Head and neck cancers are rather chemoresponsive when compared with the other types of solid cancers. The term, medical oncology, becomes popular recently, Medical oncology is the stuby how are chemotherapeutic agents including cytokines applied to cancer patients most effectively with less side effects. The author desccrided phase I, II and III studies in general. Aud it was also discussed how a new agent should be tested in clinical study, CDDP+5-FU is a fundamental combination for chemotherapy of head and neck cancers.

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Metasases were frequently found at bilateral laryngeal recurrent nerve nodes (No. 106) and deep cervical lymph nodes (No. 102) in the pharyngoesophageal (IuCe) cancer cases. The lymph node dissection in the upper mediastinum and the neck was most important. Larynx was intended to de reserved. For this purpose, the neo-adjuvant chemotherapy using CDDP and 5 Fu was employed. As the reconstruction surgery of pharyngoesophageal canver, pharyngogastrostomy or pharyngocolostomy in the posterior mediastinal route was common. However, composite reconstruction, i. e. stomach and jejunum, was carried out in some cases. Double esophageal and pharyngeal cancer was increasing recently. In synchronous double canble cancer, laryngo-pharyngo-total esophagectomy was a common procedure. At present, endoscopic mucosal resection in the esophagus was performed when the lesion was suspected to be mucosal cancer.

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As thyroid carcinoma has biological behaviours peculiar to each histological type of carcinoma, the treatment must be chosen under the consideration of the property of this tumor. Papillary carcinoma extends by intraglandular and lymphatic routes, and follicular carcinoma mainly by hematogenic route. Although anaplastic carcinoma grows very rapidly and demonstrates very poor prognosis, the chance for curable operation will be limited noly when carcinoma was detected in early stage. Malignant lymphoma of the thyroid gland is not found so frequently and involyes cervical lymph nodes. The appropriate treatment must be discussed understanding these biological characteristics of each tumor.

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The incidence of multiple primary in patients with head and neck cancer was increased in a period of recent 10 years. Recent reports descrived the frequency of second primary as over 10 per cent of index. Second primaries has developed frequently in upper aerodigestive tract including stomach.
New screening program to identify additional cancer was performed on the patients with head and neck cancer. Flexible fiberscopy of upper digestive tract was able to make diagnosis of the early cancer of esophagus or stomach. Simultaneous second primaries was detected in esophagus of 25 patients and in stomach of 12 patients during eleven year period. This observed number of esophageal cancer estimated in 673 index patients of head and neck cancer was 180 times of incidence expected in general population in Japan. High incidence of simultaneous 2nd primary of esophugus was identified among patients with risks which were male aged over 50 years old, primary sites in oral or pharyngeal mucosa and alcoholic abusers.
Twenty-two of 25 esophageal cancer was classified as T1 (UICC 1987) surgically or endoscopically. Sixteen of 25 patients have received treatment with curative intent of both head and neck/esophageal lesions. Six of 13 cases with curative therapy are alive without disease after at least 2 year follow-up period. Endoscopic mucosal resection of esophagus is a new method indicated in cases with early thin cancer without invasion into submucosal layer. This modality may be useful for patients with early cancer of esophagus with head and neck cancer.

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Important features to obtain better prognosis for the head & neck cancer are the prevention of distant metastsis and early detection of multiple primary cancer. The incidence of multiple primary cancer in 344 head and nead and neck cancer patients operated at the ENT Department of Nationl Kyoto Hospital in the past 10 years was 7.9%. The incidence increased up to 10.9% when only the patients with squamous cell carcinoma were counted. The highest incidence of 22% was obtained for cancers of meso-hypoharyngeal and esophageal cancers (54 patients). Furthermore, worse prognosis was observed in case of multiple primary cancers in the multicentric zone. Eight out of 11 patients with cancers in this zone are already dead mainly by distant metastasis. The other factor which lowers the survival rate is the synchronization of multiple cancers. Nine patients out of 15 of them are dead while 8 out of 12 metachronus cancers are alive. To gain better prognosis periodical investigation of the upper gastro-intestinal tract using flexible fiberscope is recommended. Furthermore, the effect of postoperative immuno-chemoprevention is promising.

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Synchronous multiple primary cancers were discovered in 23 cases (2.2%) out of 1026 patients with previously untreated squamous cell carcinoma of the oral cavity, and in 15 cases (6.7%) out of 224 patients with previously untreated sqamous cell carcinoma of the mesopharynx. In the mesopharyngeal cancer cases, the incidence of synchronous multiple primary cancers increased significantly in the recent five years. Of 44 second synchronous cancers, 37 (84.1%) existed in the head and neck, esophagus, or stomach. Every existing cancer could be treated radically in 29 patients (78.4%) out of 37 synchronous multiple primary cancer cases. The five-year cumulative survival rate of these radically treated patients was 48.1% in the oral cavity cancer cases, and 71.6% in the mesopharyngeal cancer cases. Considering these good results, it is concluded that the treatment of synchronous multiple primary cancer cases should aim at radical and individual eradication of every existing cancer.
To attain this goal effectively, several important points must be emphasized, which are 1) early detection of other existing cancers by physical examination, X-ray imaging and/or endoscopy of the upper aerodigestive tract and stomach, 2) selection of the optimal treatment modalities according to the location and extent of existing cancers, and 3) consideration of the general condition of patients. In oral cavity or mesopharyngeal cancer patients, the optimal treatment modality is the combination of surgery, radiotherapy and/or chemotherapy when the second synchronous cancer is located in the head and neck, whereas it is surgery or radiotherapy for the initial head and neck cancer plus surgery for the second synchronous cancer when the second cancer is found in the esophagus and/or stomach.

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In order to confirm that the total esophagectomy without thoracotomy is the good indication for hypopharyngeal and cervicoesophageal cancer, this malignancy was clinico-pathologically investigated. In 22 patients with hypopharyngeal (male, 12 cases), cervico-esophageal cancer (male 7 cases, female 3 cases), blunt dissection was performed at our hospital between 1983 and 1992.
The resected speciments were totally sliced 5 to 7mm transversely after formalin-fixation. Another cancerous lesions in men were pathologically detected in thoraco-abdominal esophagi in 12/19 (63%). Atypical epithelia were histologically found out apart from main tumors in 17/19 (89%). On the other hand, in all the female, another cancerous or dysplastic change was not seen. Carcinoma of the hypopharynx and cervical esophagus was frequently complicated with another cancerous or severe dysplastic lesions in thoraco-abdominal esophagus particularly in the male patints.
Total esophagectomy was necessary for these cases to improve the prognosis.

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A retrospective evaluation of simultaneous carcinomas of the head and neck cancer was conducted in 5448 cases with treated by radiation therapy between 1967 and 1991. Of the patients 107 (1.96%) had synchronous primary cancers (2 site: 102 patients; 3 sites: 3; 4 sites: 2). Forty-two patients had second cancers in the head and neck. Twenty-tix patients (62%) of these were managed with irradiation only or combined with shemotherapy (bleomycin, peplomycin, or cisplatin) for all cancers, 11(26%) with irradiation for the one and preoperative irradiation followed by surgery for the other, and 5 (12%) with preoperative irradiation followed by surgery or surgery alone. The overall 2 year and 5-year survivals of these were 61% and 38%, respectivly. Most of the patjents who had synchronous cancers in the oral cavity were no longer dying of local recurrence but had a high risk for development of the third or forth primary cancers. Sixty-five patients had second cancers outside of the head and neck. Of these 23 patients (35%) had surgery for second cancers, 24 (37%) palliative irradiation, and 18 (28%) palliative management only. The overall 2-year and 5-year survivals of these were 28% and 25%, respectively Most of the patients who had second cancers in the thorax or abdomen died from second cancers.

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Recently, many cases of multiple primary cancers associated with the head and neck cancer are reported.
Reconstructive methods for multiple primary cancers (mainly hypopharynx) including the thoracic esophagus have been discussed. And several problems of the esophageal reconstruction using microvascular anastomosis also have been discussed.
During five years from 1988, we have studied 83 patients who underwent esophageal recon-struction using microvascular anastomosis (Successful transfer: 81/83, 97.6%). Which comprises 12 patients who have multiple primary cancers with the thoracic esophageal cancer. In these 12 patients, 8 have had simaltaneous multiple primary cancers (The gastric pedicle with the free jejunum: 7 cases. The pedicled colon with microvascular anastomosis: 1 case). These 8 cases have achieved successful tranufer.
In order to prevent complications arised from the tracheal necrosis, the trachea was covered with a mesenteric flap (3), a pectoralis major musculo-cutaneous flap (1) or a greater omentum flap (5). There was no complication due to tracheal necrosis in these cases.
The following was very useful for recipient vessels: cervical region—the transverse cervical artery and the external jugular vein, upper region of the chest wall—the thoracoacromial artery and the cephalic vein, middle region of the chest wall—the intrathoracic artery and vein.
Also we have mentioned about the importance of the team approach at the medical treatment, and about the role of the plastic surgeon in it.

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Head and neck cancer patients who were treated at the National Kyushu Cancer Center during the past two decades were reviewed and analyzed according to the age group. As compared to the first decade, patients of high age group (older than 70 years old) increased in the second decade, but most of patients received radiation therapy alone.
In patients who received radical neck dissection during the course of treatment, the cause of death were analyzed. In high age group, many patients died due to the postoperative accidents or other diseases such as heart failure. In contrast, younger aged patients mainly died because of uncontrollable recurrenec in the regional or distant metastases.
These results indicate that the difference of systemic as well as local immune function between young and old age group is to be considered in the treatmment head and neck cancer patients.
Using an immunopathological method, we are now investigating the degree of the local biological response in the lymphnodes obtained at surgery.

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Accumulated survival rates following treatment were assessed in 104 patients with oral squamous cell carcinma. The results were examined in three groups: The young group patients aged 49 years and under, the middle-age group those aged 50-59 years and the elderly group those aged 70 years and over.
The results of treatment in 44 patients with tongue cancer were investigated by age groups.
The 3, 5-year survival rate of the young and middle-age groups at Stages I and II was considerated good. However, in the elderly group the 3, 5-year survival rate was 40.0%, 25.0% at Stage I, and 0% at Stages II, III and IV. Results of the treatment of 17 patients with cancer of the floor of the mouth at Stage IV were worse in the middle-age group than in the elderly group. In the treatment of 9 patients with cancer of the buccal mucosa at Stage IV, the 3, 5-year survival rate was poor in the elderly group. In 8 patients with cancer of the upper gingiva at Stage III, the 5-year survival rate was 50.0% in the elderly group but was poor in the other groups. In 18 patients with cancer of the lower gingiva at Stages I, II and IV, results were poor in the elderly group. In 5 patients with cancer of the maxillary sinus, 1 patient in the elderly group survived over 5 years, over 2 years in 2 patients in the middle-age group and over 2 years in 2 patients with soft palate cancer and 1 patient with lip cancer.

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Recently, Japanese has achieved a long span of life, accompaning some problems of medical treatment especially in the aged people 80 years old and over. From 1983 to 1992, we have experienced 34 patients who were 80 years old and over, including 15 of laryngeal cancer, 8 of tongue cancer, 5 of malignant lymphoma etc. Laryngeal cancer and tongue cancer are the main diseases in this group, the former dominant in male, the latter in female. In these aged patients, some complications were seen frequently, consisting of hypertension, heart disease, diabetes mellitus etc. The most important problem lies in decision making what treatment should be adopted, radical operation, or palliative therapy. As a geneal rule, the treatment for the patient with malignant tumor in head and neck was determined by TNM classification. 20 of 34 patients belonged to clinical stage 2 or less, who underwent radiation therapy mainly. The other 14 patient belonged to clinical stage 3 or more. In this group, 5 patients recieved radical operation, four patients of laryngeal cancer with total laryngectomy and/or radical neck dissection, one of maxillary cancer with maxillectomy. In laryngeal cancer patients, good prognosis was obtained. A patient of maxillary cancer was dead 9 month after the opration. In other group of 9 patients, 5 patients of laryngeal cancer recieved radiation therapy. 3 of them died of internal disease, 2 of them is alive.
The other 4 patients (3 of tongue cancer and 1 of hypopharyngeal cancer) died of their own cancer. From these result, we concluded that radical operation led to good prognosis especilly in laryngeal cancer, on the other hand some complicaitons of internal disease came to the reasons for paliative therapy and tongue cancer still remained to be poor prognosis.

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Between 1976 and 1990, 110 elderly patients of oral malignancies were treated by radiotherapy at the Department of Radiology, Tokyo Medical and Dental University. These patients more than 80 years of age were followed 2 to 16 years.
Ninety-seven patients were histlogically proved squamous cell carcinomas, 3 were verrucous carcinomas, 8 were carcinomas originated from salivary gland and 2 were malignant lymphomas.
Eighty-one patients were irradiated curatively and others were palliatively irradiated.
In case of curative irradiation group, 35 patients underwent brachytherapy using Au-198 grains mainly, because of its easy applicability under local anesthesia. Au-198 grains were used in 28 cases and in other 7 cases Ra needles and Ir-192 pins were used.
The results were as follows.
1) More than 2 years local control rate was 41% in all curative treatment group and 51% in brachytherapy group.
2) Five-year crude survival rate was 30% in all curative treatment group and was 40% in brachytherapy group.
3) Sixteen patients survived more than 5 years and these cases had no lymph node and distant metastasis during the courses.
In conclusion, our results suggest that oral cancer patients more than 80 years of age should be treated by curative radiotherapy when the perfomance status is permissible.

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The population of Japan is gradually aging. Since cancer is mainly a disease of older persons, the incidence ration of elderly patients with head and neck cancer tends to increase. So the incidence of elderly cancer patients in Japan and our hospital were studied. And problems of diagnosis and treatment for elderly patients were discussed. In Japan registry, the percentage of aged patients, 70 years old or more, with head and neck cancer except thyroid cancer was 17.7% 30 year ago, but it has increased to 26.8%, recently, and in our hospital it was 35.9%, For the treatment to elderly patients, various problems such as respiratory and/or cadiovascular complications and depressed tolerance must be considered.
We stressed it would be necessary to select the treatment very carefully and consideration of the quality of life of the patients.

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Of 146 patients with previonsly untreated carcinoma of the tongue treated at Gunma Cancer Center Hospital from 1972 through 1991, 36 were under forty yenrs of age at the time of their first visit. The youngest patient was eighteen years old. They included 22 males and 14 females. According to TNM classification by UICC (1987), 10 cases were dialnosed as stage I, 9 stage II, 14 stage III, 3 stage IV, respectively. The initial treatment was interstitial radiation with radinum needle in 21 cases, surgery in 14 and external radiation in 1. In the first ten years, 16 cases (84%) were treated with radium needle implantation and in the second ten years, 12 cases (71%) with surgery. Thirteen cases had recurrence after the initial treatment, 7 cases at the primary site, 5 at the regional lymphnode and 1 in a distant organ. Salvage operations were performed on five cases with recurrence lesion at the primary site. Three cases were disease free for more than four years. Radical neck dissection was performed on four cases with recurrence at the cervical lymphnode and two were alive and disease free for more than eight years. The cummurative 5-year and 10-year survival rates were 80.6% and 69.4%, respectively. These survival rates were higher than those of the patients aged over forty and had statistical significance. The 5-year survival rates of the first and the following ten years were 73.7% and 88.2%.
Those of cases treated by radium needle implantation and with surgery were 81.0% and 85.7%.
Treatment modality of the carcinoma of the tongue had changed from radiotherapy to surgery in the last two decades and treatment results appeared to become better. Our conclusion is that surgical treament should be recommended for young adults with carcinoma of the tongue.

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Purpose: To study the role of radiotherapy for younger patients (aged under 50 years) with squamous cell carcinoma of the head and neck.
Methods and materials: During 1962-1990, 106 (59; glottis, 32; oropharynx, 15; hypopharynx) patients aged under 50 years with squamous cell carcinoma of the head and neck, treated by definitive radiotherapy, were retrospectively analyzed. The age ranged from 26 to 49, with median value of 45. The analyzed number of patients with glottic, oropharyngeal and hypoharyngeal cancer accounted for 12%, 20% and 10% of all the patients received definitive radiotherapy, respectively.
Results: The overall 5-year survival rates and 5-year local control rates were 88% and 72% for glottic cancer, 62% and 71% for oropharyngeal cancer, and 40% and 52% for hypopharygeal cancer, respectively. There were no significant difftrences between younger patients and elder patients regarding survival and local control. Double primary cancer was found in 8 patients. Late recurrence, appeared more than 5 year after inital radiotherapy, was seen in 5 patients with glottic cancer.
Conclusion: This retrospective study did not show any disadvantage to apply radiotherapy for younger patients with squamous cell carcinoma of the head and neck.

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The incidences and the causes of flap necrosis were evaluated in 209 patients who had primary reconstruction after radical resection of head and neck cancer during 1982-1993 in Akita University and 1989-1993 in Chiba University. Incidences of extensive necrosis including total and major necrosis in 110 pedicled flaps were 1.8% (1/53) in DP flap including DP flap with clavicle, 3.0% (1/33) in PMMC including PMMC with rib, 5.8% (1/17) in LDMC and 0% (0/7) in other flaps. The incidences of minor troubles including minor and marginal necrosis and suture dehiscence were 5.6%, 3.0%, 29.4% and 0%, respectively. Retrospectively the causes of extensive necrosis in pedicled tissue transplantation were apparent which could have been prevented. Most minor troubles were observed in advanced cancer patients who had full dose preoperative irradiation and showed low albuminemia postoperatively due to massive blood loss during the operation. Incidences of extensive necrosis in 99 free transplantation with microvascular anastomosis were 4.4% (2/45) in forearm flap, 10.5% (2/19) in rectus abdominis mc flap with or without rib, 0% (0/1) in LDMC, 0% (0/3) in scapular flap with bone. 0% (0/2) in serratus antrior mc flap with rib incorporated with LDMC, 33.3% (3/9) in scapular flap with bone incorporated with LDMC with or without serratus anterior mc flap. Incidences of minor troubles in those tranplanted tissues were 2/45, 0/19, 1/1, 2/20, 0/3, 0/2 and 1/9 respectively. Recipient vessels in 5 out of 7 cases had full doses preoperative irradiation. The causes of extensive necrossis in free tissue transplantation could not be specified in most cases.

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