On the basis of our experience, we investigated the indication, the required extent and the suitable procedure for elective neck dissection (END) of clinically N0 neck (deep lateral cervical nodes) in squamous cell carcinoma of the larynx, hypopharynx, oropharynx and tongue & oral floor. A representative technique for END at our clinic, i. e. lateral neck dissection (LND) were described. We considered that if the probability of occult neck metastasis was greater than 20 %, END would be warranted. The indication was clarified by clinical T category and tumor site. Most of the occult neck metastses were found in level II, III, IV, and very few, i. e. 5 % (5/92) in level V. The rates of recurrence in the dissected neck were 4 % (5/120) for LND and 8 % (1/12) for RND in the patients with carcinoma of the larynx, hypopharynx or oropharynx, and were 12 % (3/26) for supraomohyoid neck dissection (SOND) and 14 % (1/7) for RND in those with carcinoma of the tongue & oral floor. These results suggested the following two procedures appropriate for END ; 1) LND for carcinoma of the larynx, hypopharynx or oropharynx, and 2) SOND for that of the tongue & oral floor, with preservation of sternocleidomastoid muscle, accesoty nerve, internal jugular vein and cerical plexus.

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In our series of treatment of hypopharyngeal carcinoma, 7 patients died of retropharyngeal metastasis. Resection of the retropharyngeal node was performed in 56 patients of hypopharyngeal carcinoma 1988 through 1995. The subf ascial plane of the middle pharyngeal constrictor muscle was entered at the greater horn of the hyoid bone. The retropharyngeal nodes located in front of the capitis longus muscle were removed between the above fascia and internal carotid artery. Of these patients, the preoperative diagnosis for nodal involvement was available only in 2 patients. The postoperative histopathological study revealed nodal involvement in 12 patients. As far the relationship to the preoperative N classification of these patients, two of 11 were for N0, 2 of 8 for N1, 1 of 4 for N2a, 3 of 22 for N2b, and 4 of 8 for N2c. This result revealed no corelation between the incidence of the involvement of the retropharyngeal node and preoperative N classification. Finaly in coclusion, the resection of the bilateral retropharyngeal node is highly recommended at the surgery of hypopharyngeal carcinoma.

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Ultrasonograghy (US) was the most useful examination to evaluate cervical lymphnode metastasis before operation. However, the correct diagnosis of mtastatic lymphnode by US was sometimes difficult since the submandibular region was masked by the mandibule, submandibular gland and inflammatory lymphadenopathy. The presence or absence of cervical metasitasis is an important prognosticator of survival for oral cancer. So the preventive neck dissection was often performed for occult cervical metastasis in squamous cell carcinoma of the oral cavity and oropharynx. We usually performed supraomohyoid neck dissection (SOND) for T2NO cases in cancer of the oral cavity and oropharynx. Fourteen previously untreated patients with clinically negative necks was performed SOND in T2 tongue cancer. Three (21 %) neck specimens was revealed occult metastatic cancer. In this operation, it is the most important technique to protect the marginal branch of facial nerve, especially in N0 case, so we should learn clinical anatomy of facial nerve.

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Although there is general agreement that resection of paratracheal nodes is necessary to reduce the incidence of tracheal or stomal recurrence in subglottic carcinoma and hypopharyngeal carcinoma, there remains many things to be discussed. Our indications for paratracheal dissection are as follows now : 1. gllotic cance……all cases of total laryngectomy 2. subgllotic cancer…all cases 3. hypopharyngeal cancer and cervical esophageal cancer……all cases 4. tracheal cancer……all cases We change the extent of the dissection according to the size and location of the tumor. In cases of carcinoma of the hypophatynx, cervical esophagus and subgllotis, we undergo mediastinal paratracheal nodes dissection as deep as possible without manubrial resection. In this article we also present our surgical procedure.

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Salivary duct carcinoma (SDC) is a relatively rare salivary gland neoplasm that only recently has been recognized as a separate entity. We have found 6 cases of SDC treated in our department between 1968 and 1994 and have reviewed their clinical features. All patients were men and thier ages ranged from 38 to 62. Four patients had ipsilateral facial paralysis. Parotidectomy or extended parotidectomy followed by radiation therapy was performed in 4 cases ; this procedure was done with unilateral upper neck dissection in two cases. Parotidectomy followed by chemotherapy was performed in one case. Biopsy of the tumor followed by radiation and chemotherapy was done in one case. Five patients died within 3.5 years. One patient was followed up for 6.2 years and had no evidence of disease. SDC appears to be a highly malignant tumor requiring aggressive combined therapy.

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We examined the clinical efficiency of the new tumor marker CYFRA for head and neck squamous cell carcinomas and compared it with SCC antigen and TPA. The cut off values were as follows : CYFRA at 1.1 ng/ml, SCC 1.1 ng/ml and TPA 50 U/L. The sensitivity and the specificity of CYFRA were 63.2 % and 95.2 %, respectively. The sensitivity and the specificity of SCC antigen were 52.6 % and 95.2 %, respectively. The sensitivity and the specificity of TPA were 68.4 % and 100 %, respectively. TPA showed the highest positive rate on head neck squamous cell carcinomas and CYFRA was the second. As tumors progressed we found a tendency in that the positive rate of all tumor makers, rise. There was a strong correlation between CYFRA and SCC antigen and also between CYFRA and TPA. The positive rate on combination assay of SCC antigen and TPA was 78.9 %, which was the highest. Therefore, we conclude that CYFRA was a better tumor marker than SCC antigen and TPA was a best tumor marker for screening head neck squamous cell carcinomas. We expect CYFRA to be useful for follow-up because it reflects the stage of the disease.

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We performed 11 total thyroidectomy and 13 sub-total thyroidectomy for 24 cases of hyperthyroidism patients from January, 1993 to March, 1996. There were several reasons of operative indication for our cases that (1) uncontrol of anti-thyroid drugs, (2) side effects of anti-thyroid drugs as allergic reaction or agranulocytopenia, (3) prevention of thyroid crisis and (4) to have babies. We selected those two types of operations not to re-use anti-thyroid drugs after our treatment. In operation, we left not only recurrent nerves but also two or three parathyroid glands with active blood supply. After operation there were two cases of transient recurrent nerve palsy and two cases of hypo function of parathyroid glands. But we had no cases of recurrent hyperthyroidism after surgical treatment.

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We treated 12 cases of nonepidermoid epitherial malignant tumors and sarcoma bitween 1971 and 1990. There were 4 adenocarcinomas, 3 adenoid cystic carcinomas, 3 mucoepidermoid tumors, 2 acinic cell tumors and 1 rhabdomyosarcoma. The average age of patients were 60.7 yrs and sex distribution was 8 men and 5 women. Base of the tongue was the most common site of tumors. Stage distribution was stage I : 1 patient, stage II : 5 patients, stage III : 3 patients, stage IV : 4 patients. We treated these patients mainly by surgery or combined therapy of surgery and radiation, 2 patients were treated palliatively. As a result, 2 patients were died of disease (10 months and 4 years after surgery) and 8 patients were alive without disease more than 5 years. It may be said that prognosis of patients with these type of tumors were better than patients with squamous cell carcinomas.

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The central cranial base including the clivus is located deep in the skull base and surgical access to this area is difficult. Transf acial approaches with multiple osteotomies of the facial skeleton enable to expose widely the inferior aspect of this area. Following a facial cutaneous incision, the zygoma, maxillo-palatal complex and/or nose are osteotomized and translocated depending on the size, location and direction of the invasion of the tumor. The blood supply to each segment of the skeleton is preserved. If necessary, the combination with the intracranial approach is possible. After extirpation of the tumor, the translocated segments of the skeleton are replaced. This procedure resulted in minimum postoperative disfigurement and dysfunction.

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A case of a patient with advanced hypopharyngeal cancer (PS-oropharynx ; T4 N2 M0 ; Stage IV) who had undergone radical surgery after chemoradiotherapy was presented. The radical surgery performed was en-block resection of pharynx, larynx, cervical esophagus, thyroid and parathyroid glands in conjunction with bilateral neck dissection and simultaneous reconstruction with a free jejunal flap. Concurrently, parathyroid glands were dissected out from the speci-men and then transplanted beneath the fascia of the left forearm, after confirmation that there were no metastatic tumors in those glands. Postoperative course was uneventful. Viability of the transplanted parathyroid glands was confirmed with measurement of M-PTH level in the venous samples obtained from the both cubital vein. Until now the same procedure had been performed in 6 cases safely.

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Thirty-six patients who underwent vertical partial laryngectomy at National Cancer Center Hospital East between July, 1992 and December, 1995 were evaluated. Thirty-four had f ronto-lateral resections and two anterior frontal resections. Twenty-two patients received vertical partial laryngectomies as an initial treatment for laryngeal carcinoma. Thirteen were radiation failure cases and one patient had local recurrence after partial laryngectomy. Wound complications were found in eight patients in the initially treated group. Surgical management, excision of granuloma, was needed in only one patient. Significant complications, such as postoperative necrosis of the thyroid cartilage, developed in five salvage cases, two of whom required total laryngectomy because of subsequent misdeglutition. Median time to recover oral intake was 11.8 days in patients who received the operation initially and that was 15.9 days in recurrent cases. Once wound healing was achieved, no patients required total laryngectomy only for swallowing insufficiency. Although clinical course of postoperative wound healing of recurrent cases is very often eventful and resumption of oral intake is sometimes delayed, vertical partial laryngectomy is appraised as an useful salvage procedure, because most of recurrent cases can obtain their wound healing after vertical partial laryngectomy without any more operations.

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There are two main problems for artificial ossicular chain prosthesis ; extrusion and postoperative slippage of prosthesis. We manufactured a new hydroxylapatite prosthesis “carti-lage connecting ossicular chain prosthesis” with a planar-like head portion to contact with a piece of cartilage. As a result, postoperative extrusion rate was 4/124 (3.2 %) which seemed lower than the conventional type, and hearing success rates were 78.8 % in modified type III tympanoplasty, 80.0 % in modified type IV tympanoplasty. Average improvement on air conduction were 13.5 dB in modified type III tympanoplasty, 17.5 dB in modified type IV tympanoplasty. Those good results were explained by that the “Cartilage connecting ossicular chain prosthesis” Was tightly attached with a reconstructed tympanic membrane and ossicular chain prosthesis might be stable in tympanic cavity.

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