Surgery for Salivary Gland Cancer

Studies have shown that people with head and neck cancer who are treated at facilities that perform a lot of head and neck cancer surgeries, tend to live longer. Because of this and the complex nature of these operations, it’s very important to have a surgeon and cancer center with experience treating these cancers.

Surgery is often the main treatment for salivary gland cancers. Your cancer will probably be treated with surgery if the doctor believes that it can be removed completely. That is, if it is resectable. Whether or not a cancer is resectable depends largely on how far it has grown into nearby structures, but it also depends on the skill and experience of the surgeon. Choosing a surgeon who has treated many patients with salivary gland cancer gives you the best chance of having your cancer removed completely. This gives you the best chance of being cured.

In most cases, the cancer and some or all of the surrounding salivary gland will be removed. Nearby soft tissue may be taken out too. The goal is to have no cancer cells on the outside edges (margin) of the removed surgical tissue which contains the cancer. If the cancer is high grade (more likely to grow and spread quickly) or if it has already spread to lymph nodes, lymph nodes might be removed in an operation called a neck dissection (described below).

Before surgery, ask your surgeon:

• Exactly what will be done during the operation?
• What are the goals of the surgery?
• Are there are other options?
• Will the surgery change the way I look or the way my body works?
• What side effects can I expect?

Quit smoking

If you smoke, quitting for good (before treatment starts, if you can ) is the best way to improve your chances for survival. Smoking during cancer treatment can increase the risk of side effects after surgery and is linked to poor wound healing and worse outcomes. Smoking after treatment can also increase the risk of the cancer coming back as well as the risk of getting a new cancer. It is never too late to quit.

Types of surgery for salivary gland cancer

The type of surgery will depend on which salivary gland is affected.

Parotid gland surgery

Most salivary gland tumors occur in the parotid gland. Surgery here is complicated by the fact that the facial nerve (which controls movement of the facial muscles, some ability to taste, the ability to make tears and saliva, and some aspects of sensation of the skin on the same side of the face) passes through the gland. For these operations, a cut is made in the skin in front of the ear and may extend down to the neck.

Most parotid gland cancers start in the outside part of the gland, called the superficial lobe. These can be treated by removing only this lobe, which is called a superficial parotidectomy. This usually leaves the facial nerve unharmed and does not affect facial movement, taste, or sensation.

If your cancer has spread deeper, the surgeon will remove the entire gland. This operation is called a total parotidectomy. If the cancer has grown into the facial nerve, it will have to be removed as well. If your surgeon has mentioned this surgery as a possibility, ask what can be done to repair the nerve and treat side effects caused when the nerve is removed. If the cancer has grown into other tissues near your parotid gland, these tissues might also need to be removed.

Submandibular or sublingual gland surgery

If your cancer is in the submandibular or sublingual glands, the surgeon will make a cut in the skin to remove the entire gland and perhaps some of the surrounding tissue or bone. Nerves that pass through or near these glands control movement of the tongue and the lower half of the face, as well as sensation and taste. Depending on the size and location of the cancer, the surgeon may need to remove some of these nerves.

Minor salivary gland surgery

Minor salivary gland cancers can occur in your lips, tongue, palate (roof of the mouth), mouth, throat, voice box (larynx), nose, and sinuses. The surgeon usually removes some surrounding tissue along with the cancer. The exact details of surgery depend on the size and location of the cancer.

Possible risks and side effects of salivary gland surgery

All surgery has some risks, including complications from anesthesia, bleeding, blood clots, and infections. These risks are generally low but are higher with more complicated operations.

Pain: For any salivary gland cancer surgery, the surgeon may need to cut through your skin or cut inside your mouth. Most people will have some pain afterward, but this can usually be controlled with medicines.

Damage to the facial nerve: If your facial nerve is damaged during surgery, you might lose control of your facial muscles on the side where the surgery was done. That side of your face may droop. You might also have trouble closing your eyes completely on that side which can lead to dry eyes. This might be treated with eye drops, eye patches, or artificial tears. If the injury to the facial nerve is related to retraction (pulling) of the nerve during surgery and/or swelling from the operation, the damage might heal over time and the facial nerve function usually returns over a few months. If the facial nerve does not start working after a certain period of time, there are some types of surgery that might help, such as nerve grafting. It is a good idea to ask about possible treatments for this side effect.  

Frey syndrome: Sometimes, nerves cut during surgery grow back abnormally and become connected to the sweat glands of the face. This condition, called Frey syndrome or gustatory sweating, results in flushing or sweating over areas of your face when you chew. Frey syndrome can be treated with medicines or with additional surgery.

Trouble speaking or swallowing: Damage to other nerves in the face or mouth might cause problems with tongue movement, speech, or swallowing.

Change in how you look: Depending on the extent of the surgery, your appearance may be changed as a result. This can range from a simple scar on the side of the face or neck to more extensive changes if nerves, parts of bones, or other structures need to be removed.

It’s important to talk with your doctor before the surgery about what changes in appearance or other side effects you might expect. This can help you prepare for them. Your doctor can also give you an idea about what corrective options might be available afterward, such as skin grafts, nerve grafts, and reconstructive surgery.

Lymph node removal (neck dissection)

Salivary gland cancers sometimes spread to lymph nodes in the neck (cervical lymph nodes), and these may need to be removed as a part of treating the cancer. Surgery to remove lymph nodes might be called a lymph node dissection, lymphadenectomy, or neck dissection. 

A neck dissection might be done if:

• Lymph nodes in the neck are enlarged (which may be felt or seen on a CT or MRI scan)
• A PET (positron emission tomography) scan suggests the lymph nodes may contain cancer
• The cancer is high grade (looks very abnormal in the lab) or has other features that mean it has a high risk of spreading
• A biopsy of one of the abnormal lymph nodes in the neck shows cancer 

The removed lymph nodes are looked at closely in the lab to see if they contain cancer cells. Taking out the lymph nodes can help ensure all of the cancer is removed. It can also be important for staging and deciding if more treatment is needed.

There are many types of neck dissections, and they differ in how much tissue is removed from the neck. The amount of tissue removed depends on the primary cancer’s size and how much it has spread to lymph nodes.

• In a partial or selective neck dissection only a few lymph nodes are removed.
• For a modified radical neck dissection, most lymph nodes on one side of the neck between the jawbone and collarbone are removed, as well as some muscle and nerve tissue.
• In a radical neck dissection, nearly all nodes on one side, as well as even more muscles, nerves, and veins are removed.

This type of surgery is usually done through an incision (cut) across the side of the neck, but sometimes a longer incision going down the neck might be needed.

Possible risks and side effects of lymph node removal

The general risks of a neck dissection are much like those with any other type of surgery, including problems with anesthesia, bleeding, blood clots, infections, and poor wound healing. Most people will have some pain afterward , but this can usually be controlled with pain medicines.

Nerve damage: The most common side effects of any neck dissection are numbness of the ear, weakness when raising the arm above the head, and weakness of the lower lip. These side effects can happen when nerves that supply these areas are damaged during the operation. After a selective neck dissection, the nerve might only be injured and can heal over time. Nerves heal slowly and the weakness of the shoulder and lower lip may go away after a few months. If a nerve is removed as part of a radical neck dissection or because of involvement with tumor, the weakness will be permanent.

After any neck dissection procedure, physical therapy can help improve neck and shoulder movement.

Sentinel lymph node biopsy

Sentinel lymph node mapping and biopsy has become a common way to find out whether cancer has spread to the lymph nodes. It may be used in certain types of salivary gland cancer and can help keep you from needing a neck dissection. This procedure can find the lymph nodes that drain lymph fluid from the salivary gland where the cancer started. Since these lymph nodes are usually the first place cancer will go, they are taken out and checked for cancer during the surgery. If no cancer cells are found, the other lymph nodes can be left alone. If cancer cells are found in them, a more complex neck dissection is usually needed.  

Sentinel lymph node biopsy should only be done at treatment centers by doctors with a lot of experience in the technique.

Supportive surgery

Feeding tubes

Sometimes, if salivary gland cancer has spread widely to nearby tissues, these cancers may keep you from swallowing enough food to stay well nourished. This can make you weak and make it harder to complete treatment. Sometimes the treatment, such as extensive surgery, can make it hard to eat.

A gastrostomy tube (G-tube) is a feeding tube that's put through the skin and muscle of your abdomen (belly) and right into your stomach. Sometimes this tube is placed during an operation, but often it's put in endoscopically. While you are sedated (using drugs to put you in a deep sleep), the doctor puts a long, thin, flexible tube with a camera on the end (an endoscope) down the throat to see inside the stomach. The feeding tube is then guided through the endoscope and to the outside of the body. When the feeding tube is placed through endoscopy, it's called a percutaneous endoscopic gastrostomy, or PEG tube. Once in place, it can be used to put liquid nutrition right into the stomach. As long as they can still swallow normally, people with these tubes can eat normal food, too.

PEG tubes can be used for as long as needed. Sometimes these tubes are used for a short time to help keep you healthy and fed during treatment. They can be removed when you can eat normally.

If the swallowing problem is likely to be only short-term, another option is to place a nasogastric feeding tube (NG tube). This tube goes in through the nose, down the esophagus, and into the stomach. Again, special liquid nutrients are put in through the tube. Some people dislike having a tube coming out of their nose, and prefer a PEG tube.

In any case, the patient and family are taught how to use the tube. After you go home, home health nurses usually visit to make sure you are comfortable with tube feedings.