Scottish Cancer Network: Clinical Management Pathways
- Offer flexible nasoendoscopy/EUA and biopsy.
- Consider surgical excision for diagnostic purposes if there is uncertainty regarding pathology. If excision is not possible undertake incisional biopsy / core biopsy for diagnostic purposes.
Salivary gland malignancy
Warning
This consensus document is not a rigid constraint on clinical practice, but a concept of good practice against which the needs of the individual patient should be considered. It therefore remains the responsibility of the individual clinician to interpret the application of the Clinical Management Pathway (CMP), taking into account local service constraints and the needs and wishes of the patient. It is not intended that these consensus documents are applied as rigid clinical protocols.
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Surgery is the mainstay treatment for salivary gland pathology at all sites. The extent of surgery will depend upon consideration of grade, stage, and histopathological characterisation. Surgery for parotid tumours should aim to be facial nerve preserving in patients with intact preoperative facial nerve function when a dissection plane is present between the tumour and the nerve.
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The aim of surgery for resectable sublingual and minor salivary gland malignancy is to achieve R0 resection where possible.
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Consider re-excision in the presence of involved surgical margins.
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Consider re-excision in cases of recurrent non-metastatic disease.
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For patients with submandibular gland malignancy who have high grade disease, consider a suprahyoid compartmental resection which will require resection of the lingual nerve and often hypoglossal nerve.
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Consider ipsilateral neck dissection for N0 disease in high grade pathology.
- For high grade or locally advanced tumours where multi-modality treatment (surgery then adjuvant radiotherapy) is indicated, consider prior to initiating any management:
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- Balance long term control/cure with acute and late morbidity from treatment.
- Patient suitability and likelihood of completing whole package of treatment.
- Alternative non-curative options.
- Counsel patients carefully on all these factors prior to commencing radical treatment pathway, particularly if likely poor long term survival rates.
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Where there is extraparenchymal extension (T3, T4a) offer radical surgery and reconstruction (requiring resection of one or more of overlying skin, temporal bone, posterior mandible, styloid apparatus). Where pinna resection is required, offer preoperative consultation with a Maxillofacial Prosthetist / Reconstructive Scientist. Plan primary facial reanimation procedure(s) with a reconstructive surgeon. Consider a multi-disciplinary surgical approach for all advanced cases (T3, T4a) where radical resection is performed.
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For patients with submandibular gland malignancy who have T3/T4a and/or high grade disease, consider a suprahyoid compartmental resection which will require resection of the lingual nerve and often hypoglossal nerve.
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Consider ipsilateral neck dissection for T3/4 low grade pathology. Offer ipsilateral neck dissection in clinical N+ disease.
Consider prior to initiating any management for salvage:
- Balance of chance of long term control/cure versus.
- Likely acute and late morbidity from additional treatment.
- Likelihood of requiring adjuvant treatment to achieve disease control/cure and patient suitability and likelihood to be offered this depending on patient factors and previous treatment.
- Alternative non-curative options.
Counsel patients carefully on all these factors prior to commencing salvage treatment pathway.
- Recurrence at the primary site as well as distant metastases are the predominant locations of treatment failure in salivary gland cancer.
- Patients with recurrent resectable disease at the primary site may be considered for salvage surgery in the absence of distant disease. Consider salvage surgery in the event of recurrence taking into account patient factors including age, co-morbidities, and preferences. Reconstructive flap surgery is usually required.
- Isolated regional node relapse in previously untreated echelons should be salvaged with surgery and adjuvant treatment as indicated by final histopathology.
- Consider surgery to loco-regional site in highly selected patients e.g. indolent biology and limited metastatic disease or for palliation.
- Consider surgical resection in patients with imaging indicating solitary / oligometastatic distant metastasis.
The lag time from primary treatment should be influential in decision making in this setting.