Salivary duct carcinoma is rarely seen by most doctors, and because of that, providing education and information about possible treatment to patients is challenging. But, Niles, Illinois-based Endodontist Dr. Brett Gilbert notes that a simple diagnostic screening in the dental chair can catch the condition early and help to avoid complicated and invasive treatment.
Jonathan’s story
Jonathan Gegerson exercised regularly, ate healthy, and never smoked. In May 2019, he felt a bump on the right side of his neck. The doctor asked all the usual questions: Any recent dental work? The flu? A sinus infection? In the absence of all of those usual “horses,” it was time to look for “zebras.” That set in motion a battery of tests—an ultrasound, biopsy, PET scan, and head-and-neck CT scan.
The diagnosis was HER-2 positive salivary duct carcinoma (similar to ductal carcinoma of the breast) in his right head and neck area.
After an initial diagnosis in Colorado, Gegerson and his wife relocated for the next three months to MD Anderson Cancer Center in Houston for treatment. The next few years were filled with treatments, remissions, and recurrences.
Gegerson explains why lymph node cancers have a tendency to spread. He says, “Think about a lymph node as an M&M with a hard candy shell. As the lymph node expands, the candy shell breaks, and when that happens, the cancer cells spread to other lymph nodes. That’s the importance of catching this early.”
A journey through chemo, surgery, and evolving drug therapies
At first, Gegerson’s tumor was removed and a right neck dissection removed all impacted lymph nodes. This was followed by six weeks of chemotherapy and 33 sessions of radiation on his right side. Herceptin was used after surgery. This targeted therapy binds to the HER2 protein found on some cancer cells, prevents the protein from sending signals that promote cell growth, and activates the immune system to kill cancer cells.
After a year, the cancer reappeared, now affecting lymph nodes on the left. Back at MD Anderson, doctors performed a left neck dissection that removed more lymph nodes, and a section of subcutaneous fat and skin from his leg was transplanted to his neck, followed by six more weeks of chemotherapy with Herceptin and 35 radiation sessions.
Several months later, when the cancer had spread to his skin, the medicine was changed to Kadcyla, a drug that combines Herceptin and chemotherapy. According to breastcancer.org, Kadcyla was designed to deliver the chemotherapy drug emtansine to cancer cells in a targeted way by attaching the chemotherapy to Herceptin, which carries the chemotherapy to the HER2-positive cancer cells.
After a year, the cancer returned once again, along with severe head and neck lymphatic swelling due to side effects of surgery and radiation. The swelling was cutting off his airway. A 17-hour surgery for lymph node transplants and lymphedema bypass to stop the swelling involved removing the scar tissue and transplanting skin from the omentum, (an area below the stomach that contains many lymph nodes). Also, doctors redirected blood vessels in his face with micro surgery, so the lymphatic system now had a path to drain.
By the time the cancer returned behind his ear, neck, along his clavicle, shoulders, and eye, a drug called Enhertu was getting good research results. Enhertu contains a monoclonal antibody-drug conjugate called trastuzumab that binds to the HER2 protein. It also contains an anticancer drug called deruxtecan, which may help kill cancer cells. After his first treatment, Gegerson said he saw a difference almost immediately.
Currently, Gegerson receives Enhertu every four weeks until either the cancer returns or the drug stops working. Meanwhile, he has written a book, called Perspective C (available on Amazon), that focuses on his journey, emotional fortitude, involvement of family and friends, financial realities, and survival while staying positive during his long-term illness.
How can a dentist help?
Dr. Brett Gilbert notes, “Dentists can help find this type of cancer in its earliest stages. People go to the dentist often. There’s an opportunity there; as simple as this test would be, it can save a life.”
“Dentists can take just a few minutes to do what is called a Conventional Visual and Tactile Examination (CVTE) that involves inspection, palpation of the face, neck, regional lymph nodes, and assessment for any asymmetry, masses, or skin lesions,” says Dr. Gilbert. “It might take one minute, even if the patient has come in for a filling, a root canal, an extraction; they absolutely can benefit by CVTE.”
Dr. Gilbert says if the dentist does not do this type of assessment during an exam, patients should not be embarrassed to ask for it. “I think patient advocacy for early detection is critical. If you are shy, even just saying, ‘I read an article about this, and could you just check everything out and see if anything looks irregular, asymmetric, and feel my lymph nodes?’” Dr. Gilbert adds that many times, a sore lymph node is not cancer. He adds, “Maybe part of the article is just being aware that, although most of the time it’s going to be something that’s normal and not worrisome, but in any case, it should always be checked.”
High tech firms are also developing salivary tests that will detect biomarkers associated with cancer such as certain proteins or genetic material that can indicate early signs of oral and throat cancers.
Gegerson notes, “One the things that I learned from my surgeon at MD Anderson is if my cancer was caught much earlier, it could have been treated more easily. Even a month or two earlier, and they might have been able to just remove the one tumor and not have had to do a neck dissection, and it wouldn’t have had time to spread. So there’s ultimate importance that if you catch this early enough, what you can prevent is tremendous.”
