From the point of view of organ preservation, prognostic improvement and cost benefit, prediction of the chemosensitivity of individual tumors is needed. Between 1995 and 1999, chemosensitivity tests were carried out for 83 specimens of head and neck cancer including 31 of tongue cancer. Histoculture drug response assay (HDRA) with the MTT end-point was used as a chemosensitivity test. Fresh specimens obtained surgically or prior chemotherapy were placed onto collagen-gel-matrix which was incubated with medium containing cisplatin 20μg/ml and 5FU 120μg/ml. A 50% or greater inhibition of MTT assay was evaluated as positive. Efficacy rates were 32% for cisplatin and 40% for 5FU in tongue cancer, and 60% for cisplatin and 60% for 5FU in oro-hypopharyngeal cancer. There was a significant difference between tongue and oro-hypopharynx for cisplatin. HDRA can be useful in predicting chemosensitivity and in designing optimal chemotherapy for patients with tongue cancer. Chemosensitivity tests based on a molecular target have lately considerable attention. These provide us more information of tumor characteristic. Better selection of chemotherapy will afford organ preservation to responder and spare non-responder side effects and cost of ineffective therapy.

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Previously untreated 21 lingual carcinomas were treated with concurrent CBDCA and radiotherapy, weekly CBDCA at 100mg/m² given simultaneously for the conventional radiotherapy (2.5Gy×4/week) from November 1990. At the dose of 40Gy, patients were evaluated. NC cases underwent planned surgery and PR+CR cases continued this modality up to a dose of 65Gy fundamentally. Five year overall survival rate was approximately 70% in total and 81.8% in stage I-II (n=11), 71.4% in stage III (n=7) and 0% in stage IV (n=3). Advanced case showed poor prognosis in accord with previously reported data. On the other hand, new clinical-epidemiological idea of evidence-based medicine (EBM), the use of current best evidence in making decisions about individual patients, have been spotlighted recently. So, we discussed the usefullness of EBM up to now. There should be a great challenge to head and neck oncologist to explore and use the principles of EBM in everyday practice, and we will have to wait for further study in this particular area.

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Nineteen patients with stage I squamous cell carcinoma of the oral tongue and 58 stage II who had undergone neck dissection (ND) at multiple facilities between 1988 and 1992 were reviewed. In the cases of prophylactic ND, pathologically positive nodes were found in level I, II and III. We couldn't conclude whether ND is necessary for early stage tongue carcinoma, but we suggest that when prophylactic ND is performed for patients with early stage tongue carcinoma, supraomohyoid neck dissection is the first choice of treatment strategy.

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We treated 111 cases with T1 or T2 tongue cancer from 1990 to 1994. Tongue cancer has often cervical lymph node metastasis which decides the prognosis. We reviewed cervical lymph node metastasis of T1 or T2 cases and what was important to control the neck. There was no difference of survival rate between the group who underwent preventive neck dissection with N0 cases and who did not undergo neck dissection. The tumor which is poorly-differentiated or invades muscle layer had the high possibility of cervical matastasis. Latent cervical metastasis of T1 or T2 occurred in 4 or 5 months on the average and in the area of submental or submandibular or upper jugular or middle jugular. None survived who had more than 4 pathological lymph node metastases.

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One hundred and seventy-eight patients with T1/T2 carcinoma of the tongue were investigated to know the valid indication of the neck disection. Of 60 N0 patients who had undergone prophylactic neck dissection at the initial treatment, 15 (25%) had positive nodes. After all, of 166 patients without local recurrence, 58 (35%) were proved to have had positive neck metastases at the initial treatment. Metastatic lymph nodes were almost confined at the submandibular area and superior jugular area. In addition, depth of the primary tumor invasion had significant relationship with the neck metastasis. These results suggested as follows:(1) The neck dissection would be indicated for patients with T1/T2 N0 carcinoma of the tongue the depth of which exceeded more than 4mm, only when the patients and/or their family approved after detailed explanation about the advantage and disadvantage of this prophylactic surgical treatment.(2) Supra-omohyoid neck dissection would be satisfactory as an initial treatment.

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Advanced tongue cancer is associated with poor survival despite aggressive therapy. This is a retrospective view documenting the outcome of T3/T4 tongue cancer. The outcomes were assessed for the following: 1. survival, 2. indication of resection of the mandible and 3. larynx preservation after total glossectomy. The cumulative 5-year-suvival rate was 54% in the patients with T3/T4 tongue cancer. The prognosis became poor as the degree of N-stage and the number of histologically positive nodes increased. If the partial resection of mandible is necessary, marginal resection will be an appropriate procedure of the mandiblar resection because no patients had the pathological invasion into the bone marrow. The larynx preservation rate in the patients who had received total glossectomy was 70%.

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Between 1979 and 1997, 56 patients with previously untreated locally advanced squamous cell carcinoma of the tongue were treated in our hospital. Thirty patients of them were received surgery alone. Since the microvascular reconstruction started in 1987, no patients with unresectable primary lesion have appeared. The overall 5-year survival rate of 46 patients treated since 1987 was 51%, although the rate of 10 patients before 1986 was 30%. The 5-year survival rates by pN stage were 90% in pN0 (19 cases), 67% in pN1 (6 cases), 0% in pN2a (1 case), 14% in pN2b (14cases), 0% in pN2c (6 cases), respectively. The cases of pN0 and pN1 were better in prognosis than pN2 cases significantly (p<0.0001). The 5-year survival rate of 12 patients received preoperative chemotherapy was 42%, although the rate of 34 patients without preoperative chemotherapy was 54%. It demonstrated no benefit in survival using preoperative chemotherapy. It was suggested that irradiation was necessary to decrease the recurrence rate of the neck in pN2 cases, because pN stage was prognostic factor in locally advanced lingual cancer.

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To treat tongue cancer, we have been performing neo-adjuvant intra-arterial infusion therapy with multiple anti-cancer agents and booster chemotherapy (we named this technique booster chemotherapy rather than adjuvant chemotherapy because the same anti-cancer agents as in neo-adjuvant therapy are used). Good outcome have been achieved. We studied 48 newly diagnosed patients with tongue cancer treated with intra-arterial infusion therapy between 1988 and 1996 and 26 newly diagnosed patients with tongue cancer treated with radiotherapy before 1986. The complete remission (CR) rate and response rate were 52% and 92% respectively, and the 10-year survival rate with tumor -related death in Kaplan-Meier method was 76.9% by intra-arterial infusion therapy with multiple agents. That of radiotherapy group was 51%. We conclude that intra-arterial infusion therapy with multiple agents is an excellent therapeutic method for head and neck cancers. Survival rate in 7 fresh cases of advanced tongue or oral floor cancer treated with booster chemotherapy (CDDP±5FU) and 15 treated without booster chemotherapy were compared. The 10-year survival rate of the booster chemotherapy cohort was 85.7%, while that of without booster chemotherapy cohort was 35%. The usefulness of booster chemotherapy was indicated in this study. We conclude that neo-adjuvant intra -arterial infusion with multiple anti-cancer agents and booster chemotherapy is an excellent combination of therapeutic method for head and neck cancers.

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Generally, at present treatment for tongue cancer is mainly radiation therapy if interstitial irradiation is possible in early stage. On the one hand, it is mainly performed surgical therapy in advanced stage. We examined the treatment outcome in the past 10 years and the treatment in advanced stage. There were 21 cases with advanced tongue squamous cell carcinoma (stage III and IV) which underwent some treatment in our hospital between 1990-1999. Those cases had no history of prior treatment anywhere. 5 year survival rate in stage M and IV was 63.0% and 30.0%, respectively. Our treatment principle for advanced stage of tongue cancer is as follows: Preoperative irradiation is performed to secure the safety margin at operation. Its exposure dose is between 30 to 40Gy. We perform radical surgery including reconstruction. Postoperative irradiation and chemotherapy is considered when necessary. As a result of treatment outcome, it was suggested the necessity of chemotherapy to prevent distant metastasis. Our foundation of surgical treatment for advanced stage is en bloc resection.

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