The subjects were 35 patients diagnosed with multiple squamous cell carcinomas of the oral cavity among 709 patients with primary squamous cell carcinoma of the oral cavity. The incidence of multiple squamous cell carcinomas was 4.9%. The second and third primary carcinomas frequently developed in the buccal mucosa, mandibular gingiva, tongue and maxillary gingiva. Tumor size and invasiveness of treatment tended to decrease with progression to the second and third carcinomas. The mean interval between the first and second carcinomas was 60 months, while that between the second and third carcinomas was 24.5 months. The 10-year cumulative incidence of multiple squamous cell carcinoma of the oral cavity was 13.1%, and the five-year cumulative survival rate from the onset of the second carcinoma was 81.1%. Local recurrence rate was 37.1%, which was higher than that of solitary carcinomas. The high incidence rate and recurrence rate indicate the necessity of close and long-term follow-up after the treatment of the first carcinoma. Reduced invasiveness of treatment due to early detection was thought to lead to the preservation of oral function.

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Multiple skull base reconstruction using free flaps is still challenging. We report here the morbidity and problems of our procedures to improve surgical end results. The four patients were 60, 35, 14, and 14 years old, all women. The primary disease was angioepithelioma, with 2 cases of meningioma and 2 of osteosarcoma. All patients had a history of surgery of 14, 5, 3, and 7 times, of which reconstructive surgery had been performed 5, 2, 2, and 3 times, respectively. All of the patients had a defect in the anterior skull base region and either an anterolateral thigh (ALT) flap or vastus lateralis muscle (VL) flap was performed to fill and cover the defect. Superficial temporal or facial arteries and veins were used for vascular anastomosis. No flap loss was observed, but one postoperative skin fistula and one osteomyelitis occurred in different patients. The difficulties of multiple skull base reconstruction using free flap included: the selection of free flaps to be used considering future recurrence and additional secondary surgery, providing adequate recipient vessels in every procedure, and preventing complications caused by thinner craniofacial skin. Consequently, we propose the following comprehensive algorithm for multiple skull base reconstruction using free flaps. ALT flap or VL flap is the first choice. Rectus abdominis myocutaneous flap and scapular artery flaps are preserved for further large defects caused by recurrence, or secondary corrective surgery. Superficial temporal artery (STA) and vein (STV) are the first choice for the recipient vessels. STA and STV in the contralateral side and facial artery and vein should also be preserved. Finally, to prevent postoperative complications caused by less-vascularized and scarred craniofacial skin, special care must be taken not to make the elevated scalp skin thinner. Coverage with artificial materials such as titanium plate and support for thinner skin from behind with locoregional or free flaps are recommended.

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We report a case of parameningeal rhabdomyosarcoma in a 5-year-old girl, and discuss the effectiveness of second-stage operation. MRI showed a huge abnormal shadow at the parameningeal site with intra-cranial extension. We performed a second-stage operation of residual lesions which localized the pterygopalatine fossa after neoadjuvant chemotherapy. Middle skull base surgery was performed using a combination of subtemporal approach, orbito-zygomatic approach and partial maxillary swing approach. This combined surgical approach is useful for resecting a residual tumor in the pterygopalatine fossa. The operation achieved a complete resection. Such a complete second-stage operation improves local control and reduction of the dose of radiotherapy, which may diminish adverse late side effects of radiotherapy.

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Conventional superselective intra-arterial chemotherapy via the superficial temporal artery (STA) has a risk of catheter exposure outside the body, infection, and accidental withdrawal. We think that it is advisable to bury the catheter subcutaneously to avoid such risks. In this study, we report on retrograde superselective intra-arterial chemotherapy using a subcutaneous implant reservoir for oral cancer. The subjects were three cases of oral cancer with dementia. A guide wire was advanced from STA to the tumor nutrient artery and Anthron^®P-U catheter was downstreamed along the guide wire. The catheter was connected to the subcutaneous implant reservoir in the front part of the ear, and the skin was sutured. We started the intra-arterial chemotherapy (CBDCA+5-FU) and radiotherapy on post-catheterization day 4, and complications such as infection or accidental withdrawal did not occur in any of the cases by the end of treatment. Because we could avoid such risks by performing retrograde superselective intra-arterial chemotherapy using a subcutaneous implant reservoir and outpatient department chemotherapy was possible, we think that subcutaneous implant reservoirs should be used for patients with oral cancer except dementia patients.

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Parapharyngeal recurrence arising at the inner part of the mandibular angle (parapharyngeal recurrence) after surgical treatment for locally advanced tongue cancer (T3/4) is quite difficult to salvage and a major poor prognostic factor. Clinical courses of 12 patients with T3/4 tongue cancer treated in our department were analyzed, and a surgical procedure to prevent parapharyngeal recurrence is discussed. Invasions of the tongue cancers were evaluated by using gadolinium (Gd)-enhanced T1-weighted MRI, and en bloc resections of the tongue and the cervical lymph nodes were performed with a safety margin of 1.5 cm diameter by the pull-through method. Tonsillectomies and parapharyngeal dissections were performed for patients whose tongue cancers had invaded to the base of the tongue. Three patients developed parapharyngeal recurrences, all of which seemed to spread from the surface of the medial pterygoid muscle (MPM) to the deep parapharyngeal space. One patient whose tongue cancer invaded to the surface of the MPM underwent removal of the inferior portion of the MPM in addition to the parapharyngeal dissection, and presented disease-free survival. It has been reported that there is a lymphatic drainage from the base of the tongue and/or the anterior tonsillar pillar to the surface of the MPM. According to the report and the clinical courses analyzed here, it is suggested that parapharyngeal recurrence might result from residual cancer cells that have invaded the surface of the MPM. The surgical procedure including removal of the inferior portion of the MPM in addition to parapharyngeal dissection might prevent parapharyngeal recurrence for patients with locally advanced tongue cancer (T3/4) invading the base of the tongue and/or anterior tonsillar pillar.

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During 20 years from 1989, we treated 50 patients with supraglottic squamous cell carcinoma with an adequately comprehensive combination of chemotherapy and radiation followed by surgery. The patients consisted of 39 men and 11 women, median age 69 years. According to the stage classification there were 8 cases with Stage I, 9 with Stage II, 14 with Stage III, 16 with Stage IVA, 2 with Stage IVB, and 1 with Stage IVC. Radiation was used for all 50 patients by conventional X-ray (median 66Gy) associated with chemotherapy (for 30 patients chiefly at stage III and IV) as induction chemotherapy (ICT) or concurrent chemoradiotherapy (CCRT) in which fluorouracil and carboplatin were administered. Radiation alone was used for 20 patients. If the efficacy of pre-operative treatment was insufficient at 46Gy of radiation, surgery was inevitable.
In this study, our paradigm of treatment for supraglottic carcinoma was retrospectively investigated by the probabilities of 5-year overall survival rate, 5-year cause-specific survival rate, and 5-year preservation rate of the larynx, which were 65.7%, 82.6% and 64.2%, respectively. Furthermore, the probabilities of 5-year survival rates for patients at T3 and T4 with intact larynx (75.5%) or after laryngectomy (75.0%) showed no statistically significant difference. At 2 years, the proportion of 33 patients at stage III and IV who had an intact larynx after concurrent chemoradiotherapy (83.3%) was not significantly different from the proportions in the groups given induction chemotherapy followed by radiation(80.0%)or radiation alone (87.5%). In the three therapeutic groups, 2-year cause-specific survival rates were also similar (77.8%, 37.5%, 64.8%), respectively.

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A total of 72 consecutive laryngeal carcinoma patients at stage T3 or T4 were studied. The laryngeal cancer patients were treated first with concurrent chemoradiotherapy (40 Gy) in our department. Patients with residual disease subsequently underwent curative surgery, and chemoradiotherapy was continued to 70 Gy for those without residual disease. The three-year disease-specific-free survival (DSS) rates in patients with supraglottic, glottic and subglottic tumors were 58%, 71% and 100%, respectively. In patients at stage T3/T4, the DSS rates were 75%/46%, and in those with/without lymph node metastasis (N+/N-) the rates were 56%/78%. The three-year laryngeal preservation (LP) rates in patients with supraglottic/glottic/subglottic tumors, T3/T4 and N+/N- tumors were 12%/26%/50%, 28%/4% and 13%/29%, respectively. The recurrence rate was 29%, of which 75% have died, primarily of distant metastasis. These DSS and LP rates were not significantly different among the three subregions and N stages, although those in patients at stage T4 were significantly low, compared with T3 patients (p=0.01). These results suggest that additional treatment may be required for patients with T4 disease. Chemotherapy after surgery is now considered for T4 patients.

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The histopathology of parotid carcinoma is varied, and in many cases, it is difficult to make a diagnosis preoperatively. A clinical analysis was performed on 28 cases of parotid carcinoma initially treated between 1994 and 2011. We compared preoperative diagnosis based on fine-needle aspiration biopsy (FNA) or frozen section biopsy (FSB) with the final diagnosis. Sensitivity for malignancy was 45.8% in FNA and 85.7% in FSB. Diagnostic accuracy for histologic diagnosis was 20.8% in FNA and 42.9% in FSB. We performed a superficial lobectomy conserving the facial nerve in classified T1 or T2, and low-grade malignancy. We also performed a total or extended parotidectomy with total removal of the facial nerve in classified T3 or T4 and high-grade malignancy. Neck dissection was performed in 11 patients. Supraomohyoid neck dissection was performed in 6 patients and total neck dissection in 5 patients with high-grade T3 or T4, and clinically positive neck metastasis. Postoperative radiotherapy was performed in 12 patients with close safety margin, pathological T3 or T4, high-grade malignancy, multiple neck metastasis and extranodal extension. The factors influencing a poor outcome were high-grade malignancy (p=0.0268), stageIV (p=0.0069), and N+ stage (p=0.0005). Of 10 deaths, causes were local failure in 3 and distant failure in 5. We consider that preoperative histologic diagnosis is important for deciding surgical management. Appropriate surgery and indications for postoperative radiotherapy and chemotherapy are required in patients with high-grade malignancy, stage IV, and N+.

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Although pathologic progression stage on the basis of the extent of capsular invasion has been considered to be a useful prognostic indicator for carcinoma ex pleomorphic adenoma (CXPA), this pathologic factor is not adopted in the T-factor of the current TMN classification for salivary cancer. In this study, we examined the pathologic progression stage in 31 cases of CXPA, and evaluated its clinical and prognostic significance in CXPA, with a comparison with the current T-classification. Among the cases in category pT1 and 2, 25% and 50% showed invasion beyond the capsule of preexisting pleomorphic adenoma, 25% and 30% developed distant metastasis after surgery, and 25% and 20% eventually died of cancer, respectively. In contrast, 41.7% of the cases in category pT3 were histopathologically non-invasive carcinoma, and none of them developed local recurrence or distant metastasis. Moreover, noninvasive or minimally invasive CXPAs showed excellent prognoses, regardless of their sizes or strategies for postoperative adjuvant therapy. In addition, pathologic progression stage was a more useful prognostic indicator in CXPA than the current T-classification regarding disease-free and overall survival rates. These results demonstrate that appropriate postoperative treatment and clinical follow-up based on the pathologic progression staging is important for patients with CXPA.

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Acinic cell carcinoma (AciCC) is a rare tumor, mainly originating in the parotid gland. We assessed the clinical features and the response to treatment of six patients with newly diagnosed AciCC of the parotid gland. Over the 25-year period from 1985 to 2010, six patients with AciCC of the parotid gland were treated in our hospital. No patient who had fine needle aspiration biopsy was diagnosed with AciCC before operation. Three patients had partial parotidectomy and the other patients had wide resection, two cases had relapsing tumor and one of them died of multiple metastases after about 20 years. Post-operative radiation therapy or chemotherapy was not effective for tumor control. Further follow-up is very important to determine the long-term response to treatment.

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The parapharyngeal space is anatomically difficult to approach, with the great vessels and hypostatic cranial nerve in its vicinity. Therefore, appropriate results may not be obtained without unreasonableness when performing fine needle aspiration preoperatively.
We report our experience with navigation-guided fine needle aspiration for a tumor of the parapharyngeal space.
In navigation-guided fine needle aspiration, the rate of correct diagnosis is likely to increase by confirming an intratumoral paracentesis needle by a monitor, because we can perform FNA. Also, injury to the great vessels can be avoided when the procedure is performed with enhanced-CT guidance. However, we cannot avoid the risk of nerve injury.

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We retrospectively reviewed the data of elderly patients aged 80 years old and over with thyroid carcinomas, who underwent thyroid surgery in our hospital between 2000 and 2010. Of the 24 patients, 18 (75%) had invasions to respiratory related organs including the recurrent laryngeal nerve. Of the 18 patients with invasions, 13 had invasions to the recurrent laryngeal nerve; immediate anastomosis of the recurrent laryngeal nerve was performed for 5 patients, and immediate type I thyroplasty for 2 patients. Partial removal of the trachea due to the invasion of thyroid carcinoma was performed for 5 patients, and closure of the stomas was successful in all 5 patients. Hemithyroidectomy with D1 neck dissection was performed for 6 patients without invasion to respiratory related organs except for follicular carcinoma. Though 3 patients died due to distant metastasis, recurrence in respiratory related organs was not observed. These data indicate that surgical treatment for thyroid carcinomas in elderly patients should be performed, because invasion to respiratory related organs is inevitable eventually.

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In recent years, there have been some reports stating that PET/CT is useful in diagnosing cervical lymph node metastasis in head and neck squamous cell carcinoma. We also use PET/CT in our department to determine N classification before treatment. We examined the usefulness of PET/CT in diagnosing cervical lymph node metastasis by comparing preoperative PET/CT images and postoperative pathological diagnosis of the patients who underwent neck dissection in our department. The subjects were 42 patients (59 sides) who underwent neck dissection within one month after PET/CT was performed and did not receive preoperative treatment such as induction chemotherapy. Among 23 sides diagnosed as positive for metastasis by preoperative PET/CT, metastatic lymph nodes were recognized in 19 sides in postoperative pathological diagnosis. Meanwhile, among 36 sides diagnosed as negative for metastasis by PET/CT, no metastatic lymph nodes were observed in 33 sides in postoperative pathological diagnosis. With the sensitivity at 86% and the specificity at 89%, PET/CT was considered useful in diagnosing cervical lymph node metastasis, however, attention needs to be paid to false-positive or false-negative cases.

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A total of 40 patients with previously untreated mucosal malignant melanoma of the head and neck underwent resection at our hospital between 1980 and 2010. We reviewed the clinical data of these 40 patients. There were 20 men and 20 women, aged 24-79 years (median: 62 years). The site of the primary lesion was the nasal/paranasal cavity in 28 patients, oral cavity in 9 patients, and pharynx in 3 patients. The clinical TNM classification according to the 7th AJCC/UICC was as follows: Stage III, 6 cases; Stage IVA, 23 cases; Stage IVB, 9 cases; T3, 8 cases; T4a, 23 cases; and T4b, 9 cases. The 5-year overall survival rate according to the TNM Stage was 100% for Stage III, 46% for Stage IVA, and 11% for Stage IVB. The 5-year overall survival rate (Kaplan-Meier method) was 43%, the 5-year local control rate was 70%, and the disease-free survival rate was 29%. In this study, the TNM classification was well correlated with the clinical outcome; especially, the prognosis of patients with T4b and N1 was poor. A local recurrence was a therapeutic challenge for the maxillary tuberosity and the pterygoid direction. The subsequent cervical lymph node metastasis rate was high, but neck dissection was considered to have a definitive beneficial effect on survival.

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This report describes our first experience with a peripherally inserted central catheter (PICC) for head and neck chemotherapy. It is more convenient and safer than conventional central venous catheter insertion. We used a PICC 40 times from December 2009 to May 2010. There were no serious complications, pneumothorax. Catheter-related bloodstream infection occurred only in one early case. This catheter may be useful for head and neck chemotherapy.

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We propose the “CAT concept”, a new theory for surgical reconstruction after oncological segmental mandibulectomy. The essence of the theory is to reconstruct three reference points on the mandible —“C” (condylar head), “A” (mandibular angle)and “T” (mental tubercle)— necessary and sufficient for its surgical reconstruction.
An anthropometric analysis of the mandible of ten preserved human cadavers showed that the mandibular contour can be made merely 3 to 7 mm smaller than the original when the CAT concept is adopted, suggesting that the concept sufficiently satisfies the condition for surgical reconstruction of the mandible.
A review of our 45 clinical cases of mandibular reconstruction after oncological ablation demonstrated a positive trend between the number of reconstructed or non-resected reference points of the CAT concept and the esthetic outcome of each patient (Fisher's exact test, p＜0.01), suggesting that the concept satisfies the necessary condition.
Given these results, we concluded that the CAT concept is a highly practical theory for the surgical reconstruction of segmental mandibular defects.

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In the case of total or subtotal glossectomy with extended resection of unilateral middle pharynx, the posterior part of the tongue was reconstructed to a slope shape which goes down to the preserved root of the tongue from the contralateral superior part of the oropharnx. Postoperative function was compared between the slope-shaped neotongue and the traditional dome-shaped neotongue. Thirteen patients were reconstructed to the dome shape and 6 patients were reconstructed to the slope shape. The average follow-up period was 7 years and 1 month. Although the slope-shaped neotongue was slightly inferior in swallowing and speech function compared with the dome-shaped neotongue, comparatively good results were obtained also with the slope-shaped tongue. In four patients with the dome-shaped neotongue, the tongue changed to a flat shape and the function worsened after a long period. In contrast, all the patients with the slope shape maintained their form and function. The patients with the slope-shaped neotongue will swallow using only the side on which the function to elevate the tongue is preserved. For cases in which it is difficult to maintain the dome shape for a long period of time, for example, tabescence patients, slope type reconstruction is considered to be an effective method.

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The number of free flap transfer procedures carried out for the recurrence of head and neck malignant tumors is increasing. Among these cases are patients who undergo multiple free flap reconstruction. The procedures tend to be difficult in such cases and are associated with risks of postoperative complications from scarring or radiotherapy. In this study, we examined 30 cases with 33 flaps reconstructed by sequential multiple microsurgical tissue transfer between January 1999 and May 2010. There were no significant differences between primary and secondary procedures in intraoperative bleeding, duration of surgery, and rates of postoperative complications, or between scar site and non-scar site microsurgical anastomosis. These findings underscore the safety of the sequential multiple free flap reconstruction procedure, and suggest the possibility that vessels in the scar could serve as recipient vessels.

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Objective: The aim of our study was to identify predictive factors for postoperative wound complications of advanced head and neck cancer. The Chi-square test and logistic regression method were used for the statistical analysis.
Material and Methods: A retrospective chart review was performed for patients with advanced head and neck cancer who had been surgically treated at Kyoto Medical Center between January 2008 and June 2011.
Results: A total of 106 patients (mean age 66.4, male: female=84: 22) were enrolled in this study. Forty-six (43.4%) patients had postoperative wound complications. The selected candidate predictive factors were: sex, age, ASA score, T4 stage, induction chemotherapy, bilateral neck dissection, free flap reconstruction, contaminated cervical field, mandibular resection, and blood loss (>600g). On univariate analysis, the factors associated with wound complications included free flap usage and contaminated cervical field. Only free flap reconstruction remained independently significant on multivariate analysis (p=0.030, Odds ratio 3.36).
Conclusion: Free flap reconstruction is an independent predictive factor for postoperative wound complications in patients with advanced head and neck cancer.

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Decision-making for advanced head and neck cancers has become increasingly difficult because the treatment modality has become complicated. It has been proven that a multidisciplinary head and neck tumor board contributes to optimum clinical results. A cancer board is a multi-center and multidisciplinary board intended to make better decisions on the treatment of head and neck cancer patients. The Head and Neck Unit of the Cancer Institute at Kyoto University has held several cancer boards since 2009. The current study examined the clinical impact of the board for 26 cases with advanced or recurrent head and neck cancers. The board encompassed multiple centers including university hospitals and cancer centers. The results show that diagnosis and treatment were changed in 1 and 5 cases, respectively. A cancer board may contribute to appropriate decision-making for the treatment of difficult cases of head and neck cancer.

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