We reviewed 47 patients who underwent cervical esophageal reconstruction using a free jejunal flap transfer between July 2001 and December 2011. There were 40 males and 7 females with an average age of 64.3. Fifteen patients had radiotherapy preoperatively, and 24 patients postoperatively. The patients who underwent preoperative radiotherapy tended to suffer postoperative complications including surgical site infection and leakage, whereas those who underwent postoperative radiotherapy tended to suffer contracture at the anastomosed site between the free jejunal flap and the esophagus. We consider that free jejunal flap transfer in patients with cervical esophageal cancer is a safe procedure.

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In 69 patients with superficial oral cancer (32 with tongue cancer, 22 with gingival cancer, 10 with oral floor cancer, and 5 with buccal mucosal cancer), preoperative examinations and treatment were evaluated. The lesion visualization rate was significantly higher for tongue ultrasonography (89.9%) than for CT (21.9%) or MRI (42.4%). Narrow band imaging (NBI) revealed type 3 or 4 abnormal blood vessels (Arima's classification), which are frequently observed in esophageal cancer, in about 80%. The correct diagnosis rate using cytology was 77.9%. However, in 66.7% of false-negative cases, the diagnosis could be corrected based on abnormal blood vessels on NBI images. Lesions identified using NBI were frequently consistent with iodine-unstained areas. In cases showing type 4 abnormal blood vessels on NBI images and the YK-4 histopathological mode of invasion, the possibility of late cervical lymph node metastasis was high. Concerning surgery, excisional biopsy in view of cancer dissemination was frequently performed. Autofluorescence and infrared imaging enhanced cancer lesions, allowing visual identification. Therefore, improvement in diagnosis and clarification of the accurate lesion range by adding special preoperative light observation methods such as NBI to conventional examinations are necessary to accurately perform excisional biopsy, which is frequently used as a treatment for superficial oral cancer.

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MR imaging provides a means of noninvasive imaging of the salivary glands with excellent spatial resolution and soft tissue contrast. The goals of salivary gland cancer imaging are two-fold: histological differential diagnosis, and localization and determination of the extent of the tumors. We describe the radiologic information essential for devising a treatment plan and choosing the surgical technique.

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We analyzed the feasibility of performing selective neck dissection in oral cavity squamous cell carcinoma (SCC) patients according to clinical neck stage and primary subsite.
We reviewed the records of 394 patients who underwent neck dissection between April 2001 and December 2011 in our department.
In the cN0 group, occult cervical lymph node metastasis was histologically confirmed in 51 patients. Distribution of cervical lymph node metastasis was level Ia in 2 patients, Ib in 19, IIa in 28, III in 4, and others in 3. The primary tumor sites of the cases with level III metastasis were tongue in 3 patients and lower gum in 1 patient. For elective neck dissection, dissection of levels I + IIa + III is recommended in patients with SCC of the tongue and lower gum, while dissection of levels I + IIa is applicable in patients with SCC of other subsites.
In the cN1 group, the distribution of lymph node metastasis was level IV in one patient, others in 2, as well as levels I-III. The primary site of the case that involved level IV nodes was the tongue. Patients with tongue SCC should have level I-IV nodes removed. In addition, the dissection of levels I-III is an appropriate treatment for patients with other SCC.
In the cN2b group, the metastatic nodes were located in levels I-V. It is necessary to dissect level I-V nodes in patients with cN2b disease.

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Chemoradiotherapy (CRT) is the basis of organ preservation treatment for laryngopharyngeal cancer. If one also considers induction chemotherapy, the timing of neck dissection varies. Thus, there are diverse approaches to neck management, including the indication and extent of neck dissection. We describe neck dissection after CRT from the point of view of the strategy as a part of multi-disciplinary treatment.
The current mainstream is early salvage neck dissection, and the necessity or not of neck dissection is determined depending on the effect of the CRT. Therefore, the diagnosis of lymph node metastases is important to determine whether or not there is indeed a case of lymph node metastasis. The extent of neck dissection is tending to be reduced in order to minimize invasiveness and avoid complications. It is widely accepted that selective neck dissection is the current standard. Super-elective neck dissection is a new treatment strategy to reduce the extent of neck dissection even more. We also introduce the idea that up-front neck dissection is attracting attention again as a new treatment strategy.

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From April 2002 to March 2013, we conducted reconstructive surgery in 33 patients who underwent maxillary and mandibular resection or who had complications from head and neck cancer.
Overall, 19 patients were treated by a fibular osteocutaneous free flap for a maxillar or mandibular bone defect, 8 patients received a reconstructive titanium plate for the mandible and 6 patients were reconstructed by soft tissue transfer only. In the fibular group, 3 patients had an additional operation to install osseointegrated implants into the transferred bone (for the mandible in two patients and the maxilla in one patient).
In the fibular bone group, 4 patients could wear an ordinary denture and three patients could successfully wear a special denture based on the installed implants.
In the ordinary denture group, one patient needed to remove the denture while eating and used it only for esthetics. The other patients could use the denture both for esthetics and while eating, but they tended to chew food on the unaffected side of the maxilla or mandible.
In the implant denture group, one patient could chew on both sides of the mandible and the other two tended to chew only on the unaffected side.
It is thought that wearing a denture could provide esthetic value and improve masticatory function on the unaffected oral side, and the implant denture could provide stability for the denture apparatus.
The Japanese government has recently allowed osseointegrated implants and a special denture attached to them to be covered by national health insurance. As a result, implant dentures accompanied with bone grafts will become widely used for head and neck cancer patients. For the future, we must evaluate its quality for not only masticatory function of the affected side, but also total masticatory function, esthetics and psychological function.

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Objective: To perform a clinical study of sphenoid sinus tumors.
Subjects and Methods: We retrospectively studied the outpatient and inpatient medical records of 15 patients diagnosed with sphenoid sinus tumors or referred to the International University of Health and Welfare, Mita Hospital Head and Neck Oncology Center for the treatment of sphenoid sinus tumors.
Results: The 15 patients diagnosed with sphenoid sinus tumors accounted for 4% of the cases of malignant nasal tumors and malignant tumors at our hospital. Pain was the primary reason for seeking medical attention; however, patients were equally aware of other neurological symptoms. The histopathological images of the patients were diverse. The median tumor volume was 43 cm³, and all patients showed intracranial invasion. All patients received radiation therapy; none of the patients underwent surgery. The median survival time was 28 months (range, 3-82 months), the 3-year disease-free survival rate was 38%, and the 3-year disease-specific survival rate was 68%. Serious complications occurred in 2 patients.
Conclusion: The selection of an appropriate therapy such as radiation and chemotherapy on an individual basis can help to prolong patients' survival time.

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Clinical presentation of hyponatremia was investigated in patients with oral cavity carcinoma who underwent cisplatin (CDDP)-based chemotherapy. Sixty-five patients with oral cavity cancer who underwent CDDP-based chemotherapy or chemoradiotherapy at the Department of Oral Maxillofacial Surgery, Tokai University Hospital, between April 2007 and October 2012 were evaluated. Hyponatremia was observed in 53.8% of patients at the time of initial CDDP administration, and grade 3 or higher hyponatremia was observed in 16.9% of patients with relatively high frequency. Queasiness of grade 2 or higher, stomatitis, presence of moisture load, and febrile neutropenia were evaluated as risk factors for hyponatremia. Hyponatremia was believed to be triggered by reduction in sodium intake, loss of sodium, and presence of moisture load. Furthermore, although the detailed mechanism remains unclear, febrile neutropenia may be a marker of hyponatremia.

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We report five cases of oral squamous cell carcinoma that developed after hematopoietic stem cell transplantation (HSCT). The primary diseases of these patients (three males and two females) were hypoplastic leukemia, acute myeloid leukemia, follicular lymphoma, acute lymphocytic leukemia, and myelodysplastic syndrome. Three patients underwent sibling bone marrow transplantation, and the other two patients underwent sibling peripheral blood stem cell transplantation. All patients showed no recurrence of primary diseases, and three patients suffered from chronic oral graft-versus-host disease (GVHD) after HSCT. The intervals between HSCT and oral oncogenic transformation were from 3 years 5 months to 17 years 2 months. The patient with multiple oropharyngeal cancers underwent palliative surgery, and the other patients underwent curative surgical treatment. As a result, one patient with a recurrence of cancer after one year showed no recurrence after undergoing surgery. Three patients died of oral cancer, and one patient died of a respiratory disorder. These five patients shared no common factor regarding carcinogenesis or prognosis of secondary oral cancer.

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In our department, total laryngectomy (TL) has been performed in principle for patients with locally advanced laryngeal cancer. Herein, we evaluated the outcomes of patients treated for locally advanced laryngeal cancer. Of the 36 patients included in this study, 30 patients underwent TL and 6 others, including those who refused surgery, received radiotherapy (RT), and 4 of the 6 patients received concomitant chemotherapy. Cervical recurrence occurred in 5 patients in the TL group, and salvage was possible in 1 of these patients. In the RT group, 1 patient developed distant recurrence, and 1 patient had persistent lymph node involvement following RT but refused to undergo surgery and eventually died of the cancer. Two patients treated with RT for T3 tumors achieved recurrence-free survival. The 3-year disease-specific survival rate was 83.0%; by subsite, it was 81.8%, 88.9%, and 75.0% for the glottis, supraglottis, and subglottis, respectively. According to T staging, the 3-year survival rate was 100% for T3 tumors (n = 13) and 73.0% for T4a tumors (n = 23). According to N staging, it was 91.7% for node-negative tumors (n = 24) and 64.2% for node-positive tumors (n = 12). The results of this study showed that the rate of larynx preservation at 3 years was low at 20.5% for T3 tumors and 8.7% for T4a tumors because the majority of the patients had undergone TL, although overall treatment outcomes were good. Larynx-preserving treatment still remains a challenging issue to be addressed.

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Transoral surgery assisted by endoscope for superficial cancer and early-stage cancer of the head and neck area has been performed. The safety and usefulness of Endoscopic Laryngo-pharyngeal Surgery (ELPS) and Transoral Videolaryngoscopic Surgery (TOVS) have been reported. We developed a new Endoscopic Transoral Surgery method used a flexible-tip rigid endoscope and have used it. The key point is that this surgical procedure uses a flexible-tip rigid endoscope, so we can choose various types of laryngoscope to match the tumor location. We report a study of 29 laryngeal/ oropharyngeal/hyopharyngeal cases who underwent E-TOS at our institution from March 2010 to December 2012. The age of patients was 45-86 (mean: 65) years old, and the male-to-female ratio was 25:4. The observation period was 20-983 (median: 262) days. Four cases were superficial cancers, 24 cases were invasive cancers, and one case was MALT lymphoma. 24 cases were fresh cases, 3 cases were recurrence after irradiation, and two cases were recurrence after resection by the cervical approach at another hospital. We carried out curative treatment for 28 cases. We were able to perform en-bloc resection for 25 cases (89%) and curative resection for 26 cases (93%), which was equivalent to TOVS. Using this procedure, we can perform wide and safe resection of almost the whole area of the larynx, oropharynx and hypopharynx, so it is a possible choice for minimally invasive and transoral surgery.

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The most common chemoradiotherapy regimen is high-dose (100 mg/m²) three-weekly cisplatin with concomitant radiotherapy; however, this protocol is associated with acute and late toxicities. A recent study demonstrated that HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) patients showed good prognosis. Here, we reviewed the efficacy of concomitant weekly cisplatin and radiotherapy in patients with OPSCC.
Twenty-two patients with untreated OPSCC were enrolled and evaluated at our institution from July 2006 to June 2012. Weekly cisplatin (40 mg/m²) was given at weeks 1, 2, 3, 5, 6 and 7 with radiotherapy, which comprised a standard dose of 70 Gy delivered in 35 daily fractions over 7 weeks. The presence of HPV was analyzed using the multiplex PCR method. Median follow-up time was 38.6 months for surviving patients.
Of the 22 oropharyngeal carcinomas, 13 (59%) were HPV-positive. Twenty-one patients (95.4%) received the full dose of radiotherapy. Over the course of the chemotherapy, 14 patients (63.6%) received more than 200 mg/m² cisplatin. The acute and late toxicity was manageable in all cases. HPV-positive patients had better three-year overall survival rates (92.3% vs 66.7%) than HPV-negative patients. For HPV-positive patients, 1 of 13 died of distant metastasis, whereas for HPV-negative patients, 1 of 9 died of local recurrence and 2 of 9 died of distant metastasis. Because of its favorable outcome and lower toxicity, concomitant weekly cisplatin and radiotherapy appears to be a suitable treatment for HPV-positive OPSCC.

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Salivary duct carcinoma (SDC) is considered to be a high-grade malignant tumor with morphological resemblance to invasive ductal carcinoma of the breast, and develops high mortality. We retrospectively investigated the outcomes of 7 SDC cases (1 stageI, 1 stageII and 5 stageIVa) treated in Yokohama City University from 2003 to 2011. The treatment consisted of definitive surgery, postoperative concurrent chemoradiotherapy and adjuvant chemotherapy. The five-year disease specific survival rate was 83.3%, which was better than those of previous reports. Our multidisciplinary regimen might be an effective therapeutic option for SDC.

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We report three cases of well-differentiated liposarcoma of the head and neck. Case 1 was a 78-year-old man with liposarcoma of the neck and mediastinum. After thoracotomy and excision of the mediastinal lesion, the neck lesion was completely excised. Case 2 was a 41-year-old man with liposarcoma of the oropharynx and hypopharynx. The tumor recurred after transoral excision and was then completely removed using a transcervical approach. Pathologic analysis revealed myxoid degeneration, and the patient thus went postoperative radiotherapy. Case 3 was a 62-year-old man with liposarcoma of the neck and mediastinum. The tumor was completely excised using a transcervical approach.
Liposarcoma is a common soft-tissue malignancy, but rarely develops in the head and neck. A large area of excision and wide margins are usually necessary in resecting soft-tissue malignancies; however, there is no consensus regarding the treatment of well-differentiated liposarcoma, as it is considered a low- to intermediate-grade tumor. The present patients were treated with marginal excision, and there has been no recurrence to date. Our results suggest that marginal excision with preservation of adjacent organs is indicated for well-differentiated liposarcoma without surrounding invasion.

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Evaluating metastases to cervical lymph nodes is important and requires accurate diagnostic methods. The present study investigated the diagnosis of metastases to cervical lymph nodes by ultrasonography. We reviewed 88 neck dissections in 62 patients who underwent neck dissection between January and December 2012. This review resulted in 61% sensitivity, 97% specificity, and 90% accuracy. Ultrasonographic evaluation involving internal echo patterns of the lymph nodes provided more accurate diagnoses than thickness alone. The sensitivity, specificity, and overall accuracy of this diagnostic method allowed easier diagnosis of lymph node metastases in oral carcinomas than in pharyngeal carcinomas. Pathological features of false-negative results were small amounts of keratin and necrosis, a metastatic focus within a lymph node aside from the hilum of the lymph node and diffuse cellular infiltration. Diagnosis of metastases to cervical lymph nodes by ultrasonography alone has limitations, so the use of other modalities like computed tomography, magnetic resonance imaging, and positron emission tomography is important, and fine-needle aspiration during ultrasonography can improve diagnosis.

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The 2010 Japanese clinical guideline for thyroid tumor has three risk classifications for papillary cancer: high-risk, low-risk, and gray-zone. Total thyroidectomy is recommended for high-risk cancer, and hemithyroidectomy is permitted for low-risk cancer. On the other hand, the limits of resection are not decided for unilateral thyroid papillary cancer in the gray-zone. We present 372 cases with papillary cancer in the gray-zone, and hemithyroidectomy was performed for 355 of these cases. Among the 355 cases, total thyroidectomy was added due to local recurrence and/or iodine isotope for lung metastasis for 19 cases. In the 19 cases, 14 cases have survived without recurrence, and only 2 cases died due to lung metastasis. From these data, hemithyroidectomy for unilateral papillary cancer in the gray-zone is permitted. Permanent postoperative paralysis of recurrent laryngeal nerve was observed in only one case of 372 cases with gray-zone cancer. Permanent postoperative hypoparathyroidism was observed in only one case of 17 cases who underwent total thyroidectomy. We did not select hemithyroidectomy due to concerns about postoperative complications.

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We reviewed the medical records of patients with well-differentiated thyroid cancer who were treated with ¹³¹I in our hospital between 1995 and 2009. A total of 462 patients were identified. Among these, 81 had metastatic bone lesions at the time of initial ¹³¹I therapy (52 had bone metastases alone and the remaining 29 also had metastases in other organs). Median age at the time of treatment was 63 years and the male-to-female ratio was 31:50. Histologically, 56 cases were follicular adenocarcinoma, 14 cases were papillary adenocarcinoma, and 11 cases were other types. The median amount of ¹³¹I in each treatment was 100 mCi (range, 50-200 mCi). Sixty-four cases (79%) showed concentration of ¹³¹I in metastatic lesions. The 5-year survival rate and median survival of cases with ¹³¹I concentration were 59% and 7.8 years, respectively, and those of cases without ¹³¹I concentration were 28% and 3.2 years, respectively (p=0.0007). Among cases with ¹³¹I concentration, the 5-year survival rate was 76% for patients who had only bone metastases, compared to 17% for patients with additional metastases in other organs (p < 0.0001). The 5-year survival rate was 71% for those who had ≤4 bone metastases, compared to 38% for those with ≥5 bone metastases (p=0.008). The 5-year survival rate was 74% for patients with initial serum thyroglobulin level <10,000 ng/ml, compared to 34% for those with initial serum thyroglobulin level ≥10,000 ng/ml. Therapy with ¹³¹I might improve the prognosis of patients with bone metastases from well-differentiated thyroid cancer. Patients without metastases in other organs, with oligometastases, and with low initial thyroglobulin level show more favorable prognoses.

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We herein report 13 cases of anaplastic thyroid carcinoma (ATC) treated in the National Kyushu Cancer Center from 1972 to 2012. All patients' outcomes were death from ATC, and the survival period was from 1 to 15 months (mean: 5.3 months). The rates of local control and distant metastasis were 8% and 88%, respectively. Survival periods compared by the Prognostic Index, which was useful for predicting the prognosis of ATC, were not significantly different. The survival period of the radical operation group tended to be longer than that of the non-radical operation group, but not significantly.
It is important to consider multimodal therapy for local control according to local progression and no distant metastasis. However, since ATC rapidly becomes uncontrollable, we should consider best supportive care as one of the choices.

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Primary malignant melanoma of the head and neck is a rare disease that has an extremely poor prognosis. Thirteen patients with malignant melanoma of the head and neck treated at our hospital were reviewed retrospectively. Eight patients who were treated with surgery demonstrated a 3-year locoregional control rate of 73%. The 3-year overall survival rate for all patients was 31%. The rate of distant metastases in the first medical examination was 38%, and the 3-year cumulative rate of distant metastases was 72%. We analyzed the relationship between prognosis and interval from the day of incisional biopsy to the day of initial treatment. No statistically significant differences were observed, but there was a tendency that a longer interval between incision biopsy and the start of treatment led to deterioration of locoregional control rate, overall survival rate, median survival term, and rate of distant metastases.

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Stenosis of the tracheostoma after surgery is a frequent complication. According to the literature, the incidence of this complication ranges from 4% to 42%. Once stenosis occurs, the patient either has to use a stent or needs surgical revision. Many techniques for creating the tracheostoma to prevent stenosis have been attempted, such as by using skin triangles. We performed a simple surgical technique for creating tracheostoma using buried sutures in 23 consecutive patients (21 males, 2 females) after total pharyngolaryngoesophagectomy, between November 2011 and January 2013. The follow-up period of these patients varies from 5 to 25 months, and none of them have needed surgical revision. We speculate that tracheostomal stenosis is created by scar contracture because of excessive scar tissue, skin around the stoma and supportless tracheal ring. This new surgical technique yields good results for preventing tracheostomal stenosis.

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Background: Orbital floor reconstruction is essential for maintaining orbital function after extensive resection of cancers of the head and neck. We report our experience of orbital floor reconstruction with the transfer of free flaps and titanium mesh (TM).
Methods: From July 2000 through January 2013, orbital floor reconstruction was performed immediately after ablation of cancers of the head and neck in 25 patients (17 men and 8 women; mean age: 61 years). A TM plate was transferred simultaneously with a free rectus abdominis musclocutaneous flap, a vascularized fibula osteocutaneous flap, or a vascularized fibula osteocutaneous flap combined with an anterolateral thigh flap.
Results: The transferred vascularized fibula osteocutaneous flap underwent total necrosis in 1 case and necessitated reconstruction with a free rectus abdominis musclocutaneous flap. Three patients had diplopia and 2 patients lost their sight on the affected side because of cancer infiltration or postoperative edema. Lagophthalmos or ectropion of the lower eyelid developed in 13 cases and necessitated secondary revision surgery in 4 of these cases. Delayed TM infection and exposure developed in only 1 patient, who then underwent removal of the TM and secondary reconstruction with a latissimus dorsi muscle flap.
Discussion: Orbital floor reconstruction with a TM is useful for maintaining orbital function because of the ease with which the 3-dimensional structures of the orbital floor can be formed. However, a TM should not be used over a wide area because of the increased risk of infection.

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An electronic larynx can be used promptly after surgery by patients who have undergone a total laryngectomy. In our institute we effectively use an electronic larynx with oral adapter for patients after total laryngectomy or patients undergoing radiotherapy as an alternative communication tool. To estimate the efficacy of the oral adapter, we compared the words and speech intelligibility of patients who use an electronic larynx with patients who use an electronic larynx with oral adapter by a single-word intelligibility test for evaluating the speech of adults with articulation disorders. The results showed that the words and speech intelligibility of patients who use an electronic larynx with oral adapter were superior to those of patients who use an electronic larynx. We consider that an electronic larynx with oral adapter is a useful option as an alternative communication tool.

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