Salivary Gland Cancer: Staging and Treatment

What is staging for cancer?

Staging is the process of learning how much cancer is in your body and where it is. Tests like biopsy, ultrasound, PET scan, CT, and MRI may be done to help stage your cancer. Your providers need to know about your cancer and your health so that they can plan the best treatment for you.

Cancer staging looks at the size of the tumor and where it is, and if it has spread to other organs. The staging system for salivary gland cancer is called the “TNM system.” It has three parts:

• T-describes the size/location/extent of the "primary" tumor.
• N-describes if the cancer has spread to the lymph nodes.
• M-describes if the cancer has spread to other organs (called metastases).

Your healthcare provider will use the results of the tests you had to determine your TNM result and combine these to get a stage from 0 (zero) to IV (four).

How is salivary gland cancer staged?

Staging for salivary gland cancer is based on:

• The size of your tumor seen on imaging tests and what is found after surgery (if you have had surgery).
• If your lymph nodes have cancer cells in them.
• Any evidence of spread to other organs (metastasis).

Salivary gland cancer has both a pathological and a clinical staging process. If you have had surgery, your cancer will be given a pathological stage. If you have not had surgery, you will be given a clinical stage based on your physical exam, biopsy, and imaging tests. The staging systems are very complex. Below is a summary of pathological staging. Talk to your provider about the stage of your cancer.

Stage 0 (Tis, N0, M0): The cancer is only in the cells lining the salivary duct (Tis). It has not spread to nearby lymph nodes (N0) or distant sites (M0).

Stage I (T1, N0, M0): The cancer is 2 cm or smaller. It’s not growing into nearby tissues (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage II (T2, N0, M0): The cancer is 2 to 4 cm in size. It’s not growing into nearby tissues (T2). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

Stage III (T3, N0, M0): The cancer is bigger than 4 cm and/or is growing into nearby tissues (T3). It has not spread to nearby lymph nodes (N0) or to distant sites (M0); OR (T0-T3, N1, M0): The cancer is any size and may have grown into nearby tissues (T0-T3) AND has spread to 1 lymph node on the same side as the primary tumor. The cancer has not grown outside the lymph node and the lymph node is not bigger than 3 cm (N1). It has not spread to distant sites (M0).

Stage IVA (T4a, N0-N1, M0): The cancer is any size and is growing into nearby structures (T4a) AND:

• It has not spread to nearby lymph nodes (N0) OR
• It has spread to 1 lymph node on the same side of the head or neck but has not grown outside of the lymph node and the lymph node is not bigger than 3 cm (N1).

It has not spread to distant sites (M0); OR (T0-T4a, N2, M0): The cancer is any size and may have grown into nearby tissues or structures (T0-T4a) AND any of the following:

• It has spread to 1 lymph node on the same side as the primary tumor but has not grown outside of the lymph node and the lymph node is 3 to 6 cm in size (N2a) OR
• It has spread to 1 lymph node that is smaller than 3cm and the cancer has grown outside of the lymph node (N2a) OR
• It has spread to more than 1 lymph node on the same side as the primary tumor, but it has not grown outside of any lymph nodes and none of the lymph nodes are bigger than 6 cm (N2b) OR
• It has spread to 1 or more lymph nodes, either on the other side as the primary tumor or on both sides of the neck, but has not grown outside any lymph nodes and all are 6 cm or smaller (N2c).

It has not spread to distant organs (M0).

Stage IVB (Any T, N3, M0): The cancer is any size and may have grown into nearby tissues or structures (Any T) AND any of the following:

• It has spread to a lymph node that is bigger than 6 cm but has not grown outside of the lymph node (N3a) OR
• It has spread to a lymph node that is bigger than 3 cm and has grown outside the lymph node (N3b) OR
• It has spread to more than one lymph node with growth outside of the lymph node(s) (N3b) OR
• It has spread to a lymph node on the opposite side of the primary tumor that is 3 cm or smaller and has grown outside of the lymph node (N3b).

It has not spread to distant organs (M0); OR (T4b, Any N, M0): The cancer is any size and is growing into nearby structures or other bones nearby, or it surrounds the carotid artery (T4b). It may have spread to nearby lymph nodes (Any N). It has not spread to distant organs (M0).

Stage IVC (Any T, Any N, M1): The cancer is any size and may have grown into nearby tissues or structures (Any T) AND it may have spread to nearby lymph nodes (Any N). It has spread to distant sites (M1).

How is salivary gland cancer treated?

Treatment for salivary gland cancer depends on many things, like your cancer stage, age, overall health, and testing results. There are steps to take before treatment can begin for any kind of head and neck cancer:

• Multidisciplinary treatment is very important. This means you will have providers from many different specialties involved in your care. Many of these providers will see you before you start cancer treatment during visits called consultations. They will work together and with you to create a plan to treat your cancer.
• If you smoke, quit as soon as possible. Smoking may lessen how well your cancer medications work and can worsen side effects.

Your treatment may include some or all the following:

• Surgery
• Radiation Therapy.
• Chemotherapy.
• Targeted Therapy.
• Immunotherapy.
• Supportive/Palliative Treatment.
• Clinical Trials.

Surgery

Surgery is often the main treatment for salivary gland cancer and the goal is to remove the cancer completely. The type of surgery you have depends on where your tumor is, the stage, and your overall health. Surgery for head and neck cancer can be quite challenging, including removal of tissue and bone and the use of plastic surgery to rebuild facial features to improve how they work and look. There are a few kinds of surgery used to treat salivary gland cancer:

• Superficial parotidectomy: The superficial (outer part) of the parotid gland is removed. The surgeon makes a cut (incision) in front of the ear and down the neck. This does not often affect how the face moves, because the surgeon tries to stay away from the facial nerve.
• Total parotidectomy: The whole parotid gland is removed. The surgeon makes a cut in front of the ear and down the neck. The facial nerve, as well as other tissues, may need to be removed depending on where the tumor is. This could affect how your face moves.
• Submandibular sialadenectomy: The whole submandibular gland is removed through a small cut made below the lower jaw.
• Sublingual gland surgery: The whole sublingual gland and, in some cases, tissue and bone are removed through a mouth or facial/neck incision. Nerves that control tongue and face movement, sensation (feeling), and taste may be affected.
• Minor salivary gland surgery: Removes cancer from minor salivary glands. These glands can be found in the lips, tongue, palate (roof of mouth), mouth, throat, voice box (larynx), nose, and sinuses. Some tissue may also be removed.
• Lymphadenectomy (also called neck dissection): Lymph nodes from the neck are removed. Connective tissue, muscles, nerves, and blood vessels may also need to be removed through a large cut in the neck.

Talk with your care team about surgical options you have, any concerns about your body image and function, what you will need to do to heal after surgery, and side effects that you may have.

Radiation Therapy

Radiation therapy is the use of high-energy x-rays to kill cancer cells. Radiation for salivary gland cancer can be used:

• Alone or with chemotherapy (called chemoradiation).
• After surgery (called adjuvant radiation).
• If the cancer has come back (recurrence).
• For palliative treatment (to ease symptoms).

External radiation therapy is when a beam of radiation from outside of the body is directed into the body. It may also be called x-ray therapy, 3D conformal radiation, intensity-modulated radiation therapy (IMRT), cobalt, photon, or proton therapy. When this type of radiation is used, you will likely need to wear a mask that is fitted for you to help you keep still during treatments. This mask can cause anxiety and claustrophobia. Your providers will be able to give you advice to help you with wearing the mask during treatment.

Chemoradiation is the use of chemotherapy and radiation together to treat cells that cannot be seen. It is not often used but clinical trials are being done to determine if it is beneficial.

Because radiation can affect nearby tissues, there are many potential side effects of radiation for head and neck cancers.

Before you start treatment, you will likely need to be seen by a dentist. Radiation to this area can affect the teeth and gums. It is important to ensure you have proper dental health before starting treatment with radiation.

Chemotherapy

Chemotherapy is the use of anti-cancer medications to kill cancer cells. It is not often used to treat salivary gland cancer, but may be used if:

• The cancer has metastasized (spread) to distant organs.
• If there is still cancer after surgery and radiation.

Chemotherapy medications that may be used are cisplatin, mitoxantrone, doxorubicin, epirubicin, cyclophosphamide, paclitaxel, docetaxel, vinorelbine, and methotrexate.

Targeted Therapy

Salivary gland cancer may be treated with targeted therapies that focus on specific gene mutations or proteins in the tumor. Targeted therapies work by targeting something specific to a cancer cell, which lets the medication kill cancer cells and affecting healthy cells less. Sometimes the “target” is found on a certain type of healthy cell and side effects can happen as a result. Example of targeted therapies used for this type of cancer are bicalutamide (often given with leuprolide [for men]/leuprolide [for women]), trastuzumab, ado-trastuzumab emtansine, larotrectinib, and entrectinib.

Immunotherapy

Immunotherapy is the use of a person's own immune system to kill cancer cells. An example of an immunotherapy medication used to treat this type of cancer is pembrolizumab. Your tumor may need to be tested to make sure immunotherapy medications will work for you.

Supportive/Palliative Therapy

Your quality of life is very important during and after treatment for head and neck cancer. Supportive and palliative treatments are used to lessen symptoms or side effects that you may have. Head and neck cancer treatment and the cancer itself can cause:

• Pain: Your care team will help you with medications and other therapies for pain. Radiation, surgery, and a nerve block can help as well.
• Nutrition issues: For some patients, difficulty swallowing, mucositis (sore mouth and throat), loss of taste, or a lack of saliva production may make eating hard or impossible. It is important that you are followed closely by a dietitian to support you in food and supplement choices, and to keep good nutritional status. If needed, a speech and swallowing specialist can test if you can swallow safely without choking or inhaling food. Many patients will need to be fed through a tube placed in their stomach (called a PEG or ‘G' tube). In most cases, this is only temporary (for a short time).
• Changes in Body Image: Social workers and psychologists may be needed to help in dealing with the changes in body image and your role in your family.
• Speech problems: A speech therapist can help you regain as much of your speech as possible, and also give you other ways to communicate.

Clinical Trials

You may be offered a clinical trial as part of your treatment plan. To find out more about current clinical trials, visit the OncoLink Clinical Trials Matching Service.

Making Treatment Decisions

Your care team will make sure you are included in choosing your treatment plan. This can be overwhelming as you may be given a few options to choose from. It feels like an emergency, but you can take a few weeks to meet with different providers and think about your options and what is best for you. This is a personal decision. Friends and family can help you talk through the options and the pros and cons of each, but they cannot make the decision for you. You need to be comfortable with your decision – this will help you move on to the next steps. If you ever have any questions or concerns, be sure to call your team.

You can learn more about head and neck cancers at OncoLink.org