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Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 196-198

Submandibular pleomorphic adenoma – Imaging findings on sonography, color doppler, and strain elastography with pathological correlation

Department of Radio Diagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission16-Oct-2020
Date of Decision13-Jan-2021
Date of Acceptance26-Feb-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Suresh Phatak
Department of Radio Diagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_367_20

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Submandibular gland tumors are uncommon. Elastography is a recent addition in ultrasound diagnosis particularly in cases of soft-tissue tumor imaging. In this case report, we are describing ultrasonographic and elastographic imaging findings of submandibular pleomorphic adenoma.

Keywords: Elastography, pleomorphic adenoma, strain ratio, submandibular gland, ultrasonography

How to cite this article:
Nagendra V, Phatak S. Submandibular pleomorphic adenoma – Imaging findings on sonography, color doppler, and strain elastography with pathological correlation. J Datta Meghe Inst Med Sci Univ 2021;16:196-8

How to cite this URL:
Nagendra V, Phatak S. Submandibular pleomorphic adenoma – Imaging findings on sonography, color doppler, and strain elastography with pathological correlation. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 16];16:196-8. Available from: http://www.journaldmims.com/text.asp?2021/16/1/196/322633

  Introduction Top

Pleomorphic adenoma is the most common benign tumor affecting submandibular gland, it has similar histological appearance to typical pleomorphic adenoma of parotid gland and has better prognosis and less chance of malignant transformation.

The ultrasound is regarded as the first imaging tool to be used for the preoperative examination of tumors in the salivary gland. Pleomorphic adenoma incidence is highest in parotid gland about (70%) followed by submandibular gland (5%–10%), sublingual (1%), and minor salivary glands constitute the remaining (5%–15%).[1] Pleomorphic adenoma most commonly presents as swelling in the neck, pain is uncommon unless there is local ulceration or infiltration. Rarely, it presents with dysphagia or change in voice. Pleomorphic adenoma is more common in females and the median age group of occurrence is in 3rd to 5th decade.[2]

  Case Report Top

A 35-year-old female presents to outpatient department with complaints of painless swelling of size approximately 3 cm in the left submandibular region of neck which was gradual in onset and progressive in nature since 3 months. No complaints of difficulty in speaking or swallowing. There is no significant past medical or surgical history. On examination, there is no tenderness and the lesion is soft in consistency and freely mobile. Routine hematological investigations are within normal limit. She was referred for neck sonography. Ultrasonographic examination revealed a solitary well-defined lobulated heterogeneously hypoechoic lesion of size 3.7 cm × 2.1 cm showing prominent posterior acoustic enhancement [Figure 1], arising from left submandibular gland (intraglandular). On elastography, the lesion was graded as Tsukuba score II (mosaic pattern taking up blue and green shades) with strain ratio of 1.63 suggestive of benign lesion [Figure 2] with minimal peripheral vascularity on color Doppler [Figure 3]. There is no associated regional lymphadenopathy. It was provisionally diagnosed as pleomorphic adenoma of the left submandibular gland on ultrasonography, which was later confirmed by FNAC.
Figure 1: A well-defined heterogeneously hypoechoic lobulated solid lesion of size 3.7 cm × 2.1 cm occupying most of the left submandibular gland with marked posterior acoustic enhancement. No cystic changes or calcification noted

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Figure 2: Elastography image showing Tsukuba score II with strain ratio of 1.63 indicating benign nature of the lesion

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Figure 3: Color Doppler image showing minimal peripheral flow

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  Discussion Top

Pleomorphic adenoma is a mixed type of salivary gland tumor containing both epithelial and mesenchymal components. The most common site is parotid gland. It occurs more commonly in females in the age group between 30 and 50 years. Risk of malignant transformation is <5% and risk of recurrence is 15% either due to preoperative biopsy causing infiltration of capsule or incomplete resection of pleomorphic adenoma.[3] Pleomorphic adenoma is usually slow growing and mostly Without infiltrating adjacent tissues. On ultrasonography it is capsulated with well-defined margins and averaging 2–3 cm in size.[2] It appears as homogenously hypo echoic lesion with well-defined hyperechoic margins, wider than taller, and with or without areas of calcification. The absence of capsule is very rare and may suggest malignancy. In large lesions, there can be areas of necrosis appearing as irregular anechoic areas within. Due to their mixed intra cellular content, the sonographic appearance varies from common pattern.[3] The size of tumor is considered to suspect the malignant potential of the mass, the cutoff being 4 cm.[4] The presence of lobulations is the most common feature of pleomorphic adenoma.[5],[6] The absence of regional cervical lymphadenopathy is necessary to rule out malignant change in pleomorphic adenoma. On color Doppler the lesion typically takes up peripheral flow around the nodule termed as “basket like flow pattern” due to subtle vascular pattern around the mass.[2] An indication of malignancy is elevated blood flow with a peak systolic volume of more than 60 cm/s[7] Elastographic nature of the lesion is described using TSUKUBA score, where lesion is graded from 1 to 5. (1) Indicates the whole lesion is homogenous and coded with green, (2) mosaic pattern of blue and green shade due to some areas not taking the up the strain, (3) strain is not taken up in the center so it appears blue and the border appears green, (4) lesion does not take up strain appearing blue but the adjacent area is not included, and (5) both the lesion and the adjacent area does not take up the strain and appear blue. Dark blue is for hard tissue, red and green indicates soft tissue. Malignant lesions are hard whereas benign lesions are soft.[8] Strain ratio is used to know the stiffness of the tissue. On elastography strain ratio is calculated by taking average of strain ratio measured between the pathological area and the adjacent normal area of interest. Region of interest should be in the center of sample and should not go beyond the extent of lesion and the necrotic portion is avoided. Software calculates the strain ratio of the lesion to the adjacent soft tissue automatically to display the result. Higher strain ratio suggests possibility of malignant lesion.[9]

The differential diagnosis to pleomorphic adenoma is Warthin's tumor, which characteristically appears as oval shaped with well-defined borders containing cystic areas and good vascularization on color Doppler.[10],[11],[12]

  Conclusion Top

Sonoelastography is a diagnostic preoperative noninvasive technique which aids in diagnosis of soft-tissue tumors and differentiating benign from malignant tumors.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Alves FA, Perez DE, Almeida OP, Lopes MA, Kowalski LP. Pleomorphic adenoma of the submandibular gland: Clinicopathological and immunohistochemical features of 60 cases in Brazil. Arch Otolaryngol Head Neck Surg 2002;128:1400-3.  Back to cited text no. 1
Carotti M, Ciapetti A, Jousse-Joulin S, Salaffi F. Ultrasonography of the salivary glands: The role of grey-scale and colour/power Doppler. Clin Exp Rheumatol 2014;32:S61-70.  Back to cited text no. 2
Fodor D, Pop S, Maniu A, Cosgaria M. Gray scale and Doppler ultrasonography of the benign tumors of parotid gland (pleomorphic adenoma and Warthin's tumor). Pictorial essay. Med Ultrason 2010;12:238-44.  Back to cited text no. 3
Speight PM, Barrett AW. Salivary gland tumours. Oral Dis 2002;8:229-40.  Back to cited text no. 4
Yuan WH, Hsu HC, Chou YH, Hsueh HC, Tseng TK, Tiu CM. Gray-scale and color Doppler ultrasonographic features of pleomorphic adenoma and Warthin's tumor in major salivary glands. Clin Imaging 2009;33:348-53.  Back to cited text no. 5
Dumitriu D, Dudea SM, Botar-Jid C, Băciuţ G. Ultrasonographic and sonoelastographic features of pleomorphic adenomas of the salivary glands. Med Ultrason 2010;12:175-83.  Back to cited text no. 6
Martinoli C, Derchi LE, Solbiati L, Rizzatto G, Silvestri E, Giannoni M. Color Doppler sonography of salivary glands. AJR Am J Roentgenol 1994;163:933-41.  Back to cited text no. 7
Itoh A, Ueno E, Tohno E, Kamma H, Takahashi H, Shiina T, et al. Breast disease: Clinical application of US elastography for diagnosis. Radiology 2006;239:341-50.  Back to cited text no. 8
Hahn S, Lee YH, Lee SH, Suh JS. Value of the strain ratio on ultrasonic elastography for differentiation of benign and malignant soft tissue tumors. J Ultrasound Med 2017;36:121-7.  Back to cited text no. 9
Fidvi M, Jadhav A, Kasatwar A, Borle R. Pleomorphic Adenoma of the Cheek: Report of a Rarity. J Datta Meghe Inst Med Sci Univ 2018;13: 63-5. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_108_17. [Last accessed on 2020 Feb 08].  Back to cited text no. 10
Panchbhai A, Bhowate R. MRI Evaluation of Involvement of Parotid and Submandibular Glands by Tongue Squamous Cell Carcinoma. Oral Oncol 2020;102:565-72. Available from: https://doi.org/10.1016/j.oraloncology.2019.104557. [Last accessed on 2020 Feb 08].  Back to cited text no. 11
Chandak SR, Chandu R. Submandibular Gland Wharton's Duct Phlegomous Calculus Sialoadenitis: A Rare Case Report. J Datta Meghe Inst Med Sci Univ 2020;15:292-4. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_56_20. [Last accessed on 2020 Feb 08].  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]


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