Background: Recent developments in transoral surgery （TOS） have improved outcomes in early-stage hypopharyngeal cancer. To date, however, indications for TOS and partial pharyngectomy with primary closure （PP-PC）, which is also used in these early-stage diseases, have not been considered in detail. Here, we investigated whether TOS could be used as minimally invasive surgery while maintaining outcomes comparable to those of PP-PC.
Methods: This was a single-center retrospective case control study. Median follow-up period was 59.4 months （1.2-174） for TOS and 88.8 months （3.6-158.4） for PP-PC. Patients who received initial surgical treatment for hypopharyngeal cancer were recruited from 2002 through 2014. Among these patients who underwent TOS or PP-PC, cT1-3N0M0 was included. Those with histopathological invasion of the muscularis propria were excluded. Of 117 consecutive cases, 87 cases were treated with TOS and 30 with PP-PC. Median age was 66 years （42-88）. Lesions were in the pyriform sinus （PS） in 91 cases, posterior wall （PW） in 18, and postcricoid area （PC） in 8. cT classification was cT1 in 62 cases, cT2 in 51, and cT3 in 4. We compared patients by patient background; prognosis, including postoperative complications; and functional preservation.
Results: Median operation time was 40 minutes （12-240） for TOS and 118 minutes （58-250） for PP-PC. Postoperative complications occurred in 10 cases （10/87, 11.5％） with TOS and 10 （10/30, 33.3％） with PP-PC （P＝0.0275）. Median postoperative hospital stay was 7 days （4-137） with TOS and 15 days （9-37） with PP-PC （P＝0.002）. Laryngo-pharyngeal function preservation rate was 100％ （87/87 cases） with TOS and 86.7％ （26/30 cases） with PP-PC. Five-year overall survival rate was 81.4％ for TOS and 88.3％ for PP-PC （P＝0.99）.
Conclusion: Transoral surgery is considered to be indicated as a minimally invasive surgery for early-stage hypopharyngeal cancer （cT1N0, cT2N0 and some cT3N0 without muscular infiltration）.

View full abstract

Recent developments in surgical devices and techniques for transoral surgery, including transoral videolaryngoscopic surgery （TOVS）, have led to reports regarding transoral resection of tumors in the parapharyngeal space （PPS） and metastatic retropharyngeal lymph nodes （RPLNs）. In our institution, TOVS has been performed for six cases of PPS tumors and metastatic RPLNs, including for biopsy. Our experience, and reports from other institutions, suggest that the indications for transoral resection of PPS tumors and metastatic RPLNs may include: tumors located below the level of the hard palate and the pterygoid hamulus with protrusion toward the pharynx lumen, a single lesion without adhesion to the surrounding tissue, a tumor that is not highly vascularized, no history of irradiation, and a size of ＜7-8cm. Relative to the conventional transcervical approach, transoral resection may provide less operative trauma and a minimally invasive procedure, although ultrasonography, a nerve monitoring system, and a navigation system should be considered to minimize the risk of adverse events. Additional cases with long-term follow-up are needed to clarify the indications for transoral resection of PPS tumors and metastatic RPLNs.

View full abstract

Adenoid cystic carcinoma of the head and neck is a rare malignant tumor, accounting for approximately 1％ of all head and neck malignancies. Tumor growth is relatively slow and the short-term prognosis is good. However, the tumor is accompanied by extensive local tissue invasion and perineural invasion, leading to distant metastasis, especially in the lungs. Therefore, the long-term prognosis is considered to be poor.
Radical surgery is the standard treatment for patients with adenoid cystic carcinoma. However, even in cases that are determined to be resectable, complete resection is often difficult due to strong invasion of adjacent tissues, especially the nerves. Therefore, postoperative radiotherapy is considered an important adjuvant treatment.
Although adenoid cystic carcinoma is regarded as a radioresistant tumor, radiotherapy has recently progressed and the results of definitive radiotherapy for unresectable cases have been reported.
In this review, we report on postoperative radiotherapy and definitive radiotherapy （photon and particle therapy） for adenoid cystic carcinoma of the head and neck.

View full abstract

Nivolumab is an immune checkpoint inhibitor that exerts its antitumor effect by inhibiting the binding of programmed cell death protein 1 （PD-1） to its ligands to prolong overall survival in patients with recurrent or metastatic head and neck cancer. In the present study, we studied 44 patients with recurrent or metastatic head and neck cancer treated with nivolumab in our department, focusing on treatment efficacy and prognostic factors. Survival analysis showed that the median overall survival was 12.0 months. The median progression-free survival was 3.9 months, with a significantly better prognosis for patients in the Performance Status 0 group （p-value: ＜0.001） and the group that continued treatment after completion of nivolumab therapy （p-value: 0.003）, suggesting that continued chemotherapy after completion of nivolumab therapy was associated with longer overall survival. In addition, the neutrophil-to-lymphocyte ratio （NLR） at the beginning of the treatment was examined as a predictor of treatment efficacy. Patients with an NLR of 5 or more had a significantly poorer prognosis （p-value: 0.040）, suggesting that the NLR may be useful in predicting treatment effect.

View full abstract

Xerostomia is one of the most common adverse events of radiotherapy （RT） in head and neck cancer patients. The salivary glands are highly sensitive to and damaged by radiation, leading to xerostomia, which decreases patients’ quality of life （QOL） after radiotherapy. The purpose of this study was to evaluate long-term changes of oral health related QOL after definitive RT. Patients who were treated by RT with 60Gy or more for head and neck cancer were analyzed retrospectively. Patients with recurrence were excluded. Oral health related QOL was assessed with the General Oral Health Assessment Index （GOHAI） at follow-up dates. Sixty-six patients without recurrence were enrolled in this study. Oral health related QOL decreased rapidly during RT and recovered to the same level as normal in 3-3.5 months after the completion of RT. The nadir of GOHAI score appeared immediately after radiotherapy and the score had recovered significantly in all periods. There was no significant difference in changes in oral related QOL after RT between patients with a mean irradiated dose to the bilateral parotid glands of less than 35Gy and those of 35Gy or more.

View full abstract

pT re-classification according to the UICC, 8th edition and evaluation of tumor invasion potential by the Yamamoto-Kohama （YK） classification were performed for 45 patients with pT1, 2N0 oral tongue cancers （UICC, 7th edition） who had undergone surgical resection as initial treatment followed by observation. Association between the two factors and late cervical metastases and survival rates were analyzed. The number of patients with pT1/2/3 （UICC, 8th edition） and YK-1, 2/3/4C, 4D was 17/20/8 and 10/18/17, respectively. The late cervical metastasis rate and 5-year disease-specific survival rate for pT1/2/3 were 29/45/63％ and 88/85/63％, and for YK-1, 2/3/4C, 4D were 10/39/65％ and 100/100/53％, respectively. Tumor invasion potential was more strongly associated with prognosis than pT classification （8th edition）. All of the low to moderately invasive YK-1-3 tumors were controlled by neck dissection after the appearance of late cervical metastasis, and therefore, the observation strategy seems to be appropriate for these tumors. In contrast, the highly invasive YK-4C, 4D tumors presented poor control rates by the observation strategy, and therefore, might need more intensive treatments such as additional neck dissection following primary tumor resection before late cervical metastasis appears.

View full abstract

Chemoradiotherapy for head and neck cancer （HNC） causes various adverse events, among which weight loss is a major concern. Methodologies for the prevention and care of adverse events have not yet been standardized; therefore, we created a clinical pathway （CP） as a tool for standardized assessment and care. In this study, we assessed whether CP is useful in weight loss reduction during chemoradiotherapy for HNC. We retrospectively analyzed 108 patients who underwent treatment with high-dose cisplatin concurrent with radiotherapy （CRT） and cetuximab concurrent with radiotherapy （BRT） from January 2014 to March 2020. We stratified the patients into those with and without a CP. In CRT, the maximum weight loss rate was not significantly reduced in the CP-use group; however, aggravation of oral mucositis was suppressed in the CP-use group （p＝0.043）. In BRT, the maximum weight loss rate was significantly reduced in the CP-use group compared with the non-use group （p＝0.011）, and oral mucositis was equally suppressed in the CP-use group （p＝0.037）. We believe that in BRT, using CP is effective in the weight loss reduction that occurs during the treatment.

View full abstract

We have previously shown that some lingual leukoplakia had pathologically “mixed” status, and an excisional local biopsy led to under-diagnosis in 36％ of cases. After this report, total excision has been the basic policy in our institute for dealing with oral leukoplakia. The purpose of this study was to evaluate the validity of this policy; we discuss how we set a surgical margin for safe excision based on pathological findings, additional treatments, and the rate of recurrence. Forty-seven cases of lingual leukoplakia treated during the past 11 years were enrolled in this study. The histopathological diagnoses included invasive carcinoma in 27cases, carcinoma in situ in 7cases, dysplasia in 6cases, proliferative verrucous leukoplakia in 1 case, hyperkeratosis without dysplasia in 3cases, and 3 other cases; 34cases （72％） were malignant lesions, and 41cases （87％） were considered to be indicated for surgical treatment. In 34cases of malignant lesions, the surgical margins were set at 4mm or less in 5cases, 5mm in 23cases, and 10mm in 6cases from the edge of the leukoplakia （6cases） or the edge of the lugol-voided lesion （28cases）. Intra-operative frozen sections were utilized in all except one case. There were 3recurrences after the excisional biopsy. Two patients had recurrence out of 3patients whose safety margin had been set at 2mm （66％）, while one patient recurred out of 23patients whose margin had been set at 5mm （4％）. No death due to the disease was observed, however, 6patients developed metachronous cancers in other lesions. In conclusion, total excision for lingual leukoplakia is a reasonable treatment under the use of lugol staining and frozen section. A safe surgical margin is considered to be 5mm from the edge of a lugol-voided lesion.

View full abstract

There are few reports on the transition and prognosis of postoperative facial nerve paralysis in patients undergoing parotid gland cancer surgery that preserves the facial nerve. The treatment policy for parotid gland cancer in our department is, in principle, combined resection of the facial nerve and one-stage reconstruction of the nerve if there is facial nerve paralysis before surgery, and preservation of the nerve if there is no paralysis regardless of histological type. We examined 31 cases of parotid gland cancer surgery that preserved the facial nerve over the past 15 years. The median observation period was 60 months. Total resection was performed in 24 cases, and lobectomy was performed in 7 cases. The average score of postoperative facial nerve paralysis was 24 points, and the median score was 27 points. The transition of postoperative facial nerve paralysis, although there were cases of transient complete paralysis, eventually recovered to an average of 39.5 points. The recovery period was 6 months after surgery in many cases. The treatment results were good, with 5-year overall survival rate, 5-year disease-free survival rate, and local control rate of 96.0％, 89.5％, and 93.5％, respectively. In cases of parotid gland cancer without facial nerve paralysis, treatment results are considered to be guaranteed even if the nerve is preserved regardless of the pathological type.

View full abstract

This study included 115 patients who underwent total laryngectomy and received speech therapist （ST） intervention between April 2016 and December 2019. In our hospital, STs intervene in all patients undergoing total laryngectomy from the preoperative period after hospitalization and provide cancer rehabilitation including voice rehabilitation, so we cannot make comparisons based on whether STs intervened or not. For this reason, we compared 85 patients who were instructed using the Provox Coming Home^TM （Atos Medical） with 30 patients who were not instructed using the Provox Coming Home^TM. In the Provox Coming Home^TM use group, the alternative communication was an electrolarynx in 46％ of cases, and 69％ of cases used a heat and moisture exchanger （HME） after discharge. In the non-use group, the alternative communication was the electrolarynx in 47％ of cases, and there were no cases using HME after discharge. In the future, doctors, nurses, and STs should work closely together to intervene in the use of HME during outpatient visits. Since September 2020, HME and related items have been covered by national public insurance as medical devices in Japan. Thus, Provox and HME are expected to become more widespread.

View full abstract

Kyoto Prefectural University of Medicine launched the head and neck cancer study group （Koto-SG） in 2017 and started a prospective cohort study of elderly head and neck cancer cases. The treatment, prognosis, indicators of nutritional status such as albumin, body mass index, and GNRI （geriatric nutritional risk index）, and G-8, which is an evaluation of elderly function, are investigated in all cases with oral, pharyngeal, and laryngeal cancer aged 75 years or older. Subsequently, a medical record review is conducted as appropriate. The curative treatment group had significantly better survival than the non-curative treatment group. However, there was no difference among the age groups in the curative treatment group. In the examination of nutritional status and prognosis, the overall survival rate of the group with GNRI of 100 or more was significantly better than that of the group with GNRI of less than 100 in the curative treatment group. It was found that GNRI was an age-independent index and its decrease was one of the poor prognostic factors in elderly head and neck cancer cases.

View full abstract

Occult thyroid carcinoma is typically defined as thyroid malignancy with microscopic primary tumor subsequently diagnosed by the presence of metastatic sites, most commonly central and lateral cervical lymph nodes. Here, we report a case of occult papillary thyroid carcinoma initially presenting with single-site metastasis to a superficial cervical lymph node with no evident primary and other metastatic sites. A 51-year-old man presented with an anterior cervical mass that had been growing for several years. A subcutaneous tumor at the suprasternal notch was detected, and fine-needle aspiration cytology revealed atypical cells of uncertain significance. Complete resection of the tumor under general anesthesia was performed for diagnostic purposes. The tumor was distant from the thyroid, exhibiting a superficial mass on the sternohyoid muscle without adhesion to the surrounding tissue. The pathology was metastatic papillary thyroid carcinoma. Since primary tumors and other metastatic lesions were not detected, the superficial cervical lymph node was identified as the initial manifestation of occult papillary thyroid carcinoma. Fourteen months after the operation, a central lymph node metastasis was identified, and total thyroidectomy with central lymph node dissection was performed. The histological examination revealed multifocal micropapillary carcinomas in the thyroid and central lymph node metastases. In conclusion, the rare clinical course of this case deserves further attention for the diagnosis and management of enlarged superficial cervical lymph nodes.

View full abstract

We report our experience of a patient with oropharyngeal carcinoma with lung metastasis, whose pathological diagnosis was changed from squamous cell carcinoma to clear cell carcinoma consequent to multi-gene cancer panel testing after completion of standard treatment. The patient was a 57-year-old woman diagnosed with oropharyngeal squamous cell carcinoma, HPV negative, cT3N2bMx. She underwent cisplatin concomitant radiotherapy, but a lung lesion suspected of metastasis showed progression. Nivolumab was administered, but the lung lesion progressed further, and the chemotherapy regimen was changed to cetuximab plus paclitaxel. Multi-gene cancer panel testing was performed as the standard treatment had been completed. Although no genetic abnormality leading to treatment was found, the EWSR1-ATF1 fusion gene was detected. This fusion gene is detected in 80-90％ of cases of salivary gland clear cell carcinoma. Based on the re-examination with this result, the pathological diagnosis was revised from squamous cell carcinoma to clear cell carcinoma. The diagnosis of clear cell carcinoma was difficult, even by retrospectively examining the tissue, and multi-gene cancer panel testing was the trigger for the revision in diagnosis.

View full abstract

Total pharyngolaryngoesophagectomy （TPLE） is performed on patients with advanced head and neck cancer. It is most frequently followed by pharyngoesophageal reconstruction with free jejunal flap because there is a relatively low operative risk and it improves postoperative function of the reconstructed pharynx and esophagus. A 79-year-old man developed hypopharyngeal carcinoma and underwent TPLE, neck dissection on both sides, and free jejunal transfer at our hospital. Early after surgery, we conducted thrombectomy because obstruction by the artery anastomotic region occurred. Blood flow was improved by early thrombectomy, and the flap survived. However, a scarring stenosis which gradually reached full length occurred, and so we performed free jejunal transfer again. The pathological findings indicated that the mucosa had atrophied and been lost, while blood vessels were preserved. Even if the free jejunal flap survives early reoperation for vascular problems after TPLE, it may gradually develop scarring and stenosis.

View full abstract

We report a case of basal cell adenocarcinoma （BCAC） of the hard palate. A 63-year-old woman visited our hospital because of swelling of the left cheek. The tumor occupied the hard palate and gingiva on her left side. CT scan and MRI scan revealed that the tumor had destroyed her maxillary bone and invaded the infraorbital wall and skin of the cheek. Pathological examination revealed that the tumor was BCAC. The tumor was resected, including the maxillary bone, skin of the cheek and orbital periosteum. After resection, we reconstructed her hard palate using a vascularized iliac flap with internal oblique muscle and reconstructed her cheek skin using a cervicofacial flap. However, the cervicofacial flap became partially necrotic three weeks after operation, so we reconstructed her cheek skin using a median forehead flap.

View full abstract