It is well known that patients with hypopharyngeal cancer often have esophageal cancer as multiple primary cancers. We may not choose radiotherapy for patients who have already been irradiated for esophageal cancer. Therefore, we regard partial pharyngectomy for the purpose of laryngeal preservation as a very important strategy in hypopharyngeal cancer treatment. When we perform these operations, the setting of the appropriate extent of resection and the choice of reconstructive surgery are critical.
Currently, we have two approaches for laryngo-pharyngeal surgery.
One is endoscopic laryngo-pharyngeal surgery (ELPS) in cooperation with a gastrointestinal endoscopist as a minimum invasive surgery. We showed that this is a good therapy for patients with superficial pharyngeal cancer. Pharyngeal expansion using a curved laryngoscope is useful for observation and the spread of the lesion can be determined by gastrointestinal endoscopy. We have performed over 70 cases of ELPS in the past 7 years.
The other approach is laryngeal preservation surgery for invasive hypopharyngeal cancer. In such cases, we perform pharyngeal partial excision and jejunum patch reconstruction. We have performed 40 laryngeal preservation surgeries in the past 10 years. Recently, to make an appropriate resection, we determine the extent of resection using an endoscope and perform a mucosal incision. Then, we remove the tumor by approaching from the neck. Postoperative histopathological examination showed that complete resection was achieved in all cases treated by this method. The cause-specific survival rate is approximately 90%.

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Acneiform rash, the most common cetuximab-related toxicity, frequently appears within 1 month after administration. The severity of the rash has been reported to be associated with improved survival. However, there are very few reports of this association in patients with recurrent or metastatic head and neck cancer. We retrospectively analyzed 23 patients with recurrent or metastatic head and neck cancer who received cetuximab plus platinum-based chemotherapy. The patients included 22 men and 1 woman (median age, 68 years). The primary tumor sites were the hypopharynx (n=9), cervical esophagus (n=5), maxillary sinus (n=3), oropharynx (n=3), larynx (n=2) and parotid (n=1). Seven, 10, and 6 patients had Grade 0, Grade 1, and Grade 2 acneiform rash, respectively. Severity peaked 2–14 weeks (median, 3.5 weeks) after the initial treatment, and 75% of the patients (except for those with Grade 0 acneiform rash) exhibited a peak within 5 weeks after the initial treatment. The median survival duration was 7 months (range, 1–17 months). Compared with a mild rash (Grade 0–1), a severe rash (Grade 2 or higher) at the fifth week of initial treatment was associated with improved survival. Therefore, the severity of the acneiform rash predicted improved survival in patients with recurrent and metastatic head and neck cancer.

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The pedicled buccal fat pad (BFP) fills an anatomical gap formed by the buccinator muscle, the masseter muscle, and the ramus of the mandible. It has a sufficient blood supply from the surrounding arteries. We have been using BFP grafting for the reconstruction of oral defects induced by ablative surgery for a tumor, ankylosis of the temporomandibular joint and so on. This study aimed to evaluate the applicability of pedicled BFP grafting following oral and maxillofacial surgery. We retrospectively evaluated 50 graftings in 49 cases. The grafts were applied for defects of the lower gingiva (n=14), the upper gingiva (n=13), the palate (n=9), the buccal mucosa (n=8), the ramus of the mandible (n=3), and other regions (n=3). According to the primary diseases, we applied it for cases of squamous cell carcinoma (n=24), carcinoma in situ (n=4), pleomorphic carcinoma (n=3), ankylosis of the temporomandibular joint (n=3), verrucous carcinoma (n=2), osteoradionecrosis of the jaw (n=2), and other lesions (n=12). Complete epithelialization of the BFP occurred within 4 weeks in 49 of the 50 graftings. BFP grafting appears to be suitable for the reconstruction of surgical defects in the oral region.

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The pedicled pectoralis major myocutaneous (PMMC) flap is versatile and still used for the reconstruction of surgical defects following oral, head and neck cancer resection. Although microvascularized free-tissue transfer is often used as the main flap method for oral and maxillofacial reconstruction, it cannot be used effectively in certain situations, such as in recurrence after reconstruction (salvage), poor systemic or local conditions, in arteriosclerosis, and/or in the very elderly. According to individual considerations for oral cancer treatment, the clinical benefits of the PMMC flap should not be overlooked. When harvesting the PMMC flap, we modified the conventional technique: (1)Use of the subclavian route and (2) Preservation of the lateral thoracic vessels. These modified PMMC flap preparation techniques ensure sufficient blood supply and an increased rotation arc. We have applied this modified technique instead of microvascularized free flaps or conventional PMMC flap techniques since 2013. To date, we have treated 8 patients with advanced or recurrent (salvage) oral cancer, as well as very elderly patients, with our modified technique and no critical flap problems or fistula formation have occurred. In this retrospective clinical study, we review this modified PMMC flap and compare the clinical results for the treatment of surgical defects following oral cancer resection in terms of the feasibility of additional blood supply of the lateral thoracic vessels in the clinical setting.

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The aim of this study was to evaluate the failure pattern and clinical results of recurrent nasopharyngeal cancer (NPC) following definitive chemoradiotherapy (CRT). Between 2000 and 2013, 76 patients with NPC were treated with concurrent CRT. For all patients, 70 Gy in 35 fractions by IMRT was combined with concurrent chemotherapy (CDDP 80mg/m²/ 3 weeks). For the 76 patients, the 3- and 5-year overall survival (OS) rates were 83% and 71%, respectively. Twenty-nine (38%) of the 76 patients showed loco-regional recurrence (LR) or distant metastasis (DM). In terms of the initial failure pattern, 10 patients showed LR and 19 patients showed DM. The median time to LR and DM was 40 months (5–147 months) and 14 months (2–90 months), respectively. Four patients showed LR or DM after 5 years. Long-term observation is important for NPC. Regarding treatment after initial failure, 25 of the 29 patients received radiotherapy, chemotherapy, or surgery. The other four patients received no further treatment. Re-irradiation (52.5–66Gy) was performed for six patients with LR. IMRT was used for five patients. Among the 25 patients, the 3-year OS rates for patients with LR and DM were 25% and 43%, respectively. In conclusion, long-term survival is achievable for recurrent NPC after definitive CRT.

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【Objectives】Cases of cervical esophageal cancer account for less than 5% of all cases of esophageal cancer. Although a multimodal treatment approach is adopted in such cases, the associated mortality is poor and the post-treatment quality of life is insufficient, given that most patients present with advanced stage cancer, and because pharyngo-laryngo-esophagectomy and gastric pull-up reconstruction are often required. In the present study, we aimed to evaluate the outcomes of surgical and radiation treatment for cervical esophageal cancers in the Hyogo Cancer Center.
【Methods】We examined the records of 42 patients with cervical esophageal cancer from 2001 to 2012.
【Results】Of the 42 patients, 30 were men, and the median patient age was 65.5 years. All patients had squamous cell carcinoma (SCC) ; 29 underwent surgery and 13 received chemoradiation. The 5-year overall survival rate for patients who underwent surgery was 52.5%, and that for patients who received chemoradiation was 59.8%.
【Conclusions】The survival rates of the present study are consistent with previous reports. We believe that treatment should be individualized in terms of the expected functional outcomes and tolerability.

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Background: Preservation of the facial nerve in the treatment of parotid gland carcinoma is controversial. In our institution, the facial nerve is preserved as much as possible.
Method: We retrospectively reviewed 59 patients with parotid gland cancer treated between 1997 and 2014.
Results: Surgery (n=47), definitive RT (n=5), and CRT (n=7) were performed. Postoperative radiotherapy (RT)/concurrent chemoradiotherapy (CRT) was performed in 32 patients. The 5/7-year overall survival (OS) according to treatment was 78%/69% with surgery±postoperative RT/CRT, 35%/35% with CRT, and 20%/20% with RT, respectively.
There was a significant difference in OS and loco-regional control (LRC) between patients with facial nerve palsy (FNP) and without FNP. There were no significant differences in OS, LRC, or distant metastasis free survival between patients with no neural invasion and with neural invasion without FNP treated conservatively.
Conclusions: If patients have no facial nerve palsy, the facial nerve should be preserved as much as possible with postoperative RT/CRT.

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Dental implants are useful in prosthetic treatment for patients who have lost teeth, but also for patients with bone defects due to resection of benign or malignant tumors.
Public health insurance coverage for bone-anchored devices and prostheses for wide edentulous areas was introduced in 2012, and implant treatment was added as an insurable treatment method at facilities equipped with the prescribed equipment.
We report here three cases of oral cancer treated using implants provided by public health insurance in our hospital and discuss some of the problems related to this system.

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We reviewed retrospectively the records of 50 consecutive patients who underwent a total laryngectomy during the period from January 2007 to December 2013 at the Department of Otorhinolaryngology, Head & Neck Surgery, Mie University Hospital. Thirty-eight of the 50 received primary total laryngectomy, 5 underwent radiotherapy or chemoradiotherapy, and 7 underwent chemotherapy followed by total laryngectomy. Wound complications such as pharyngocutaneous fistula (PCF), stomal stenosis, bleeding and infections were analyzed. PCF occurred postoperatively in 2 (4%) patients, and surgical closure was performed in both of them. Tracheal stenosis developed in 7 cases. Our experience confirmed that good pre-operative condition and careful operation might reduce the incidence of PCF after total laryngectomy. In addition, the primary plastic technique including Z plasty should be considered in female patients to prevent stomal stenosis.

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Metastasis of a tumor to the tonsil is a rare event in usual practice. We report a case of tonsillar metastasis from large cell neuroendocrine carcinoma of the lung. An 81-year-old man was referred to our hospital because of tonsillar tumor. In CT findings, he had a lung tumor suspected to be lung cancer. The tonsillar tumor suddenly increased, and he became unable to eat or speak. We promptly removed the tonsillar tumor and the pathological result was large cell neuroendocrine carcinoma. Thereafter, the pathological result of the lung tumor was the same. We diagnosed tonsillar metastasis from large cell neuroendocrine carcinoma of the lung.

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Purpose: The aim of this study was to compare the clinical response and histopathological response of patients with hypopharyngeal cancer.
Patients and Methods: Neoadjuvant chemotherapy (NAC) was administered to 62 operable patients with locally advanced hypopharyngeal cancer. Forty-one patients received the PF arm (CDDP 20mg/m² × 5 days ＋ 5-FU 1000mg/m² × 5 days) and 21 patients received the TPF arm (CDDP 60mg/m² × 1 day ＋ TXT 60mg/m² × 1 day ＋ 5-FU 700mg/m² × 5 days); both regimens were administered for one cycle. We evaluated the clinical response and histopathological response according to the General Rules for Clinical Studies on Head and Neck Cancer (5th Edition).
Results: Clinical Response: The PR rate was 44% in the PF arm and 54% in the TPF arm (p=0.49). Histopathological Response: The response rate of the primary sites was 25% in the PF arm and 43% in the TPF arm (p=0.13), while that of the lymph nodes was 18% in the PF arm and 37% in the TPF arm (p=0.10). In both the primary sites and lymph nodes, the histopathological response was lower than the clinical response.
Conclusion: In many cases, the clinical response and the histopathological response did not correlate with one another. Therefore, care must be taken when selecting organ preservation treatment and determining the perioperative excision range.

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The lateral retropharyngeal lymph node (RLN), also known as the Rouvière lymph node, is often metastasized from head and neck cancer. Here, we retrospectively assessed 19 cases with RLN metastasis from head and neck squamous cell carcinoma, excluding nasopharyngeal carcinoma, treated at our hospital between 2003 and 2012. Because we often utilize the CyberKnife system (CK) for the treatment of late metastatic RLN, we focused on its efficacy. CK was introduced to 7 cases, and the short-term response rate of their lesions was 100%. However, the effect of CK was not so high in terms of RLN control rate and survival rate in relation to the long-term response due to recurrence or bleeding from metastatic RLN. On the other hand, univariate analysis identified aging as a significant predictor for better control of metastatic RLN.
RLN lesions of all cases were treated with radiation therapy including CK, and the 2-year overall survival rate was 55%. This is equivalent to the survival rate in previous reports including patients mainly treated by surgery, suggesting that radiotherapy is also a favorable choice for the treatment of metastatic RLN.

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【Purpose】 Evaluation of the quality of life (QOL) after neck dissection (ND) needs to include not only objective findings such as range of motion or muscular weakness but also symptoms such as pain. The aim of this study was to evaluate the validity of DASH scores (Disability of the Arm, Shoulder and Hand, Japanese edition) in assessing patients who underwent ND.
【Subjects and methods】 We retrospectively evaluated 63 sides of 45 patients who underwent neck dissections including level II and III . The median age was 66 years (26-83) ; 36 were men and 9 were women. The median follow-up period was 433 days (183-706) . Spinal accessory nerves were preserved in all cases. We used DASH as a questionnaire to evaluate the QOL. Surveys were conducted six months or more after the operation.
【Results】 The average DASH score was 16.0 points. Degree of injury was classified as follows: Normal: 0 points (9 patients, 20%), Mild: 1〜33 points (28 patients, 62%), Moderate: 34〜67 points (7 patients, 16%) , and Severe: 68〜100 points (1 patient, 2%). The DASH score accurately reflected upper extremity disability and symptoms following ND.
【Conclusion】 We conclude that continuous rehabilitation in an outpatient clinic is important in all cases after modified radical neck dissection because the disability of the upper extremities estimated by DASH continues for a long period even if the accessory nerves were preserved.

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Patients receiving concurrent chemoradiotherapy (CRT) for locally advanced head and neck cancer often experience acute toxicity such as mucositis, dysphagia, xerostomia, and so on. It is associated with higher prevalence of weight loss and malnutrition during therapy, and it also causes a decline in the quality of life and increases treatment interruption. We evaluated the effects of the degree of nutrition intervention on the rates of weight loss, treatment interruption and adverse effects during CRT with high-dose cisplatin. Enteral nutrition was administered by oral intake, a nasogastric tube or percutaneous endoscopic gastrostomy (PEG) in addition to usual diet.
A review was performed on 43 patients treated for head and neck cancer with CRT. The median of average caloric value during CRT was 1484 kcal/day in all patients. Outcomes were compared between group A (ncitation=21) that took less than the median caloric value and group B (ncitation=22) that took more than the median caloric value. The average weight change in group A and B was –7.7% and –2.9%, respectively (pcitation=0.0047). Group B had a significantly lower number of treatment interruptions (pcitation=0.042) and nephrotoxicity (pcitation=0.0071). Nutritional support with enteral nutrition during CRT is useful for preventing of weight loss, treatment interruption and nephrotoxicity.

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Objective: The aim of this study was to establish the optimal antimicrobial prophylaxis for oral reconstructive surgery.
Materials and methods: A retrospective chart review of patients who underwent oral reconstructive surgery at the Department of Oral Surgery, Hokuto Hospital was performed. The selected candidate predictive factors for surgical site infection (SSI) and remote infection (RI) were: duration of prophylaxis, sex, age, anemia, preoperative serum albumin (Alb), obesity, chronic obstructive pulmonary disease (COPD), performance status (PS) , duration of the surgical procedure, tracheostomy, mandibulotomy, mandibular reconstruction using a metal plate, prior radiation therapy, blood transfusion, and delayed postoperative ambulation.
Results: For SSI, significant factors on logistic regression analysis were Alb, PS, tracheostomy, and prior radiation therapy (p＜0.05). For RI, PS (p＜0.05) was a significant factor. Patients receiving only CEZ (cefazolin) for 24 perioperative hours did not have a significantly increased SSI rate when compared to those patients receiving long-duration prophylaxis. Prophylaxis with CEZ for 24 perioperative hours was generally considered optimal prophylaxis, but it may have increased the RI rate.
Conclusion: Antimicrobial prophylaxis appears to be controversial in a compromised host.

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We retrospectively reviewed the lifetime of indwelling voice prostheses (Groningen^® voice prosthesis, Povox^®2) used in 33 outpatients, and analyzed influences of the type of prosthesis, surgical procedure and irradiation on device lifetime.
We replaced 771 prostheses, and the median device lifetime was 91 days. Surgical procedure (TE shunt or TJ shunt) was significantly associated with the device lifetime (p=0.003). Groningen^® voice prostheses tended to have longer device lifetime compared to Provox^®2 (p-0.059). There were no significant differences in device lifetime between the patients with or without radiation therapy (p=0.466).
The results of this analysis provide a useful yardstick, although the replacement interval depends on each situation. Further examination of methods to reduce unplanned replacement is necessary.

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