1. DIAGNOSTIC EVALUATION
2. EXAMINATION UNDER ANESTHESIA AND BIOPSY
3. DEFINITIVE TREATMENT
4. FOLLOW UP
5. BIBLIOGRAPHY

I. DIAGNOSTIC EVALUATION

Clinical Evaluation

• Complete history and physical examination
  
  Includes bimanual palpation of the floor of the mouth and assessment of tongue sensation and mobility. The status of the dentition and the relationship of the tumor to the mandible must be noted. The cervical lymph nodes must be carefully assessed, including number, level and mobility when positive.

Imaging Studies

• Panoramic x-ray of mandible or occlusal dental x-ray (submental-vertex view)
  
  When the mass is small and of uncertain etiology, this may help to rule out a calculus.
  
• Chest PA and lateral radiographs
  
  To rule out metastases or another synchronous lung tumor.
  
• Computed tomography (CT) of the neck
  
  Useful when it is not clear whether a submandibular mass involves the gland itself, or adjacent level I lymph nodes. When dealing with submandibular gland carcinoma, CT can also help define the relationship of the tumor to the mandible and other oral structures and may delineate lymph node metastases that are not appreciated clinically.
  
• MRI
  
  Unlikely to add more information than a CT and should not be ordered except for special circumstances.

Laboratory Tests

According to institutional guidelines

Consultations

• Radiation oncology
  
  In anticipation of postoperative radiotherapy when dealing with a locally advanced carcinoma - Stage 3,4
  
• Dental
  
  When postoperative radiation is anticipated, or the proposed surgery includes jaw resection.
  
• Reconstructive (microvascular) surgery
  
  When an extensive resection, including segmental mandibulectomy is anticipated.
  
• Internal medicine, cardiology and/or anesthesiology
  
  When the patient has significant medical problems or the extent of the tumor suggests that anesthesia may be complicated.

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• EUA
  
  Occasionally indicated when office assessment is inadequate in order to accurately establish the limits of the tumor and the extent to which the floor of the mouth and the mandible are involved. This would include direct laryngoscopy, but not necessarily bronchoscopy or esophagoscopy.
  
• Fine needle aspiration biopsy - FNAB
  
  Indicated for any submandibular mass unless the history and findings clearly indicate sialadenitis.
  
• Excision of the submandibular gland
  
  Appropriate when the diagnosis cannot established by the FNAB, with the patient prepared for whatever additional surgery may be required depending on the frozen section report during the procedure. Open biopsy is acceptable only if FNAB is non-diagnostic and the submandibular mass is too extensive for simple excision.
  
• Review of original specimen slides
  
  When a patient is referred for definitive treatment after biopsy or gland excision elsewhere has yielded a diagnosis of carcinoma.

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Surgery

Adequate primary excision is the preferred treatment.

Primary Tumor

• Gland excision
  
  Initial procedure when the diagnosis is uncertain despite FNAB, preserving the ramus marginalis branch of the facial nerve, the lingual nerve and the hypoglossal nerve.
  
• Extended gland excision
  
  When a carcinoma extends to or beyond the capsule of the gland, resection of any of the above structures, as well as adjacent digastric, mylohyoid or hyoglossus muscles may be required.
  
• Composite resection
  
  Including segmental mandibulectomy when a large carcinoma involves the mandible and the adjacent floor of the mouth.

Neck

• N₀:An elective, selective neck dissection (Levels I-III) may be appropriate in selected patients whose neck is clinically negative when the primary tumor is sizable and/or high grade histologically.
  
• N₁:Less than a comprehensive ND and accessory nerve sparing may be reasonable in selected patient with minimal node involvement; e.g. 1 node positive and <2cm in size.. The extent of the lymphadenectomy is the surgeon's choice and postoperative radiation therapy is usually indicated in this setting.
  
• N_2-3:A comprehensive neck dissection is indicated when there is clinical evidence of nodal metastasis. The accessory nerve should be preserved when feasible.

Reconstruction

• Primary closure
  
  Usually suffices.
  
• Repair with regional flap
  
  Neck or pectoralis myocutaneous flap may be indicated when a locally advanced tumor involves the skin.
  
• Free tissue transfer
  
  Appropriate for selected patients with extensive tumors which require composite resections, including segmental mandibulectomy.

Intraoperative Considerations

• Frozen section assessment of margins as needed to ensure adequate resection
  
• Suction drains
  
• Insertion of a feeding tube
  
• Tracheostomy (when segmental mandibulectomy is performed)

Postoperative care

• Hospitalization: 2-5 days for gland removal only, 4-10 days for gland removal with neck dissection, composite resection or composite resection with free mandibular graft
  
• Drains on low suction for 3-4 days (or removal when output <30cc/24 hours)
  
• Oral sprays b.i.d. (for patients with intraoral suture lines)
  
• Tracheostomy care daily (in patients who required mandibulectomy) with tube change in 4-5 days and decannulation in 6-7 days
  
• Tube feedings (in patients who have intraoral suture lines) for 6-7 days
  
• Discharge planning (provide instruction to the patient and at least one other person when discharge with a feeding tube or a tracheostomy is anticipated. In the latter case, arrangements must be made for a portable suction machine at home, and possibly visiting nurse service.)
  
• Suture removal from neck wounds in 7 - 10 days (longer if previously irradiated)

Radiation Therapy

• Definitive
  
  External beam radiation therapy when the tumor is unresectable, or when the patient's medical status precludes surgery. It is usually delivered using photons, electrons or a combination of the two in a manner that minimizes irradiation of the contralateral salivary glands. The usual dose range is 50-70 Gy in 1.8-2.0 Gy daily fractions over 5 to 8 weeks. Hyperfractionation may be appropriate and interstitial implants may be used to boost the dose. Neutron therapy may be considered for recurrent or unresectable local/regional disease.
  
• Postoperative
  
  When there is concern about adequacy of the primary tumor excision, when the extent of the tumor indicates a high risk of local recurrence (T3,4), or when nodal metastases are confirmed. Radiation is initiated within a reasonable period after healing has occurred. The usual dose range is 50 - 70 Gy in daily fractions of 1.8 to 2.0 Gy in 5 to 8 weeks. This include a brachytherapy boost when indicated by pathological findings such as unsatisfactory margins. Entire ipsilateral neck is treated, but the contralateral neck is usually not treated.
  
• Combined modality therapy
  
  When malignant diagnosis confirmed only after gland excision and the primary tumor is small and does not extend to the capsule of the gland. As an alternative to additional surgery, external radiation is delivered to the entire ipsilateral neck according to the postoperative regimen listed above.
  
• Chemotherapy
  
  No proven role for neoadjuvant use of chemotherapy (CT) in the surgically resectable patient. In patients deemed unresectable, CT used in conjunction with XRT may enhance local control in patients who are not surgical candidates.

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IV. FOLLOW-UP

• Every one or two weeks during XRT
  
• Complete head and neck exam monthly for first year (every 6 weeks if XRT given), every 3 months for second and third years, every 6 months thereafter
  
• Chest PA and lateral yearly

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Spiro RH, Hajdu SI, Strong EW. Tumors of the submaxillary gland. Am J Surg 1976; 132:463-468.

Spiro JD, Spiro RH. Submandibular gland tumors. In: Shockley WW and Pillsbury HC, ed. The Neck, Diagnosis and Surgery. St. Louis: Mosby, 1994: 295-306.

Weber RS, Byers RM, Petit B, et. al. Submandibular gland tumors, adverse histologic factors and therapeutic implications. 1990; Arch Otolaryngol Head Neck Surg 116:1055.