The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative evaluation for extent of disease, and
role of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aim
of the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad experience residing
in the membership of the Society, under the direction of Alfred M. Cohen,
MD, Chief, Colorectal Service, Memorial-Sloan Kettering Cancer Center,
to produce guidelines that were not likely to result in significant controversy.
Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.
The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.
Symptoms and Signs
- Early-stage disease
- Lump in the parotid region
- Advanced-stage disease
- Enlarged cervical lymph nodes
- Rapidly enlarging mass in the parotid region
- Mass in the parotid region that has been present for a long time,with
recent rapid growth
- Facial weakness
- Pressure symptoms in the ear
- Involvement of the skin by a parotid mass
Evaluation of the Symptomatic Patient
- Clinical examination and thorough head and neck examination
- Fine-needle aspiration of the parotid mass in selected patients
- CT scan for large tumors
- Appropriate timeliness of surgical referral
- A lump in the parotid region should be considered a parotid tumor unless
- If the patient's general condition is satisfactory, all parotid masses
should be surgically removed both for diagnostic and therapeutic purposes.
Preoperative Evaluation for Extent of Disease
- Physical examination
- Chest x-ray
- Indicated in selected patients to evaluate the extent of disease and
the presence of nodal metastasis
Role of the Surgeon in Initial Management
- Surgical considerations
- The surgeon's responsibilities include:making a standard parotid incision
and being prepared to do a superficial parotidectomy with identification
and preservation of the facial nerve.
- For most standard masses in the parotid region, surgical therapy includes
superficial parotidectomy with identification and preservation of the facial
nerve. In HIV-positive patients, local excision of a lymphoepithelial cyst
may be considered.
- If the tumor shows a high-grade malignancy, the deep jugular lymph
nodes should be evaluated and performance of a supraomohyoidneck dissection
should be considered if there are no suspicious nodes.
- If the nodes are clinically apparent, a comprehensive neck dissection
should be considered.
- If the facial nerve is functioning preoperatively, every attempt should
be made to preserve it or, if the tumor is involving the nerve, to graft
- If the facial nerve is paralyzed preoperatively, a radical parotidectomy
should be considered. Immediate nerve repair with the greater auricular
nerve or sural nerve should be considered.
These guidelines are copyrighted by the Society of Surgical Oncology
(SSO). All rights reserved. These guidelines may not be reproduced in any
form without the express written permission of SSO. Requests for reprints
should be sent to: James R. Slawny, Executive Director, Society of Surgical
Oncology, 85 West Algonquin Road, Arlington Heights, IL 60005.
The major salivary glands include the parotid, submandibular, and sublingual
glands. In addition, there are approximately 600 to 700 minor salivary
glands distributed throughout the upper aerodigestive tract.
Although salivary gland tumors are not very common, they represent an
interesting clinical entity for which early diagnosis and appropriate treatment
afford the best chance of cure. The incidence of salivary tumors is estimated
at 40 cases per million people. Approximately 75% to 80% of these tumors
involve the parotid gland.
The vast majority (80%) of parotid masses are benign, while only 20%
are malignant. In contrast, 50% of submandibular salivary tumors and 80%
of minor salivary gland tumors are malignant. Of parotid tumors, 90% originate
in the superficial lobe of the parotid and only 10% arise from the deep
The diagnosis of a parotid gland tumor is based primarily on clinical
examination. A lump in the parotid region should be considered a parotid
tumor unless proven otherwise.
Ancillary diagnostic tests include CT scanning and fine-needle aspiration
biopsy. Computed tomography is very helpful in evaluating the extent of
the tumor when clinical evaluation of involvement of the deep lobe is difficult.
In general, fine-needle aspiration is unnecessary for superficial parotid
tumors. However, if there is a clinical dilemma regarding the extent of
disease or whether a lesion is of salivary or nonsalivary pathology, fine-needle
aspiration is of considerable help. Fine-needle aspiration is also useful
in differentiating a mass in the tail of the parotid from an enlarged lymph
node. It is vitally important to distinguish between a high neck mass and
The diagnostic accuracy of fine-needle aspiration exceeds 80%. However,
the fine-needle aspiration biopsy findings should be critically evaluated
in view of the clinical judgment. Other investigations, such as sialography
and CT sialography, are not commonly used.
The operating surgeon should be prepared to make the appropriate incision
for parotid exposure and be sufficiently skilled to find the facial nerve
and preserve it. Evaluation of facial nerve function is very critical preoperatively
and postoperatively. A functioning facial nerve rarely needs to be sacrificed.
Armstrong JG, Harrison LB, Spiro RH, et al: Malignant tumors of major
salivary gland origin: A matched pair analysis of the role of combined
surgery and postoperative radiotherapy. Otolaryngol Head Neck Surg
Duncan W, Orr JA, Arnott SJ, et al: Neutron therapy for malignant tumors
of the salivary glands: A report of the Edinburgh experience. Radiother
Oncol 8:97-104, 1987.
Fu KK, Leiber SA, Levine ML, Friedlander LM, et al: Carcinoma of the
major and minor salivary glands. Cancer 40:2882-2890, 1977.
Spiro RH: Salivary neoplasms: Overview of a 35 year experience with
2807 patients. Head Neck Surg 8:177-184, 1986.
Spiro RH, Huvos AH, Strong EW: Cancer of the parotid gland, a clinicopathologic
study of 288 primary cases. Am J Surg 130:452-459, 1975.