In the management of the neck for early tongue cancer, the ‘wait and see’ policy is not recommended, because of high occult cervical metastasis, which has an occurrence rate of more than 20%, and poor survival rates. Sentinel node navigation surgery (SNNS) has been decided upon for neck dissection for early stage tongue cancer.
In our department, SNNS was performed on 29 patients (stage I: 14, stage II: 15) from 2000 to 2007. Tc-labeled phytate was injected as a radiotracer a day before SNNS. The sentinel node (SN) was then examined pathologically during surgery. Six cases (21%) were proven metastatic SNs and neck dissections were performed. For the prevention of postoperative submandible node metastasis, the lead plate technique was effective. Nineteen (65.5%) patients could avoid unnecessary neck dissection. In our cases, the 5-year overall survival rate of patients with SNNS tended to be better than that of the 52 patients with the ‘wait and see’ policy (96% vs. 84%, p < 0.05).
Although SNNS provides useful information to make decisions about neck dissection in early stage tongue cancer, the current methods still involve some drawbacks. Indocyanine green (ICG) fluorescence, CT Lymphography and superparamagnetic iron oxide-enhanced MRI lymphography could become useful tracers for predicting lymph node metastasis without using a radioisotope. The conventional intraoperative pathological examination for SNNS has been controversial. One step nucleic acid amplification could become useful in intraoperative cervical lymph node diagnosis.

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We investigated the present situation and future prospects for training specialists in head and neck cancer from the viewpoint of oral and maxillofacial surgeons. The system for clinical oral oncology specialists was really established and started in 2012 based on the Japan Society for Oral Tumors. This system mainly consisted of three required steps: the specialist in oral and maxillofacial surgery for the first step, the general clinical oncologist for the second step and the specialist in clinical oral oncology for the third (final) step. We expect this system will greatly contribute to guarantee and raise the quantitative levels of general clinical oncologists and specialists in oral and maxillofacial surgery, who will treat oral cancer as a subspecialty. Moreover, this system will also contribute to train specialists and increase the number of them who are highly motivated for oral cancer treatment.

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Recently, concomitant chemoradiotherapy (CCRT) has been widely used for locally advanced laryngeal and hypopharyngeal squamous cell carcinoma (SCC) as initial treatment with the intention of organ preservation. However, the long-term outcome of pharyngo-laryngeal function after CCRT is not necessarily satisfactory and the incidence of postoperative complications in salvage surgery is higher than that of initial surgery. We always make a decision on larynx preservation by a multidisciplinary approach considering the patient's wish, performance status, general conditions and complications. In this article, we review the oncological and functional outcomes of patients with advanced (Stage III/IV) laryngeal and hypopharyngeal SCC at Kobe University Hospital and discuss how to define the optimal approach for larynx preservation in the clinical setting.

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Head and neck cancer, particularly potentially unresectable advanced lesions, should be accurately evaluated because the results strongly impact on a treatment planning and patient outcomes. Radiologists must carefully detect the presence of deep invasion that may upstage a tumor to stage T4b and predict inoperability in cases of lymph node metastases. The most common and crucial factors associated with unresectability are carotid encasement, prevertebral fascia involvement (primary and Lymph node lesion) and nasopharyngeal extension (primary). CT offers high spatial and temporal resolution, and MR offers high contrast resolution for images. Understanding the advantages, limitations, and appropriate criteria of each imaging modality (CT/MRI) for detecting the factors that determine unresectability improves decision-making regarding treatment, thus ensuring optimal therapeutic outcomes.

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We report a case of combined small cell carcinoma and adenocarcinoma (CSCCA) in the ethmoid sinus. A 53-year-old man was seen for left nasal bleeding and left neck induration. Computed tomography showed swelling of the left ethmoid mucosa and neck lymph nodes. Nasal tumor biopsy yielded a diagnosis of CSCCA. He was treated with irradiation (total dose 74Gy/37fr), and neck dissection and paranasal surgery by the external incision method. No recurrence has been seen in the 5 years since initial treatment. The reason for the long-term survival is suggested to be that the Ki–67 labeling index showed a lower grade of tumor cells.

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Free vascularized fibula flaps are commonly used for mandibular reconstruction. However, when performing mandibular reconstruction using such flaps, it is necessary to consider the patient's general condition or tumor prognosis. From September 2009 to November 2013, mandibular reconstruction was performed on 25 patients in the Division of Dentistry, Department of Oral and Maxillofacial Surgery, Yamagata University Hospital. In all, immediate mandibular reconstruction was performed using reconstruction plates (RP) on 13 patients with benign tumors. Seven of these 13 patients underwent secondary mandibular reconstruction using autogenous bone grafting. In patients with malignant tumors (11 immediate mandibular reconstructions and 1 secondary case), free vascularized fibula flaps were used for 4 patients, rectus abdominis myocutaneous flaps (RAMC) with RP were used for 3 patients, RAMC without RP were used for 2 patients, an anterolateral thigh flap with RP was used for 1 patient, and a forearm flap with RP was used for 1 patient. A titanium mesh tray and iliac particulate cancellous bone and marrow were used in the secondary case. To improve postoperative masticatory function, 9 out of the 25 patients underwent dental implant placement in the reconstructed area. Two patients who completed prosthetic treatment with implant overdentures showed considerable improvement in occlusal function.For patients requiring mandibular reconstruction, a comprehensive treatment strategy that considers not only facial contours but also occlusal rehabilitation is indispensable for improving quality of life.

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To correlate the indication of laryngeal suspension for patients who underwent a subtotal glossectomy, a retrospective analysis of 44 patients with previously untreated squamous cell carcinoma of the tongue was reviewed. The object was classified into two types; type 1 (n = 17): the contralateral genioglossus muscle was partially resected, type 2 (n = 27): the contralateral genioglossus muscle was entirely resected. The postoperative swallowing function was evaluated with an AsR score in a first-time videofluorography. In both groups, the AsR score was not correlated with the extent of the resection of suprahyoid muscles. In type 1, laryngeal suspension did not contribute to the postoperative swallowing function. On the other hand, in type 2, the AsR score was significantly improved with laryngeal suspension in the case of the resection of hemi-suprahyoid muscles. The adequate indication of laryngeal suspension for subtotal glossectomy was the excision of the bilateral suprahyoid muscles or of the hemi-suprahyoid muscles in type 2.

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We divided extracapsular spread (ECS) into 2 types, and examined the relativity with a prognosis. Among 124 cases with oral squamous cell carcinoma (OSCC) from January 2008 to December 2012 in the Department of Oral and Maxillofacial Surgery, Nagasaki University Hospital, extracapsular spread (ECS) was observed in 23 cases. Type B, which were macroscopically defined as the extent tumor invasion to the perinodal fat or muscle tissue, revealed a high recurrence rate (60%), and there were 3 cases of distant metastasis death. The two-year disease-specific survival rate of Type B was 53.3%, and Type B significantly revealed poor prognosis (P < 0.05). In this report, univariate analysis revealed that the prognosis of ECS in OSCC patients might be associated with the number of pathological positive lymph nodes (pN ≥ 4) and type B of ECS, respectively (P < 0.01).

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Here we report a case of mucoepidermoid carcinoma of the parotid gland accompanied by invasion through an unusual route. A 46-year-old female visited our department complaining of a growth in the external auditory canal and a purulent discharge. She had no swelling in her parotid region. Repeated biopsies of the external ear revealed inflammatory granulations and they made it difficult to point out the neoplasm. Contrast enhanced CT and MRI findings showed a solid tumor of the parotid gland that extended to the cranial side of the gland. Finally, a low-grade mucoepidermoid carcinoma that had originated in the upper pole of the parotid gland had progressed to the external auditory canal via "Santorini's fissures," which is a notch in the cartilage of the auditory meatus. Both otolaryngologists and pathologists should pay attention to this kind of unusual route taken by a parotid gland tumor invasion.

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A case of acinic cell carcinoma ex pleomorphic adenoma arising in the parotid gland is reported. A 32-year-old woman visited our hospital with the chief complaint of a left asymptomatic parotid tumor 30 mm in diameter. Subsequently, she underwent an extended total parotidectomy because of the involvement of a branch of the facial nerve and the frozen sections that revealed the tumor, which was diagnosed as malignant. Postoperatively, a series of 50 Gy irradiation doses was performed. Eighty-seven months have passed after the treatment and she has not shown any sign of recurrence.
Carcinoma ex pleomorphic adenoma (CXPA) is an uncommon neoplasm and one of the salivary gland tumors initially assigned to the WHO Classification established in 2005. It arises most frequently in the parotid gland and the occurrence rate in all parotid cancer cases is reported to be 13%. The malignant components of CXPA are mostly reported to be adenocarcinoma NOS, salivary duct carcinoma, anaplastic carcinoma and myoepithelial carcinoma. But based on a thorough search of the literature, we found only one case reported of acinic cell carcinoma ex pleomorphic adenoma. Clinical malignancy of CXPA is defined according to the malignant component of the CXPA. Despite the definition of acinic cell carcinoma as a low grade malignancy, a close follow-up is mandatory.

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We retrospectively evaluated methods of neck dissection in patients with previously untreated parotid carcinoma who received definitive surgery. The subjects were 42 patients treated in our department from 1987 through 2011. All 10 patients with clinical neck lymph node metastasis underwent ipsilateral neck dissection and 6 developed neck lymph node recurrence, 2 of which recurred in the non-dissection field. Of 32 patients without clinical neck lymph node metastasis, 23 did not undergo prophylactic neck dissection among which latent neck lymph node metastasis developed in only 1 case. Pathological positive lymph nodes in 11 patients who underwent neck dissection were detected all over (level I to V) the ipsilateral neck and the recurrent positive rate at level II was 100%. We conclude that in cases with clinical neck lymph node metastasis, ipsilateral radical neck dissection is appropriate, and in cases without clinical neck lymph node metastasis, prophylactic neck dissection is not usually needed. We suggest that it is useful to perform pathological examinations using frozen sections from intraoperative level II nodes to decide whether prophylactic neck dissection should have been carried out.

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This study aimed to determine the diagnostic value of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) in predicting the respectability. Fourteen patients with neck metastasis with clinical suspicion of carotid artery invasion from head and neck cancer were evaluated. Neck dissection was performed in all 14 patients. In 4 patients, the lymph node metastases could be dissected radically from the wall of the carotid artery (dissection group). In 10 patients, the carotid artery was invaded and resected (resection group). Eleven patients out of these patients underwent further evaluation with preoperative MRI. Both preoperative MRI and histopathological examination after surgery were obtained for 7 cases out of 10 patients with resection of the carotid artery.
Patients in the resection group had tumors more than 180° around the carotid artery in enhanced CT scans. All patients with attachments of more than 270° to the carotid artery required resection of the carotid artery. In MRI, we focused attention on the signal intensity around the carotid artery on T2-weighted images. In the resection group, all patients had some obscure part of the low signal intensity band around the carotid artery. We considered that a carotid artery was possibly involved when any part of this low signal band around the carotid artery was obscure and broken. Our study of histopathological findings of the carotid artery compared with MRI results revealed that the degrees of microscopic invasion into the outer layer of the carotid artery corresponded with those of the obscure part of the low signal band around the carotid artery.

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A combination of concurrent chemoradiotherapy in the treatment of advanced-staged head and neck cancer has improved loco-regional control and increased complete clinical and pathologic response rates in the neck. However, for those patients with residual neck disease on a post-treatment computed tomography (CT) scan or ultrasonography, there remains significant controversy as to how to further assess the neck for the presence of viable tumor cells. In this study, we investigated the accuracy of ultrasound-guided fine-needle aspiration cytology after chemoradiotherapy.
Twenty-three patients with suspicion of residual neck disease who initially received chemoradiotherapy underwent ultrasound-guided fine-needle aspiration cytology prior to salvage neck dissection. Neck dissection specimens contained viable tumors in 10 (43.5%) patients. Ultrasound-guided fine-needle aspiration cytology had a sensitivity of 60.0% and specificity of 83.3% when an inadequate specimen was included in negative results.
We conclude that ultrasound-guided fine-needle aspiration has some worth in evaluating whether or not residual neck disease is viable.

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Papillary thyroid carcinoma is in general considered to have a good prognosis. But mediastinal lymph node metastasis causes esophageal stenosis and airway obstruction unless it is carefully observed for a long period. Therefore, mediastinal lymph node dissection is sometimes in the operative indication, even if there is distant metastasis to the lung or bones. Although it is important to evaluate the patient's age, general condition and extent of tumor invasion in the planning for mediastinal dissection, L- shaped partial sternotomy is convenient when the airway and upper digestive tract are also preserved. Because this operative method is thought to be safe and not so difficult and has few demerits, such as restriction of lateral arm extension on the affected side three months after the operation, we advocate this method to head and neck physicians to treat mediastinal lymph node metastasis with papillary thyroid cancer.

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Among 463 patients who underwent radiotherapy for primary lesions of head and neck cancer between 2006 and 2013, 10 had uncontrolled distant metastases. There were 9 males and 1 female with a median age of 63 years. The primary lesion was the pharynx in 6, nasal cavity in 2, oral cavity in 1, and salivary gland in 1 patient. Histology was squamous cell carcinoma in 5, adenoid cystic carcinoma in 3, malignant melanoma in 1, and adenocarcinoma in 1 patient. The metastatic lesion was bone in 5 (including 1 with both bone and liver), and lung in 5 (including 2 with both lung and liver) patients. All metastases were multiple. Palliative radiotherapy was administered for primary lesions in a median dose of 60 Gy, and also for bone metastases in 3 patients. The grade of performance status (PS) was PS1 in 7, PS2 in 1, and PS3 in 2 patients before radiotherapy. The best tumor response within 90 days was CR in 4 and PR in 6 patients. Two adenoid cystic carcinoma patients developed marginal recurrences, resulting in a 1-year local control rate of 60%. The 1-year overall survival rate was 64% for patients with initial PS 1–2, and 0% with initial PS 3. The cause of death was meningitis carcinomatosa in 1, pleuritis carcinomatosa in 3, and aspiration pneumonitis in 1 patient. Patients with distant metastases could undergo palliative radiotherapy for their primary lesions if their initial PS was 2 or less, and life expectancy was prolonged by chemotherapy or targeted therapies.

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Cetuximab is an anti-epidermal growth factor receptor (EGFR) monoclonal antibody, and is currently the only molecular-targeted drug approved for the treatment of squamous cell carcinoma of the head and neck. The NCCN guidelines state that the standard care for locally advanced head and neck squamous cell carcinoma (HNSCC) is radiotherapy with concurrent cisplatin, and radiotherapy combined with cetuximab is one of the choices for locally advanced HNSCC. Based on these definitions, we introduced radiotherapy with concurrent cetuximab as an initial treatment for head and neck squamous cell carcinoma at Shikoku Cancer Center from April 2013. We applied this treatment for 11 patients, 6 of whom were suffering from oropharyngeal carcinoma, 2 from hypopharyngeal carcinoma and 3 from laryngeal carcinoma. Four of the patients had Stage II disease, three had Stage III, and four had Stage IVA. Ten patients were male and one was female, and the median age of the patients was 63 years. The performance status of the patients was 0. Grade 3 radiation dermatitis and mucositis occurred in almost all the patients, but there were no grade 4 adverse events. All patients completed the planned therapy. The 12-week outcome after the treatment was nine complete responses (CR) and two partial responses (PR), so positive results were provided by the combination of cetuximab and radiotherapy.

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Cetuximab, a human–mouse chimeric IgG1 monoclonal antibody used against the epidermal growth factor receptor, is approved for the treatment of squamous cell carcinoma of the head and neck. Currently, cases of hypersensitivity to cetuximab are attributed to the production of an IgE antibody specific for galactose-alpha-1,3-galactose (α-Gal) positioned on the Fab portion of the cetuximab heavy chain. Because such IgE antibodies bind to various mammalian proteins, red meat allergy is also related to α-Gal. In addition, tick bites also induce the production of this IgE antibody against α-Gal. Therefore, we retrospectively investigated 17 patients diagnosed with head and neck cancer for the incidence of infusion reactions, following cetuximab chemotherapy from January to December 2013 at the Department of Otolaryngology-Head and Neck Surgery, Ehime University Hospital. We conducted serological analysis for specific IgE reactions to beef, pork, chicken, α-Gal and interviewed the patients to see whether or not they had tick bites. Infusion reactions were observed in 4 patients (23.5%) and IgE antibodies specific for pork, chicken, or α-Gal were detected in 3 of these 4 patients. These data suggest that the infusion reactions resulted from allergic reactions induced by cetuximab-containing α-Gal.

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Purpose: To assess the safety profile and efficacy of chemotherapy with docetaxel plus cisplatin (DC) for recurrent or metastatic head and neck cancer, we retrospectively reviewed the medical chart of the patients in our institution.
Patients and methods: From July 2008 to October 2012, twenty-four patients with recurrent or metastatic head and neck cancer were treated with chemotherapy with DC. DC was administered until disease progression or unacceptable toxicities. DC consisted of docetaxel (DTX) 60∼70 mg/m² d1 and cisplatin (CDDP) 75∼80 mg/m² d1.
Results: We identified 17 patients with recurrent or metastatic squamous cell carcinoma of head and neck excluding 3 patients with nasopharyngeal carcinoma. We included these 17 patients in efficacy analysis. DC achieved response rate of 47% (complete response 18%, partial response 29%) and median overall survival and progression free survival were 390 days and 188 days, respectively. All of the 24 patients were included in safety analysis. Following grade 3/4 adverse events, including neutropenia (79%), anemia (17%), febrile neutropenia (FN, 33%), nausea (4%), anorexia (21%), stomatitis (4%) and diarrhea (17%) were observed. Of the eight patients complicated with FN, five patients suffered from FN at first course of DC. Twelve patients (50%) needed dose reduction of DC due to toxicities and 2 patients (8%) had to discontinue DC due to unacceptable toxicities. No treatment related death was observed.
Conclusion: Considering that this study was small sample sized retrospective analysis, chemotherapy with DC appeared to have at least similar efficacy to those reported previously. Because of the high incidence of FN, we have to take care of prevention and management of FN.

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Supraclavicular Artery Island Flap (SCAIF) is a pedicled fasciocutaneous flap based on the supraclavicular artery and vein. Originally, SCAIF had been used for surgery on post-burn scars. However, it gradually came to be used for reconstruction after head and neck cancer resection. Although it has been shown as useful in foreign countries, there were no reports in Japan.
We used SCAIFs for reconstruction after head and neck cancer resection in four cases. The time for harvesting the flap was about one hour and the donor site could be primarily closed. Only head and neck surgeons participated in the surgery, but it was not so difficult to harvest SCAIFs for surgeons experienced in harvesting various flaps.
As a result, there were no flap failures in this series; however, one case experienced salivary leak, but this was managed via DP flap onlay. All of the patients could resume an oral diet without gastric tube supplementation.
Therefore, we consider that SCAIF can be one of the options available for reconstruction after head and neck cancer resection.

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In patients with a history of previous neck dissection, recipient vessel dissection can be more challenging because of scarring and fibrosis. Reconstructive surgeons often need to use the contralateral neck recipient vessels. Under a microscope, we safely dissect the ipsilateral neck recipient vessels with a scalpel. A retrospective analysis was performed in Aichi Cancer Center between January 2011 and May 2014 on cases where free flap reconstructions were planned after the resection of oral, oropharyngeal or maxillary cancer. Only 22 patients had undergone previous neck dissections. In 13 out of 22 cases, the ipsilateral recipient vessels were used. In 8 out of 22 cases, the contralateral ones were used. In 1 out of 22 cases, a pedicle flap was used. There were no cases of flap failure. Careful dissection under a microscope makes the ipsilateral neck recipient vessels available even in a scar. The recipient vessels within the vicinity of the defect site offer more alternative flaps and the chance of technical reconstruction.

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