Salivary Gland Cancer Treatment in India and UAE | Complete Patient Guide

• Newly diagnosed or recurrent primary salivary gland malignancy confirmed by core-needle or incisional biopsy with histopathological review

• Resectable disease (T1–T4a) in the parotid, submandibular, sublingual, or minor salivary glands where curative intent surgery is feasible

• Patients with high-grade histology (salivary duct carcinoma, carcinoma ex pleomorphic adenoma, high-grade mucoepidermoid) who require adjuvant IMRT ± systemic therapy

• Patients with locally advanced or recurrent disease being evaluated for re-irradiation, palliative surgery, or systemic therapy

• Individuals with molecularly characterised metastatic disease (HER2+, NTRK fusion, AR+, RET alteration) seeking targeted therapy protocols

• Patients who have received prior treatment abroad and require second-opinion multidisciplinary tumour board review

Required Diagnostic Workup Before Travel:

• Contrast-enhanced MRI of the primary site (preferred over CT for soft-tissue and perineural invasion detail)

• CT chest, abdomen, and pelvis with contrast (staging, distant metastasis)

• FDG-PET/CT (recommended for high-grade histology, stage III–IV, or suspected recurrence)

• Core-needle biopsy pathology report with WHO histological subtype and grade; immunohistochemistry for S100, p63, SOX10, mammaglobin, GCDFP-15

• Molecular/genomic profiling panel (HER2 FISH/IHC, NTRK fusion testing by NGS or IHC, androgen receptor IHC, Ki-67 proliferation index)

• Panoramic dental X-ray and dental oncology clearance prior to radiation planning

• Audiogram and renal function panel (if platinum-based chemotherapy is anticipated)

• Full blood count, LFTs, thyroid function (baseline for systemic therapy)

• ECHO or MUGA scan if HER2-directed therapy or anthracycline-containing regimen is planned

• Speech-language pathology and dietetic assessment for swallowing baseline

Contraindications and Cautions:

• Medically inoperable patients (ASA Class IV or above) may be directed toward definitive radiation or systemic therapy rather than surgery

• Distant metastatic disease with high burden may shift intent from curative to palliative — goals of care must be explicitly discussed

• Prior high-dose radiation to the head and neck region (cumulative dose constraints must be reviewed before re-irradiation)

• Severe coagulopathy, active anticoagulation, or thrombocytopenia requiring correction before surgery

• Active systemic infection or uncontrolled comorbidity (uncontrolled diabetes, severe hypertension) must be optimised pre-operatively

• Pregnancy: radiation and most systemic agents are contraindicated; surgical management requires multidisciplinary maternal-fetal input

SURGICAL APPROACHES

Parotidectomy (Superficial, Total, or Radical): The cornerstone of parotid salivary gland cancer management. Superficial parotidectomy (removal of the lobe lateral to the facial nerve) is performed for low-grade, laterally confined tumours with careful intraoperative facial nerve monitoring using continuous electromyographic (EMG) nerve monitoring systems. Total parotidectomy with facial nerve preservation is performed for deeper lobe involvement. Radical parotidectomy — sacrificing the facial nerve — is reserved for direct tumour invasion of the nerve, with immediate facial nerve reconstruction using the greater auricular nerve, sural nerve graft, or hypoglossal-to-facial anastomosis where feasible. Frozen-section margin analysis at the time of surgery is standard practice to achieve R0 (microscopically clear) resection.

Submandibular Gland Excision and Floor-of-Mouth Resection: For submandibular and sublingual primaries, en-bloc resection including the gland, capsule, and adjacent soft tissue is performed. Involvement of the mandible requires marginal or segmental mandibulectomy with microvascular free-flap reconstruction (fibula free flap, radial forearm free flap, anterolateral thigh flap) to restore form and function.

Neck Dissection: Selective neck dissection (levels I–III or I–IV) is standard for clinically or radiologically node-positive necks (cN+). Elective neck dissection is recommended for high-grade histology, T3/T4 tumours, or perineural/lymphovascular invasion even when the neck is clinically N0, given occult nodal metastasis rates of 20–49% in these scenarios. Modified radical neck dissection preserving the sternocleidomastoid, internal jugular vein, and accessory nerve is preferred over radical dissection.

Robotic-Assisted Surgery (TORS — Transoral Robotic Surgery): For minor salivary gland tumours of the oropharynx, soft palate, or base of tongue, TORS using the da Vinci Surgical System provides magnified, tremor-free, wristed instrumentation in the confined oral cavity. TORS achieves comparable oncological margins with significantly reduced morbidity — no mandibulotomy, shorter hospital stay, faster swallowing recovery — compared to open transcervical or transmandibular approaches. Leading cancer centres in India (Mumbai, Chennai, Delhi) and the UAE (Dubai) have fully operational TORS programmes.

SKULL BASE SURGERY: Adenoid cystic carcinoma with perineural spread to the skull base requires endoscopic endonasal skull base surgery or open cranio-facial resection performed by a joint neurosurgery and head-and-neck oncology team. Intraoperative navigation systems (Brainlab, Stryker) are used for precision.

RADIATION THERAPY

Intensity-Modulated Radiation Therapy (IMRT): The standard adjuvant and definitive radiation modality. IMRT uses computer-optimised beam arrangements to deliver 60–66 Gy to the tumour bed/gross disease while sparing the spinal cord, brainstem, contralateral parotid, mandible, and cochlea — substantially reducing xerostomia, osteoradionecrosis risk, and sensorineural hearing loss compared to older 3D conformal techniques.

Volumetric Modulated Arc Therapy (VMAT): An evolution of IMRT using continuous gantry rotation for faster treatment delivery and improved dose conformality. Available at leading centres in both India and the UAE.

Proton Beam Therapy: Offered at select Indian centres and internationally, proton therapy is particularly valuable for adenoid cystic carcinoma with skull base involvement, paediatric salivary gland tumours, and re-irradiation scenarios, as the Bragg peak allows maximal dose deposition at target depth with near-zero exit dose.

Stereotactic Radiosurgery (SRS/SBRT): For isolated oligometastatic lesions (lung, bone, liver) or localised recurrences not amenable to surgical salvage, SBRT delivers ablative doses in 3–5 fractions with sub-millimetre precision using Varian TrueBeam STx, Elekta Versa HD, or CyberKnife platforms available in both countries.

Neutron Capture Therapy / Fast Neutron Radiotherapy: Fast neutron radiotherapy has demonstrated superior local control rates for inoperable or recurrent adenoid cystic carcinoma; availability is limited to specialised international centres, but patients may be counselled regarding referral.

SYSTEMIC THERAPY (MEDICAL ONCOLOGY)

Cisplatin/Carboplatin + 5-FU or Docetaxel: First-line palliative chemotherapy for platinum-eligible patients with unresectable or metastatic salivary gland cancer.

HER2-Directed Therapy: Approximately 20–30% of salivary duct carcinomas overexpress HER2 (IHC 3+ or FISH-amplified). Trastuzumab (Herceptin) monotherapy or in combination with pertuzumab or paclitaxel yields objective response rates of 50–70% in this subgroup. Ado-trastuzumab emtansine (T-DM1) and trastuzumab deruxtecan (T-DXd) are emerging options with impressive activity.

Androgen Deprivation Therapy (ADT): Salivary duct carcinoma is AR-positive in 70–95% of cases. Androgen deprivation (LHRH agonists + bicalutamide) or enzalutamide produces durable disease control analogous to its role in prostate cancer.

NTRK Inhibitors: Larotrectinib (Vitrakvi) and entrectinib (Rozlytrek) produce response rates exceeding 75% in ETV6-NTRK3 fusion-positive secretory carcinomas — an essentially tumour-agnostic, biomarker-selected treatment. Both agents are available in India and the UAE through approved channels.

Immune Checkpoint Inhibitors: PD-L1 expression is variable across histological subtypes. Pembrolizumab and nivolumab have modest single-agent activity (ORR ~15%) but may be used in later lines or in high TMB tumours. Clinical trial enrolment is encouraged.

RET Inhibitors: Selpercatinib or pralsetinib for RET fusion-positive cases (rare, identified on comprehensive NGS panels).

PHASE 1 — REMOTE CONSULTATION AND PRE-TRAVEL PREPARATION (Weeks 1–2)

GAF Healthcare's oncology case managers receive your medical records digitally (MRI, PET-CT, biopsy reports, molecular panel). These are reviewed by the assigned head-and-neck surgical oncologist and submitted to the multidisciplinary tumour board (MDT) — comprising head-and-neck surgery, medical oncology, radiation oncology, pathology, radiology, speech therapy, and dentistry — for a virtual pre-consultation opinion. A detailed treatment plan and personalised cost estimate are issued within 48–72 hours. Medical visa application (India) or entry visa/visa-on-arrival process (UAE) is initiated simultaneously.

PHASE 2 — ARRIVAL AND IN-PERSON ASSESSMENT (Days 1–3 in Country)

On arrival, the patient undergoes in-hospital registration and is seen by the surgical oncologist. Imaging is reviewed on hospital PACS; repeat or additional investigations (updated MRI, dental OPG, pre-anaesthetic echo, PFTs if applicable) are completed within 24–48 hours. Formal MDT case presentation occurs on Day 2–3. Anaesthesiology pre-assessment, dental clearance, speech-language pathology baseline swallowing assessment (FEES or videofluoroscopy), and nutritional optimisation are completed. Informed consent covering surgical scope, facial nerve risks, reconstruction plan, and expected adjuvant therapy is obtained with interpreter support.

PHASE 3 — SURGICAL INTERVENTION (Day 3–5)

Surgery is performed under general anaesthesia. Duration ranges from 2–3 hours for a straightforward superficial parotidectomy to 8–12 hours for a radical parotidectomy with facial nerve reconstruction, segmental mandibulectomy, free-flap reconstruction, and bilateral neck dissection. Intraoperative continuous facial nerve EMG monitoring is used throughout parotid surgery. Frozen-section margin assessment is performed; if margins are positive, re-excision is attempted in the same sitting. A Jackson-Pratt drain is placed in the neck dissection field. For cases involving free-flap reconstruction, the patient is typically monitored in ICU overnight with hourly flap checks.

PHASE 4 — EARLY POST-OPERATIVE RECOVERY (Days 5–10 in Hospital)

Drain output is monitored daily; drains are removed when output falls below 30 mL/24 hours (typically Day 3–5 post-op). Nasogastric or oral feeding is initiated based on swallowing assessment — patients with intact oral competence begin clear liquids on Day 1–2 post-op and advance to a blended diet. Physiotherapy for shoulder rehabilitation (accessory nerve-sparing neck dissection) begins on Day 2. Wound inspection for Frey's syndrome precursors and Sialocele is performed at each dressing change. Facial nerve function is formally graded using the House-Brackmann scale at discharge. Pathology of the resected specimen (including final margin status, lymph node count, extranodal extension) is issued within 5–7 business days.

PHASE 5 — ADJUVANT THERAPY PLANNING (Weeks 2–4 in Country)

Oncology MDT reconvenes with final pathology to confirm adjuvant therapy recommendation. Radiation oncology marks treatment volumes: a radiation planning CT simulation with customised thermoplastic mask fabrication is performed. IMRT/VMAT planning is completed within 5–7 days. Adjuvant radiotherapy (typically 6 weeks, 30 fractions) begins 4–6 weeks post-surgery when wound healing is confirmed. If concurrent chemotherapy is indicated, weekly carboplatin (AUC 2) or weekly cisplatin is administered during radiation. Patients requiring radiotherapy are expected to remain in the country for the full 6-week course.

PHASE 6 — SYSTEMIC THERAPY (If Applicable, Ongoing)

For patients with metastatic or unresectable disease starting targeted therapy (trastuzumab, larotrectinib, enzalutamide), the first 1–2 treatment cycles are administered in-country with response and toxicity assessment. A follow-up care plan is issued to the patient's home oncologist for continuation, including drug sourcing guidance (both agents are available in most countries).

PHASE 7 — DISCHARGE AND FIT-TO-FLY ASSESSMENT (Weeks 4–8)

For patients who required surgery only (no adjuvant radiation), fit-to-fly assessment typically occurs at Week 4–6 post-operatively: wound fully healed, no active fistula or sialocele, post-operative CT/MRI baseline imaging completed, swallowing adequate to maintain oral hydration during flight, no active systemic anticoagulation concerns, and surgical oncologist clearance documented. For patients who completed adjuvant radiotherapy, fit-to-fly is assessed at 1–2 weeks post-radiation completion (Week 8–10 total). A detailed discharge summary, pathology reports, radiation treatment records (including DVH dosimetry files for home oncologist), and follow-up surveillance schedule are provided in both English and the patient's preferred language.

SURVEILLANCE MILESTONES (Remote Follow-Up via GAF Healthcare Telemedicine):

• Month 1 post-discharge: clinical review, wound check (virtual with photographs)

• Month 3: contrast-enhanced MRI of the primary site and neck; clinical examination

• Month 6: MRI primary + CT chest (high-grade histology); speech and swallowing re-assessment

• Year 1–2: every 6 months — MRI, clinical exam, thyroid function (if neck irradiated)

• Year 3–5: annually — MRI primary site, CT chest; dental review

• Adenoid cystic carcinoma: annual imaging extended to 15–20 years due to late distant relapse pattern