60-year-old male with left parotid mass, PET avid. Additional information per chart review in EPIC: Patient had an episode in April of left parotid swelling associated with food intake that resolved with conservative measures. He was told that this could be related to a parotid sialolith, however this has not occurred since. He also endorses pin point pain in the region that occurs at regular time periods during the day and lasts for a number of seconds. No constant facial pain. No facial weakness/facial paralysis, history of head and neck cancers. MRI BRAIN: The ventricles and sulci are within normal limits. The cisterns remain patent. There is no midline shift or mass effect. There are scattered T2/FLAIR hyperintense foci within the periventricular and subcortical white matter in an asymmetric distribution predominantly within the left cerebral hemisphere. There is a nonspecific punctate enhancing focus within left anterior parietal bone. There is no diffusion abnormality. There is a retrocerebellar cyst causing mild mass effect on the left paramedian posterior cerebellar hemisphere; otherwise there are no extra-axial collections present.Normal flow-voids are demonstrated in the major intracranial vascular structures. The midline structures and craniocervical junction are within normal limits. MRI SOFT TISSUE NECK: PHARYNX/LARYNX: The nasopharynx, oropharynx, and hypopharynx are unremarkable. The larynx is unremarkable. The upper trachea and esophagus are unremarkable. There is no abnormal soft tissue mass or pathological enhancement.GLANDS: Within the tail of the superficial lobe of the left parotid gland there is an oval-shaped lesion measuring 13 mm x 9 mm (series 901, image 16). The lesion demonstrates well-defined margins only on the T1-weighted sequence but is somewhat difficult to delineate on the other sequences, including the postcontrast sequences. The lesion demonstrates slightly hyperintense but heterogenous signal relative to the background parotid tissue on the T2-weighted images, slightly hypointense signal on the T1-weighted images and mild heterogenous enhancement on the postcontrast sequences. The lesion demonstrates restricted diffusion.Within the right parotid gland there is also a 10 x 8 mm lesion (series 701, image 28) with part of the lesion demonstrating low T1 signal intensity and high signal on T2-weighted sequences relative to the background parotid tissue compatible with a cystic component; the anterolateral component of the lesion demonstrates a different signal intensity pattern (series 901, image 28) and may be more nodular in nature. The cystic component of the lesion appears to demonstrate T2 shine through on the diffusion weighted images with no definite restricted diffusion identified. There was no definite corresponding increased uptake on the previous PET scan.The bilateral submandibular and sublingual glands are unremarkable. ORAL CAVITY: The oral tongue and the floor of mouth are unremarkable.CERVICAL SOFT TISSUES: Scattered small cervical lymph nodes are identified which are not pathologic by CT size criteria.
1. 13 mm heterogeneously enhancing lesion in the left parotid tail demonstrating restricted diffusion with intermediate T2 and low T1 signal. Findings are suspicious for a primary parotid neoplasm, which given the location may represent a Warthin's tumor; of note on the postcontrast and T2-weighted sequences, the margins are not well-defined raising the possibility of more aggressive malignancy. Differential diagnosis also includes metastatic disease. Correlate with recent biopsy results, note should be made that imaging characteristics may be altered by the preceding biopsy which could result blood products.2. 10 mm superficial right parotid lesion is indeterminate demonstrating a partially cystic component without definite restricted diffusion or uptake on recent PET scan. This may represent a lymph node however an ultrasound is recommended for further characterization, to exclude another primary parotid lesion.3. Likely chronic small vessel ischemic disease, left greater than right.4. Nonspecific punctate enhancing focus within the anterior left parietal bone, although could represent a hemangioma.