Salivary Gland Pathology
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Группа авторов. Salivary Gland Pathology
Table of Contents
List of Tables
List of Illustrations
Guide
Pages
SALIVARY GLAND PATHOLOGY. DIAGNOSIS AND MANAGEMENT
Contributors
Foreword First Edition
Foreword Second Edition
Foreword Third Edition
Preface First Edition
Preface Second Edition
Preface Third Edition
Acknowledgments
About the Companion Website
Chapter 1 Surgical Anatomy, Embryology, and Physiology of the Salivary Glands
Outline
Introduction
Parotid Gland. EMBRYOLOGY
ANATOMY
CONTENTS OF THE PAROTID GLAND. Facial Nerve
Auriculotemporal Nerve
Retromandibular Vein
External Carotid Artery
Parotid Lymph Nodes
Parotid Duct
Nerve Supply to the Parotid
Submandibular Gland. EMBRYOLOGY
ANATOMY
Superficial Lobe
Deep Lobe
Submandibular Duct
Blood Supply and Lymphatic Drainage
Nerve Supply to the Submandibular Gland. Parasympathetic innervation
Sympathetic innervation
Sensory innervation
Sublingual Gland. EMBRYOLOGY
ANATOMY
Sublingual Ducts
Blood Supply, Innervation, and Lymphatic Drainage
Minor Salivary Glands
Tubarial Salivary Glands
Histology of the Salivary Glands
Control of Salivation
Summary
Case Presentation – Wait, What?
Past Medical History
Imaging
Diagnosis
TAKE HOME POINTS
References
Chapter 2 Diagnostic Imaging of Salivary Gland Pathology
Outline
Introduction
Imaging Modalities. COMPUTED TOMOGRAPHY (CT)
CT Technique
Advanced computed tomography
MAGNETIC RESONANCE IMAGING (MRI)
MRI Technique
Spin‐echo T1
Spin‐echo T2
Proton density images (PD)
Gradient recalled echo imaging (GRE)
Short tau inversion recovery (STIR)
Gadolinium (Gd) contrast
Fluid attenuation inversion recovery (FLAIR)
Diffusion weighted images (DWI)
MR spectroscopy
Dynamic contrast‐enhanced magnetic resonance imaging
Other magnetic resonance imaging techniques
ULTRASONOGRAPHY (US)
Ultrasound (US) Technique
SIALOGRAPHY
IMAGE‐GUIDED BIOPSIES OF SALIVARY GLAND PATHOLOGY
RADIONUCLIDE IMAGING (RNI)
POSITRON EMISSION TOMOGRAPHY (PET)
POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY (PET/CT)
Diagnostic Imaging Anatomy. PAROTID GLAND
SUBMANDIBULAR GLAND
SUBLINGUAL GLAND
MINOR SALIVARY GLANDS
Pathology of the Salivary Glands
VASCULAR LESIONS. Lymphangioma (Cystic Hygroma)
Hemangioma
ACUTE SIALADENITIS
CHRONIC SIALADENITIS
HIV‐ASSOCIATED LYMPHOEPITHELIAL LESIONS
MUCOUS ESCAPE PHENOMENA
SIALADENOSIS (SIALOSIS)
SIALOLITHIASIS
SJÖGREN SYNDROME
SARCOIDOSIS
CONGENITAL ANOMALIES OF THE SALIVARY GLANDS. First Branchial Cleft Cyst
NEOPLASMS – SALIVARY, EPITHELIAL. Benign. Pleomorphic adenoma
Warthin tumor
Oncocytoma
Malignant Tumors. Mucoepidermoid carcinoma
Adenoid cystic carcinoma
NEOPLASMS – NON‐SALIVARY. Benign. Lipoma
Neurogenic tumors
Malignant. Lymphoma
Metastases
Summary
Case Presentation – Duplicity
Past Medical History
Social History
Examination
Imaging
Diagnosis
TAKE‐HOME POINTS
References
Chapter 3 Infections of the Salivary Glands. Outline
Introduction
General Considerations
Bacterial Salivary Gland Infections. ACUTE BACTERIAL PAROTITIS
Variants of ABP and Their Etiology
Diagnosis of Acute Bacterial Parotitis
Treatment of Acute Bacterial Parotitis
CHRONIC (RECURRENT OR REFRACTORY) BACTERIAL PAROTITIS
Treatment of Chronic Bacterial Parotitis
CHRONIC RECURRENT JUVENILE PAROTITIS
Treatment of Chronic Recurrent Juvenile Parotitis
ACUTE BACTERIAL SUBMANDIBULAR SIALADENITIS
Treatment of Acute Bacterial Submandibular Sialadenitis
CHRONIC RECURRENT SUBMANDIBULAR SIALADENITIS
BARTONELLA HENSELAE (CAT‐SCRATCH DISEASE)
TUBERCULOUS MYCOBACTERIAL DISEASE
NONTUBERCULOUS MYCOBACTERIAL DISEASE
Viral Salivary Gland Infections. MUMPS
HUMAN IMMUNODEFICIENCY VIRUS
INFLUENZA A
Bacterial Sialadenitis in Pregnancy
Autoimmune Sialadenitis and IgG4‐Related Disease
Summary
Case Presentation – Gadzooks
Past Medical History
Physical Examination
Imaging
Diagnosis
TAKE‐HOME POINTS
References
Chapter 4 Cysts and Cyst‐Like Lesions of the Salivary Glands. Outline
Introduction
Mucous Escape Reaction
CLINICAL FEATURES AND TREATMENT OF THE MUCUS ESCAPE REACTION
Mucocele
Ranula and Plunging Ranula
Submandibular Gland Mucocele
Cyst of Blandin and Nuhn's Gland
Mucous Retention Cyst
Parotid Cysts Associated with Human Immunodeficiency Virus Infection
Branchial Cleft Cysts
Parotid Neoplasms Masquerading as Cysts
Summary
Case Presentation ‐ Down Yonder
Past Medical History
Imaging
Surgical Procedure
TAKE‐HOME POINTS
References
Chapter 5 Sialolithiasis. Outline
Introduction
Pathophysiology of Sialolithiasis
Clinical Features of Sialolithiasis
MULTIPLE SIALOLITHS
BILATERAL SIALOLITHS
Differential Diagnosis and Diagnosis of Sialolithiasis
Treatment of Sialolithiasis
SUBMANDIBULAR SIALOLITHIASIS
PAROTID SIALOLITHIASIS
TREATMENT OF MULTIPLE SIALOLITHS AND BILATERAL (MULTIPLE GLAND) SIALOLITHS
Sialolithiasis of the Sublingual Gland and Minor Salivary Glands
The Relationship of Salivary Lithiasis to Nephrolithiasis, Cholelithiasis, Primary Hyperparathyroidism, and Gout
Summary
Case Presentation – Stoneorama
Past Medical History
Imaging
Diagnosis
Surgical Intervention
TAKE‐HOME POINTS
References
Chapter 6 Systemic Diseases Affecting the Salivary Glands. Outline
Introduction
Sjögren Syndrome
PATHOPHYSIOLOGY OF SJÖGREN SYNDROME
CLINICAL MANIFESTATIONS OF SJÖGREN SYNDROME
LYMPHOMA AND SJÖGREN SYNDROME
MIKULICZ DISEASE AND THE BENIGN LYMPHOEPITHELIAL LESION
DIAGNOSIS OF SJÖGREN SYNDROME WITH SALIVARY GLAND BIOPSY
Histopathology of Sjögren Syndrome
Sarcoidosis
PATHOPHYSIOLOGY OF SARCOIDOSIS
CLINICAL MANIFESTATIONS OF SARCOIDOSIS
DIAGNOSIS OF SARCOIDOSIS WITH SALIVARY GLAND BIOPSY
Histopathology of Sarcoidosis
Sialosis
CLINICAL MANIFESTATIONS OF SIALOSIS
DIAGNOSIS OF SIALOSIS WITH SALIVARY GLAND BIOPSY
Histopathology of Sialosis
IgG4‐Related Disease
Summary
Case Presentation – Esoterica
Past Medical History
Imaging
Cytology
Surgical Intervention
Diagnosis
TAKE‐HOME POINTS
References
Chapter 7 Salivary Gland Pathology in Children and Adolescents. Outline
Introduction
Nonneoplastic Salivary Gland Lesions
MUCOUS ESCAPE REACTION
BACTERIAL SIALADENITIS
Acute Submandibular Sialadenitis
Acute Suppurative Parotitis
Chronic Juvenile Recurrent Parotitis
Neoplastic Salivary Gland Disease
EPITHELIAL TUMORS
MESENCHYMAL TUMORS
Vascular Tumors
Lymphatic Malformations
Neural Tumors
PAROTID TUMORS
SUBMANDIBULAR GLAND TUMORS
MINOR SALIVARY GLAND TUMORS
Summary
Case Presentation – Size Matters
Past Medical History
Social History
Examination
Diagnosis
Imaging
Surgical Intervention
TAKE HOME POINTS
References
Chapter 8 Classification, Grading, and Staging of Salivary Gland Tumors
Outline
Introduction
Classification Systems for Salivary Gland Neoplasms
CELLULAR CLASSIFICATION OF SALIVARY GLAND NEOPLASMS
Benign Epithelial Salivary Gland Neoplasms. Pleomorphic Adenoma (Benign Mixed Tumor)
Warthin Tumor (Papillary Cystadenoma Lymphomatosum)
Basal Cell Adenoma
Canalicular Adenoma
Oncocytoma
Sebaceous Adenoma
Sebaceous Lymphadenoma
Myoepithelioma
Cystadenoma
Ductal Papilloma
Sialadenoma Papilliferum
Sclerosing Polycystic Adenoma
Malignant Epithelial Neoplasms. Mucoepidermoid Carcinoma
Adenoid Cystic Carcinoma
Acinic Cell Carcinoma
Polymorphous Adenocarcinoma
Adenocarcinoma, NOS (Otherwise Specified)
Basal Cell Adenocarcinoma
Clear Cell Carcinoma
Hyalinizing Clear Cell Carcinoma
Cystadenocarcinoma
Sebaceous Adenocarcinoma
Sebaceous Lymphadenocarcinoma
Oncocytic Carcinoma
Salivary Duct Carcinoma
Malignant Mixed Tumors
Carcinoma Ex‐Pleomorphic Adenoma
Salivary Carcinosarcoma
Metastasizing Mixed Tumor
Sialoblastoma
Primary Squamous Cell Carcinoma
Epithelial‐Myoepithelial Carcinoma
Poorly Differentiated Carcinomas
Undifferentiated Carcinoma
Small Cell Neuroendocrine Carcinoma
Large Cell Neuroendocrine Carcinoma
Lymphoepithelial Carcinoma
Myoepithelial Carcinoma
Adenosquamous Carcinoma
Secretory Carcinoma
Non‐Epithelial Neoplasms. Lymphomas and Benign Lymphoepithelial Lesion
Mesenchymal Neoplasms
Benign Mesenchymal Salivary Gland Tumors
Malignant Mesenchymal Salivary Gland Tumors
Malignant Secondary Neoplasms
Grading and Staging of Salivary Gland Tumors. MOLECULAR SYSTEMATICS OF SALIVARY GLAND NEOPLASMS
TNM and Staging of Salivary Gland Tumors
EXTRAPARENCHYMAL EXTENSION
TNM DESCRIPTORS
ADDITIONAL DESCRIPTORS
Summary
Case Presentation – Reclassified
TAKE‐HOME POINTS
References
Chapter 9 The Molecular Biology of Benign and Malignant Salivary Gland Tumors
Outline
Introduction: The Puzzle and the Promise
Salivary Gland Tumor Cell Biology
Molecular Biology of Salivary Gland Neoplasms
PROTEIN DYSREGULATION AND SALIVARY GLAND NEOPLASM PHENOTYPES
Enhanced Proliferation
Evasion of Apoptosis
Immortalization
Neovascularization
Invasion and Metastasis
NUCLEIC ACID DYSREGULATION IN SALIVARY GLAND NEOPLASMS
Genetic Alterations in Salivary Gland Tumors
Epigenetic Alteration of Gene Expression in Salivary Gland Tumors
Summary and Clinical Applications
DIAGNOSTIC APPLICATIONS
THERAPEUTIC APPLICATIONS
Summary
References
Chapter 10 Tumors of the Parotid Gland. Outline
Introduction
Etiology and Epidemiology
Diagnosis
Surgical Management
BENIGN TUMORS. Pleomorphic Adenoma (PA)
WARTHIN TUMOR
MALIGNANT TUMORS. Principles of Management of Parotid Carcinoma
Summary
Case Presentation – How Did This All Start?
Past Medical History
Social History
Examination
Diagnosis
TAKE‐HOME POINTS
References
Chapter 11 Tumors of the Submandibular and Sublingual Glands. Outline
Introduction
Epidemiology and Etiology
Diagnosis. SUBMANDIBULAR GLAND TUMORS
SUBLINGUAL GLAND TUMORS
Management. SUBMANDIBULAR GLAND TUMORS
SUBLINGUAL GLAND TUMORS
Summary
Case Presentation – But I Took the Road Less Traveled
Past Medical History
Social History
Examination
Diagnosis
TAKE‐HOME POINTS
References
Chapter 12 Tumors of the Minor Salivary Glands. Outline
Introduction
Etiology of Minor Salivary Gland Tumors
Diagnosis of Minor Salivary Gland Tumors
Treatment of Minor Salivary Gland Tumors. GENERAL PRINCIPLES OF SURGERY FOR MINOR SALIVARY GLAND TUMORS
SURGICAL TREATMENT OF BENIGN MINOR SALIVARY GLAND TUMORS
Pleomorphic Adenoma
Canalicular Adenoma
SURGICAL TREATMENT OF MALIGNANT MINOR SALIVARY GLAND TUMORS
Mucoepidermoid Carcinoma
Central Mucoepidermoid Carcinoma
Adenoid Cystic Carcinoma
Polymorphous Adenocarcinoma
Acinic Cell Carcinoma
Epithelial‐Myoepithelial Carcinoma
Secretory Carcinoma
SURGICAL MANAGEMENT OF THE NECK FOR MINOR SALIVARY GLAND MALIGNANCIES
THE ROLE OF RADIATION THERAPY IN THE MANAGEMENT OF MINOR SALIVARY GLAND MALIGNANCIES
THE ROLE OF CHEMOTHERAPY IN THE MANAGEMENT OF MINOR SALIVARY GLAND MALIGNANCIES
Summary
Case Presentation – Two Peas in a Pod
Past Medical History
Imaging
Surgical Intervention
TAKE‐HOME POINTS
References
Chapter 13 Radiation Therapy for Salivary Gland Malignancies
Outline
Introduction
Low‐Risk Salivary Gland Malignancies
Moderate‐Risk Salivary Gland Malignancies
High‐Risk Salivary Gland Malignancies
Evolution of Radiation Techniques in Salivary Gland Malignancies
Complications of Radiation Therapy in Salivary Gland Malignancies. XEROSTOMIA
OSTEORADIONECROSIS
DYSPHAGIA
Radiation Technique for Low‐ and Moderate‐Risk Salivary Gland Tumors
Radiation Technique for High‐Risk Salivary Gland Tumors
ADENOID CYSTIC CARCINOMA
Advanced Radiation Therapy Techniques. PROTON THERAPY
NEUTRON THERAPY
CARBON ION THERAPY
Summary
References
Chapter 14 Systemic Therapy for Salivary Gland Cancer
Outline
Introduction
Epidemiology and Risk Factors
Molecular Biology of Salivary Gland Tumors
Clinical Presentation
Treatment
ADJUVANT TREATMENT
TREATMENT OF METASTATIC DISEASE
TARGETED THERAPY
Targeting C‐KIT
EGFR Inhibition
Her2 Inhibition
Multi Kinase Inhibition
Proteasome Inhibition
Androgen Receptor Inhibition
NTRK Inhibition
Immune Checkpoint Inhibition
Summary
Case Presentation – Well, If It Works for Breast Cancer!!
Past Medical History
Social History
Examination
Diagnosis
TAKE‐HOME POINTS
References
Chapter 15 Non‐salivary Tumors of the Salivary Glands. Outline
Introduction
Mesenchymal Tumors. BENIGN MESENCHYMAL TUMORS. Hemangiomas
Lymphangiomas
Neural Tumors
Lipomas
MALIGNANT MESENCHYMAL TUMORS. Sarcomas
Epithelial Non‐salivary Tumors. DIRECT INVOLVEMENT BY SKIN CANCERS
Tumors of Salivary Gland Lymph Nodes. PRIMARY LYMPH NODE TUMORS. Lymphomas
SECONDARY LYMPH NODE TUMORS. Mucosal Primary Cancer of the Head and Neck Metastasizing to Salivary Glands
Cutaneous Cancer Metastasizing to Parotid Nodes
Distant Metastases to Salivary Glands
Miscellaneous
Summary
Case Presentation – From One Salivary Gland to Another
PAST MEDICAL HISTORY
SOCIAL HISTORY
EXAMINATION
DIAGNOSIS
TAKE HOME POINTS
References
Chapter 16 Trauma and Injuries to the Salivary Glands. Outline
Introduction
Penetrating Injuries. TRAUMA TO THE GLAND. Salivary Fistula
Sialocele
Facial Nerve Injuries. Facial nerve injury in primary trauma
Facial nerve injury in elective surgery
Frey Syndrome
Hollowing
TRAUMA TO SALIVARY GLAND DUCTS. Transection of the Salivary Duct
Stricture of the Salivary Duct
Radiation Injury. EXTERNAL BEAM
RADIOACTIVE IODINE
PSMA Radioligand Therapy
Barotrauma
Summary (Figures 16.22 and 16.23)
References
Chapter 17 Miscellaneous Pathologic Processes of the Salivary Glands. Outline
Introduction
Hereditary and Congenital Conditions. APLASIA
DUCT ATRESIA
ABERRANT GLANDS
POLYCYSTIC DISEASE OF THE SALIVARY GLANDS
FIRST BRANCHIAL CLEFT CYSTS, FISTULAE, AND SINUSES
CYSTIC FIBROSIS
Saliva. SALIVA AS A DIAGNOSTIC FLUID
DROOLING
SALIVA IN THE MANAGEMENT OF XEROPHTHALMIA
Ischemic/Degenerative Changes. NECROTIZING SIALOMETAPLASIA
AGE CHANGES IN SALIVARY GLANDS
Küttner Tumor
Salivary Gland Biopsy for Systemic Disease
AMYLOID AND THE SALIVARY GLANDS
Hereditary Amyloidosis
AL Amyloidosis (Primary Amyloidosis)
AA Amyloidosis (Secondary Amyloidosis)
PARKINSON DISEASE
Summary
Case Presentation – The Great Pretender
Past Medical History
Social History
Examination
Diagnosis
TAKE‐HOME POINTS
References
Chapter 18 Complications of Salivary Gland Surgery
Outline
Introduction
General Considerations
Complications of Parotid Gland Surgery. FACIAL NERVE PARALYSIS
Relationship of the Facial Nerve to the Parotid Gland
Approaches to the Parotid Gland
Blair incision
Retromandibular incision
Assessment of Facial Nerve Weakness
THE AURICULOTEMPORAL NERVE AND FREY SYNDROME
Diagnosis of Frey Syndrome
Management of Frey Syndrome
Surgical Prevention of Frey Syndrome and Facial Defects
Temporoparietal fascia flap
Sternocleidomastoid muscle flap
Superficial musculoaponeurotic system flap
Acellular dermal matrix
Fat grafting
PAROTID GLAND SALIVARY LEAKAGE
Classification of Parotid Gland Salivary Leakage
Management of Parotid Salivary Leakage
Conservative management of parotid gland salivary leakage
Botulinum toxin for the management of parotid gland salivary leakage
Scopolamine patch
Sclerosing agents
Surgical repair of parotid gland salivary leakage
Tympanic neurectomy
Radiotherapy
Temporalis fascia and cyanoacrylate
Postoperative Infections
Parotid Duct Leakage
MANAGEMENT OF PAROTID DUCT INJURIES
Endoscopic Management of Parotid Salivary Duct Injuries
Surgical management of a parotid megaduct
Avulsion of the Parotid Duct
Stenosis of the Parotid Duct Orifice
Complications of Submandibular and Sublingual Gland Surgery
COMPLICATIONS ASSOCIATED WITH AN INTRAORAL APPROACH TO THE SUBLINGUAL AND SUBMANDIBULAR GLANDS
Ranulas (Mucous Extravasation Phenomenon)
Complications associated with the management of ranulas
Recurrence of ranulas
Lingual nerve injury during sublingual gland removal
Submandibular duct injury during sublingual gland removal
Complications Associated with Intraoral Surgery of Submandibular Ducts
Stricture of the submandibular gland duct
Lingual nerve injuries
Extravasation of fluid and airway obstruction
Ranula formation
Submandibular duct avulsion
COMPLICATIONS ASSOCIATED WITH TRANSCERVICAL APPROACHES TO THE SUBMANDIBULAR GLAND
Marginal Mandibular Branch Injury During a Sialadenectomy
Lingual Nerve Injury during a Sialadenectomy
Hypoglossal Nerve Injury during a Sialadenectomy
Hematoma Formation
Hyposalivation
Complications Associated with Removal of Minor Salivary Gland Mucocele
COMPLICATIONS ASSOCIATED WITH REMOVAL OF MUCOCELE OF THE LOWER LIP
Mucocele Recurrence
Neurosensory Change
Esthetic Defects of the Lip
Summary
Case Presentation – Get It Right the First Time. That's the Main Thing
TAKE HOME POINTS
References
Chapter 19 Innovations in Salivary Gland Surgery
Outline
Minimally Invasive Parotid Gland Surgery. HISTORY OF PAROTID SURGERY
MINIMALLY INVASIVE SURGICAL APPROACHES TO THE PAROTID GLAND
Partial Superficial Parotidectomy
Extracapsular Dissection with Extended Option
ECD Performed for Malignant Parotid Tumors
Extended ECD
Minimally Invasive Sublingual Gland Surgery
SUBLINGUAL GLAND ANATOMY
DIAGNOSIS OF MUCOCELE, RANULA, AND PLUNGING RANULA
TREATMENT OF MUCOCELE, RANULA, AND PLUNGING RANULA. Mucocele
Simple Ranula in Floor of Mouth
Plunging Ranula
Minimally Invasive Salivary Gland Surgery with Sialendoscopy
IMAGING MODALITIES IN THE MANAGEMENT OF SIALOLITHIASIS. Ultrasound
Sialography
Other Imaging Modalities
SIALENDOSCOPY
Basket Retrieval of Stones
Fragmentation of Stones
Microforceps
Laser Lithotripsy
Intracorporeal Shock Wave Lithotripsy
Extracorporeal Shock Wave Lithotripsy
Intraoral Stone Release of Submandibular Gland Hilar Stones
Combined Open and Endoscopic Removal of Parotid Stones
ROBOTIC‐ASSISTED PROCEDURES
SALIVARY DUCT STRICTURES
Investigation of Salivary Duct Strictures
Classification of Salivary Duct Strictures
Treatment of Salivary Duct Strictures
Sialendoscopy‐Guided Duct Dilatation
Balloon Dilatation
Treatment Adjuncts
Treatment Outcomes of Salivary Duct Dilatation
Other Treatment Options for Stenoses
Summary
References
Index
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The role of FDG PET or PET/CT and that of conventional CT and MRI on the diagnosis, staging, restaging, and follow‐up post‐therapy of salivary gland tumors has been studied (Keyes et al. 1994; Bui et al. 2003; Otsuka et al. 2005; Alexander de Ru et al. 2007; Roh et al. 2007). Although both CT and MRI are relatively equal in anatomic localization of disease and the effect of the tumors on local invasion and cervical nodal metastases, FDG PET/CT significantly improved sensitivity and specificity for salivary malignancies including nodal metastases (Otsuka et al. 2005; Uchida et al. 2005; Alexander de Ru et al. 2007; Jeong et al. 2007; Roh et al. 2007).
Early studies have demonstrated FDG PET's relative inability to distinguish benign from malignant salivary neoplasms (Keyes et al. 1994). The variable uptake of FDG by pleomorphic adenomas and the increased uptake and SUVs by Warthin tumors result in significant false positives (Jeong et al. 2007; Roh et al. 2007). In a similar manner, adenoid cystic carcinomas, which are relatively slower growing, may not accumulate significant concentrations of FDG and demonstrate low SUVs and therefore contribute to the false negatives (Jeong et al. 2007; Keyes et al. 1994). False negatives may also be caused by the relatively lower mean SUV of salivary tumors (SUV 3.8 ± 2.1) relative to squamous cell carcinoma (SUV 7.5 ± 3.4) (Roh et al. 2007). The low SUV of salivary neoplasms may also be obscured by the normal uptake of FDG by salivary glands (Roh et al. 2007). In general, FDG PET has demonstrated that lower grade malignancies tend to have lower SUV and vice versa for higher grade malignancies (Jeong et al. 2007; Roh et al. 2007). FDG PET has been shown to be more sensitive and specific compared to conventional CT or MRI (Otsuka et al. 2005; Cermik et al. 2007; Roh et al. 2007). Small tumor size can contribute to false negative results and inflammatory changes contribute to false positive results (Roh et al. 2007). The use of concurrent salivary scintigraphy with 99mTc‐pertechnetate imaging can improve the false positive rate by identifying Warthin's tumors and oncocytomas, which tend to accumulate pertechnetate (and retain it after induced salivary gland washout) and have increased uptake of FDG (Uchida et al. 2005).
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