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Salivary Gland Cancer

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If an adult in your life has salivary gland cancer, you may want to understand more about it. This page contains information about salivary gland cancer and what you can expect to happen.

First, you should understand what salivary gland cancer is. Cancer is a disease of unhealthy cells. Our bodies are made up of cells so tiny you need a microscope to see them. Cancer cells don’t look or act like normal cells, and they don’t allow our normal cells to work properly. There are many different types of cancer, and it can grow anywhere in the body.1 What is cancer? National Cancer Institute. http://www.cancer.gov/cancertopics/cancerlibrary/what-is-cancer.

Salivary gland cancer begins in the salivary glands of the mouth, cheek, neck or throat. Salivary glands release saliva (spit) into your mouth and throat to help digest food and protect against infection.

Your loved one may have noticed a lump or swelling in his or her salivary gland and brought it to the attention of a doctor. Not every lump or bump is cancer, but it is a good idea to ask a doctor when you are not sure. The earlier cancer is found, the better the outcome can be.

Understanding the anatomy

In order to understand salivary gland cancer, you need to have a basic understanding of the anatomy (parts) of your head and neck. There are different types of salivary glands, including major and minor salivary glands.

Major Salivary Glands Minor Salivary Glands
 
21_glands
               
14_minor_glands
The major salivary glands are called “major” because they are big. Each one has its own single tube (or duct) that leaves the gland and opens into the mouth to deposit saliva. There are three major salivary glands on each side of the face and neck. The minor salivary glands are found all over the mouth and throat. They are called “minor” because they are much smaller.

The biggest salivary gland is called the parotid gland. Most salivary gland cancers (80 percent) are found in the parotid gland.2 Califano J, Eisele DW. Benign salivary gland neoplasms. Otolaryngologic clinics of North America. 1999;32:861.

Causes of salivary gland cancer

You may want to know what caused your loved one’s salivary gland cancer. The short answer is that we don’t know. Most cancers in the head and neck are caused by drinking too much alcohol and smoking. However, salivary gland cancers do not seem to be caused by these bad habits. You can be sure that there is nothing you did to cause it. Also, it is not contagious, so you can’t catch it.

In most cases of salivary gland cancer, there is no clear cause. There are a few factors that may raise the risk, though. These include radiation, viruses, workplace environment and hormones.

Radiation: Radiation is energy that travels in the form of particles (small bits of matter) or waves. Most kinds of radiation aren’t dangerous. Dangerous radiation comes from nuclear power, nuclear weapons and medical sources such as X-ray machines or cancer treatments. Being around high levels of radiation for a long time raises the risk of developing salivary gland cancer. For example, scientists have studied survivors of the atomic bombs that were dropped on Hiroshima and Nagasaki, cities in Japan, during World War II. The people there were exposed to very high levels of radiation. Their risk of developing salivary gland cancer is up to eleven times higher than for people who were not exposed to such a high level of radiation.2 Califano J, Eisele DW. Benign salivary gland neoplasms. Otolaryngologic clinics of North America. 1999;32:861.

Microwaves and cellular telephones do not seem to raise the risk of cancer of the salivary glands.3, 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;93:203-7.4 Auvinen A, Hietanen M, Luukkonen R, Koskela RS. Brain tumors and salivary gland cancers among cellular telephone users. Epidemiology. 2002;13:356.

Viruses: Viruses are germs that cause illness. A few viruses may raise the risk of salivary gland cancer, but we are not certain. Viruses such as HIV-1, HPV types 16 and 18, polyomavirus and Epstein-Barr virus might be related.5, Atula T, Grenman R, Klemi P, et al. Human papillomavirus, Epstein-Barr virus, human herpesvirus 8 and human cytomegalovirus involvement in salivary gland tumours. Oral Oncol. 1998;34:391–395.6 Sun EC, Curtis R, Melbye M, et al. Salivary gland cancer in the United States. Cancer Epidemiol Biomarkers. 1999;Prev 8:1095-1100.

Workplace environment: Chemicals and other substances that are present in the place where a person works may raise the risk of salivary gland cancer. People who work in manufacturing, plumbing, hairdressing and the auto industry may be at greater risk than others.6, Sun EC, Curtis R, Melbye M, et al. Salivary gland cancer in the United States. Cancer Epidemiol Biomarkers. 1999;Prev 8:1095-1100.7 Horn-Ross PL, Ljung BM, Morrow M. Environmental factors and the risk of salivary gland cancer. Epidemiology. 1997:414-9.

Hormones: Hormones are your body’s chemical messengers.8 Hormones. MedlinePlus. http://www.nlm.nih.gov/medlineplus/hormones.html. Researchers believe there may be a link between hormones and the risk of salivary gland cancer. The results of their research are not yet clear.

Signs and symptoms of salivary gland cancer

The most common sign of possible salivary gland cancer is a lump on the face, neck or somewhere in the mouth or throat.9 Perzin KH, Livolsi VA. Acinic cell carcinoma arising in ectopic salivary gland tissue. Cancer. 1980;45:967-72. It is not possible to say whether the lump is cancer, though, without looking at a piece of it (a biopsy) under a microscope. Some symptoms that mean it might be cancer include:

  • Numbness or tingling in the face, mouth or tongue
  • Pain that keeps getting worse in a specific area
  • Weakness of the muscles of the face or tongue
  • Difficulty opening the mouth
  • Unexplained bleeding from the mouth (or rarely even from an ear in certain cases)
  • Another lump somewhere in the neck, away from a salivary gland lump

What will happen at the doctor visit

Step 1: History

First, the doctor will listen to your loved one talk about his or her health. The doctor will probably ask many questions, too.

The doctor might ask some of these questions:

  • How long has the lump been there?
  • Is it growing, and if so, how quickly?
  • Does it come and go?
  • Is it painful?
  • Do you have numbness or tingling anywhere in your face?
  • Have you ever been exposed to high levels of radiation in your head and neck?
  • Do you have a family history of cancer?
  • Have you been treated for any other cancers, including skin cancer?

Step 2: Physical Exam

Next, the doctor will look at and feel your loved one’s head and neck. There are a few “red flags” (danger signs) the doctor will be looking for. These raise the likelihood that a lump is actually cancer.

Some of these “red flags” include:

  • There is weakness in the face on the side of the lump.
  • The lump is attached to the skin on top of it.
  • The skin inside the mouth has a sore or looks different from the skin around it.
  • There is numbness or tingling in certain parts of the face.
  • The inside of the ear canal has a sore or lump.10Mehanna H, McQueen A, Robinson M, Paleri V. Salivary gland swellings. BMJ. 2012 Oct 23;345-352.

The doctor will also check the facial nerve by having the patient move his or her face. This is a test to see if the cancer has grown into the nerve. Nerves are important because they control muscle movements and feeling in the face.11 Wierzbicka M, Kopeć T, Szyfter W, Kereiakes T, Bem G. The presence of facial nerve weakness on diagnosis of a parotid gland malignant process. European Archives of Oto-Rhino-Laryngology. 2012:1-6.

Step 3: Reviewing Tests

After getting background information and doing a physical exam, the doctor will look at the results of any tests your loved one has already had.

Step 4: Suggestions

Finally, the doctor will make suggestions about next steps. This will probably include more tests and doctor visits.

Diagnosing salivary gland cancer

If the patient has a lump with any “red flag” symptoms, the doctor will be concerned that it might be salivary gland cancer. In order to check if it is actually cancer, the doctor will choose one or more of the following actions.

Removal

Most growths in the salivary glands are not actually cancer. Salivary gland tumors, whether they are cancer or not, should usually be removed. Therefore, some doctors will decide to do surgery to take out any tumors without doing more tests. In the operating room, the surgeon can see the whole tumor and learn more about it. The surgeon can then send whatever he removed to be tested. Another doctor, called a pathologist, will look at the cells under a microscope to decide if the tumor is cancer.

Imaging

Imaging refers to radiologic studies, or scans, that take pictures of the structures inside the head and neck. In general, imaging might not be necessary for small tumors that can be easily seen by the doctor. For larger tumors, or tumors in locations difficult to examine, the doctor will probably order some sort of imaging to get more information about the tumor location and to see if the tumor has spread to nearby lymph nodes. An important reason to get a scan for sinonasal tumors is to see if there is any evidence of spread into nearby structures. Spread into other structures will influence what treatment the doctor recommends.

Some surgeons also say getting imaging (pictures of the inside of the head and neck) will lower the chance of surprises in the operating room. Imaging will also give some clues about whether the tumor is really cancer. This will prepare the patient and the surgeon for what to expect during surgery.

There are many different kinds of imaging scans. The doctor may recommend more than one kind of scan to see a better picture of the tumor.

The two main types of imaging used in the U.S. are CT scans and MRI scans.

CT SCAN MRI
 CT Scan  MRI
Advantages A computed tomography (CT) scan is a quick test that shows a great deal of useful information. A CT scan can show the size of the tumor and how far it has spread. It can help a surgeon plan an operation. Magnetic resonance imaging (MRI) is better at showing how the tumor has spread to body parts around it. The patient will not be exposed to radiation during an MRI.
Disadvantages A CT scan does use radiation. The pictures might not be clear if your parent moves or has a lot of dental work. Also, a CT only shows later (worse) damage from the tumor spreading to nearby body parts. An MRI takes a lot longer than a CT scan. It requires the patient to sit perfectly still for almost an hour. The patient can’t have an MRI if he or she has metal implants.

For most head and neck cancers, if imaging is required, the doctor will likely start with a CT scan with contrast. Other tests might include an MRI and/or a positron emission tomography (PET) scan.

CT and Positron Emission Tomography (PET-CT): A PET-CT is useful for two reasons. It is used to see if the cancer has spread to other parts of the body. It can also help find the first tumor if the cancer has already spread. The PET-CT scan is used more often after treatment.

Biopsy

A biopsy is the main way to find out if a growth is cancer. For a biopsy, the doctor takes out a small piece of the lump or the entire tumor. Another doctor, called a pathologist, then looks at the sample under a microscope to see if it is cancer. Doctors often do biopsies because they can usually be done quickly and safely. The doctor can sometimes do a biopsy during the first visit and there is a very low chance of anything going wrong.

Some tumors can be biopsied in the office with a little numbing medicine (either a spray, or a tiny injection or both). It usually takes only a few seconds to do the biopsy.

In some cases, however, the doctor may want to do the biopsy in the operating room, especially if there is concern about involvement into the neck or throat.

A biopsy can help the doctor plan the surgery if the decision is to take out the whole tumor. A biopsy can also prevent unnecessary surgery.

As good as biopsies sound, there are a few problems. First, biopsies are not 100 percent accurate. A biopsy could show that a growth is NOT cancer when it really is; this is called a false-negative biopsy. A false-positive is also possible when the biopsy seems to show that a growth is cancer but more testing shows it isn’t. Sometimes doctors can’t be sure from a biopsy.12Iro H, Waldfahrer F. Evaluation of the Newly Updated TNM Classification of Head and Neck Carcinoma with Data From 3247 Patients. Cancer. 1998;83:2201-7.

Determining the type of salivary gland cancer

After the tumor has been closely looked at, the doctor will need to figure out what type of cancer it is. He or she may be able to tell from biopsy results. The doctor may also want a second opinion from a specialist to be sure. Remember, not all lumps and bumps in the neck are cancer. Most growths are benign (non-cancerous), and some tumors are on the borderline between benign and malignant (cancerous).

Salivary gland cancer types are among the most difficult to diagnose. They are extremely rare and often very complicated.

There are four categories of salivary gland cancers.

  • Epithelial tumors form in the surface layer of the glands. These are the most common types of salivary gland cancer.
  • Soft tissue tumors form deeper in the salivary glands.
  • Blood and lymphatic cancers are in the blood and lymph systems. These are both circulatory, which means they move fluids around the body. Blood and lymphatic cancers are called lymphomas.
  • Metastatic tumors are cancer that has spread to the salivary glands from somewhere else in the body.14 Agulnik M, McGann CF, Mittal BB, Godon SC, Epstein JB. Management of salivary gland malignancies: current and developing therapies. Oncol Rev. 2008;2:86-94.

The doctor will determine the treatment for the cancer based on the category (type), grade (abnormality) and stage (severity) of the tumor.

Determining the grade of the tumor

The doctor will also decide the grade of your loved one’s tumor. A tumor can be low grade, intermediate grade or high grade, based on the level of risk. Knowing the grade of the tumor will help the doctor to decide how best to treat the cancer.

Some types of tumors are easy to grade because they almost always have a lower or higher risk compared to other types. Doctors can look up the outcomes for many past patients with the same kind of tumor. They can use that information to make an informed decision about risk based on results for those other patients. However, sometimes grading a tumor can be a bit more difficult. A type of tumor that is usually low-grade can occasionally be of higher-risk and a tumor that is usually high-grade can actually be low-risk. If this is the case, the doctor who looks at the tumor after it is removed will note this on the report, and the treatment plan will be adjusted.

Determining the stage of the cancer

The final step before treatment is identifying the stage or the extent of the cancer. This will be determined by the physical exam, imaging studies, laboratory work and biopsies.

As with all cancers of the head and neck, doctors in the U.S. use the AJCC Cancer Staging Manual (7th Ed) to figure out the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

Note that minor salivary gland cancers fall into the staging system based on where they are located. This means that if the cancer is inside the mouth, the stage will follow the rules in the oral cavity cancer section.

T stage: the main tumor

Based on a physical examination and review of any imaging, the doctor should be able to assign a T stage that falls within one of the following categories.

25_parotid_Tstages

Tx The doctor knows it’s a salivary gland cancer but doesn’t know where the first tumor is.
T0 There is no evidence of the first tumor, despite looking everywhere.
T1 The tumor is 2 centimeters or less in its widest part. It does not appear to be growing outside of the gland.
T2 The tumor is more than 2 centimeters but less than or equal to 4 centimeters in its widest part. There is no obvious growth outside of the gland.
T3 Either the tumor is more than 4 centimeters in its widest part, OR the tumor is of any size but is clearly growing outside of the gland.
T4a This is moderately advanced disease. The tumor has clearly grown into the skin, jawbone, ear canal or facial nerve (that is, the face doesn’t move properly).
T4b This is very advanced disease. The tumor is growing into the skull base (bones below the brain) or pterygoid plates (bones deep in the middle of the head) and/or surrounds the carotid artery (the main blood supply to one half or both sides of the brain).

N stage: spread of cancer to the lymph nodes in the neck

Next, the doctor will use all the available information to figure out the N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

06_Nstages

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the lymph nodes.
N1 The cancer has spread to a single node, on the same side of the main tumor, that is 3 centimeters or less in greatest size.
N2a Cancer has spread to a single lymph node, on the same side as the main tumor, and it is more than 3 centimeters but less than or equal to 6 centimeters in its greatest size.
N2b There are multiple lymph nodes that have cancer on the same side as the main tumor, But none  are more than 6 centimeters in size.
N2c There are cancerous lymph nodes in the neck on either the opposite side as the main cancer or on both sides of the neck, but none are more than 6 centimeters.
N3 The cancer has spread to one or more neck lymph nodes. The size is greater than 6 centimeters.

M stage: spread of cancer outside the head and neck

Finally, the doctor will identify an M stage. The M stage is based on an examination of the entire body.

M0 No evidence of spread outside the head and neck.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.)

The cancer stage

After TNM staging, the doctor can assign a cancer stage based on the following chart.

Stage I TI N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVB T4b AnyN M0
AnyT N3 M0
Stage IVC AnyT AnyN M1

The clinical stage

After TNM staging, the doctor can assign a cancer stage based on the following chart.

CLINICAL STAGE
Example
Site Major Salivary Gland
Subsite Parotid
Type Mucoepidermoid
Grade Low grade
cT cT2
cN cN0
cM cM0
cStage cIII

* The lower-case subscript c indicates that this is a CLINICAL STAGE, the stage assigned based on all information available to the doctor before starting treatment.

After surgery, your loved one should get a pathologic stage. The pathologic stage is more accurate than the clinical stage because a doctor will have looked at the actual tumor that the surgeon removed.

The pathologic stage may look something like this:

PATHOLOGIC STAGE
Example
Site Major Salivary Gland
Subsite Parotid
Type Mucoepidermoid
Grade High grade
pT pT3
pcN pN0
pcM pM0
pcStage pIII

* The lower-case subscript p indicates that this is a PATHOLOGIC STAGE, the stage assigned after tumor removal and confirmation of cancer by a pathologist.

Deciding on a treatment plan

Like all cancers in the head and neck, there are three general treatment options:

Let’s look at the types of treatments available.

Surgery

The main treatment for almost all salivary gland cancers is complete surgical removal of the tumor. The surgeon will cut out the tumor plus a little bit of normal tissue around it to be sure he or she gets all the cancer. Another doctor, called a pathologist, will look at the entire tumor under a microscope to identify a more exact stage for the tumor. This report, called the pathologic stage, can help the doctor decide if radiation and/or chemotherapy are needed.

Radiation

Radiation therapy kills cancer cells with high-energy radiation such as X-rays or gamma rays.15 Radiation therapy for cancer. National Cancer Institute. http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation. Radiation may be used as a main treatment for tumors that cannot be easily removed. The surgeon will use radiation alone or radiation with chemotherapy, depending on the characteristics of the tumor. Radiation is also often used after surgery to lower the chances that the tumor will come back.

Chemotherapy

Chemotherapy, or “chemo,” uses drugs to kill cancer cells. Unfortunately, it does not seem to work very well in salivary gland cancers. In general, it may help control distressing symptoms. The problem is that there are no well-designed studies that have been able to see how effective chemotherapy is for salivary gland patients.

Still, chemotherapy should be considered in a few cases16, Rentschler R, Burgess MA, Byers R. Chemotherapy of malignant major salivary gland neoplasms. A 25‐year review of MD Anderson hospital experience. Cancer. 2006;40:619-24.17 Suen JY, Johns ME. Chemotherapy for salivary gland cancer. The Laryngoscope. 2009;92:235-9.:

  • 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
  • There are close margins (meaning that when the tumor was removed, some cancer cells near the edge of the tumor may have been left behind).
  • Growth into nerves
  • Spread into lymph nodes
  • Growth into lymphatics or vessels

Determining the prognosis

The prognosis is a prediction of how the treatment will turn out. How likely is it that your loved one will be cured? Will the cancer come back? How will your loved one’s life change? These are the big questions on most people’s minds when they find out that someone they love has salivary gland cancer.

Stage This is the most important factor that affects your loved one’s chances of being cured.
Site Major salivary gland cancers have a better prognosis than minor salivary gland cancers.
Type and Grade The stage of the cancer is based on the type and grade of tumor.
Spread to Lymph Nodes If there is spread to lymph nodes in the neck, there is a lower chance of cure.
The Tumor Margins The ability to completely remove the tumor is the single most important factor that will indicate whether your loved one will be cured.
Spread into Local Structures Spread into large nerves, skin and bone has been shown to indicate a worse prognosis.18 Wierzbicka M, Kopeć T, Szyfter W, Kereiakes T, Bem G. The presence of facial nerve weakness on diagnosis of a parotid gland malignant process. European Archives of Oto-Rhino-Laryngology. 2012:1-6.

In general, it is very difficult to discuss prognosis without understanding all the details of the cancer; to give a percentage chance of cure is really difficult because cancer research looks at all sorts of different types of cancers and may include patients from long ago.

What to expect after treatment is completed

After making it through treatment, your loved one will need to follow up closely with the doctor. Follow-up doctor visits and testing are to make sure the cancer doesn’t come back or to catch it quickly if it does. In general, your loved one should have regularly scheduled doctor’s visits every one to three months for the first year, every two to six months in the second year and every four to eight months in the third to fifth year. After the first five years, your loved one can then see the doctor once a year.


References

1 What is cancer? National Cancer Institute. http://www.cancer.gov/cancertopics/cancerlibrary/what-is-cancer.

2 Califano J, Eisele DW. Benign salivary gland neoplasms. Otolaryngologic clinics of North America. 1999;32:861.

3 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.

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

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

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

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

8 Hormones. MedlinePlus. http://www.nlm.nih.gov/medlineplus/hormones.html.

9 Perzin KH, Livolsi VA. Acinic cell carcinoma arising in ectopic salivary gland tissue. Cancer. 1980;45:967-72.

10 Mehanna H, McQueen A, Robinson M, Paleri V. Salivary gland swellings. BMJ. 2012 Oct 23;345-352.

11 Wierzbicka M, Kopeć T, Szyfter W, Kereiakes T, Bem G. The presence of facial nerve weakness on diagnosis of a parotid gland malignant process. European Archives of Oto-Rhino-Laryngology. 2012:1-6.

12 Iro H, Waldfahrer F. Evaluation of the Newly Updated TNM Classification of Head and Neck Carcinoma with Data From 3247 Patients. Cancer. 1998;83:2201-7.

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

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

15 Radiation therapy for cancer. National Cancer Institute. http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation.

16 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.

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

18 Wierzbicka M, Kopeć T, Szyfter W, Kereiakes T, Bem G. The presence of facial nerve weakness on diagnosis of a parotid gland malignant process. European Archives of Oto-Rhino-Laryngology. 2012:1-6.