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Oral Salivary Gland Cancer

Diagnosing Oral Salivary Gland Cancer

Getting to a diagnosis begins with a history and physical examination. If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lesion is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and definitely if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up. Like most cancers in the head and neck, this will include some combination of biopsy and imaging tests, which is the term that doctors use to refer to X-rays, MRIs, CT scans, etc.

If you came to a specialist after having something small removed from your mouth and found it was cancer only afterwards, your doctor might skip some of the tests and jump to close follow-up or additional treatment. Be sure to bring all the reports and images from any prior treatment with you to your appointment with your head and neck cancer specialist.

Imaging

Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, for small tumors that are easily evaluated on physical examination (especially those in the front of the mouth), imaging might not be necessary. For larger tumors, or tumors in locations in the mouth that are difficult to examine, your doctor will probably order some sort of imaging to get more information about the tumor location and possible spread to regional lymph nodes. An important reason to get a scan for oral cavity tumors is to see if there is any evidence of spread into the jawbones. Spread into the jawbones will influence what treatment your doctor recommends for you.

For oral cancers, if imaging is required, your doctor will most likely start with a computed tomography (CT) scan with contrast. Other tests might include magnetic resonance imaging (MRI) and/or a positron emission tomography (PET) scan.

Other tests might include jaw X-rays (Panorex), Dentascans or Cone Beam CT scans. These can help determine the extent of tumor invasion into the jawbones from the cancer.

Biopsy

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion in your mouth (or a mass in your neck).

Fortunately, almost all tumors in the mouth can be biopsied in the office with a little numbing medicine (either a spray or a tiny injection or both). Just keep your mouth open and stay still. It will only take a few seconds to do the biopsy. After a piece of the lesion is removed, you will probably apply pressure with a bit of gauze to stop any tiny amount of bleeding that will result from the biopsy. The bleeding usually stops after a few minutes, or your doctor might dab it with a chemical to stop the bleeding.

In some cases, your doctor might take you to the operating room to perform a surgical biopsy.

The most common ways to do a biopsy inside the mouth include:

  • Incisional oral biopsy: This is a biopsy in which your doctor will take a piece of the suspicious lesion without removing it all. He or she has to be sure to get deep enough to make a good diagnosis.
  • Punch biopsy: This is really just another way to perform an incisional biopsy. Your doctor will use a tool called a punch forcep, which makes a quick snip to remove a piece of the suspicious area in your mouth.
  • Excisional oral biopsy: In this technique, the whole area of concern is removed. Typically, if the diagnosis is unknown, it is better to do an incisional biopsy to find out what the diagnosis is, and then determine how much normal tissue needs to be removed around the lesion.
  • Brush biopsy: This is often used by dentists, and they basically rub a few cells off the surface of a suspicious lesion. This is not ideal for diagnosing oral cancer because it doesn’t get into deeper layers of tissue. However, it can give some information and lead to a diagnosis of cancer.

The biopsy report is extremely important. Sometimes a doctor or dentist who cares and wants to help you will remove something that looks abnormal and send it off to a pathologist; unfortunately, the pathology report may be missing some important information, such as the grade of tumor, how deep it goes, whether it is endophytic, exophytic or ulcerated and whether there is a rim of normal tissue around the cancer. All of these things need to be evaluated either after a biopsy or after a more definitive removal of the cancer. Ask your doctor about the CAP Protocols, which is a standard way for pathology doctors to report results of their analysis.

Neck biopsy

If there is also a lump in the neck, your doctor might decide to biopsy that as well. There are a few different ways to do a biopsy of the neck:

  • Fine needle aspiration biopsy: The most common and easiest way to biopsy is fine needle aspiration biopsy (FNAB), in which a tiny needle is placed into the tumor and some cells are drawn out through a syringe. The pathology doctor, known as a cytologist or cytopathologist, will then immediately look at the cells under the microscope and let your doctor know if there were enough cells to make a diagnosis. A number of “passes” might be done to increase the likelihood that there are enough cells to make a diagnosis. The final diagnosis may take a few days to come back, so be patient.

 

DIFFERENT TYPES OF FINE NEEDLE ASPIRATION BIOPSIES

By Feel” FNAB Ultrasound Guided FNAB CT-Guided FNAB
When Your Doctor Might Use This Technique If the lump can be easily felt by your doctor If your doctor thinks it will be difficult to get the needle directly into the lump with certainty If your doctor doesn’t think he or she will be able to get into the tumor by feel or with ultrasound guidance
What to Expect Your doctor will feel the lump and place a tiny needle directly into it to extract some cells. Your doctor will use a gentle probe on your face or neck, identify the tumor with the ultrasound and then watch the needle go directly into the tumor on the ultrasound machine. You will be placed into a CT scanner, and a few low-dose CT scans will be performed—first to localize the tumor and then to make sure the needle that is placed is actually within the tumor.There is new technology known as fluoroscopic CT scanning in which the radiologist can quickly take a few scans without leaving the room in order to quickly insert the needle into the right place.
  • Core biopsy: Core biopsy is an alternative to fine needle aspiration. A core biopsy is done in the same way as an FNA biopsy, but it uses a larger needle and removes a core of tissue from the tumor rather than just a few cells. The likelihood of false positives and false negatives is much lower with a core needle biopsy than with a fine needle biopsy.8Horn-Ross PL, Ljung BM, Morrow M. Environmental factors and the risk of salivary gland cancer. Epidemiology. 1997:414-9.
  • Open neck biopsy: An open biopsy involves making an incision over the tumor and removing a piece or all of the tumor to make a diagnosis. An open biopsy of a neck mass is performed through an incision over the lump, and either a piece (incisional open neck biopsy) or the entire lump (excisional open neck biopsy) is removed to make a diagnosis. Except in a few special circumstances (such as if the tumor is likely a lymphoma or if other methods of diagnosis have not worked), this method should not be used to find the diagnosis of a neck mass.
  • Sentinel lymph node biopsy (SLNB): A sentinel lymph node biopsy is a new type of lymph node biopsy being used for some cancers of the head and neck. They are mainly used in skin cancers, such as melanomas and Merkel cell cancers, but some doctors are using them in oral cancers as well.10, Morton DL, Wen DR, Foshag LJ, Essner R, Cochran A. Intraoperative lymphatic mapping and selective cervical lymphadenectomy for early-stage melanomas of the head and neck. J Clin Oncol. 1993;11:1751-6.11Civantos FJ, Zitsch RP, Schuller DE, Agrawal A, Smith RB, Nason R, Petruzelli G, Gourin CG, Wong RJ, Ferris RL, El Naggar A, Ridge JA, Paniello RC, Owzar K, McCall L, Chepeha DB, Yarbrough WG, Myers JN. Sentinel lymph node biopsy accurately stages the regional lymph nodes for T1-T2 oral squamous cell carcinomas: results of a prospective multi-institutional trial. J Clin Oncol. 2010 Mar 10;28(8):1395-400.

Cancer cells spread from a tumor to regional lymph nodes by traveling through a channel of lymph and making a stop in the first lymph node along the way—the sentinel node. In SNLB, special techniques are used to figure out where that first lymph node is located. Then, that lymph node is removed and analyzed. If there is cancer in that lymph node, then the rest of the lymph nodes in the region are removed. If there is no cancer in that lymph node, then your doctor will closely watch the area but save you from undergoing additional treatment that might not be necessary.

For oral cancer, the advantages and disadvantages of SLNB are not very clear and are still being studied.12, Koch WM, Choti MA, Civelek AC, Eisele DW, Saunders JR. Gamma probe-directed biopsy of the sentinel node in oral squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. 1998;124:455-9.13Shoaib T, Soutar DS, MacDonald DG, Camilleri IG, Dunaway DJ, Gray HW, McCurrach GM, Bessent RG, MacLeod TIF, Robertson AG. 2001. The accuracy of head and neck carcinoma sentinel lymph node biopsy in the clinically N0 neck. Cancer. 91:2077-2083.

References

1 Kakarala K, Bhattacharyya N. Survival in oral cavity minor salivary gland carcinoma. Otolaryngol Head Neck Surg. 2010 Jul;143(1):122-6.

2 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed November 9, 2016. To view the most recent and complete version of the guideline, go online to www.NCCN.org.

3 Petersen PE, Oral cancer prevention and control – The approach of the World Health Organization. Oral Oncol. 2008.

4 Johansen C, Boice Jr JD, McLaughlin JK, Olsen JH. Cellular telephones and cancer—a nationwide cohort study in Denmark. Journal of the National Cancer Institute. 2001;93:203-7.

5 Auvinen A, Hietanen M, Luukkonen R, Koskela RS. Brain tumors and salivary gland cancers among cellular telephone users. Epidemiology. 2002;13:356.

6 Atula T, Grenman R, Klemi P, et al. Human papillomavirus, Epstein-Barr virus, human herpes virus 8 and human cytomegalovirus involvement in salivary gland tumours. Oral Oncol. 1998;34:391-395.

7 Sun EC, Curtis R, Melbye M, et al. Salivary gland cancer in the United States. Cancer Epidemiol Biomarkers.1999;Prev 8:1095-1100.

8 Horn-Ross PL, Ljung BM, Morrow M. Environmental factors and the risk of salivary gland cancer. Epidemiology. 1997:414-9.

9 Spiro RH, Thaler HT, Hicks WF, Kher UA, Huvos AH, Strong EW. The importance of clinical staging of minor salivary gland carcinoma. Am J Surg. 1991 Oct;162(4):330-6.

10 Morton DL, Wen DR, Foshag LJ, Essner R, Cochran A. Intraoperative lymphatic mapping and selective cervical lymphadenectomy for early-stage melanomas of the head and neck. J Clin Oncol. 1993;11:1751-6.

11 Civantos FJ, Zitsch RP, Schuller DE, Agrawal A, Smith RB, Nason R, Petruzelli G, Gourin CG, Wong RJ, Ferris RL, El Naggar A, Ridge JA, Paniello RC, Owzar K, McCall L, Chepeha DB, Yarbrough WG, Myers JN. Sentinel lymph node biopsy accurately stages the regional lymph nodes for T1-T2 oral squamous cell carcinomas: results of a prospective multi-institutional trial. J Clin Oncol. 2010 Mar 10;28(8):1395-400.

12 Koch WM, Choti MA, Civelek AC, Eisele DW, Saunders JR. Gamma probe-directed biopsy of the sentinel node in oral squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. 1998;124:455-9.

13 Shoaib T, Soutar DS, MacDonald DG, Camilleri IG, Dunaway DJ, Gray HW, McCurrach GM, Bessent RG, MacLeod TIF, Robertson AG. 2001. The accuracy of head and neck carcinoma sentinel lymph node biopsy in the clinically N0 neck. Cancer. 91:2077-2083.

14 Agulnik M, McGann CF, Mittal BB, Gordon SC, Epstein JB. Management of salivary gland malignancies: current and developing therapies. Oncol Rev. 2008;2:86-94.

15 Eveson JW, Auclair PL, Gnepp DR, et al. Tumors of the salivary glands: introduction. In: Barnes EL, Eveson JW, Reichart P, Sidransky D, editors. World Health Organization classification of tumours: pathology & genetics. Head and neck tumours. Lyon: IARCPress; 2005:220-1.

16 WHO histological classification of tumors of the salivary glands. World Health Organization. 2005.

17 Seethala RR. An update on grading of salivary gland carcinomas. Head Neck Pathol. 2009 March;3(1):69-77.

18 Douglas JG, Koh WJ, Austin-Seymour M, Laramore GE: Treatment of salivary gland neoplasms with fast neutron radiotherapy. Arch Otolaryngol Head Neck Surg.2003;129:944-948.

19 Rentschler R, Burgess MA, Byers R. Chemotherapy of malignant major salivary gland neoplasms. A 256–94.de in oralinked above experience. Cancer. 2006;40:619-24.

20 Suen JY, Johns ME. Chemotherapy for salivary gland cancer. The Laryngoscope. 2009;92:235-9.

21 Kakarala K, Bhattacharyya N. Survival in oral cavity minor salivary gland carcinoma. Otolaryngol Head Neck Surg. 2010 Jul;143(1):122-6.

22 Terhaard CHJ, et al. Salivary gland carcinoma: independent prognostic factors for locoregional control, distant metastases, and overall survival: results of the Dutch head and neck oncology cooperative group. Head & Neck. 2004;26(8):681-693.

23 Spiro, et al. Stage means more than grade in adenoid cystic carcinoma. The American Journal of Surgery. 1992;164(6):623-628.