Scope and Format of Guidelines

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.

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Society of Surgical Oncology Practice Guidelines: Parotid Gland Cancer

Symptoms and Signs

Early-stage disease

• Asymptomatic
• 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
• Pain

Evaluation of the Symptomatic Patient

Work-up

• 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 proven otherwise.
• 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

CT scan


• 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 it.
• 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.

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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 lobe itself

Evaluation

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 parotid tumor.

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.