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SALIVARY GLANDS & TUMORS

There are multiple salivary glands of varying sizes in the face, neck, and lining mucous membranes of the mouth & throat. The largest is the parotid gland (outlined in Green) which sits in front and below the ear; interestingly it produces only 10% of your saliva. The next largest gland is the submandibular gland (outlined in blue) that produces the most amount of saliva at 25%.

The sublingual glands (outlined in orange) produce a smaller portion of saliva, and the minor salivary glands are very small glands that line the lips, cheeks, palate & throat. They continually produce saliva to keep the mouth moist & begin the process of digestion.

Most of the tumors of the salivary glands happen in the parotid gland; close to 80% of salivary gland tumors occur in the parotid gland. Fortunately majority of those tumors, or roughly 80%, are benign or non-cancerous in the parotid gland. In other words, only 20% of tumors in the parotid gland are cancerous.

Tumors occur a lot less often in the submandibular glands, and even less so in the sublingual and minor salivary glands. However, the when tumors occur in the smaller salivary glands they tend to be cancers more often.

TYPES OF CANCEROUS TUMORS

There are 21 different types of malignant tumors (aka cancers) that occur in the salivary glands. The difference between benign & malignant (cancerous) tumors is that benign tumors don’t tend to spread & generally don’t eat through adjacent structures, but rather as they grow push on the tissue next to them. Cancers can both invade and destroy adjacent structures (nerve, muscle, bone, blood vessels, etc…) and can spread to lymph nodes and other parts of the body (lung, liver, bones, etc.).

Cancers typically begin as painless lumps in the parotid gland, other salivary glands beneath the jaw, or within the mouth and throat. All masses should be promptly biopsied to determine if they are benign or cancerous. As the tumors grow, they can damage nerves, causing pain and paralysis. A parotid mass that is either painful or accompanied by facial weakness is very likely to be a cancer. Each type of cancerous tumor in the salivary glands have different characteristics and behavior patterns. The type of surgery & extent of treatment can be very different for each type. As such, salivary cancers require immediate attention by an expert team of salivary specialists. In this section, we briefly discuss some of the more prevalent types of salivary cancers. Please schedule a consultation with our expert physicians at the CENTER. You can either visit our office or have a video (Zoom) appointment to review your pathology report, examine your scans (which can be electronically sent to us in advance of the appointment), and discuss your personalized treatment plan in detail. We are here to help you!

MUCOEPIDERMOID CARCINOMA

Mucoepidermoid carcinoma (MEC) is the most common type of parotid gland cancer in both adults and children. Despite this it is still a very uncommon cancer. Mucoepidermoid carcinoma is more common in women in the middle ages. Like all salivary cancers, it starts from an alteration in the DNA of a cell in the salivary gland. This mutated/altered cell continues to duplicate & grow, and as it grows mutates more losing more inhibitions & becomes more aggressive. MEC can be low grade, intermediate grade & high grade. Low grade MEC tends to be more cystic & have more mucus cells which form glandular structures, while high grade tumors are more cellular, less cystic, with a lot of atypical cells (they don’t look like a salivary gland anymore).

The low grade mucoepidermoid carcinomas tend to be slow growing with a very low chance of spread, and usually require complete excision with only a limited parotidectomy for cure. The intermediate MECs tend to be slightly more aggressive with a slight more chance of spread to lymph nodes. Treatment for low grade and smaller intermediate grade tumors is just a parotidectomy with removal a small amount of additional salivary tissue around it. For larger Intermediate tumors then removal of the lymph nodes in the neck below the parotid gland is also considered.

High-grade mucoepidermoid carcinomas have a lot more genetic alterations/mutations (genetic errors due to toxin/radiation exposures), which makes them grow faster & behave more aggressively. They are more likely to invade what is around them and spread to lymph nodes. Consequently, prompt treatment with surgery (parotidectomy and lymph node removal in the neck, known as neck dissection) is essential. This is often followed by radiation therapy, and in some cases, additional treatments may be necessary. Signs of advanced disease are spread to lymph nodes, involvement of nerves, involvement of vessels (lymphovascular invasion), or tumor coming out of the parotid gland and invading adjacent tissue (muscle, bone or skin).

To determine the extent of the tumor and develop an appropriate treatment plan, imaging studies are crucial. Early diagnosis and prompt treatment by a parotid specialist are vital for achieving the best possible outcomes. If you have been diagnosed with MEC, please contact us at the CENTER to start prompt treatment.

ADENOID CYSTIC CARCINOMA

A very unusual cancer that can grow in glandular tissue all over the body Including salivary glands, breasts, tear glands, prostate, trachea & other areas. Adenoid cystic carcinoma (ACC) happens most often in the 5th & 6th decade of life, and occurs equally in women & men. Interestingly, it is the most common salivary gland cancer in the African continent. In the US, it is diagnosed roughly in 1300 people a year. It comes in three histologic (under the microscope) forms: tubular, cribriform & solid. The more solid component seen under the microscope, the more aggressive the cancer’s behavior.

ACC is a slow growing cancer that likes to penetrate surrounding areas and especially loves nerves. It uses nerves as a highway to travel to other areas. Once it has gotten on to the nerves it becomes more difficult to treat because the nerves don’t have any boundaries to spread, so once ACC has gotten on a nerve it can go from the parotid forward into the face or upwards into the brain. The key is early diagnosis and surgery before it has had a chance to spread to nerves or other parts. Even when it spreads it still grows slowly (which is a very unusual character). These cancers are defined by MYB or MYLB1 genetic alterations, which means the diagnosis can be confirmed by the presence of these abnormal genetic changes.

In the early stages ACC presents as a painless lump in the parotid, or anywhere in the mouth, but as it advances and involves nerves it becomes painful and can cause paralysis. In the case of parotid gland, it can cause facial nerve paralysis. Early tumors can often be treated & cured by surgery alone or in combination with radiation treatment. Advance tumors are difficult to cure & like to spread to lungs, bones & liver, making early detection and treatment critical. Once treated the person must be followed up for many years by their doctors, as they may recur years later.

Unfortunately radiation treatment alone cannot get rid of ACC. Chemotherapy has not proven effective in curing ACC, but may slow down the progression. Alternative therapies are continually being investigated and clinical trials are always ongoing for this unusual cancer.

ACINIC CELL CARCINOMA

Acinic cell carcinoma is generally a slow-growing tumor. It can occur at any age, although it’s rare in children. It tends to affect a slightly younger population of patients compared to other salivary gland cancers. It has a predilection for people in their 40s and 50s and is slightly more common in women. It occurs more frequently in Caucasians than in other populations and is seen least often in people of African descent. It can run in families, and interestingly in 3% of cases, it can be present in both salivary glands simultaneously. The only known risk factor is previous radiation exposure, such as radiation treatment for a medical condition.

Most often Acinic Cell Carcinomas are low grade and don’t tend to spread unless not treated and given enough time to change and become more aggressive. In the early stages they show up as a painless lump in the parotid or other salivary glands. Once they become more aggressive they may start to hurt, grow more rapidly, invade surrounding tissue & nerves, and spread to other areas. The treatment if caught early enough is parotid surgery so that the entire tumor is removed along with an additional portion of healthy salivary tissue around it.

Rarely Acinic cell carcinomas are genetically very aggressive and eat through nerves, muscle or skin. And equally rarely spread to lymph nodes. Pain, facial weakness or enlarged lymph show that the Acinic cell cancer is aggressive and will require more involved surgical treatment and after surgery radiation treatment.

CARCINOMA EX-PLEOMORPHIC ADENOMA

Carcinoma ex-pleomorphic adenoma or Ca-Ex-PA makes up roughly 10% of salivary gland cancers. It always arises or transforms from a benign pleomorphic adenoma that has not been removed or has recurred after incomplete surgery. The chance of a benign pleomorphic adenoma transforming into cancer is 1.5% at 5 years and 10% at 15 years, and unfortunately the chance continues to increase in time. The transformation starts in one cell that turns into a cancer. Then that cell starts to rapidly duplicate and get bigger. At first the transformed cancer is small and exclusively inside the capsule of the pleomorphic adenoma. This is designated as non-invasive Ca-ExPA, since the cancer cells are not invading the capsule (the covering of the benign pleomorphic adenoma tumor). As the cancer grows at some point it starts to eat through the capsule of the benign tumor, and grow out; when the cancer has grown out less than 1.5 millimeters it is called minimally invasive carcinoma ex-pleomorphic adenoma. It will continue to grow more, and once beyond 1.5 millimeters, it is now called invasive Ca-Ex-PA.

Additionally, carcinoma ex-pleomorphic adenoma can take the form of any of the other salivary cancer, most commonly adenocarcinoma, epithelial-myopithelial carcinoma, or salivary ductal carcinoma. Whatever type of cancer it becomes, the level of aggressiveness will be similar to that particular cancer. So if the cancer is diagnosed at non-invasive or minimally-invasive stage and it happens to be a type that is relatively low grade then surgery alone may be adequate as treatment. However, if the Ca-Ex-PA is invasive, a more aggressive type, or has spread to lymph nodes, it necessitates more extensive parotid surgery, lymph node removal, followed by radiation therapy, and potentially immunotherapy or chemotherapy. Post-surgery, specialized testing will be done to determine the exact cancer type and identify specific proteins that can be targeted for immunotherapy (targeted therapy).

This presents a particularly challenging scenario because it’s often uncertain whether the pleomorphic adenoma has transformed before surgery. The expertise of your surgeon greatly enhances the chances of detecting that the tumor has already transformed during surgery and taking appropriate action to address it. And also know how to plan an optimal treatment for you after surgery.

SALIVARY DUCTAL CARCINOMA

Salivary ductal carcinoma or SDC is a rare & aggressive cancer that occurs more commonly in men in the sixth & seventh decades of life. Interestingly the incidence of SDC has been increasing in the past few decades. It happens most often in the parotid gland followed by the submandibular gland. It commonly spreads to the lymph nodes. In fact a great majority of patients with SDC initially go see their doctors because of enlarged lymph nodes in the neck and not necessarily because they find the original tumor in the parotid gland. SDC grows rapidly and if left untreated can quickly invade any structure next to it, including paralyzing the facial nerve, or spread to other parts of the body.

Salivary ductal carcinoma can arise on its own or due to transformation from a benign pleomorphic adenoma. In either scenario the progression of disease and treatment remains the same. SDC shares similarities with breast ductal carcinoma. Signs of advanced disease are spread to lymph nodes, involvement of nerves (facial weakness or paralysis), larger tumor, high grade histology and spread to other organs (lung, liver or bone). Greater then 70% of SDC have androgen receptor on their surface, and roughly 30% have amplification of HER2 gene which is a target for immunotherapy. Treatment is almost always multi-modality, which means it will require surgery (parotidectomy with removal of neck lymph nodes – aka neck dissection), followed by radiation therapy, and immunotherapy, androgen blockade and/or chemotherapy. SDC is a very aggressive cancer that demands prompt intervention to prevent progression. Therefore, immediate action is of utmost importance.

Adenocarcinoma NOS

There are many different types of Adenocarcinoma that occur in the salivary glands, however Adenocarcinoma NOS (not otherwise specified) is the most common type in the parotid gland and will be discussed here. It is more common in older caucasian men, generally greater then 67 years of age. The grade of tumor can be determined by histologic features (findings under the microscope), with high grade tumors acting more aggressively as compared to low grade ones. Indicators of aggressiveness in adenocarcinoma include a large tumor size, a tumor that is immobile or firmly attached to the surrounding structures, facial nerve weakness or paralysis, and the enlargement of lymph nodes.

Since Parotid Adenocarcinomas (NOS) are very aggressive, and can very early on spread to the lymph nodes in the neck under the parotid, prompt treatment is needed. Needle biopsy can help diagnose the type of tumor, while imaging studies determine its size and extent. Surgery involves complete removal of the cancer, along with an additional 1 cm of normal parotid tissue. Additionally, neck dissection is performed to remove any lymph nodes in the neck that may contain microscopic cancer cells. Post-surgery, radiation therapy significantly enhances the likelihood of cure and reduces the risk of recurrence in both the parotid gland and neck lymph nodes.

METASTASIS FROM OTHER CANCERS

Metastasis are cancer cells that have spread from the original site of a cancerous tumor to a different organ. When there is a metastasis, it indicates that the cancer has changed on a genetic level enough to be able to travel through lymph or blood vessels to other parts. The parotid gland has several lymph nodes within it. These lymph nodes are in charge of surveillance and filtration of the local area including the skin of the side of the face, temple, scalp and ear. As such the great majority of metastasis to the parotid start from skin cancers in the vicinity that travel through lymph vessels to get to the lymph nodes inside the parotid gland. Most of these metastasis are squamous cell carcinomas, followed by melanomas. Needle biopsy will often be able to tell if it is a squamous cell carcinoma, but melanoma in the lymph nodes may not be as easily identified. Some of the cancers originating in the parotid gland may have a similar appearance on needle biopsy to a melanoma making the distinction almost impossible.

Parotid squamous cell cancers are often preceded by a history of skin cancer that was removed some time in the past, or there may be one presently in an area that is not visible (like under scalp hair or beard). The treatment involves parotidectomy & removal of the some the lymph node groups in the neck that are associated with the parotid gland (called a neck dissection). Prior to this a through investigation of the skin in the local area must be done to assess wether there is still any skin cancer remaining that may have to be removed as well. This is usually followed by radiation therapy for much improved outcome.

IMAGING STUDIES

There are 4 main modalities used for parotid cancer imaging. They are ultrasound, CT scan, MRI & PET scan. Each has its own particular indication and utility.

ULTRASOUND

Ultrasound, specially when done in the office by the parotid surgeon can be very helpful because it can immediately give you very important detail about the tumor. It give you the size, wether the borders of the tumor are clearly visible, is it invading any of the surrounding structures, and are any of the lymph nodes inside the parotid or under the parotid in the neck enlarged or appear abnormal. Ultrasound can also be used to safely do a needle biopsy of the parotid tumor and lymph nodes (if needed).

Image Notes: Left Parotid gland outlined in blue & tumor in red.

CT SCAN

CT scans are quick and can give a fair amount of information. Some tumors are very visible as seen in the images to the right; the parotid glands on each side are outlined in blue, the jawbone in yellow, the throat in orange and the tumor in green. A great majority of tumors may not be quite so visible and distinct. It is not the primary scan that we chose at the CENTER to evaluate parotid tumors. CT scans show bone structures really well, such the jaw bone and the bone behind the ear that has the facial nerve going through it. It is primarily used when the tumor is close to the area where the facial nerve comes out of the bone (mastoid bone & stylomastoid foramen – exit hole for the facial nerve in the skull). In these rare situations the CT scan tell us if there is room between the tumor and the exit point of the facial nerve to allow for safe identification of the main branch of the nerve.

Image Notes: CT scan cross section images at the level of both parotids & lower jawbone.

MRI SCAN

The MRI scan is a very sophisticated scan that shows the parotid gland itself in detail along with the dimensions and shape of the tumor. It also shows other soft tissue structures such as muscles, fat, blood vessels, lymph nodes and spinal cord in great detail. It uses magnets to create the image and has no radiation exposure. It is very useful in showing the characteristics of the tumor that may indicate it has features that are suspicious for a cancer. And how to best approach tumor that are deeper in the parotid gland for a needle biopsy.

In the images on the right you can clearly see the anatomy well with both parotids being outlined in blue, the top portion of the jawbone just in front of it in yellow, and the throat outlined in orange. On the top set of images the tumor is bright white with smooth borders extending from the superficial to the deep aspect of the parotid behind the jaw bone, outlined in green. It is impossible from these images to tell if this is a cancer or benign tumor, but it is clear that the tumor is distinct & not invading the surrounding tissues (bone or muscle).

The bottom images show a tumor whose borders are not distinct at all; it is hard to tell where it begins or ends; a rough outline is drawn in red but there is the possibility that the tumor is invading the muscles behind it. This lack of clear borders very much indicates a cancerous process. The areas of the lymph nodes in the neck can also be seen to see if there are any enlarged suspicious lymph nodes. This allows the surgeon plan the optimal surgery, and what type of reconstruction should be done.

Image Notes: MRI scan cross section images at the level of both parotids & palate.

PET SCAN

PET Scans are based looking at areas of the body that take in high concentrations of low dose radiolabled sugar. Sugar is easy fuel for a growing cancer and concentrate in cancer cells. The scan can detect any area of the body that has high concentration of the labeled sugar and (blue circle), based on that your doctor can tell if your tumor is limited to its area of origin (parotid gland for example), or has it spread to the lymph nodes in the neck or to the lungs, bones, liver etc.

This is very helpful to tell us if the cancer is limited to the site of origin or has it spread, so your doctor can tell if surgery is appropriate as in the case of cancers that are limited to the parotid or at most have spread to the local lymph nodes. On the other hand if the tumor has spread to other parts of the body then the plan of action may change to treating with a combination therapy rather then surgery.

Image Notes: Highly active area in the parotid & small area in the lung

NEEDLE BIOPSY

Needle biopsy of parotid tumors is a very accurate way of identifying the type of tumor you are dealing with. At the CENTER we perform ultrasound guided needle biopsy of almost all parotid tumors, and for our patients that live in other cities we help you arrange for a biopsy. Needle biopsies of salivary tumors are accurate in about 96% of cases; this means in roughly 4% of cases, the needle biopsy results that indicated a benign tumor will be found to be not benign during or after surgery. It is rare for the opposite to happen where the biopsy shows a cancer and on final pathology it is found to be benign. Needle biopsy of deeper tumors can also be done under ultrasound guidance or at times under CT guidance. Some tumors will be accessible through the mouth. The pathology reports can guide your surgeon how aggressive the cancer is, and what is the appropriate course of action.

Image Notes:
Small Needle Going Into the Tumor.
Cross-section of the Needle Going Into The Parotid Tumor.

TREATMENT OF PAROTID CANCERS

Treatment of parotid cancers is very individualized. Each type of cancer has a different behavior pattern, growth rate, likelihood to invade the surrounding tissue (nerve, muscle or bone), and potential to spread to lymph nodes or other organs. As such each person’s particular situation is considered individually at the CENTER to come up with most ideal plan. Every effort is made to preserve the facial nerve, when possible. This may require a prolonged surgery, a lot of expertise and patience; and that is exactly what the surgeons at the CENTER offer.

Surgery is the main treatment for cancers originating in the parotid gland or any salivary gland. The extent of parotid surgery is dependent on the size, location and the degree of aggressiveness of the cancerous tumor. The need to remove the lymph nodes under the parotid in the neck is also dependent on if the cancer has already spread to the lymph nodes or how likely it is that the particular cancer type has microscopically spread to the lymph nodes without it being visible. The procedure to remove the lymph nodes is called a neck dissection. Some cancers will require radiation therapy after surgery is done and others may not. Some may even need immunotherapy, which is antibody treatment harness the power of you immune system to attack any remaining cancer cells. Occasionally, some may require chemotherapy. All this will be determined by your doctor at the CENTER. We will help guide you along this path and will coordinate your care with all the specialist necessary wherever you live or choose to have treatment (even if it is another country).

Unfortunately not treating a parotid cancer will ultimately lead to the cancer growing and eventually invading the facial nerve to cause facial paralysis. When left untreated as the cancer grows it becomes more aggressive and ultimately will spread to other parts. So early treatment is the key to getting the best outcome. Having a physician partner that you trust and know is fully committed to your health is what you need. We are here to help you along this challenging path to ensure the best possible outcome, and our team of experts will do everything possible to save the facial nerve. We always reconstruct the area of surgery to make sure there is symmetry and harmony of the face. If you live locally, we will refer you to an oncologist and radiation oncologist, should you need it. For our out of town patients, we will work with your team of oncologists & radiation oncologists to come up with the best treatment plan and optimize your care.

PAROTID CANCER CASE EXAMPLES

Presented cases are progressively more complex below.

All images transformed into animation.

LOW GRADE MUCOEPIDERMOID CARCINOMA

64 year old woman with 5 year history of a slow growing mass in the left parotid. Initially, she was told that was a lymph node and did not need to be treated. Over the years it persisted and was treated with antibiotics without resolution. After years of continuing to grow, she was referred to an Ear, Nose & Throat specialist, who ordered a scan.

The MRI scan showed a 1.3 cm solid mass with distinct borders in the mid portion of the gland. FNA (needle biopsy) indicated that it was a low grade mucoepidermoid carcinoma. An ultrasound was performed the day before surgery in the office by Dr. Larian which showed the exact dimensions & location of the tumor, as well as looking at the lymph nodes in the neck; fortunately the lymph nodes appeared all to be normal.

He underwent a micro-parotidectomy with facial nerve monitoring and preservation, as well as reconstruction. The tumor was removed with an additional amount of normal parotid tissue. The facial nerve was fully functional. Final pathology confirmed the tumor was a low grade mucoepidermoid carcinoma, with the margins (edges of what was removed) being negative for tumor. This means the tumor was removed with an additional area of normal parotid tissue as an extra measure of safety so that the cancer does not come back.

Image notes: Mass just beneath the ear (Green Hashmark). Tumor (Green Arrow) was in between the upper and lower division of the facial nerve (Blue Arrows) & was removed safely.

In the images the tumor can be seen marked out before the surgery just under the earlobe. Since this was a low-grade tumor that has a very low chance of spread to the lymph nodes the decision was made to remove it through a micro-parotidectomy approach which allows the surgeon more then adequate view of the area of surgery, the tumor, the Greater Auricular Nerve and the Facial Nerves. Once the facial nerve branches were identified, all of the tissue between the upper and lower divisions of the facial nerve (Blue Arrows) was removed. The facial nerve was then tested and all the branches were found to working properly. A simple reconstruction was performed by suturing the edges of the remaining parotid gland together with absorbable sutures. The parotid was separated from the skin by using the SMAS fascia layer which also helped create a smooth contour and symmetry between the two sides of the face. This was an outpatient procedure and the patient went home the same day. The tumor and the extra parotid tissue that was removed measured 2.6 cm which is just over an inch.

The patient did not require radiation treatment or chemotherapy. He has done well over the years and has shown no signs of recurrence of this cancer.

ACINIC CELL CARCINOMA

60 year old woman with 1.5 year history of a slowly growing mass in the right parotid gland. She had no pain or discomfort and her facial movements were full and symmetric.

The MRI scan showed a solid mass with distinct borders in the superficial aspect of the parotid gland, and no enlarged lymph nodes in the parotid or the neck. On MRI both parotids are outlined in blue, the top portion of the jawbone just in front of it in yellow, and the throat outlined in orange. The tumor (cancer) is outlined in red. The FNA (needle biopsy) indicated that it was a low grade carcinoma, favoring acinic cell carcinoma. An ultrasound was performed the day before surgery in the office by Dr. Larian which showed the exact dimensions & location of the tumor, as well as looking at the lymph nodes in the neck; again fortunately the lymph nodes appeared all to be normal.

She underwent a micro-parotidectomy with facial nerve monitoring and preservation, as well as reconstruction. The tumor was removed with an additional area normal parotid tissue. The facial nerve was fully functional and was tested (stimulated with very low electric energy) to make sure all branches were functioning properly. The defect was reconstructed by suturing the remaining parotid to itself and covering it with a SMAS flap (to create a smooth contour). The reconstruction not only prevents a divot on the face & neck, and creates facial asymmetry but also places a barrier between the parotid and the skin to avoid Frey’s Syndrome.

Final pathology confirmed the tumor was an acinic cell carcinoma, with the margins (edges of what was removed) being negative for tumor. This means the tumor was removed with an additional area normal parotid tissue as an extra measure of safety so that the tumor does not come back.

The patient did not require radiation treatment or chemotherapy. She has done well over the years and has shown no signs of recurrence of this cancer.

Image notes: MRI shows a mass in the superficial parotid (outlined in Red).

The removed cancer. The facial nerve (Blue Arrows) after tumor removal. Closed incisions at end of surgery

ADENOID CYSTIC CARCINOMA

56 year old woman with a 4 month history of a growing firm mass in the right parotid gland. As the mass got larger it became painful. She had full facial function.

The MRI scan showed a 1.8 cm solid mass in the deep lobe of the parotid gland with distinct borders, and no enlarged lymph nodes in the neck. FNA (needle biopsy) had features consistent with adenoid cystic carcinoma. PET scan showed the cancer was limited to the parotid gland. Dr. Larian had an extensive discussion with the patient in regards to this type of cancer’s preference to involve nerves and spread. Specifically, focusing on what are her wishes if we encountered facial nerve involvement in terms of sacrificing the nerve or preserving it despite cancer involvement. If the involved nerve is preserved then we would be depending on radiation to potentially get rid of it, which does not have a high likelihood. She was very clear which nerve branches she would be ok with sacrifice and which she would not be.

Image notes:
Mass just beneath the ear. The cancer was deep to the main trunk of the facial nerve (Green Arrow) & the very important upper division branch (Blue Arrow); both were displaced downwards & forward, but fortunately were not invaded by the cancer. In the image above the cavity left behind from the removal of the cancer & additional normal parotid tissue is visible deeper than the level of the nerve.

The surgery was done through a micro-parotidectomy approach. The facial nerve was identified the branches tracked out, fortunately there was somewhat of a distance between the facial nerve branches and the cancer. The tumor (cancer) was deep to the level of the facial. The tumor was removed with ample normal parotid tissue around it, along with lymph nodes in the upper neck. Frozen section pathology during the surgery showed that the edges of specimen that was removed were free of cancer. The defect was reconstructed primarily and covered by parotid tissue and SMAS fascia flap.

Final pathology confirmed it to be an intermediate grade adenoid cystic carcinoma, with negative margins. There was perineural invasion of small nerve fibers (not facial nerve, rather probably autonomic nerve branches) but no extension to the margin. As such, she underwent radiation therapy to minimize the risk of recurrence. She has been free of cancer for the past 7 years.

CARCINOMA EX-PLEOMORPHIC ADENOMA IN PARAPHARYNGEAL SPACE

43 year old woman with headaches who underwent an MRI, which incidentally showed a mass in the left paraphyarngeal space. A needle biopsy under CT guidance showed it to be a pleomorphic adenoma. Since the biopsy was benign she decided to monitor the tumor with serial MRIs, rather then surgically remove it (which was the recommendation). After several years of monitoring with only gradual growth of the tumor she became concerned and decided to proceed with surgery.

The MRI before surgery shown here clearly visualizes the tumor (outlined in red) extending from the deep end of the left parotid gland (blue), deep to the jawbone (yellow) & jaw muscles (green). The tumor has grown inwards towards the throat (orange) and the palate (purple). There were no enlarged lymph nodes in the parotid gland or in the neck.

The surgery was done through an incision in the neck below the level of the jaw (trans-cervical approach). The blood vessels and nerves were identified and the tumor was removed with additional parotid tissue, as well as muscle and fat surrounding it. The facial nerve was fully functional. Final pathology revealed the majority of the tumor was pleomorphic adenoma, however there was an area that had transformed into a cancer (carcinoma expleomorphic adenomas). The cancer occupied roughly 30% of the tumor and was eating through the capsule and invading the adjacent fat.

Due to the fact that the cancer had spread outside of the capsule of the benign tumor, it was necessary to have radiation treatment. She has done well over the years and has shown no signs of recurrence of this cancer over the past decade.

Image Notes: Mass (Red) extending from the deep end of the parotid gland into the parapharyngeal space. The trans-cervical incision (Green Line) was used to remove the tumor

SKIN CANCER SPREAD (METASTATIC) TO THE PAROTID GLAND

57 year old man with 8 month history of a firm mass growing in the right parotid gland. MRI revealed a singular mass in the parotid gland without any enlarged lymph nodes in the neck. Needle biopsy showed it to be a melanoma. Inspection of the skin on the right side reveals an irregular mole on the right upper posterior neck (blue arrow).

PET scan revealed only activity in the area of the skin mole and parotid gland, and no activity in the neck or other parts of the body. As such, he was an appropriate candidate for surgery. An ultrasound was performed the day before surgery in the office by Dr. Larian which showed the exact dimensions & location of the tumor, as well as looking at the lymph nodes in the neck; fortunately the neck lymph nodes appeared all to be normal.

During the parotidectomy the area of the skin mole was also cut out with an extra amount of skin around it (to make sure any microscopic tentacle of melanoma is removed). The skin and parotid were removed as one unit (en bloc). This is done so that if there are any intervening cancer cells in transit from the skin to the parotid gland, they would all be captured. A group of lymph nodes in the neck, under the parotid gland, were also removed to see if the melanoma had spread to them. During the surgery the edges of what was removed in the skin and parotid were sent to pathology and found to have no cancer cells (negative margins). This meant an adequate amount of tissue had been removed.

The area was reconstructed with a stenrocleidomastoid (SCM) muscle flap. All branches of the facial nerve were preserved and fully functional.

The final pathology report indicated that skin cancer had been removed completely with negative margins. There was one large lymph node (the visible mass) & 2 smaller lymph nodes in the parotid gland with melanoma in them. And 2 of the lymph nodes in the neck had microscopic melanoma in them. He was started on immunotherapy protocol and has continued to remain free of cancer.

Image Notes: The parotid tumor (Green Arrow). The melanoma in the skin (Blue Arrows) was in the upper neck.

HIGH GRADE CARCINOMA WITH LYMPH NODE INVOLVEMENT FACIAL NERVE IDENTIFIED IN THE MASTOID BONE

52 year old woman with an 8 month history of a growing mass in the left parotid gland. She started to develop pain in the area of the mass and ultimately had a CT scan that revealed a parotid mass sitting adjacent to the skull bone (mastoid bone), and some enlarged lymph nodes in the neck. She underwent a needle biopsy, which revealed it to be a high grade cancer, but the exact type could not be determined. A PET scan was done, which showed the tumor to be limited to the parotid and the lymph nodes in the neck, without spread to other parts of the body.

Her case was reviewed at our multidisciplinary tumor board, and the decision was made to proceed with surgery followed by a radiation treatment. As the tumor was immediately adjacent to the skull bone, which would make it difficult to identify the facial nerve, Dr. Slattery the surgery by exposing the facial nerve in the bone behind the ear (called the mastoid bone) at the beginning of the surgery. This would allow Dr. Larian to follow the nerve into the parotid gland and safely dissect out the remaining branches.

The surgery was commenced by Dr. Slattery; after the facial nerve was identified inside the mastoid bone (White Arrow), it was traced down into the parotid. Dr. Larian was then able to meticulously identify all the branches of the nerve inside the parotid gland (Blue Arrow). Once all the benches were safely identified the tumor was removed along with an extra amount of normal parotid tissue to make sure all the little tentacles of the cancer had been removed. The muscles, nerves and blood vessels were then identified in the neck after which the lymph nodes areas related to parotid tumors were removed. The facial nerve was then tested and all the branches were found to working properly

Dr. Azizzadeh then proceed to reconstruct the defect with an SCM muscle flap as well as SMAS fascia flap to fill in the defect as well as creating a smooth contour so that the patient’s face is symmetric.

The patient did undergo radiation treatment. She has done well over the years and has shown no signs of recurrence of this cancer.

Image Notes: Before & after images. Green Arrow points at the healed surgery scar. In the images below the White & Blue Arrows point to the facial nerve.

Images above shows the defect after cancer removal & the reconstruction of the area before suturing the skin layer together. Below the pathology specimens can be seen in the parotid & the neck.

HIGH GRADE CARCINOMA WITH FACIAL PARALYSIS

45 year old man living outside of USA with 9 month history of progressive facial weakness, starting with lip weakness & progressing to complete facial paralysis. He was seen by a neurologist that performed a brain CT that did not show a tumor or stroke. Later on, an MRI revealed a non-discrete mass in the left parotid gland, immediately adjacent to the skull at the area where the facial nerve comes out of the skull and enters the parotid gland, as well several abnormal lymph nodes in the neck. The needle biopsy was consistent with a high grade carcinoma. Scans of lung, abdomen & pelvis showed no metastasis.

Dr. Larian, Dr. Azizzadeh & Dr. Slattery each had an extensive discussion with the patient about the surgery and the role each doctor plays, as well as what are the possibilities for facial nerve repair and what to expect.

The surgery was started by Dr. Slattery who identified the facial nerve in the skull bone (Mastoid Bone). This bone located behind the ear contains a bony canal that has the facial nerve traveling through it. Dr. Slattery was able to open the canal and expose the facial nerve in the canal through an incision behind the ear (shown in the surgery image); this allowed Dr. Larian & Dr. Azizzadeh to have access to the facial nerve above the area where the cancer was. Stimulation of the facial nerve in this area showed no facial movement which confirmed the cancer had completely eaten through the nerve. Biopsy of the nerve in the skull showed no cancer in it, which gave the team the possibility of using the remanent facial nerve for a nerve graft.

Dr. Larian then followed the nerve from the canal into the parotid and saw the cancer completely invading the facial nerve. He went on to find the all the branches further forward in the front part of the parotid gland. He then removed the entire parotid along with a small portion of muscle around & deep to the parotid gland as well as a portion of the skull bone next to the tumor. A small specimen was sent to the pathologist from the edges of the areas the removed parotid to make sure there is no residual tumor left behind. He then identified the blood vessels and nerves in the neck and removed the lymph nodes in between these important structures (neck dissection). On the surgery image to the right you can see the cavity after the parotid gland and the tip of the mastoid bone was removed. The remanent facial nerve branches (blue arrows) are visible in front of the earlobe, which can be used for nerve grafts.

Dr. Azizzadeh proceeded with performing a very complex reconstruction. A portion of the sural nerve was removed through small incisions in the leg. This nerve is in charge of feeling in a small area of skin on the foot and can easily be sacrificed without consequence. It was attached to the remanent facial nerve in the facial canal in the skull bone (mastoid) under the microscope to get precise sutures to connect the nerves. The other end of the nerve graft (marked in green in the image) was attached to the branch of the facial nerve that are attached to midface muscles (smile muscles). A branch of a nerve going to one of the muscles of chewing (masseter muscle) was also identified and connected to another branch of the facial nerve.

The paralyzed eyebrow was drooping down and pushing the eyelid down and partially blocking the left eye. That eye also could not blink. The position of the eyebrow was corrected (green arrow) by performing a brow lift. The eyelid was also revised to allow better closure at night and with blinking. Now it was time to address the position of the corner of the lip. The paralysis of the lip and especially the midface muscles caused the angle of the lip to droop downwards, which could cause dribbling when drinking. Dr. Azizzadeh corrected the position of the lip by using a tissue from the covering of a thigh muscle called Tensor Fascia Lata. This is a very strong tissue that can be used to pull the lip. The tissue on the side of the lip was connected to one end of the Tensor Fascia Lata and the other end was sutured to the tissue in the temple thus pulling the side of the lip upwards & outwards.

The cavity left by removing the parotid tissue was reconstructed with a sternocleidomastoid muscle (SCM) flap. This was done by rotating a small portion of the SCM into the defect and suturing to the remaining tissue around the cavity. The SCM continues to be attached at one end to the rest of the SCM so that it gets blood flow and continues to survive. The SMAS fascia was also used to cover the SCM and create a smooth contour and be and additional layer to cover the SCM.

This was done on an outpatient basis and by the next day the patient was started on some degree of activity to get the blood circulating and help get rid of any residual anesthesia medicine in the system. The final pathology revealed this to be a squamous cell carcinoma, with nerve invasion & lymphovascular invasion, as well as involvement of 9 of the 28 lymph nodes in the neck.

Dr. Larian coordinated his care with the oncologist and radiation oncologist in his country, His treatment was started soon after.

Image Notes:
Tumor In the parotid spread to the lymph nodes. The incision for the surgery.
MRI -Tumor in the parotid & the facial nerve next to it. Similar to image below.

Tumor In the parotid at the area where facial nerve exits the skull and enters parotid.
Cross-section of tumor on facial nerve as it exits the skull. Same orientation as MRI

The mastoid bone being opened to identify the facial nerve above the cancer.
The entire parotid removed leaving a cavity. The lymph nodes in the neck removed.

Once the cancer & the parotid gland were removed, a nerve graft (green) is placed between the part in the bone and the smile muscles branch. A jaw muscle nerve (blue) is also connected to another smile nerve branch.

Before surgery, the full faical paralysis causing drooping of the eye and the lips. During the reconstructive surgery eyelid & brow (Green Arrow) & the lip (Blue Arrows) are elevated.

One week after surgery, the incision is healing well. A brow lift & eyelid adjustment, as well as the suspension of the lip was done. The brow & lip positions are now more appropriate & symmetric.

FREQUENTLY ASKED QUESTIONS

What happens if a parotid cancer is not treated?

The cancer continues to grow. As it grows more mutations (genetic mistakes) occur that take away inhibitions (or control commands). In time the cancer will invade the facial nerve and cause the nerve to stop working which will lead to facial paralysis. As it continues to grow more changes occur (mutations in control commands) in the cancer that allows it to exist outside of the parotid gland. Once this occurs the cancer can travel through lymph or blood vessels and spread to other parts of the neck or the whole body. Generally speaking, as parotid cancer grow they cause the problems (complications) a person would be afraid of with surgery.

Can parotid tumors be treated with natural remedies with success?

I wish that would be the case. Because all cancers arise from mutations in the genetic code, and those mutations/ mistakes are passed along to all the children of the cancer cells, a natural treatment that could eradicate the disease has to correct all the mutations in all of the cancer cells. When a cancer is 2mm wide it will contain 1 million cells. So the treatment would have to correct the genetic mistakes in millions of cells at the same time.

The alternative is to use supplements to boost the immune system, however since these millions of cancer cells have already evaded the immune system, it is unlikely that immune boosters alone would be able to eradicate the cancer. There are natural remedies, that in my experience, can help the our bodies with the fight against cancer, however, they should be used in conjunction with know effective treatments rather then instead.

Can a salivary cancer be treated without surgery?

The primary treatment for salivary gland cancers is surgery. Non-surgical treatments such as chemotherapy combined with radiation therapy have a much much lower chance of cure, and are generally reserved for those who are either too ill to undergo surgery, or their cancer is so advanced that surgery would not be able to get around the cancer and remove it.

Is the facial nerve cut with every cancer parotid surgery?

Absolutely not. If the facial nerve is fully functional before surgery, then every effort must be made to save the facial nerve and all its branches. This will require experience, dedication, and immense patience. At the CENTER we firmly believe this is time well spent and worth spending to save the facial nerve. The facial nerve and facial movements are exceeding important, and I would say much more important than one would imagine.

Most of the time when the facial nerve is involved with cancer, there are signs. At first, the facial muscles may start to twitch and then become weak before becoming fully paralyzed. There are the very rare cases, where during the surgery we find the nerve is wrapped by the cancer without any symptoms.

Are there any scans that would tell us the facial nerve is involved when it is fully functional?

Unfortunately not. The facial nerve is not visible on any scans, so when on a scan a tumor is seen in the parotid gland, it is impossible to tell if there is a nerve adjacent or inside the tumor.

The bony canal of the facial nerve in the skull is visible on CT scan, so if the cancer has invaded the skull bone (mastoid bone), then it can be seen to be in the canal.

Do other cancers besides skin cancers spread to the parotid gland?

Although rare, some types of cancers can spread from other parts of the body (organs) to the parotid gland. For example, renal cell cancers (kidney cancers) on occasion can spread to the parotid. Usually, a needle biopsy can tell us what type of cancer and potentially where it originated from. If a needle biopsy fails to pinpoint the cancer’s origin, we use a PET scan, which comprehensively scans the entire body.

Are there cancers that have a higher af finity for the facial nerve?

Yes. Some types of cancers, speci fically adenoid cystic carcinoma, like invading the nerve and traveling on then nerve or eating through it. When we encounter these types of cancers our degree of suspicion for nerve involvement is raised and speci fically look for it

Can parotid cancers invade the skull?

Unfortunately yes. There are two mechanisms to get into the skull. 1) Once the cancer has grown large enough to touch the skull (mastoid bone) then it can directly eat through the bone and grow into it. 2) The facial nerve leaves the brain and goes through a long bony canal to exist the skull and immediately enter the parotid gland before dividing into multiple branches. A parotid cancer that has migrated onto the facial nerve can travel up the nerve to enter the skull; it can potentially travel all the way up to the brain.

Meet The Team

Led by board-certified parotid surgeon, Dr. Babak Larian, our team of specialists has decades of experience successfully diagnosing and treating diseases of the parotid glands with minimally invasive procedures. Distinguished by our compassionate care and cutting-edge techniques, the CENTER has developed a reputation for delivering the best parotid tumor surgery available.

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