indiacancer.org - Salivary Gland Cancer

	Salivary Gland Cancer

		What are the Salivary Glands?
		What are Salivary Gland Cancers?
		How do Salivary Gland Cancers present?
		How are Salivary Gland Cancers detected?
		What is staging and grading?
		How is Salivary Gland Cancer treated?
		What are the side effects of treatment for Salivary Gland Cancer?
		What is the importance of follow up?

What are the Salivary Glands?

These are saliva producing glands. Saliva is a fluid which keeps the mouth moist. It also moistens and softens food during the act of chewing and has a minimal digestive action on food components as well.

The salivary glands are chiefly arranged in three paired groups (major salivary glands):

The Parotid Gland (In front and beneath the ear)

The parotid glands are the largest, placed just in front of the ear.

The submandibular glands are placed just beneath the jaws, protruding partially into the top of the neck.

The sublingual glands are arranged on both sides of the floor of the mouth.

There are several minor salivary glands as well, scattered randomly in the mouth and other parts of the upper gastrointestinal tract.

What are Salivary Gland Cancers?

Tumors arising from the salivary glands are usually benign, (non cancerous). A few however, may be cancers.

Cancers arising from the salivary glands are of several types.

How do Salivary Gland Cancers present?

Usually, the presentation is in the form of a painless swelling in front of the ear (parotid), in the upper neck close to the jaw line (submandibular) or a swelling on the floor of the mouth (rare).

If the facial nerve, which is the chief nerve to the face gets involved (as it passes through the parotid gland), then one side of the face may become numb or even show signs of paralysis (inability to move the muscles in that area).

How are Salivary Gland Cancers detected?

If any of the above symptoms present, one should see a doctor immediately (preferably an Ear, Nose and Throat or ENT surgeon), who will carefully examine the neck, throat and mouth or oral cavity.

If a lesion is detected, some doctors prefer to take a biopsy, which is the removal of a small piece of representative tissue, usually using just a fine needle (FNAC), while others prefer to go directly for surgery. This decision should be left in the hands of your specialist.

Your doctor may also order some imaging tests such as CT scan of the head and neck region to look for local spread and involvement of lymph nodes, if any. CAT or CT(computer assisted tomography) scans are produced when the X-ray machine is linked to a computer. The X-ray machine is shaped like a large doughnut (Vada) with a hole. The patient lies on a bed which passes through this hole. As the patients body goes through it, the machine takes X-rays of different parts of the body. The computer then puts the X-ray pictures together to produce detailed, three dimensional pictures. Lymph nodes are small bean-shaped structures, which act as stations for drainage of lymph, a clear watery fluid, which courses through out the body in transparent, thin tubes called lymph channels or lymphatics,from various organs.

What is staging and grading?

	These are terms with which you must become familiar, if you are dealing with any form of cancer. When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs. The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive. Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome. Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, Bone scan or chest X-ray. Stage I The cancer is no more than 4 cms in diameter and has not spread into the surrounding tissues or to the lymph nodes in the region Stage II One of the following scenarios is true:
		The cancer is between 4 to 6 cms in diameter and has not spread into the surrounding tissues or to the lymph nodes in the region.
		The cancer is no more than 4 cms in diameter and has spread into the surrounding tissues including the skin, soft tissues, bone or nerve near the gland, but there is no spread to the neighboring lymph nodes.
	Stage III The cancer is no more than 4 cms in diameter and has not spread into the surrounding tissues near the gland, but there is spread to a single neighboring lymph node.
	Stage IV One of the following scenarios is true:
		The cancer is more than 6 cms in diameter and has spread into the surrounding tissues near the gland, and there may or may not be spread to neighboring lymph nodes.
		The cancer is any size and has spread to more than one lymph node on the same side of the neck as the cancer, to lymph nodes on one or both sides of the neck, or to any lymph node that measures greater than 6 cms in diameter.
		There is spread of the cancer to distant parts of the body. (metastatic salivary gland cancer).

How is Salivary Gland Cancer treated?

	A lot depends on the patient's constitution, the grade of his disease, and its staging. Patients are usually treated by a team of specialists, which utilizes a multipronged approach. This includes an otorhinolaryngologist (ENT surgeon), a surgical oncologist, a reconstructive or plastic surgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy may become an add-on. Treatment strategies The bastion of treatment for salivary gland cancers is surgery. Surgery in which the facial nerve is spared and just the superficial lobe of the parotid gland is removed is known as superficial or suprafacial parotidectomy. Surgery in which the entire parotid gland is removed , along with a dissection for lymph nodes in the neck, and if necessary, surrounding involved tissues, is called radical parotidectomy. The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the salivary glands is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks). Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after. Stage I If the cancer is low grade,
		Surgery.
	If the cancer is high grade,
		Surgery.
		Surgery followed by radiation.
	Stage II If the cancer is low grade,
		Surgery, most probably followed by radiation.
		Chemotherapy, if surgery or radiation show no response.
	If the cancer is high grade,
		Surgery.
		Surgery followed by radiation.
		Radiation alone.
	Stage III If the cancer is low grade,
		Surgery followed by radiation.
		Chemotherapy, if surgery or radiation show no response.
		Specialized radiation techniques or therapy or newer chemotherapeutic drugs.
	If the cancer is high grade,
		Surgery.
		Surgery followed by radiation.
		Radiation alone.
	Stage IV
		Radiation.
		Chemotherapy, with or without radiation.

What are the side effects of treatment for Salivary Gland Cancer?

	Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. Surgery may result in damage to or removal of the facial nerve (for parotid surgery) and result in one side of the face becoming permanently numb or paralyzed. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient.
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

What is the importance of follow up?

The importance of follow-up cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.