US and Elastography of the Salivary Glands
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1 US and Elastography of the Salivary Glands Hasan YERLI, MD Baskent University Zubeyde Hanim, Practice and Research Center, Department of Radiology
2 Disclosures Nothing to disclose related to this presentation
3 Educational objectives Define the importance of US method Present the features of common and uncommon major salivary gland lesions Define the place of sonoelastography(se) in the management of the salivary gland lesions Present correlative imaging findings with CT and MRI approach
4 Salivary glands Major Parotid Submandibular Sublingual Minor aggregations of glandular tissue
5 Normal salivary gland parenchyma seems homogeneously hyperechoic Parotid gland
6 Submandibular gland S p D M D F M
7 Sublingual gland m GH GG D
8 METHODS B-mode Sonography Color Doppler Sonography Spectral Doppler Sonography Dynamic CEUS US-guided FNAB Sonoelastography CT MRI with Dynamic CE Diffusion-weighted imaging Sialography (DSA, MR-sialo) Scintigraphy
9 US approach to salivary gland lesions Echogenicity Location Border Vascularity Size Shape Presence of cystic areas Distal enhancement
10 DIFFERENTIAL DIAGNOSIS FOR SALIVARY GLANDS LESIONS Congenital diseases: Branchial cleft cyst, agenesis, ektopy Sialolithiasis Inflammatory diseases :Acute sialadenitis: Viral (mumps), bacterium (Staf. Aureus) Juvenile recurrent parotidit, radiation sialadenitis Chronic sialadenitis: Granulomatous:Tbc, sarcoidosis, Kimura dis., Wegener Autoimmune: Sjogren Tumors Benign: Pleomorphic adenoma Warthin tumor Lipoma Basal cell adenoma Myoepithelioma Canalicular adenoma Oncocytoma Nörofibroma Hemangioma Lymphangioma Angiolipoma Malign: Carcinomas: Mucoepidermoid, adenoid cystic, adeno, acinic cell squamous cell, basal cell adeno, Myoepithelial, duktal Other: metastatic, lymphoma, leukemia, sarcoma
11 LYMPH NODES Parotid contains lymph nodes
12 Branchial cleft cyst Lymphangioma Lowe et al. Radiographics 2001
13 Nineteen years old woman with neck lump at the rest position with Valsalva maneuver
14
15 at the rest position with Valsalva maneuver
16 Unilateral Submandibular Gland Agenesis associated with Herniated Hypertrophic Sublingual Gland Yerli H. Dynamic Sonography and CT Findings of Unilateral Submandibular Gland Agenesis associated with Herniated Hypertrophic Sublingual Gland. J Clin Ultrasound. 2013
17 be careful, don t assume it a real mass
18 Sialolithiazis
19 Sialadenosis
20 Abscess Tender mass in febrile patient Secondary to sialadenitis or ductal obstruction Irregular or regular contour
21 Chronic recurrent sialadenitis -Enlarged glands with small amorf 2-10 mm hypoechoic areas -This pattern is also seen in Sjogren s syndrome with permission N.Erdoğan
22 Salivary gland tumors Tumors are mostly hypoechoic The commonest site is parotid Incidence of malignancy: 5-20%parotid, 50-60% submandibular, 80% sublingual and minor salivary gland
23 LIPOMA Range from hypoechoic to isoechoic to hyperechoic See linear internal septation Difficult to separate from the adjacent fat No Doppler flow
24 Differentiation of Pleomorphic Adenoma and Warthin tumor Pleomorphic adenoma Well-defined Hypoechic Distal enhancement Mostly solid Solitary Lobulated Slightly vascular Mostly peripheral vasc. Whartin tumor Well-defined Hypoechic Distal enhancement Presence cystic areas Oval Common multifocality Markedly vascular Mostly mixed or central vasc.
25 Malignant salivary gland tumors Irregular-poorly border Strong vascularity Markedly hypoechoic Cystic changes
26 CE DYNAMIC US Whartin PA Malignant Bozzato A. O Head Neck S Knopf et al. EJR 2012 TP 0.74± ± ±0.08 MTT 0.62± ± ±0.05
27 HU Contrast enhancement features on CT for common parotid tumors Warthin's tumor Pleomorphic adenoma Malignant tumor Basal cell adenoma s 90 s 5 min Time Yerli H, et al. Dynamic multi-slice computed tomography findings for parotid gland tumors. J Comput Assist Tomogr 2007
28 SONOELASTOGRAPHY qualitative analysis-scoring External-internal compression Quantitative Share Wave (kpa) Acoustic Radiation Force Impulse Imaging(ARFI)(m/sec) Semi-quantitative-strain ratio
29 qualitative analysis SCORE 1. An almost entirely elastic SCORE 2. Mostly elastic pattern SCORE 3. Most of the lesion had no strain SCORE 4. No strain (An almost entirely blue color) Yerli H, et al. J Ultrasound Med 2012
30
31 Table. The distribution of 36 benign and malignant salivary gland masses for each score level Histo diagnosis/location (N) Score level Benign/parotid (24), submandibular (4) Warthin tumor/parotid (10), submandibular (1) Pleomorphic adenoma/parotid (10), submandibular (1) Lymphadenopathy/parotid (3) Lipoma/submandibular (1) Abscess/parotid (1), submandibular (1) Malignant/parotid (6), submandibular (2) Adenoid cystic carcinoma/ parotid (1), submandibular (1) Mucoepidermoid ca/parotid (2) Adenocarcinoma/parotid (2), submandibular (1) Lymphoma/parotid (1) Yerli H, et al. J Ultrasound Med. 2012
32 Table. Shear elastic modulus values for 60 salivary gland masses n Elastic modulus (kpa) median (range) Whole_Mean Whole_SD Normal parotid parenchyma ( ) 1.9 ( ) Normal submandibular parenchyma ( ) 1.4 ( ) Pooled malignant diagnoses ( ) 4.6 ( ) Mucoepidermoid Ca (high grade) ( ) 44.2 ( ) Myoepithelial carcinoma (high grade) Non-Hodgkins lymphoma (B-cell) Nasopharyngeal cancer metastasis Pooled benign diagnoses ( ) 6.0 ( ) Pleomorphic adenoma ( ) 12.4 ( ) Warthin s tumour ( ) 4.8 ( ) Chronic sclerosing sialadenitis ( ) 5.2 ( ) Sialocele/cyst ( ) 3.5 ( ) Reactive node ( ) 6.5 Lipoma Abscess Bhatia KS et al. Eur Radiol 2012
33 Mean ARFI quantification (m/sec) of the 22 parotid gland tumors mean ± SD Control 1.75 ± 0.64 Pleomorphic adenomas 2.23 ± 0.53 Malignant tumors 2.58 ± 0.63 Warthin s tumors 2.58 ± 0.77 Other benign tumors 2.64 ± 0.72 Ductal dilatation 2.89 ± 1.04 Mansour et al. Ultraschall in Med 2012
34 US-guided biopsy If the combination of B-mode sonography color Doppler and CEUS and SE are nonspecific US-guided FNAC is effective and safe for diagnosis
35 FNAC have a similar diagnostic value for determining specific histological types of common parotid masses, when compared with MRI including diffusion-weighted imaging with ADC calculation. Yerli et al. Dentomaxillofacial Radiology (2010)
36 Conclusion US is helpful method in differential diagnosis of a wide array of salivary gland lesions Use advance imaging if necessary SE might partially benefit the improvement of patient management When necessary, get tissue diagnosis
37
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