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Technetium-99M Pertechnetate Salivary Gland Imaging: Its Role in the Diagnosis of Warthin's Tumor

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Technetium-99M Pertechnetate Salivary Gland Imaging: Its Role in the Diagnosis of Warthin's Tumor Technetium-99m Pertechnetate Salivary Gland Imaging: Its Role in the Diagnosis of Warthin's Tumor Case Presentation and Discussion: Gregory S. Weinstein, Robert T. Harvey, Wayne Zimmer, Suat Ter and Abass Alavi Fmm the Case Reports ofthe Hospital ofthe University of Pennsylvania cinoma of the lung. No furtherinterventionwas considered nec JNucIMedl994;35:179—183 essaiy for the parotidmasssinceit was confirmedto be a benign lesion and did not cause significantdiscomfort. CASE PRESENTATION DISCUSSION A 74-yr-oldmalecomplainedof painlessswellingin the right parotid area which started several months ago. There was no Pre-operative diagnosis of a Warthin's tumor is of con associated numbness in the area, and he denied facialweakness. siderable value in the evaluation of patients with parotid Essentially, the masswas asymptomatic. His past medical history gland swelling. In this case, the benign nature of the parotid wasunremarkableandhehadnopriorsurgery.Hewasnotonany tumor allowed the attending physicians to concentrate medications. He denied allergies. He had smoked tobacco, two their effortson the managementof lung cancer. The useof packs a day for 55 yr and quit 6 yr prior to the current medical parotid radionuclide scanning with [@Tc]pertechnetate problem.He didnotdrinkalcohol. greatly facilitated the pre-operative evaluation of this pa. Physicalexaminationrevealeda well developedman in no tient's presenting complaint. acute distress. He had no head and neck abnormalities except for Technetium-99m-pertechnetate was first used for brain a right-sided 2 x 3-cm parotid mass. A fine needle aspiration was performedduring the initial visit. and thyroid scanning in the early 60s (1,2). Its use for An MRI scanrevealeda largerightparotidmass,measuring3 parotid gland imagingwas realized incidentally while im cminitsgreatestdimensionwithintheinferioraspectofthegland. aging the brain (1,2). Grove and DiChiro were the first to Two otherincidentalfindingswere alsonoted.The firstwas a study the salivary glands with [@Tc]pertechnetate (3). rightcerebellopontineangletumor,andthesecondwastwo en Manyreportshave appearedin the literaturesubstantiating hancinglesionswithinthecerebellum,bothsuspiciousfor meta the role of this imaging technique in the management of static disease. Fine needle aspiration cytology of the parotid mass patients with parotid gland disease and especially with revealednormalparotidaciniandafewoncocyticcellsassociated Warthin's tumor (4—12).We hope to lend additional sup with numerouslymphoid cells, consistentwith Warthin's tumor. port for this effective diagnostic study, which may have No evidenceof malignancywas found.Becauseof the incidental since lost popularity in favor of fine-needle aspiration. detectionof massesin the head, it was decidedto initiatea Warthin's tumor (papillary cystadenoma lymphomato workupto locatea primarytumor.In addition,a radionuclide sum), a benign neoplasm of the majorsalivaryglands (par scan to assess the nature of the parotid mass and to confirm its benign nature was also scheduled. ticular the parotid gland), was described in 1910 by two A radionuclidescanof the parotidglandwas performedfollow German physicians, Albrecht and Arzt (13). The first En ing the intravenousadministrationof [@Tc]pertechnetate (Fig. glish cases were described as adenomas of heterotopic 1).A SPEC!' scan of the head was also obtainedas part of this salivary glands in the preparotidlymph nodes by Nichol examination.The imagerevealedan areaof increasedfocal up son in 1923 (14). This tumor has a varied nomenclature takeintherightparotidgland,consistentwiththepatient'sknown including adenolymphoma, papillary cystadenoma lym Warthin's tumor. No posteriorfossa uptakewas noted. A chest phomatosum, lymphomatous adenoma and oncocytoma, x-rayrevealeda rightupperlobemass,suggestingcarcinomaof but the termWarthin'stumorhas been extensively used to thelungandchronicobstructivepulmonarydisease.At thispoint, credit Aldred Scott Warthinwho published the first two thepatientwasreferredfor definitivetherapyfor metastaticcar case reports in the American literaturein 1929 (15). War thin's tumor is the second most common benign parotid ReceivedOct.11,1993;revisionacceptedOct 11,1993. tumor (benign mixed tumors are the most common), and ForcorrespondenceandreçX1ntSCOnta@AbassPJa@,M.D.,DMSbnOfNUdear MedIcine,Departmentof R&ik@Ogy,Hospftaiofthe Un@iersftyof Penns@1vania,I classically accounts for 2% of all head and neck tumors and DonnerBldg.,3400SpruceSt, Philadelphia.PA19104. 6%—lO%of parotid gland epithelial tumors (4—6,16—20). [@TcJPertethnetate Salivary Gland Imaging •Weinstein et al. 179 lung cancer deaths among women in an age-matched co hort. In this study, 82%of the female patientswere smok ers. Given that the parotid duct epithelium is in direct continuity with the oral cavity, they postulated that orally inhaled tobacco smoke may play a role in ductal epithelial metaplasia leading to tumor formation (22). The peak incidence of Warthin's tumor is frequently PIGHT LEF observed in the sixth and seventh decades (4,6,18,21). As alludedto earlier, the overwhelmingmajority of Warthin's tumors are benign, and malignant transformationis rare. Carcinomas arising from this tumor have been estimated at 0.3% of all lesions (16). Grossly, the tumor is round or oval, encircled by a thick capsule. It rarely infiltrates the surrounding gland. The surface is pink-grayin color, smooth or lobulated (17,19). The histologic diagnosis of Warthin's tumor requires the @ 1@ri, ,‘ 1::4@ presence of an epithelial parenchyma and a lymphoid FiGURE1. Technebum-99m-peitechnetatescan acquiredin stroma, distinguishing it from an oncocytoma (4,5,16,17). @edor,antenorandbothlateralprojectionsrevealedincreased The parenchyma is organized in a tubulopapillaiy-cystic focaluptakeinthe lowernghtparotidgland.Thiswas interpretedto pattern and features epithelial cells with numerous mito be consistentwithWarthin'stumor. chondria, surroundingdilated cystic spaces of secretory material,which is clear, serous, milky, mucoid or choco late in color (17). The epithelium lining of the cysts is There are reports, however, of highincidences, citing 14%, usually a double layer of cells with papillary projections 14.4% and even 24.4% of all parotid tumors (5,16,17). into the cysts. The inner layer consists of tall columnar Warthin's tumor is the most common salivary tumor to cells with a dense oxyphilic granularcytoplasm due to an be bilateraland multifocal (11,16). Chapnikobserved 12% abundance of mitochondria (4,17,19,21). These cellular of patients developing more than one lesion, which can changes (referredto as oncocytic changes) commonly oc manifest as multiple, discrete prhnaiy lesions occurring cur with aging and their significance is not known, though within one parotidgland(4). Numerous other reportshave they are implicatedin the neoplastic process (4). The outer identified a bilateral incidence of 3%—8%of cases, while layer consists of rounded or cuboidal cells. There is wide 4%—12%are multifocal (8@19,21,23). Finkeistein et al. re variation regarding the extent of cyst formation and cyst ported a case of Warthin's tumor presenting as multiple contents, the degree of epithelial metaplasia, and the pro bilateral synchronousparotid masses,which is believedto portion of lymphoid stroma to epitheium (4,8,17,21). A be the third such casein the literature (8). Additionally, basement membrane separates the epithelium and lym Warthin's tumor has a postoperative recurrence rate of phoid stroma, which supports the epithelial parenchyma 6%—i2%(16,23) which may result from a high frequency of andhasbeenfound to containgerminalcentersalongwith undiagnosed multifocal lesions at the time of original sur stem cells, lymphocytes, plasma cells, mast cells, histio gery (11). cytes and macrophages (4,8,17). The origin of lymphoid Clinically, Warthin's tumor is very slow growing and stroma has been debated, as will be discussed below. may even appear static over many years. It commonly Paralleling the tumor's interesting histologic composi presents as an asymptomatic painless swelling at the lower tion is its histogenesis,which is based on the fact that pole of the parotidgland for many months (8,17,18,21,22). lymph nodes are contained within the normal mature pa Chapnik reported a range from 3 wk to 10yr (4). The facial rotid gland. During development, the salivary tissue of the nerve is usually spared, as nearly all cases are benign expected parotid gland intermingles with the neighboring (8,16). The majority of tumors are 1—3cm in diameter, well lymphoid tissue of expected lymph nodes. As these tissues circumscribed, and encapsulated. Fluctuations in tumor mature, they remain in close proximity of the gland. The size do not appear to occur (4,21,22). Historically, War matureparotidgland is encircled by a capsule, but encap thin's tumor has demonstrateda predilection for males, sulationoccurslate in developmentandresultsin intrusion andthe literatureconsistently cites male-to-femaleratiosof of lymph nodes into the parotid gland, and invasion of the at least 5:1 (4,6,23). However, recent reports have docu peri-parotidlymph nodes with salivary duct tissue. Thus, mented changes in the male versus female distribution, such elements become a diagnostic component of the tu with equal incidence in both sexes since the mid 1970s mor(4,8,21,23). Neoplastic transformationofthe heteropic without explanation.Male-to-femaleratios of lessthan 2:1 salivary gland tissue trappedwithin
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