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Salivary Gland Cancer

Diagnosing Salivary Gland Cancer

If you have any of the symptoms described above, your doctor will be concerned that you might have a salivary gland cancer. Once your doctor thinks there is any possibility you might have salivary gland cancer, you will go down a diagnostic pathway. The exact type and order of the diagnostic evaluation may vary, depending on your doctor’s preferred methods, but you can expect one or a few of the following.

PROACTIVE REMOVAL

Because most tumors in the parotid gland are benign, and because the treatment for most salivary gland tumors is surgical removal, some surgeons will remove salivary gland tumors (especially those within the parotid gland) without a biopsy. Some doctors will even move forward with surgery without imaging. These surgeons see no reason to put patients through additional tests when they plan to remove the growth regardless. Once in the operating room, the surgeon can see the full extent of the tumor and its invasion characteristics. The surgeon can then send the whole specimen to the pathologist to tell you what type of tumor it is.

IMAGING

While going directly to surgery is a reasonable approach, other surgeons say obtaining some imaging will decrease the chance of surprises in the operating room and will give some clues as to whether the tumor is benign or malignant. This will prepare you and your surgeon for what to expect during surgery.

In general, for small tumors that are evaluated during your physical examination, imaging is probably not necessary. However, many head and neck specialists will order some sort of high-resolution imaging to gather more information about the extent of the tumor and the lymph nodes to which tumor cells drain.

Imaging can help your doctor determine the location and extent of the tumor, how it relates to major structures in the head and neck and in some cases evidence of invasion into nerves.

There are a few options for imaging, each with its advantages and disadvantages. In some cases, particularly for large and/or advanced tumors, more than one imaging technique might be used.

The two main techniques are CT scans and MRI scans.

CT SCAN MRI
Advantages A computed tomography (CT) scan is a quick that is readily available and provides a great deal of useful information.A CT scan can help determine the size and extent of a tumor, and it can help a surgeon to plan an operation. Also, it can show a tumor extending outside of the salivary gland and identify destruction of nearby bones. Magnetic resonance imaging (MRI) is better at showing interfaces between the tumor and certain surrounding structures. It can help determine the extent of large tumors, including extension into critical structures at the skull base, including the brain, as well as early spread along nerves. Also, an MRI does not involve radiation exposure.
Disadvantages A CT scan involves radiation, and the images can be degraded by movement and dental work. Also, a CT only shows late changes associated with invasion into nerves (such as destruction of the bone as the nerve enters the skull). An MRI takes a lot longer than a CT scan and requires you to sit perfectly still for almost an hour.You can’t have an MRI if you have certain metal implants in your body.
Important Points A CT scan for salivay gland tumors should be done with contract injected into your veins. An MRI should be done with and without contrast to help the radiologist formulate an accurate diagnosis

There are a number of other tests your doctor might consider, including PET-CT, high-resolution ultrasonography and sialography. The PET-CT is worth discussing a little further.

CT and Positron Emission Tomography (PET-CT): This study is most useful for two main purposes. It is used to see if there is spread of the cancer to other parts of the body. It can also help find the primary tumor if you have a diagnosis of a metastatic salivary gland cancer but your doctor doesn’t know where the first tumor is located. The PET-CT scan is not used often in the initial evaluation of salivary gland cancers because of variability in uptake in different tumors. In some cases, especially for a high-grade or poorly differentiated tumor (one without well-defined edges), your doctor might get PET-CT scans on a routine basis after treatment.

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 lump in your salivary gland (or a mass in your neck).

There are a few different ways to proceed.

  • 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, moving the needle around to get it 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, but it is not always clear which patients should have core biopsies rather than FNA biopsies.27Spiro 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.
  • Open Biopsy: An open biopsy involves making an incision over the tumor and removing a piece or all of the tumor to make a diagnosis. Except in a few special circumstances (such as if the tumor is likely to be a lymphoma), this method is not recommended to diagnose salivary gland cancer.
References

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30 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2014. © National Comprehensive Cancer Network, Inc 2014. All rights reserved. Accessed June 18, 2014. To view the most recent and complete version of the guideline, go online to www.NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.