We reclassified and evaluated 38 consecutive patients with primary unknown carcinoma with cervical neck lymph node metastasis treated definitively from July 2011 to February 2018 to clarify the content and clinical problems of the new 8th version of the UICC TNM classification. According to the new classification, if pathological diagnosis reveals p16 immunostaining positive in cervical neck lymph node with squamous cell carcinoma metastasis, the case is categorized as p16 positive mesopharyngeal cancer; if it reveals Epstein-Barr virus in situ hybridization positive, the case is categorized as nasopharyngeal cancer; and others are categorized as primary unknown squamous cell carcinoma. Thus, about 70％ of patients were reclassified as primary unknown squamous cell carcinoma and 30％ of these were reclassified as p16 positive mesopharyngeal cancer. Additionally, clinical stage and pathological stage are also classified as stageⅢ or stageⅣbased on the existence of extra-nodal extension. Because criteria for clinical extra-nodal extension were not precisely estimated pathologically, the clinical stage was probably lower than the pathological one, causing the survival curves to diverge from one another. This is an important clinical problem.
Evidence supporting the benefit of adding topical steroids in general nursing care for radiation dermatitis induced by high-dose （>60Gy） irradiation plus chemotherapy is insufficient. To clarify the prophylactic efficacy of topical steroids in basic nursing care for radiation dermatitis, we are conducting a multicenter two-arm randomized double-blinded placebo-controlled phase 3 trial to compare basic nursing care with or without topical steroid for radiation dermatitis induced by radiotherapy with concurrent cisplatin in patients with head and neck cancer （J-SUPPORT 1602 study, TOPICS）. The primary endpoint is a comparison of the proportion of patients with ≥grade 2 radiation dermatitis by NCI Common Terminology Criteria for Adverse Events Version 4.0. This trial is supported by the Japan Supportive, Palliative and Psychosocial Oncology Group （J-SUPPORT）. To conduct the TOPICS study, we organized four multidisciplinary working groups, consisting of physicians, pharmacists, and nurses. Each working group has been working on: （1） investigation and management of placebo topical cream （Vaseline） and topical steroid, （2） basic nursing skin care based on a dermatitis control program to minimize inter-institutional variation, （3） the procedure of taking photographs of the irradiation field, and （4） a central review of radiation dermatitis using photographs taken weekly. The TOPICS study may provide novel evidence as to whether the use of topical steroid is efficient in preventing radiation dermatitis induced by high-dose irradiation with chemotherapy. Furthermore, the TOPICS study will be a model trial providing multidisciplinary operating procedures when conducting clinical trials for cancer supportive care. Trial registration number: UMIN000027161.
Conservation of the quality of life after tumor surgery requires a total treatment plan for reconstruction such as postoperative occlusion, chewing and pronunciation function, as well as treatment of the original disease before surgery. A smooth transition from surgery to maxillofacial prosthodontic treatment will enable an early return to life after surgery. In cases of maxillary defects in which an oral nasal cavity fistula is expected after surgery, the appropriate application of an immediate surgical obturator （ISO）, is an important factor in maintaining postoperative quality of life and early social reintegration.
The oropharynx is a complex anatomic structure which serves multiple functions, primarily in pronunciation, swallowing and immunity. Treatment strategies involving the oropharynx should therefore consider quality of life and organ function after treatment. In recent years, the incidence of HPV-related oropharyngeal cancer （OPC） has continued to increase globally. The 2017 TNM revision classifies OPC into two types: HPV-related OPC （p16-positive） and non-HPV-related OPC （p16-negative）. HPV-related OPC has a better prognosis than non-HPV-related OPC. Chemoradiotherapy, a non-surgical treatment for OPC, requires management of acute and chronic side effects in order to prevent treatment interruption. Clinical trials aimed at decreasing treatment intensity are now underway.
It is recognized that professional oral care performed by dental health providers can help to prevent post-surgical complications in cancer patients, as well as perioperative bacterial infections in cardiovascular surgery or organ transplantation. Accordingly, medical expenses for oral management have been covered by the Japanese health insurance system under ‘Perioperative Oral Functional Management’ since April 2012. Aichi Cancer Center Hospital undertook a model project of medical-dental collaboration to develop a community medical cooperation system of oral functional management（OFM）in cancer patients from 2011 to 2013. This project also carried out practical training programs on OFM for dental clinics and pharmacies in Aichi prefecture. Dental practitioners and pharmacists who completed this training were certified as cooperative clinicians at our hospital. As part of the training programs, a clinical study was conducted to examine the effects of OFM performed by regional collaborators for 41 prehospital patients of head and neck or upper gastrointestinal cancers. In 2017, an additional clinical study was performed by a questionnaire survey for 199 cooperative dentists of our hospital. These studies revealed the problems of patient referral documents in community medical cooperation and the necessity of continuous practical training in OFM of cancer patients.
Background: The EXTREME regimen is the most established standard treatment for patients with recurrent/metastatic head and neck squamous cell carcinoma. Methods: We retrospectively reviewed R/M HNSCC patients who were treated with the EXTREME regimen in our institution from February 2013 to October 2015. The EXTREME regimen consists of cisplatin or carboplatin on day 1, continuous 5-FU on days 1 to 4, and cetuximab on days 1, 8, and 15, for every 3 weeks, the same as the original article. The response rate （RR）, progression-free survival （PFS）, overall survival （OS）, and adverse events （AE） were evaluated. Results: A total of 34 patients were enrolled. Partial response rate was 50％, and there was no complete response. The median PFS was 5.1 months, and the median OS was 15.9 months. The most common grade 3 AEs were neutropenia, leukopenia, anorexia, and hyponatremia. Conclusions: In our institute, the EXTREME regimen is a safe and effective treatment for R/M HNSCC patients.
We analyzed the treatment outcomes and safety of concomitant chemoradiotherapy （CCRT）, especially with a combination of docetaxel, cisplatin and 5FU （TPF）, for local advanced external auditory canal squamous cell carcinomas. In addition, we analyzed the correlation between tumor invasion site and prognosis. The study comprised 21 patients with the following criteria: （1） external auditory canal squamous cell carcinomas which were subject to radical treatment at Hokkaido University Hospital between 2007 and 2017, and （2） T3–4 classified according to the University of Pittsburg system. As a result, tumor invasion into the dura or temporomandibular joint was associated with neck lymph node metastasis, and tumor invasion into the temporomandibular joint was associated with local recurrence. The 2-year overall survival rate （OS） and 2-year local control rate （LC） were 61.1％ and 52.1％ in all patients, respectively. In patients treated with CCRT, the 2-year OS was 85.7％ in CCRT with TPF and 25.0％ in CCRT with others, and the 2-year LC was 57.1％ in CCRT with TPF and 25.0％ in CCRT with others. Grade 3-4 leucopenia and neutropenia occurred in 55％ and 45％ of patients treated with CCRT with TPF, respectively. CCRT with TPF shows high efficacy and safety for local advanced external auditory canal squamous cell carcinomas.
Double primary cancers of the head and neck and the esophagus are often caused by field cancerization. It is difficult to determine the treatment strategy for cases of synchronous double cancers not indicated for endoscopic resection. We investigated 20 cases of synchronous double primary cancers of the head and neck and the esophagus without indications for endoscopic resection. Treatments for head and neck cancer were chemoradiotherapy in 11 cases, operation in 8 cases and best supportive care （BSC） in 1 case. Treatments for esophageal cancer were chemoradiotherapy in 12 cases, operation in 3 cases, induction chemotherapy （ICT） followed chemoradiotherapy in 2 cases, ICT followed by operation in 2 cases, and BSC in 1 case. The 5-year survival rate was 15.8％, and the 3-year survival rate was 31.7％, which were poor results. Three out of four survival cases without recurrence are receiving simultaneous chemoradiotherapy for the head and neck cancer and the esophageal cancer. Multidisciplinary treatment is not always superior in the case of synchronous double primary cancers, and so we should decide different treatment strategies based on whether there is head and neck cancer or esophageal cancer alone.
Introduction: Free reconstructive surgery for oropharyngeal cancer or oral cancer often involves a tracheotomy to manage the airway. All cases undergo a tracheotomy in principle, and we have switched to RetinaⓇ （KOKEN） for when postoperative laryngeal edema has improved and there is reduced pulmonary aspiration of saliva. Previously, the switch to Retina was made on an empirical basis, but now we have switched to Retina by scoring and assessing laryngeal findings objectively. In this study, we investigated the usefulness of scoring by comparing the number of days after surgery when the switch to Retina was made, as well as the frequency of pneumonia. Materials and methods: We scored the postoperative laryngeal findings of 51 patients who underwent free flap reconstruction for oropharyngeal cancer/oral cancer. Two doctors specializing in treating head and neck cancer gave one of three scores to three items: paralysis of the vocal cords, laryngeal edema, and retention of saliva, and calculated a total score. These were compared with 48 cases before the scoring was implemented. Results: The scored patients were 36 men and 15 women, aged 22 to 86 （median: 65 years）, with a median of 8 days after surgery when the switch to Retina was made, and three cases of pneumonia （6%）. Cases from before scoring were 34 men and 14 women, with a median of 8.5 days after surgery when the switch to Retina was made, and two cases of pneumonia （4%）. Discussion: There was no apparent worsening between before and after the scoring was introduced. The switch to Retina, which was done on an empirical basis in the past, is made more objective by the scoring.
We investigated the efficacy of surgical resection of metastatic lesions from head and neck squamous cell carcinoma （HNSCC）. We retrospectively reviewed 26 patients who underwent pulmonary or hepatic metastasectomy from HNSCC at Kyushu University Hospital between 2000 and 2016. The primary sites of HNSCC were as follows: nasopharynx in 3 cases, oropharynx in 6 cases, hypopharynx in 8 cases, larynx in 5 cases, tongue in 3 cases, and submandibular gland in 1 case. The metastasectomy was performed for pulmonary metastases in 22 cases and hepatic metastases in 4 cases. The overall 1- and 2-year survival rates were 78％ and 70.9％, respectively. The short disease-free interval from initial treatment to distant metastasis was associated with shorter overall survival after metastasectomy. Continued and careful surveillance is important after surgical resection of metastatic lesions.
Esophageal speech, electrolarynx, and tracheoesophageal shunt with prosthesis are the most common methods of rehabilitation after total laryngectomy. The Amatsu tracheoesophageal shunt operation reduces the risk of aspiration and the rehabilitated voice has a good quality and does not require additional costs for its maintenance. It is one of the ideal ways of producing sound. In 1996, the Amatsu tracheoesophageal shunt was reported by the Oto-Rhino-Laryngological Society of Japan. However, it has not yet spread much except at some facilities. Between 2015 to 2017, 7 patients received the Amatsu method after total laryngectomy in the Shizuoka Cancer Center （Mishima, Shizuoka, Japan）. Six were able to speak intelligibly, requiring a median time of 10 months. The time to starting speech training was 26-40 postoperative days （median: 29 days）. The date when the audio was confirmed was 33-64 days （median: 53 days）. There were no cases with aspiration from the bronchesophageal shunt and the phonation time was 7-27 seconds （median: 22 seconds）. It seems that postoperative management including ventilation and bougie is necessary for the patient to acquire voice.
In some cases, activities of daily living （ADL） decline after surgery for head and neck malignancy, and the patients are unable to leave the hospital and must be transferred to another hospital. The purpose of this study was to clarify the risk factors. We retrospectively analyzed 71 patients with head and neck cancer who were over 70 years old and who underwent curative surgery as an initial treatment from January 2006 to December 2015. We evaluated the ADL of each patient using Barthel’s index at the time of admission and discharge, and judged that ADL had declined in a case with a score of 60 or less at the time of discharge, and in a case with a score of 60 or less at the time of admission, more nursing care would be needed than at the time of admission as ADL declined. Adult Comorbidity Evaluation-27 index （ACE-27 index） was used for evaluating comorbidities. We examined preoperative conditions, surgical details, and postoperative courses. As a result, it was considered that the performance status （PS）, ASA physical status （ASA-PS）, cerebral nervous system comorbidities, moderate or more cardiovascular comorbidities, hypoalbuminemia, decreased respiratory function, and the occurrence of postoperative complications were risk factors for ADL decline. It is considered that patients aged 70 years or older with moderate comorbidities and poor respiratory function or nutritional status before surgery need careful monitoring for postoperative ADL decline regardless of surgical details.
Radiotherapy combined with cetuximab（Bioradiation therapy：BRT）is one of the standard care methods for locally advanced squamous cell carcinoma of the head and neck（LA-SCCHN）. Since its introduction in routine clinical practice, there have been a few reports regarding the use of BRT in Japan. To evaluate the safety and efficacy of therapy including cetuximab, a prospective observation study of Japanese patients with SCCHN treated by combination therapy with cetuximab has been launched. We report the scheduled interim appraisal of the safety and treatment compliance in BRT performed for half of the total accruals（90 patients）. This study received support from Merck Serono, and was conducted by the Japanese Radiation Oncology Study Group（JROSG）. We analyzed 69 cases that were available for analysis among the 90 cases enrolled from August 2013 to May 2015. Data on baseline characteristics, treatment compliance, and the incidence and severity of adverse events were collected. Patients with cancer of the hypopharynx, oropharynx, larynx, and oral cavity were enrolled. Median age was 66（36-83）, and 14 patients（20％）were 75 years old or older. 49 patients（71％）had stage ⅣA disease. The rate of treatment completion, defined as receiving weekly cetuximab of 6 or more courses and radiotherapy dose of 60Gy or more, was 75％, which was lower than expected. Treatment compliance was especially low in elderly patients. The most frequently reported Grade 3 or 4 adverse events were pharyngeal mucositis（58％）, radiation dermatitis（42％）, and oral mucositis（39％）. Respiratory complications such as aspiration pneumonia（5％）and pneumonitis（3％）were higher than previously reported. Therefore, careful respiratory monitoring is necessary for safe treatment. BRT was adopted widely for patients with LA-SCCHN in Japan. However, treatment compliance was slightly lower than expected, and careful observation during treatment is needed. Safety and efficacy after 1 year will be followed up and described in a final report.
We present a patient with intestinal type adenocarcinoma of the nasal cavity. A 63-year-old male was referred to our hospital due to repetitive, right-side nasal bleeding over a period of a year. Nasal endoscopy revealed a right-sided olfactory cleft tumor. CT and MRI studies detected a right nasal tumor 37mm in the longer axis and 26mm in the shorter axis. The tumor was diagnosed as a Stage Ⅳa nasal carcinoma due to extension to the sphenoid sinus. Transnasal endoscopy-assisted skull base surgery was performed. No postoperative complications except anosmia were observed. Histological findings confirmed an intestinal type adenocarcinoma without infiltration of dura and negative margins. Two years after 56Gy of postoperative radiotherapy, neither locoregional recurrence nor distant metastasis was found.