24465-Parotis Gland Lecture MdWin

DISCLOSURES
INTRODUCTION
Parotid gland: No disclosures
anatomy and spectrum of pathologies
ECHNR 2021
1st Cycle Module 2
Maartje M.L. de Win

Head, neck & neuroradiology
Amsterdam UMC, AMC
ECHNR 2021 1st Cycle Module 2 m.m.dewin@amsterdamumc.nl ECHNR 2021 1st Cycle Module 2 m.m.dewin@amsterdamumc.nl
LEARNING OBJECTIVES PAROTID GLANDS

ANATOMY
ANATOMY
- Imaging techniques
RADIOLOGICAL APPROACH - Epidemiology
- Imaging characteristics
Congenital
Tumors
Inflammation
Paired, major salivary gland Netter
PAROTID GLANDS PAROTID GLANDS

ANATOMY
ANATOMY
parotid gland
superficial layer deep cervical
fascia
masticator space
parotid duct (Stensen)
parapharyngeal space
carotid space
Facial nerve!!
PAROTID GLANDS ACCESSORY PAROTID GLANDS
-Incidental finding
-Incidence 20-30%
ANATOMY
ANATOMY
-Lateral from masseter
-Superior to Stensons duct
-Separate blood supply and secondary duct
parotid gland
superficial layer deep cervical
fascia
parapharyngeal space
PAROTID SPACE PAROTID GLAND and the FACIAL NERVE
Within the parotid space

ANATOMY
ANATOMY
- parotid gland
- parotid ducts
- branches of the facial nerve
- lymph nodes ‫ ׽‬20
- retromandibular vein
- external carotid artery
Branches of the facial nerve divide the parotid gland in superficial

(2/3) and deep lobe (1/3)
PAROTID GLAND and the FACIAL NERVE SURGERY ON A PAROTID LESION

What the surgeon needs to know
Relationship with facial nerve
ANATOMY
ANATOMY
Not seen on imaging

Predict by facial nerve line
Chung-O Lee at al, 2012
FACIAL NERVE – PAROTID MRI of the PAROTID SEGMENT nVII
ANATOMY
ANATOMY
3D-PSIF-DWI with a surface coil.
2 cases of pleiomorphic adenoma

J. Chu et al. AJNR Am J Neuroradiol 2013;34:1643-1648
PAROTID IMAGING PAROTID IMAGING

Pre-auricular swelling Pre-auricular swelling
- unilateral vs bilateral - unilateral vs bilateral
- age - age
IMAGING
IMAGING
- painfull vs painless - painfull vs painless
• Ultrasound / US guided FNA • Ultrasound / US guided FNA

• MRI • MRI
• CT • CT
• PET-CT • PET-CT
Radiation, poor soft tissue discrimination
MRI SALIVARY GLANDS PATHOLOGY OF THE PAROTID GLAND

MRI PROTOCOL (1.5 & 3T) Congenital
PATHOLOGY
TSE T1 - 1st branchial cleft cyst

IMAGING
- venolymphatic malformation
TSE T2
DWI
Post gadolinium: fatsat TSE T1 or 3D T1 (VIBE, eTHRIVE) Tumors
(DCE-MRI) - benign
- malignant
Axial & Coronal

Including skull base / cavernous sinus / mastoids Parotitis
- infection
High resolution, slice thickness 3 mm - inflammation
PATHOLOGY OF THE PAROTID GLAND 1st BRANCHIAL CLEFT CYST
• Persisting branchial cleft remnants
Congenital
PATHOLOGY
• Rare (8% of branchial remnants)

- 1st branchial cleft cyst
• Recurrent peri-auricular swelling, enlarging after infection
CONGENITAL
- venolymphatic malformation
• In parotid gland, near pinna & EAC
• Recurrent parotid space abscess or otorrhea without otitis

• Majority presents < 10 y but also in adults
1st BRANCHIAL CLEFT CYST 1st BRANCHIAL CLEFT CYST

CONGENITAL
CONGENITAL
Imaging Imaging
Ultrasound 1st step Ultrasound 1st step
• Anechoic cystic lesion • Anechoic cystic lesion
• Posterior acoustic enhancement • Posterior acoustic enhancement
MRI for extension

• Unilocular cyst
• Sometimes sinus tract
• Thickened and enhancing wall when infected
VENOLYMPHATIC MALFORMATION VENOLYMPHATIC MALFORMATION

CONGENITAL
CONGENITAL
• Spectrum of venous and lymphatic developmental abnormalities

• Spongy soft tissue mass that grows proportionately with patient
• Ń Ń in si]e with Valsalva, bending over, crying
Imaging
• Ń rapidly after trauma or infection or under hormonal influences
Ultrasound 1st step
• Present at birth • Compressible
• Percutaneous sclerotherapy • No arterial flow on Doppler
VENOLYMPHATIC MALFORMATION VENOLYMPHATIC MALFORMATION
• Percutaneous sclerotherapy
CONGENITAL
CONGENITAL
Imaging
MRI for extension & exclude high flow
• Trans-spatial
• Venous
- Flow-voids, phleboliths, enhancement
• Lymphatic
- Unilocular or multilocular
- Fluid-fluid levels, peripheral & septal enhancement
PATHOLOGY OF THE PAROTID GLAND M62 y, PREAURICULAR SWELLING

PATHOLOGY
TUMORS
Tumors SET1 SET2 DWI-B1000

- benign
- malignant
SET1 & Gd SET1 & Gd & FS ADC
M62 y, PREAURICULAR SWELLING M62 y, PREAURICULAR SWELLING
9 Solid neoplasm 9 Solid neoplasm

9 Superficial lobe of the parotid gland 9 Superficial lobe of the parotid gland
9 Benign characteristics 9 Benign characteristics
TUMORS
TUMORS
Most likely diagnosis? Most likely diagnosis?
Pleomorphic adenoma
EPIDEMIOLOGY SG TUMORS EPIDEMIOLOGY SG TUMORS
• Rare lesions
• 2-6% of all head and neck tumors
TUMORS
TUMORS
• 0,5% of all head and neck malignancies
WHO revised classification 2017
EPIDEMIOLOGY SG TUMORS EPIDEMIOLOGY PAROTID TUMORS
Benign most common

Location Incidence % Malignancy Pleomorphic adenoma
TUMORS
TUMORS
Parotid 70-80% 20% Warthin (only parotid)
Submandibular 10-15% 50%

Malignant most common
Sublingual 5% 80-90%
Mucoepidermoid carcinoma
Minor salivary 5% 50%
Adenoid cystic carcinoma
Carcinoma ex-pleomorphic adenoma
PLEOMORPHIC ADENOMA PLEOMORPHIC ADENOMA

= benign mixed tumor
MRI
Epidemiology
Solitary, unilateral
70% of all benign tumors
Ovoid, lobulated
TUMORS
TUMORS
80% in parotid gland

T2 very hyperintens to
40-50 yrs intermediate
F>M T1 hyperintens if hemorrhagic
Histology:
Cartilage
Very high ADC values
Myxoid stroma
DCE contrast retention
Myoepithelial
cells
Ducts
PLEOMORPHIC ADENOMA ON T2 PLEOMORPHIC ADENOMA
What the surgeon needs to know

Extension
TUMORS
TUMORS
Relationship with facial nerve
Total resection very important
TSE T2
chondroid/myxoid matrix vs higher cellularity (myoepithelial cells)
RECURRENT PLEOMORPH ADENOMA PLEOMORPHIC ADENOMA
M, 66y Why surgery?

• resection of deep lobe pleomorphic • 5-10% risk of malignant degeneration
adenoma 18 y before. • Carcinoma ex pleomorphic adenoma
• Multifocal recurrent disease parotid
TUMORS
TUMORS
and parapharyngeal space • Risk increases with time
carcinoma ex pleomorphic adenoma

16 years after biopsy-proven pleomorphic adenoma
CASE 2 CASE 2
Incidental finding on brain MRI in 27 year old male

TUMORS
TUMORS
Incidental finding Looks like pleomorphic adenoma
Deep lobe/PPS What’s next?
INCIDENTAL LESION INCIDENTAL LESION
Possible strategies Possible strategies

9 surgical resection Æ facial nerve! 9 surgical resection Æ facial nerve!
TUMORS
TUMORS
9 wait – and – scan 9 wait – and – scan
• elderly people
• difficult to reach
Æ be sure it’s benign
INCIDENTAL LESION TUMOR CHARACTERIZATION
Possible strategies
Possible strategies
9 FNA
9 surgical resection Æ facial nerve! Difficult location, sample error (15% non diagnostic)
TUMORS
TUMORS
9 wait – and – scan 9 ‘Standard’ imaging (borders, heterogeneity, infiltration)

Not discriminative between benign and malignant
disease
Æ be sure it’s benign 9 Multiparametric imaging

T1, T2, ce T1 FS
Diffusion weighted imaging
Dynamic Contrast Enhanced Imaging
HOW?
Yabuuchi et al 2008, Freling et al 1992
TUMOUR CHARACTERIZATION MRI TUMOUR CHARACTERISATION

Possible strategies
9 FNA
Difficult location, sample error (15% non diagnostic)
TUMORS
TUMORS
9 ‘Standard’ imaging (borders, heterogeneity, infiltration)

Not discriminative between benign and malignant
disease T1 & fat sat
T1
9 Multiparametric imaging
T1, T2, ce T1 FS
Yabuuchi et al 2008, Freling et al 1992

T2 T1 & fat sat & Gado
MRI TUMOUR CHARACTERISATION MRI TUMOUR CHARACTERISATION
TUMORS
TUMORS
TT1 TT1
1 & ffat
att sat
a T1
T1 Gd
T2 T1 & fat sat & Gado

TUMOR CHARACTERIZATION TUMOR CHARACTERIZATION

Possible strategies Possible strategies
9 FNA 9 FNA
Difficult location, sample error (15% non diagnostic) Difficult location, sample error (15% non diagnostic)
TUMORS
TUMORS
9 ‘Standard’ imaging (borders, heterogeneity, infiltration) 9 ‘Standard’ imaging (borders, heterogeneity, infiltration)
Not discriminative between benign and
malignant disease 9 Multiparametric imaging
T1, T2, ce T1 FS
Functional imaging techniques
9 Multiparametric imaging • DIFFUSION WEIGHTED IMAGING
T1, T2, ce T1 FS
• DYNAMIC CONTRAST ENHANCED IMAGING
Functional imaging techniques
Yabuuchi et al 2008, Freling et al 1992 Yabuuchi et al 2008, Lam et al 2014, Couldert et al 2021
DIFFUSION WEIGHTED IMAGING DIFFUSION WEIGHTED IMAGING
• High cellularity Æ low ADC • High cellularity Æ low ADC

– Warthin, lymphoma, carcinoma – Warthin, lymphoma, carcinoma
IMAGING
IMAGING
• Low cellularity Æ high ADC • Low cellularity Æ high ADC

– Pleiomorphic adenoma, – Pleiomorphic adenoma,
inflammation, edema inflammation, edema
ADC =2,2x10-3 cm2/sec ADC = 0,8x10-3 cm2/sec ADC =2,2 cm2/sec ADC = 0,8x10-3 cm2/sec
pleiomorphic adenoma Warthin pleiomorphic adenoma Warthin
DIFFUSION WEIGHTED IMAGING DWI SALIVARY GLANDS
• TSE- DWI preferable to EPI-DWI Yabuuchi et al 2008
ADC values
• TSE- DWI less distortions
IMAGING
IMAGING
• At least 3 B values (0, 500, 1000 sec/m2)
• ROI to measure ADC
• DWI may differentiate between malignant and benign tissue

– Cut-off 1.4x10-3 mm2/sec Æ pleomorphic adenoma vs carcinoma (sens&spec > 90%)
• ADC Warthin resembles malignant tumors

• IVIM for the future
Hirata et al, Medicine 2018
DYNAMIC CONTRAST-ENHANCED MRI DCE ACQUISITION
• Microvascular characteristics / biomarkers • Baseline T1 mapping before Gd

– Blood volume • Short T1 GE images after iv Gd (0,2mmol/kg; 4mL/s)
IMAGING
IMAGING
– Blood flow
• Temporal resolution 3-4s
– Permeability
• Duration 3-5 min
– Wash-in & wash-out
Paldino et al, Magn Reson Imaging Clin Am, 2009 Lavini & Pieters, Imago 2016
DCE ACQUISITION TIME-INTENSITY CURVES (TIC’s)

• Postprocessing software
• ROI selection
IMAGING
IMAGING
TUMORS
– Exclude cystic and hemorrhagic areas
• Visual /non-parametric analysis

– Time Intensity Curves (TICs)
• Time to peak
• Washout
• Parametric analysis
– Pharmacokinetic modeling Type A: Ascending plateau, no washout
Æ Benign: pleomorphic adenoma
Lavini, Imago 2016; Khalifa et al Med Phys 2014 Yabuuchi H. et al. 2003, Hisatomi M. et al. 2007; Espinoza et al 2013, Lavini et al Imago 2016
TIME-INTENSITY CURVES (TIC’s) TIME-INTENSITY CURVES (TIC’s)
IMAGING
IMAGING
Type B: rapid uptake, high washout Type C: rapid uptake, low washout
Æ Warthin Æ Malignant tumor
Yabuuchi H. et al. 2003, Hisatomi M. et al. 2007; Espinoza et al 2013, Lavini et al Imago 2016 Yabuuchi H. et al. 2003, Hisatomi M. et al. 2007; Espinoza et al 2013, Lavini et al Imago 2016
TIME-INTENSITY CURVES (TIC’s) INTERPRETATION ALGORITHM

IMAGING
TUMORS
Not 100% sensitive/specific

Overlap in low grade malignancies, Warthin
Yabuuchi H. et al. 2003, Hisatomi M. et al. 2007; Espinoza et al 2013, Lavini et al Imago 2016 S. Espinoza et al, Diagnostic and Interventional Imaging 2013
M, 74y PAROTID LESION – DWI & DCE

preauricular swelling M, 74y, preauricular swelling
TUMORS
TUMORS
DWI ADC = 2,2 cm2/sec DCE
9 No diffusion restriction
9 Ascending uptake
Histology: pleiomorphic adenoma
Curve: TTP> 120s, no washout
MULTIMODALITY IMAGING MULTIMODALITY IMAGING
Do we always need multimodality imaging?

TUMORS
TUMORS
No!
HIST: Mucoepidermoid carcinoma
M, 75y M, 75y
What to do?
– MRI with Diffusion &Perfusion
– US guided FNA: Warthin tumor
TUMORS
TUMORS
SET1
• Smoker
• Swelling preauricular
WARTHIN’s TUMOR = ADENOLYMPHOMA WARTHIN’s TUMOR = ADENOLYMPHOMA

T2
Epidemiology
15% of all benign SG
tumors
TUMORS
TUMORS
Parotid only
FDG-PET
M:F = 1:1; smoking ++
50-70 yrs. Imaging
Bilateral 10-15% T1 & T2 Heterogeneity

Cysts + blood
DWI: low ADC
No malignant
transformation DCE: wash-out > 30%
ADC
No surgery needed! B1000 FDG-PET: uptake!
DIFFERENTIAL WARTHIN’s TUMOR DIFFERENTIAL WARTHIN’s TUMOR
Single lesion Single lesion Multiple/ bilateral lesions

Pleomorphic adenoma Pleomorphic adenoma Lymphoma
Low grade ACC Low grade ACC Lymphadenopathy

TUMORS
TUMORS
Mucoepithelial carcinoma Mucoepithelial carcinoma Benign lymphoepithelial cysts (HIV)
Lymphoma Lymphoma Chronic auto-immune sialoadenitis

Metastasis
Metastasis
ADENOID CYSTIC CARCINOMA F, 28y

Epidemiology
40-70yrs, F>M
Most common high grade salivary
gland tumor
TUMORS
TUMORS
MRI T1 T2
Low grade: well described • Preauricular swelling right side
since months
High grade: infiltrative
• Facial nerve paralysis since 1
T2 hyperintens to intermediate week
Contrast: homogeneous
enhancement
Perineural spread
T1 & fat sat
F, 28y WHAT THE SURGEON WANTS TO KNOW
• Extension of the lesion

• Perineural spread
• Surgical options vs chemo & radiation therapy
TUMORS
TUMORS
T1 T1 ctr • Diagnosis
Stylomastoid foramen!
T1 & FS ctr
PERINEURAL SPREAD IF THE PATIENT IS A CHILD
TUMORS
TUMORS
IS IT BENIGN?
M, 2yr
Facial nerve (VII) Trigeminal nerve (V-3)
EPIDEMIOLOGY: AGE MATTERS! IF THE PATIENT IS A CHILD
Children Adults
Incidence: 3-4 /million/yr 80/million/yr M, 3yr
TUMORS
TUMORS
Parotid BIOPSY!
benign 48% 90%
malignant 52% 10% Histology:
Sialoblastoma
Bradley et al. 2007 ORL; 69:137-145
PATHOLOGY OF THE PAROTID GLAND INFLAMMATION
– Acute (unilateral)
PATHOLOGY
– Chronic
• obstructive
PAROTITIS
• non-obstructive: autoimmune (bilateral)
Parotitis
- infection
- inflammation
INFLAMMATION MRI IN PAROTITIS
– Acute (unilateral) MRI salivary glands

– Chronic Æ Chronic autoimmune (selected cases)
• obstructive
PAROTITIS
PAROTITIS
• non-obstructive: autoimmune (bilateral)
MR sialography with ductal involvement
Æ Chronic obstructive sialadenitis
- Sialithiasis
Start with ultrasound - Strictures
¥ Infiltration & hyperemia - Post radiation xerostomie
¥ Dilatation of the duct
¥ Cystic changes
¥ Calculi
AUTOIMMUNE PAROTITIS AUTOIMMUNE SIALADENITIS
• Diffuse enhancement of enlarged or atrophied glands

• Cystic changes
PAROTITIS
PAROTITIS
Top differential
• Sjögren = myoepithelial sialadenitis
• IgG4 related sialadenitis
• Sarcoidosis
M. Sjögren
M SJÖGREN = MR SIALOGRAPHY
MYOEPITHELIAL SIALADENITIS
Autoimmune disease of the 9 Saliva as natural contrast

salivary & lacrimal glands
9 No cannulation
PAROTITIS
PAROTITIS
F>>M, 40-60 yrs

9 Information about the salivary gland distal to obstruction
Parotid 85%, submandibular 15%
Sicca symptoms
Swelling 60%
ŃŃ risk of lymphoma
MRI: non-obstructive sialectasia,
multiple cystic lesions
MR SIALOGRAPHY MR SIALOGRAPHY
MRI PROTOCOL
TSE T1 ax
TSE T2 ax & cor
PAROTITIS
PAROTITIS
DWI
T2 3D-CISS/DRIVE
or 2D-single shot FSE axial 0,6mm & MIP
Calculus
Head coils / Surface coils

Sialogogue (5cc lemon juice)
Patiënt should be hydrated
Erdogan et al. Biomed Res Int. 2013
MR-SIALOGRAPHY TAKE HOME 1: EPIDEMIOLOGY
• Parotid tumors are rare

TAKE HOME
• Many different histological types

• 80% in parotid Æ 80% benign
PAROTITIS
• Different DDx for children:

– Congenital, venous malformation & infantile hemangioma
Erdogan et al. Biomed Res Int. 2013
– 50% of parotid tumors malignant
TAKE HOME 2: CHOICE OF IMAGING TAKE HOME 3: MRI
• CT not first choice • Standard MRI sequences do not discriminate between malignant
TAKE HOME
TAKE HOME
• US + FNA (without MRI) and benign neoplasms

– Warthin Æ no resection
– Superficial, benign on FNA • Include DWI with ADC in your standard protocol
Æsuperficial parotidectomy without MRI – Easy, short, no postprocessing
– (Acute) Sialadenitis – MRI + DWI: high sens & spec
– Warthin mimics malignant tumor on DWI (also on FDG-PET)
• MRI
– in all other salivary gland neoplasms
• DCE Perfusion has additional benefit
– selected cases of (chronic) sialadenitis
– Postprocessing needed (also software)
THANK YOU FOR YOUR ATTENTION
m.m.dewin@amsterdamumc.nl

24465-Parotis Gland Lecture MdWin

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DISCLOSURES

anatomy and spectrum of pathologies

Maartje M.L. de Win

LEARNING OBJECTIVES PAROTID GLANDS

PAROTID GLANDS PAROTID GLANDS

PAROTID SPACE PAROTID GLAND and the FACIAL NERVE

Within the parotid space

Branches of the facial nerve divide the parotid gland in superficial

PAROTID GLAND and the FACIAL NERVE SURGERY ON A PAROTID LESION

Not seen on imaging

Chung-O Lee at al, 2012

2 cases of pleiomorphic adenoma

PAROTID IMAGING PAROTID IMAGING

- painfull vs painless - painfull vs painless

• Ultrasound / US guided FNA • Ultrasound / US guided FNA

Radiation, poor soft tissue discrimination

MRI SALIVARY GLANDS PATHOLOGY OF THE PAROTID GLAND

TSE T1 - 1st branchial cleft cyst

Axial & Coronal

• Rare (8% of branchial remnants)

• Recurrent parotid space abscess or otorrhea without otitis

1st BRANCHIAL CLEFT CYST 1st BRANCHIAL CLEFT CYST

MRI for extension

VENOLYMPHATIC MALFORMATION VENOLYMPHATIC MALFORMATION

• Spectrum of venous and lymphatic developmental abnormalities

PATHOLOGY OF THE PAROTID GLAND M62 y, PREAURICULAR SWELLING

Tumors SET1 SET2 DWI-B1000

SET1 & Gd SET1 & Gd & FS ADC

M62 y, PREAURICULAR SWELLING M62 y, PREAURICULAR SWELLING

9 Solid neoplasm 9 Solid neoplasm

Most likely diagnosis? Most likely diagnosis?

WHO revised classification 2017

EPIDEMIOLOGY SG TUMORS EPIDEMIOLOGY PAROTID TUMORS

Benign most common

Parotid 70-80% 20% Warthin (only parotid)

Submandibular 10-15% 50%

PLEOMORPHIC ADENOMA PLEOMORPHIC ADENOMA

80% in parotid gland

What the surgeon needs to know

chondroid/myxoid matrix vs higher cellularity (myoepithelial cells)

RECURRENT PLEOMORPH ADENOMA PLEOMORPHIC ADENOMA

M, 66y Why surgery?

and parapharyngeal space • Risk increases with time

carcinoma ex pleomorphic adenoma

Incidental finding on brain MRI in 27 year old male

Incidental finding Looks like pleomorphic adenoma

Deep lobe/PPS What’s next?

Possible strategies Possible strategies

INCIDENTAL LESION TUMOR CHARACTERIZATION

9 wait – and – scan 9 ‘Standard’ imaging (borders, heterogeneity, infiltration)

Æ be sure it’s benign 9 Multiparametric imaging

TUMOUR CHARACTERIZATION MRI TUMOUR CHARACTERISATION

9 ‘Standard’ imaging (borders, heterogeneity, infiltration)

Yabuuchi et al 2008, Freling et al 1992

T2 T1 & fat sat & Gado

TUMOR CHARACTERIZATION TUMOR CHARACTERIZATION

DIFFUSION WEIGHTED IMAGING DIFFUSION WEIGHTED IMAGING

• High cellularity Æ low ADC • High cellularity Æ low ADC

• Low cellularity Æ high ADC • Low cellularity Æ high ADC

• DWI may differentiate between malignant and benign tissue

• ADC Warthin resembles malignant tumors

DYNAMIC CONTRAST-ENHANCED MRI DCE ACQUISITION