 March 2012

KEYWORDS Abstract The aim of the work: To evaluate the diagnostic value of apparent diffusion coefficient
Lacrimal gland mass; (ADC) maps in the characterization of lacrimal gland lesions.
MRI diffusion weighted; Material and methods: A retrospective study was conducted on 40 patients (26 female and 14 male
ADC; subjects aged 13–74 years) with lacrimal gland mass. They underwent echo-planar diffusion-
Lesion characterization; weighted magnetic resonance imaging (MRI) of the orbit with a b-factor of 0500 and 1000 s/
Benign; mm2 at 3-Tesla magnetic resonance (MR) unit. ADC maps were reconstructed and the ADC of
Malignant each mass lesion was calculated. Lesion diagnosis was confirmed by the clinical follow-up or the
results of histopathology analysis depending on the specific disease to identify the specificity, sen-
sitivity and accuracy of diffusion-weighted imaging (DWI) in the differentiation between benign
and malignant lacrimal lesions.
Results: Forty-two lesions were detected in the examined 40 patients included in this study. Thirty-
one were benign and 11 were malignant. The mean ADC value of the malignant lacrimal tumors
(0.76 ± 0.14 · 10 3 mm2/s) was significantly (P = 0.001) lower than that of the benign lacrimal
lesions (1.17 ± 0.22 · 10 3 mm2/s). A statistically significant (P = 0.001) difference is identified
between the subjects with lacrimal adenitis and those with idiopathic orbital inflammatory syn-
drome (orbital pseudotumor). Lacrimal lymphoma has the lowest ADCs among a wide range of

* Tel.: +20 1000382338.

E-mail addresses: selkhamary@hotmail.com, Selkhamary@yahoo.
com

0378-603X  2012 Egyptian Society of Radiology and Nuclear

Medicine. Production and hosting by Elsevier B.V.
Open access under CC BY-NC-ND license.
Peer review under responsibility of Egyptian Society of Radiology and
Nuclear Medicine.
doi:10.1016/j.ejrnm.2012.02.003

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166 S.M. Elkhamary

lacrimal masses. The selection of an ADC value of 0.90 · 10 3 mm2/s as a threshold value for dif-
ferentiating malignant tumors from benign lacrimal lesions has an accuracy of 90%, a sensitivity of
90%, and specificity of 89%.
Conclusion: ADC offers a useful reliable safe non-invasive imaging parameter that can be used for
the differentiation of malignant tumors from benign lacrimal lesions with high sensitivity and spec-
ificity. The absence of contrast media in DWI reduces the cost of the examination and leads to an
increase in the overall accuracy of MRI, hence reducing the number of false positive results and
consequently reducing the number of unnecessary biopsies.
 2012 Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V.
Open access under CC BY-NC-ND license.

1. Introduction and aim of the work 13–74 years; mean 39 years). The inclusion criteria were pa-
tients with lacrimal masses who underwent diffusion MR
Lacrimal gland lesions comprise a spectrum of benign and malig- imaging of the orbit without previous biopsy, surgery, or treat-
nant pathologies. They may be classified as epithelial or non-epi- ment before imaging. Informed consent was waived because
thelial lesions. Patient history and clinical features are important this is a retrospective study, approved by the institutional eth-
in the differential diagnosis of lacrimal gland lesions; however the ics committee.
clinical findings may vary from patient to patient. Orbital imag-
ing is required to confirm diagnosis and characteristic of the le-
2.2. MRI protocol and image acquisition
sion; however, it is frequently very difficult to differentiate each
specific disease on the basis of image characteristics alone be-
MRI studies were performed at 3-Tesla scanner (Magnetom
cause of intrinsic similarities (1–5). Enhancement after contrast
Allegra; Siemens, Erlangen, Germany) with the use of a dedi-
injection does not seem to be a reliable sign in differentiating lac-
cated head coil. The gradient strength was 40 mT/m and the
rimal gland lesions from one another (6–8), although the pres-
slew rate was 400 T/m/s. First, sagittal then coronal spin-echo
ence of bone destruction strongly favors the diagnosis of a
T1-weighted MR images were obtained with TR/TE of 450–
malignant lacrimal gland tumor. However, not all malignant lac-
750/9–13 ms. Transverse and coronal T2-weighted MR images
rimal gland lesions produce bone destruction. Jakobiec and asso-
were obtained with TR/TE of 2400–2800/19–96 ms, FOV of
ciates reported that two of the nine malignant epithelial tumors in
20 · 22 cm, section thickness of 4 mm, interslice gap of
their series did not produce bone change using computed tomog-
1–2 mm and matrix of 320 · 320.
raphy (CT). Furthermore, long-standing cases of benign pleo-
All patients had axial, sagittal and coronal post contrast T1-
morphic adenoma can lead to bone destruction (8–11).
weighted MR images with fat suppression accomplished with a
So, although CT and MRI are complementary imaging
frequency-selective presaturation pulse using intravenous injec-
techniques in localization and characterization of lacrimal le-
tion of 0.1 mmol/kg gadopentate dimeglumine (Magnevist;
sions, distinction between different tumor types, malignant
Schering, Berlin, Germany), (TR/TE = 400–575/13–15ms).
and benign neoplasms or even neoplastic and non-neoplastic
DWI was obtained in the axial plane using a multislice spin
lesions is frequently not possible by using either clinical criteria
echo planar imaging (EPI) sequence. Imaging parameters were
or conventional imaging, and biopsy is usually required
as follows: TR/TE of 3200/81 ms, FOV of 20 · 22 cm, section
(8–11). Therefore, it would be clinically useful to have a non-
thickness of 4.0 mm, interslice gap of 1.0–2.0 mm, number of
invasive method to help lesion characterization.
excitations of 6, matrix of 128 · 128, EPI factor of 128 and
Diffusion-weighted MRI has been used for differentiation be-
RF pulse bandwidth of 1200. Diffusion-probing gradients
tween benign and malignant head and neck masses, cervical
were applied in the three orthogonal directions (x, y and z)
lymph nodes, parotid tumors, thyroid nodules and orbital mass
with the same strength. Diffusion-weighted MR images were
(12–16). A few studies discussed the role of 1.5 and 3-Tesla diffu-
acquired with diffusion-weighted b factor, of 0500 and
sion MR imaging in the predication of malignant orbital tumors,
1000 s/mm2, and ADC maps were generated for all images.
the differentiation of lymphoma from pseudotumor and other
The data acquisition time for the diffusion- weighted images
orbital masses, the assessment of orbital cellulitis (16–20) and in
was 1.33 min.
the assessment of the diagnostic value of DW MR microimaging
of the lacrimal glands in patients with Sjögren’s syndrome (21).
The purpose of this work was to assess the diagnostic use- 2.3. Image analysis
fulness of the ADCs calculated from diffusion-weighted echo-
planar MR images in the characterization of lacrimal gland Quantitative analysis of the ADC map was made. To achieve
masses and to assess whether –variation in the ADC is a reli- standardized conditions for results analysis and avoiding data
able marker for the differentiation. contamination by adjacent structures, 2 ROIs placed within a
given area of the solid part taking into consideration the pre-
2. Material and methods contrast and post-contrast spin-echo MR images while blinded
to the final clinical and pathological diagnosis. Distortion arti-
2.1. Study population facts were carefully excluded from the region of the interest
delimitation, avoiding the cystic parts as much as possible be-
A retrospective analysis of a total number of 42 lacrimal cause it could give a falsely elevated ADC value. We obtained
masses of 40 patients (26 female and 14 male subjects aged averaged ADC values of 2 ROIs. Pixel-based ADC maps were
Lacrimal gland lesions: Can addition of diffusion-weighted MR imaging improve diagnostic accuracy in characterization?
obtained at a commercial workstation (Syngo’s Siemens
Medical Solutions, Erlangen, Germany).
The final diagnosis of lacrimal masses was confirmed either
by histo-pathological examination or clinical follow-up in re-
sponse to proper medical treatment by which time the lesion
had healed satisfactory. Lastly, the final diagnosis was corre-
lated with the ADC values.
2.4. Statistical analysis
Data were expressed as mean and standard deviation (SD). All
data were revealed to be parametric with normal distribution
by the Kolmogorov Smirnoff test. The data analysis was per-
formed to test the statistically significant difference. Student’s
t-test was used to compare between two groups and one way
ANOVA test was used to compare between more than two
groups. Receiver operating curve (ROC) was made to deter-
mine the cutoff point with the highest accuracy and sensitivity
that was used to differentiate malignant from benign tumors,
as well as lacrimal adenitis and orbital inflammatory lesions.
P value was considered to indicate significant difference if less
than or equal to 0.05 .The statistical analysis of data was per-
formed using the Excel and the SPSS programs (Statistical
Package for the Social Science version 16; SPSS Inc., Chicago,
Il, USA).
3. Results
In this work, the image quality of ADC map was accepted and
it was associated with mild image distortion and mild elonga-
tion of the globe that has no effect on the imaging interpreta-
tion in 6 patients. Forty-two lesions were detected in the
examined 40 patients included in this study. Thirty-one lesions
were benign; and 11 were malignant according to the final his-
topathological diagnosis in 18 lesions (including biopsy in 4
sclerosing type of orbital pseudotumors, 3 lesions with lym-
phoma, 2 pleomorphic adenoma and 1 plexiform neurofi-
broma while excisional biopsy was done in 4 adenoid cystic
carcinoma, 2 pleomorphic adenoma, 1 carcinoma ex pleomor-
phic adenoma, and 1 myoepthelial carcinoma). The other
groups including 24 lesions were diagnosed on the basis of his-
tory, clinical course of disease, and follow-up response to ther-
apy (17 dacroadenitis and 7 idiopathic orbital inflammatory
lesions). Table 1 shows the distribution of the benign and
malignant lesions among the lacrimal masses.
The mean ADC value of benign lesions was
(1.11 ± 0.22 · 10 3 mm2/s) (Figs. 1–3), that of malignant tu-
mors was 0.76 ± 0.14 · 10 3 mm2/s (Figs. 4–7) with statisti-
cally significant difference in the ADC values between the
malignant tumors and benign lesions (P = 0.003) (Fig. 8).
For benign diffuse lacrimal lesions, the ADC values for dac-
ryoadenitis (1.03 ± 0.17 · 10 3 mm2/s) was significantly differ-
ent (P = 0.006) than that of the idiopathic orbital inflammation
(pseudotumor) (1.16 ± 0.20 · 10 3 mm2/s) and sclerosing
inflammation (1.42 ± 0.03 · 10 3 mm2/s) (Figs. 1 and 2).
The ADC values of pleomorphic adenomas (1.21 ± 0.03 ·
10 3 mm2/s) were significantly higher than those of carcinoma
(Fig. 3). The lowest ADC value seen among the lacrimal lesions
was seen in lymphoid lesions (0.63 ± 0.03 · 10 3 mm2/s),
which is significantly different than that in carcinoma
(P = 0.003). The mean ADC value of carcinoma ex pleomor-
167
phic adenoma is 0.79 ± 0.02 · 10 3 mm2/s, that of adenocystic
carcinoma is 0.82 ± 0.018 · 10 3 mm2/s, and that of myoep-
thelial carcinoma is 0.80 ± 0.03 · 10 3 mm2/s. However, there
is no significant difference between the different types of carci-
noma (Table 1). The difference often was apparent on gross vi-
sual inspection on conventional DWI images and on ADC
maps as demonstrated in Figs. 4–7.
Thus in this study, we determine two cut-off levels: cut-off
A was 0.90 · 10 3 mm2/s, which was used as a threshold value
for differentiating malignant tumors from benign lesions; the
best result was obtained with a sensitivity of 90%, a specificity
of 89%, an accuracy of 90% and area under the curve (AUC)
was 0.95 (Fig. 9). The Cut-off P value is 1.22, which was used
as a threshold value for differentiating lacrimal adenitis from
sclerosing type of orbital inflammation lesions with a sensitiv-
ity of 85%, a specifically of 72% and an accuracy of 79%).
4. Discussion
DWI provides biological information that is based on the
molecular motion of water caused by the change in the tissue
environment because of pathologic process. DWI is based on
the ‘‘Brownian motion’’ of the molecules. Malignant lesions
have higher cellularity and lower ADC values than benign
lesions (13–20).
In this study, we investigated the value of DWI and their
ADC for the characterization of lacrimal lesions aiming to as-
sess their role in differentiating benign from malignant lacri-
mal lesions. We showed that ADCs provide an accurate
noninvasive quantitative index for the differentiation of lacri-
mal gland masses which is crucial in the therapeutic strategy
that may help triage patients to either early intervention or
conservative treatment.
To the best of our knowledge, there is no extensive evalua-
tion to assess the role of DWI and ADC values in the diagnosis
of lacrimal mass lesion and no available previous study
pointed to the cut-off value in the differentiation of lacrimal
mass. Abdelrazek et al. (13) reported that when ADC value
of 1.23 · 10 3 mm2/s was used as a threshold value for differ-
entiating malignant tumors from benign lesions, the best result
was obtained with a sensitivity of 95%, a specificity of 88%, an
accuracy of 92%, and area under the curve (AUC) of 0.89. In
this study, selection of 0.90 · 10 3mm2/s as a threshold ADC
value for differentiating malignant lacrimal tumors from be-
nign lesions was achieved with high accuracy. The difference
in the cutoff ADC value may be due to the different magnetic
field and technical parameters used in both studies.
In this study, a total of 31 benign lesions showed signifi-
cantly higher ADC. Sclerosing variant of orbital inflammation
is characterized as a mass not responding to initial corticoste-
roid therapy. The differentiation from idiopathic orbital
inflammatory disease is diagnosed typically by biopsy in which
there is evidence of marked fibrosis, scarring, and mixed
chronic inflammatory cells (22–23). Inflammatory dacroadeni-
tis lesion has similar characteristics to orbital pseudotumor
and sclerosing type of orbital pseudotumor on conventional
imaging; however the ADC value of chronic adenitis
(1.03 ± 0.17 · 10 3 mm2/s) was significantly (P = 0.006) low-
er than that of sclerosing- type orbital pseudotumor,
1.42 ± 0.02 · 10 3 mm2/s).
168 S.M. Elkhamary

Table 1 Mean, minimum, maximum and standard deviation of the ADC value of malignant and benign orbital masses
(·10 3 mm2/s).
Group Pathology Number of lesions ADC (mean & SD) ADC minimum ADC maximum
Benign
Dacryoadenitis 17 1.03 ± .17 .83 1.41
Idiopathic orbital inflammatory lesion 7 1.16 ± .20 1.01 1.28
Sclerosing inflammation 4 1.42 ± .02 1.40 1.44
Benign pleomorphic adenoma 2 1.22 ± .03 1.18 1.23
Plexiform neurofibroma 1 1.69 1.69 1.69
Total 31 1.11 ± .22 .83 1.69
Malignant
Lymphoid tumors 5 .63 ± .03 .55 .60
Adenoid cystic carcinoma 4 .79 ± .02 .77 .81
Carcinoma ex pleomorphic adenoma 1 .82 ± .18 .62 .98
Myoepthelial carcinoma 1 .80 ± 0.03 .79 .81
Total 11 .76 ± .14 .55 .98

Fig. 1 (A–C) Dacroadenitis: A 24 years old male. (A) Coronal T2-weighted image and (B) coronal T1-weighted contrast-enhanced fat
suppression MRI images show enlarged right lacrimal gland (arrow), which appear slightly hyperintense compared with the adjacent
extraocular muscles conforming to the shape of the globe, the gland responds rapidly improving to treatment. (C) Axial ADC map shows
free diffusion of the mass with high (ADC value 1.17 · 10 3 mm2/s).

Fig. 2 (A–C) Sclerosing type orbital pseudotumor: A 14 year old girl with a 5 month history of pain, proptosis. (A) Axial T2-weighted
image and (B) axial T1-weighted contrast-enhanced fat suppression MRI images show ill defined enlarged right lacrimal gland not
responding to medical treatment (arrow). (C) Axial ADC map shows free diffusion of the mass with high ADC value 1.42 · 10 3 mm2/s).

Previous different studies proved restricted diffusion of
malignant tumor compared with benign lesions in different re-
gions of the head and neck (23–26). Malignant orbital lesions
had lower ADCs than benign lesions, irrespective of the pa-
tients’ age (P < 0.02) and in adults specifically (P < 0.05).
The ADC value is estimated to be lower in viable tumor tissue
with densely packed diffusion-hindering obstacles than in tis-
sues with less densely packed obstacles, such as tumor necrosis
and benign tissue (18,19,21). In this work, the mean ADC va-
lue of malignant lacrimal tumors was significantly lower
(P = 0.003) than that of benign lesions. This is attributed to
enlarged nuclei and hypercellularity of malignant tumors.
These histological characteristics reduce the extracellular ma-
trix and the diffusion space of water protons in the extracellu-
lar and intracellular dimensions with a resultant decrease in
ADCs (17,19–23).
Orbital lymphoma represents a diagnostic challenge for
both the clinician and the radiologist because of nonspecific
manifestation and characteristic on conventional images. Lym-
phomatous lesions of the lacrimal gland include a broad spec-
trum from reactive lymphoid hyperplasia, a localized benign
disease of unknown cause, to malignant lymphomas of various
types. Lymphomas of the lacrimal gland may be associated
with Sjögren’s syndrome. Mucosa-associated lymphoid tissue
Lacrimal gland lesions: Can addition of diffusion-weighted MR imaging improve diagnostic accuracy in characterization? 169

Fig. 3 (A–D) Pleomorphic adenoma: (A) Axial T2-weighted image and (B) post contrast fat suppression images show a well-defined
enlarged left lacrimal gland, isointense to the muscle that shows marked (white arrow) contrast enhancement (white arrow). (C) Axial
ADC map shows free diffusion of the mass with high ADC = 1.22 · 10 3 mm2/s. (D) Follow up 2 years with past history of an incomplete
resected pleomorphic adenoma showed irregular soft tissue mass with heterogenous enhancement combined with aggressiveness of the
recurrent, malignant mixed tumor (black arrow).

Fig. 4 (A–C) 48 year old lady with lymphoid tumor: Left lacrimal gland was resected several years previously because of atypical
angiofollicular lymphoid hyperplasia ‘‘Castleman’s’’ disease, hyaline vascular type with lymphomatous transformation). (A) Axial T2 and
(B) coronal T1-weighted contrast-enhanced fat suppression MRI images show that the lesion involves the right lacrimal gland, well
defined intense homogeneously enhancing mass with molded appearance and rounded border. (C) The lesion appears marked hypointense
on ADC with restricted diffusion of the lesion with the mean ADC right lacrimal gland = 0.57 · 10 3 mm2/s.

Fig. 5 (A and B) MALT lymphoma: 49 year old woman with Sjögren’s syndrome and mucosa-associated lymphoid tissue of both
lacrimal glands. (A) Axial T2WI show bilateral enlargement of the lacrimal glands with retention cysts (arrow) manifesting as
honeycombing. (B) ADC map shows restricted diffusion of the lesion with the mean ADC lacrimal gland 0.80 ± 0.03 · 10 3 mm2/s.
170 S.M. Elkhamary

Fig. 6 (A–C) Adenoid cystic carcinoma basaloid variant in 25 year old lady. (A) Axial T2WI and (B) coronal post contrast fat
saturation MR images show mass involving the right lacrimal gland display irregular margin bone destruction and infiltrative nature. (C)
ADC map shows restricted diffusion of the lesion with the mean ADC = .79 ± .18 · 10 3 mm2/s.

Fig. 7 (A–C) A case of carcinoma ex pleomorphic adenoma developed in a recurring pleomorphic adenoma 6 years after incomplete
resection of a pleomorphic adenoma, the patient complained of a progressive swelling of her left upper eyelid: (A and B) Coronal post
contrast and T2WI fat saturation MR images show mass involving the left lacrimal gland, bone destruction with dural infiltration. (C)
Restricted ADC = .82 ± .18 · 10 3 mm2/s.

Fig. 8 Bar graph of the ADC value of malignant and benign

orbital tumors. The mean ADC value of malignant tumors was
(0.78 ± 0.22 · 10 3 mm2/s) is significantly lower (P = 0.001) than
those of the benign lesions (1.11 ± 0.24 · 10 3 mm2/s).
Fig. 9 Receiver operating characteristic (ROC) curve. The cutoff
value of ADC value used for differentiation of malignant from
lymphoma represents approximately 50% of all ocular adnexal
benign lesion is 0.90 · 10 3 mm2/s; the area under curve (AUC) is
lymphoma (22–25). There is significant difference in DWI
0.95 with a sensitivity of 90%, a specificity of 89% and an
intensities, ADC values between orbital lymphoid lesions,
accuracy of 90%.
pseudotumor and lacrimal adenitis (P = 0.05). In the study,
the result is correlated with previous study as lymphoma
showed marked lower ADC than pseudotumor (23,26,27).
Fig. 1 shows an example of dacroadenitis compared with pseu-
dotumor (Fig. 2) and atypical lympho-proliferative disorder The current data confirm and expand on the observation that
(Cattleman’s disease) developing malignant lymphoma (Figs. 4 adenxal lymphoma have ADCs significantly lower than those of
and 5). the majority of other lacrimal lesions elsewhere in the head and
Lacrimal gland lesions: Can addition of diffusion-weighted MR imaging improve diagnostic accuracy in characterization?
neck, probably related to greater cellularity, high nucleus to cyto-
plasmic ratio, less extracellular space, and, therefore, less random
motion of water. This is additional information provided by
DWI, and ADC therefore improves the diagnostic accuracy of
MRI, consequently reducing the number of unnecessary biopsies
with subsequent implications for patient care.
Malignant changes in pleomorphic adenoma have been
associated with a long duration, tumor recurrence, radiation
therapy, advanced age and tumor size. The MRI findings of
carcinoma ex pleomorphic adenoma are not specific because
of the coexistence of different tissue types. It is difficult to dis-
tinguish pleomorphic adenoma from low-grade malignant tu-
mors in the absence of an irregular margin or infiltration of
the surrounding structure (28–30). Also if the differential diag-
nosis of the lacrimal mass includes pleomorphic adenoma, the
incisional biopsy is contraindicated, and either an-enbloc
resection or fine needle aspiration biopsy is required for diag-
nosis (11). Motoori et al. proposed that the significance of
myxomatous tissue detection on MRI is differentiating be-
tween pleomorphic adenoma and malignant tumors (31). In
this study, the author found that the mean ADC for the Pleo-
morphic adenoma was significantly higher than the corre-
sponding value for malignant tumors. We agree with Sumi
et al. (32) who studied a total of 22 benign solid masses of
the head and neck including 10 pleomorphic adenoma and re-
ported that adenomatous tumor contains areas of accumulated
fluid; therefore it could be that water protons are relatively
heavier than in the glandular tissue. They suggested that
ADC value is higher than 1.22 ± 0.13 · 10 3 mm2/s. This
agrees with the current study; the tumor had an ADC value
of 1.24 ± 1.18 · 10 3 mm2/s. Thus, we agree with the previous
studies to include diffusion-weighted and ADC mapping imag-
ing in MRI protocols of the lacrimal gland to facilitate the
differentiation.
There was a statistically significant difference in the ADC
value between carcinomas and lymphomas in the head and
neck (23–25). In this study, we agree with Kato et al. and Lo-
sen et al. (33,34) who stated that there was a significant differ-
ence in the ADC value between lymphoma and carcinoma. On
the other hand, there was an insignificant difference in the
ADC value of different pathological types of lacrimal carci-
noma. This may be attributed to the small number of patients
with orbital carcinoma. Further studies conducted on large
number of malignant tumors are recommended for better char-
acterization of lacrimal tumors.
Although satisfactory echo-planar DW images can be ob-
tained by a parallel imaging technique, which allows rapid
imaging times of less than 1 min; however, there is limitation
and challenges to orbital DWI such as image degradation
and distortion as a result of magnetic susceptibility artifact,
and anatomic distortion of the orbital structures, with mild
elongation of orbital structures and wavy appearance of mar-
gins of the globe (16–19) that were more prominent at 3 Tesla,
which is most pronounced at interfaces between air, bone, and
soft tissue (24–25).
This study has some limitations. First, we include a rela-
tively small number of benign and malignant neoplasms which
limit the statistical power. This needs further study with a large
number of patients. Second, lesions smaller than 1 cm cannot
be recognized, and therefore, the exact location of ROI on
ADC map is difficult to find leading to the possibility of false
sampling from the adjacent tissue .Also, the study is limited by
171
the heterogeneity of pathological types at pediatric and adult
patients. Further studies are recommended to study certain
pathological entities at a specific age group. Application of
multichannel coil with small 4-mm sections, shorter echo time
and smaller in-plane voxel sizes can be used to decrease suscep-
tibility artifacts of the orbit at 3 Tesla scanner (17–19,24).
Addition of parallel imaging will speed up the examination
and increase imaging contrast with decreased susceptibility
artifacts. Application of new post processing methods with
automated ADC calculation increased the diagnostic perfor-
mance of diffusion MRI and would be more precise and easily
performed (18,19). Finally, diffusion tensor imaging may im-
prove image contrast and decreased associated artifacts (18).
A continuous effort to improve DWI technique in the head
and neck will likely allow the expanded use of this valuable
tool. Future exploration into the targeted orbit DWI and alter-
native DWI techniques that are less sensitive to magnetic sus-
ceptibility artifact may be valuable.
5. Conclusion
ADC measurement coupled with MRI technique enables effec-
tive characterization of pathological features of lacrimal gland
lesions. This limited series provided promising preliminary
data on the utility of DWI in the characterization of lacrimal
gland lesions with high sensitivity and specificity leading to
an increase in the overall accuracy of MRI, hence reducing
the number of false-positive results and consequently reducing
the number of unnecessary biopsies.
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