To identify useful molecular markers for the treatment of head and neck cancers (HNCs), mutations of the TP53 and EGFR genes were analyzed in 56 HNCs, including 39 head and neck squamous cell carcinomas (HNSCCs). No EGFR mutation was observed in the fragments of exons 18-21. By contrast, 17 of 39 (44%) HNSCCs, as well as 3 of 6 cases (50%) with salivary gland carcinoma showed TP53 mutation in the fragments of exons 5-9. The incidence of nonsense mutation was 47%, which was higher than that in previous reports in other countries, suggesting the presence of etiological factors characteristic to Japanese patients. Further clinical assessment, including drug response and prognosis, is required in HNSCCs carrying the null-type mutation of TP53.

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Oral leukoplakia is defined as “a predominantly white lesion of the oral mucosa that cannot be characterized as any other definable lesion”. Leukoplakia is used only as a clinical term and is classified histopathologically into hyperkeratosis, dysplasia, carcinoma in situ, and invasive carcinoma. As multistep carcinogenesis is the common process by which malignant neoplasms are generated, one leukoplakia may have “mixed” different histopathological states such as hyperkeratosis, dysplasia, and invasive carcinoma. Local biopsy at an unsuitable site might lead to under-diagnosis and hence suboptimal treatment. The purpose of this study was to investigate the effect of total excision of tongue leukoplakia for histopathological diagnosis. Twenty-eight cases of tongue leukoplakia treated during the past 13 years were enrolled in this study and were divided into two groups: 1) 10 cases examined by local biopsy before total excision and 2) 18 cases treated by total excision without local biopsy. In the first group, there were 4 cases (40%) having a histopathological diagnostic mismatch between local biopsy and surgical excision afterward. Three cases were pathologically “mixed” cases in which an unsuitable site was biopsied, and one case was biopsied at only a superficial site. In the second group, 6 cases (33%) had pathologically “mixed” states. In conclusion, total excision should be performed for the diagnosis of tongue leukoplakia because local biopsy may lead to under-diagnosis.

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A clinicopathological study was made of 41 patients with squamous cell carcinoma of the upper gingiva. All patients had been treated at the Maxillofacial Surgery Department of the Tokyo Medical and Dental University hospital, consisting of 15 men and 26 women, mean age 62 years, range 38-85 years. According to the T classification there were 8 cases with T1, 13 with T2, 10 with T3, and 10 with T4. Eleven patients were treated with surgery alone, 26 with both chemo-radiotherapy and surgery, and 4 with other combinations. Neck dissection was performed in 18 patients, among whom histopathological cervical lymph node metastasis was confirmed in 14. The most common site of metastasis was level II of the neck. There were no patients with level III, IV or V disease. The 5-year overall survival rate was 80.9%. With regard to tumor location, the 5-year overall survival rate was 100% in the group with the anterior region type, 88.5% in the molar region and 52.5% in the posterior region. There was a statistically significant difference in survival rate between the molar region group and the posterior region type group (p < 0.05). One patient died of primary recurrence, 1 died of cervical recurrence, 3 died of pulmonary metastasis, and 1 died of gastric cancer.

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Sometimes patients with gingival cancer receive surgical procedures such as tooth extraction before treatment, because its clinical similarity to inflammatory disease may be difficult to diagnose. We evaluated the influence of surgical procedures for gingival cancer before our examination.
Between April 2001 and December 2009, 152 cases of gingival cancer were treated in our department. The primary sites were the upper gingiva in 53 cases, and the lower gingiva in 99 cases.
We compared a group of 45 cases who had received surgical procedures before treatment with a group of 117 cases who had not. In the former group, the rates of endophytic tumors and T3/4 cases were significantly higher. Nineteen cases (42.2%) had histologically confirmed cervical lymph node metastasis in the former, while 24 cases (22.4%) had in the latter. In those cases of the lower gingiva who had received surgical procedures, the rate of moth-eaten type of radiographical bone resorption was significantly higher. In the former group, the rates of subtotal maxillectomy and segmental or hemimandibulectomy were significantly higher. The 5-year disease-specific survival rates of the two groups that had or had not received the surgical procedures before treatment were 90.9% and 91.8%, respectively.
Surgical procedures may affect the progression of gingival cancer and the extent of resection for primary tumors.

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For preoperative treatment, selective arterial injection chemoradiotherapy (arterial injection therapy) for the primary focus and lymph node metastasis has been performed in our department. In this study, we investigated the therapeutic effects of arterial injection therapy on lymph node metastasis. For arterial injection, we employed Seldinger's method. Initially, the dose of CBDCA was calculated using Calvert's formula. After a catheter was inserted into a nourishing blood vessel of the lymph node, contrast-enhanced CT was performed to confirm the enhancement effects prior to arterial injection therapy. For radiotherapy, external irradiation of the entire cervical region on the affected side at 42 Gy (3 Gy/day) was carried out. Resection of the primary tumor and radical neck dissection were performed 4 weeks after preoperative treatment. The subjects were 16 stage-III/-IV patients with cervical lymph node metastasis (23 lymph nodes). When histopathologically evaluating the primary focus, the response rates were 87.5% in grade-IIb or higher patients and 68.8% in grade-III or higher patients. Concerning the resected cervical lymph nodes, the response rates were 87.0% in grade-IIb or higher patients and 69.6% in grade-III or higher patients. These results showed that arterial injection therapy, which is employed in our department, was effective for cervical lymph nodes, suggesting its usefulness.

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Since 2006, we have performed minimal invasive resection combined with biopsy (MIRB) or minimal invasive resection (MIR), which we devised as conservative surgery for patients with tongue cancer who were responsive to intra-arterial chemotherapy with docetaxel, cisplatin, and peplomycin combined with intravenous chemotherapy with 5-fluorouracil (TCP intra-arterial and 5-FU intra-venous chemotherapy). In this report, we discuss the validity of the resection method. This study included 21 patients with squamous cell carcinoma of the tongue who underwent TCP intra-arterial and 5-FU intravenous chemotherapy alone via the superficial temporal artery prior to surgery. MIRB was performed in clinical CR patients, and MIR was performed in clinical PR patients.
Evaluation of the therapeutic effects revealed clinical CR in 15 patients (71%) and PR in 6 (29%). Pathological CR was achieved in 10 of the 15 clinical CR patients, and the carcinoma remained histologically in the other 11 patients. In 2 patients (10%), recurrence at the primary lesion was observed, but this event was not related to the surgical margin.
This chemotherapy for tongue cancer is expected to provide a radical cure with high probability when combined with MIRB, though its single use involves the risk of the carcinoma remaining histologically even in clinical CR patients. In addition, the present study results suggest that MIR is feasible even in PR patients.

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Between February 2009 and January 2010, 13 patients with locally advanced squamous cell carcinoma of the tongue underwent proton beam therapy combined with intra-arterial infusion chemotherapy via a superficial temporal artery. Their characteristics were as follows: median age 64 years old, 4 females and 9 males. Two patients were clinical stage III and 11 patients were clinical stage IVA. Though the follow-up period was short, the initial results of this therapy were 12 CR and 1 PR. Later, local recurrence was detected in 4 patients and neck recurrence was detected in 2 patients. The local control rate for the primary site and the neck were 69.2% (9/13) and 80.0% (2/10), respectively. In cases of local recurrence, most of them occurred from non-perfusion areas; there was no case with distant metastasis and osteoradiation necrosis of the mandibular bone and tooth during the follow-up period. These results confirm the importance of examining the perfusion area. Though the period of observation was short, proton beam therapy combined with intra-arterial infusion chemotherapy is thought to be an effective treatment for locally advanced tongue cancer, and proton therapy may also be effective for cervical lymph node metastases.

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It has been considered that oral cancer is cured if more than five years pass without recurrence or metastasis after the initial treatment. Treatment results are usually evaluated as a 5-year survival rate, but we sometimes find recurrence more than five years after the initial treatment. We retrospectively investigated treatment results by long-term follow-up of advanced squamous cell carcinoma of the oral cavity after radical surgery, and analyzed the relation between the period of follow-up and the time to recurrence. One hundred and sixteen patients with advanced squamous cell carcinoma of the oral cavity were enrolled between November 1994 and October 2004 in this study. Seventy-six patients were Stage III and 40 were stage IV, and the mean age of this cohort was 63.0 years. All patients received radical surgery with or without preoperative chemoradiotherapy and were followed for a minimum of 5 years. Overall actuarial survival of all patients was 77.8% at 10 years. The 10-year cumulative local and regional recurrence rates were 20.1% and 12.9%, respectively. The actuarial loco-regional recurrence rate was the highest within 2 years after initial treatment at 19.0%, and was seen in 3.4% even after 5 years. These results showed that it is necessary to follow-up patients with advanced oral cancer even beyond 5 years after the initial treatment because there was delayed loco-regional recurrence in 3.4%.

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We treat early glottic squamous cell carcinoma with chemoradiation and evaluate the effects of the chemoradiation at the dose of 30-40 Gy as an intermediate evaluation. To investigate the need for this intermediate evaluation, we retrospectively analyzed 97 patients, 92 men and 5 women aged 36 to 86 years, with glottic squamous cell carcinoma at stage I and II treated at our institution from January 2000 to May 2007. The three-year survival rate was 98% in all cases, 100% in T1a, 93% in T1b and 94% in T2. The three-year preservation rate of the larynx was 92% in all cases, 98% in T1a, 93% in T1b and 83% in T2. In the intermediate evaluation, complete response was 78% in T1a, 85% in T1b and 53% in T2. In cases of larynx preservation, the recurrence rate of the primary site was significantly higher in cases without complete response in the intermediate evaluation than in cases with complete response (p < 0.05). It seemed that the not complete response case in the intermediate evaluation paid attention to a primary tumor recurrence in particular and needed careful follow-up.

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A clinical study was made of 53 patients with previously untreated hypopharyngeal squamous cell carcinoma in our department between 2005 and 2009. Forty cases were treated by concurrent chemoradiotherapy with 5-fluorouracil (5-FU) 800 mg/m² from day 1 to day 5 and cisplatin (CDDP) 80 mg/m² on day 6. Complete response in the primary region was obtained in 34 (85%) out of the 40 patients, and 26 (97%) in 27 resectable cases. Cause-specific five-year survival rates were 51% in all cases and 68% in resectable patients. Major adverse effects were leucopenia and mucositis, which were tolerable and no fatal case was observed. This study showed that concurrent chemoradiotherapy of CDDP plus 5-FU was an effective treatment for hypopharyngeal squamous cell carcinoma, and also was well tolerated. However, further investigation is required on new therapeutic strategies for advanced hypopharyngeal carcinoma.

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Thirty-seven cases with hypopharyngeal carcinoma who underwent pharyngolaryngectomy and pharyngolaryngoesophagectomy in our department between 1991 and 2008 were clinically analyzed. The cases were equivalent to 31.4% of all hypopharyngeal cases. The ages of the cases ranged from 39 to 83 years old (mean: 65), and the ratio of males was 94.6%. The histopathology of all the cases was squamous cell carcinoma, and the most common clinical stage was stage VIA (67.6%) followed by stage III, stage II, and stage VIB. Regarding surgical procedures, 62.2% of the cases underwent pharyngolaryngectomy and 37.8% pharyngolaryngoesophagectomy. Postoperative radiotherapy was used in 62.2% of cases, and chemotherapy in 40.5%. Recurrence was observed in 37.8%, and the disease-specific 5-year survival rate was 58.5%. Since the prognosis of postoperative radiotherapy cases who were histopathologically high-risk was not significantly different from those of non-radiotherapy cases, postoperative radiotherapy was considered to be useful for these patients. Chemotherapy cases had significantly lower local recurrence rate and better prognosis, suggesting the effectiveness of multidisciplinary treatment including chemotherapy in the treatment of hypopharyngeal carcinoma.

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We retrospectively analyzed the treatment outcomes of post-operative radiation therapy (PORT) after radical surgery for locally advanced hypopharyngeal carcinoma. From August 2000 to July 2009, 62 patients with hypopharyngeal squamous cell carcinoma were treated with radical surgery followed by PORT in our institute. All patients were followed up for more than 6 months or until any events. All patients underwent a total laryngectomy and neck node dissection prior to PORT. There were 55 male and 7 female patients, with ages ranging from 45 to 82 years (median: 64). Pathologic stage was IVA in 55 and IVB in 7 patients. Irradiation dose ranged from 46 to 70 Gy (median: 60). Twenty-four patients received concurrent chemotherapy. The median follow-up period for surviving patients was 43 months. The 3-year overall and relapse-free survival rates were 56% and 51%, respectively. There was 1 patient with local recurrence and 9 patients with neck node recurrence, and the 3-year loco-regional control rate was 85%. There were 16 patients with distant metastases and the 3-year freedom form distant metastasis rate was 71%. Patients with extra nodal invasion (ENI) had a statistically poorer prognosis (p = 0.008). The incidence rate of loco-regional recurrence and distant metastasis were statistically higher in the patients with ENI (p = 0.017 and p = 0.009, respectively). PORT with concurrent chemotherapy is deemed to be a standard treatment for such high-risk patients. Conformal and precise radiation treatment such as IMRT might also be considered for such high-risk patients in the near future.

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Salivary duct carcinoma (SDC) is a very rare tumor, especially originating in the submandibular gland. We encountered two patients with SDC arising from the submandibular gland.
A 59-year-old man was referred to our institute with a complaint of a firm, fixed submandibular mass on the right side. The mass was resected with the surrounding tissue and diagnosed by pathologic examination as SDC. Radiotherapy of 66 Gy was done after the surgical procedure. Seven months after the initial resection, a 2.0-cm-diameter mass was noticed in the lower lobe of the left lung. A lower lobectomy was performed, and the pathologic examination showed recurrent metastasis from the SDC. Three years after lobectomy, he remains in good condition with no evidence of disease.
The other patient was a 52-year-old man who complained of a right neck swelling. A submandibular tumor was resected with the surrounding tissue and total neck dissection was performed. Histological examination revealed that the tumor presented with papillary and cribriform patterns with comedo necrosis. Because no tumor close to the cut-end and no positive lymph node were detected, postoperative therapy was not performed. Thirty months after the surgery, the patient remains alive without any evidence of recurrence.

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Salivary gland malignancies are unique in their histological and behavioral variability. Decisions on treatment regimens and prognostic prediction require evaluation of the histological diagnoses. Positron emission tomography (PET) using 18F-fluoro-2-deoxy-D-glucose (FDG), which reflects glucose metabolism, has been reported to be useful for the diagnosis of several malignancies. However, the clinical utility of 18F-FDG-PET in evaluating salivary gland malignancies has not been clarified.
In this study, we investigated the utility of FDG-PET in histologic grading and prognostic prediction for patients with salivary gland malignancies. To indicate the degree of 18F-FDG accumulation, the standardized uptake value (SUV) was used. High-grade malignancies had significantly higher mean maximum SUVs than did low- and intermediate-grade malignancies. In univariate survival analysis, the cumulative survival decreased as the SUV increased, when the maximum SUV of 7.8 was taken as a cut-off for high and low uptake tumors. We concluded that FDG-PET has a significant impact in histologic grading and prognostic prediction for patients with salivary gland malignancies.

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INTRODUCTION: Regional lymph node metastases significantly influence the prognosis of patients with parotid cancer. To assess our indications of elective neck dissection and postoperative radiotherapy for parotid cancer, a retrospective chart review was performed.
MATERIALS AND METHODS: Between 2001 and 2009, 35 patients with parotid cancer were initially treated at our department. The median follow-up was 30 months (range, 10-90 months).
RESULTS: Out of all patients, 31 (89%) patients were preoperatively diagnosed as malignant, while 4 (11%) patients were initially diagnosed as benign. Mucoepidermoid carcinoma was the most common histological type (10 patients). Twenty-two tumors (63%) were pathologically diagnosed as high-grade. The numbers of patients with Stages I, II, III, and IVA were 3, 10, 7, and 15, respectively. Ipsilateral neck dissection (Level II-V) was performed in seven patients with clinically positive neck metastasis (cN+), and in ten patients without lymph node metastasis who had T4 disease, high-grade malignancy, or positive neck (Level II) metastasis during intraoperative evaluation. Postoperative radiotherapy was performed in 24 patients with pathological T4, high-grade malignancy, positive surgical margin, multiple neck metastasis and/or extranodal extension (ENI). Seven of 28 (25%) patients with clinically N0 had pathologically positive neck metastasis (pN+). Regional recurrence developed in one patient with high-grade malignancy and ENI (T4N2b). Disease-specific survival rates for Stages I, II, III, and IVA at 3 years were 100%, 73%, 100%, and 37%, respectively. Loco-regional control rates for pN0 (21 patients) and pN+ (14 patients) at 3 years were 90% and 95%, respectively.
CONCLUSION: Our present favorable loco-regional control supported our current indications of elective neck dissection and postoperative radiotherapy. We also recommend intraoperative biopsy of level IIB nodes to study the need for elective neck dissection.

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Anaplastic thyroid carcinoma (ATC) is one of the most aggressive malignancies. Its prognosis is extremely poor, and many reports described that complete resection of the tumor showed better locoregional control. We urgently performed radical resection in two patients with locoregionally advanced ATC within 10 days after the first visit.
Case 1: A 63-year-old man presented with a rapidly growing thyroid mass that had been noticed one month earlier. The cytologic examination performed at the previous clinic showed ATC. He was referred to our hospital for treatment of the disease. Ten days after the first visit, a total thyroidectomy combined with total laryngectomy and bilateral neck dissection was performed. He has been alive for 27 months with no evidence of disease.
Case 2: A 66-year-old woman suffered from right neck pain, and had noticed a rapidly growing thyroid mass one month earlier. At the previous clinic, her thyroid mass was diagnosed as ATC by cytologic examination. Seven days after visiting our hospital, a total thyroidectomy in conjunction with total laryngopharyngoesophagectomy and bilateral neck dissection was performed, and her gullet was reconstructed with a free jejunum. She received 54 Gy of irradiation postoperatively. However, multiple metastases developed 4 months later, and she died 5 months after the operation without local recurrence.
For ATC, radical complete dissection for locoregional control should be performed as soon as possible due to the possibility of cure and airway management.

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The aim of this retrospective study was to determine the diagnostic value of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) in predicting the resectability of papillary thyroid carcinoma around the carotid artery.
Between January 2004 and December 2009, 8 patients presented with papillary thyroid carcinoma for which pathological and surgical findings could be compared. Tumor involvement of the carotid artery around more than 225° of its circumference was used to predict carotid artery invasion. If loss of the intervening fat plane was not presented, no carotid artery invasion was predicted.
Although 6 patients revealed carotid artery invasion radiologically, 3 of these 6 patients had carotid invasion pathologically, an accuracy of 62.5% (5 of 8). The discontinuity of the arterial wall corresponded to the result of pathological tumor invasion.
We conclude that carotid artery invasion on CT and MR images can be accurately diagnosed by discontinuity of its wall regardless of measurement of the tumor circumference of the carotid artery. It is thought that carotid artery invasion is not predicted when small vessels between the tumor and carotid artery are recognized.

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We investigated 80 cases of malignant thyroid tumors that were diagnosed and received primary treatment at our department between January 1995 and June 2010. Only those patients for whom the following could be confirmed were included in the analysis: chief complaint, gender, fine-needle aspiration cytology (FNAC), histopathological classification, and TNM classification. The male-female ratio was 1:2.6, with a higher proportion of female patients. Histopathological classification of thyroid cancer was as follows: papillary 71 patients (88%), follicular 6 patients (8%), and undifferentiated 1 patient (1%). There were no cases of medullary cancer. Malignant lymphoma was found in 2 patients (3%). Fine-needle aspiration cytology sensitivity was 90.3%. The most common operative procedure was lobectomy (44%), followed by total thyroidectomy (33%), subtotal thyroidectomy (19%), total thyroidectomy with tracheal resection (3%), and thyroidectomy with total laryngectomy (1%). Average follow-up was 39.9 months. With the exception of one case of undifferentiated cancer, all patients survived.

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In our institute, neck dissection (ND) is considered to be a part of multidisciplinary treatments involving surgery and concurrent chemoradiotherapy (TAR therapy). We have applied modified neck dissection as well as less extensive selective neck dissection to patients with head and neck squamous cell carcinoma, based on a definite policy.
During 2004-2008, 45 NDs were performed in 41 patients (33 males and 8 females) at Kyushu Kosei Nenkin Hospital. We retrospectively analyzed the treatment results to validate the therapeutic efficacy of our organ-preserving and less-extensive surgical policy. Classical radical neck dissection was performed in only 4 cases. In 36 (80%) cases, at least two of the spinal accessory nerve, the sternocleidomastoid muscle and the internal jugular were spared, while in 19 (42.2%) cases all three organs were preserved.
SND was administered for 31 cases omitting 40% and 48% of the respective level I and V in laryngeal and pharyngeal cancer; 31.6%, 57.9% and 73.7% of the respective level III, IV and V in oral cancer. Among these 31 cases, 24 (66.7%) NDs were carried out as a therapeutic selective neck dissection (TSND) for N+ neck. Lymph node recurrence was observed in only 4 cases (8.9%). The cumulative regional control rate with SND and comprehensive ND were 93.6% and 83.6%, respectively. For N+ cases, 91.7% of the regional control rate was obtained in TSND, while 82.5% was obtained in comprehensive ND. These favorable results indicate that in the multimodality treatment setting, organ-preserving and less-extensive ND are appropriate treatment choices with respect to both QOL and oncological results.

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Salvage operations (including reconstruction) should be done much more cautiously after chemoradiotherapy than primary operations because postoperative complications often occur. We report one case that had recurrences following definitive organ-preserving therapy for laryngeal cancer using a nasolabial flap to close the pharyngocutaneous fistula caused by total laryngectomy. Selected chemoradiotherapy after induction chemotherapy for radical modality was initially effective, but a salvage operation was unavoidable due to regional recurrence and one lung metastasis after 8 months. Subsequent total laryngectomy and VATS (video-assisted thoracic surgery) resulted in a pharyngocutaneous fistula in his right side. It was thought that the use of a hinged flap and other nearby flaps would be difficult because this region had received radiation (total 70 Gy). To close this fistula, we selected a nasolabial flap with buccal mucosa on his left side, which was more distant and unexposed to radiation. Although congestion of the nasolabial flap was found, we avoided further complications by exsanguination and the therapeutic use of medical leeches. A nasolabial flap is useful for pharyngocutaneous fistula closure after chemoradiotherapy, and is worth considering in addition to deltopectoral and pectoralis major flaps.

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Background: Early postoperative ambulation is well recognized as a potential method for decreasing perioperative complications in general surgery. However, the efficacy of early postoperative ambulation has not been evaluated in head and neck surgery. We conducted a retrospective study to assess the efficacy of ambulation around postoperative day 2 in patients with head and neck cancer who underwent free reconstruction surgery, compared to postoperative day 5 or later.
Methods: Between 2006 and 2009, 37 patients performed ambulation at around postoperative day 2 after free reconstructive surgery. As a control group, 50 patients on postoperative day 5 or later between 2001 and 2005 were selected. The differences between the two groups with respect to incidence of free flap necrosis, delirium, postoperative complications (airway and others), indications of infection and length of hospital stay after surgery were analyzed.
Results: In the early ambulation group, the incidence of free flap necrosis was 5.4%, which was less than that in the control group (10%). Delirium occurred in 5 patients (13.5%) in the early ambulation group, which was less frequent than that in the control group (22.0%). In the early ambulation group, the incidence of postoperative airway complications was less than two-thirds of that in the control group with or without laryngectomy. Other postoperative complications in the early ambulation group were similar in both groups. Duration of antibiotic therapy, duration of fever and length of hospital stay after surgery in the early ambulation group were significantly lower than in the control group.
Conclusion: Early postoperative ambulation in patients with head and neck cancer is efficient and safe in the postoperative period, and may facilitate early hospital discharge.

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Recently, oropharyngeal cancer is more frequently being managed with concurrent chemoradiotherapy (CCRT). As more patients receive CCRT, there is increasing attention on dysphagia. Since 2009, speech therapists in our hospital have performed swallowing rehabilitation for dysphagia associated with CCRT. We evaluated dysphagia after CCRT and examined the relationship between swallowing rehabilitation and swallowing disability. A total of 26 patients (22 males and 4 females) with a mean age of 63 years (range, 41 to 79), underwent CCRT between March 2008 and March 2010. Dysphagia after treatment was graded at the end of CCRT and discharge according to CTCAE version 4.0 and Fujishima dysphagia grade. Ten of the 26 patients underwent swallowing rehabilitation, exercise and education on muscle strengthening programs before and during CCRT. They tended not to have severe dysphagia, but there were no significant differences.

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Since hypopharyneal/cervical esophageal cancer is often associated with other cancers in the upper gastrointestinal tract, there are cases in which total esophagectomy combined with total pharyngolaryngoesophagectomy (TPLE) is necessary. On the other hand, with recent advances in chemoradiotherapy, the number of cases of hypopharyngeal cancer which can be treated with partial pharyngectomy instead of TPLE is increasing. Because the conventional reconstruction strategy cannot be applied to such cases, appropriate reconstruction methods for these defects are required. We reviewed cases of hypopharyngeal/cervical esophageal cancer which were variably resected by other than TPLE and reconstructed with free flap.
Five cases of partial pharyngectomy and 5 cases of total esophagectomy combined with TPLE are reviewed. The reconstruction methods were free jejunal patch, free radial forearm flap in partial pharyngectomy cases, and elongated stomach roll with supercharge, free jejunum combined with gastric pull-up in extensive resection cases.
Each reconstruction method has advantages and disadvantages. Therefore, it is important to discuss age, sex, prognosis, resection area, preserved vessels and general condition preoperatively with head and neck surgeons and gastrointestinal surgeons when planning appropriate reconstruction methods.

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We reviewed seven patients who underwent reconstruction using an infrahyoid myocutaneous flap after ablative surgery for head and neck cancers, and examined the safety and eligibility of using this flap. Although one patient developed partial necrosis of the skin island, the other six patients showed total survival of the flap. The patient with partial flap loss developed a small pharyngocutaneous fistula, and two other patients developed local wound infection without fistula, but those complications healed conservatively. The time taken till starting oral intake ranged from 5 to 20 days after surgery (mean: 9 days), and all patients finally regained oral intake without tube feeding.
Because the skin island and the feeding vessels of the infrahyoid myocutaneous flap are included in the neck and the flap is technically easy to harvest, using this flap is minimally invasive for head and neck cancer patients. However, the flap is not indicated for some patients due to the size and position of the primary tumor and neck lymph node metastases. If eligible patients are properly selected, the infrahyoid myocutaneous flap provides a safe and useful option in head and neck reconstruction.

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With the recent improvement of free tissue transfer for oral and maxillofacial reconstruction, more patients are requiring second resections and reconstructions. The aim of this study was to evaluate the applications, complications and success rate of second free flaps for oral and maxillofacial reconstruction.
Thirty-six second free flaps for oral and maxillofacial reconstruction were performed in 32 patients from 1995 to April 2010, at Hokuto Hospital and Hokkaido University Hospital. Four patients who underwent a third free flap reconstruction were also included in this study. The reason for reconstruction using a second free flap was secondary jaw reconstruction in 21 flaps, recurrence or metachronous carcinoma in 6 flaps, osteoradionecrosis of the mandible in 7 flaps, and first free flap failure in 2 flaps. Thirty of the 36 second free flaps were bone reconstruction using scapula (16 cases) and fibula (14 cases). The overall complication rate among the second free flaps was 27.8% (10 of 36 flaps). The complications were: delayed wound healing at the flap harvest site (3 cases), cervical wound infection or dehiscence (4 cases), partial flap necrosis (1 case), and total flap necrosis (2 cases). Thus, the success rate for the second free flap was 94.4%. Although many second free flaps were used for secondary jaw reconstruction, the success rate was relatively high with a low overall complication rate. This study demonstrates that second free flaps are a promising and safe resource for oral and maxillofacial reconstruction, and that the appropriate choice of flap and availability of recipient vessels are of vital importance to avoid complications.

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The adverse events associated with planned neck dissection (PND) conducted after concurrent chemoradiotherapy (CCRT) in oropharyngeal and hypopharyngeal cancers were investigated. A questionnaire survey related to subjective neck symptoms, meals, conversation, etc. was conducted for patients who visited the outpatient ward, and the results were compared between the cases who received PND and those who received CCRT only. Although a significant difference was observed in some items related to the subjective symptoms, most of the items did not demonstrate any significant difference between the former and the latter. Accordingly, it is not considered necessary to be averse toward PND for the reason of adverse events.

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Purpose: To compare the clinical results of superselective intraarterial infusion (IAI) therapy with non-selective IAI therapy, and to evaluate the complications related to the IAI procedure in patients with head and neck cancer treated by intraarterial chemo-radiation therapy.
Materials and Methods: This study retrospectively reviewed 93 patients with head and neck cancer treated by intra-arterial chemotherapy (247 infusion procedures). The 93 patients were divided into two groups by means of the catheter-cannulation technique: the superselective IAI group (67 patients) and the non-selective IAI group (26 patients). The arterial channel alteration method was performed with coil embolization at the first IAI session in each of these 26 patients. We evaluated the clinical results of 56 patients (superselective IAI: 42, non-selective IAI: 14) with squamous cell carcinoma who had been treated with a curative radiation dose. In addition, the complications related to the infusion procedure were reviewed in all 93 patients (247 procedures).Results: The clinical results for the primary tumors of the superselective IAI group were 27 CR cases (64.3%) and 15 PR cases (35.7%), and in the non-selective IAI group were 10 CR cases (71.4%) and 4 PR cases (28.6%). No significant difference was observed between the two groups in the clinical results for the primary tumors. IAI procedural complications were observed in 4 (6.0%) from the superselective IAI group (total: 67 patients) and in one (3.8%) from the non-selective IAI group (total: 26 patients). No significant difference was observed between the two groups regarding the incidence of IAI procedural complications.
Conclusion: Non-selective IAI therapy by means of the channel alteration method and superselective IAI therapy is therefore considered to provide safe and effective treatment for patients with head and neck cancer treated by intraarterial chemo-radiation therapy.

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Since 1995, we have conducted intra-arterial chemotherapy for advanced head and neck cancer to improve prognosis and to preserve significant organs.
Novel approaches have increased the organ preservation rate in spite of frequent distant metastasis. Cimetidine, a kind of H2-blocker, inhibits the development of E-selectin on vascular endothelial cells, and contributes to a decrease in distant metastasis and improvement in prognosis for digestive cancer.
Objective: To evaluate the decrease in distant metastasis and its relation to the administration of Cimetidine when used concurrently with intra-arterial chemotherapy for advanced head and neck cancer.
Method and Patients: 153 patients treated by intra-arterial chemotherapy for stage IV head and neck cancer from May 2000 to December 2008 were divided into two groups: the Cimetidine group (114 patients) and the non-Cimetidine group (39 patients). Analysis of distant metastasis between the two groups was performed retrospectively. Intra-arterial chemotherapy was administered at 150 mg/m² of CDDP four times per week. In the Cimetidine group, 800 mg of Cimetidine was administered for a period of more than one year prior to treatment. FDG-PET was performed 2 months after the treatment. Pulmonary CT was performed every 6 months, and chest X-ray examination was conducted every three months.
Results: The median period of observation was 45 months for the Cimetidine group and 64 months for the non-Cimetidine group (p < 0.05). Distant metastasis was detected in 10 out of the 39 cases in the non-Cimetidine group and in 6 out of the 114 cases in the Cimetidine group (p < 0.05). Metastatic organs consisted of: 8 cases in lungs, 5 cases in bones, 2 cases in brain, and 1 case in retroperitoneum. The mean time of distant metastasis after treatment was 6.9 months (2-20).
Conclusion: Combined intra-arterial chemotherapy and Cimetidine is useful for the treatment of advanced head and neck cancer due to increased loco-regional control and decreased distant metastasis.

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Background: Appropriate supportive care is essential for intensive chemoradiation therapy (CRT), and pain management is an important supportive care for CRT for head and neck cancer. We developed an opioid-based pain control program for head and neck cancer patients undergoing CRT, and assessed its efficacy and safety.
Objective and Method: 110 head and neck cancer patients undergoing platinum-based concomitant CRT were enrolled from 10 cancer centers or university hospitals. Their pain caused by CRT was managed with a four-step opioid-based pain control program, and adverse events and usage of opioid were analyzed.
Results: 101 suitable cases of 110 patients were analyzed. 53% of cases suffered grade 3-4 mucositis. The rate of completion of radiotherapy was 99% and the rate of unplanned breaks in radiotherapy was 13%. The usage rate of opioid was 83% and the rate of compliance with the pain control program was 92%. The median maximum quantity of morphine used per day was 35 mg. No patient had to stop the opioid program or radiotherapy due to adverse effects of opioids.
Conclusion: An opioid-based pain control program for head and neck cancer patients undergoing CRT achieves a high completion rate of radiation.

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