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Cancer Medicine :: Salivary Gland Cancer

Salivary Gland Cancer

Making treatment decisions

After the cancer is found and staged, your cancer care team will discuss treatment options (choices) with you. The options may include surgery, radiation therapy, chemotherapy, or some combination of these. How you are treated depends upon many factors, including the type and stage of the cancer, your overall health, the chances of curing the disease, and the impact of the treatment on functions like speech, chewing, and swallowing.

It is important to take time and think about all of your choices. If time permits, seeking a second opinion from a doctor experienced with salivary gland cancer is often a good idea. It can provide you with more information and help you feel more confident about the chosen treatment plan. Some insurance companies may require a second opinion before they will agree to pay for treatments.

Common treatments for salivary gland cancer include: Surgery, Radiationtherapy, Chemotherapy

Surgery for salivary gland cancer

Surgery is often the main form of treatment for salivary gland cancers. Your cancer will likely be treated with surgery if the doctor believes that he (or she) can remove it completely (the cancer is resectable). Whether or not a cancer is resectable depends largely on how far it has grown into nearby structures, but it also depends upon the skill and experience of the surgeon. Being treated by a surgeon who treats many patients with salivary gland cancer gives you the best chance of having your cancer completely removed with surgery. This, in turn, gives you the best chance of being cured.

In most cases, the cancer and some or all of the surrounding salivary gland will be removed. Nearby areas of soft tissue may be removed as well. If the cancer is high grade (more likely to grow and spread quickly) or if it has already spread to lymph nodes, the surgeon will usually remove lymph nodes from the same side of the neck in an operation called a neck dissection.

Before surgery, ask your surgeon exactly what will be done during the operation, whether there are other options, and what side effects you can expect.

The type of surgery will depend on which salivary gland is affected.

Parotid gland surgery:Most salivary gland tumors occur in the parotid gland. Most parotid gland tumors are benign. Surgery here is complicated by the fact that the facial nerve, which controls movement on the same side of the face, passes through the gland. For these operations, a cut (incision) is made in the skin in front of the ear and may extend down to the neck.

Most parotid gland cancers start in the outside part of the gland, called the superficial lobe. These can be treated by removing only this lobe, which is called a superficial parotidectomy. This usually spares (does not injure) the facial nerve and so does not interfere with facial movement.

If your cancer has spread into deeper tissues, the surgeon will remove the entire gland. This operation is called a total parotidectomy. If the cancer has grown into the facial nerve, it will have to be removed as well. If your surgeon has mentioned this surgery as a possibility, ask about operations to repair the nerve and ways to treat side effects caused by removing the nerve. If the cancer has grown into other tissues near your parotid gland, these tissues might also need to be removed.

Submandibular or sublingual gland surgery:If your cancer is in the submandibular or sublingual glands, the surgeon will remove the entire gland and perhaps some of the surrounding tissue or bone. Several important nerves pass through or near these glands. These nerves control movement of the tongue and the lower half of the face, as well as sensation and taste. Depending on the size and location of the cancer, the surgeon may need to remove some of these nerves.

Minor salivary gland surgery:Minor salivary gland cancers can occur in your lips, tongue, hard and soft palate (roof of the mouth), oral cavity, throat, voice box (larynx), nose, and sinuses. The surgeon usually removes some surrounding tissue along with the cancer. The exact details of surgery depend on the size and location of the cancer.

Possible risks and side effects of salivary gland surgery:With any salivary gland cancer surgery, the surgeon may need to cut through your skin or your mouth. You may have problems with anesthesia or with wound healing, infections, or excessive bleeding during or after surgery. Most people will have some pain for a time after the operation, although this can usually be controlled with medicines.

If your facial nerve is damaged during surgery, you may lose control of your facial muscles on the side where the surgery was done. That side of your face may droop. Damage to other nerves may cause problems with speech or swallowing. If the injury to the facial nerve is related to retraction (pulling) of the nerve during surgery and/or swelling from the operation, the weakness may just be temporary.

Sometimes, nerves cut during surgery grow back abnormally and become connected to the sweat glands of the face. This condition, called Frey syndrome or gustatory sweating, results in flushing or sweating over areas of your face when you chew. Frey syndrome can be treated with medicines or with additional surgery.

Depending on the extent of the operation needed, your appearance may be changed as a result of surgery. This can range from a simple scar on the side of the face or neck to more extensive changes if nerves, parts of bones, or other structures need to be removed. It's important to talk with your doctor before the surgery about what these changes might be to help prepare you for them. He or she can also give you an idea about what options might be available afterward, such as reconstructive surgery.

Lymph node removal:Surgery to remove lymph nodes is called a lymph node dissection or lymphadenectomy. Salivary gland cancers sometimes spread to lymph nodes in the neck (cervical lymph nodes), and these may need to be removed as a part of treating the cancer. This is called a neck dissection. If lymph nodes in the neck are enlarged or if a PET scan suggests they may contain cancer, then a neck dissection may be done to be sure all of the cancer is removed. The lymph nodes that are removed are looked at under the microscope to see if they really contain cancer cells. This information is important for staging and deciding on the need for further treatment. A lymph node dissection may also be done if the cancer is high grade (looks very abnormal under the microscope) and has a high risk of spread.

There are many types of neck dissections, but their major purpose is to remove lymph nodes that might contain cancer. In doing this, the surgeon may need to remove connective, muscle, and nerve tissues, and blood vessels from one side of your neck.

Possible side effects:The general risks with a neck dissection are similar to those with any other type of surgery, including problems with anesthesia, bleeding, infections, and poor wound healing. Because this surgery can affect nerves that run through the neck, it can sometimes lead to ear numbness, weakness in raising your arm above your head, and weakness of the lower lip. These may get better with time. You can be helped by physical therapists who can teach you exercises to improve your neck and shoulder movement.

Radiation therapy for salivary gland cancer

Radiation therapy uses high-energy x-rays or particles to destroy cancer cells or slow their rate of growth.

Radiation therapy may be used:

As the main treatment (alone or with chemotherapy) in some cases of salivary gland cancer that cannot be removed by surgery because of the size or location of the tumor or if a person is in poor health

After surgery (alone or with chemotherapy) as an adjuvant (additional) treatment to try to kill any cancer cells that may have been left behind (but were too small to be seen) if the tumor is thought to have a high chance of recurring (coming back)

In people with advanced salivary gland cancer to help with symptoms such as pain, bleeding, or trouble swallowing

External beam radiation therapy, which focuses radiation from outside the body on the cancer, is the type of radiation therapy used most often to treat salivary gland cancer.

The treatment is much like getting an x-ray, but the radiation is more intense. The procedure itself is painless. Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. This may take a couple of hours or more on the first visit. After this, each daily treatment lasts only a few minutes, but the setup time -- the time to get you into place for treatment -- usually takes a bit longer. Most often, radiation treatments are given 5 days a week for 6 or 7 weeks.

In recent years, doctors have found that newer forms of radiation therapy may be more effective than the standard treatment. One approach is to give radiation twice a day over a shorter total length of time. This is known as accelerated hyperfractionated radiation therapy.

Doctors can now use 3-dimensional images (taken by CT or MRI scans) and computers to figure out how best to aim radiation at the cancer while limiting the radiation to normal tissues. This seems to lower side effects. Three-dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) are examples of this highly-focused approach to treatment.

Another approach is to use a special type of radiation known as fast neutron beam radiation. Instead of using x-rays, neutron radiation therapy uses a beam of high-energy neutrons. Neutrons are electrically neutral particles that can be found in many atoms. Some studies have suggested that this type of radiation may be more effective, but it may also lead to more side effects. Neutron therapy machines are available in only a handful of cancer centers in the United States at this time.

Possible side effects:External beam radiation may cause sunburn-like skin changes, nausea, vomiting, and fatigue. Often these go away after treatment.

Radiation therapy of the salivary glands can cause specific problems, because several important structures in the head and neck may also get some radiation during treatment. The most common side effect from radiation to the salivary glands is reduced production of saliva, which can lead to a dry mouth (see below). Radiation can also cause a temporary sore throat, sores in the mouth and throat, hoarseness, trouble swallowing, temporary partial or complete loss of taste, bone pain, and bone damage. Radiation can also make tooth problems worse. Most doctors advise that you have your teeth checked by a dentist prior to radiation therapy to the head or neck area. In some cases, the dentist may even recommend removing some teeth before treatment to lessen the chance you will have problems later.

For most major salivary gland cancers, radiation is only given to the side of the face and neck with the cancer, which reduces the risk of serious long-term side effects. But in rare instances, it may be necessary to treat both sides of your face and neck with radiation. This may damage other salivary glands, resulting in a permanently dry mouth. Dry mouth often causes problems with eating and swallowing and can lead to tooth decay.

Some of the damage to the salivary glands may be lessened if a drug called amifostine (Ethyol®) is given before each radiation treatment. This drug can be hard to tolerate, so it is not appropriate for everyone.

Radiation therapy may also damage your thyroid gland. It can take months or even years before the thyroid stops putting out enough thyroid hormone. Tests of thyroid function will be done during follow up (after treatment is complete). Some patients later need to take pills to replace thyroid hormone.

It is important to discuss the possible side effects of radiation therapy with your doctor before starting treatment, and to make sure everything is being done to try to limit these side effects as much as possible. If you do have side effects, there are ways to relieve many of them, so it is important to discuss your symptoms with your cancer care team.

Chemotherapy for salivary gland cancer

Chemotherapy (chemo) is treatment with anti-cancer drugs that are given into a vein or by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment useful for cancers that have spread beyond the head and neck. Some chemo drugs may also make cancer cells more vulnerable to radiation.

Chemotherapy is not often used to treat salivary gland cancers. Some doctors may use it along with radiation therapy to try to make the radiation more effective, but it's not yet clear how helpful this is. More often, chemo is used in patients whose cancer has spread (metastasized) to distant organs and in patients whose cancers could not be controlled by surgery and radiation therapy. Chemotherapy sometimes shrinks tumors when used in these patients, but it is not likely to cure this type of cancer.

Doctors give chemo in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Chemotherapy cycles generally last about 3 to 4 weeks. Chemotherapy is often not recommended for patients in poor health, but advanced age by itself is not a barrier to getting chemo.

Some of the chemo drugs used to treat salivary gland cancers include: Cisplatin, Carboplatin,Doxorubicin (Adriamycin®),5-fluorouracil (5-FU),Cyclophosphamide (Cytoxan®),Paclitaxel (Taxol®),Vinorelbine (Navelbine®),Methotrexate

These drugs may be used alone, but are more often used in combinations of 2 or more drugs. Because salivary gland cancers are so uncommon, there are no large studies proving one regimen is better than the others. The situation is also complicated by the fact that there are different types of salivary gland cancers. New chemo drugs and combinations of drugs are currently being studied.

Possible side effects of chemotherapy

Chemo drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, like those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemo, which can lead to side effects.

The side effects of chemo depend on the type and dose of drugs given and the length of time they are taken. These side effects can include: Hair loss,Mouth sores,Loss of appetite,Nausea and vomiting,Increased chance of infections (due to low white blood cell counts),Easy bruising or bleeding (due to low blood platelet counts),Fatigue (due to low red blood cell counts)

These side effects are usually short-term and go away after treatment is finished. There are often ways to lessen these side effects. For example, there are drugs that can be given to help prevent or reduce nausea and vomiting. Be sure to ask your doctor or nurse about medicines to help reduce side effects, and let him or her know when you do have side effects so they can be managed effectively.

Some drugs can have other side effects. For example, cisplatin, carboplatin, and paclitaxel can damage nerves (called neuropathy). This can sometimes lead to hearing loss or symptoms in the hands and feet such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. In most cases this improves or goes away once treatment is stopped, but it may be long lasting in some people. You should report this, as well as any other side effects or changes you notice while getting chemotherapy, to your medical team so that they can be treated promptly. In some cases, the doses of the chemotherapy drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

Treatment options by stage of salivary gland cancer

The treatment options for salivary gland cancer depend largely on the stage (extent) of the cancer, as well as the grade of the cancer (how likely it is to grow and spread quickly) and other factors.

Stage I:If you have stage I salivary gland cancer, your doctors will probably recommend surgery to remove the cancer and part or all of the salivary gland.

Adjuvant radiation therapy may be recommended after surgery if you have an intermediate- or high-grade cancer or an adenoid cystic carcinoma, if the cancer could not be completely removed, or if the edges of the removed specimen contain cancer cells (indicating that some cancer may have been left behind).

Stage II:Stage II salivary gland cancers are larger but are still confined within the salivary gland. They are also treated mainly with surgery, but it may be more extensive (covering a wider area) than for stage I cancers. The surgeon may also remove lymph nodes in your neck on the same side to see if they contain cancer.

Radiation therapy may be given after surgery if your cancer is intermediate or high grade, if the cancer could not be completely removed, or if the edges of the removed specimen contain cancer cells. There is a greater chance that some cancer may have been left behind with stage II cancers.

Stage III:These cancers are even larger and/or have started to grow outside of the salivary gland. Doctors generally recommend more extensive surgery (removing the gland containing the tumor, nearby tissues, and all lymph nodes in your neck on the same side) for these cancers if it is possible, combined with radiation therapy. Chemotherapy (chemo) may be added as well, but this is still being studied.

Radiation therapy (with or without chemo) may be used as the main treatment if surgery is not a good option (for example, if surgical removal of the cancer would cause serious problems with your eating, speech, or appearance).

Stage IV:Because of the size and extent of spread of stage IV salivary gland cancer, cure is usually not possible, particularly if the cancer has spread to distant organs. Radiation therapy to the head and neck is often used as the main treatment in this situation to try to shrink the tumor(s) and relieve pain, bleeding, or other symptoms from the cancer. This may be combined with chemo. If you have metastases, chemo may shrink or slow the growth of the cancer for a time and may help relieve your symptoms.

These cancers can be hard to treat effectively, so taking part in a clinical trial of newer treatments may be a good option.

Recurrent salivary gland cancer

Cancer is called recurrent when it comes back after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or liver). If your cancer returns after treatment, the choices available to you depend on the location and the extent of the cancer and what treatment was used the first time around. It is important to understand the goal of any further treatment -- whether it is to try to cure the cancer or to help relieve symptoms -- as well as the likelihood of benefits and risks.

If the cancer is thought to be resectable (able to be completely removed with surgery), surgery is usually the treatment of choice when possible. This is often followed by radiation therapy if it wasn't given before.

If the cancer returns in the area where it started but is not resectable, radiation therapy may be an option. Chemotherapy (chemo) may be used along with the radiation or by itself (especially if radiation therapy was already used as part of the initial treatment).

Cancers that recur in distant parts of the body are usually treated with chemo. In selected cases, other treatments such as surgery or radiation therapy may be used to help relieve symptoms from the spread of the cancer. Because these cancers can be hard to treat, clinical trials of newer treatment approaches may be a good option.

What happens after treatment for salivary gland cancer?

For some people with salivary gland cancer, treatment may remove or destroy the cancer. Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer coming back. (When cancer comes back after treatment, it is called recurrence.) This is a very common concern in people who have had cancer.

It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are living full lives.

For other people, the cancer may never go away completely. These people may get regular treatments with chemotherapy, radiation therapy, or other therapies to try to help keep the cancer in check. Learning to live with cancer that does not go away can be difficult and very stressful. It has its own type of uncertainty. 

Follow-up care

When treatment ends, your doctors will still want to watch you closely. It is very important to go to all of your follow-up appointments. During these visits, your doctors will ask questions about any problems you may have and may do exams and lab tests or x-rays and scans to look for signs of cancer or treatment side effects. Almost any cancer treatment can have side effects. Some may last for a few weeks to months, but others can last the rest of your life. This is the time for you to talk to your cancer care team about any changes or problems you notice and any questions or concerns you have.

Most doctors recommend follow-up exams every few months for the first year after treatment, then every 2 to 6 months for the next year, and less frequently after that. If you had radiation therapy to the neck, your doctor will likely want to get blood tests as well to check your thyroid function.

Imaging tests such as CT scans may be done after treatment to get a baseline idea of what the head and neck area look like. Further imaging tests may be done if you later develop any signs or symptoms that might be due to a return of the cancer.

You may be advised to see your dentist after treatment to check on the health of your teeth. Your doctor will also want to keep a close eye on your hearing, speech, and swallowing, which can be affected by treatment. If you are having problems with any of these, your doctor may refer you to a therapist for help with rehabilitation.

It is important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

Your appearance and other changes

Surgery or other treatments can affect nerves and other structures in the face and neck. This can affect how you look and may have an impact on other functions such as speech and swallowing.

These issues can often be addressed after treatment has ended. Many surgical and non-surgical techniques can be used to correct these problems. For example, if you are having problems with speech or swallowing, your doctor may refer you to a physical or speech therapist.

Talk with your doctor or nurse about any other problems you are having. There are also groups that can provide support and help teach you how to manage any lingering problems you may have. 

If treatment for salivary gland cancer stops working

If cancer keeps growing or comes back after one kind of treatment, it is possible that another treatment plan might still cure the cancer, or at least shrink it enough to help you live longer and feel better. But when a person has tried many different treatments and the cancer has not gotten any better, the cancer tends to become resistant to all treatment. If this happens, it's important to weigh the possible limited benefits of a new treatment against the possible downsides. Everyone has their own way of looking at this.

This is likely to be the hardest part of your battle with cancer -- when you have been through many medical treatments and nothing's working anymore. Your doctor may offer you new options, but at some point you may need to consider that treatment is not likely to improve your health or change your outcome or survival.

If you want to continue to get treatment for as long as you can, you need to think about the odds of treatment having any benefit and how this compares to the possible risks and side effects. In many cases, your doctor can estimate how likely it is the cancer will respond to treatment you are considering. For instance, the doctor may say that more chemo or radiation might have about a 1% chance of working. Some people are still tempted to try this. But it is important to think about and understand your reasons for choosing this plan.

No matter what you decide to do, you need to feel as good as you can. Make sure you are asking for and getting treatment for any symptoms you might have, such as nausea or pain. This type of treatment is called palliative care.

Palliative care helps relieve symptoms, but is not expected to cure the disease. It can be given along with cancer treatment, or can even be cancer treatment. The difference is its purpose - the main purpose of palliative care is to improve the quality of your life, or help you feel as good as you can for as long as you can. Sometimes this means using drugs to help with symptoms like pain or nausea. Sometimes, though, the treatments used to control your symptoms are the same as those used to treat cancer. For instance, radiation might be used to help relieve bone pain caused by cancer that has spread to the bones. Or chemo might be used to help shrink a tumor and keep it from blocking the bowels. But this is not the same as treatment to try to cure the cancer.

At some point, you may benefit from hospice care. This is special care that treats the person rather than the disease; it focuses on quality rather than length of life. Most of the time, it is given at home. Your cancer may be causing problems that need to be managed, and hospice focuses on your comfort. You should know that while getting hospice care often means the end of treatments such as chemo and radiation, it doesn't mean you can't have treatment for the problems caused by your cancer or other health conditions. In hospice the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult time. You can learn more about hospice in our document called Hospice Care.

Staying hopeful is important, too. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends -- times that are filled with happiness and meaning. Pausing at this time in your cancer treatment gives you a chance to refocus on the most important things in your life. Now is the time to do some things you've always wanted to do and to stop doing the things you no longer want to do. Though the cancer may be beyond your control, there are still choices you can make.

What`s new in salivary gland cancer research and treatment?

Many medical centers across the nation are doing research on the causes and treatment of salivary gland cancer. This is a challenging disease to study because it is not common and there are many types of salivary gland cancer. But each year, scientists find out more about what causes the disease and how to improve treatment.

Biology of salivary gland cancers

Recent studies have found certain consistent changes in chromosomes and genes of various types of salivary gland cancers. Researchers are learning more about how these changes cause salivary gland cells to become malignant. They have found that in some salivary gland cancer cells, 2 chromosomes have swapped parts of their DNA. This is known as a translocation. These changes often cause activation of genes that control cell growth. For example, adenoid cystic carcinomas often have translocations involving chromosomes 6 and 9; in mucoepidermoid carcinomas, the translocations usually involve chromosomes 11 and 19.

As scientists learn more about these and other DNA, RNA, and protein changes in salivary gland cancers, they hope to use this information to develop new treatments for salivary gland cancers that are more effective and cause fewer side effects.

Treatment

Surgery:Advances in surgical techniques now allow teams of head and neck surgeons and neurosurgeons to remove cancers that have spread near the base of the skull. These operations were not thought possible a few years ago but are becoming more common and successful.

Reconstructive surgery is becoming more sophisticated and successful. This permits more extensive surgery to be done and improves patients' quality of life after treatment.

Radiation therapy:Advances in radiation therapy now permit more precise targeting of radiation. Some types of radiation, such as fast neutron beam radiation have been found to be particularly useful, but they require specialized equipment that is not available in many hospitals.

Chemotherapy:Advanced salivary gland cancer is rare, so knowledge about treating these cancers with chemotherapy (chemo) is still evolving. Chemo drugs such as gemcitabine, capecitabine, and oxaliplatin are now being tested in clinical trials and may provide more options for people with advanced salivary gland cancer.

Targeted therapy:As researchers have learned more about the changes in cells that cause cancer, they have been able to develop newer drugs that specifically target these changes. These targeted drugs work differently than standard chemotherapy drugs. They often have different (and less severe) side effects.

Studies of salivary gland cancer have identified changes in several proteins that promote growth and spread of cancer cells. Some of these changes are more common in particular forms of salivary gland cancer and some affect proteins that can be blocked by targeted therapies that are active against cancer of some other organs. This information is being used to guide clinical trials of targeted therapies for salivary gland cancers and to develop new targeted drugs.

One drug, imatanib (Gleevec®), has shown some promise in treating advanced salivary gland cancers when combined with the chemo drug cisplatin. Studies of other targeted drugs are ongoing.

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