Rai S, Rohit M, Kaur M, Mukul P.

Pleomorphic adenoma: Choice of radiographic imaging modality - Computed

tomography or magnetic resonance imaging? Illustration through a case report. Dent Hypotheses [serial online]
2013 [cited 2019 Mar 17];4:33-6. Available from: http://www.dentalhypotheses.com/text.asp?2013/4/1/33/110181

Computed tomography (CT) is one of the primary imaging modalities used to assess the tumours of salivary glands.
However, magnetic resonance imaging (MRI) may provide additional information over CT.

Case Report: We report the case of a 60-year-old male with a slowly enlarging, well-defined, round, painless, non-
fixated, rubber-like swelling over the left ramus region below the ear, measuring about 4 × 4.5 cm, covering the
lower border of the mandible near the angle. A provisional diagnosis of PA was given and CT and MRI were used
to study the lesion.

Discussion: Through this case, which was suspected to have undergone malignant transformation because of
indistinct margins and focal hypodense areas on CT but was later confirmed to be a benign salivary gland
tumour on MRI, we illustrate the role of CT and MRI as diagnostic aids in PA and emphasize on what should be
the choice of imaging modality for parotid tumours.

https://www.ncbi.nlm.nih.gov/pubmed/18337041

For lesions in the superficial parotid and submandibular gland, ultrasound is an ideal tool for initial
assessment. These are superficial structures accessible by high resolution ultrasound and FNAC which provides
excellent resolution and tissue characterization without a radiation hazard. Nodal involvement can also be
assessed.

If deep tissue extension is suspected or malignancy confirmed on cytology, an MRI or CT is mandatory to

evaluate extent, local invasion and perineural spread.

For all s in the sublingual gland, MRI should be performed as the risk of malignancy is high. For lesions of
the deep lobe of parotid gland and the minor salivary glands, MRI and CT are the modalities of choice.

Ultrasound has limited visualization of the deep lobe of parotid gland which is obscured by the mandible. Minor
salivary gland lesions in the mucosa of oral cavity, pharynx and tracheo-bronchial tree, are also not accessible by
conventional ultrasound.

Recent study suggests that Magnetic Resonance Spectroscopy (MRS) may differentiate malignant and
benign salivary glands as well as distinguishing Warthin's from pleomorphic adenoma. However, its role in
clinical practice is not well established.

MRS is a non-invasive, ionizing-radiation-free analytical technique that has been used to study metabolic
changes in brain tumours, strokes, seizure disorders, Alzheimer's disease, depression and other diseases
affecting the brain.

Similarly, the role of nuclear medicine and PET scan, in imaging of parotid masses is limited. Sialography is used
to delineate the salivary ductal system and has limited role in assessment of extent.

Positron emission tomography (PET) uses small amounts of radioactive materials called radiotracers, a
special camera and a computer to help evaluate your organ and tissue functions. By identifying body changes
at the cellular level, PET may detect the early onset of disease before it is evident on other imaging tests.

https://www.ncbi.nlm.nih.gov/pubmed/10823330

Warthin's tumours were detected by dual-isotope SPET imaging; however, MRI failed to differentiate Warthin's
tumour from pleomorphic adenoma. Dual-isotope SPET correctly diagnosed benign tumours. Dual-isotope
SPET gave an accuracy of 94%, whereas CT gave an accuracy of 70-90%. MRI was 73-91% accurate in
differentiating between benign (Warthin's) and malignant tumours.

Burket’s Oral Medicine

MRI provides superior soft tissue resolution over CT and is particularly advantageous in staging oral cavity
malignancies involving the floor of the mouth and complex disease processes involving multiple anatomic spaces.
MRI has become the imaging modality of choice for preoperative evaluation of salivary gland tumours because of
its excellent ability to differentiate soft tissues and availability of multiplanar imaging (Figure 10-11). MRI allows
for not only localization of a lesion but also the assessment of extracranial extent. It also provides a higher
degree of accuracy in assessing perineural and intracranial spread of malignancies. Using contrast-enhanced
MRI, detection of early perineural invasion or a mildly enlarged nerve is possible: a great advantage over
CT. MRI has also proven to be valuable in the detection of postoperative recurrences. In addition, MRI is
particularly useful in the assessment of disorders that mimic parotid swelling such as hypertrophy of the muscles
of mastication.

MRI is further preferred for salivary gland imaging because patients are not exposed to radiation, no
intravenous contrast media are required routinely, and it is less prone to artifact from dental restoration
than CT. The utility of MRI has been enhanced by combining it with sialography. This allows a much finer evaluation
of ductal alterations and any filling defects. MRI is contraindicated for patients with cardiac pacemakers,
automatic cardioverter defibrillators, or ferromagnetic metallic implants. Patients who cannot maintain a still
position or those with claustrophobia may have difficulty tolerating the MRI procedure.

Recently, new MRI techniques, such as dynamic contrast-enhanced MRI (DCEMRI), diffusion-weighted MRI,
and proton MRI spectroscopy, have shown promising results in the differentiation between benign and
malignant salivary gland tumors.