Benign Tumors of Major Salivary Glands Workup

Updated: Sep 04, 2019
  • Author: Michael J Eliason, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Workup

Laboratory Studies

Perform a white blood cell (WBC) count to investigate for any evidence of leukocytosis and shift that might indicate a possible infectious process or lymphoproliferative disease.

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Imaging Studies

Imaging studies are most helpful in the diagnostic evaluation of salivary gland tumors (SGTs). [2, 10]

Ultrasonography (US) is often the first-line modality for characterizing a neoplasm within the parotid or submandibular glands. In many cases, high-resolution US can adequately assess the size, evaluate the general morphology (cystic, solid, or complex), and define the type of borders (well-circumscribed vs poorly defined), thereby facilitating diagnosis and surgical management. Surgeon-performed US may serve as an extension of the physical examination or may be ordered as a separate standalone study, depending on institutional preferences.

Magnetic resonance imaging (MRI) and computed tomography (CT) may be used to further characterize larger tumors, those that extend beyond the depth that US can adequately assess, and those that raise concerns for malignant features on US or clinical assessment. (See the images below.) MRI is the most sensitive test for establishing the borders of soft-tissue tumor extension and perineural invasion or spread. 

Heterogeneous, predominantly low-density mass in t Heterogeneous, predominantly low-density mass in tail of right parotid gland with minimal thin peripheral enhancement consistent with Warthin tumor.
Dense, small, solid lesions in parotid glands (mor Dense, small, solid lesions in parotid glands (more on left side than on right) in patient with lymphoma. This is representative of lymphomatous involvement of glands.
Ill-defined masses in parotid glands bilaterally, Ill-defined masses in parotid glands bilaterally, proven to be large B-cell lymphoma in this patient with known Sjögren disease.
Large B-cell lymphoma in patient with known Sjögre Large B-cell lymphoma in patient with known Sjögren disease.
Large B-cell lymphoma in patient with known Sjögre Large B-cell lymphoma in patient with known Sjögren disease.
Bilateral, solid, inhomogeneous parotid gland mass Bilateral, solid, inhomogeneous parotid gland masses that are larger on left side than on right, with minimal necrosis. These were caused by lymphoma.

In most circumstances, findings from CT and MRI cannot reliably be used to differentiate benign from malignant disease. In a study of 46 major SGTs, Aghaghazvini et al found that dynamic contrast-enhanced MRI had potential utility for differentiating SGTs preoperatively, specifically with regard to distinguishing between Warthin tumors and benign non-Warthin tumors. [11]

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Biopsy

In selected cases, fine-needle aspiration (FNA) biopsy (FNAB) may facilitate the management of a mass in the salivary gland by helping to distinguish a tumor from certain nonneoplastic or inflammatory processes that may respond better to medical management. 

In most patients who present with a salivary mass, the decision to offer surgical management is likely to be determined by clinical and imaging characteristics, and FNA may be considered as part of the workup on the basis of specific considerations of the case. Most benign tumors and low-grade malignancies without lymphadenopathy are treated by surgical extirpation of the primary tumor alone. Patients with high-grade salivary malignancies may require removal of the primary tumor and lymphadenectomy at the same time.

The reliability of FNA in making the diagnosis and determining the grade of malignancy remains a controversial issue. Additionally, the utility of FNA in distinguishing high-grade malignancies from low-grade malignancies and benign tumors may be limited by the local availability of expertise. In the absence of the ability to differentiate the grade of malignancy, FNA may play a limited role in the decision to offer an operation; however, if the diagnosis of a high-grade salivary gland malignancy is made preoperatively, FNA may influence the extent of the operation. [5, 12]

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