0:00

Let's take a look at this case of an elderly gentleman

0:04

who presented with a palpable mass

0:07

in the right parotid gland.

0:09

On the T2-weighted imaging,

0:12

you see that this lesion has gross heterogeneity

0:15

as far as its signal intensity.

0:17

It almost looks like there's a fluid-fluid level in

0:19

one of the cystic portions of the mass and

0:22

it has some very dark areas as well.

0:24

And it is in the superficial portion of the parotid

0:29

gland. And if we take the images a little bit lower,

0:32

you can see that it gets down to the angle of the

0:35

mandible here. So a large lesion, heterogeneous.

0:38

This is not what we would expect of

0:40

a pleomorphic adenoma, not at all.

0:42

On the T1-weighted scan we see both the brighter

0:45

areas as well as the darker areas.

0:48

Again, having something that has bright areas within the

0:52

mass is not typical of a pleomorphic adenoma.

0:57

That's more likely to be something like a Warthin's

0:59

tumour with its heterogeneity. Now,

1:01

we want to make sure that this wasn't biopsied,

1:03

but the next thing we look at is the ADC map.

1:08

So if it's bright on the ADC map,

1:10

we'll feel a little bit more reassured

1:12

that this is a benign tumour,

1:14

possibly one of those monomorphic adenomas or

1:17

something atypical about a pleomorphic adenoma.

1:20

However, this is the ADC map and as you can see,

1:23

we have dark areas,

1:25

very dark area, more posteriorly in this mass.

1:28

There might be a little bit of a cystic

1:30

component out superficially,

1:32

but this is not a reassuring finding.

1:37

So now we have a high likelihood that

1:40

this is a Warthin's tumour.

1:42

Based on the heterogeneity on T1 as well as T2

1:45

and the lower signal intensity on the ADC map,

1:49

this would still require aspiration cytology

1:52

in order to exclude a malignancy.

1:55

If that aspiration cytology is equivocal,

1:59

what one can try is a technetium pertechnetate

2:03

nuclear medicine study.

2:05

Warthin's tumours are relatively unique in that they

2:08

show avid uptake of technetium pertechnetate as

2:13

opposed to pleomorphic adenomas and most malignancies.

2:17

So that would be our next step.

2:19

Just for the sake of completion,

2:20

we will look at this on post-gadolinium enhanced scan

2:24

and Warthin's tumors do show enhancement.

2:28

You can see that there are portions that are and are

2:31

not enhancing in this lesion as

2:33

well as this cystic area,

2:35

which may occur both in malignancies as well

2:40

as pleomorphic adenomas. At this juncture,

2:43

one of the next things you want to do is to make sure

2:45

you look through the contralateral parotid gland and

2:51

elsewhere within the ipsilateral parotid and to

2:55

ensure that there are not multiple lesions.

2:59

As Warthin's Tumor is the most common tumor

3:04

to have bilateral and or multiple ipsilateral tumors.

3:13

There's something over here which kind of looks

3:15

more like a lymph node than anything else.