The lymph node metastasis in the neck is a critical prognostic factor in oral cancer. Crude and ineffective attempts had long been performed to remove cervical lymph nodes at the time of resection of the primary tumor. In the early 1800s, however, complete removal of neck metastases was considered impossible, and the excision of individual lymph node metastases was usually performed. Then, limited regional neck dissections, including normal tissues such as submandibular gland, were attempted. During the late 19th and early 20th century, a systemic approach to anatomically “en bloc” removal of cervical lymph node metastases was developed. This development enabled really curable surgery of neck lymph node disease, and the systemic method was called “radical neck dissection” in honor of this great advancement. Now, this history of the development of neck dissection is abundant in suggestion to advance the management of neck lymph node disease in the future. In this article, the factors of “curability” of neck dissection are reconsidered and the possible developments of future neck dissection are discussed. Additionally, our selective neck dissection is shown as an example of an advanced method of neck dissection.
The dissection of surgical specimen from the neck is often difficult due to the anatomically complicated nature of this area. A neck dissection consists of a tissue mass containing the cervical lymphatics extending from the submandibular to the supraclavicular tissue, bordered latellary by platysma and medially by the internal jugular vein. The lymph nodes in this area are divided into six compartments, the so-called levels as proposed by American Academy of Otolaryngology's Committee for Head and Neck Surgery and Oncology, and as same as other guidelines provided by several committees in Japan. Practical methods for pathological examination should be established and designed by pathologist based on each institutional environment, for example, a specifically designed record chart for pathological examination of neck dissection. Adequate investigation of surgical specimens requires knowledge of the various types of surgical procedures used and preoperatively performed diagnostic imaging. The histological examination on lymph nodes should be performed by a definite procedure such as start from the hilum along with the peripheral sinus by low magnification. It seems to easily define a relatively large focus of metastatic carcinoma by low magnification, however metastatic micro foci are difficult to define and confused with reactively proliferated histiocytes that have large cytoplasm and nucleus resemble to epithelial cells. A precise histological preparation with adequate staining, especially Eosin staining is essential for precise histological examination and to avoid miss individual carcinoma cells as micro metastasis in the lymph node. There are several reactive changes that should be avoided to confuse from metastatic foci in the lymph nodes received after a radiation therapy. The reactive changes in lymph node are massive proliferation of histiocytes, sinus histiocytosis, cicatrized fibrous hyperplasia with melanin pigmentation. Moreover, a metastatic carcinoma often shows a different histological type from that of original focus, such as metaplastic mucous-laden cells and cystic change. Although there is several issues should be settled of the centinel lymph node examination, it is useful for determination of surgical procedure of neck dissection and for improvement of quality of life. It is required for improvement of sensitivity and accurate detection for micro metastasis in lymph nodes, and standardization of methods.
The presence of regional lymph node metastases has a major influence on the prognosis of patients with oral cancer. Modern imaging techniques play a major role in the diagnosis of lymph node metastases. The characteristics of metastatic lymph nodes that can be depicted are increased size, a rounder shape, and heterogeneity caused by central necrosis, cystic degeneration, or tumor keratinization. Abnormal internal structure of the lymph node is a reliable criterion for diagnosing metastases rather than size or shape. Central necrosis and/or cystic degeneration are corresponding to the focal area of low attenuation with or without rim enhancement on post-contrast CT, whereas the predominantly hypoechoic with heterogeneous internal echogenicity on ultrasonography. On the contrary, tumor keratinization is corresponding to a focal area of high attenuation on non-contrast CT, whereas a focal hyperechoic area not in continuity with the surrounding fatty tissue on ultrasonography. Although central necrosis or tumor keratinization is a very reliable criterion for lymph node metastases, it is unfortunately not visible in every metastatic lymph node. The minimal axial diameter is a better criterion than the maximal axial diameter and a round shape is considered more suspicious than an oval or flat shape. Additionally, watchful observation of individual lymph nodes is essential. We recommended the use of follow-up examination of ultrasonography at an interval of 1 month for at least one year and a half after treatment of the primary tumor. In this article, the comparison between imaging and histopathological findings on a side-by-side basis was described.
A case of epithelial-myoepithelial carcinoma transformed in pleomorphic adenoma occurring in palate of a 61 years old woman is reported. The tumor was composed of 2 different components, pleomorphic adenoma and epithelial myoepithelial carcinoma, accounting for approximately 40% and 60% of whole tumor, respectively. As the results of the immunohistopathologic study, epithelial-myoepithelial carcinoma showed multiple tubular or solid nest, which were separated by a basement membrane and considered of variable proportion of 2 cell types, cuboidal epithelial cells positive for cytokeratin and clear myoepithelial cells positive for glial fibrillary acid protein, wheres the myoepithelial nest of pleomorphic adenoma intermingled with hyaline and myxoid stroma. The malignancy was demonstrated by convincing evidence of invasion into the submucosa, although the epithelial-myoepithelial carcinoma component was mostly surrounded by the pleomorphic adenoma components. An increased immunoreactivity of proliferating cell nuclear antign in the epithelial myoepithelial carcinoma area in comparison to the pleomorphic adenoma also suggested epithelial-myoepithelial carcinoma arising in a pleomorphic adenoma.
Aberrations on the short arm of chromosome 8 (8p) are frequent events in several human cancers. In this study, 20 specimens of squamous cell carcinoma (SCC) of the tongue were examined to evaluate the role of 8p in tongue SCC. Microsatellite analysis using 14 markers demonstrated two commonly deleted regions (CDRs) on 8p. Reverse transcription-PCR (RT PCR) revealed frequent down-regulation of the FEZ1 gene, mapped at 8p22, and frequent over-expression of the Cathepsin B gene, mapped at 8p-21-22. The present results suggest that genetic aberrations are involved in the development of tongue SCC; however, no significant relation was observed between those alterations and clinicopathological features. Thus, further investigations are necessary to clarify the clinical roles of 8p in tongue carcinoma.
A case of paraneoplastic pemphigus (PNP) associated with Castleman's disease in the retroperitoneal region is reported. A 54-year-old woman presented at our hospital because of multiple regions of severe oral mucositis. Biopsy of the buccal mucosa was performed, and the histopathological diagnosis was a lichenoid lesion. The results of indirect immunofluorescence and immunoblotting strongly suggested PNP. General screening by CT scanning, endscopy of the upper and lower gastrointestinal tracts, and nuclear medical examinations was performed to search for the cause of PNP. A 60×43mm mass was found in the right retroperitoneal region on CT. The tumor was extirpated by urologists at our university hospital. The histopathological diagnosis of the mass was Castleman's disease. The oral lesion was diagnosed as PNP and was treated with high-dose prednisolone and cyclosporine A gargle. After treatment, the oral lesion resolved completely. The clinical course of the patient has been good, with no evidence of recurrence 1 year after discharge from our hospital.
Discomfort or an abnormal feeling in the laryngopharynx during swallowing can be arise with various causes. However, the discomfort caused by anomaly of the uvula is very rare. We encountered a patient with a long uvula touch to the tongue who had an abnormal feeling during mastication and swallowing. The patient had been done a partial uvulectomy, then the abnormal feeling was disappeared.