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Salivary Gland Cancer

Deciding on a Treatment Plan

Like all cancers in the head and neck, there are three general therapeutic treatment options to consider, which may be used alone, together, or one after the other:

The latest National Comprehensive Cancer Network (NCCN®) Clinical Practice Guidelines In Oncology (NCCN Guidelines®) for Head and Neck Cancers will help your doctor recommend the best course of action based on the evidence.30Referenced 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.

 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 guidelines®, there are a few reasons for radiation to be considered and a few cases in which it should definitely be recommended.30Referenced 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.

 

When Should Radiation Be Considered Following Surgery? When Should Radiation Be Recommended Following Surgery?
  • A low grade T1 or T2 tumor in which there was spillage of the tumor during the surgery
  • A low-grade T1 or T2 tumor that has invasion into or around nerves
  • 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 tumor that was not completely removed, and additional surgical resection is not possible
  • 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
    • Invasion into or around nerves
    • Lymph node spread
    • Invasion into lymphatics or vessels

Radiation almost always refers to photon beam radiation, not neutron beam radiation. As of now, neutron beam 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.22Douglas JG, Koh WJ, Austin-Seymour M, Laramore GE: Treatment of salivary gland neoplasms with fast neu- tron radiotherapy. Arch Otolaryngol Head Neck Surg 2003, 129:944–948.

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 cases:23, Rentschler R, Burgess MA, Byers R. Chemotherapy of malignant major salivary gland neoplasms. A 25‐year review of MD Anderson hospital experience. Cancer 2006;40:619-24.24Suen JY, Johns ME. Chemotherapy for salivary gland cancer. The Laryngoscope 2009;92:235-9.

  • Cancer that has spread beyond the head and neck

Chemotherapy combined with radiation should be considered in a few cases

  • 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)
    • Invasion into or around nerves
    • Lymph node spread
    • Invasion into lymphatics or vessels

Chemotherapy combined with radiation is an option in a few cases:

  • A T3 or T4 tumor in which surgery cannot remove all of the tumor
  • Disease that returns (ie, recurrence)
References

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18 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. p. 220–1.

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

23 Rentschler R, Burgess MA, Byers R. Chemotherapy of malignant major salivary gland neoplasms. A 25‐year review of MD Anderson hospital experience. Cancer 2006;40:619-24.

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

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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.