Warthin tumors, also known as lymphomatous papillary cystadenomas, are benign, sharply demarcated tumors of the salivary gland. They are of lymphoid origin and most commonly arise from parotid gland tail. They may be bilateral or multifocal in up to 20% of cases and are the most common neoplastic cause of multiple solid parotid masses.
Warthin tumors are the 2nd most common benign parotid tumor (after pleomorphic adenoma) and represent up to 10% of all parotid tumors. They are the commonest bilateral or multifocal benign parotid tumor. They typically occur in the elderly (6th decade), and twice as common in men (2.2:1) 11. Patients typically present with painless parotid swelling.
They are often multicentric (20%) and are usually small (1-4 cm). They have a typically heterogeneous appearance on all modalities, often with cystic components (30%).
Tends to favor the parotid tail region at the level of mandibular angle.
In <10% cases, they are found elsewhere, including the submandibular glands, cervical lymph nodes and ectopic nests of salivary tissue, e.g. larynx, maxillary antrum, oral cavity (e.g. lower lip, buccal mucosa) 11,12.
Has a greater tendency to undergo cystic change (~30%) than any other salivary gland tumor 4,5.
Most tumors tend to be ovoid, with well-defined margins and multiple irregular, small, sponge-like anechoic areas 10. Tumors that are large (e.g. >5 cm) tend to have a higher proportion of cystic content than smaller lesions had and in some cases can be composed almost entirely of cystic material. They are often hypervascular.
- classic appearance is a well-defined heterogeneous solid cystic lesion within the superficial lobe of parotid/parotid tail
- well defined
- no calcification
- cystic changes appear as intralesional lower attenuation
- moderate enhancement
- presence of mural nodule is strongly suggestive of Warthin tumor
- can be often seen bilaterally
Well defined and can be bilateral.
- T1: low to intermediate signal with cyst containing cholesterol components containing focal high signal 2
- T2: heterogeneous and variable signal intensity
- T1 C+ (Gd): usually no contrast enhancement 3
Often shows uptake with Tc99-pertechnetate, thallium and FDG-PET 7.
Treatment and prognosis
They are benign with an extremely low incidence of malignant transformation (~1%). Some advocate surgical excision while others favor conservative management with follow-up imaging. The commonest surgery is a superficial parotidectomy and recurrence rate is low, less than 5% in one of the largest published series 11,12.
Possible imaging differential considerations include:
- pleomorphic adenoma
- other salivary gland tumors
- parotid nodal metastasis
- parotid non-Hodgkin lymphoma
- Sjogren syndrome
- benign lymphoepithelial lesions (BLEL) in HIV
- infiltrative lesion, e.g. sarcoidosis
- 1. Ikeda M, Motoori K, Hanazawa T et-al. Warthin tumor of the parotid gland: diagnostic value of MR imaging with histopathologic correlation. AJNR Am J Neuroradiol. 2004;25 (7): 1256-62. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 2. Minami M, Tanioka H, Oyama K et-al. Warthin tumor of the parotid gland: MR-pathologic correlation. AJNR Am J Neuroradiol. 14 (1): 209-14. AJNR Am J Neuroradiol (abstract) - Pubmed citation
- 3. Joe VQ, Westesson PL. Tumors of the parotid gland: MR imaging characteristics of various histologic types. AJR Am J Roentgenol. 1994;163 (2): 433-8. AJR Am J Roentgenol (abstract) - Pubmed citation
- 4. Choi DS, Na DG, Byun HS et-al. Salivary gland tumors: evaluation with two-phase helical CT. Radiology. 2000;214 (1): 231-6. Radiology (full text) - Pubmed citation
- 5. Harnsberger HR, Glastonbury CM, Michel MA et-al. Diagnostic Imaging: Head and Neck. Lippincott Williams & Wilkins. (2010) ISBN:1931884781. Read it at Google Books - Find it at Amazon
- 6. Thoeny HC. Imaging of salivary gland tumours. Cancer Imaging. 2007;7 (1): 52-62. doi:10.1102/1470-7330.2007.0008 - Free text at pubmed - Pubmed citation
- 7. Uchida Y, Minoshima S, Kawata T et-al. Diagnostic value of FDG PET and salivary gland scintigraphy for parotid tumors. Clin Nucl Med. 2005;30 (3): 170-6. Pubmed citation
- 8. Nguyen VX, Nguyen BD, Ram PC. Bilateral and multifocal Warthin's tumors of parotid glands: PET/CT imaging. Clin Nucl Med. 2012;37 (2): 175-7. doi:10.1097/RLU.0b013e318238f244 - Pubmed citation
- 9. Christe A, Waldherr C, Hallett R et-al. MR imaging of parotid tumors: typical lesion characteristics in MR imaging improve discrimination between benign and malignant disease. AJNR Am J Neuroradiol. 2011;32 (7): 1202-7. doi:10.3174/ajnr.A2520 - Pubmed citation
- 10. Kim J, Kim EK, Park CS et-al. Characteristic sonographic findings of Warthin's tumor in the parotid gland. J Clin Ultrasound. 2004;32 (2): 78-81. doi:10.1002/jcu.10230 - Pubmed citation
- 11. Yoo GH, Eisele DW, Askin FB, Driben JS, Johns ME. Warthin's tumor: a 40-year experience at The Johns Hopkins Hospital. (1994) The Laryngoscope. 104 (7): 799-803. doi:10.1288/00005537-199407000-00004 - Pubmed
- 12. Chulam TC, Noronha Francisco AL, Goncalves Filho J, Pinto Alves CA, Kowalski LP. Warthin's tumour of the parotid gland: our experience. (2013) Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale. 33 (6): 393-7. Pubmed