Accepted Manuscript

Title: Differentiation between benign and malignant palatal tumors using

conventional MRI: a retrospective analysis of 130 cases

Author: Yingyan Zheng, Zebin Xiao, Hua Zhang, Dejun She, Xuehua Lin, Yu
Lin, Dairong Cao

PII: S2212-4403(18)30042-7
DOI: https://doi.org/10.1016/j.oooo.2018.01.006
Reference: OOOO 1930

To appear in: Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Received date: 28-6-2017

Revised date: 24-11-2017
Accepted date: 7-1-2018

Please cite this article as: Yingyan Zheng, Zebin Xiao, Hua Zhang, Dejun She, Xuehua Lin, Yu
Lin, Dairong Cao, Differentiation between benign and malignant palatal tumors using
conventional MRI: a retrospective analysis of 130 cases, Oral Surgery, Oral Medicine, Oral
Pathology and Oral Radiology (2018), https://doi.org/10.1016/j.oooo.2018.01.006.

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Title page

Differentiation between Benign and Malignant Palatal Tumors Using

Conventional MRI：A Retrospective Analysis of 130 Cases

Type of Manuscript: Research Articles

Yingyan Zheng, MD1, Zebin Xiao, MD1, Hua Zhang, MD1, Dejun She, MD1, Xuehua
Lin, MD1, Yu Lin, MD1, Dairong Cao, MD1*

1
Department of Radiology, First Affiliated Hospital of Fujian Medical University,
Fuzhou, Fujian 350005, China

Corresponding author:
Dairong Cao, MD
Department of Radiology
First Affiliated Hospital of Fujian Medical University
20 Cha-Zhong Road, Fuzhou, Fujian 350005, P.R.China
Phone: +86-591-87983333
Fax: +86-591-83318716
E-mail: dairongcao@163.com

Compliance with ethical standard

*Funding: No funding was received for this study.
*Conflict of interest: The authors declare that there is no conflict of interests.
*Ethical approve: The protocols were reviewed and approved by the Ethics
Committee of our University Hospital and was conducted in accordance with the
Declaration of Helsinki.

Page 1 of 40
*Informed consent: The requirement for patient informed consent was waived due to
the retrospective nature of this study.
*Acknowledgement: None.

Abstract: 189 words

Manuscript+Figure Legends: 3441 words
References: 32
Figures: 6
Tables: 3

Page 2 of 40
Statement of Clinical Relevance
Accurate differentiation between malignant and benign palatal lesions is essential for
directing further therapeutic strategy, as well as assessment of the preoperative staging,
which could be predominantly complemented by the conventional MRI beyond
clinical examination.

Abstract
Objectives: To evaluate the discriminative value of conventional maganetic resonance
imaging (MRI) between benign and malignant palatal tumors.
Study Design: Conventional MR imaging features of 130 patients with palatal tumors
confirmed by histopathology were retrospectively reviewed. Clinical data and
imaging findings were assessed between benign and malignant tumors and between
benign and low-grade malignant salivary gland tumors. The variables that were
significant in differentiating benign from malignant lesions were further identified
using logistic regression analysis. Moreover, imaging features of each common
palatal histologic entity were statistically analyzed with the rest of the tumors to
define their typical imaging features.
Results: Older age, partially-defined and ill-defined margins, and absence of a capsule
were highly suggestive of malignant palatal tumors, especially ill-defined margins (β
= 6.400). The precision in determining malignant palatal tumors achieved a sensitivity
of 92.8% and a specificity of 85.6%. In addition, irregular shape, ill-defined margins,
lack of a capsule, perineural spread, and invasion of surrounding structures were more
frequently associated with low-grade malignant salivary gland tumors.
Conclusion: Conventional MRI is useful for differentiating benign from malignant
palatal tumors as well as benign salivary gland tumors from low-grade salivary gland
malignancies.
Keywords: Magnetic resonance imaging; Palatal tumor; Benign; Malignancy;
Differential diagnosis

Page 3 of 40
Introduction
Tumors in the palatal region comprise a broad spectrum of pathoses, resulting in a
great challenge for precise clinical diagnosis.1 Accurate differentiation between
benign and malignant palatal lesions, especially low-grade malignancies, is of great
clinical relevance since radiotherapy and chemotherapy may be required along with
surgical resection in some patients with malignancies .2-4 In addition, therapeutic
strategy and prognosis vary substantially for each tumor type in the palate.
However, clinical manifestations are of limited value in diagnosing palatal
malignancies, particularly in some submucosal lesions thatare relatively difficult to
discover through inspection and palpation.5 Even though histopathology canbe
confirmed by incisional biopsy with certainty, this is an invasive procedure and does
not allow preoperative staging.6 Therefore, the formation of differential diagnoses and
therapeutic strategies for benign and malignant palatal neoplasms are supplemented
by modern imaging techniques.
Conventional magnetic resonance imaging (MRI) plays an important role in
delineating the extent of palatal lesions and demonstrating perineural spread as well as
spread to lymph nodes due to its superior soft tissue resolution,1, 7
thereby
complementing clinical examination. Although diffusion weighted imaging (DWI)
and other advanced MR approaches have been used to assess palatal tumors,8, 9 Yuan
et al. 9 noted that DWI did not dramatically improve the ability of conventional MRI
to differentiate between benign and malignant palatal lesions, indicating routine MRI
remains the mainstay imaging modality in the palate.
However, to the best of our knowledge, little research concerning the discriminative
value of conventional MRI in diagnosing palatal neoplasms has been reported.1, 5, 7, 10
In spite of overlapping imaging findings, we hold the hypothesis that some MRI
characteristics differ significantly between benign and malignant tumors. The purpose
of this study was to evaluate whether conventional MRI can be effective in
differentiating between benign and malignant lesions in the palate and describe the
typical imaging features of each common palatal tumor.

Page 4 of 40
Materials and methods

Patients
This retrospective study was approved by our institutional review board and the
requirement of informed consent was waived. Conventional MRI examinations of the
patients with palatal tumors were performed from July 2009 to August 2017. Patients
were excluded if any of the following conditions were met: (1) MR imaging or
pathological examination was absent; (2) metal or motion artifacts interfered with the
diagnosis; or (3) the tumor was treated (surgical management, biopsy, or radiotherapy)
before the MRI examinations. Of these cases, 78 patients were excluded from the
present study owing to insufficient imaging data (n=66), poor imaging quality (n=4)
or prior intervention (n=8). Ultimately, 130 patients with palatal tumors were enrolled
into our study, including 89 males and 41 females [mean age ± standard deviation (SD)
53.53 ±17.417 years, range from 1 to 85 years]. The histopathological type of masses
in the palate included 92 malignant tumors (63 squamous cell carcinomas, 5
malignant melanomas, 11 mucoepidermoid carcinomas, 7 adenoid cystic carcinomas,
1 adenocarcinoma, 1 polymorphous low-grade adenocarcinoma and 4 lymphomas)
and 38 benign tumors (4 papillomas, 26 pleomorphic adenomas, 5 myoepitheliomas, 2
cavernous hemangiomas, and 1 solitary fibrous tumor).

MRI protocol
Images of eighty-four patients were acquired with a 1.5-Tesla MR system (SIGNA
Excite HD; GE Healthcare, Milwaukee, Wisconsin) and forty-six patients with a
3.0-Tesla MR system (Magneton Verio, Siemens Medical Solutions, Erlangen,
Germany). The protocols of the 1.5-Tesla MR system consisted of the following
sequences: axial T1-weighted images (T1WI, TR/TE 560 ms/20 ms) and T2-weighted
images with fat suppression (fs-T2WI, TR/TE 4600 ms/85 ms) in the axial and coronal
planes. In addition, three orthogonal plane contrast-enhanced T1-weighted images
with fat suppression (CE-T1WI, TR/TE 525 ms/9.2 ms) were obtained after
intravenous injection of Gd-DTPA at a dosage of 0.1mmol/kg of body weight. All
5

Page 5 of 40
sequences were uniform with a matrix of 288 × 224, the field of view (FOV) of 240
mm × 240 mm, and slice thickness of 5mm with an intersection gap of 1 mm. The
total acquisition time was about 20 minutes. The sequence parameters on the 3.0T MR
system were as follows: axial T1-weighted images (T1WI, TR/TE 250 ms/2.5 ms) and
T2-weighted images with fat suppression (fs-T2WI, TR/TE 4600 ms/75 ms) in the
axial and coronal planes. Additionally, three orthogonal plane contrast-enhanced
T1-weighted images with fat suppression (CE-T1WI, TR/TE 520 ms/9.1 ms) were
obtained after intravenous injection. All sequences were uniform with a matrix of 256
× 320, the FOV of 220 mm × 220 mm, and slice thickness of 3mm with an
intersection gap of 1 mm. The total acquisition time was about 25 minutes.

Image analysis
Qualitative image assessments were performed by two experienced radiologists (17
and 23 years of clinical experience in head and neck diagnostic imaging, respectively)
who were blinded for clinical information, histopathological diagnosis, and study
design. If disagreement existed, consensus was reached by discussing the images with
another radiologist (28 years of clinical experience).
The imaging manifestations of location, size, margin, morphology, signal intensity,
inner nature, cystic/necrosis, degree of enhancement, capsule, invasion of adjacent
structures, perineural spread, and metastatic lymph nodes were assessed. The location
of palatal entities was classified into hard palate, border area of hard and soft palate,
and soft palate. The tumor size was measured in maximal dimensions on the
transverse plane. The margin of lesions was described as well-defined (more than
two-thirds of the border sharply demarcated), partially-defined (in between), and
poorly-defined (less than one-third of theborder sharply demarcated ). The
morphology was defined as round/oval, lobular, and irregular. Compared with that of
the adjacent muscle, T1WI signal intensity was graded as hypointense, isointense, and
hyperintense; T2WI signal intensity was defined as hypointense, isointense,
hyperintense and highly-hyperintense in comparison to that of the adjacent muscle
and parotid gland. Inner nature of masses was classified as homogeneous or
6

Page 6 of 40
heterogeneous on both pre- and post-contrast images. Cystic areas were defined as
demonstrating hypointensity on T1WI and hyperintensity on T2WI. In
contrast-enhanced T1WI, these areas showed no enhancement with a relatively clear
boundary. Areas with heterogeneous signal intensity without enhancement and with
an unclear demarcation were considered as necrosis. Degree of enhancement was
categorized as mild (lower than adjacent muscle), moderate (enhancement degree
between mild and intense) and intense (greater than the submandibular gland).11
The capsule was demonstrated as a peripheral ring-like area with hypointense
signal intensity on both T1WI and T2WI. Adjacent structure invasion including soft
tissue invasion (e.g., tensor veli palatini muscle, medial pterygoid muscle, palatine
tonsil, gingiva of mandibular molar, lateral pterygoid muscle, levator veli palatini
muscle, and tongue base) and bone destruction (including hard palate, walls of the
maxillary sinuses, mandible, and sphenoid bone) was evaluated. Perineural spread
was defined with the following criteria: enlargement or excessive enhancement of a
nerve, or abnormal signal intensity and enhancement, or widening of the neural
pathway.12 Lymph nodes were evaluated regarding swelling (defined as short axial
diameter larger than 10mm), morphology (irregular or regular), , border (well-defined
or poorly defined), and internal necrosis.13

Statistical Analysis
All statistical analyses were performed with statistical software (SPSS, v.19.0; IBM,
Armonk, New York). The inter-observer reliability between observer 1 and observer 2
was evaluated with Cohen’s kappa coefficient (k). We used the following guidelines to
judge the degree of reliability: k<0.40 poor; 0.40-0.75 fair to good; >0.75
excellent.14 The Kolmogorov-Smirnov test was adopted for normally distributed data
analysis. The frequency distribution of gender and MRI findings between benign and
malignant palatal tumors was compared with the chi-squared test or Fisher exact test.
Comparisons of patients’ age and tumor size between the two groups were performed
with the Student’s t-test. The variables that were found to be significantly different
between benign and malignant lesions were further evaluated with logistic regression
7

Page 7 of 40
analysis. Additionally, benign salivary gland tumors (26 pleomorphic adenomas and 5
myoepitheliomas) and low-grade malignant salivary gland tumors (4 mucoepidermoid
carcinomas, 4 adenoid cystic carcinomas and 1 polymorphous
low-gradeadenocarcinoma ) were compared using the same statistical analyses
mentioned above. Furthermore, clinical data and MRI findings of each common
palatal entity (n > 5), including squamous cell carcinoma, mucoepidermoid carcinoma,
adenoid cystic carcinoma, and pleomorphic adenoma, were statistically analyzed with
the rest of lesions to define their typical imaging features. Receiver operating
characteristic (ROC) analysis was performed to determine the cut-off point for
significant numeric values. A difference with a P value less than 0.05 was considered
to be significant.

Results
There were significant differences in the age (P < 0.001) and gender distribution (P =
0.037) between benign and malignant lesions in the palate, while no difference was
found between benign and low-grade malignant salivary gland tumors (P > 0.05). In
addition, most squamous cell carcinomas had a tendency to occur in males (54/63,
85.71%).while no difference in gender was found between benign and low-grade
malignant salivary gland tumors.
Kappa values revealed excellent inter-observer reliability (k>0.75) for all
parameters (Table I). The conventional MR imaging findings of benign and
malignant palatal tumors are summarized in Table I. There were significant
differences in location (P = 0.004) and margin (P < 0.001) between benign and
malignant palatal tumors. Specifically, malignancies had a predilection for involving
the soft palate (55/92, 59.8%) and manifesting ill-defined margins (53/92, 57.6% ).
For morphology, irregular shapes were more frequently demonstrated in malignancies
(78/92, 84.8% ), whereas benign tumors usually produced round/oval contours (22/38,
57.9% ). There were no differences in tumor size, signal intensity, innernature ,
cystic/necrosis, and degree of enhancement between benign and malignant palatal
masses (all P > 0.05).
8

Page 8 of 40
 There was a statistically significant difference between benign and malignant
lesions regarding the presence of a capsule (P < 0.001). This positive MRI finding
was frequently observed in pleomorphic adenomas (23/26, 88.5% ), but also occured
in some malignancies in our cohort (Table I; Fig. 1), including adenoid cystic
carcinomas (n = 2), mucoepidermoid carcinomas (n = 2) and polymorphous
low-grade adenocarcinoma (n = 1).In addition, the presence of adjacent structure
invasion (Table I) and perineural spread (Table I; Fig. 2) were strongly suggestive of
malignancies (p < 0.001). The surrounding structure most commonly involved was
the tensor veli palatini muscle (34/92, 37.0%). I Irregular shape and inner necrosis of
lymph nodes were more frequently seen in the malignancies but size and margin
showed no significant difference (Table I; Fig. 3).
Age, gender, location, margin, morphology, capsule, adjacent structure invasion,
perineural spread, irregular shape, along with irregular morphology and internal
necrosis of lymph nodes, were further adapted into logistic regression analysis. As
shown in Table II, older age, partially-defined and ill-defined margins, and the
existence of a capsule were the most important predictive variables for the differential
diagnosis. In addition, the existence of a capsule was the only imaging finding that
favored benign tumors (β = -4.628). More importantly, an ill-defined margin was the
strongest indicative imaging feature for differential diagnosis (β = 6.400). The
forecast precision achieved a sensitivity of 92.8% and a specificity of 85.6%.
Low-grade malignant salivary gland entities typically displayed an irregular
morphology (P = 0.011) and ill-defined margins (P = 0.014), with a tendency for
infiltration of surrounding tissues (P = 0.007) and perineural spread (P = 0.011).
Mucoepidermoid carcinomas exhibited perineural invasion in 4 of the 11 cases
(36.4%). The presence of a capsule was still significantly correlated with benign
salivary neoplasms (P = 0.001). Location, size, signal intensity, inner nature,
cystic/necrosis, enhancement and lymph nodes did not help distinguish benign from
low-grade malignant salivary masses.
Typical conventional MRI appearances for the most common palatal tumors are
listed in Table III. Age with a cutoff of ≥ 55-years-old demonstrated a sensitivity of
9

Page 9 of 40
76.2% and specificity of 64.2% in predicting squamous cell carcinomas, while age ≤
54-years-old showed a sensitivity of 57.1% and specificity of 81.8% for
mucoepidermoid carcinomas.

Discussion
Our study indicated that older age, partially defined and ill-defined margins, and the
absence of a capsule were findings that could dramatically improve diagnostic
accuracy in predicting malignant palatal neoplasms. Ill-defined margin, the
well-known manifestation of the majority of malignancies15-17, was the most effective
conventional MRI feature in differentiating benign from malignant palatal tumors in
our investigation.
Patients with malignancies in the palate were generally older than those withbenign
lesions. , This was particularly true for patients with squamous cell carcinomas, while
mucoepidermoid carcinomas had a predilection among young and middle-aged
patients. Conversely, the presence of a capsule was the most important factor that
favored benign palatal lesions, as revealed by the negative value of the partial
regression coefficient. This appearance was predominately associated with
pleomorphic adenomas, which was in concordance with previous studies18-20.
Nevertheless, tumor capsule could also be encountered in myoepitheliomas (5/5,
100%), and even in some malignant lesions.Microscopically , pleomorphic adenomas
have pseudocapsules with small protrusions and finger-like pseudopodia rather than
true capsules.21 Benign palatal masses with incomplete capsules occasionally may be
misinterpreted as ill-defined malignancies in our clinical experience, which may be
histopathologically correlated with tumor cells extending into the surrounding normal
tissue (Fig. 4).
The predilection for soft palate involvement was significant for squamous cell
carcinomas, whereas benign lesions could occur anywhere in the palate in ourstudy .
Salivary gland neoplasms rarely arise in the anterior part of hard palate and are
usually lateral to the midline owing to the distribution of salivary glands.1, 22

Irregularmorphology , as one of the characteristic findings of squamous cell

10

Page 10 of 40
carcinoma, was more frequently associated with malignancies in this study. Some
squamous cell carcinomas in the early stage may only manifest as irregular or
abnormally enhanced lesions, and contrast-enhanced coronal T1-weighted imaging is
the best imaging sequence in displaying tumor thickness.
Adjacent structure involvement including bone invasion, perineural extension, and
metastasis to lymph nodes, has considerable implications for predicting the prognosis
12, 23-25
and determining the therapeutic strategy for malignant palatal tumors. The
palate is innervated by the maxillary branches of the trigeminal nerve and facial
nerve.12, 26
Generally, malignant palatal tumors, especially mucoepidermoid
carcinomas as shown in this study, can spread perineurally through the greater and
lesser palatine foramina to the pterygopalatine fossa. This is the most prevalent
infiltration route for palatal malignancies and usually results in destroyed or widened
neural pathways on MRI. As documented in previous studies, 13, 27-29 morphological
criteria for indicating pathological lymph nodes usually include irregular contour or
visualized necrosis. Enlargement of cervical lymph nodes at level II may be
suggestive of but not definitive for metastasis, since enlargement can also be caused
by hyperplasia or inflammation.
Although signal features and the degree of enhancement offer little contribution to
differential diagnosis, characteristic manifestations in certain tumors on conventional
MRI might indicate their specific histopathology.10, 27 For example, solitary fibrous
tumors derived from fibroblasts in mesenchymal tissue typically revealed
homogeneous hypointensity on both T1WI and T2WI (Fig. 5). Melanoma usually
showed hyperintensity on T1WI and hypointensity on T2WI. Additionally, the typical
enhancement pattern of cavernous hemangioma, which displayed heterogeneous
enhancement on the early enhanced-contrast examinations and progressive
enhancement on delayed phase imaging (Fig. 6), could be helpful for discriminating
this lesion from other entities with markedenhancement . However, the presence of
cystic/necrosis areas did not yield statistically significant differences between benign
and malignant lesions, since such areas also had a high prevalence in benign lesions,
particularly in salivary gland tumors.
11

Page 11 of 40
 Clinically, precise discrimination of benign salivary gland tumors from low-grade
malignant salivary gland tumors is difficult with conventional MRI because of the
similar imaging manifestations of those tumors in the major or minor salivary glands.7,
28
In the present study, we found that irregular shape, ill-defined margins, absence of a
capsule, perineural spread, and invasion of surrounding structures were significantly
more frequent in low-grarde malignancies, allowing a differentiation between benign
29
and malignant palatal tumors. As discovered in a previous study, low-grade
malignant salivary gland neoplasms typically appear hyperintense on both T1 and
T2-weighted images, histopathologically corresponding to fewer tumor cells and more
proteinaceous mucin, which is believed to be helpful in distinguishing them from
other diseases. From the previously described typical imaging appearances of
pleomorphic adenoma, our current research confirmed the characteristic finding in
this tumor of high signal intensity on T2WI. However, proteins or hemorrhage within
some pleomorphic adenomas could appear hyperintense on T1WI, decreasing the
significance of signal intensity in differential diagnosis.
Squamous cell carcinoma, the most common malignant lesion in the palate, was
significantly more frequent in older males in our study, which was consistent with
previous research.32, 30
It had a propensity to infiltrate adjacent tissues due to its
aggressive growth pattern;therefore, it might sometimes be difficult for radiologists in
determine the origin of the tumor. For instance, squamous cell carcinoma in the
maxillary sinus or gingiva cannot easily be distinguished from tumors in the palate.
Thus, tumor localization usually depends on the central position of the tumor in these
cases. Furthermore, the incidence of histopathologically confirmed nodal involvement
was higher in squamous cell carcinoma (14/63, 22.2% in our study) than that of other
palatal masses. Adenoid cystic carcinomas mostly occurred in females and displayed
high T2 signal intensity in our study, which was inconsistent with the low signal
intensity on T2WI of adenoid cystic carcinoma in some previous research .7, 16 We
argue this difference may be caused by the high occurrence of low-grade tumors in
our cohort. In contrast to the lobulated shape in major salivary glands, most
pleomorphic adenomas showed oval or round contours in the palate. As stated above,
12

Page 12 of 40
a fibrous capsule was characterized as the most significant conventional MRI feature
of pleomorphic adenomas. Careful evaluation of the tumor capsule is necessary
because recurrence rate and prognosis are closely associated with the degree of
encapsulation. 31
Our research has several limitations. Since our study involved retrospective
analysis, malignant lesions comprised approximately three-quarters of all palatal
entities in our cohort, which was a greater percentage than in a previous study .32 This
may be influenced by regional or population differences.In addition, some patients
with benign palatal lesions only underwent CT rather than MRI in our institution,
resulting in a lower prevalence compared to epidemiological data. This might also
have some influence on the role of clinical information in predicting malignancy.
Another limitation was the fact that certain histopathological types of palatal lesions
are rare, and this was related to their low occurrence in our study. Thus, prospective
multicenter studies that include patients with different histopathological types would
be required in further research. The large sample size of squamous cell carcinomas in
our study with typical imaging findings might have influenced the results of statistical
analysis, but sometimes they might be confused with certain benign conditions such
as necrotizing sialometaplasia,7 so they still need to be included for overall
assessment of palatal tumors. Patients in our institution had MRI scans performed
with 1.5T and 3.0T MR systems, which may have influenced the image analysis due
to improved spatial resolution.Finally, the thickness slice in the present study was not
optional for detecting perineural spread. Therefore, high resolution MRI (HR-MRI)
using thin-section and advanced imaging techniques should be adopted in the future.
In conclusion, conventional MRI can improve the diagnostic performance for
differentiating between benign and malignant palatal tumors according to their typical
appearances. Clinical data and imaging features including margin definition, the
presence or absence of a capsule, and patient’s age were the best discriminators for
differential diagnosis betweenbenign and malignant lesions, with the ill-defined
margin serving as the best discriminator on the basis of logistic regression analysis.
Furthermore, irregular contour, ill-defined margin, absence of capsule, perineural
13

Page 13 of 40
infiltration and invasion of surrounding structures as defined on conventional MRI
were suggestive imaging findings for low-grade salivary gland malignancies, which
probably is helpful for discriminating low-grade salivary gland malignancies from
benign gland salivary tumors in the palate.

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Fig. 1 A 42-year-old male with a low-grade mucoepidermoid carcinoma displays an
incomplete capsule in the right hard palate (arrow) (A-B). Contrast enhanced T1WI (C)
reveals a a homogeneously enhancing mass, which might present difficulty in
accurately differentiating this lesion from benign palatal tumors.
Fig. 2 Squamous cell carcinoma with an irregular contour and poorly-defined margin
in a 61-year-old male patient (A). The tumor involved the left maxillary sinus and
destroyed the palatine bone (B). Sagittal T1WI (C) shows destruction of the left
greater and lesser palatine foramina with widening of the left pterygopalatine canal
(arrow), which reveals abnormal enhancement in post-contrast T1WI (D). This
indicates that the tumor spread perineurally along the nerve derived from maxillary
branches of the trigeminal nerve.
Fig. 3 A 71-year-old male with a squamous cell carcinoma in the right soft palate (A).
Multiple enlarged lymph nodes with visualized necrosis in level II show
heterogeneous signal intensity on T2WI (B) and irregular nodal enhancement on
post-contrast T1WI (C).
Fig. 4 A Pleomorphic adenoma in a 34-year-old female manifested as an irregular
ill-defined mass (arrow)(A), which was initially misdiagnosed as malignancy.
Post-contrast coronal T1WI (B) shows marked enhancement of the mass in the right
soft palate. Pathological examination reveals that tumor cells have infiltrated the
capsule and extend into the surrounding normal tissue (arrow) (C).
Fig. 5 Pre-contrast T1WI and T2WI images (A-B) depict a well-demarcated
hypointense neoplasm in the left soft palate of a 27-year-old female. The solitary
fibrous tumor presents with slightly heterogeneous enhancement on post-contrast
T1WI (C).
Fig. 6 A 62-year-old male with a cavernous hemangioma in the right hard palate. This
tumor typically displays prominent heterogeneous enhancement in the early enhanced
stage and becomes homogeneously enhanced on delayed phase imaging (A-C).

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Table I. Imaging findings of benign and malignant tumors on conventional MRI

Malignant Benign

Characteristics lesions (92) lesions (38) P value k

N(%) N(%)

Location 0.004* 0.977

Hard palate 29(31.5) 14(32.6)

Border area of hard and

8(8.7) 11(28.9)
soft palate

Soft palate 55(59.8) 13(34.2)

Size (mm) 27.541.448 24.371.861 0.216 0.831

Margin <0.001* 0.863

Well-defined 8(8.7) 30(78.9)

Partially-defined 31(33.7) 3(7.9)

Poorly-defined 53(57.6) 5(13.2)

Morphology <0.001* 0.915

Round/Oval 8(8.7) 22(57.9)

Lobular 6(6.5) 9(23.7)

Irregular 78(84.8) 7(18.4)

Signal intensity: T1WI 0.860 0.923

Hypointense 73(79.3) 29(76.3)

Isointense 7(7.6) 4(10.5)

Hyperintense 12(13.0) 5(13.2)

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Signal intensity: T2WI 0.082 0.909

Hypointense 0(0.0) 0(0.0)

Isointense 3(3.3) 1(2.6)

Hyperintense 53(57.6) 14(36.8)

Highly-hyperintense 36(39.1) 23(60.5)

Inner nature 0.066 0.890

Homogenous 12(13.0) 10(26.3)

Heterogeneous 80(87.0) 28(73.7)

Cystic/necrosis 81(88.0) 29(76.3) 0.092 0.853

Degree of enhancement 0.201 0.831

Mild 5(5.4) 0(0.0)

Moderate 31(33.7) 10(26.3)

Intense 56(60.9) 28(73.7)

Capsule 5(5.4) 28(76.3) <0.001* 0.915

Adjacent structure invasion 50(54.3) 6(15.8) 0.001* 0.885

Perineural spread 15(16.3) 0(0.0) 0.019* 0.969

Lymph nodes

Swelling 21(22.8) 5(13.2) 0.210 0.853

Morphology: Irregular 12(13.0) 0(0.0) 0.045* 0.869

Border: Ill-defined 9(9.8) 0(0.0) 0.106 0.931

Internal necrosis 14(15.2) 0(0.0) 0.025* 1.000

*: P < 0.05

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Table II. Results of logistic regression analysis for benign and malignant tumors

Variable β P OR 95%C.I.

Age 0.078 0.002 1.081 0.880-8.972

Partially-defined 3.680 <0.001 39.014 9.681-68.338

Ill-defined 6.400 <0.001 621.342 368.282-947.045

Capsule -4.628 0.002 9.774 0.037-29.359

β, Partial regression coefficient; OR, Odds ratio; C.I., Confidence interval

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Table III. Typical imaging findings of common palatal tumors

Tumor Appearance P value

Squamous cell
Age ≥ 55 years old a <0.001
carcinoma

Male <0.001

Soft palate <0.001

Irregular shape <0.001

Ill-defined margin 0.002

Hypointense on T1WI 0.003

Hyperintense on T2WI 0.001

Adjacent structure invasion <0.001

Lymph nodes:
Irregular borders 0.030
Ill-defined borders 0.002
Internal necrosis <0.001
Adenoid cystic
Female 0.026
carcinoma

Highly-hyperintense 0.028

Mucoepidermoid
Age ≤54 years old a 0.038
carcinoma

Perineural spread <0.001

Pleomorphic
Round/oval shape <0.001
adenoma

Well-defined margin <0.001

Capsule <0.001

a
cutoff age by ROC analysis

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Fig 1A.jpg

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Fig 1B.jpg

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Fig 1C.jpg

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Fig 2A.jpg

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Fig 2B.jpg

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Fig 2C.jpg

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Fig 2D.jpg

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Fig 3A.jpg

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Fig 3B.jpg

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Fig 3C.jpg

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Fig 4A.jpg

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Fig 4B.jpg

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Fig 4C.jpg

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Fig 5A.jpg

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Fig 5B.jpg

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Fig 5C.jpg

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Fig 6A.jpg

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Fig 6B.jpg

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Fig 6C.jpg

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