Diagnostic imaging Plain radiography and sialography are useful for ductal inflammatory disease, but

computed tomography (CT), ultrasonography, CT sialography, and magnetic resonance imaging (MRI)
are usually better for evaluation of suspected neoplastic disease. MRI is particularly useful when
inflammatory disease is not suspected. It does not have the risks of radiation exposure nor
complications with intraductal injection of contrast media, and it is often superior in demonstrating the
interface of tumour and surrounding tissues. T1-weighted images of normal parotid have an image
signal intermediate between fat and muscle whereas submandibular tissue is closer to muscle in
intensity. With advanced age and fatty infiltration, the signal intensity of parotid tissue approaches fat.
Most salivary gland tumours are brighter on T2 than T1 images but this difference is minimal in
prominently cellular tumours. Lesions with higher water content, such as human immunodeficiency
virus related parotid cysts, Warthin tumours, cystadenomas and cystadenocarcinomas, and cystic
mucoepidermoid carcinomas, have a bright T2 signal. Fine needle aspiration biopsy Fine needle
aspiration biopsy (FNA) can provide clinicians with rapid, non-surgical diagnoses. It can be performed at
the time of initial consultation. Correlation of the clinical impression, cytologic diagnosis and
radiographic imaging studies can then guide along different treatment pathways. FNA can be used both
as a diagnostic test and as a screening tool to triage patients into different treatment groups i.e. surgical
vs. medical management vs. to follow without intervention {2109}. FNA biopsy is useful in establishing
whether a given lesion is inflammatory or neoplastic, is a lymphoma or an epithelial malignancy, or
represents a metastasis or a primary tumour {424, 1585,2892}. Unnecessary surgery can be avoided in
approximately one third of cases {668} especially in: (1) patients whose salivary gland lesion is part of a
more generalized disease process, (2) inflammatory lesions where a clinical suspicion of malignancy is
low, (3) patients in poor health who are not good operative candidates, (4) patients with metastasis to a
salivary gland or adjacent lymph node, (5) some examples of lymphoproliferative disease {763} or (6) in
a primary soft tissue or skin appendage lesion arising in the area of a major salivary gland. A number of
series have examined the diagnostic accuracy of salivary FNA {26, 495,2474,2887} with false positive and
false negative rates ranging from 1-14%. The rate of correctly establishing a diagnosis as benign or
malignant ranges from 81-98% in most recent reports. However, a specific diagnosis can only be made
in approximately 60-75% of cases {668}. False negative diagnoses due to inadequate sampling appear to
be the most frequent error.

Staging Staging of carcinomas of the major salivary glands is based on tumour size, BB9_3.ps -
6/14/2007 2:26 PM Introduction 215 local extension of tumour, metastasis to regional nodes, and
distant metastases (see TNM classification). Recent changes in the staging system include a revision in
the definition of T3 and the division of T4 into tumours that are resectable (T4a) and unresectable (T4b)
{947,2418}. According to TNM rules, tumours arising in minor salivary glands are classified according to
the criteria for other carcinomas at their anatomic site of origin, e.g., oral cavity. Spiro and coworkers
have successfully applied the criteria used for squamous cell carcinoma of the oral cavity, pharynx,
larynx, and sinus to mucoepidermoid carcinoma {2305,2863}.