Salvage surgery is often the only curative option for locally recurrent advanced carcinomas of the oral cavity. However, postoperative functional and cosmetic disorders are severe, because extended local excision is needed to eradicate the disease. Surgery is followed by radiotherapy with or without chemotherapy when possible; however, the outcome of such salvage surgery is poor.
We considered the indications of salvage surgery for locally recurrent diseases were rT1-4a and some rT4b diseases (with invasion of the masticatory space or lower portion of the pterygoid process), and diseases involving the skull base or internal carotid artery were considered to have no surgical indications.
As for the outcome of salvage surgery for locally recurrent advanced (rT3 and rT4) cases, 9 of 13 cases treated primarily in other hospitals were alive with NED, and 5 of 9 cases treated in our hospital were alive with NED.
An extended local excision usually requires reconstructive surgery. In patients with surgery as the primary treatment, selection of flaps and anastomotic vessels for reconstruction may often be limited. A thorough preoperative treatment plan with informed consent and postoperative supportive care are necessary for salvage surgery of locally recurrent advanced diseases of the oral cavity.

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A retrospective study was conducted of loco-regional recurrence in 324 patients with squamous cell carcinoma of the oral cavity treated with surgery. Local recurrence occurred in 26 (8.0%) patients: 4.3% for T1-2 patients, and 17% for T3-4. Among them, only 12 patients were salvaged, and especially those with advanced stage showed extremely poor prognosis. The most frequent recurrent site was the masticatory space.
Neck recurrence was seen in 12 of 199 patients (6.0%) who underwent neck dissection. Three patients had their necks cured, although two of them developed distant metastasis. The prognosis of those with neck recurrence was extremely poor. The most frequent recurrent site was the parahyoid bone region.
Prophylaxis for loco-regional recurrence was discussed including internal masticatory space dissection, surgical approach to the lingual lymph nodes, and postoperative chemoradiotherapy with high dose cisplatin.

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Carbon-ion radiation is a high linear energy transfer radiation, and is associated with high levels of biological effects. In addition, it has an excellent dose concentration, thus allowing effective radiation therapy with less damage to the surrounding organs. Here, we report the favorable therapeutic effects of carbon-ion radiation therapy on postoperative residual or recurrent tumors, which are often difficult to treat. The study was conducted on 52 cases of postoperative residual or recurrent tumors of the oral and maxillofacial region, including the parotid glands, treated with carbon-ion radiation therapy at the National Institute of Radiological Sciences between April 1997 and August 2013. Adenoid cystic carcinomas accounted for 26 cases (50%), and locally advanced Stage T4 tumors accounted for 39 cases (75%). The treatment was conducted using 57.6 or 64 GyE in 16 fractions over 4 weeks. The median observation period was 47.7 months. The local control and crude survival rates were 84.6% and 76.8%, respectively, at 3 years, and 75.2% and 63.2%, respectively, at 5 years. As for adverse reactions, Grade 3 mucositis was found in 12 cases during the acute stage, although recovery to Grade 1 or lower occurred in all cases during the later stages. Our results suggest that carbon-ion radiation therapy is an effective local treatment for radioresistant locally advanced recurring tumors that are difficult to treat using other methods.

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We evaluated the efficacy of adjuvant concurrent chemoradiotherapy with a 3-weekly cycle of cisplatin (3W-CDDP/RT) for patients with post-operative high-risk squamous cell carcinoma of the head and neck. High-risk factors were a microscopically incomplete resection, extracapsular extension and two or more lymph node metastases. Patients received three cycles of cisplatin at a dose of 80mg/m² or 100mg/m² concurrent with radiation therapy.
Between April 2007 and November 2013, 52 patients were enrolled: 45 males and 7 females, with a median age of 62 years (range 22-75), Stage III/IVA/IVB/recurrent (4/35/2/11), and oral cavity/oropharynx/hypopharynx/larynx (23/4/20/5). The protocol completion rate was 84.6%. After a median follow-up of 28 months, estimated 3-year locoregional control rate and overall survival were 75.5% and 56.2%, respectively. On multivariate analysis, oral cavity cancer and a cumulative cisplatin dose below 200mg/m² seemed to be poor prognostic factors.
Among high-risk patients with post-operative locally advanced head and neck cancer, adjuvant concurrent chemoradiotherapy improved the rate of locoregional control.

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Super-advanced oral cancer cases were provided for this study for post-treatment evaluation. Statistics on oral cancer cases (1,487 cases treated from 1988 to 2013) in our department revealed that 103 cases (6.9%) were under the categories of (1) super advanced cases, (2) radical surgery cases of secondary and/or recurrence cancer, or (3) pathologically intractable cancer cases. In this study, adenoid cystic carcinoma, malignant fibrous histiocytoma (MFH), osteosarcoma and myxosarcoma were classified in the above category (3), if those were advanced cases equivalent to the condition of T4a or T4b in squamous cell carcinoma (SCC). Among the cases presented in this presentation, 32.1% of them were primary cases and 35.6% were secondary, multicentric and/or double cancers.

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The therapeutic strategy for unresectable recurrent and advanced oral cancer is limited and so it is important to develop new therapeutic methods. Although cetuximab, as a molecular-targeted drug against epidermal growth factor receptor, is expected to have significant therapeutic efficiency in oral cancer patients, the incidence of IR during the administration or post-administration of monoclonal antibody has been reported. Cases of drug-induced interstitial pneumonia with cetuximab therapy also have been reported. We have experienced 11 cases of cetuximab therapy in unresectable recurrent and advanced oral cancer patients, in which there were 2 cases of severe IR and 1 case of drug-induced interstitial pneumonia. The patients with risk factors for infusion reaction and interstitial pneumonia must be checked carefully before starting cetuximab therapy.

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A 59-year-old male with T2N0M0 carcinoma of the right oral floor of the mouth underwent partial excision of the oral floor and partial mandibulectomy. Forty months after the initial surgery, late cervical lymph node metastases developed in the right upper neck. FDG-PET scan revealed high uptake in the right neck as well as the bilateral pulmonary apexes, mimicking malignancy. Chemotherapy resulted in a temporary reduction of FDG uptake in both those regions. Thereafter the cervical nodes enlarged, however SUVmax in the lung decreased. Modified radical neck dissection was performed, and finally nontuberculous mycobacterial avium complex (MAC) was detected. There has been no evidence of recurrence or metastasis in the 87 months after the initial surgery and in the 40 months after the neck dissection. The incidence of pulmonary MAC infection is increasing. It is notable that the PET image of MAC infection is similar to that of pulmonary metastases and lung malignancy.

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Undifferentiated high-grade pleomorphic sarcoma (UHPS) is a highly malignant tumor that has polymorphisms but does not show specific differentiation. We report a very rare case of UHPS occurring in the mandible. A 66-year-old woman was referred to our hospital complaining of paresthesia of the right mental region. A soft elastic mass of 2cm diameter was palpable in the right cheek. There were no abnormal findings in panoramic radiography except for bone absorption around the crown of an impacted mandibular third molar. CT images revealed a 2-cm contrast-enhanced mass lesion in the proximity of the anterior border of the mandibular ramus, with moth-eaten type bone destruction. On MR images, the signal in the bone marrow of the ascending ramus of the mandible was decreased on T1-weighted images. Hemimandibulectomy, right neck dissection, and reconstruction using a pectoralis major myocutaneous flap were performed under the diagnosis of sarcoma. The excised tumor specimen was diagnosed as undifferentiated high-grade pleomorphic sarcoma. There has been no sign of recurrence or metastasis for 1 year and 2 months postoperatively.

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