Technetium-99m Pertechnetate Salivary Gland Imaging: Its Role in ...

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cinoma of the lung. No furtherinterventionwas considered nec essaiy for the parotidmass since it was confirmedto be a benign lesion and did not cause significantdiscomfort. JNucIMedl994;35:179—183 [@TcJPertethnetate Salivary Gland Imaging • Weinstein et al. 179 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 CASE PRESENTATION A 74-yr-oldmalecomplainedof painlessswellingintheright parotid area which started several months ago. There was no associated numbness in the area, and he denied facial weakness. Essentially, the mass was asymptomatic. His past medical history wasunremarkable andhehadnopriorsurgery. He wasnotonany medications. He denied allergies. He had smoked tobacco, two packs a day for 55 yr and quit 6 yr prior to the current medical problem.He didnotdrinkalcohol. Physicalexaminationrevealeda well developedmanin no acute distress. He had no head and neck abnormalities except for a right-sided 2 x 3-cm parotid mass. A fine needle aspiration was performedduring the initial visit. AnMRIscanrevealedalargerightparotidmass,measuring 3 cminitsgreatest dimensionwithintheinferioraspect ofthegland. Two otherincidentalfindingswere alsonoted.The firstwasa right cerebellopontine angletumor,andthesecondwastwoen hancing lesionswithinthecerebellum, bothsuspicious for meta static disease. Fine needle aspiration cytology of the parotid mass revealednormalparotidaciniandafewoncocyticcellsassociated with numerouslymphoid cells, consistentwith Warthin's tumor. No evidenceof malignancywas found.Becauseof the incidental detectionof massesin the head,it was decidedto initiatea workupto locatea primarytumor. In addition,a radionuclide scan to assess the nature of the parotid mass and to confirm its benign nature was also scheduled. A radionuclidescanof the parotidglandwas performedfollow ing the intravenousadministrationof [@Tc]pertechnetate (Fig. 1). A SPEC!' scan of the head was also obtained as part of this examination.The imagerevealedan areaof increasedfocal up takeintherightparotidgland,consistent withthepatient'sknown Warthin's tumor. No posterior fossa uptake was noted. A chest x-rayrevealeda rightupperlobemass,suggesting carcinomaof thelungandchronicobstructivepulmonarydisease. At thispoint, thepatientwasreferredfordefinitivetherapyformetastaticcar ReceivedOct.11,1993;revisionacceptedOct11,1993. Forcorrespondenceand reç[email protected] [email protected], M.D.,DMSbnOfNUdear MedIcine, DepartmentofR&[email protected], Hospftaiofthe [email protected] of [email protected], I DonnerBldg.,3400SpruceSt, Philadelphia. PA 19104. DISCUSSION Pre-operative diagnosis of a Warthin's tumor is of con siderable value in the evaluation of patients with parotid gland swelling. In this case, the benign nature of the parotid tumor allowed the attending physicians to concentrate their effortson the managementof lung cancer. The use of parotid radionuclide scanning with [@Tc]pertechnetate greatly facilitated the pre-operative evaluation of this pa. tient's presenting complaint. Technetium-99m-pertechnetate was first used for brain and thyroid scanning in the early 60s (1,2). Its use for parotid gland imagingwas realized incidentally while im aging the brain (1,2). Grove and DiChiro were the first to study the salivary glands with [@Tc]pertechnetate (3). Many reports have appearedin the literaturesubstantiating the role of this imaging technique in the management of patients with parotid gland disease and especially with Warthin's tumor (4—12).We hope to lend additional sup port for this effective diagnostic study, which may have since lost popularity in favor of fine-needle aspiration. Warthin's tumor (papillary cystadenoma lymphomato sum), a benign neoplasm of the majorsalivary glands (par ticular the parotid gland), was described in 1910 by two German physicians, Albrecht and Arzt (13). The first En glish cases were described as adenomas of heterotopic salivary glands in the preparotidlymph nodes by Nichol son in 1923 (14). This tumor has a varied nomenclature including adenolymphoma, papillary cystadenoma lym phomatosum, lymphomatous adenoma and oncocytoma, but the term Warthin'stumor has been extensively used to credit Aldred Scott Warthin who published the first two case reports in the American literaturein 1929 (15). War thin's tumor is the second most common benign parotid tumor (benign mixed tumors are the most common), and classically accounts for 2% of all head and neck tumors and 6%—lO% of parotid gland epithelial tumors (4—6,16—20). by on April 1, 2018. For personal use only. jnm.snmjournals.org Downloaded from
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  • cinoma of the lung. No furtherinterventionwas considered necessaiy for the parotidmasssince it was confirmedto be a benignlesion and did not cause significantdiscomfort.

    JNucIMedl994;35:179183

    [@TcJPertethnetate Salivary Gland Imaging Weinstein et al. 179

    Technetium-99m Pertechnetate Salivary GlandImaging: Its Role in the Diagnosis of Warthin'sTumorCase Presentation and Discussion: Gregory S. Weinstein, Robert T. Harvey, Wayne Zimmer, Suat Ter andAbass Alavi

    Fmm the Case Reports ofthe Hospital ofthe University of Pennsylvania

    CASE PRESENTATION

    A 74-yr-oldmalecomplainedof painlessswellingin the rightparotid area which started several months ago. There was noassociated numbness in the area, and he denied facialweakness.Essentially, the masswas asymptomatic. His past medical historywasunremarkableandhehadnopriorsurgery.Hewasnotonanymedications. He denied allergies. He had smoked tobacco, twopacks a day for 55 yr and quit 6 yr prior to the current medicalproblem.He didnotdrinkalcohol.

    Physicalexaminationrevealeda well developedman in noacute distress. He had no head and neck abnormalities except fora right-sided 2 x 3-cm parotid mass. A fine needle aspiration wasperformedduring the initial visit.

    An MRI scanrevealeda largerightparotidmass,measuring3cminitsgreatestdimensionwithintheinferioraspectofthegland.Two otherincidentalfindingswere alsonoted.The firstwas arightcerebellopontineangletumor,andthesecondwastwo enhancinglesionswithinthecerebellum,bothsuspiciousfor metastatic disease. Fine needle aspiration cytology of the parotid massrevealednormalparotidaciniandafewoncocyticcellsassociatedwith numerouslymphoid cells, consistentwith Warthin's tumor.No evidenceof malignancywas found.Becauseof the incidentaldetectionof massesin the head, it was decidedto initiateaworkupto locatea primarytumor. In addition,a radionuclidescan to assess the nature of the parotid mass and to confirm itsbenign nature was also scheduled.

    A radionuclidescanof the parotidglandwas performedfollowing the intravenousadministrationof [@Tc]pertechnetate (Fig.1). A SPEC!' scan of the head was also obtainedas part of thisexamination.The imagerevealedan areaof increasedfocal uptakeintherightparotidgland,consistentwiththepatient'sknownWarthin's tumor. No posterior fossa uptakewas noted. A chestx-rayrevealeda rightupperlobemass,suggestingcarcinomaofthelungandchronicobstructivepulmonarydisease.At thispoint,thepatientwasreferredfor definitivetherapyfor metastaticcar

    ReceivedOct.11,1993;revisionacceptedOct 11,[email protected]@,M.D.,DMSbnOfNUdear

    MedIcine,Departmentof R&[email protected],Hospftaiofthe [email protected] [email protected],IDonnerBldg.,3400SpruceSt, Philadelphia.PA19104.

    DISCUSSION

    Pre-operative diagnosis of a Warthin's tumor is of considerable value in the evaluation of patients with parotidgland swelling. In this case, the benign nature of the parotidtumor allowed the attending physicians to concentratetheir effortson the managementof lung cancer. The useofparotid radionuclide scanning with [@Tc]pertechnetategreatly facilitated the pre-operative evaluation of this pa.tient's presenting complaint.

    Technetium-99m-pertechnetate was first used for brain

    and thyroid scanning in the early 60s (1,2). Its use forparotid gland imagingwas realized incidentally while imaging the brain (1,2). Grove and DiChiro were the first tostudy the salivary glands with [@Tc]pertechnetate (3).Manyreportshave appearedin the literaturesubstantiatingthe role of this imaging technique in the management ofpatients with parotid gland disease and especially withWarthin's tumor (412).We hope to lend additional support for this effective diagnostic study, which may havesince lost popularity in favor of fine-needle aspiration.

    Warthin's tumor (papillary cystadenoma lymphomatosum), a benign neoplasm of the majorsalivary glands (particular the parotid gland), was described in 1910 by twoGerman physicians, Albrecht and Arzt (13). The first English cases were described as adenomas of heterotopicsalivary glands in the preparotidlymph nodes by Nicholson in 1923 (14). This tumor has a varied nomenclatureincluding adenolymphoma, papillary cystadenoma lymphomatosum, lymphomatous adenoma and oncocytoma,but the termWarthin'stumorhas been extensively used tocredit Aldred Scott Warthinwho published the first twocase reports in the American literaturein 1929 (15). Warthin's tumor is the second most common benign parotidtumor (benign mixed tumors are the most common), andclassically accounts for 2% of all head and neck tumors and6%lO%of parotid gland epithelial tumors (46,1620).

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  • lung cancer deaths among women in an age-matched cohort. In this study, 82%of the female patients were smokers. Given that the parotid duct epithelium is in directcontinuity with the oral cavity, they postulated that orallyinhaled tobacco smoke may play a role in ductal epithelialmetaplasia leading to tumor formation (22).

    The peak incidence of Warthin's tumor is frequentlyLEF observed in the sixth and seventh decades (4,6,18,21). As

    alludedto earlier, the overwhelmingmajority of Warthin'stumors are benign, and malignant transformationis rare.Carcinomas arising from this tumor have been estimated at0.3% of all lesions (16).

    Grossly, the tumor is round or oval, encircled by a thickcapsule. It rarely infiltrates the surrounding gland. Thesurface is pink-grayin color, smooth or lobulated (17,19).The histologic diagnosis of Warthin's tumor requires thepresence of an epithelial parenchyma and a lymphoidstroma, distinguishing it from an oncocytoma (4,5,16,17).The parenchyma is organized in a tubulopapillaiy-cysticpattern and features epithelial cells with numerous mitochondria, surroundingdilated cystic spaces of secretorymaterial, which is clear, serous, milky, mucoid or chocolate in color (17). The epithelium lining of the cysts isusually a double layer of cells with papillary projectionsinto the cysts. The inner layer consists of tall columnarcells with a dense oxyphilic granularcytoplasm due to anabundance of mitochondria (4,17,19,21). These cellularchanges (referredto as oncocytic changes) commonly occur with aging and their significance is not known, thoughthey are implicatedin the neoplastic process (4). The outerlayer consists of rounded or cuboidal cells. There is widevariation regarding the extent of cyst formation and cystcontents, the degree of epithelial metaplasia, and the proportion of lymphoid stroma to epitheium (4,8,17,21). Abasement membrane separates the epithelium and lymphoid stroma, which supports the epithelial parenchymaandhasbeenfound to containgerminalcentersalongwithstem cells, lymphocytes, plasma cells, mast cells, histiocytes and macrophages (4,8,17). The origin of lymphoidstroma has been debated, as will be discussed below.

    Paralleling the tumor's interesting histologic composition is its histogenesis,which is based on the fact thatlymph nodes are contained within the normal mature parotid gland. During development, the salivary tissue of theexpected parotid gland intermingles with the neighboringlymphoid tissue of expected lymph nodes. As these tissuesmature, they remain in close proximity of the gland. Thematureparotidgland is encircled by a capsule, but encapsulationoccurslate in developmentandresultsin intrusionof lymph nodes into the parotid gland, and invasion of theperi-parotidlymph nodes with salivary duct tissue. Thus,such elements become a diagnostic component of the tumor (4,8,21,23). Neoplastic transformationofthe heteropicsalivary gland tissue trappedwithin lymphoid tissue maybe responsible for the formationof these tumors (4). Thisdevelopmentalprocess leads to several observations, mostnotably, (1) the presence of ductal tissue within lymphoid

    PIGHT

    [email protected],@ , 1::[email protected]

    FiGURE1. Technebum-99m-peitechnetatescan [email protected],antenorandbothlateralprojectionsrevealedincreased

    focaluptakeinthe lowernghtparotidgland.Thiswas interpretedtobe consistentwithWarthin'stumor.

    There are reports, however, of highincidences, citing 14%,14.4% and even 24.4% of all parotid tumors (5,16,17).

    Warthin's tumor is the most common salivary tumor tobe bilateraland multifocal (11,16). Chapnikobserved 12%of patients developing more than one lesion, which canmanifest as multiple, discrete prhnaiy lesions occurringwithin one parotidgland (4). Numerous other reportshaveidentified a bilateral incidence of 3%8%of cases, while4%12%are multifocal ([email protected],21,23). Finkeistein et al. reported a case of Warthin's tumor presenting as multiplebilateral synchronousparotid masses,which is believedtobe the third such case in the literature (8). Additionally,Warthin's tumor has a postoperative recurrence rate of6%i2%(16,23) which may result from a high frequency ofundiagnosed multifocal lesions at the time of original sur

    gery (11).Clinically, Warthin's tumor is very slow growing and

    may even appear static over many years. It commonlypresents as an asymptomatic painless swelling at the lowerpole of the parotidgland for many months (8,17,18,21,22).Chapnik reported a range from 3 wk to 10yr (4). The facialnerve is usually spared, as nearly all cases are benign(8,16). The majority of tumors are 13cm in diameter, wellcircumscribed, and encapsulated. Fluctuations in tumorsize do not appear to occur (4,21,22). Historically, Warthin's tumor has demonstrateda predilection for males,andthe literatureconsistently cites male-to-femaleratiosofat least 5:1 (4,6,23). However, recent reports have documented changes in the male versus female distribution,with equal incidence in both sexes since the mid 1970swithout explanation.Male-to-femaleratios of lessthan 2:1are quite common (7,18,21,22). Lamelas et al. found thatthe increasing incidence of Warthin's tumor in womenparalleled similar increases in tobacco consumption and

    180 TheJournalof NuclearMedicineVol.35No.1 January1994

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  • tissue; (2) the location of almost all Warthin's tumors inlymphatic tissue within or adjacent to the parotid gland;and (3) the multifocal nature of the tumor (8,23).

    Debate exists over the role of the lymphoid tissue in thistumor.

    Some believe it is a cellular response to epithelial neoplasia, and others believe it is a normal lymph node surrounded by epithelial proliferation. Studies have demonstrated that both T and B lymphocytes are contained withinthe lymphoid stroma, which may indicate that the tumormay have originated in pre-existing lymph nodes. Othershave found functional germinalcenters and an abundanceof IgA plasma cells in Warthin's tumors, suggesting animmune response to the tumor. It has also been shown thatmost Warthin's tumors have excessive amounts of lymphoid tissue compared to normal lymph nodes. Nonetheless, most authors believe that the majority of Warthin'stumors develop from heterotopic salivary ducts within preexisting lymphoid tissue, which undergoes subsequent reactive changes in response to the neoplastic epitheium(4,21 ). In contrast, the submandibular and sublingualglands develop independently of lymphoid tissue, and areencapsulated early. Their developmental process precludes intermingling of salivary and lymphoid tissues, thuslimiting Warthin's tumor to the parotid gland and its immediate environment (11).

    Diagnosis of Warthin's tumor based on clinical assessment is questionable since the tumor is indistinguishablefrom other benign lesions of the parotid gland (17). Avariety of tissue analyses and imaging techniques havebeen employed in an attempt to arrive at the correct diagnosis, and such methods include plain radiographs,sialography, [@TcJpertechnetate scanning and tissue biopsy.

    Sialographyis useful for evaluatingthe ducts and parenchyma of the parotid glands, which also may suggest thepresence of a tumor as evidenced by displayingthe effectson the ductal system (stretching and displacement withoutduct destruction) (4,5,21). Since this finding is commonamong all benign parotid gland neoplasms, its presence isnot specified as Warthin's tumor. Malignanttumors morecommonly show invasion and destruction of the ducts (5).Thus, the study is limited and therefore should not play amajor diagnostic role in this regard (4,17). The combination of sialography and CT scanning may be more reliablethan sialography alone in identifying small tumors, determininglocation of tumor, assessing invasiveness and identifying intrinsic and extrinsic lesions (4,19). This analysiscan be further enhanced with the adjunctive use of intravenous administration of contrast, particularly if the lesionis a vascular tumor (4).

    Controversy surrounds the use of needle biopsy andaspirationof salivaryglandlesions. Needle biopsy is usefulin that a tissue specimen is procured upon which a histologic diagnosis may be conferred. If a Warthin's tumor isidentified, surgery may be avoided in high-risk patients orthe surgical approach may be tailored for adequate resection of the mass thus sparing neighboring structures (e.g.,

    the facial nerve). However, this procedure also has somelimitations in that the specimen may not be representativeof the acturallesion andthereforean errorin diagnosis maybe made (4). Additionally, the facial nerve may be injuredduring aspiration of a parotid gland mass. Lindberg andAkerman have reported that fine-needle aspiration cytology can be used to achieve a positive preoperative diagnosis in 81%of specimens, while yielding 8% false-negativeresults (24). Their false-negative rate was reduced to under5% when the biopsy and cytology were performed by cxperienced individuals. An 11% nondiagnostic rate could

    not be reduced because of the cystic nature of the tumor(24). X-ray studies (plainfilms and CT scans) provide somediagnostic information (e.g., size of lesion, extension,etc.), but lack detailed analysis (e.g., cystic or solid). Radionucide imaging with [@FcJpertechnetatehas beenshown to provide some useful specific information aboutcertaindisorders, and can also reflect alterationsin normalphysiological function (5).

    Radionuclide scanning with [@Tc]pertechnetate is asimple and noninvasive method for assessing salivaryglandfunction. It is a suitable radioactive tracerfor humanuse because of its short half-life of 6 hr and pure gammaemission of 140keV, which is readilydetected by a gammacamera(4). The techniqueiswell describedin the literature(4,5,10) and involves imaging of the parotid gland in theposterior projection after the intravenous infusion of 5 mCiof the tracer at 60-secintervals for 20 min and obtainingfinal images of the patient in water, right lateral and leftlateral positions, followed by washout images obtained 3min after stimulationwith orally administeredlemon juiceto determineadequacyand symmetiy of glandularsecretion (6).

    Salivary imaging with a gamma camera interfaced to acomputerallows rapidsequential images andassessment ofthe three distinct phases: blood flow (uptake), functional(concentration and storage) and washout (drainageof thetracer) (4,5). The activity is compared with the normaltissue surrounding the lesion during these phases, andone ofthree patternsis noted; cold,warm,or hot.A scan is cold if the lesion does not concentrate[99mTc]pertechnetate as much as the normal gland. A scanis warm if the uptake is similarbetween the lesion and thenormaltissue. A scan is hot if the lesion displays increased[@TcJpertechnetate uptake (4).

    Neoplasms and inflammatory lesions are distinguished

    from avascular lesions (e.g., cysts), and glandularatrophybased on the activity in the initialblood flow phase: Bloodflow is increased in the former, and decreased in the lattergroup. The functional phase is analyzed for increased ordecreased function: Nonfunctioning lesions are usuallysuggestive of carcinoma, mixed tumors or cysts, whereashyperfunctioning intrinsic lesions frequently representWarthin's tumors. Oncocytomas which are ectopically 1cated are also functional. A normalwashout phase is characterized by accumulation of radioactivity within the oralcavity following a secretory stimulus. Delays in this drain

    [@Tc]Pertechnetate SalivaryGland ImagingWeinsteinet al. 181

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  • age pattern may result from obstructed glands, whereaslocal retention within the gland is strongly supportive of aWarthin's tumor. This pattern is quite typically seen withWarthin's tumor because the tumor is capable of concentrating the tracer, but cannot secrete it since the tumordoes not communicate with the gland's ductal system(4,5).

    Classically, two parotid neoplasms yield a hot [@Tc]pertechnetate scan; Warthin's tumor and oncocytoma.Some pleomorphic adenomas can appear with mildly increased uptake of [@Fc]pertechnetate, but the remainingbenign tumors do not (4,6,11). However, Abramson et al.found that only the Warthin'stumorwas able to produce atruly hot scan (25). The increased uptake of[@Fc]pertechnetate by Warthin's tumor and oncocytomas is due to epitheium contained within these tumorswhich can extract large anions from the blood (such aspertechnetate). There is, however, a subtle difference inthe way the Warthin'stumor and the oncocytoma concentrate [@Tc]pertechnetate.An oncocytoma concentratesthe radionucide within the proper tumor cells, whereas aWarthin's tumor will concentrate the radionucide withinthe tumor mass and thus will not demonstrate a cavitaiyappearance as might the former (4). Additionally, multifocality does not occur with oncocytoma, which may help inthe differentiationof these two similartumors (9), but thishas been disputed (4).

    As stated, Warthin's tumor does not communicate withthe ductal system, allowing the accumulated [@Fc]pertechnetate to remain in the gland without being Secreted. Therefore, the washout images are very importantin diagnosing Warthin's tumor, because this tumor is notcapable of secreting the tracer whereas both normal parotid gland and most other parotid abnormalities drainupon stimulation. Thus, a washout patternthat shows unchanged or even increased pattern of activity is quiteunique for Warthin's tumor (6).

    Several authors have reported successwith [@Tc]pertechnetate scanning. Chapniknoted 10/10patients withWarthin's tumor to have a positive scan (4). Elledge andMoss found the scan very predictive in their series of 23patientswith Warthin'stumor(7). Higashiet al. (6) and Luet al. (9) also reportedsuccess in 5/5 and 4/4 patientswithWarthin's tumors, respectively. Sostre et al. found that thewashout scan successfully identifiedWarthin'stumorsin 9fl)patients(12). Despite this widespreadsuccess with radionucide scanning,there are reportswhich dispute its routineapplication,claimingthatsalivaryglandimaginglacks sensitivity and can detect only clinically apparent mass lesions;[@FcJpertechnetate scanning is nonspecific for Warthin'stumor; salivary gland function is incompletely understood;and protocols for salivary gland imaging are cumbersomeandoftendiscouragenuclearmedicinelaboratoriesfrom cariying out such studies (10).

    False-positive scans indicating poor specificity havebeen reported. Not all hot nodules are Warthin's tumors(4,6,10,19). False-positive scans may result from partial

    obstruction of the parotidgland, or from stasis or poolingof secretions within dilated acini and ducts as in Sjogren'ssyndrome. Additionally, a normal gland could be interpreted as a hot gland if the contralateralparotid gland isnonfunctioning (4). Acute parotitis was also found to mimick Warthin's tumor in that both produced a hot uptakescan. However, the two conditions differedin the washoutscans, again reinforcing the importance of performing thefinal phase in order to detect Warthin's tumor (9).

    False-negative scans indicating a lack of sensitivity havealso been reported (4). Not all Warthin's tumors activelyconcentrate [@Tc]pertechnetateto a higherlevel thanthesurrounding normal tissue. In this instance, the washoutphase assumes even greater importance in detecting a tumor since the tracerwill wash out of normalparotidtissue(5). Additionally, some Warthin's tumors will display amixed washout patternas has been definedby Sostre et al.:homogeneous (evenly hot), nonhomogeneous (alternatinghot and warm areas) and mixed (hot and cold areas). Theclassic homogeneously hot pattern was seen in 44% ofpatients. Nonhomogenous andmixed lesions were found in22% and 33% of patients, respectively. These latter scanpatterns resulted from cystic inclusions within the tumormass. Large cysts produced a mixed scan pattern andmultiple small cystsproduceda nonhomogeneouspattern.In contrast, those patients with a homogeneous pattern hadmucoid or mucopurulent material within the tumor andnoticeably lacked cystic formation (12). Mishkin indicatesthat patients with focal swellings (inflammatoryor metastatic foci, cysts and abscesses involving the glands) maynot benefit from radionucide scanning since they are nonfunctioning (10). Radionucide scanning however, may beable to determine the underlying cause in diffuse parotidgland swellings, which includes parotitis, functional or mechanical obstruction due to major duct occlusion or ductabnormalities, as well as infiltration of the lobules by lyinphocytes. He stated that [@Fc]pertechnetate scanning of

    fers an excellent functional image of the salivary glands,but is not always specific for Warthin's tumor and interpretationof a scan relies on humanjudgment (10).

    CONCLUSION

    Surgery is considered curative in the management ofpatients with Warthin's tumor. Since the tumor is usuallywell-defined and superficial, its removal is easily achieved.However, if incompletely removed, or if detected foci remain after the original surgery, tumor recurrence is cxpected (5,17). Approaches to the removal are based ontumor size and location, and include limited resection,superficial and deep lobe parotidectomy. Usually, the facial nerve is spared (4). The literature has shown, as hasthis report, that tumor assessment can be enhanced byperforming [@FcJpertechnetate radionucide scanning.From a surgical perspective, these scans are extremelyuseful. Greyson and Noyek firmly believed that the preoperative diagnosisof a functional parotid gland tumor

    182 TheJournalof NuclearMedicineVol.35No.I January1994

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  • Warthin's tumorwith technetiuin.99mpertechnetate.ClinNuciMed 1987;12:796800.

    7. ElledgeES,MossJ. Papillaiycystadenomatymphomatosum(Warthin'stumor)[email protected]?EarNoseThorati 1990;69:732-736.

    8. FinklesteinDM,NoyekAM,ChapnikJS.MultipkbilateralsynchronousWarthin'stumors:a case report and reviewof the literature.I OtOIWyngOI1989;18:357361.

    9. Liuas, YehSH,YenIC, HsuDF.SalivaiySCintigraphywithvitaminCstimulation:an aid in differentiatingunilateralparotitisfrom Warthin's tumor. EUrINUC! Med 1990;16:689-691.

    10.MishkinFS.Radionuclidesalivaiyglandimaging.SeminNuciMed 1981;11:258-265.

    11. ShugariM, Som PM, BilIerHF. Warthin's tumor, a multifocal [email protected];91:246249.

    12.SostreS,MedianL, DeArellanoOR.ThevariousscintigraphicpatternsofWarthin's tumor. Cli, NuciMed 1987;12:620626.

    13. Albrecht H, Ant L Beitrage zur Frage der Gewebsvenrrung. PapillareCysadenome in Lymphdrrusen. Frankfurt Ztscbrl. path:1910;41-17.

    14.NicholsonOW.Studiesintumorformation.Guy'sHospRep1923;73:37.15.WaithinAS.Papillaiycystadenomalymphomatosum.A rareteratoidofthe

    parotid region. I CancerRes 192913:116.16.BatsakisJO.Carcinomacx papillalycystadenomalymphomatosummalig

    nant Warthin's tumor. Ann Owl Rhino! La,yngol 1987;X:234235.17. @haudiyAP, GorlinRi. Papillaiycystadenomalymphomatosum(ade

    nolymphoma): a review of the literature. Am I Surg 1958;95:923-931.18.KennedyTL.Warthin'stumor:areviewindicatingnomalepredominance.

    Lwyngoscope 1983;93:889891.19.MiksanekT, ReyesCV,BorkenhagenR.Warthin'stumor.AmFamPhys

    198327:157160.20. Rubio PA, Farrell EM. Superficial solid and deep cystic independent War

    thin's tumorsof the parotidgland.hit Swg 1981;66:279.21. EvesonJW,CawsonRA.Warthin'stumor(cystadenolymphoma)of sali

    vai)rglands:aclinicopathologicinvestigationof278cases.OnilSwg 1986;61:256262.

    22. Lamelas J, Teriy iii, Alfonso AE. Warthin's tumor: muhicentiicity andincreasing incidence in women. Am I Surg 1987;154:347-351.

    23. HeHerKS, AttieJN. Treatmentof Warthin'stumorby enucleation.AmISurg 1988;156:294-297.

    24. Lindberg LO, Akerman M. Aspiration [email protected]@of salivaiy gland tumors.Diagnostic experience from six years of routine laboratory work. Laryngoscopu 1976;86:584594.

    25. Abramson AL, Levy LM, Goodman M, Attic JN. Salivary gland scintiscanning with technetium-99m-pertechnetate. Laryngoscope 1969;1105-1117.

    183

    indicates a Warthin'stumor, and given its benign nature, aless aggressive surgical approach would be indicated (5).Frequently, patients who are in the sixth and seventh de

    cadesof life haveconfoundingmedicalproblems,andmaynot be able to tolerate the rigors of surgery. It would beunjust to remove a parotid gland mass in these patients,only to discover that it was a benign tumor. We believe thatsuch a scenario could be avoided with the use of[@Fc]pertechnetatescanning. Clearly it would be moreappropriate in such instances to periodically monitor thetumor's courseand behavior.

    The combinationof a fine-needleaspirationindicativeofWarthin's tumor plus a radionucide scan virtually confirms the presence of a benign Warthin's tumor. This isdiagnostically acceptable and allows the surgeon to thenmake a sound decision and to avoid surgery in patients inwhom it is safe to follow these slow-growing tumors. Anelderly patient of 70 yr with a 3-cm mass in the parotidgland can easily be followed for the remainderof his life ifsurgery is precluded for other reasons. Therefore, it behooves the surgeon and the nuclear medicine physician towork together to provide the most sound approach in patients with suspectedWarthin's tumors.

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    1. McAfeeJO,FuegerCF,SternHS,WagnerHM Jr, MigitaT. Technetium.99m-pertechnetatefor brain scanning.INuci Med 19645:811-827.

    2. Harper PV, Lathrop KA, JiminezF, Fink R, OOttSChaIICA. Technetium.99mas a scanningagent.Radiology1965;85:101.

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