Jehovah's Witnesses will refuse a blood transfusion for religious reasons, so there are some problems when an extended surgery is indicated. We present two Jehovah's Witness patients with oral cancer who underwent surgery.
Case 1 was a 64-year-old female with squamous cell carcinoma of the mandibular gingiva (T2N2bM0) .She underwent neck dissection and marginal mandibulectomy. Blood loss was 300 g. Case 2 was a 50-year-old male with squamous cell carcinoma of the tongue (T2N2bM0) . He underwent neck dissection, hemiglossectomy, and reconstruction with major pectoral musculocutaneous flap. Blood loss was 445 g. We exchanged some documents that certified our exemption from obligations with the patients before the operations. Low blood pressure anesthesia was done in each operation. Some other problems on treating Jehovah's Witness patients were discussed.

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A method corresponding to the state of progress of necrosis is necessary for the treatment of mandibular osteoradionecrosis considering the healing conditions of the original focus. We devised a three-step treatment method that combined active application of platelet rich plasma (PRP) with particulate cancellous bone marrow (PCBM) with resolutive treatment using external skeletal fixation, as a step preceding wide segmental mandibulectomy and vascularized free combination flap graft when bone necrosis progressed.
Patients and method
From January 2002 until December 2004, 14 patients (12 patients of oral cancer and 2 patients of mesopharygeal cancer) in whom mandibular osteoradionecrosis developed after radiation therapy, were treated. First step: when only alveolectomy is done, the wound is closed with a mucosal flap after PRP is applied to the bone surface as there is little sequestration. Second step: when sequestrectomy spreads to the central part of the mandible, PCBM is transplanted in addition to PRP, and the wound is closed by a local skin flap. Third step: when bone defect is segmental, any issue with soft tissue is first resolved and bone grafting is performed after that, while holding the remaining bone in position by using an external skeletal fixation device.
Results
A decrease in exposure of bone surface and alleviation of pain symptoms were achieved in all cases by treatment with the first step. However, outer cortical bone necrosis relapsed. The outcome of the second and third step treatment was good, and bone regeneration was achieved in 8 cases where PRP and transplantation of PCBM were done. Two cases suffered an infection, and curettage or retransplantation of PCBM was necessary.
Discussion
It is suggested that improvement of blood circulation and resolution of soft tissue are important for treatment of osteoradionecrosis. Therefore, waiting for resolution of the soft tissue using external skeletal fixation was effective, and PRP was useful in the healing process.

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This report concerns a 55-year-old male with intracranial invasion and recurrence of lower gingival squamous cell carcinoma along the lingual nerve after initial treatment.
At hospital admission, he had stabbing left facial pain and dysesthesia of the left lower lip and chin. After preoperative radiotherapy, the patient underwent left hemimandibulectomy and radical neck dissection, right submandibular neck dissection, and then immediately received reconstructive surgery by using PMMC flap. Three months later, MRI revealed an enhanced mass in the base of the skull that was suspected to be the residual tumor progressing intracranially along the trigeminal nerve. The patient died 4 months later due to rapid growth of the residual tumor into the left middle cranial fossa. We confirmed by later histological examination that the carcinoma cells had invaded into the lingual nerve at the surgical margin of the efferent side, and residual cells had progressed to the skull base along the nerve via the foramen ovale. In a case like this, with paresthesia in the mental region and bone invasion detected at initial treatment, preoperative or postoperative radiotherapy of the area containing the skull base as well as extensive surgical excision of the primary lesion would seem to be an important preventive measure.

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Multiple myeloma represents a neoplastic proliferation of plasma cells, and is often diagnosed as solitary plasmacytoma of bone before multiple lesions form. The lesions frequently occur in the 4th to 7th decades of life, but may occur in younger patients. Multiple myeloma is usually found in the molar, angle, ramus and condyle regions of the mandible. Radiographical features of the lesion indicate a predominantly osteolytic lesion with various characteristics that are useful in differential diagnosis. Multiple punched-out lesions are a typical in the skull.
We encountered a patient displaying a radiolucent lesion in the right molar region of the mandible on first examination. The patient was initially diagnosed with malignant lymphoma in the oral surgery department of another general hospital. Enhanced computed tomography indicated a heterogeneous expanded mass that showed irregular destruction of the mandible. Magnetic resonance imaging demonstrated signal hypointensity on axial T1-weighted imaging (T1WI), and signal hyperintensity compared with fatty bone marrow on T2-weighted imaging with fat saturation. Gadolinium-enhanced T1WI demonstrated a light homogeneous enhanced mass. Scintigraphy of the whole body revealed hot lesions in the right humerus and femur.
The final diagnosis was multiple myeloma based on data from radiographic diagnostic imaging, immunohistochemistry, clinical laboratory examination and FACS analysis of tumor cells.

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In this paper, we report on the clinical course of a case of metastatic hepatocellular carcinoma to bilateral maxillary gingiva.
The patient is a 91-year-old male with terminal-stage hepatoma, who visited Hakujikai Memorial Hospital because of external hemorrhage of the right maxillary gingiva. Although hemostasis using electrocauterization was tried by an otolaryngologist, it was unsuccessful. Consequently the patient was referred to our Department of Oral and Maxillofacial Surgery. A bloody and elastic-soft mass was present in the right palatomaxillary gingiva of the molar region, adjacent to the border of the partial denture. In addition, another lesion was observed in the left buccal gingiva of the left maxillary first premolar. It looked like an angiomatoid epulis. Excisional biopsy was performed for each lesion, in order to enable hemostasis and pathological examination. As a result, hemostasis was complete and we diagonosed metastatic tumors in the maxillary gingiva on the basis of their pathological diagnosis of moderate differentiated hepatocellular carcinoma.

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