The objective of this retrospective study was to analyze the incidence and causes of postoperative complications in patients following head and neck cancer surgery with microvascular free flap reconstruction. We reviewed 318 patients in 3 years who had undergone head and neck cancer surgery with microvascular free flap reconstruction. Complications were classified according to the Clavien-Dindo classification system （CDC）. As a result, 115 patients （36.2％） of the total had major complications （CDC Grade Ⅲa and above）. With regards to microvascular complications, postoperative pedicle thrombosis occurred in 20 cases （6.3％）. Vascular reanastomosis was carried out in 14 cases, of which 12 cases were salvaged. Complete flap necrosis occurred in 8 cases （2.5％）. As for pulmonary complications, 17 cases required mechanical ventilation due to postoperative respiratory failure. These complications significantly prolonged hospital stay. Although serous fluid collection, chylous or lymphatic fistula occurred in around 5％ each, there was little effect on prolonged hospital stay. In the present study, the flap salvage rate was improved in comparison with our previous report on 1,031 patients in 8 years. This fact highlighted the importance of postoperative seamless observation and appropriate re-exploration.

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The objective of this study was to clarify the characteristics of multiple primary squamous cell carcinomas of the oral cavity, with special reference to coexisting oral potentially malignant disorders （OPMD）. We reviewed 15 patients with multiple oral cancers, who were treated at our department between January 2008 and December 2018. Of the 15 patients, four had synchronous multiple cancers, and 11 had metachronous multiple cancers. There was a female predilection （female-to-male ratio; 11:4）, and gingiva was the most prevalent site, accounting for 51.4％ of 35 cancers occurring in 15 patients. Eleven patients （73.3％） showed OPMD in the same sites as cancers or other sites. OPMD included oral lichen planus （OLP） in 5 patients, oral lichenoid lesion （OLL） in 2, oral leukoplakia in 3, and both oral leukoplakia and oral chronic hyperplastic candidiasis in 1. The rate of concordance between the sites of cancers and OPMD was 63.0％ in the 11 cases with OPMD, showing high rates in oral leukoplakia and oral chronic hyperplastic candidiasis. Only three patients had habits of smoking and alcohol drinking. This study shows that multiple oral cancers have different clinical features from those of single oral cancers and that coexistence of OPMD is closely associated with multiple occurrence of cancers in the oral cavity.

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Among head and neck cancer survivors with post-treatment and late-onset dysphagia, quality of life （QOL） is often significantly impaired. Although rehabilitation is effective for dysphagia, surgical intervention should be considered in some cases with persistent dysphasia despite rehabilitation. We investigated the pre- and post-treatment swallowing function of surgically treated dysphagia patients after head and neck cancer treatment, and discuss the surgical indications of dysphagia after such treatment.
We surgically treated two cases in whom swallowing function was improved, and one case in whom aspiration was prevented. The surgical indication was made based on physical and social factors. The surgery for improving swallowing function was beneficial in cases 1 and 2, and should be considered even in patients after head and neck cancer treatment. In case 3, the surgery for preventing aspiration was beneficial for the patient with a severe physical and social background. All three patients showed improved oral intake. Swallowing improved earlier in the patient treated with surgery for preventing aspiration than the other patients.
The surgery for improving swallowing function is effective in some cases, however, the surgical procedure should be selected considering physical and social factors.

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We report a rare case of a cutaneous scalp angiosarcoma that was diagnosed based on detection of parotid gland metastases. A 79-year-old woman visited Aso Iizuka Hospital for evaluation of a left infra-auricular mass. Magnetic resonance imaging revealed a poorly circumscribed mass within the left parotid gland （52×41×40mm） and enlargement of the right-sided cervical lymph nodes. Fine-needle aspiration cytology of the mass and lymph nodes revealed atypical cells in both specimens. Initially, we diagnosed the patient with left parotid carcinoma （cT3N2cM0） and planned heavy ion radiotherapy for the primary lesion. We performed an incision biopsy of the left parotid gland and right neck dissection. Interestingly, postoperative histopathological and immunohistochemical evaluation showed angiosarcoma. The patient developed purpura （approximately 6cm in diameter） in the midline at the border between the scalp and the forehead, and skin biopsy evaluation revealed angiosarcoma, similar to the histopathological findings of the parotid mass. Follow-up computed tomography revealed multiple new lung and liver metastases. Sentinel lymph nodes in cases of frontal and facial malignancies include the upper jugular and parotid nodes; therefore, it is reasonable to conclude that the left infra-auricular mass, which was initially considered a primary lesion, was a metastatic angiosarcoma involving the parotid node. Based on these findings, we eventually diagnosed the patient with cutaneous scalp angiosarcoma accompanied by multiple metastases （T2N1M1）. The patient opted for best supportive care; unfortunately, she died 4 months after her first visit. Scalp or facial malignancies should be considered in the differential diagnosis in cases with parotid gland malignancy.

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Salivary secretory carcinoma is an uncommon neoplasm characterized by the frequent presence of an ETV-NTRK3 gene fusion in addition to distinct histologic features. Secretory carcinoma has been included in the WHO classification of head and neck tumors （4th edition） since 2017. We report herein a case of secretory carcinoma arising in minor salivary glands. The patient was a 68-year-old man who was initially diagnosed in his 30s, by surgery for a tumor of the hard palate, with acinic cell carcinoma arising from the minor salivary glands of the hard palate. He underwent multiple surgeries and radiotherapy for postoperative local recurrence. However, the tumor gradually grew. The local recurrence lesion progressed from the soft palate to the lateral pharyngeal wall and the parapharyngeal space, and multiple lymph node metastases were observed. Multi-gene cancer panel testing was performed. The ETV6-NTRK3 fusion gene was detected, leading to a diagnosis of secretory carcinoma. The patient was treated with Larotrectinib, a TRK inhibitor, and has maintained a complete response at 1 year and 6 months after the start of treatment. We believe this case exemplifies the use of targeted TRK inhibition as a well-tolerated treatment achieving a rapid and durable response in a secretory carcinoma, for which there is no standard systemic therapy.

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Renal cell carcinoma （RCC） is known to metastasize frequently to every organ of the body, but metastasis to the thyroid gland is rare. We report a case of metastasis of RCC to the thyroid gland which caused a thrombus in the cervical vein. The patient was a 73-year-old man who had undergone right nephrectomy for renal cancer 18 years ago. The CT scan showed a tumor in the left lobe of the thyroid gland, a tumor embolus from the left internal jugular vein to the subclavian vein, and multiple lung nodules. As the thyroid tumor and embolus in the vein tumor showed the feature of contrast stain at the early phase and washout in the late phase on dynamic CT images, metastatic RCC was highly suspected. Surgery was performed to prevent the tumor from spreading and narrowing the airway. Left thyroid lobectomy with ipsilateral neck dissection, removal of tumor embolus in the veins, and reconstruction of the left subclavian vein were employed. The transmanubrial osteomuscular sparing approach was selected and carried out in cooperation with the Department of Respiratory and Cardiovascular Surgery. Although the patient temporarily had a postoperative infection at the surgical site of the sternum, treatment with an immune checkpoint inhibitor could be started three months after surgery.

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