Warthin tumours (or papillary cystadenoma lymphomatosum) are benign, sharply demarcated tumours of the salivary gland. They are of lymphoid origin and most commonly arise from parotid gland tail. They may be bilateral or multifocal in up to 20% of cases and are the most common neoplastic cause of multiple solid parotid masses.
Warthin tumours are the 2nd most common benign parotid tumour (after pleomorphic adenoma) and represent up to 10% of all parotid tumours. They are the commonest bilateral or multifocal benign parotid tumour. They typically occur in the elderly (6th decade) with a recognised male predilection. Patients typically present with painless parotid swelling.
They are often multicentric (20%) and are usually small (1-4 cm). They have a typically heterogeneous appearance on all modalities, often with cystic components (30%).
Tends to favour the parotid tail region at the level of mandibular angle.
Has a greater tendency to undergo cystic change (~30%) than any other salivary gland tumour 4,5.
Most tumours tend to be ovoid, with well-defined margins and multiple irregular, small, sponge-like anechoic areas 10. Tumours that are large (e.g. >5 cm) tend to have a higher proportion of cystic content than smaller lesions had and in some cases can be composed almost entirely of cystic material. They are often hypervascular.
- classic appearance is a well-defined heterogeneous solid cystic lesion within the superficial lobe of parotid/parotid tail
- well defined
- no calcification
- cystic changes appear as intralesional lower attenuation
- moderate enhancement
- presence of mural nodule is strongly suggestive of Warthin tumour
- can be often seen bilaterally
Well defined and can be bilateral.
- T1: low to intermediate signal with cyst containing cholesterol components containing focal high signal 2
- T2: heterogeneous and variable signal intensity
- T1 C+ (Gd): usually no contrast enhancement 3
Often shows uptake with Tc99-pertechnetate, thallium and FDG-PET 7.
Treatment and prognosis
They are benign with extremely low incidence of malignant transformation. Some advocate surgical excision while others favour conservative management with follow-up imaging.
Possible imaging differential considerations include:
- pleomorphic adenoma
- other salivary gland tumours
- parotid nodal metastasis
- parotid non-Hodgkin lymphoma
- Sjogren syndrome
- benign lymphoepithelial lesions (BLEL) in HIV
- infiltrative lesion, e.g. sarcoidosis
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