The salivary glands are found in and around the mouth and are divided into major and minor. The former are bilateral and symmetrical, including the parotid gland (in front of the ear and behind the angle of the mandible), the submandibular gland (posterior inferior mandible) and the sublingual gland (under the floor of the mouth to the sides of the tongue); the latter are present in different regions of the face, including the nose and sinuses, and are very numerous (hundreds) but too small to be seen with the naked eye.

STAFF

At the IEO salivary gland cancer is treated by a multidisciplinary team consisting of specialists in:

• Otolaryngology - Head and Neck Surgery
• Urogenital and Head and Neck Tumors Medical Treatment
• New Drugs and Early Drug Development for Innovative Therapies
• Department of Pathology and Laboratory Medicine
• Department of Medical Imaging and Radiation Sciences

Defining risk factors for salivary gland tumor is not simple. In the case of the salivary glands it is known that exposure to radiation in the area of the head and neck (for a previous medical treatment) increases the risk. This parotid gland tumor appears as rarely painful nodular masse (to be placed in differential diagnosis with the most frequent benign tumours) in the face, neck, or mouth. Dimorphisms may appear on the face (grimacing, changes in the shape and attitude) if the lesions affect the facial nerve (the nerve intended to the mimic muscles) or one of its branches.

For a correct diagnosis of parotid tumor an examination must be performed by a specialist with careful assessment of the medical and family history, and a targeted ultrasound examination allowing needle aspiration of a cell sample to be manoeuvred from the suspected areas, and the subsequent cytological diagnosis are required, which may also be repeated using needle biopsy technique for histological diagnosis. Additional radiological CT (computed tomography) and especially MRI (magnetic resonance) are considered second instance examinations for parotid gland tumors and are required by the specialist in selected cases.

The salivary gland cancers are rare and account for no more than 1% of all cancers. They can occur at any age but are unlikely to occur before the age of 40. Men and women are both affected with no substantial differences between the two. The histology of these tumours depends on the type of originating cell. Examples are muco-epidermoid carcinoma (more common in the parotid), cystic adenoid carcinoma, and many different types of adenocarcinoma (clear cell, basal cell, not specified, mucinous). In the salivary glands other cancers such as squamous cell carcinomas, undifferentiated carcinomas, melanomas and lymphomas (very rare) may be generated.

Good standards for prevention

• Adopting a healthy lifestyle, not smoking and limiting alcohol intake.
• Adopting a few precautions in eating habits: eating fruit, vegetables, and foods rich in carotenoids, such as tomatoes, carrots, sweet and spicy peppers, pumpkins, apricots, herbs (probable evidence).
• Keeping a careful eye on oral hygiene.
• Not underestimating any injury of the mouth although small or painless (nodules, small ulcers, white or red patches, growths).
• After the age of 60 in subjects with risk factors, examination of the oral cavity and pharyngeal-laryngeal district is recommended.
• Undergoing regular visits, if already affected in the past by a carcinoma of the head and neck district.

The most common symptoms and signs are small ulcers of the lip or mouth, a white or red spot in the oral mucosa, frequent epistaxis (nosebleeds), nasal respiratory obstruction, hoarseness, persistent sore throat, feeling of closed ears, pain radiating to the ear, blood in sputum, difficulty chewing, swallowing or breathing, numbness of the tongue, painless and persistent swelling in the neck. The durability of these disorders should be considered as an alarm bell; if they have not resolved spontaneously or with treatment within 3 weeks, a specialist should be consulted.

The first approach to treatment is essential. Cure is the main goal, and is considered as important as the quality of life and functionality of the treated organs, such as the voice, language, swallowing, taste and breathing. IEO provides patients with a multidisciplinary team dedicated to diagnosis, treatment and rehabilitation

Innovative and minimally invasive therapies: over the years the Division has developed some original techniques and minimally invasive approaches to improve the oncological and functional results of interventions, so that patients have more therapeutic options with less surgical impact. Some of these therapies are available only here in IEO.

Surgery: our head and neck surgeons perform the highest number of operations for malignant tumours each year than any other center in Italy (AGENAS data). Moreover, for more than 20 years we have been conveying the message of Prof Veronesi, that is, "the minimum effective therapy" also for head and neck lesions. We were the first in Italy to offer conservative thyroid surgery, with over 15 years of experience in hemi-thyroidectomy even for malignant tumours. We were among the first to perform endoscopic conservative surgery of the larynx with over 250 procedures a year, we were pioneers in functional tongue surgery allowing a near normal post-op quality of life. Finally, for over 20 years we have been performing very delicate salivary gland surgery. This is the only recognised head and neck surgery department in Italy.

USDAS (Ultrasound dye assisted surgery): The division has developed an original technique by means of vital dye and ultrasound guidance to identify recurrent nodules in the thyroid, salivary and lymph node areas. This technique is more effective and reduces the risks of complications[1]

THE VALUE OF A MULTIDISCIPLINARY TEAM

Our multidisciplinary team is dedicated to the diagnosis, treatment and rehabilitation of patients with tumors of the head and neck, and to the study of these diseases. Our team includes over thirty oncology professionals with expertise in various specialties, such as ENT, maxillofacial surgery, emergency surgery, plastic-reconstructive surgery, radiotherapy, medical oncology, radiology, pathology, nuclear medicine, nutrition, physiotherapy, endocrinology, dentistry, voice therapy, speech therapy, psychology, and biology.

 The integration of various skills can address complex clinical problems, from diagnosis and treatment planning, to the functional recovery (speech, breathing, swallowing) in order to achieve the best results with cancer and adequate quality of life. The cervicofacial surgery program consists of the medical-surgical team, Radiotherapy and Medical Oncology specialists, dedicated radiologists, endocrinologists, nuclear physicians and pathologists.

The team works in harmony and meets on a weekly basis to discuss cases of patients who trust in our structure. They develop comprehensive personalized care plans considering all aspects of treatment and rehabilitation, considering the different treatment options, taking into account the needs of individual patients in accordance with internal, national and international guidelines.

The team, in close collaboration with the Scientific and Health Management Board, monitors the results of treatment and the quality of the performances in real time in order to point out critical issues and identify areas for improvement and development. The multidisciplinary meetings are an opportunity for professional development based on the exchanges in the group, the evidence in the literature, and the critical review and update of guidelines as well as diagnostic and therapeutic approaches. The information obtained from the critical review of the clinical activities, from technological innovations, from the study of the evolution of the cancers treated, and from continuous updating are used to identify open issues and propose research activities. Thanks to this approach, clinical research activities and institutional research projects in collaboration with national and international institutions have been put in place.

Parotid gland tumor

The treatment of choice of parotid gland tumor is surgery for the salivary glands (except for a few rare exceptions such as lymphoma). Surgery allows the removal of the parotid tumor and some surrounding tissues and the lateral cervical lymph nodes (which may be the site of metastases), when necessary. Interventions are sensitive especially because of the presence of nerve structures in the salivary glands (the facial nerve and its branches). The surgical techniques are very advanced and use magnification (with a microscope and/or magnifying glasses) and facial nerve reconstruction when it has been damaged during the removal of the parotid tumour. On the basis of the definitive histological examination of the parotid tumor, postoperative radiotherapy is prescribed in selected cases. 

When it is necessary to sacrifice the facial nerve (due to parotid tumor infiltration), immediate reconstruction can be performed by transposing one or more segments of a donor nerve (great auricular, sural, latissimus dorsi). The donor nerve can be sacrificed because it does not imply major functional deficits. This technique can be practised in patients undergoing postoperative radiotherapy and allows recovery of face motility within 4-12 months. If for some reason immediate reconstruction cannot be performed, the patient may decide to undergo different types of delayed reconstruction.

Access to the most innovative therapies: Immunotherapy is one of the most promising non-surgical treatments, and works by strengthening the patient's immune response against the tumor. Adrotherapy (radiotherapy with protons or carbon ions) is the therapy of choice for many neoplasms of the salivary glands or for tumors located in sensitive anatomical sites or those are difficult to surgically remove.

Distant metastases of head and neck carcinoma

Distant metastases are defined as tumor spread to other organs. Lung, liver, and bone are the most common sites for hematogenous metastases of head and neck squamous cell carcinoma. The incidence of distant metastasis in head and neck squamous cell carcinoma is low for the general head and neck squamous cell carcinoma population: generally below 5% at presentation. Head and neck squamous cell carcinoma patients with distant metastases are generally candidates for palliative treatment scenarios only, because currently no systemic therapy has curative potential in head and neck squamous cell carcinoma patients with distant disease. Consequently, extensive locoregional treatment is usually considered futile in these patients. Particular attention is paid to our collaboration with CNAO, National Centre of Oncology Hadrontherapy) for Phase II, the clinical trial on radiotherapy boost, using protons (hadron therapy) for locally advanced tumours of the cervical-cephalic district.

Attention to the patient and his quality of life: since 2003, the department has been equipped with a speech therapy service, one of the best in Italy, which deals with the rehabilitation of swallowing, phonation and the articulation of the word. The division also has a dentistry service that deals with the preparation for surgery and postoperative dental rehabilitation. The IEO also has a physiotherapy service for motor and respiratory rehabilitation and a dietician for the management of nutritional aspects.  Pain management and Psychological support services are also offered. A holistic approach which takes care of all the needs of the patient, allowing a more rapid return to normal life.

Clinical nutrition

Stage and location of the disease, anatomical changes resulting from any surgical procedure, and the acute and late toxicity of chemo-radiotherapy are all factors that may contribute to the impairment of swallowing and create deficiency in the oral protein-calorie intake.

Artificial Nutrition (AN) is indicated in cases of cancers that cause a stenosis (narrowing), severe dysphagia (difficulty in eating that contraindicate oral feeding), or in the case of evident malnutrition or in the patient who, although feeding through the mouth, takes on a calorie-protein amount <50% of nutritional needs. AN must also be started when you expect a period of severe dysphagia longer than 7 days or inadequate intake (<60% of the nutritional requirements) for at least 10 days.

In patients with cancer of the cervical-facial district, Enteral Nutrition (EN) represents the primary route of choice when the gastrointestinal tract is accessible and functioning. It can be performed via nasogastric tube or via Percutaneous Endoscopic Gastrostomy (PEG) or Jejunostomy Nutrition, in case of expected duration of nutritional support greater than 3-4 weeks. EN is effective in containing the decline in body weight, prevent dehydration and interruptions of the radio-chemotherapy treatment, reduce the frequency and duration of hospitalisations, and improve the quality of life.

 Adequate nutritional support during radiotherapy treatment can reduce the impact and degree of morbidity (mucositis, odynophagia, dysphagia, xerostomia, dysgeusia, nausea, vomiting, and anorexia), minimise weight loss, preserve the nutritional status, improve the quality of life and optimise by speeding it up the recovery of the patient at the end of treatment.

The use of early and intensive nutritional counseling and oral caloric supplementation have been shown to increase the protein-calorie oral intake, reduce the extent of body weight loss, and reduce the interruptions of the cancer treatment.

In the presence of a sufficiently safe swallowing, oral feeding (using a diet modified in consistency) is the first choice.