Pleomorphic adenoma head and neck Poster No.: C-1042 Congress: ECR 2015 Type: Educational Exhibit Authors: M. E. Pérez Montilla, I. Bravo Rey, E. Roldán Romero, F. BravoRodríguez; Cordoba/ES Keywords: Education and training, elearning, MR, CT, Ultrasound, Head and neck DOI: 10.1594/ecr2015/C-1042 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 17
Learning objectives Know different locations of pleomorphic adenoma in head and neck, its radiological findings and illustrate with cases from our hospital. Background The pleomorphic adenoma (or benign mixed tumor) is the most common tumor in the major salivary glands, especially the parotid gland. It also sits in the minor salivary glands and is rare in other locations of the head and neck. Pleomorphic adenoma is a benign tumor that contains both mesenchymal and epithelial elements. At histologic analysis, pleomorphic adenoma has a fibrous pseudocapsule with epithelial cells. Cells may form nests or tubules that resemble ducts. The background stroma may appear myxoid with spindle-shaped cells and mucin or may contain heterologous elements such as cartilage or bone. Pleomorphic adenoma occurs in people in the fourth and fifth decades of life, but may arise at any age. There is a slight predominance in women. Clinically, it manifests as slowly growing painless mass. However, small lesions may be detected incidentally at imaging tests. In exceptional cases, pleomorphic adenomas may be clinically aggressive. Once clinical and imaging diagnosis is established, a pleomorphic adenoma is excised en bloc. After incomplete excision, pleomorphic adenomas often recur, usually multifocally. Nontreated pleomorphic adenomas may undergo malignant transformation after decades; they may metastasize and even be fatal. With successful excision, prognosis is excellent. Findings and procedure details Page 2 of 17
We reviewed cases of pleomorphic adenoma of the head and neck from our hospital. The most common locations were the major salivary glands (parotid and submandibular gland). Less frequent locations were the soft palate, parapharyngeal space and lacrimal gland (figure 1, diapo 7). The algorithm of imaging proposed included ultrasound, contrast-enhanced computed tomography and/or nonenhanced and contrast-enhanced magnetic resonance (MR) imaging, applied in a different order depending on clinical data. Generally it was presented as solid, lobulated, well-defined and homogeneous mass and normally a solitary lesion. The larger lesions may have a heterogeneous appearance due to necroticcystic changes, hemorrhage or calcifications (figure 2, diapo 8). The feature of lobulated shape is being emphasized in differential diagnosis. In ultrasound are usually hypoechoic solid lesions, with posterior acoustic enhancement and that may contain calcifications. Vascularization in pleomorphic adenomas is often poor or absent (even when the sensitive power Doppler mode is used), but may be abundant. In CT normally have a similar density to muscle with mild to moderate enhancement after contrast administration. Because of its slow growth, pleomorphic adenoma may demonstrate bone remodeling. Lesions are typically hypointense on T1-weighted images and hyperintense with a complete and hypointense capsule on T2-weighted images. Small lesions show an intense and homogeneous enhancement and larger lesions a heterogeneous enhancement (figure 3, diapo 9). Images for this section: Page 3 of 17
Fig. 1: PLEOMORPHIC ADENOMA LOCATIONS Page 4 of 17
Fig. 2: RADIOLOGICAL FINDINGS Page 5 of 17
Fig. 3: RADIOLOGICAL FINDINGS Page 6 of 17
Fig. 4: CASE 1. PLEOMORPHIC ADENOMA IN PAROTID GLAND Page 7 of 17
Fig. 5: CASE 2. PLEOMORPHIC ADENOMA IN PAROTID GLAND Page 8 of 17
Fig. 6: CASE 3. PLEOMORPHIC ADENOMA IN PAROTID GLAND Page 9 of 17
Fig. 7: CASE 4. PLEOMORPHIC ADENOMA IN PAROTID GLAND Page 10 of 17
Fig. 8: CASE 5. PLEOMORPHIC ADENOMA IN SUBMANDIBULAR GLAND Page 11 of 17
Fig. 9: CASE 6. PLEOMORPHIC ADENOMA IN SUBMANDIBULAR GLAND Page 12 of 17
Fig. 10: CASE 7. PLEOMORPHIC ADENOMA IN SOFT PALATE Page 13 of 17
Fig. 11: CASE 8. PLEOMORPHIC ADENOMA IN PARAPHARYNGEAL SPACE Page 14 of 17
Fig. 12: CASE 9. PLEOMORPHIC ADENOMA IN PARAPHARYNGEAL SPACE Page 15 of 17
Fig. 13: CASE 10. PLEOMORPHIC ADENOMA IN LACRIMAL GLAND Page 16 of 17
Conclusion The pleomorphic adenoma is more common in the major salivary glands, but may also be located in other areas of the head and neck. It has a characteristic appearance on imaging tests that allows recognizing it in atypical locations. Personal information References Bialek E, Jakubowski W, Zajkowski P, Szopinski K, Osmolski A. US of the Major Salivary Glands: Anatomy and Spatial Relationships, Pathologic Conditions, and Pitfalls. Radiographics, 2006; 26:745-63. Rabinov JD. Imaging of salivary gland pathology. Radiol Clin North Am 2000; 38:1047-57. Yousem DM, Kraut MA, Chalian AA. Major salivary gland imaging. Radiology 2000; 216:19-29. Bialek EJ, Jakubowski W, Karpinska G. Role of ultrasonography in diagnosis and differentiation of pleomorphic adenomas: work in progress. Arch Otolaryngol Head Neck Surg 2003; 129:929-33. Varghese BT, Sebastian P, Abraham EK, Mathews A. A case report: Pleomorphic adenoma of minor salivary gland in the parapharyngeal space. World J Surg Oncol 2003; 1:2. Hakeem AH, Hazarika B, Pradhan SA. Primary pleomorphic adenoma of minor salivary gland in the parapharyngeal space. World J Surg Oncol 2009; 7:85. Mendelsohn AH, Bhuta S, Calcaterra TC. Parapharyngeal space pleomorphic adenoma: a 30-year review. Laryngoscope 2009; 119(11):2170-4. Jung WS, Ahn KJ, Park MR, et al. The radiological spectrum of orbital pathologies that involve the lacrimal gland and the lacrimal fossa. Korean J Radiol 2007; 8(4):336-42. Page 17 of 17