Salivary Gland Cancer: Stages and Grades

Approved by the Cancer.Net Editorial Board, 02/2018

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread, as well as what the cancer cells look like under a microscope. This is called the stage and grade. Use the menu to see other pages. Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.

Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until the doctor performs a biopsy. Knowing the stage helps the doctor to

decide what kind of treatment is best and can help predict a person's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

TNM staging system

One tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

Tumor (T): How large is the primary tumor? Where is it located? Node (N): Has the tumor spread to the lymph nodes? If so, where and how

many? Metastasis (M): Has the cancer spread to other parts of the body? If so,

where and how much? The results are combined to determine the stage of cancer for each person. There are 5 stages: stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Staging can be clinical or pathological. Clinical staging is based on the results of tests done before surgery, which may include physical examinations and imaging tests. Pathological staging is based on what is found during surgery. In general, pathological staging provides the most information to determine a patient’s prognosis.

Here are more details on each part of the TNM system for salivary gland cancer:

Tumor (T)

Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Tumor size is measured in centimeters (cm). A centimeter is roughly equal to the width of a standard pen or pencil.

Stage may also be divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below.

TX: Indicates the primary tumor cannot be evaluated. T0 (T plus zero): No evidence of a tumor was found. T1: Describes a small, noninvasive (has not spread) tumor that is 2 centimeters (cm) at its greatest dimension. T2: Describes a larger, noninvasive tumor between 2 cm to 4 cm. T3: Describes a tumor that is larger than 4 cm but not larger than 6 cm and has spread beyond the salivary glands but does not affect the seventh nerve, the facial nerve that controls expression, such as smiles or frowns. T4a: The tumor has invaded the skin, jawbone, ear canal, and/or facial nerve. T4b: The tumor has invaded the skull base and/or the nearby bones and/or encases the arteries.

Node (N)

The “N” in the TNM staging system is for lymph nodes. Lymph nodes near the head and neck are called regional lymph nodes. Lymph nodes in other parts of the body

are called distant lymph nodes. There are many nodes located in the head and neck area, and careful evaluation of lymph nodes is an important part of staging cancer of the major salivary glands.

NX: The regional lymph nodes cannot be evaluated. N0: There is no evidence of cancer in the regional nodes. N1: Cancer has spread to a single node on the same side as the primary tumor, and the cancer found in the node is 3 cm or smaller. N2: Describes any of these conditions: N2a: The cancer has spread to a single lymph node on the same side as the

primary tumor and is larger than 3 cm but smaller than 6 cm. N2b: The cancer has spread to more than 1 lymph node on the same side as

the primary tumor, and none measures larger than 6 cm. N2c: The cancer has spread to more than 1 lymph node on either side of the

body, and none measures larger than 6 cm. N3: The cancer found in the lymph nodes is larger than 6 cm.

Metastasis (M)

The "M" in the TNM system describes cancer that has spread to other parts of the body, called distant metastasis.

MX: Indicates distant metastasis cannot be evaluated. M0: Indicates the cancer has not spread to other parts of the body. M1: Describes cancer that has spread to other parts of the body.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Stage I: Noninvasive tumors (T1, T2) with no spread to lymph nodes (N0) and no distant metastasis (M0).

Stage II: An invasive tumor (T3) with no spread to lymph nodes (N0) or distant metastasis (M0).

Stage III: Smaller tumors (T1, T2) that have spread to regional lymph nodes (N1) but have no sign of metastasis (M0).

Stage IVA: Any invasive tumor (T4a) with either no lymph node involvement (N0) or spread to only a single same-sided lymph node (N1), but no metastasis (M0). It is also used for a T3 tumor with 1-sided nodal involvement (N1) but no metastasis (M0), or any tumor (any T) with extensive nodal involvement (N2).

Stage IVB: Any cancer (any T), with more extensive spread to lymph nodes (N2, N3), but no metastasis (M0).

Stage IVC: Any cancer with distant metastasis (any T, any N, and M1).

Recurrent: Recurrent cancer is cancer that has come back after treatment. If the cancer does return, there will be another round of tests to learn about the extent of

the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis. Used with permission of the American College of Surgeons, Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing.

Grade (G)

Doctors also describe this type of cancer by its grade (G). The grade describes how much cancer cells look like healthy cells when viewed under a microscope.

The doctor compares the cancerous tissue with healthy tissue. Healthy tissue usually contains many different types of cells grouped together. If the cancer looks similar to healthy tissue and contains different cell groupings, it is called “differentiated” or a “low-grade tumor.” If the cancerous tissue looks very different from healthy tissue, it is called “poorly differentiated” or a “high-grade tumor.” The cancer’s grade may help the doctor predict how quickly the cancer will spread. In general, the lower the tumor’s grade, the better the prognosis.

Salivary Gland Cancer: Treatment Options

Approved by the Cancer.Net Editorial Board, 02/2018

ON THIS PAGE: You will learn about the different types of treatments doctors use for people with salivary gland cancer. Use the menu to see other pages. This section explains the types of treatments that are the standard of care for salivary gland cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. To learn more about clinical trials, visit the About Clinical Trials and Latest Research sections.

Treatment overview

Many salivary gland cancers can often be cured, especially if found early. Although curing the cancer is the primary goal of treatment, preserving the function of the nearby nerves, organs, and tissues is also very important. When doctors plan treatment, they consider how treatment might affect a person’s quality of life, including how a person feels, looks, talks, eats, and breathes.

In cancer care, different types of doctors often work together to create a person's overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. An evaluation should be done by individual head-and-neck specialists before any treatment begins. The team may include these specialists: Medical oncologist: a doctor who specializes in treating cancer with

medication Radiation oncologist: a doctor who specializes in giving radiation therapy to

treat cancer

Surgical oncologist: a doctor who specializes in treating cancer using surgery

Maxillofacial prosthodontist: a specialist who performs restorative surgery in the head and neck areas

Otolaryngologist: a doctor who specializes in the ear, nose, and throat Oncologic dentist or oral oncologist: dentists experienced in caring for

people with head and neck cancer Physical therapist: a professional who addresses functional challenges that

may develop as a result of cancer and cancer treatment Speech pathologist: a specialist who helps people use muscles in the mouth

and throat Psychiatrist: a doctor who specializes in detecting and treating mental

disorders Psychologist: a professional who helps detect and treat mental disorders Cancer care teams also include a variety of other health care professionals, including physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Descriptions of common types of treatments used for salivary gland cancer are listed below. Your care plan also includes treatment for symptom and side effects, an important part of cancer care.

Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Surgery

Surgery is recommended for nearly everyone diagnosed with salivary gland cancer and is usually the first treatment. During surgery, a doctor performs an operation to remove the cancerous tumor and some surrounding healthy tissue, called a margin. A surgical oncologist is a doctor who specializes in treating cancer using surgery.

The goal of surgery is to remove as much of the tumor as possible and leave negative margins. This means no trace of cancer was found in the healthy tissue that was removed. The type of surgery depends on the location and extent of the tumor.

Types of surgery used to treat salivary gland cancer include:

Parotidectomy. The removal of the parotid gland is called a parotidectomy. This surgery may involve the facial nerve. If cancer has spread to the facial nerve, frequently a nerve graft is necessary for the person to regain use of some facial muscles. Any tissue that is removed can often be restored through reconstructive surgery (see below) and tissue transplantation.

Endoscopic surgery. Occasionally, it is possible to remove the tumor by endoscopic surgery (see Endoscopy, under Diagnosis), which is less destructive to healthy tissues than regular surgery. This is used particularly when a salivary gland tumor begins in the paranasal area (around the nose) or in the larynx. However, this is rare. More often, a tumor may be found

unexpectedly during endoscopic surgery for what is believed to be chronic sinusitis (inflammation).

Neck dissection. A neck dissection is when the surgeon examines all of the critical structures in the neck and removes lymph nodes from the neck. This may be performed if the doctor suspects that the cancer has spread. A neck dissection may cause numbness of the ear, weakness when raising the arm above the head, and weakness of the lower lip. These side effects are caused by injury to nerves in the area. Depending on the type of neck dissection, weakness of the lower lip and arm may go away in a few months. Weakness will be permanent if a nerve is removed as part of the dissection.

Reconstructive surgery. Reconstructive (plastic) surgery may be used to replace tissue and nerves that were removed during surgery to eliminate the cancer.

Surgery can have significant risks because the cancer may be close to the eyes, mouth, brain, and important nerves and blood vessels. Surgical side effects can include swelling of the face, mouth, and throat, which makes it difficult to breathe and swallow. Frequently, a person may receive a temporary tracheostomy, a hole in the windpipe, to make breathing easier.

Facial nerves may also be affected, either temporarily or permanently. Changes to a person’s appearance because of surgery may need to be addressed using reconstructive plastic surgery. If the maxilla (upper jaw) is removed, a prosthodontist will play a large role in the rehabilitation process. A prosthodontist is a dentist who specializes in replacing teeth and parts of the jaw. Learn more about cancer rehabilitation. Surgery is typically followed by additional treatment, most often radiation therapy. Sometimes, more than 1 operation may be needed to remove the cancer and to help restore the appearance and function of the affected tissues. Occasionally, it is not possible to remove salivary gland cancer using surgery. This type of tumor is called inoperable. In these cases, doctors will recommend other treatment options (see below).

Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.

There are 2 main types of radiation therapy used for salivary gland cancer:

External-beam radiation therapy. This is the most common type of radiation treatment and is given from a machine outside the body. External-beam radiation therapy may be used when a tumor has grown into the soft tissue, has spread to the lymph nodes, or surrounds a nerve. Doctors also recommend this type of radiation therapy for poorly differentiated tumors. (See the Stages and Grades section for more information.)

A specific method of external radiation therapy, known as intensity modulated radiation therapy (IMRT), allows more effective doses of radiation therapy to be delivered while reducing damage to nearby healthy cells. Another type of external-beam radiation therapy used for salivary gland tumors is proton therapy. At high energy, protons can destroy cancer cells. Proton therapy may be used when a tumor is located close to structures of the central nervous system, such as the brain and spinal cord.

Internal radiation therapy. When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy. Internal radiation therapy involves surgically implanting tiny pellets or rods containing radioactive materials in or near the tumor.

For a salivary gland tumor, radiation therapy is most often used in combination with surgery. Radiation therapy may also be given along with chemotherapy (see below). If a person cannot have surgery or decides not to have surgery, radiation therapy may be used as the main treatment.

Before beginning radiation treatment for salivary gland cancer, a person should receive a thorough examination from an oncologic dentist or oral oncologist. These doctors are experienced in treating people with head and neck cancer. Radiation therapy can cause tooth decay. Often, tooth decay can be prevented with proper treatment from a dentist before beginning treatment. Learn more about dental and oral health. Other side effects from radiation therapy to the head and neck may include redness or skin irritation in the treated area, dry mouth (xerostomia) or thickened saliva from damage to salivary glands, bone pain, nausea, fatigue, mouth sores, and/or sore throat. People may also experience pain or difficulty swallowing; loss of appetite, often due to a change in sense of taste; hearing loss, due to the buildup of fluid in the middle ear; and buildup of earwax that dries out because of the radiation therapy’s effect on the ear canal.

Radiation therapy may also cause a condition called hypothyroidism in which the thyroid gland (located in the neck) slows down and causes the person to feel tired and sluggish. People who receive radiation therapy to the neck area should have their thyroid checked regularly. Talk with your health care team about what side effects of your treatment plan are possible and how they can be prevented or managed.

Learn more about the basics of radiation therapy.

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for salivary gland cancer include chemotherapy.

Chemotherapy is the use of drugs to destroy cancer cells, usually by ending the cancer cells’ ability to grow and divide.

Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A person may receive 1 drug at a time or a combination of different drugs given at the same time.

Chemotherapy is not often used to treat salivary gland cancer. Combining chemotherapy with radiation therapy is being studied as part of clinical trials to determine its effectiveness. For salivary gland cancer, chemotherapy is most often used to treat later-stage cancer or to relieve symptoms. Some chemotherapy drugs are available in clinical trials that may treat cancer at an earlier stage. Each drug or combination of drugs can cause specific side effects, and it is important to talk with your doctor about which side effects to expect and whether any may be permanent. In general, chemotherapy side effects can include fatigue; nausea; vomiting; hair loss; dry mouth; loss of appetite, often due to a change in sense of taste; weakened immune system; diarrhea and/or constipation; and open sores in the mouth. Open sores in the mouth, coupled with a low immunity, can lead to infections. Talk with your health care team about how they can help manage or relieve treatment side effects. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatments intended to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the person with his or her physical, emotional, and social needs.

Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting people with cancer and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process.

People often receive treatment for the cancer at the same time that they receive treatment to ease side effects. In fact, people who receive both at the same time often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive

palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of the specific treatment plan and palliative care options. During and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible. Learn more about palliative care.

Metastatic salivary gland cancer

If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan. Your treatment plan may include 1 or more of the treatments listed above. Typically, the main treatment is chemotherapy or taking part in a clinical trial. Palliative care will also be important to help relieve symptoms and side effects.

For most people, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other people with cancer, including through a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence. If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above, such as surgery, radiation therapy, or chemotherapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.

If treatment does not work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support people with cancer and their families. Making sure a person is physically comfortable and free from pain is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

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