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Oral Salivary Gland Cancer

Deciding on a Treatment Plan

Your doctors will typically use National Comprehensive Cancer Network® (NCCN®) Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers, as well as their own professional experience, to decide on the appropriate treatment course.2Referenced 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. If these guidelines are not followed, they will discuss it with you and explain why your situation might be special.

Before starting treatment, your doctor will make sure that the following steps are completed.

Pretreatment evaluation

  • A full history and physical examination, including a complete head and neck exam (mirror and fiberoptic exam if needed)
  • An evaluation by the members of a head and neck cancer team
  • A biopsy to confirm a diagnosis of cancer
  • Imaging of the lungs to check for spread, if needed
  • Imaging of the primary tumor and the neck
  • Maybe a CT/MRI for advanced cancers
  • Pretreatment medical clearance and optimization of medical conditions

Then, your doctor will recommend a course of treatment for you, depending on a number of factors. Depending on whether the cancer has spread or not, there are three general therapeutic options to consider:

Surgery

The primary treatment for almost all salivary gland cancers is complete surgical removal of the tumor, unless your surgeon determines it’s just not possible to safely remove all of the tumor. You should talk to your doctor in detail about the risks of the surgery and how extensive the surgery will need to be to ensure all the tumor is removed.

In addition to removing the tumor completely, plus a margin of normal tissue, your surgeon might recommend a neck dissection during the same surgery or soon after (once the pathologist has looked at the tumor in great detail under the microscope).

 

When Should Your Surgeon Recommend a Neck Dissection? When Should Your Surgeon Consider a Neck Dissection?
There is evidence of spread of cancer into the lymph nodes in the neck.This is called a therapeutic neck dissection. That is, the neck dissection surgery is done as therapy to remove cancerous lymph nodes from the neck. There is no clear evidence of spread into neck lymph nodes, BUT the tumor is either high-grade or high stage.This is called an elective (or prophylactic) neck dissection. That is, the neck dissection surgery is done electively or “just in case” because there is a high chance that there are cancerous lymph nodes in the neck or that you will later develop cancerous lymph nodes in the neck.

 

Radiation

Radiation as a primary treatment may be recommended for tumors in which surgical resection is not possible. This will be determined by your surgeon but usually includes T4b tumors. In this case, either radiation alone or radiation with chemotherapy may be recommended.

More commonly, radiation is used after surgery to decrease the chances that the tumor will come back. Based on the NCCN Guidelines2Referenced 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., there are a few reasons for radiation to be considered and a few cases in which it should definitely be recommended.

When Should Radiation Be Considered Following Surgery? When Should Radiation Be Recommended Following Surgery?
  • A low-grade T1 or T2 tumor that has invasion into or around nerves
  • A low grade T1 or T2 tumor in which there was spillage of the tumor during the surgery
  • A T1 or T2 tumor that ends up being adenoid cystic carcinoma
  • A T1 or T2 tumor that ends up being intermediate or high-grade
  • A T3 or T4 tumor that was completely removed, but the tumor type is found to be adenoid cystic carcinoma
  • A T3 or T4 tumor that was completely removed BUT has certain bad features found under the microscope, such as:
    • Intermediate or high-grade
    • Close or positive margins
    • Neural/perineural invasion
    • Lymph node spread or invasion into lymphatics or vessels
  • A tumor that was not completely removed, and additional surgical resection is not possible

 

Radiation almost always refers to photon beam radiation, not neutron beam radiation. Interestingly, there are a few treatment centers in the U.S. that use neutron beam radiation. In fact, a small study that compared patients with inoperable salivary gland cancer at 10 years post-treatment showed that, though there was no real difference in the number of patients who were alive, fewer patients had cancer at the original site in the neutron beam group.19Rentschler 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. For now, this type of radiation is experimental, and it is only done at a few places around the country for patients in whom the cancer just cannot be removed by surgery and who have a poor prognosis.

Chemotherapy

Chemotherapy has not been shown to be very effective in salivary gland cancers. In general, it can be considered to help control distressing symptoms of a salivary gland cancer. The problem is there are no well-designed experiments with enough patients that have really been able to see how effective chemotherapy is in these patients.

Still, chemotherapy should be considered in a few cases20, Suen JY, Johns ME. Chemotherapy for salivary gland cancer. The Laryngoscope. 2009;92:235-9.21Kakarala K, Bhattacharyya N. Survival in oral cavity minor salivary gland carcinoma. Otolaryngol Head Neck Surg. 2010 Jul;143(1):122-6.:

  • Cancer that has spread beyond the head and neck
  • A T3 or T4 tumor in which surgery cannot remove all of the tumor
  • A T3 or T4 tumor that has certain bad features found under the microscope, such as:
    • Intermediate or high-grade
    • Close or positive margins (edges)
    • Neural/perineural invasion
    • Lymph node spread
    • Invasion into lymphatics or vessels
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.