Management of Salivary Gland Malignancy
Publication Date: March 31, 2021
Last Updated: March 14, 2022
Recommendations
Preoperative evaluation
1.1. Providers should perform imaging (neck ultrasound, computed tomography [CT] with intravenous contrast, and/or magnetic resonance imaging [MRI] of the neck and primary site) in patients with a suspicion of a salivary gland cancer. (EBIS)
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1.2. Providers should perform CT of the neck with intravenous contrast for patients with suspicion of salivary gland cancer and involvement of adjacent bone. (EBIS)
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1.3. Providers should perform contrast-enhanced MRI with a diffusion sequence of the neck and skull base for patients with suspicion of salivary gland cancer with concern for perineural invasion and/or skull base involvement. (EBIS)
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1.4. Providers may perform a PET/CT from the skull base to mid-thighs for patients with advanced-stage high-grade salivary gland cancers. (EBLW)
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1.5. Providers should perform a tissue biopsy (either fine needle aspiration biopsy [FNAB] or core needle biopsy [CNB]) to support distinction of salivary gland cancers from nonmalignant salivary lesions. (EBHS)
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1.6. Providers may perform CNB if FNAB is inadequate or subsite precludes FNAB such as deep minor salivary glands. (EBLM)
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1.7. Pathologists should report risk of malignancy using a risk stratification scheme for salivary FNABs with particular attention to high-grade features. (EBIS)
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1.8. Pathologists may perform ancillary testing (immunohistochemical or molecular studies) on FNABs and core needle biopsies to support diagnosis and risk of malignancy. (EBLW)
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Diagnostic and therapeutic surgical procedures
2.1. Surgeons should offer open surgical excision for histologically confirmed salivary gland malignancies. (EBHS)
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2.2. Surgeons may request intraoperative pathologic examination to support immediate alterations in intraoperative management (extent of resection and neck dissection). Decisions that would result in major harm such as facial nerve resection should not be based on indeterminate preoperative or intraoperative diagnoses alone. (EBLW)
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2.3. Surgeons may perform partial superficial parotidectomy for appropriately located superficial T1 or T2 low-grade salivary gland cancers. (EBLW)
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2.4. Because of the risk of intraparotid nodal metastases in high-grade or advanced-stage parotid cancer, surgeons should perform at least a superficial parotidectomy with consideration of a total or subtotal parotidectomy for any high-grade or advanced (T3-T4) parotid cancer. (EBIS)
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2.5. Surgeons should perform facial nerve preservation in patients with intact preoperative facial nerve function when a dissection plane can be created between the tumor and the nerve. (EBIS)
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2.6. Surgeons should perform resection of involved facial nerve branches in patients with impaired facial nerve movement preoperatively or when branches are found to be encased or grossly involved by a confirmed malignancy. (EBIM)
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2.7. Surgeons should offer an elective neck treatment over observation in a clinically negative neck in T3 and T4 tumors and high-grade malignancies. (EBIM)
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2.8. For operative elective neck management of salivary cancers, ipsilateral selective neck dissection should be performed with levels dependent on the primary site. For parotid malignancies, levels may include 2-4. (EBLM)
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2.9. For a cN+ neck, surgeons may perform an ipsilateral neck dissection of involved and at-risk levels and may extend to adjacent levels, up to levels 1-5. (EBLM)
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2.10. In the setting of resectable, recurrent locoregional disease and no distant metastatic disease, regardless of prior treatment type, patients should be offered revision resection and appropriate surgical reconstruction and rehabilitation. (EBIS)
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2.11. In the setting of resectable, recurrent locoregional disease and distant metastatic disease, regardless of prior treatment type, treatment may include palliative revision resection and appropriate surgical reconstruction and rehabilitation, if the metastatic disease is not rapidly progressive or imminently lethal. (EBIM)
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2.12. Patients undergoing revision surgery for recurrent salivary gland cancer should be evaluated for potential adjuvant therapy. (EBIM)
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Radiotherapy
3.1. Postoperative radiation therapy (RT) should be offered to all patients with resected adenoid cystic carcinoma (ACC). (EBIS)
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3.2. Postoperative RT should be offered to patients with tumors with the following features: high-grade tumors, positive margins, perineural invasion, lymph node metastases, lymphatic or vascular invasion, and T3-T4 tumors. (EBIS)
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3.3. Postoperative RT may be offered to patients with tumors with close margins or intermediate-grade tumors. (ICIW)
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3.4. In postoperative cases, the high-dose target should cover the salivary gland surgical bed and appropriate nodal levels. (EBIS)
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3.5. In the case of perineural invasion, the associated nerve(s) may be covered with an elective or intermediate dose to the skull base. (ICIM)
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3.6. Elective nodal coverage may be offered for T3-T4 primary and high-grade malignancies. (ICIM)
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3.7. Radiation should be initiated within 8 weeks of surgery. (ICIM)
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3.8. Particle therapy, including proton, neutron, and carbon ion therapy, may be used for patients with SGM; there are no indications for the use of heavy particle therapy over photon or electron therapy. (EBLW)
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3.9. Elective neck irradiation may be offered to patients with cN0 disease for the following indications: T3-T4 cancers or high-grade malignancies. (EBIM)
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3.10. Radiotherapy should be offered to patients with SGM who are not candidates for surgical resection (because of extent of disease or medical comorbidity). (EBIM)
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Note. The high-dose target should cover the gross disease in the salivary gland and any appropriate nodal levels.
Systemic therapy
4.1. In the setting of patients undergoing adjuvant radiotherapy, the addition of concurrent chemotherapy may not be routinely offered outside of a clinical trial. (EBLM)
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4.2. In the setting of patients undergoing radiotherapy for nonoperable salivary gland cancer, the addition of concurrent chemotherapy may not be routinely offered outside of a clinical trial. (ICIM)
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4.3. In patients with salivary gland tumors expressing androgen receptor (AR) and/or HER2-Neu, adjuvant endocrine or targeted therapy may not be routinely offered outside of a clinical trial. (ICIM)
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Follow-up evaluations
5.1. Clinical follow-up with history and physical examination should be completed on a regular basis with decreasing frequency as time elapses from completion of treatment of salivary gland cancer. (ICIM)
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5.2. Post-treatment baseline imaging with contrast CT or MRI (for patients without contraindications) of the primary site and/or positron emission tomography/CT should be obtained 3 months after completion of all treatment. (ICLM)
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5.3. Follow-up surveillance imaging of the primary site (contrast CT or MRI) and the chest CT may be obtained every 6-12 months for the first 2 years after treatment. (ICLM)
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5.4. Follow-up imaging of the primary site and the chest from years 3-5 should be directed by symptoms and physical examination findings. Yearly follow-up imaging may be offered in cases of high-grade histology or poor prognostic clinicopathologic features. (ICLM)
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5.5. Long-term follow-up (beyond 5 years) with yearly examination should be offered to all patients with salivary gland cancer. Yearly chest CT may be offered especially in patients with high-grade histology or poor prognostic clinicopathologic features. (ICLM)
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Recurrent-metastatic disease
6.1. Patients presenting with metastatic disease may be evaluated for further treatments such as local ablative treatments or systemic therapy. These options should be discussed with the patient and will depend on the patient and tumor factors. (ICLW)
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6.2. In the setting of ACC and/or low-grade tumors with indolent biology with limited metastases (ie, ≤5 metastases), local ablative treatments such as surgery (metastatectomy) or stereotactic body radiation therapy may be offered to delay local disease progression. (ICLW)
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6.3. Patients may be considered for initiation systemic therapy in the following circumstances:
(1) metastatic deposits are symptomatic and not amenable to palliative local therapy,
(2) growth has the potential to compromise organ function, or
(3) lesions have grown more than 20% in the preceding 6 months.
(ICLM)(2) growth has the potential to compromise organ function, or
(3) lesions have grown more than 20% in the preceding 6 months.
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6.4. For patients with ACC who are candidates for initiation systemic therapy, a multitargeted tyrosine kinase inhibitor (TKI), such as lenvatinib or sorafenib, may be offered if a clinical trial is not available. (EBLM)
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6.5. For patients with nonadenoid cystic salivary gland cancer who are candidates for initiation of systemic therapy, targeted therapy based on tumor molecular alterations (ie, AR, HER2, and NTRK) may be offered if a clinical trial is not available. (EBLM)
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6.6. Cytotoxic chemotherapy combinations may be offered to patients with symptomatic disease. (ICLW)
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6.7. For patients who are candidates for systemic therapy, checkpoint inhibitors should not be routinely offered at this time except for patients with selected molecular alteration (high tumor mutational burden [TMB], MSI-H). (ICLW)
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6.8. For patients with histologic tumor types with a high prevalence of targetable molecular alterations (ie, AR in salivary duct carcinoma and NTRK3 in secretory carcinoma), confirmatory target-specific testing should be performed. (EBIS)
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6.9. Patients who may be potential candidates for systemic therapy with histologic tumor types with low prevalence of targetable molecular alterations and unknown driver mutation status should be screened using a comprehensive panel for driver mutations; patients with driver mutation–negative tumors may then be offered target-specific testing (ie, AR and NTRK3). (EBLW)
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Recommendation Grading
Overview
Title
Management of Salivary Gland Malignancy
Authoring Organization
American Society of Clinical Oncology
Publication Month/Year
March 31, 2021
Last Updated Month/Year
November 1, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To provide evidence-based recommendations for practicing physicians and other healthcare providers on the management of salivary gland malignancy.
Target Patient Population
Patients with salivary gland malignancy
Target Provider Population
Medical oncologists, radiologists, radiation oncologists, clinical oncologists, surgeons, nurses, pathologists, oncology pharmacists
PICO Questions
What is the appropriate preoperative evaluation for patients with salivary gland malignancy?
What are the proper surgical procedures for salivary gland malignancy?
What are the treatment considerations and appropriate radiotherapy techniques for patients with salivary gland malignancy?
What is the role of systemic therapy in the management of salivary gland malignancy?
What are the appropriate post-treatment follow-up and evaluation procedures for patients with salivary gland malignancy?
What are the treatment options for recurrent or metastatic disease in patients with salivary gland malignancy?
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Keywords
Clinical Guideline, salivary gland malignancy
Source Citation
Geiger JL, Ismaila N, Beadle B, et al. Management of Salivary Gland Malignancy. J Clin Oncol. 2021 April 26. doi: 10.1200/JCO.21.00449