The role of the Plastic surgeon in head and neck reconstruction involves reconstruction after ablative surgery and secondary revision. In addition, donor site closure after flap harvest is performed by the plastic surgeon during microsurgery and flap suture in most cases. Details of donor site closure have rarely been reported. In this paper, we describe a device for donor site closure in head and neck reconstruction using primary closure, skin grafts and local flap. In many cases, secondary revision after reconstruction is required. Plastic surgery techniques are very useful in this situation. Techniques used for secondary revision include: 1) scar revision, 2) local flaps, 3) dermal fat graft, 4) liposuction, 5) lipoinjection, 6) free flap and so on. It is very important to choose adequate reconstruction methods to improve the better QOL of patients.

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We have carried out about 600 head and neck reconstructions with radial forearm free flap transfer and basic/clinical studies on flap circulation and surgical procedures. Knowledge obtained and refinement of surgical procedures in flap elevation, venous anastomosis and donor site coverage introduced at Kobe University Hospital are as follows:
1) Deep and superficial venous systems of the flap are connected by including the cubital perforating vein in the venous pedicle.
2) Our studies have revealed that the deep venous system has dominant blood flow compared with the superficial system. Consequently, drainage of the former system is crucial in reducing venous disturbance of the flap.
3) “Network venous anastomosis”, where the two separate venous systems of the flap are anastomosed with the two venous systems of the neck (the internal and external jugular veins) including their connecting perforating vein, imitates the anatomical venous drainage in the forearm, providing a reliable, fail-safe drainage system.
4) Skin grafts preserving subdermal vascular networks provide aesthetically more optimal results in covering the donor site of the flap.
5) Fixation of skin grafts to the donor site of the flap with polyurethane foam and film without using the tie-over procedure is an easy and time-saving method requiring no assistants.

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Local flaps for reconstruction of the outer lamella of eye lids have many advantages, including an excellent skin color and texture match. An advancement flap based on the orbicularis oculi muscle is available. A lower lid switch flap is functionally and esthetically useful for defects of the upper eye lid. For large defects of the upper eye lid, thin flaps, an auricular island flap and a radial forearm flap are available for reconstruction of the movable upper eye lid. When a total upper eye lid reconstruction is performed using a radial forearm flap with a hard palate mucosal graft, despite lack of levator function, our patients can raise their eye lid by using only the superior rectus muscle without frontalis suspension. The reconstructed upper eye lid results in an excellent color and texture match. Another free flap is used for the loss of total eye lids and orbital content. An anterolateral thigh flap is inferior in color and texture match to the ratissimus dorsi musclocutaneous flap and rectus abdominis musculocutaneous flap. A median forehead flap combined with tissue expander offers excellent color and texture match, but staged operation is a disadvantage. For defects of the lower eye lid, a nasolabial flap, a transverse musculocutaneous flap from the upper eye lid, and a cheek rotation flap can be used. A conchal cartilage graft without skin is used as a posterior lining for lower eye lid reconstruction. The raw surface of the graft is smooth enough to cause no corneal irritation and is epithelialized from the surrounding mucosa. If the fornix is not reserved, the lining of the lower eye lid should be reconstructed with nasal chondromucosa.

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The right (left) bronchomedistinal lymph trunks are classified into the superiormost, superficial and deep (superior and inferior) groups. Because mediastinal nodes often issue these trunks to the venous angle or thoracic duct, most of the mediastinal nodes are considered as the last-intercalated node or end node. Cancer metastasis along the lymphatics from the neck to the medistinum seems to be caused by 1) thick vessels communicating between the pretracheal node and brachiocephalic angle node and 2) lymph flow reflux toward the periphery due to intranodal shunt and lymphatic valve insufficiency. Submucosal lymphatics of the esophagus seem to cause early skip metastasis. There is little information available as to whether famous fascial structures at the base of the neck are histologically proven structures or dissection artifacts.

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Carcinomas of the cervicothoracic esophagus frequently invade the trachea and complete removal of the tumor often requires mediastinal tracheostomy. Traditionally, this surgical management was associated with high morbidity and mortality. Several types of myocutaneous flaps have been used for mediastinal tracheostomy to reduce complications. We present our surgical management for carcinomas of the cervicothoracic esophagus and our experience on a technique for construction of mediastinal tracheostomy following total laryngo-esophagectomy.
POINT OF TECHNIQUE: The anterior chest wall was amply resected and the distal end of the trachea was placed low between the superior vena cava and aortic arch. We mobilized the entire omentum with the stomach and brought it up to the neck through the posterior mediastinum. The omentum was put around the trachea, main arteries and the anastomosis.
CONCLUSIONS: We suggest the use of the omentum as a simple and reliable technique in constructing mediastinal tracheostomy following total laryngo-esophagectomy for cervicothoracic esophageal cancer.

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There have been few comprehensive studies on the treatment and results of thyroid cancer patients with mediastinal lymph node metastasis because of its rarity. Total median sternotomy is generally adopted for mediastinal lymph node dissection, however, L-shaped, reversed L-shaped, or reversed T-shaped sternotomy can be used in these patients for minimally invasive surgery. We report our modification of the reversed T-shaped sternotomy. Our modification involves shifting the transverse division lines one costal space between the right and left sides for perfect apposition of the divided upper and lower sternum. Recently, we have tried upper mediastinal lymph node dissection in selected cases through the cervical approach. Even though mediastinal lymph node metastasis was removed by these procedures, the prognosis of patients with mediastinal lymph node metastasis is poorer than those without its metastasis because of distant metastasis.

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Mediastinal tracheostomy was performed to establish an airway after resection of advanced tumor in the cervicothoracic region, such as trachea or esophagus. Historically, radical operations involving superior mediastinum have been associated with high operative mortality, secondary to mediastinal infection and rupture of the innominate artery. To analyze the operative procedures and the complications of mediastinal tracheostomy, the authors performed a retrospective review of their 9-year experience of mediastinal tracheostomy at the Cancer Institute Hospital in Tokyo. Thirty-two patients were resected a part of the manubrium and the medial right clavicle. The trachea was transposed to the right of the innominate artery in 36 patients. DP flap was used for resurfacing the anterior neck and mediasinum around tracheostome in 26 patients. There were 2 operative deaths, 1 from esophago-innominate artery fistula and the other from respiratory failure. There was an overall wound complication rate of 76% (29 of 38). These included major vessel rupture of the mediastinum in two and wound dehiscence of tracheostome in 14 patients. Mechanical ventilatory support was required in 4 patients, three of whom had partial necrosis of the tracheal wall. All patients who survived the operation achieved good airway patency and relief of dysphagia. By careful selection of patients, successful operation resulted in acceptable quality of life.

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We describe mandibular reconstructions using particulate cancellous bone and marrow (PCBM) and bioabsorbable poly [L-lactic acid] (PLLA) mesh.
PLLA mesh trays/sheets and PCBM were used to regenerate the mandibles of 57 patients (23 malignant tumors, 34 benign tumors). Clinical evaluations six months after surgery showed that 32 patients (52.6%) had an excellent outcome (bone formation range greater than 2/3), 17 (29.8%) had a good outcome (bone formation range less than 2/3, but re-operation not necessary), and 10 (17.5%) had a poor outcome (all other outcomes). Long-term observations (39 cases; 1-11 years; average 5.3 years) showed that bone absorption was less than 10% of the regenerated bone for 31 (79.5%) patients. In no case was there a complication associated with using PLLA mesh.
After surgery, 21 patients were fitted with dentures and 4 patients received dental implants in the regenerated mandible. We conclude that mandibles can be successfully reconstructed using PCBM and PLLA mesh; this technique is less invasive during operation and excellent in shape and function recovery compared to the conventional bone grafting. However, therapies that combine bioactive factors to promote angiogenesis and osteogenesis or hybrid artificial bone may be needed for patients with critical bone defects over 8 cm in length, poor regional blood circulation and elderly patients with few osteoprogenitor cells.

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Recently, some grafting techniques utilizing cultured keratinocytes are widely used to treat various skin wounds. However, fetal calf serum (FCS) is indispensable for their optimal growth in these culture methods. FCS may carry the risk of transmitting infectious agents such as prions and unknown viruses, although there has been no report on the development of such infectious diseases after grafting cultured keratinocytes. When feeder layer cells, irradiated to render them nonproliferative, such as 3T3 mouse cells are utilized for the culture of keratinocytes, the grafted procedures should be detined as xenotransplantation under the FDA in the U.S. and Ministry of Health, Labour and Welfare in Japan. We never use any serum or animal cells to culture keratinocytes, and obtained a stratified squamous epithelium which histologically resembled the in vivo original structures of normal epithelium, using an acellular dermis (AlloDerm^®) as a scaffold. In these basic researches, we tried using the ex vivo produced oral mucosa equivalent in a total of 106 cases of clinical applications after gaining informed consent, supported by a Grant for the Development of Highly Advanced Medical Technology B from the Ministry of Education, Culture, Sports, Science, and Technology of Japan for three consecutive years from 2002 to 2004. As a result, 90 grafts clinically took well and became almost normal oral mucosa uneventfully. The advantages of our method are that our material is not regarded as a xenogeneic graft tissue because we avoid any risk of transmitting infections theoretically and that the surgeon can grasp the grafted equivalent with forceps and easily suture the wound bed with a tie-over technique. The disadvantages are that an acellular dermis from cadaveric skin is used to make a composite equivalent, and it takes about one month to produce it.

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Intra-arterial chemotherapy in combination with radiotherapy is useful for the treatment of cancer in the head and neck, but severe side effects have been reported. Therefore, a safe treatment with which the incidence of systemic side effects is low is required. We developed a new combination intra-arterial and intra-venous chemotherapy with docetaxel (TXT), cisplatin (CDDP), peplomycin (PEP), and 5-FU (TCPF intra-arterial chemotherapy), and evaluated its usefulness and safety. The subjects were 29 patients with oral squamous cell carcinoma. A catheter for intra-arterial administration was inserted via the superficial temporal artery or occipital artery. Continuous intra-arterial administration of 15 mg/m² TXT (day 1-5) and 10 mg/body PEP (day 6-10), intra-arterial administration of 7-15 mg/m² TXT (day 3) and 15-30 mg/m² CDDP (day 4), and continuous intravenous administration of 250 mg/body/day 5FU (day 1-10) were performed as 1 course. The second course was performed 4 weeks after the completion of the first course in patients for whom it was required. Radiotherapy was additionally performed in 7 patients with locally-advanced cancer or metastasis in the neck. In 25 patients, excision biopsy or radical excision was performed after the completion of this treatment. The effects of this method on the primary lesions were CR 23/29 (79%), PR 6/29 (21%), and pathological CR 13/26 (50%). As the side effects, no cerebrovascular disorder was detected, but grades 2-3 mucositis and alopecia on the intra-arterial administration side were observed, without marked systemic disorders. These results indicated that this chemotherapy was very useful and safe, and can be applied to high-risk elderly patients as a radical treatment method.

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The national cancer incidence in Japan in 2000 was estimated as 310 thousand for males and 222 thousand for females. The cancer incidence of lip, oral cavity and pharynx, larynx, and thyroid was 6,650, 3,250, 1,642 for males, and 2,825, 209, and 6,246 for females, respectively. Based on data from the Osaka Cancer Registry, time-trends in head and neck cancer incidence were analyzed according to their detailed site (annual average of every 5 years for 1965-1999, and 2002). The cancer incidence of lip, oral cavity and pharynx, and larynx increased from 93 to 500 for males, and from 41 to 187 for females. The increase was remarkable for hypopharynx and oropharynx among males. The cancer incidence of larynx increased from 106 to 197 for the period of 1965-99, turning to a decrease for males, while it decreased consistently from 26 to 16 for females. The cancer incidence of nasal cavity and middle ear, and accessory sinuses decreased from 68 to 59 for males, and from 45 to 22 for females. A strong positive correlation was observed between the age-adjusted cancer incidence of oral cavity, oro- and hypo-pharynx, and the incidence of larynx among 8 populations of males and females for 6 Japanese registries, US-White, US-Black, and US-Japanese. A similar correlation was also observed between the cancer incidence of the former sites and that of esophagus. Smoking and drinking habits are important risk factors of head and neck cancer, like esophageal cancer.

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Although surgery has played an important role in the treatment of advanced head and neck cancer, there are many cases of surgery with inconclusive evidence. We reviewed the evidence of head and neck surgery obtained by multi-institutional studies in foreign countries, and considered the direction to be taken in Japan in the future. We classified the studies into four groups: the comparison of surgery and other treatment methods, the comparison of two surgical methods, the analysis of the added value of some surgery, and the comparison of postoperative treatment. We reviewed the comparison of surgery and chemoradiation, the comparison of comprehensive neck dissection and selective neck dissection, the planned neck dissection after chemoradiation, and the comparison of postoperative radiation and chemoradiation. In order to carry a multi-institutional study, it is necessary to share a common language among the head and neck surgeons, radiation oncologists and medical oncologists. Clarifying the definition of unresectability and referring to the NCCN (National Comprehensive Cancer Network) clinical practice guideline are important for that purpose.

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To derive high quality evidence in chemoradiotherapy (CCRT) for head and neck cancers, prospective clinical trials are mandatory. In the prospective clinical study, appropriate design of experimental therapy and prescription of radiotherapy parameters will be essential. Quality assurance (QA) that evaluates the consistency of radiotherapy to the protocol is very important. Radiation oncologists should participate in all these processes of CCRT prospective clinical trials for head and neck cancers.

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Supracricoid laryngectomy with cricohyoidoepiglotto-pexy (SCL-CHEP) is an organ preservation surgery for treating glottic carcinoma. Respiration from the natural airway, restoration of laryngeal functions, and superior oncological results can be achieved post-operatively. SCL-CHEP is mainly indicated for massive T2 and T3 glottic carcinomas. This surgery has become one of the major treatment options in our laryngeal cancer management. Proper selection of the patients, using the advanced technique, and employing appropriate post-operative cares are prerequisites for the success of this treatment.
Further evaluations need to be done to identify whether SCL-CHEP can be one of the standard treatments for laryngeal cancer management in Japan.
Approximately 200 to 300 cases are presumed to be potential candidates for this organ preservation surgery. When the patient desires organ preservation treatment and the surgeon is not experienced with this surgery, one should refer the patient to the appropriate institutes for a second opinion.

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Endoscopic laryngo-pharyngeal surgery (ELPS) is a trans-oral surgery in which superficial lesions are resected directly with the assistance of a laryngoscope. Four cases of post-radiation superficial carcinoma in the hypopharynx were resected with ELPS. Two cases were cancer remaining or recurrence of post-radiation T2 hypopharynx carcinomas, and two other cases were secondary superficial carcinomas. In one case, the surgical margin was positive and ELPS was performed again. In all cases, the carcinomas were completely resected. A curved laryngoscope enabled us to expand the hypopharynx. A magnifying NBI endoscope, lugor staining, and EUS were useful for identifying the area of the lesion. ELPS enabled us to do en bloc resection even for large lesions that could not be treated with EMR or with microscopic surgery.
Superficial carcinoma of the hypopharynx seems to be treatable in the first place with ELPS even in post-radiation cases of cancer remaining or recurrence. In these cases, additional treatment must be considered with pathological diagnosis of the ELPS.

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[Material and methods] We compared 24 cases of partial laryngectomy (PL) and 14 case of partial laryngo-pharyngectomy (PPL) that we performed from 1993 to 2005 with 17 cases of superselective arterial infusion and concomitant radiotherapy (iaCRT) in the same period. In addition, for 20 hypopharyngeal cancer patients who received radiotherapy from 1999 to 2003 we examined whether laryngeal preservation surgery was possible.
[Results] As for the cause-specific five-year survival rate by Kaplan-Meier's method for laryngeal cancer, PL cases were 81.3% and iaCRT cases were 87.5% (N.S.). As for the survival rate for hypopharyngeal cancer, PPL cases were 39.5% and iaCRT cases were 55.6% (N.S.). For the hypopharyngeal cancer patients who received radiotherapy, it was judged to be passible in 12 of 20 cases laryngeal preservation surgery.
[Conclusions] Patients who have received radiotherapy may be suitable for laryngeal preservation surgery for laryngeal cancer and hypopharyngeal cancer.

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Objective: To evaluate the treatment results of patients with early glottic and hypopharyngeal cancers with respect to laryngeal preservation.
Patients and Methods: Between 2001 and 2005, 93 patients with laryngeal cancers and 102 patients with hypopharyngeal cancers were treated at Kobe University Hospital. In general, T1 and T2 glottic cancers were treated with conventional and hyperfractionated radiotherapy, respectively. For hypopharyngeal cancers, Tis and T1 cancers were treated with laryngomicrosurgery followed by conventional radiotherapy. T2 cancers without deep invasion were treated with platinum-based concurrent chemoradiotherapy. More advanced T2 hypopharyngeal cancers were treated with pharyngolaryngectomy. Conservative surgery with laryngeal preservation was considered as salvage for radiation failure.
Results: The larynx was preserved in all patients with T1 glottic cancer (34/34) and 85% of the patients with T2 glottic cancer (28/33). As for hypopharyngeal cancers, local control rate was 100% not only in patients with Tis or T1 hypopharyngeal cancer (21/21) but also in patients with T2 cancer treated by chemoradiothreay (9/9), regardless of the status of nodal metastases. On the other hand, pharyngolaryngectomy was performed in 30 patients with more advanced T2 cancer.
Conclusion: Although the follow-up periods were not long enough, promising results were obtained. Treatment strategy for more advanced cancers remains an issue to be solved.

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The ion beam treatment in the Hyogo Ion Beam Medical Center (HIBMC) is carried out with a comprehensive system that consists of an irradiation system, a treatment planning system and a treatment verification system. The treatment verification system consists of a positron emission tomography (PET) camera. As charged particles produce short-lived positron-emitting isotopes in tissues, the treated site can be verified by images taken immediately after irradiation using a PET camera.
A technician sets up an immobilizing device fitted to an individual patient using plastic materials, and takes CT and MRI images of the treatment target site. Treatment planning is carried out using the 3-D treatment planning system. At this time CT and MRI fusion images are used for treatment planning. Before treatment, a rehearsal is done and on the day of treatment, the positioning is performed in the same way as the rehearsal. After positioning, ion beam therapy is started. A respiratory gating system is used for patients with lung or liver cancer.
On April 1, 2001, HIBMC was opened as the world's first facility to provide both proton and carbon-ion radiotherapy. We have treated more than 950 patients with a variety of malignant tumors including skull base, head and neck, lung, liver and prostate tumors. Excellent local control for these tumors has been obtained with minimum side effects. Experience of clinical trial and general practice, showed that radio-resistant tumors in the head and neck region like mucosal malignant melanoma and adenoid cystic carcinoma could be locally controlled with proton beam therapy. In the future we will analyze the difference between two beams for the patient with head and neck cancer.

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The most characteristic feature of the pathology of head and neck cancer is the various histological malignancies in various organs in head and neck. Last year, the 4th edition of General Rules for Clinical Practice and Pathology in Head and Neck Cancer in Japan was published. Since more than 80% of malignancies in the head and neck region are squamous cell carcinoma, the new rules describe the following items: 1) Macroscopic and microscopic findings, 2) Judgment of surgical and frozen section, 3) Intraepithelial neoplasma and dysplasia and 4) Superficial lesions of squamous cell carcinoma in the head and neck region. The present paper explains the new general rules for pathology of head and neck cancer focusing on the above items to add useful information for head and neck surgeons and oncologists.

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Our group has studied about function of a tumor suppressor p53 molecule as a predictive indicator for cancer therapies by using head and neck cancer cells. This molecule plays an important role in carcinogenesis and cancer therapy, because the p53 molecule induces cell-cycle arrest, apoptosis and DNA repair. Mutations of p53 are observed at a high frequency in human tumors, and are recognized in about half of all malignant tumors in humans. An abnormality of the p53 gene might reduce the low efficiency of their cancer therapies. In the both systems of a human cell culture and their transplanted tumor, the sensitivities to radiation and anti-cancer agents were observed in wild-type (wt) p53 cells, but not in mutated (m) or deleted p53 cells. In this review, we discuss the p53 activation signaling pathways after radiation and/or anti-cancer agents. In addition, we applied a chemical chaperone such as glycerol which restores mp53 to wtp53 function through conformational change of mp53. In contrast, we found that high linear energy transfer (LET) particles such as carbon beams introduced efficiently apoptosis in mp53 or deleted p53 cells. Namely, these results suggest that high LET radiations are effective for all patient regardless p53 gene status. From these scientific processes, we confirmed that studies of the p53 molecule are important for cancer science including carcinogenesis from gene stability and cancer therapy from a factor for predicting therapy effectiveness.

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Postoperative dysarthria was evaluated in 20 oral cancer patients usig the Asahi speech mechanism test in comparison with the speech intelligibility test. The Asahi speech mechanism test was performed using a simple version and evaluated according to the criteria. The speech intelligibility test was performed using 100 Japanese syllables. The results of the Asahi speech mechanism test ranged from 44 to 99% and those of the speech intelligibility test from 46 to 91%. There was a significant correlation between them with a correlation coefficient of r=0.703 (P<0.01). A significant correlation was also observed between the results of the selected items concerned with tongue movement in the Asahi speech mechanism test and those of the speech intelligibility test with a correlation coefficient of r=0.893 (P<0.01) in tongue cancer patients. These results show that the Asahi speech mechanism test is well correlated with the speech intelligibility test and is useful for evaluating the degree of speech disorders in postoperative patients for oral cancer, since it is easily performed without any special environment or equipment.

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Materials and methods: Eighty patients underwent vertical partial laryngectomy (VPL) for laryngeal cancer; 43 patients had not been treated previously, and 37 patients had previously received radiation therapy. All but 3 of the patients were male with an average age of 63.6 years (range 47-85). Mean follow-up was more than five years.
Results: The larynx preservation rate and the local control rate were 79.5% and 80.0%. Resection of one arytenoid cartilage influenced the post-operative recovery of the swallowing function, although resection of the arch of the cricoid cartilage did not reduce the function. The nasogastric tube was removed after a mean duration of 7 days. The contralateral recurrence rate was low. The paraglottic space was infiltrated in 23 cases. The local control rate was statistically lower in patients with positive paraglottic space invasion.
Conclusion: Post-operative swallowing function recovered early after VPL. Preoperative assessment of the involvement of the paraglottic space is necessary in planning this treatment modality for laryngeal cancer.

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In head and neck cancers, it is sometimes necessary to remove the recurrent laryngeal nerve with the cancer. Recently, in thyroid cancer, reconstruction of the recurrent laryngeal nerve has been generally performed in consideration of the patient's quality of life. In this study, we examined 5 cases receiving recurrent laryngeal nerve reconstruction after removal of the tumor with mediastinal dissection. All patients showed an acceptable recovery postoperatively without aspiration or pneumonia. From the aspect of postoperative recovery and life expectancy, reconstruction of the recurrent laryngeal nerve is important in serious cases with mediastinal dissection.

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Carcinomas of the mesopharynx, hypopharynx, and larynx with early-stage primary tumor and with cervical lymph node metastasis, were treated by neck dissection for cervical metastasis and definitive irradiation of the primary tumor. In this study, the primary sites of the 16 cases were the mesopharynx (10), the hypopharynx (3), and the larynx (3). Twelve cases of early T stages (T1 or T2) and 15 cases of advanced N stages (N2 or N3) were chosen for this treatment concept. Neck lesions were controlled in all cases and all the primary tumors showed complete response at the end of the initial treatment. One case of mesopharyngeal cancer died due to recurrence of the primary tumor and one case of hypopharyngeal cancer died due to complicated lung cancer.
The treatment modality for cases of early primary cancer and advanced cervical lymph node metastasis requires well-balanced strategies for both lesions. In these cases, optimal prognosis was obtained because of careful patient selection. The treatment strategy described in this paper should be considered for cases of early T tumors and advanced N tumors.

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Two of 82-year-old patients were operated on for high risk thyroid cancer with invasion to the aero-tract. In the first case, because the recurrent nerve could not be preserved, thyroplasty was simultaneously pertormed. In the other case, a few funicles of recurrent nerve could be preserved microscopically. Tracheo-cutaneous fistula enabled safe and easy post-operative care in both cases. Post-operative hoarseness was not severe in both cases. Both cases could take oral nutrition without aspiration within a few days after the operation. Active radical surgery for advanced aged patients with invasion to the aero-tract is recommended.

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Patients with more than 3 multiple malignancies (13 patients, 45 sites) including head and cancer treated in our hospital were clinically evaluated. The most common primary site of multiple malignancies in the head and neck was the oral cavity. Esophagus and lung were common sites other than the head and neck. Although a history of smoking and drinking was a common risk factor, the amount of smoking and drinking was not proportional linear to the incidence, and multiple malignancies also occurred in the patients without a history of smoking and drinking. The importance of screening examination was emphasized since most of the subsequent malignancies were found during pre-treatment screening and follow-up of previous malignancies at early stages. Long-time follow-up was considered to be important since several subsequent malignancies occurred more than 5 years after the treatment of previous malignancy, especially in the head and neck. The prognosis of patients with more than 3 malignancies was not always poor when early diagnosis and treatment was performed.

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We investigated the safety and efficacy of alternative and concurrent chemoradiotherapy with 5-FU/CDGP for head and neck cancer. From January 2003 to August 2005, 19 patients with head and neck squamous cell carcinoma were treated in our institution. Alternative chemoradiotherapy (ACRT) was performed for 8 cases of nasopharyngeal cancer. Concurrent chemoradiotherapy (CCRT) was performed for 11 cases of other head and neck cancer. Median total dose of radiotherapy was 63Gy. ACRT consisted of 5-FU at a dose of 500mg/m² on days 1-5 and 28-32 and CDGP at a dose of 60mg/m² on days 6 and 33. CCRT consisted of 5-FU at a dose of 500mg/m² on days 1-4 and 28-31 and CDGP at a dose of 60mg/m² on days 5 and 32. Median follow-up periods was 13 months. CR+PR was admitted in five cases (63%) with ACRT, and in 9 cases (82%) with CCRT. Non-hematological adverse effects of grade 3 were admitted in eight cases (100%) of ACRT, and in 9 cases (82%) of CCRT. Chemoradiotherapy attained good results and non-hematological adverse effects were able to be managed by preserved treatment.

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We report our method of perioperative management under clinical pathway for laryngopharyngoesophagectomy with free jejunum reconstruction. We treated 44 patients diagnosed as hypopharyngeal carcinoma between 2002 and 2005. Thirty-six of them were treated under clinical pathway. Variances were assessed and the clinical pathway was improved twice. Comparing the cases before improving the clinical pathway (17 patients) those after improvement (7 patients), the period until start of walking was shortened from 4 days to 2 days. The period until start of peroral nutrition was also shortened from 9 days to 7 days. Caloric intake of each patient increased from 1045 kcal/day to 1388 kcal/day. Patients who deviated from clinical pathway management decreased from 41% to 14%. Clinical pathway combined with an electronic medical record system was highly effective for an interdisciplinary medical team approach.

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