Bilateral multifocal Warthin's tumors in upper neck lymph nodes. Report of a case and brief review of the literature

Abstract

Cystadenolymphomas (Warthin's tumors) are the second most frequent lesions of the parotid gland. Due to their benign clinical behavior, the low rates of recurrence and malignant transformation they were classified as tumor-like lesions. In addition, a polyclonal growth of the epithelial components of the tumor could be detected. Warthin's tumors occur bilateral in 7-10%, whereas a multifocal appearance is extremely rare. Even if the pathogenesis is still unclear a heterotopia of salivary tissue during embryogenesis is the most likely explanation for the origin of these tumors in the upper neck and periparotideal region. Here we present a rare case of bilateral, multifocal, extraglandular Warthin's tumors in lymph nodes of the upper neck and give a brief review of the literature. If a primary malignancy can be excluded by a careful staging procedure prior to the operation an isolated excision of the lesions of the neck is the adequate treatment.

Figure 1

Contrast-enhanced CT-scans showed a lesion next to the angle of the mandible on both sides (red arrows). The ovoid lesion showed a defined border with an intense uptake of the contrast medium.

Figure 2

Ultrasound examination of the lymph-nodes in regio IIA on both sides (upper panel: the lymph node on the right side; lower panel: the lymph node on the left side): The masses showed a widely defined border, a hypoechoic internal pattern with anechoic areas and a dorsal enhancement. No vessels within the lesions could be detected by Doppler-ultrasound and the regular lymph node anatomy with hilum and cortex was depleted. Therefore, the lesions were suspicious of containing metastastic tumor masses.

Figure 3

HE-stained slide of one of the right-sided Warthin tumours. Warthin tumour with the typical two-layered oncocytic epithelium forming closely packed tubules accompanied by a lymphoid stroma (50 × magnification).