Journal of Japanese Society of Oral Oncology
Online ISSN : 1884-4995
Print ISSN : 0915-5988
ISSN-L : 0915-5988
Volume 26, Issue 3
Displaying 1-11 of 11 articles from this issue
The 32nd Annual Meeting of Japan Society for Oral Tumors
Symposium 2: “Key points for successful mandibular reconstruction”
  • Kazuki HASEGAWA, Kazunobu HASHIKAWA
    2014 Volume 26 Issue 3 Pages 53
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
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  • Tetsuro Yamashita
    2014 Volume 26 Issue 3 Pages 54-56
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    Reconstruction of the mandible is a universal modality for all cases, where the bony structure is removed regardless of the range. The purpose of the reconstruction is to achieve functional and esthetic recovery after surgery and also to guide the patients toward regaining personality with dignity as independent human beings. Vascularized osteo-muscular composite grafts are ideal materials for the reconstruction. The scapular composite musculo-cutaneous free flap is one of the best selections among various modalities. By using this flap, the recipient site can be effectively covered by the flap because of the three-dimensional flexibility both of the muscular pedicle and the transplanted bone. Dental implant-supported dentures may then be necessary if masticatory reconstruction is expected.
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  • Kazunobu Hashikawa
    2014 Volume 26 Issue 3 Pages 57-62
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    This article reports a new classification system and a practical theory in surgical reconstruction for segmental mandibular defects after oncological ablative surgery: the "CAT classification system" and the "CAT concept". The CAT classification system classifies a mandibular defect with three letters indicating reference points: "C" signifies loss of the condylar head of the mandible, "A" the mandibular angle and "T" the mental tubercle. For example, the defect is described as "A" when the mandibular angle is segmentally resected, as "CA" when the condylar head and the mandibular angle are resected, as "CAT" when the entire hemi-mandible is resected, as "ATT" when the angle and the bilateral mental tubercle are resected, as "body" when only the mandibular body is resected and the angle and the mental tubercle are preserved, and as "neck" when only the mandibular ramus is resected and the condylar head and the angle are preserved. The CAT concept is a theory that is necessary and sufficient to reconstruct three reference points of the CAT classification system ("C", "A" and "T") in order to reconstruct oncological segmental mandibular defects. Previous studies showed that the CAT system and CAT concept are highly practical and useful in the standardization of mandibular reconstructive surgery.
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  • Minoru Sakuraba
    2014 Volume 26 Issue 3 Pages 63-68
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    Vascularized fibula graft (VFG) has been the most favored method for mandible reconstruction, because of the availability of long bone segments, pliable skin paddle, and possibility of multiple osteotomies. This report describes details of the surgical technique and clinical key points of VFG reconstruction.
    The preoperative design of a VFG is placed at the ipsilateral leg with mandible bone defect, and a certain amount of the flexor hallcis longus muscle is harvested simultaneously as a usual surgical plan. The harvested flexor muscle is used to eliminate the dead space in the submandibular region after cervical lymphadenectomy.
    Elevation of the VFG is carried out under avascularization with a tourniquet in the supine position, and skin paddle and bone segment of sufficient size are harvested. Osteotomy to reestablish the shape of the new mandible should be carried out at the donor leg after deflating the tourniquet. Care must be taken to keep the minimal length of the osteotomized bone segment larger than 2cm. After completion of shaping the bone graft, the VFG is taken from the donor leg and transferred to the cervical defect.
    The transferred VFG is then fixed to the remnant mandible with a miniplate or mandible reconstruction plate and screws. The optimal occlusal plane must be obtained with temporary inter-maxillary fixation during the surgery. Vascular anastomosis between the pedicle of the flap and cervical vessels is carried out after bone fixation. Finally, the skin paddle of the VFG is sutured with intraoral mucosal defect, and the cervical skin is closed.
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  • Kazuki Hasegawa
    2014 Volume 26 Issue 3 Pages 69-77
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    Mandibular defects arising from tumor ablation, result in significant esthetic and functional consequences. In particular, esthetic problems may be caused mainly by loss of bony buttress of the lower face, especially in the chin area.
    Today, mandibular defects are reconstructed mainly using fibula, iliac bone and scapula, although there are many advantages and disadvantages of each type of osteocutaneous flap.
    Scapular osteocutaneous flap is nourished by the subscapular vascular system. This vascular system can nourish various types of flap as follows: scapular cutaneous flap, scapula based on circumflex scapular artery or angular branch, bi-pedicled scapula, latissimus dorsi myocutaneous flap, serratus anterior myocutaneous flap and costal bone flap. They can be modified and combined in various ways for reconstruction sites.
    This report introduces a fundamental technique for mandibular reconstruction using scapular osteocutaneous flap. The vascular anatomy, principal procedures, characteristics of this flap and its indications, etc. are discussed.
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  • Yoshiki Hamada, Hiroyuki Yamada, Kenichi Kumagai, Kazutoshi Nakaoka, T ...
    2014 Volume 26 Issue 3 Pages 78-88
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    This article introduces mandibular reconstruction using a custom-made titanium mesh tray and autogenous particulate cancellous bone and marrow (PCBM) harvested from the ilia and/or tibiae, and discusses its clinical usefulness through a retrospective investigation on the clinical course of 17 patients who underwent our mandibular reconstruction.
    All surgical procedures were uneventfully completed, and the mean operating time was 452 minutes. The amount of harvested PCBM for each patient was sufficient and ranged from 37 to 113 g. Although the postoperative clinical course with prosthetic treatments was generally acceptable, three patients with mandibular defect including the mentum region required repeated mandibular reconstruction using a double-layer tray, due to a postoperative local infection with much bone loss and fractures of the single-layer tray used for primary reconstruction. These repeated reconstructions were successful, and we have since used a double-layer tray in every reconstruction for mandibular defects including the mentum region, without additional tray fractures. The mean postoperative painless range of mandibular motion was 45.6 mm, and overall ability of daily life was not severely disturbed. Although the level of satisfaction with postoperative facial appearance was relatively low in a few patients because of lower lip rotation caused by anterior missing teeth or slight facial asymmetry, most patients obtained symmetrical and natural facial contours and were highly satisfied. Moreover, the mean Visual Analog Scale (VAS) for postoperative facial appearance was 79.8.
    In conclusion, the present mandibular reconstruction seems to be a highly predictive and clinically useful modality.
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  • Ikuo Hyodo, Seiko Okumura, Takahide Mizukami
    2014 Volume 26 Issue 3 Pages 89-94
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    The fibula flap is widely used for immediate reconstruction after segmental mandibulectomy. We evaluated six long-term follow-up patients following free fibula transfer. Their postoperative course is more than 5 years.
    All patients are able to eat a normal diet, speech function is normal, and there are no limits on their daily life. There is no donor-site morbidity like toe flexion contracture or leg weakness.
    We concluded that reconstruction using fibula flap after segmental mandibulectomy is useful and all of our patients have no long-term functional limitations.
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Original Articles
  • Mie Mochizuki, Akiko Kobayashi, Masashi Yamashiro, Satoshi Yamaguchi, ...
    2014 Volume 26 Issue 3 Pages 95-102
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    The purpose of this study is to investigate the tongue sensation (warm, cold, tactile and thermal pain) of 22 postoperative tongue cancer patients. In 11 of the 22 patients, hemiglossectomy and reconstruction of the tongue using forearm flap were performed (skin flap group). In the other 11 patients, partial glossectomy with primary suture (6 cases) or artificial skin graft (5 cases) was performed (partial glossectomy group).
    Sensory recovery in all categories (warm, cold, tactile and thermal pain) was recorded in 1 patient of the skin flap group and 5 of the partial glossectomy group. Total anesthesia was found in 2 patients of the skin flap group, but there were no patients with total anesthesia in the partial glossectomy group. The improvement of warm thresholds was slower than that of cold or tactile on the affected side. No significant factors relating to the recovery of sensation were detected statistically.
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  • Souichi Yanamoto, Michihiro Ueda, Tetsuro Yamashita, Yoshihide Ota, Mi ...
    2014 Volume 26 Issue 3 Pages 103-112
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    To evaluate the clinical outcomes of patients with delayed cervical lymph node metastasis in stage I-II squamous cell carcinoma (SCC) of the oral cavity, we performed a multicenter retrospective study. We analyzed the records of 141 patients with delayed cervical lymph node metastasis admitted to hospitals between 2002 and 2011. Survival rates of the subjects were compared with those of 27 patients who underwent elective neck dissection (END).
    The 5-year cumulative disease-specific survival and overall survival rates were 75.7% and 68.9%, respectively. In patients with delayed cervical lymph node metastasis, radical neck dissection or modified radical neck dissection should be performed. Univariate and multivariate analyses showed that variables independently prognostic for survival were multiple nodal metastases, ipsilateral lower neck metastasis (level IV/V), and extracapsular spread. In patients with these prognostic factors, postoperative adjuvant therapy should be performed. Because there is little difference between the wait-and-see policy and END, we believe that END is unnecessary if there is strict follow-up observation. However, to further improve the survival of stage I-II SCC of the oral cavity, it is necessary to elucidate the predictive factors for occult metastasis and conduct a large prospective clinical trial.
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Case Reports
  • Rieko Doi, Isamu Kodani, Kazunori Kidani, Takayuki Tamura, Hideharu Ok ...
    2014 Volume 26 Issue 3 Pages 113-121
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    As society ages and inspection technology develops, the incidence of secondary malignancies has increased. Esophageal and gastric cancers are common for primary tumors of oral secondary malignancies, but, on the otherhand, ML (malignant lymphomas) are rare. We report here two cases of mandibular SCC (squamous cell carcinoma) complicated with ML as metachronous secondary malignancies. In both cases, oral SCCs were aggressive and the clinical courses were rapid.
    Case 1 was a 62-year-old man who had a past history of CLL (chronic lymphocytic leukemia)/SLL (small lymphocytic lymphoma) and developed oral SCC.
    Though he had a surgical resection after chemoradiotherapy, SCC recurred just two months post operation.
    Case 2 was an 83-year-old man who developed oral SCC during treatment for Epstein-Barr Virus (EBV)-positive DLBCL (diffuse large B-celllymphoma) of the elderly. He discontinued chemotherapy and he had an operation for oral SCC. Etoposide was resumed for exacerbation of EBV-positive DLBCL of the elderly; he is alive without any relapse of oral SCC.
    Aggressive clinical features of secondary oral malignancies are considered to be closely related to a long-term immunosuppressive state due to ML and chemotherapy.
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  • Michiko Okita, Yasushi Hariya, Katsuhisa Sekido, Masashi Harada, Takas ...
    2014 Volume 26 Issue 3 Pages 123-129
    Published: September 15, 2014
    Released on J-STAGE: October 01, 2014
    JOURNAL FREE ACCESS
    Metastatic tumors in the oral cavity are rare. Most of them occur in the mandibular bone, and thus, the metastasis of the tumor to the oral mucosa is very rare. We herein reported a case of metastatic renal cell carcinoma at the soft palate, which is extremely rare.
    A 75-year-old man was referred to our clinic; the chief complaint was a mass at the soft palate. As for past medical history, the patient underwent left radical nephrectomy because of renal cell carcinoma with multiple metastases to the lung 33 months previously, followed by adjuvant immunotherapy. The physical examination revealed the elastic soft, smooth-surfaced, painless mass in the soft palate, measuring 13 × 10mm in size. The mass in the soft palate has a central part with iso-signal intensity and a periphery with high signal intensity with a relatively clear margin, on the T2-weighted MR image. The clinical diagnosis was a malignant tumor of the salivary gland in the soft palate.
    Under general anesthesia, the lesion was securely removed surgically with a 7-8mm safety margin with the help of intraoperative rapid frozen diagnosis. The pathological examination of the resected specimen revealed the clear cell carcinoma of the soft palate similar to the previously resected renal cell carcinoma. Moreover, the immunohistochemical study with monoclonal antibody against CD10 and vimentin substantiated strong positivity in the tumor cells, which eventually played a key role in the differential diagnosis. Based on the pathological and the histochemical findings, the tumor in the soft palate was finally diagnosed with the metastatic renal cell carcinoma.
    There was neither recurrence in the oral cavity nor growth of the pulmonary metastases for 25 months after the surgical resection of the palatal mass.
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