Warthin tumours (or papillary cystadenoma lymphomatosum) are a benign, sharply demarcated tumour of the salivary- lymphoid origin most commonly arising from parotid gland tail. They are bilateral or multifocal in up to 20% of cases, and are the most common neoplastic cause of multiple solid parotid masses.
They are the 2nd most common (up to 10% of all parotid tumours) benign parotid tumour (after pleomorphic adenoma) and are the commonest bilateral or multifocal benign parotid tumour. It typically occurs in the elderly (6th decade). There is 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, had well-defined margins, contain 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 intra lesional 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: heterogenous 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
- 1. Ikeda M, Motoori K, Hanazawa T et-al. Warthin tumor of the parotid gland: diagnostic value of MR imaging with histopathologic correlation. AJNR Am J Neuroradiol. 2004;25 (7): 1256-62. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 2. Minami M, Tanioka H, Oyama K et-al. Warthin tumor of the parotid gland: MR-pathologic correlation. AJNR Am J Neuroradiol. 14 (1): 209-14. AJNR Am J Neuroradiol (abstract) - Pubmed citation
- 3. Joe VQ, Westesson PL. Tumors of the parotid gland: MR imaging characteristics of various histologic types. AJR Am J Roentgenol. 1994;163 (2): 433-8. AJR Am J Roentgenol (abstract) - Pubmed citation
- 4. Choi DS, Na DG, Byun HS et-al. Salivary gland tumors: evaluation with two-phase helical CT. Radiology. 2000;214 (1): 231-6. Radiology (full text) - Pubmed citation
- 5. Harnsberger HR, Glastonbury CM, Michel MA et-al. Diagnostic Imaging: Head and Neck. Lippincott Williams & Wilkins. (2010) ISBN:1931884781. Read it at Google Books - Find it at Amazon
- 6. Thoeny HC. Imaging of salivary gland tumours. Cancer Imaging. 2007;7 (1): 52-62. doi:10.1102/1470-7330.2007.0008 - Free text at pubmed - Pubmed citation
- 7. Uchida Y, Minoshima S, Kawata T et-al. Diagnostic value of FDG PET and salivary gland scintigraphy for parotid tumors. Clin Nucl Med. 2005;30 (3): 170-6. Pubmed citation
- 8. Nguyen VX, Nguyen BD, Ram PC. Bilateral and multifocal Warthin's tumors of parotid glands: PET/CT imaging. Clin Nucl Med. 2012;37 (2): 175-7. doi:10.1097/RLU.0b013e318238f244 - Pubmed citation
- 9. Christe A, Waldherr C, Hallett R et-al. MR imaging of parotid tumors: typical lesion characteristics in MR imaging improve discrimination between benign and malignant disease. AJNR Am J Neuroradiol. 2011;32 (7): 1202-7. doi:10.3174/ajnr.A2520 - Pubmed citation
- 10. Kim J, Kim EK, Park CS et-al. Characteristic sonographic findings of Warthin's tumor in the parotid gland. J Clin Ultrasound. 2004;32 (2): 78-81. doi:10.1002/jcu.10230 - Pubmed citation