Diagnostic Value of Superb Microvascular Imaging in Parotid Tumors.

BACKGROUND The aim of this study was to evaluate the clinical diagnostic value of superb microvascular imaging (SMI) in assessing vascular distribution, vascularity, and vessel morphology of parotid tumors (PTs). MATERIAL AND METHODS PT patients confirmed by postoperative histopathological detection and who underwent color Doppler flow imaging (CDFI), microvascular imaging (MVI), and SMI examination were recruited. PTs were classified into 3 groups: pleomorphic adenoma (PA), Warthin tumor (WT), and malignant PT (MT). The tumor vascular distribution, vascularity, and vessel morphology recorded by CDFI, MVI, and SMI were compared among PA, WT, and MT group. PT diagnosis was performed using histopathological detection. Fisher's exact test was used to compare the diagnostic sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy between SMI and MVI examination in PTs. RESULTS We enrolled 198 PTs consisting of 114 PAs, 56 WTs, and 28 MTs into our study. CDFI examination found no significant differences in vascular distribution and vascularity among the PA, WT, and WT groups. SMI examination found significant differences in vascular distribution and vascularity among the 3 groups. MVI found significant differences in vessel morphology, including uneven distribution of blood flow, arborization, and irregular blood flow among the PA, WT, and MT groups. SMI found significant differences in arborization and irregular blood flow, but none of the differences in uneven distribution of blood flow among the 3 groups were significant. The diagnostic sensitivity, specificity, and accuracy of SMI and MVI in PTs showed no significant differences. CONCLUSIONS SMI more accurately evaluated the vascular distribution and vascularity of PTs than CDFI. SMI might be a potential non-invasive diagnostic method for PTs in clinical practice.

Diagnosis of lymphoepithelial carcinoma in parotid gland with three dimensional computed tomography angiography reconstruction: A case report.

Lymphoepithelial carcinoma (LEC) is an uncommon malignant neoplasm. Due to the complicated anatomical structure of the human head, standard imaging modalities including ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) scan remain limited in detection of salivary tumors. We used three-dimensional computed tomography angiography (3D-CT angiography) for the assessment and pre-operative surgical planning of facial fractures of a case with LEC. The study results demonstrated that 3D-CT angiography provided an insightful approach to preoperative evaluation in the treatment of salivary tumors.

Diagnostic value of CT perfusion imaging for parotid neoplasms.

OBJECTIVES: To assess the value of CT perfusion imaging in the differentiation of different histological categorization of benign tumours from malignant tumours in patients with parotid neoplasms. METHODS: CT perfusion was successfully performed in 62 patients with parotid neoplasms whose diagnoses were confirmed by surgery or biopsy. The software generated a tissue time-density curve (TDC) and measured blood volume, blood flow, mean transit time and capillary permeability surface product. One-way ANOVA and receiver operating characteristic curves were used to analyse the difference and diagnostic efficacies of all perfusion data between each one of the benign tumours and malignancies. Statistical significance was assigned at the 5% level. RESULTS: Pleomorphic adenomas mainly had a gradually ascending TDC. Warthin tumours showed a fast ascent followed by a fast descent. The TDC of basal cell adenomas had a fast ascension followed by a plateau, then a gradual descent. Malignant tumours mainly showed a rapidly ascending curve with a stable plateau. Significant differences were observed in blood flow, blood volume and mean transit time between pleomorphic adenomas and malignant tumours (p < 0.05) as well as in blood flow and blood volume between the Warthin tumours, the basal cell adenomas and the malignant tumours (p < 0.05). Differences in permeability surface between the basal cell adenomas and malignant tumours were significant (p < 0.01). CONCLUSION: CT perfusion of parotid gland could provide TDC and perfusion data, which were useful in the differentiation of different histological benign tumours and malignant tumours in the parotid gland.

Large carcinoma ex pleomorphic adenoma of the parotid gland: a case report and review of literature.

Pleomorphic adenoma (PA) is one of the most common benign tumors of the parotid gland. PA usually grows slowly and is painless. Surgery is necessary for treating PA. Facial palsy, salivary fistula, and Frey syndrome have been reported as complications of tumor resection. PA can transform into a carcinoma ex pleomorphic adenoma (CXPA) over time and as it enlarges. This report describes a case of a large CXPA that transformed from a PA that had developed over 17 years and caused withdrawal from social contact because fear of surgery made the patient refuse treatment. The tumor gradually enlarged without any pain for a decade, but rapid growth and bleeding began a year before admission. Postoperative facial function and local control of the tumor were excellent, but the patient required adjuvant chemotherapy for lung and mediastinum lymph node metastasis leading to dyspnea from tracheal stenosis. This case indicates the importance of adequate explanation and advice when choosing therapy for PA, especially given the risk of a PA transforming to a CXPA.

Management of vascular malformations of the parotid area.

OBJECTIVES: To describe our experience in the management of vascular malformations of the parotid area. MATERIALS AND METHODS: This was a retrospective study. Among 614 parotidectomy performed between 1998 and 2008 at our institution, 10 cases (1.6%) of vascular malformations have been identified. Clinical features and management of these patients were analyzed. RESULTS: Clinical presentation was usually related to that of a benign, slow-growing and asymptomatic tumor. There was a marked female predominance (90%). In any case, the diagnosis of vascular malformation could be obtained with certainty preoperatively. Surgical excision was performed most often referred to diagnosis. Sixty percent of vascular malformations were located in the superficial lobe of the parotid gland. On the histological we found a classic look with benign vascular proliferation of endothelial cells in the walls. The vessel lumen was either the head of a congestion or thrombosis or calcification (phleboliths). CONCLUSION: Vascular malformations of the parotid gland, rare disease, are mainly venous. The terminology is based on clinical data, scalable, histological and hemodynamic as classified by the International Society of Study of Vascular Anomaly (ISSVA). Despite advances in imaging including MRI they remain difficult to diagnose. The treatment of reference is surgical excision.

[Capabilities of ultrasound study in the differential diagnosis of neoplasms of the major salivary glands].

Seventy patients aged 20 to 75 years with suspected parotid gland disease were examined to study the capabilities of an ultrasound study in the diagnosis of neoplasms of the major salivary glands. B-mode ultrasonography and color Doppler imaging presented a means of detecting the presence of masses in the gland, their topography and dimensions, and specific vascularization, which allowed the option and scope of treatment to be planned.

Ultrasonographic appearances of mucoepidermoid carcinoma of the salivary glands.

OBJECTIVE: The objective of this study was to investigate the ability of sonography for diagnosis of mucoepidermoid carcinoma (MEC) in the salivary glands. STUDY DESIGN: Sonographic images of 74 cases were analyzed retrospectively; the features evaluated included size, echogenicity, shape, internal structure, distal acoustic enhancement, and regional lymph node enlargement and vascularization, and categorized them into 3 groups based on histology (low, intermediate, and high grade). RESULTS: The lesion size of low-grade MEC was smaller than those of intermediate- and high-grade MEC. MEC lesions of the salivary glands were mostly associated with heterogeneous echotexture, indistinct margins, irregular shape, and absence of distal acoustic enhancement. They sometimes showed cystic areas, calcifications, regional lymph node enlargement, or were well vascularized on Doppler. There were no significant sonographic differences in low-, intermediate-, and high-grade MEC. CONCLUSIONS: Salivary MEC presents a variety of sonographic appearances, which would aid in the diagnosis of salivary MEC.

Role of ultrasound in the assessment of benignity and malignancy of parotid masses.

OBJECTIVES: This study aimed to investigate the value of ultrasound in the identification of benign and malignant parotid masses. METHODS: Data of 189 patients with parotid gland masses undergoing ultrasound-guided fine-needle aspiration (FNA), core biopsy or surgery were reviewed retrospectively and the presumed sonographic diagnoses were compared with the histopathology. The sensitivity, specificity and accuracy of sonographic diagnoses were assessed and the sonographic characteristics of those lesions, including shape, margin, echogenicity, echotexture and vascularization, were studied. RESULTS: Of the 189 patients, the final pathological diagnosis included 18 malignant tumours and 171 benign masses; the presumed sonographic diagnoses showed 165 cases as benign and probably benign masses (11 cases were confirmed malignant, 154 cases benign) and 24 cases were diagnosed as probably malignant and malignant masses (7 cases were confirmed malignant, 17 cases benign). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ultrasound for the diagnosis of parotid gland masses were 38.9%, 90.1%, 29.2%, 93.3% and 85.2%, respectively, and accuracy for malignant masses was 20%. The sonographic characteristics of parotid masses between benign and malignant lesions had no significant differences. The parotid gland masses in this study included pleomorphic adenoma, Warthin's tumour, retention cyst, haemangiomas, chronic granuloma, lymphoma, fibrolipoma, abscess, basal cell adenoma, oncocytoma, lymphatic tuberculosis, myoepithelioma, neurilemmoma, mucoepidermoid carcinoma, adenoid cystic carcinoma, alveolar soft part sarcoma and retinal blastoma (metastasis). CONCLUSIONS: It is challenging to use sonography for differentiating between benign and malignant parotid gland masses. To make a definite diagnosis, ultrasound-guided FNA or core biopsy is advocated.

Anomalous relationship of the retromandibular vein to the facial nerve as a potential risk factor for facial nerve injury during parotidectomy.

Finding and protecting the facial nerve are a challenge for the surgeon performing parotid surgery. The abnormal relationship between the retromandibular vein and facial nerve and its branches may increase the risk of facial nerve injury during surgery. In this clinical report, we have reported a 41-year-old female patient with pleomorphic adenoma undergoing superficial parotidectomy, and we have discussed a new variation of facial nerve-retromandibular vein relationship.

Recapitulating orthotopic tumor model through establishment of a parotid gland tumor with lung metastasis using HeLa cell injection into nude mice.

The interaction between tumor cells and surrounding normal cells is very important in the prognosis of tumors. The object of this study was to determine the effect of recipient bed of tumor xenograft on tumor metastasis using a novel parotid gland tumor model. HeLa cells were xenografted into the parotid gland or subcutaneous tissues of athymic mice. Eight weeks after the transplantation, all mice were euthanized and specimens were immunostained with antibodies for angiogenic factors. FGF-2 was given to HeLa cells and the effect on the cellular migration was determined. EGF was also given to HeLa cells for the evaluation of FGF-2 induction. Immunohistochemical staining was done for the vascular metastasis-related factors on 26 human salivary gland tumors. HeLa cells showed significantly higher lung metastatic potential in the parotid gland than in the subcutis. Immunohistochemical staining revealed overexpression of FGF-2 in the parotid tumors compared to the subcutaneous tumors. The application of FGF-2 to implanting HeLa cells increased the cellular invasion in a dose-dependent manner. The application of EGF increases FGF-2 expression in HeLa cells. In clinical specimens, EGF and VEGF signaling proteins were more expressed than in normal salivary glandular tissues. In conclusion, a parotid tumor model of HeLa cells was successfully developed and it closely mimics high metastasis. These results indicate that recipient bed with intense EGF expression increases tumor metastasis through upregulation of FGF-2 expression.

Spontaneous infarction of pleomorphic adenoma: report of a case simulating malignancy on fine-needle cytology sample.

Ischemic or hemorrhagic infarction has been described as an uncommon but possible complication of fine-needle cytology sampling in numerous organs, more frequently the thyroid, the salivary glands, the breast, the lymph node, and the kidney. In these situations, infarction appears to be directly related to the vascular disturbances caused by needle sampling, though fine this latter might be. One case of a spontaneous infarction of a parotid pleomorphic adenoma in a 46-year-old lady is here described in which the cytopathologic findings, which were related to ischemic infarction, preceded fine-needle cytology sampling and mimicked malignancy. The cytopathologic picture showed a quizzical mixture of necrosis and inflammation coupled to hyperplastic changes of the acinar cells, oncocytic metaplasia, and atypical squamous metaplasia of extreme degree simulating high-grade epidermoid- or mucoepidermoid carcinoma. Due to the cytologically suggestive changes, a nerve-sparing radical parotidectomy was performed. The differential diagnostic problems encountered in this case are discussed together to the possible medical-legal implications originating from such striking atypias as to closely simulate malignancy.

Angiogenic and lymphangiogenic microvessel density in recurrent pleomorphic adenoma.

BACKGROUND: Recurrent pleomorphic adenoma (RPA) is an uncommon and challenging disease. The aim of this study was to determine if there is a difference between RPA and the pleomorphic adenoma (PA) without recurrence related to tumor blood and lymphatic vascularization. Moreover, we compared the microvessel density (MVD) between cell-rich areas (predominance of epithelial cells) and cell-poor areas (predominance of myxoid and chondroid areas) of the stroma of PA and RPA. In addition, immunohistochemical staining for the Ki-67 antigen was conducted simultaneously to evaluate cell proliferation in PA and RPA. METHODS: A total of 19 cases of PA and 24 cases of RPA, blood, and lymphatic vessels were analyzed by immunohistochemical technique using the antibodies CD34, CD105, D2-40, and Ki-67. RESULTS: Comparing no recurrent with recurrent tumor, no significant difference was found in terms of lymphatic vessel density, MVD, and proliferation index. When MVD and proliferation index were compared with different areas in cellular composition (cell-rich and cell-poor areas), there was a significant difference in PA, as well as in RPA. CONCLUSION: This study shows that although RPA presents more aggressive clinical behavior than PA, there is no difference between tumor blood and lymphatic vascularization, suggesting that there is no correlation between vascularity and risk of recurrence. Furthermore, vascularized stroma in PA, as well as RPA, depends on the proportion of the cellular composition.

Image interpretation for squamous cell carcinoma of Stensen duct.

A case of squamous cell carcinoma presumed to have arisen from the right Stensen duct is reported. The patient, a 62-year-old man, was referred to our hospital with swelling in the right cheek. Magnetic resonance imaging (MRI), including contrast-enhanced MRI, and contrast-enhanced computerized tomography (CECT) enabled diagnosis of a solitary mass in the Stensen duct. Fat-suppressed T(2)-weighted imaging, in particular, demonstrated a mass-like lesion in the dilated Stensen duct and obstructive parotitis where the duct transitions into the parotid gland. Gadolinium-DTPA-enhanced T(1)-weighted imaging demonstrated the mass-like lesion surrounded by signal-hyperintense layer showing continuous transition from the thickened Stensen duct wall, which was also hyperintense. The CECT revealed peripheral annular enhancement surrounding the tumorous mass, with no enhancement of the duct wall itself, reflecting an increase in micro blood vessels in the stroma of the neoplasm. These image findings correlated well with subsequent histopathologic findings. A mass with rim enhancement and dilated Stensen duct accompanied by parotitis and no salivary calculus may suggest a differential diagnosis of malignant tumor of Stensen duct.

Differentiation of benign and malignant parotid tumors using deconvolution-based perfusion CT imaging: feasibility of the method and initial results.

AIM: We evaluated the feasibility of perfusion CT (CTP) of the parotid gland and attempted to differentiate benign from malignant tumors. MATERIALS AND METHODS: CTP was performed in 17 patients with benign tumors and 10 patients with malignant parotid tumors. Data were postprocessed by using deconvolution-based perfusion analysis. Postprocessing-generated maps showed blood flow (BF), blood volume (BV), mean transit time (MTT), and capillary permeability surface product (PS). Regions of interest were placed through the tumor site and the contralateral healthy parotid tissue. Ratios of the perfusion values between the tumors and the contralateral healthy structures were also calculated. Pearson correlation coefficients were determined to compare the agreement between the two readers. RESULTS: Perfusion maps of all tumors were successfully obtained. High Pearson correlation coefficients comparing the two readers' visually measured abnormalities were observed (r=0.79-0.86, P=0.001) for all perfusion maps, The MTT and PS values between malignant and benign tumors were not significantly different. The BF and BV values were statistically significant different between the benign and malignant tumors (0.00

Evidence of lymphangiogenesis in Warthin's tumor of the parotid gland.

The details of the pathogenesis of cystadenolymphoma (Warthin's tumor) of the parotid gland are still unclear. Neovascularization is considered to be a pivotal factor for solid tumor progression and biological behavior of the tumor. Using double-labeling immunohistochemistry for LYVE-1 and CD34 (specific markers for lymphatic and vascular endothelial cells, respectively) this study analyzes lymphatic vessel density (LVD) and blood vessel density (BVD) in 10 Warthin's tumors and 10 pleomorphic adenomas of the parotid gland as well as in 5 normal parotid glands and 5 normal parotid lymph nodes. There was no significant difference in the intratumoral LVD and BVD among pleomorphic adenoma and normal parotid gland tissue. In contrast, the intratumoral LVD and BVD were significantly higher in Warthin's tumor than pleomorphic adenoma, normal parotid gland and parotid lymph node (P<0.0001 versus P<0.004). The increase in lymphatic vessels in Warthin's tumor suggests that epithelial tumor cells might promote lymphangiogenesis in this kind of lesions.

[Rare entity of a macroscopically visible tumor cone of squamous cell carcinoma in the greater veins of the head and neck]. / Seltene Entität eines makroskopisch sichtbaren Tumorzapfens eines Plattenepithelkarzinoms in den grossen Kopf-Hals-Venen.

Cones of malignant tumors are commonly known but only a few descriptions of cones in the head and neck area exist - as seen in a 91-year-old patient under our care. Cones of thymic and thyroid cancers are described in the literature. There are no descriptions of cones of head and neck squamous cell carcinomas. Metastases of squamous cell carcinoma in the head and neck area are very aggressive and have a high potential for vascular neogenesis. A vascular cone might be possible by vascular formation or by mechanical intrusion as described elsewhere.

Spontaneous infarction of a pleomorphic adenoma in parotid gland: diagnostic problems and review.

Although infarction of parotid gland pleomorphic adenoma (PA) following fine-needle aspiration (FNA) has been well-documented, spontaneous infarction of PA has remained as an uncommon entity in the literature. To our knowledge, we report the second case of spontaneous infarction occurring in a parotid gland PA. A 44-yr-old man presented with a 2-yr history of slowly enlarging right parotid mass, which had become painful 1 mo before performing FNA biopsy. Smears revealed abundant necrotic debris, atypical squamous cells, and small cells with dark nuclei suggestive of a carcinoma. Histologic examination of the tissue fragments demonstrated degenerated clusters of cells and chondromyxoid matrix. The parotidectomy specimen had features consistent with those of an infarcted PA. Although appears to be rare, spontaneous infarction of PA should be considered in the differential diagnosis, since necrosis may mimic carcinoma and cause misinterpretation of necrosis as an indication of malignancy, in an otherwise benign salivary gland neoplasm.

Carotid artery resection: preoperative temporary occlusion is not always an accurate predictor of collateral blood flow.

CONCLUSION: The morbidity predicted by means of preoperative PET studies does not always correlate with the morbidity experienced after permanent carotid artery occlusion. A pre-resection extracranial-intracranial bypass may be necessary to reduce the risk of neurologic morbidity, in particular when carotid artery resection is planned for tumors involving the skull base. OBJECTIVES: Carotid artery resection is generally considered the only curative treatment for patients with advanced head and neck carcinoma involving the carotid artery. PET can be used during temporary occlusion of the internal carotid artery to assess the safety of the procedure. The aims of this paper were to clarify the risk of carotid artery resection and the benefit of extracranial-intracranial bypass. MATERIAL AND METHODS: Twelve patients diagnosed with head and neck cancer adherent to the carotid artery and in proximity to the skull base who had shown good hemispheric collateral blood flow by means of PET underwent carotid artery resection without preoperative bypass. RESULTS: Of the 12 patients who underwent carotid artery resection without reconstruction, 10 suffered no serious neurologic complications; however, 2 suffered cerebral infarctions intraoperatively.