SALIVARY GLAND

TUMORS - IMAGING

Introduction
1% of all head and neck malignant neoplasms
arise in the salivary glands.
Large range of differential diagnoses;
influences prognosis and treatment.
Pre-operative imaging has a major role in
surgical planning.
Most parotid gland tumours are benign (80%).
Probability for malignancy increases to 40
50% in submandibular gland and 5081% in
the sublingual and minor salivary glands.

Imaging modalities
Most patients present with painless
palpable mass.
Certain symptoms such as pain,
facial nerve palsy and enlarged
lymph nodes may suggest
malignancy.
MRI- method of choice for palpable
masses, esp. with strong suspicion
that the lesion is neoplastic.

Imaging modalities
CT- for inflammatory disease (abscess,
calculi, major salivary duct dilatation, and
acute inflammation) or in patients with
contraindication for MR imaging.
USG- first step in children and in
pregnant women; for lesions in the
superficial lobe of the parotid gland,
submandibular gland; assess adjacent
vascular structures and vascularity,
distinguish solid from cystic, guide FNAC.

Imaging issues
Is the mass intra- or extraparotid? Pattern of
displacement of parapharyngeal space has to be
analyzed.
Is the parotid space mass single or multiple?
Unilateral or bilateral?
Does the tumor show benign or malignant
characteristics?
The surgical approach will depend on these
characteristics. If malignancy is suspected, is
there evidence of perineural spread along the
facial nerve or branches of the trigeminal nerve?

Imaging issues
Is the tumor limited to the superficial
lobe of the parotid?
A superficial lesion extending in the
deep lobe requires a total
parotidectomy.
What is the relationship of the mass to
the facial nerve?
Is it possible to determine the
histologic type of a benign tumor?

IMAGING FEATURES
BENIGN MASSES

First branchial cleft cyst

Type I- Periauricular cystic mass, anterior/inferior/posterior

to EAC
Type II- Periparotid cyst, extending from EAC to angle of
mandible
Chronic unexplained otorrhea, recurrent parotid abscess.

Type I BCC

Type II BCC, pointing inferiorly to

posterior submandibular space.

Well-circumscribed unilocular ovoid cyst.

If infected- thick enhancing rim.
Increased signal intensity on T1-weighted
sequences suggests prior bleeding or infection.

Type II first branchial

cleft cyst

Axial (A), coronal (B), and sagittal (C) T2-weighted

MRIs show the well-defined unilocular cystic lesion
involving the superficial and deep lobes of the left
parotid gland.

DD- Abscess

Post-contrast axial image: (A) demonstrates a rim enhancing

abscess involving the superficial lobe of the left parotid gland
(arrow); (B) is an image caudal to A, and shows the presence of
a necrotic intra-parotid node involving the superficial lobe of
the left parotid gland (curved arrow)

Hemangioma,
Lymphangioma
Hemangioma- most common benign salivary
gland mass in children; classified as capillary or
cavernous.
CT/MRI- capillary hemangiomas are seen as welldefined masses with strong enhancement. Flow
voids due to prominent vasculature are often
present in or around the mass.
Lymphangioma- consist of cystic areas and thin
septations, but also solid enhancing portions.
Hemorrhage can lead to fluid levels with variable
signal intensities.

Infantile hemangioma

Cystic
lymphangioma

Multiple Intraparotid Cystic

Lesions
Benign lymphoepithelial lesions- HIV: Multiple,
bilateral cystic and solid masses, enlarging
both parotid glands, associated with tonsillar
hyperplasia and bilateral cervical adenopathy.
Well-circumscribed, sometimes
heterogeneous, with low T1-weighted and
high T2-weighted signal intensities.
Sjogren syndrome- mimic BLL-HIV. Punctate
calcifications may be present, while tonsillar
hyperplasia not seen.

AIDS Related Parotid Cysts

AxialT2weighted images show enlarged bilateral

parotid glands with multiple tiny hyperintense foci
involving the bilateral glands.

Sjogren
syndom
eMultiple uniform
sized foci with
hypointense
signal
onT1weighted
images and
hyperintense
onT2weighted
images,
suggesting
sialectasis, are
seen. Sagittaloblique HASTE
image of right
parotid gland
shows multiple
globular highsignal intensity
areas within the
glandular

Sjgren syndrome with secondary

lymphoma

Axial contrast-enhanced CT image shows a

homogeneously enhancing mass lesion in the
right parotid gland. Multiple small
hypoattenuating foci are seen involving the left
parotid gland. AxialT1weighted image reveals a
large hypointense mass lesion (arrow) involving
the superficial lobe of the right parotid gland.

Pleomorphic adenoma (Benign

Mixed Tumor)
Most common benign salivary gland tumour in
adults.
Small BMT- smoothly marginated, hypoechoic on
USG, homogenously enhancing ovoid mass; low T1 &
high T2 signal intensities.
Large BMT- lobulated mass with heterogenous
attenuation/signal from necrosis, hemorrhage; shows
inhomogenous enhancement. Calcifications are rare.
Extension to deep lobe of parotid must be looked for.
Widening of stylomandibular notch and displacement
of parapharyngeal fat anteromedially, suggest deep
lobe location.

Pleomorphi
c adenoma
with high
T2 and low
T1 signal.
They
appear as
lobulated
hypoechoic
masses on

Pleomorphic adenoma from

accessory parotid

Axial CT demonstrates the agenesis of the left parotid

gland (arrowhead) and heterogeneous lesion seen
overlying the left masseter muscle (arrow).

Facial nerve
plane

Deep lobe
BMT

Facial nerve plane projects from stylomastoid

foramen, anteroinferiorly to just lateral to
retromandibular vein, then anteriorly over surface of
masseter muscle.
The line connecting the lateral surface of the posterior
belly of the digastric muscle and the lateral surface of
the mandibular ascending ramus has also been used

Carcinoma ex pleomorphic
adenoma

Extension into the deep parotid lobe (arrow), infiltration of

the subcutaneous tissue and skin.
The tumour is heterogeneous on T2-weighted images (B).
Shows large necrotic areas and irregular contours.

Recurrent pleomorphic
adenoma
Recurrence rate reported to vary between 1% and 50%
depending on the initial surgical procedure.
Recurrences are often multiple and clustered, though they
may be uninodular.
Pleomorphic adenomas have pseudocapsules with small
protrusions extending into the surrounding normal parotid
gland tissue.

POST-ENUCLEATION Multinodular recurrence

Multifocal recurrence after

partial parotidectomy

Warthin tumor
Common in elderly males (mean age 60 yrs).
Arises almost exclusively in the lower portion of
superficial lobe of parotid.
20% multicentric, unilateral/bilateral,
synchronous/metachronous.
Well-circumscribed partly cystic, partly solid lesions.
Minimal enhancement of solid components.
Has low T1w signal intensity, with small areas of high
signal intensities due to proteinaceous fluid,
cholesterol crystals or hemorrhage. Intermediate and
high T2-weighted signal intensities.
Appears hot on Technetium scan.

Warthin tumor

(a) AxialT1weighted and (b)T2weighted images show multiple welldefined focal lesions involving bilateral parotid glands. The cystic
component of left parotid gland is hyperintense on bothT1weighted
andT2weighted images (arrow).

Other benign tumours

Oncocytoma
Myoepithelioma
Monomorphic adenoma
Basal cell adenoma
Relatively rare and lack typical
imaging patterns.

MALIGNANT TUMORS

Mucoepidermoid
carcinoma
Arise in the parotid gland (about 50%) and in the

minor salivary glands (nearly 45%) mainly in the

palate and buccal mucosa.
Low-grade lesions- well circumscribed, inhomogenous
enhancement due to mucus cystic deposits.
High-grade lesions- have poor margins and infiltrate
surrounding tissues.
Low to intermediate signal intensity on T1- and T2weighted images.
Metastasise primarily in the lymph nodes, bone and
lung.
If high grade, infiltrative or in high parotid location,
perineural spread on facial nerve can occur.

Adenoid cystic
carcinoma
Superficially located, slow growing neoplasm with

propensity for perineural spread and late recurrence.

Imaging findings nonspecific. Ill-defined margins
suggest higher grade lesion.
Metastatic spread to lungs and bones more frequent
than lymph nodes.
Perineural disease can also present with skip lesions
distally in a nerve that seems to be normal.
Cranial nerves- trigeminal (V3- foramen ovale), facial
(stylomastoid foramen) commonly involved. In minor
salivary gland malignancy of hard palate- V2
perineural spread: greater palatine foramen, PPF,
foramen rotundum, Meckel cave assessed.

Adenoid cystic carcinoma of the right

parotid gland extending to the
parapharyngeal space and the
infratemporal fossa (arrow).

Parotid Adenoid CCa

extending through
stylomastoid foramen along
mastoid segment of facial
nerve.

Assessing Perineural spread

The tumor usually enlarges the foramen or
canal. Asymmetric enhancement of the tissue
within the foramen is very suspicious for
tumor even if the foramen is not enlarged.
If fat is normal just outside a particular neural
foramen, then it is highly unlikely that tumor
has reached the foramen.
Trigeminal fat pad- small amount of fat just
below foramen ovale surrounding V3; located
along medial margin of lateral pterygoid
muscle. Tumors can follow the lingual,
mandibular, auriculotemporal nerves to this
fat pad.

Along trigeminal nerve

Axial T1-weighted image precontrast shows the

obliteration of the fat on the abnormal
pterygopalatine fossa (arrowheads).
Axial T1-weighted image after gadolinium. There is
subtle enhancement in the area of foramen
rotundum (white arrow) and along the dura (black

Axial T1-weighted image. The tumor enlarges the nerve

(arrowhead) along the medial margin of the lateral
pterygoid muscle. Arrow- nerve in the fat on the opposite
side.
Coronal T1-weighted image. The tumor (T) is visualized in
the region of the parotid gland and cheek. The enlarged
trigeminal nerve (arrows) obliterates the trigeminal fat pad
and follows through the foramen ovale to the trigeminal
ganglion in Meckel's cave (white arrowhead).

Acinic cell carcinoma

90% arise in parotid gland.
Second most common multiple or
bilateral tumour after Warthin's
tumour.
Imaging features are non-specific.
Circumscribed solid or partially cystic
lesions which may have a thin or
incomplete capsule.

Acinic cell carcinoma of the

superficial lobe of the right
parotid gland

Metastatic disease
Lymphatic/hematogenous spread to
intraparotid lymph nodes.
Normal parotid: 3-32 intraglandular
nodes.
Parotid nodes- 1st order nodal site for
skin of upper face, external ear,
scalp. Multifocal unilateral disease
most suggestive.
Bilateral nodes suggest systemic
disease or hematogenous metastatic

Melanoma metastases
from primary in external
ear.

Squamous cell
carcinoma metastases

Non-Hodgkin lymphoma
Multiple well-circumscribed,
homogenous, mildly hyperdense
intraparotid masses.
Periparotid and cervical
lymphadenopathy often present.
Mild to moderate homogenous
enhancement. T1,T2- intermediate
signal intensity.
Parotid- uncommon primary site
(<5%).

NHL

(a) AxialT2weighted MR image shows multiple focal

lesions involving bilateral parotid glands. (b)
CoronalT2weighted image reveals multiple nodes
involving the left jugular chain, bilateral axilla and

TNM Staging- Malignant

salivary gland tumors
T: Tumour
T0:no evidence of primary tumour
T1
less than or equal to 2 cm in maximal diameter
no extra-parenchymal extension

T2
2-4 cm in maximal diameter
no extra-parenchymal extension

T3
greater than 4 cm in maximal diameter OR
any size with extra-parenchymal extension

T4A:direct extension into skin, mandible, ear canal, facial nerve

T4B:direct extension into base of skull, pterygoid plates, or
encases carotid artery

 N: Nodes
N1
single ipsilateral node
<3 cm in maximal diameter

N2A
single ipsilateral node
3-6 cm in maximal diameter

N2B
multiple ipsilateral nodes
less than 6 cm in maximal diameter

N2C
contralateral or bilateral nodes
less than 6 cm in maximal diameter

N3:>6 cm in maximal diameter

M: Metastases
M0:no evidence of metastases
M1:distant metastases present

MRI in further
characterization
Malignant salivary gland tumours can be
differentiated from pleomorphic adenomas but not
from Warthin tumours using DCE-MRI at a time of
peak enhancement of 120s.
A washout ratio of 30% enabled additional
differentiation between malignant and Warthin
tumours.
Mean ADC of carcinomas has been shown to be
significantly smaller than that of benign solid
tumours; however the ADC value of Warthin
tumours was even smaller than that of malignant
tumours.

MRI in further
characterization
MR Spectroscopy: Choline/creatine
(Cho/Cr) ratios greater than 2.4 at an
echo time of 136ms helps in
distinction between benign and
malignant lesions.
Cho/Cr ratio greater than 4.5
suggested the presence of a Warthin
tumour.
MR Sialography- useful in
pseudotumoral pathologies like

IMAGING APPROACH

Age of patient

Childre
n

Hemangioma (>50%)
Lymphangioma
Branchial cleft cyst
Pleomorphic adenoma
MEC, Acinic CC

Adults

Pleomorphic adenoma
Warthin tumor
MEC
Adenoid CC
Lymphoma, Metastases

Single vs Multiple

Unifocal

Pleomorphic adenoma
MEC
Lymphangioma/hemangioma

Multifoc
al

Warthin tumor
Acinic CC
Lymphoma
Metastases
Pleomorphic adenoma
Sjogren syndrome
AIDS related Parotid cysts

Cystic mass
Warthin
tumor

Branchial
cleft cyst

Sialocele

Lymphoepith
elial cyst

Oncocystic
cystadenoma

Low-grade
MEC

Content
Calcificati
on
Ossificatio
n
Phlebolith
Fat

Chronic sialadenitis
Pleomorphic adenoma
Schwannoma
MEC

Pleomorphic adenoma

Hemangioma

Lipoma
Epidermoid

Malignancy - Pointers

Ill-defined
margins

Perineural
spread (esp
AdenoidCC)

Infiltration into
tissue planes

T2 hypointense
signal

Lymph node
spread (esp
MEC)

Hematogenous
spread
(lungs,bonesAdenoid CC)

Further reading
Bilateral parotid swelling: a radiological
review - A Gadodia, A S Bhalla, R Sharma,
A Thakar, R Parshad; Dentomaxillofac
Radiol.2011 October;40(7): 403414
Major salivary gland imaging - Yousem DM,
Kraut MA, Chalian AA. Radiology. 2000;216
(1): 19-29.
Imaging of salivary gland tumours - Harriet
C. Thoeny. Cancer Imaging. 2007; 7(1): 52
62.

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