Salivary gland cancer

These cancers can arise in the parotid, submandibular or sublingual glands, or in small salivary glands throughout the mouth and upper airway. A persistent lump, facial pain or new facial weakness deserves assessment. Not every salivary-gland lump is cancer, and a painless lump still needs a diagnosis.

Ultrasound-guided needle sampling and imaging help establish the diagnosis; core biopsy may be useful when initial sampling is inadequate. Specialist pathology review can distinguish similar-looking tumors. Ask for the histologic type, grade and any high-grade transformation, rather than accepting ‘salivary cancer’ as the complete description.

Adenoid cystic carcinoma can track along nerves and recur late. Salivary duct carcinoma is often aggressive and may have targetable HER2 or androgen-receptor findings. Mucoepidermoid carcinoma varies substantially by grade; secretory carcinoma often warrants fusion testing. These differences should shape the plan.

AJCC Version 9 for salivary gland carcinoma took effect in 2026 and includes major and minor salivary glands. Nodal categories and stage grouping changed; stage IV is reserved for distant metastatic disease in this system. An older stage IV label therefore cannot be interpreted without checking the edition and original TNM findings.

MRI is particularly useful when spread along nerves is suspected. Record facial movement, pain or numbness and compare them with imaging and pathology. If a parotid specimen shows squamous carcinoma, investigate a skin or mucosal primary and nodal metastasis before assuming a primary salivary carcinoma.

Surgery is commonly the main treatment for resectable disease. The extent depends on the gland, tumor and ability to obtain clear margins. A functioning facial nerve that is not invaded should generally be preserved; proven involvement may require removal of affected portions and discussion of immediate reconstruction or later facial rehabilitation.

Neck dissection or neck radiation is guided by nodal disease and the risk of microscopic spread. A high-grade tumor may require a different neck strategy from a small low-grade lesion. Discuss likely eye closure, facial movement, sensation and shoulder function before treatment—not only the scar.

Postoperative radiation is commonly considered for high-grade disease, advanced local extent, involved or close margins, nodal spread or perineural invasion. Adenoid cystic carcinoma often warrants postoperative radiation even after complete removal. A positive margin is one factor; the whole risk profile matters.

For unresectable disease, radiation can be a principal treatment. IMRT and selected particle-therapy approaches are assessed by expected coverage and normal-tissue dose. Evidence for routinely adding chemotherapy is less established than in head-and-neck squamous cancer; some guidelines allow selected use, but it should not be presented as a proven universal survival benefit.

For appropriate advanced non-adenoid-cystic cancers, review HER2 expression/amplification, androgen-receptor expression and relevant gene fusions. In secretory carcinoma, confirm an NTRK fusion with an appropriate molecular method; NTRK protein staining or an unrelated point mutation is not equivalent to a qualifying fusion.

US larotrectinib eligibility includes an NTRK fusion without a known acquired resistance mutation, metastatic disease or surgery likely to cause severe morbidity, and no satisfactory alternative or progression after treatment. Other matching alterations may lead to a separate tumor-agnostic option or trial; a sequencing report alone is not a treatment prescription.

HER2-positive salivary duct carcinoma may be considered for HER2-directed combinations, including trastuzumab-based treatment. Androgen-receptor-positive disease may be considered for androgen deprivation or receptor blockade. When both markers are present, disease pace, previous therapy, toxicity and access help determine sequencing; neither finding promises a response.

US trastuzumab deruxtecan has an accelerated tumor-agnostic indication for adults with unresectable or metastatic HER2 IHC 3+ solid tumors after prior systemic therapy and with no satisfactory alternative. This is not the HER2-low breast-cancer indication and should not be applied automatically to IHC 1+ or 2+ salivary tumors. Lung inflammation is an important risk requiring prompt assessment of new cough or breathlessness.

Some metastatic adenoid cystic cancers, particularly slowly growing asymptomatic lung disease, can be monitored before starting systemic treatment. Observation should have a scan schedule and clear triggers for action. Progressive symptoms, threatening sites or accelerating growth can change that balance; ‘slow growing’ does not mean harmless.

Lenvatinib and axitinib have shown activity in clinical studies, but their role, access and off-label status must be discussed locally. In a randomized phase II axitinib study, progression was delayed without demonstrating a clear overall-survival advantage. Disease stabilization and tumor shrinkage are different outcomes, and toxicity can make an apparently active drug unsuitable.

A localized recurrence may still be considered for surgery or carefully planned radiation. For widespread or symptomatic disease, treatment may include a matched therapy, chemotherapy or a clinical trial. Previously delivered radiation, tumor growth over time and current symptoms are central to the discussion.

The routine head-and-neck squamous-cancer immunotherapy pathway is not a universal pathway for salivary carcinoma. Selected tumors may qualify through biomarkers such as MSI-H/dMMR or TMB-high under the relevant tumor-agnostic label, with its line-of-treatment and other restrictions. PD-L1 positivity alone is not sufficient to promise benefit across these histologies.

Follow-up may need to continue for many years, especially in adenoid cystic carcinoma because recurrence can be late. The team should individualize local imaging and chest assessment. Facial weakness, incomplete eye closure, dry mouth, dental decay, sweating with meals and neck or shoulder stiffness deserve treatment, not just documentation.

Before review, assemble pathology and molecular reports, original scans showing change over time, surgical margin and nerve findings, radiation plans and prior drug dates. Add a short account of pain, facial movement, eating and weight. These details help compare active treatment with monitoring or symptom-focused care.