A free flap method is now a well-established and indispensable reconstructive option after resection of head and neck tumors. However, it has an inevitable disadvantage of total necrosis of a transferred flap due to thrombosis of anastomosed vessels. The author therefore describes several important technical points to avoid such troubles, and encourages young reconstructive surgeons to achieve a safe free flap surgery.

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A consecutive rehabilitation program for patients with oral SCCs is considered crucial for overcoming the predicted masticatory and swallowing dysfunction. Oral cleaning from admission reduces the risk of post-operative wound infection and aspiration pneumonia. Pre-operative maneuvers for swallowing dysfunction provide the patients with a more precise anticipation of the expected dysfunction, and better motivation for performing post-operative exercises. Early post-operative tracheal extubation necessitates earlier initiation of swallowing dysfunction maneuvers. Simultaneous rehabilitation exercises for neck and upper extremities dysfunction are also necessary for the early recovery of swallowing dysfunction. Change in body weight, occurrence of pneumonia, and changes in dietary consistency should be closely monitored for up to six months following discharge. Pre-operative PEG is recommended for some patients with oral SCCs whose swallowing function is expected to be difficult to recover despite long-term rehabilitation.

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The role of reconstructive surgery in the management of head and neck tumors involves three points: (1) Development of reconstructive procedures to maintain the postoperative swallowing and speech functions. (2) Decreasing the degree of surgical invasiveness and donor-site morbidity. (3) Minimizing early postoperative complications that may prolong hospitalization and become life-threatening. Furthermore, surgeons should always consider the prognosis when selecting reconstructive methods for patients who have undergone resection of a head and neck tumor, because the survival rate of these patients is generally low.
In this paper we report our views on reconstructive procedures to maintain the postoperative functions and discuss several problems and difficulties that must still be resolved.

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A goal of treatment in maxillofacial prosthetics is to restore the original condition of oral and maxillofacial function such as mastication, deglutition, speech and esthetics for defects and disfigurement in the head and neck region due to tumor, trauma, and cleft lip and palate. The functional and esthetic disorders of maxillofacial defect patients are various with a variety of primary disease and defect, and each disorder is far more serious compared with those of ordinary prosthodontic patients. In addition, a disorder affects others mutually, causing psychological and mental anguish of the patient. Although mastication and deglutition are improved by prosthodontic treatment, cooperative work of surgery, prothodontic treatment and co-medical care is essential to enhance the treatment result. Continuous evaluation of the function, and instruction and training, based on a clear awareness of being a member of a medical team and close information exchange, with each other are useful for improving and preserving patient QOL.

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Otolaryngologists use three approaches to rehabilitate patients with dysphagia: (1) as the physician responsible for a patient; (2) as the surgeon; and (3) as the rehabilitation physician. In this article, we review several cases to illustrate these different approaches. (1) The physician responsible for a patient must treat the patient as a person and not treat just the disease. Even before surgery, as soon as the patient provides informed consent, we start the rehabilitation program. (2) The surgeon must objectively consider the amount of resection needed, envision the changes in body structure, and anticipate the extent of the resulting impairment. This simulation should be based on an understanding of surgical anatomy and previous studies of dysphagia. (3) The physician should thoroughly evaluate swallowing function after surgery. Depending on the patient's swallowing function, we might choose surgical procedures such as laryngeal suspension or cricopharyngeal myotomy, or laryngotracheal separation for chronic aspiration patients.

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The structural changes in the oral cavity and oropharynx due to oropharyngeal surgery will impair patient's mastication and swallowing, thereby adversely affecting the patient's quality of life. Here we describe the nursing for patients with postoperative dysphagia, in the preoperative period, acute phase and convalescence in order. In the preoperative period, nurses will be able to assess changes in the patient's mastication and swallowing, then start the basic swallowing training and to take care of their oral cavity. In the acute phase, it is important that the free graft takes to the surrounding tissue. Furthermore, aspiration pneumonia due to dysphagia has to be prevented in order to maintain good physical condition. In convalescence, it is important to control some risks, to do the swallowing training, and to consistently evaluate the patient's mastication and swallowing. The risk control is to prevent aspiration pneumonia, dehydration and malnutrition. Swallowing training is done for patients whose swallowing disorder has been confirmed by vedeofluorography. Nurses will be able to do the training with other specialists, to evaluate the patient's functions, and pass along the results to the professional team for dysphagia.

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Since April 2002, a speech therapist (ST) has been participating in rehabilitation for postoperative difficulty in swallowing and articulation of patients with oral and/or oropharyngeal cancer at Kobe University Hospital. Before surgery, the ST gives a brief lecture to the patients on the postoperative rehabilitation. At the beginning of the rehabilitation, the ST evaluates the ability to swallow of the patients, with head and neck surgeons using videoendoscopy. This paper describes the contents of the lecture and its advantages. Actual examples of training procedures without food (indirect approach) and eating training (direct approach) for cancer of the tongue and oropharyngeal cancer are also presented according to the extent of surgery.

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Twenty-two patients with carcinoma of the lower alveolus underwent segmental mandibular resection and reconstruction during the period of January 1999 to December 2004, at Hokkaido University Hospital. Reconstruction plates were used in 17 cases of which 4 had primary closure; 11 had free flaps (Rectus Abdominus Myocutaneous flap 9 cases; Radial Fore-arm flap 1 case; Anterolateral thigh flap 1 case); and 2 had pedicled flaps (Pectralis Major flap; Cervical island flap). Four cases were secondarily reconstructed with osteocutaneous flaps. The other five cases were reconstructed with free fibular flap (n=4) and scapular osteocutaneous flap (n=1) without reconstruction plates. Complications following reconstruction included wound dehiscence (n=5) which did not require major surgical repair. None of the free flap cases developed fistulae or total flap necrosis. Mandibular segmental defect repair using reconstruction plates and free soft tissue flaps or vascularized bone grafts seems to have a lower risk of complication.
Three-dimensional mandibular models were prepared for some patients from computerized tomographic data, upon which surgical simulation was performed. Three-dimensional surgical simulation is a very useful tool in reconstructive surgery.

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Postoperative local neck infection in oral cancer patients can cause delay of oral feeding, postoperative treatment and can occasionally induce severe complications such as DIC, sepsis or rupture of the carotid artery. In this study, we analyzed the rate of postoperative local infection in patients who received pull-through resection and reconstruction of oral tongue cancer. A total of 52 tongue cancer patients were reviewed for postoperative infection and the relationship with operative procedures was analyzed. There were 26 cases of hemiglossectomy, 23 cases of subtotal glossectomy, and 3 cases of total glossectomy. There were 13 cases (25%) of postoperative local wound infection. There was no relationship between the postoperative infection rate and surgical extent, reconstruction procedure, operation time nor preoperative irradiation. Postoperative infection significantly extended the duration before starting oral feeding which decreased the patients' quality of life.

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Postoperative complications were evaluated in 139 patients who had undergone conduit reconstruction with free jejunum grafts after total pharyngolaryngoesophagectomy from 1999 through 2004. The patients included 119 men and 20 women, with a mean age of 64.3 years. Factors affecting the development of postoperative complications at the surgical site were analyzed. Postoperative complications at the surgical site were observed in 32 patients (23%) and included total necrosis of the transferred jejunum (2 patients), local abscess (13 patients), lymphorrhea (4 patients), major leakage (4 patients), minor leakage (5 patients), cervical skin necrosis (3 patients), hematoma (2 patients), and flap congestion (1 patient). Statistical analysis revealed that neither preoperative irradiation nor diabetes mellitus affected the rate of postoperative complications. However, small fistulae or local infections may easily develop into a severe complication in patients who have received radiotherapy. In such patients, careful treatment after reconstructive surgery is needed to avoid severe complications.

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The diagnosis procedure combination/prospective payment system (DPC/PPS) that was begun in university hospitals in fiscal 2003 is outlined. The DPC in the 2004 version concerning head and neck cancer was analyzed, and the handling of local complications in postoperative head and neck surgery patients in the DPC/PPS was examined. If major surgery of the head and neck cancer was performed, it often turned out to fall outside the scope of the inclusive evaluation. Moreover, it is understood that the presence of complication is not reflected in the classification in head and neck cancer even though it is common in other diseases to subdivide the diagnosis group classification by the presence of complication. The problem of local complication was examined in the case of oral cancer treatment by our department in 2004. It was clarified that the decision on whether complication was a negative factor of the DPC/PPS depended on the medical treatment expense concerning complication and the balance of the hospitalization period. Moreover, it seemed that cases which did not have complication and were quickly discharged from hospital were a minus in the DPC/PPS, and so improvement plans are necessary.

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The prognosis of patients with advanced hypopharyngeal carcinoma (HPC) is poor. Many studies about chemoradiation for advanced head and neck carcinoma report significant benefit for survival. They also prove improved survival rate equal to radical surgery. Chemotherapy and radiotherapy contribute to functional preservation for head and neck cancer. Some studies report survival benefit with neoadjuvant chemotherapy (NAC) for unresectable head and neck squamous cell carcinoma (HNSCC). Combination chemotherapy with CDDP, 5FU, and Docetaxel (TPF) shows strong effect for HNSCC. We studied NAC with TPF for advanced HNSCC. The response rate was 76.5% for 51 assessable patients. Patients with advanced HPC showed high response rate of 86.4%. NAC responders treated with chemoradiation showed good prognoses with larynx and hypopharynx preservation. NAC with TPF will play an important role in developing a new strategy for advanced HPC.

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To understand the therapeutic strategy for hypo-pharyngeal cancer, experience of diagnosis and treatment for esophageal cancer which has a close relationship from the viewpoint of field cancerization is helpful. Superficial esophageal cancers (SECs) in which the tumor invasion does not reach the proper muscle layer were detected in the early 1980's. After the introduction of endoscopic Lugor's staining technique, the detection of SEC became much easier and the number of SEC detected increased rapidly and the therapeutic results improved. Since then, new therapeutic techniques have been introduced and a new concept of therapeutic strategy respecting QOL has been established.
A total of 37 hypo-pharyngeal cancers in 21 patients were detected during routine upper gastro-intestinal endoscopy with characteristics of localized slight redness, blurred subepithelial vessels and slight mucosal thickening. Each lesion was treated with endoscopic mucosal resection and/or argon plasma coagulation, Five lesions needed additional endoscopic treatment and neck dissection of lymph nodes was performed in 3 cases. We lost one patient with cancer recurrence, 5 patients with other primary cancers, and 3 patients with other miscellaneous diseases. The 5-year survival rate was about 60%. Early detection of hypo-pharyngeal cancer is possible even in usual endoscopy and the early detection enables us to minimize treatment and preserve QOL.

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Recently there has been a trend toward function-conserving surgery in neck dissection. Though selective neck dissection has become popular for N0 cases, it still remains controversial whether certain nonlymphatic structures and lymph node groups can be preserved for N+ cases or not. In this study, 137 neck dissections were examined retrospectively for positive lymph node cases with tongue cancer from 1985 to 2000 and 83 neck dissections were examined with hypopharyngeal cancer from 1995 to 2001. Neck control rates were 80% for RND and 91% for mRND with tongue cancer, 79% for RND and 92% for mRND with hypopharyngeal cancer. The frequency of posterior neck metastases was 3% for tongue cancer and 8% for hypopharyngeal cancer. Most of the positive nodes were located near the posterior end of SCM. These results demonstrate that the anterior approach technique of mRND is selectively indicated for N+ cases.

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In head and neck squamous cell carcinoma (HNSCC), the presence of lymph node metastases is the most important prognostic factor. The sentinel lymph node (SLN) is the first lymph node to receive drainage from the primary site, and it is speculated that cancer cells are first trapped by the SLN. We studied whether the SLN concept holds true for HNSCC and could be indicated for neck dissection. A radiolabel with unfiltered tracer was injected submucosally around the primary site followed by lymphoscintigraphy (LS) at 2-hour intervals. Preoperative localization was performed with gamma probe (GP). After en bloc removal of the regional lymphatics, histopathologic results for the nodes were compared with the SNL radiolocalization. The LS and GP counts were well correlated, and there was concordance between SLN and neck node status in 14 of 15 cases (93.3%). In this study, micrometastases could be detected in 5/15 (33.3%) of patients, meaning that SLN study could eliminate the need for neck dissection in 67.7% of N₀ patients. We thus considered that our concept in this study was valid in determining the necessity for neck dissection for those N₀ Patients with T₂ and T₃. However, before it becomes the standard maneuver, longer term follow-up observations for large group trials are needed.

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This paper discusses Planned Neck Dissection (PND) based on our results and various other publications. The PND approach involves head and neck cancer treatment, aiming at a radical cure using chemo-radiation treatment locally. For neck lymph node metastasis, planned neck surgery must be used to obtain a better prognosis together with chemotherapy and radiation therapy. From our results, the group undergoing PND achieved a much better neck control rate than the non-operative group, although there were no significant differences. Many reports have reiterated the need for PND. On the other hand, in recent years with the very high-accuracy chemo-radiation therapy introduced for head and neck cancer treatment, the local control rate and neck control rate would be much higher. Thus, there is a good possibility that neck disease will be cured using these therapeutic modalities. Although many reports to date have suggested PND would be the most effective method for head and neck cancer treatment, we consider it should be applied only for truly necessary cases in combination with CT and PET. Thus it is important to consider the use of PND on an individual basis.

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To assess the impact of modifications to radical neck dissection on the postoperative quality of life, we have developed an "Arm Abduction Test (AAT)" and "Questions on QOL related to Neck Dissection (QQND)". A multicenter study using these measures revealed that patients who had neck disseotion sparing SAN had better shoulder function. When the SAN was preserved, patients without dissection of levels V had better scores on pain and constriction of the neck. Sacrifice of the sternocleidmastoid muscle and/or the SAN had significant impacts on daily activities as well as work and leisure. ATT scores and those of answers regarding shoulder function were significantly correlated.

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A goal of reconstructive surgery of the jawbone is to regenerate bone that is strong enough to allow the patient to wear dentures or to receive dental implants. Here we describe mandibular reconstructions using bioabsorbable poly (L-lactic acid) (PLLA) mesh and particulate cancellous bone and marrow (PCBM).
PLLA mesh trays/sheets and PCBM were used to reconstruct the mandibles of 59 patients (22 malignant tumors, 30 benign tumors, 5 cysts, and 2 cases of osteomyelitis). Surgeons cut a PLLA mesh sheet to the size of the bone defect with scissors, warmed it to 70°C, manipulated it to the correct shape, fixed it to the residual bone with stainless steel wires, then filled the tray with PCBM harvested from the ilium. Clinical evaluations six months after surgery showed that of the 59 patients, 32 (54.2%) had an excellent outcome (bone formation range greater than 2/3), 17 (28.8%) had a good outcome (bone formation range less than 2/3, but a re-operation not necessary), and 10 (16.9%) had a poor outcome (all other outcomes). Long-term observations (40 cases; 1-10 years; average 5.0 years) showed that bone resorption was less than 10% of the regenerated bone for 31 (77.5%) patients. In no case was there a complication associated with using PLLA mesh.
After surgery, 22 patients were fitted with dentures and 4 patients received dental implants in the regenerated mandible. Patients that received prosthetic restorations soon after surgery experienced less bone resorption. We conclude that mandibles can successfully be reconstructed using PLLA mesh and PCBM; this technique constitutes an advance in regenerative medicine pertaining to the mandible. However, for patients with poor regional blood circulation and elderly patients with few osteoprogenitor cells, therapies that combine bioactive factors to promote angiogenesis and osteogenesis or hybrid artificial bone need to be developed.

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Regenerative medicine is an exciting emerging branch of medicine in which cell and tissue based therapies are applied to the treatment of disease. This has been supported by the development of tissue engineering that is a combination of medicine and engineering. Tissue engineering applies the principles and methods of engineering, material science, and cell and molecular biology to the development of viable substitutes which restore, maintain, or improve the function of human tissues.
According to the doctrine of tissue engineering, tissues and organs can be regenerated by manipulating three elements: cells, scaffolds and regulation factors. Understanding and manipulating the complex relationship among these elements, however, represents a great challenge for researchers and doctors who engage in regenerative medicine.
On the other hand, clinical applications have made little progress except for limited tissues and organs. Especially, few clinical studies have been reported in the fields of otolaryngology, and head and neck region. In our research group, clinical applications in these fields based on in situ tissue engineering have been started from 2002 after approval of the ethics committee of Kyoto university. Tissues and/or organs for clinical applications at present are trachea, cricoid cartilage, mastoid air cells, and peripheral nerves including facial nerve, recurrent laryngeal nerve, chorda tympani nerve and so on.
This article discusses our clinical studies at present and in the near future of regenerative medicine in the fields of otolaryngology, and head and neck region.

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We experienced 28 patients with nasal and paranasal carcinoma who underwent superselective intra-arterial CDDP infusion combined with radiotherapy from 1998 to 2004 at Kurume University Hospital. We analyzed the results of cancer patients of 21 of the maxillary sinus, 3 of the sphenoid sinus, 1 of the ethmoid sinus, and 3 of the nasal cavites. Observation period ranged from 3 to 72 months (average 26 months). Intra-arterial CDDP infusion to the tumor (100mg/body) was delivered rapidly by a femoral artery catheterization technique at the dose of 100mg/body and usually repeated 4 times. Conventional external-beam irradiation (2Gy per fraction ×30) was also used. Complete response was obtained in 13 patients (46.4%) and partial response in 11 patients (39.3%). There was no change in 4 cases (14.3%). Although severe toxic events (grade 3) occurred in one case, other acute toxic side effects were generally acceptable. Five-year cause-specific survival rates were 100% in patients with tumor of the nasal cavity and ethmoid sinus, 83% of the maxillary sinus and 0% of the sphenoid sinus, respectively. Three-year local control rate of maxillary carcinoma was 86% in T3 and 71% in T4. This treatment strategy, therefore, is highly effective for organ (the orbita and maxilla) preservation in advanced nasal and paranasal sinus carcinomas. In conclusion, intra-arterial CDDP infusion therapy combined with radiotherapy is effective against advanced malignant nasal and paranasal sinus carcinomas.

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Recently, daily concurrent chemoradiotherapy using new superselective intra-arterial infusion via superficial temporal arterial artery is attracting attention. The catheter with curved tip is inserted superselectively to the feeding artery of the tumor via the superficial temporal artery, allowing long-term catheterization. Forty-one patients with stage III, IV oral cancer were treated. Radiotherapy (total dose: 40Gy/4weeks) and superselective intra-arterial infusion chemotherapy using docetaxel (total dose: 60mg/m², 15mg/m²/week) and cisplatin (total dose: 100mg/m², 5mg/m²/day) were concurrently performed daily, followed by surgery. In 35 patients, intra-arterial infusion was successful (success rate: 85.4%) and no major complication was observed. The clinical effects were CR in 29 patients (82.9%), and pathological effects of resected tumor after surgery were pathological CR in 31 (88.6%). This method promises to be a new strategy of choice for the treatment of oral cancer.

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Intra-arterial chemotherapy has been a focus of constant attention for its excellent local effect. We have performed the combination therapy of intra-arterial chemotherapy using carboplatin via the superficial temporal artery and radiotherapy since 1992. Of the many cases we treated by the combination therapy, we reviewed the treatment results with a focus on Stage III, IV tongue cancer. Five-year local control rate, overall survival rate, and relapse-free survival rate were estimated to be 62%, 31%, and 30% respectively. Grade III or IV neutropenia and thrombocytopenia were 43% and 35% respectively. No central nervous system complication was observed. We think that this combination therapy is worth considering for locally advanced tongue cancer which is inoperable for any reason.

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We experienced 129 head and neck vascular cases in our division of vascular surgery from 1976 to 2005. We analyze all the cases and introduce the principle of the basic procedures. Finally, basic vascular techniques in the head and neck region are shown briefly.

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Following the increasing desire of many patients to keep the form and function of speech and swallowing, interstitial brachytherapy has become the main treatment for head and neck cancer. In addition, aged and physically handicapped patients who are refused general anesthesia have come to be referred to our clinic to receive less invasive and curative treatment.
In the field of brachytherapy for head and neck cancers, less complicated and more superior treatment results have been achieved following the introduction of spacers, computer dosimetry and so on. As a result of these efforts, treatment results have come to fulfill the desire of patients and their families.
During the past 43 years from 1962 to 2005, we have treated over 2,100 patients of head and neck cancer including 850 with stage I, II oral tongue carcinoma by brachytherapy and acquired a lot of important and precious data including the treatment results, multiple primary cancers as well as radiation-induced cancers.

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While multiple development of cancer in the esophagus, and head and neck region is well-known as the phenomenon of "field cancerization", there is no modality of effective screening for early cancer in the oropharynx and hypopharynx. Most of the patients with cancer in the oropharynx and hypopharynx are diagnosed at an advanced stage with symptoms such as dysphagia. We revealed the possible mechanism of this phenomenon, and found that narrow band imaging (NBI), a groundbreaking technology in endoscopy, allowed us to detect them easily. Effective screening using magnifying endoscopy coupled with NBI might make it possible to reduce the number of patients suffering from loss of functions of speaking and swallowing after radical surgery.

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To investigate the tumor extent pattern of gingival carcinoma of the mandible, 98 surgically treated patients with squamous cell carcinoma (SCC) of the lower gingiva were clinicopathologically examined. Tumor extent pattern was classified as follows: intraosseous extent type (type I), buccal extent type (type B), lingual extent type (type L), exophytic type (type E), and gingival surface extent type (type G). Each group was further divided into two subgroups: with or without invasion into surrounding tissue.
Bone invasion involving the mandibular canal was noted in types I, B, and L. Moreover, tumors with surrounding tissue invasion frequently showed diffuse bone invasion. Regarding mandibular resection, in type I, the mandibular resection level was determined based on the degree of bone invasion. In types L and B, however, segmental mandibulectomy was often selected in cases with periosteal invasion exceeding the muscular attachment level, such as mylohyoid muscle and buccinar muscle. The incidence of local recurrence was higher in types I, B, and L, compared with types E and G. In particular, 31% of type L tumors with invasion into surrounding tissue had local recurrence. Neck metastasis was also significantly increased in such cases of type L. The overall cumulative five-year survival rate was 86.7%.
Treatment for gingival cancer of the mandible is mainly focused on bone invasion; however, evaluation of the tumor extent pattern is also an important factor to determine adequate surgical resection. Thus, establishment of standards of diagnosis and treatment for lower gingival cancer are necessary.

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We treated SCCHN patients (pts) with docetaxel (DOC) chemoradiation therapy. Twenty-three pts (24 regions) were treated by method A (DOC 60mg/m², q3w), and 26 were treated by method B (DOC 20mg/m², q1w). The first assessments of the therapeutic effects were as follows: method A: CR 95.8% and PR 4.2% for the primary site, CR 100% for 13 patients with metastasis in the cervical region; method B: CR 95.7% and PR 4.3% for the primary site, CR 92.9% and PR 7.1% for 14 patients with metastasis in the cervical region. As for side effects, a higher frequency of hematological toxicities was observed in method A. Grade 3 and Grade 4 leucopenia were observed in 91.3% of patients in method A, and 7.7% in method B. Dysphagia and mucositis were found as follows: dysphagia, 13% in method A and 26.9% in method B; mucositis, 47.8% in method A and 80.8% in method B. Accordingly, dysphagia and mucositis side effects were higher in method B.
Other side effects were Grade 3 anemia and Grade 3 dyspnea, which were found only in method A. The possibility of discontinuation of radiation therapy was higher in method B, because of higher local side effects.
In conclusion, both methods are feasible; however, it has to be decided which method to choose for which kind of patients due to expected side effects.

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In recent years, multiple primary cancers in the head and neck area are increasing. Frequently, pharyngeal cancer is reported associated with esophageal cancer.
We experienced a patient with quadruple cancers, including hypopharyngeal cancer, who has maintained high quality of life for II years.
This case is a 64-year-old man with lung cancer. He underwent a lobectomy for lung cancer in 1993. In January 1996, hypopharyngeal cancer (squamous cell carcinoma) was revealed by endoscopy, and he received chemoradiotherapy and neck dissection. Early gastric cancer was revealed in November of the same year, and subtotal extirpation of the stomach was performed. In 2001, early esophageal cancer was revealed (squamous cell carcinoma) by endoscopy, and esophagus endoscopic mucosal resection was performed. He is in good condition without any recurrence or metastasis.
The prognosis of multiple primary cancer is generally very poor compared with a single carcinoma, and it is much worse in quadruple cancer.
We experienced a very rare case of quadruple cancers with good laryngeal function and a good prognosis for a long time by early detection and treatment.

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To clarify the long-term results of connection between the cut-end of the right clavicle and the 1st rib in cases with mediastinal tracheostoma, the consequence of this connection and movement of the shoulder joint were reviewed. Six patients with cancer of the cervical esophagus extending into the thorax, and one patient with thyroid cancer, were treated with extensive circumferential resection of the mediastinal trachea. In all cases, the upper sternum and more than one-third of the right clavicle were removed, and bilateral accessory nerves were preserved upon neck dissection. Medical records of these patients were reviewed for shoulder pain, consequence of the stainless steel wire used for the connection, abduction angle, and torque of the shoulder joint, at more than six months after surgery. The wires were preserved in three cases, whereas in three cases at more than six months after surgery, the wires were cut, and in one case, the wire was disconnected from the clavicle. The abduction angle of three patients whose wires were preserved was more than 135°, and they did not complain of shoulder pain. The abduction angle of two out of three, whose wire was cut, was more than 135°, and that of the third one was 120°, and none of these patients complained of shoulder pain. One patient whose wire was disconnected has a poor abduction angle and a complaint of shoulder pain. The torque could be measured in four cases. The right shoulder torque in three out of four cases was equal to that of the left side. The torque of the cases with a successful wire-connection, or those that were cut more than six months after surgery, was not reduced, and the abduction angle of shoulder was well-preserved. Therefore, connecting the cut-end of the right clavicle and the 1st rib should be preferred in cases with mediastinal tracheostoma plasty.

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This study presents the treatment results in 37 patients (34 men and 3 women) with T1-T2 carcinomas of the hypopharynx treated initially for their disease at the University of Kumamoto between 1998 and 2003. Their average age was 67 years (from 45 years to 88 years). Seven patients were Stage I, 15 were Stage II, 4 were Stage III, and 11 were Stage IV. Basically, we performed concomitant chemoradiation therapy for T1-T2 carcinomas of the hypopharyx. Radiation therapy was administered at a dose of 1.8-2.0 Gy, with a total of more than 59.6 Gy to be given to each patient. Intravenous infusion of CDDP (4-5mg/m²) and oral administration of UFT (450mg/body) were continued concomitantly from day one of irradiation for four weeks. For various reasons, we could perform concomitant chemoradiation therapy on 21 patients only. Radiation alone was given to 16 patients. The 2-year local controls for radiation alone (RT) and concomitant chemoradiation therapy (CRT) were 56.3% (RT) and 59.9% (CRT). There was no statistically significant difference here either. At the present time, CRT was not considered to be more effective than RT for T1-T2 carcinomas of the hypopharynx.

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We analyzed 167 hypopharyngeal cancer patients who received neck dissection, investigated 544 metastatic lymph nodes histopathologically and obtained the following results.
1) Distant metastasis was detected in 15 (15%) of 98 patients with 2 or more positive nodes. On the contrary, in 69 patients with 1 or less positive node, distant metastasis was detected in 4 (6%). There was a statistically significant difference in the rate of distant metastases (p < 0.05) between them.
2) Neck recurrence was detected in 3 (7%) of 41 patients whose metastatic lymph nodes showed disappearance of secondary follicles and received postoperative radiotherapy. On the contrary, 8 (23%) of the 35 patients who did not receive postoperative radiotherapy had neck recurrence. There was no statistically significant difference in the rate of neck recurrence (p = 0.051) between them.
3) Distant metastasis was detected in 15 (20%) of 76 patients whose metastatic lymph nodes showed disappearance of secondary follicles. On the contrary, 2 (5%) of the 45 patients had distant metastasis.
There was a statistically significant difference in the rate of distant metastases (p < 0.05) between them.
4) Neck recurrence was detected in 5 (10%) of 52 patients whose metastatic lymph nodes showed destruction of capsule and who received postoperative radiotherapy. On the contrary, 6 (55%) of the 11 patients who did not receive postoperative radiotherapy had neck recurrence. There was a statistically significant difference in the rate of neck recurrence (p < 0.01) between them.
5) Distant metastasis was detected in 11 (61%) of the 18 patients whose metastatic lymph nodes showed vessel invasion. On the contrary, 6 (6%) of the 103 patients had distant metastasis.
There was a statistically significant difference in the rate of distant metastases (p < 0.05) between them.
These results indicated that patients whose metastatic lymph nodes show either disappearance of secondary follicles or destruction of capsule are recommended to receive postoperative radiotherapy. On the other hand, patients who have 2 or more metastatic lymph nodes, or whose metastatic lymph nodes show either disappearance of secondary follicles or vessel invasion are recommended to receive chemotherapy.

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