HEALTH CARE

Stanford Head and Neck Center

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Salivary Gland Program

Malignant Salivary Gland Conditions and Treatments

Malignant Neoplasms

Facial Nerve Reconstruction

  • Gold or platinum implant within the upper eyelid
  • Lower eyelid tightening
  • Static lower face sling
  • Masseter transfer to the lower face
  • Temporalis muscle transfer to the lower face
  • Facial nerve grafting

Facial volume restoration post parotidectomy

  • Sternocleidomastoid muscle flap
  • Free flaps
  • Fat grafts
  • Digastric flap
  • Temporalis or temporoparietal flap

Minor Salivary Gland Resection

Malignant Neoplasms

Primary cancers of the salivary gland are uncommon, but not rare.  Just as a benign tumor does, they often present as a painless enlarging mass that may or may not be associated with neck lymph node metastases.  A diagnosis is generally made possible via a fine needle biopsy (FNA).  Imaging (MRI) helps define its extent in the neck. A PET-CT or chest CT may be ordered to assess for distant spread. The stage is defined by the size of the tumor, presence of neck metastases, presence of distant spread (uncommon for most tumors) and whether there is facial weakness. About 20% of parotid tumors are malignant, with higher percentages for children, for the submandibular gland, and for intraoral minor salivary glands.

Types of salivary gland malignancies

Broadly speaking, salivary gland malignancies are grouped into low grade and high grade cancers. Low grade cancers have a very good prognosis, and are often cured with surgery alone.  Long-term follow-up is required need to ensure early intervention should there be a recurrence, which can occur years later.  

The pathologies listed below are among the more common malignancies seen. They may arise from the parotid, submandibular gland or minor salivary glands.  In some instances a cancer in the parotid may have actually spread to an intraparotid lymph node from elsewhere (such as from a facial skin squamous cell carcinoma or a melanoma) or such a metastasis may rarely even arise from farther away. Rarely a tumors may be malignant transformation from a prior benign tumor (as in a carcinoma arising within a prior benign pleomorphic adenoma). 

Low Grade

  • Acinic cell adenocarcinoma
  • Low grade mucoepidermoid carcinoma 
    (some also describe an intermediate grade, which largely behaves similarly)
  • Polymorphous low-grade adenocarcinoma (in palate)
  • Epithelial-myoepithelial carcinoma
  • Adenoid cystic carcinoma

High Grade

  • High grade mucoepidermoid carcinoma
  • Carcinoma-ex pleomorphic adenoma
  • Salivary duct carcinoma
  • Adenocarcinoma

Metastases:

  • Squamous cell carcinoma (a primary  squamous cell carcinoma may theoretically also occur)
  • Melanoma
  • Other metastases

Other:

  • Lymphoma: arising within gland or involve periparotid lymph nodes

Treatment

Intervention usually require surgery as first step. A low grade small malignancy may require only surgery, with surgery as described for benign parotid tumors. If in the submandibular gland, the gland is removed; likely along with upper neck nodes, a procedure with few likely side effects. A neck dissection (removal of nodes in the neck) will be done if nodes are involved in either a parotid or submandibular gland malignancy and may be recommended for some high grade tumors where the nodes are at risk.  

Irradiation after surgery is recommended for larger low grade malignancies (greater than 4 cm.) and all high grade malignant tumors. Irradiation may include the neck nodes on the same side of the malignancy if either there were nodes involved or nodes are at risk for developing metastases. Chemotherapy may play a role as a radiosensitizer or when there is distant spread. Chemotherapy as a radiosensitizer (making the irradiation possibly more effective) may be discussed within a clinical trial.

The Stanford comprehensive multidisciplinary head and neck tumor board meets weekly to review the imaging and pathology of all new patients (and existing patients with new problems). It comprises of members of different specialties with a common clinical focus on head and neck cancers: head and neck surgeons, medical oncologists, radiation oncologists, nutritionists, speech therapists, radiologists, and pathologists.  Individualized treatments options are tailored for each patient, including the applicability of available clinical trials, and are then discussed with each patient.    

As with low grade cancers, long-term follow-up is required need to facilitate consideration of intervention should there be a recurrence in the neck of a distant metastasis.

We treat all salivary cancers, including patients that have failed prior treatments.  In revision parotid cancers that have been previously radiated, intraoperative radiotherapy may be indicated (irradiation to the area of concern done at the time of surgery, such that the skin in not irradiated and critical structures may at times be able to be shielded).

Facial Nerve Reconstruction

Reconstruction after parotid cancer surgery is an important aspect of any cancer operation. The face is important to a person’s identity. Patients with facial nerve paralysis as a result of a high-grade salivary cancer receive facial nerve reconstruction at the time of cancer operation. Facial nerve reconstruction options include:

  • Gold or platinum implant to the upper eyelid
  • Lower eyelid tightening
  • Static lower face sling
  • Masseter transfer to the lower face
  • Temporalis muscle transfer to the lower face
  • Facial nerve grafting

To restore volume loss (cheek hallowing) after parotid surgery, we provide the following reconstructive techniques:

  • Sternocleidomastoid muscle flap
  • Free flaps
  • Fat grafts
  • Digastric flap
  • Temporalis or temporoparietal flap

Minor Salivary Gland Operations (in the oral cavity)

  • Composite resections of high-grade cancers