1. DIAGNOSTIC EVALUATION
2. DEFINITIVE TREATMENT
3. RECONSTRUCTION
4. POSTOPERATIVE RADIATION
5. ADJUVANT TREATMENT
6. FOLLOW UP
7. BIBLIOGRAPHY

I.DIAGNOSTIC EVALUATION:

Clinical Evaluation:

• A complete history and physical 
  
  With particular reference to a previous history of skin cancers. Head neck examination should focus on the extent of disease involvement in the parotid, parapharyngeal space and neck, presence of trismus, status of facial nerve function and presence of hypesthesia or anesthesia of the skin of face or neck, any otologic findings and assessment of the patient's dentition.
  
• FNA
  
  If the parotid mass is mobile, discrete and confined to the superficial lobe, no pre-operative FNA is necessary unless the patient's medical condition is such that a general anesthetic would be very risky and a priority needs to be established. FNA is useful when a parotid tumor is likely to be metastatic in nature (e.g. from the skin or from other organs). Some surgeons feel that FNA is useful in counseling the patient and planning treatment when malignancy is suspected. If the patient has wide-spread metastatic disease and a tissue diagnosis is necessary in order to institute treatment or if the mass is unresectable, an FNA will help in directing palliative therapy.

Imaging Studies and Laboratory Tests:

• Routine preoperative studies dictated by institutional guidelines.   
• Chest radiographs, AP and lateral.

To evaluate for acute or chronic pulmonary disease and metastases. Abnormal findings on chest x-ray with suspicions lesions may need further imaging including a chest CT.

• CT scan

Is indicated if the tumor extends beyond the superficial lobe, a deep lobe tumor is suspected or extension into the deep lobe is appreciated and the patient has trismus. In patients with large tumors it is useful to assess the medial extent of the tumor, its relationship to the mandible, the temporal bone and the cervical spine.

• MRI
  
  Is indicated if facial nerve function is affected in order to better visualize the fallopian canal. 
  
• Panorex 
  
  Is useful if there are teeth present in order to help with the dental evaluation

Consultations:

• Dental Exam is appropriate to assess status of teeth if radiation therapy may be a part of the treatment plan. 
• Radiotherapy: In anticipation of possible postoperative radiation.

Top

Neck:

N₀: Neck dissection is not indicated regardless of the histology unless clinically suspicious nodes are present. 

N₊: If nodes are present, the type of neck dissection is determined by the level of nodal involvement and the likelihood of using postoperative radiotherapy. Again, all gross disease in the neck must be resected. 

II. DEFINITIVE TREATMENT:

Primary tumor:

• A superficial parotidectomy is the minimal surgical procedure, but the final extent of the resection is determined by the extent of the disease not the histology. All gross disease should be removed. 
  
• If the tumor is encasing the facial nerve, the nerve should be resected and a nerve graft used, otherwise, the facial nerve can be spared, as long as there is a clearly identifiable plane between the tumor and the nerve 
  
• If the nerve is nonfunctioning preoperatively, grafting is appropriate if the involved portion of the nerve is resected with clear margins.

Top

A free flap or a myocutaneous flap is necessary if bone is exposed or extensive soft tissue and skin are removed. For smaller defects with no bone exposed a local/regional flap or a skin graft may be sufficient.

Top

If the tumor is an adenoma (pleomorphic, monomorphic, Warthin's) removed with clear margins, no further therapy is indicated.

If a T1 - T2 malignant tumor of low grade histology is removed with clear margins postoperative radiation is not indicated. 

Most commonly radiation therapy is employed for malignant tumors that are removed with very close margins due to their proximity to the facial nerve, tumors with extensive soft tissue/bone invasion (e.g. facial skin, masseter, pterygoids, mandible, infratemporal fossa), malignant tumors of the deep lobe that can not be excised with generous margins, tumors that exhibit extensive perineural or intravascular invasion, and tumors associated with multiple lymph node metastases.

Timing:

Radiation is initiated within a reasonable period after healing has occurred.

Total dose and fractionation:

These are determined by the clinical and pathological findings. The usual range is 50 - 70 Gy in daily fractions of 1.8 to 2.0 Gy in 5 to 8 weeks. This includes a brachytherapy boost when indicated by specific pathological findings.

A nerve graft is not a contraindication to postoperative radiation.

Top

Adjunctive chemotherapy has no proven effect on salivary gland tumor. Neutron therapy may be considered for recurrent or unresectable local/regional disease. Isolated bone metastasis may respond to localized radiation with relief of pain. Solitary pulmonary metastasis of adenoid cystic carcinoma should be evaluated for resection.

Top

VI.FOLLOW UP:

Follow-up appointments are scheduled on an individual basis determined by the risk of recurrence, to deal with morbidity from treatment (i.e. xerostomia, trismus, as well as wound care), to provide social and psychological support, and to deal with comorbidity not directly related to the cancer itself.

• Periodic examinations by the head and neck surgeon may be necessary during radiation therapy in patients experiencing difficulty with nutritional intake, or pain control.
  

• Periodic examinations by the radiation oncologist and a dentist in patients that received radiation therapy
  

• After all treatment is completed a general formula which is modified according to the individual patient's characteristics is:
  
  1st year post treatment: 1-3 months
  
  2nd year post treatment: 2-4 months
  
  3rd year post treatment: 3- 6 months
  
  4th and 5th years: 4- 6 months
  
  After 5 years: Every 12 months
  

• Chest radiographs, yearly.
  

• Liver enzymes, yearly.

Top

Spiro RH and Huvos AG. Stage means more than grade in adenoid cystic carcinoma. Am J Surg 164: 623-628, 1992.

Armstrong JG, Harrison LB, Spiro RH, Fass DE, Strong EW, and Fuks ZY. Malignant tumors of the major salivary gland origin. Arch Otolaryngol Head Neck Surgery 116: 290-293, 1990.

Harrison LB, Armstrong JG, Spiro RH, Fass DE, and Strong EW. Postoperative radiation therapy for major salivary gland malignancies. J Surg Oncol 45: 52-55, 1990.

Johns ME. Parotid cancer: a rational basis for treatment. Head Neck Surg 4:132-141, 1980.

Frankenthaler RA. Prognostic variables in parotid gland cancer. Arch Otolaryngol Head Neck Surg. 117:1251-1256, 1991

Kane WS. Primary parotid malignancies. Arch Otolaryngol Head Neck Surg. 117:307-315, 1991.