Distant metastasis （DM） from oral cancer is not common but remains a substantial problem. Brain metastasis from oral cancer is extremely rare and presents with an unusual clinical picture. The prognosis for patients with DM from oral cancer will improve with the development of various targeted therapies. Therefore, the management of brain metastasis from oral cancer will be increasingly encountered by oral surgeons.
Here, we present a case of a patient with oral cancer with brain metastasis. The proper treatment of brain metastasis from oral cancer may improve QOL in some cases, so early detection is important.

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We report a case in which liver metastasis occurred after resection of mandibular gingival cancer. In recent years, cancer treatment has changed as the disease state of each patient has diversified. Oral cancer is a rare cancer, and so it is important to share knowledge through case reports.

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Communication between medical staff and patients is very important in the treatment of cancer. Unexpected changes of a patient’s condition, or sudden death, do happen. If medical staff do not communicate well with patients and their families, they often develop distrust.
We experienced a case in which acute tumor lysis syndrome in cancer of the upper gingiva metastasized to the liver after chemotherapy.
The patient was a 70-year-old man who had undergone surgery for oral cancer in 2013, and the cancer recurred and metastasized to multiple places in the liver and bones in 2014. His condition changed the day after the chemotherapy （Paclitaxel 100mg/m2）. He was admitted to his previous emergency hospital and then transferred to Suita Tokushukai hospital to be treated for his sudden change in condition.
We had to decide the priority for the treatments and cooperate with other medical specialists through every moment of the patient’s changing condition. We treated him for acute renal failure, anemia, pneumonia, and pain management. Concurrently, we immediately had to lessen any gaps in knowledge about changes in his condition between his family and us, because such gaps were likely to exist. We explained at different times not only his condition, but also good palliative and end-of-life care options for him and his family, and so on. Finally, it seemed that they accepted his death without questions or complaints as to the treatment he received prior to it. We report the importance of communication with regard to the treatment of cancer.

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It has been recommended that postoperative concurrent chemoradiotherapy （CCRT） be administered to patients with locally advanced oral cancer with a high risk of recurrence according to the NCCN guidelines. These treatments have improved the locoregional control rate. However, a treatment protocol for distant metastasis from oral cancer has not been established, and the prognosis for these patients is extremely poor. In this report, we describe a case of sphenoidal metastasis from intraosseous squamous cell carcinoma of the mandible, and its management.
The patient was a 66-year-old male with intraosseous squamous cell carcinoma of the mandible （T4aN2cM0）. He had undergone tracheotomy, subtotal glossectomy, radical neck dissection of the right side of the neck, modified radical neck dissection of the left side of the neck, and mandibular reconstruction with a vascularized fibular graft after CCRT （S-1: 120mg/day for 4 weeks, external irradiation: total 30Gy/15Fr）. Involvement of multiple cervical lymph nodes with extracapsular spread was found in a pathological specimen, therefore postoperative CCRT was scheduled. CT for radiotherapy planning revealed a sphenoidal metastasis. After consultation with a medical oncologist and a radiologist, CCRT （two cycles of CDDP ［80mg/m2］, external irradiation: total 60.6Gy/22Fr） was administered for the sphenoidal metastasis. In a follow-up examination 1 month after the CCRT, CT revealed progression of the metastatic tumor. Chemotherapy with the anti-epidermal growth factor receptor （anti-EGFR） cetuximab was thus scheduled, but the patient wanted to be treated at a nearby hospital. He has been followed up for 1 year and 2 months since the operation.

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Oro-pharyngeal cancer is thought to be the sixth most common cancer globally. Most of the cases are at the advanced stage when detected, and the survival rate is still under average. There is no scientific evidence that oral cancer screening is effective in terms of early detection and prevention. In 2016, an international meeting on the early detection and prevention of oral cancer, the Global Oral Cancer Forum, was held in New York cosponsored by the WHO. At this forum, oral cancer screening was regarded as an integral issue for oral cancer. The development of surrogate markers to predict malignant transformation of oral potentially malignant disorders （OPMDs） and adjunct techniques for oral visual screening are key factors for effective oral cancer screening. Opportunistic screening for high-risk groups is cost effective in the dental setting in terms of incremental cost-effectiveness ratio. However, one issue is how to encourage relevant high-risk groups to visit a dentist on a sufficiently regular basis to undergo opportunistic screening in a dental practice. Further research is needed to determine how opportunistic screening may be implemented, and in which health care environments.

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Population-based oral cancer screening has been conducted in Nakatsu city, Oita prefecture since 2010. Nakatsu city consigned the Nakatsu Dental Association（NDA）to carry out mass screening for oral cancer three times a year, and the NDA asked Oita University Hospital and Kyushu Dental College Hospital to send oral surgeons to screening sites in order to inspect the oral cavity of residents in Nakatsu for oral cancer and oral potential malignant diseases（OPMD）. The number of examinees per screening was set at about 100, and a total of 2,365 have been inspected for seven years from 2010 to 2016. Among them, three cases of oral cancer and 119 cases of OPMD were discovered and sent to university hospitals for detailed examination and treatment.
The Oral Cancer Meeting, which consists of representatives of Nakatsu city, NDA and the university hospitals, has been held once a year at the beginning of the fiscal year. 　In order to maintain and improve the quality and efficacy of the oral cancer screening, the Oral Cancer Meeting members review the results of the previous year’s screening and compliance with the detailed examination, and discuss the management system of the whole screening process and the selection of high-risk subjects for individual recommendation for oral cancer screening.
We expect that the Nakatsu oral cancer screening program will increase people’s interest in oral diseases, and thereby reduce the mortality from oral cancer and prevent the decline in QOL after cancer treatment.

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Currently we are carrying out oral cancer screening in five cities and at a health care center in Oita. Among a total of 5,069 visitors from 2008 to 2016, seven patients with oral cancer （0.14％） and 133 patients with oral leukoplakia （2.62％） were found by visual and tactile examination. We regard oral cancer screening as a strategy for reducing the mortality from oral cancer as well as an educational activity for the general population concerning oral diseases. With this concept, both oral cancer screening and other enlightenment activities are being conducted. Although a decrease tendency in the rate of advanced oral cancers has not been evident in the past nine years, we consider that the oral cancer screening program and related activities should be continued for a long time to assess their effects on the mortality from oral cancer.

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To reduce the mortality rate due to oral cancer, early detection and treatment is extremely important. The Division of Oral and Maxillofacial Surgery, Tokyo Dental College, started oral cancer screening in cooperation with a local dental association in 1992. Mass screening of 13,265 subjects was performed between 1992 and 2013, and 11 cases of early oral cancer were detected （0.14%）. These achievements proved the effectiveness of screening. On the other hand, a dental association in Chiba city started opportunistic screening for oral cancer in 2006, and detected six cases of early oral cancer among 3,374 examined subjects （0.18%）. Opportunistic screening for oral cancer was more efficient to detect oral cancer than mass screening. Therefore, we consider that opportunistic screening including cytology, by general dentists at dental clinics, is particularly useful for early detection of oral cancer. Our strategy to improve the detection of early oral cancer is to establish a new screening system involving minimally invasive techniques such as fluorescence visualization and utilization of an IT network between dental clinics and hospitals with highly specialized oral and maxillofacial surgeons. We hope to help reduce the mortality rate due to oral cancer among Japanese citizens with this oral cancer screening system, and strongly recommend active collaboration between the government, companies, and academia in Japan for developing the system.

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Dedifferentiated adenoid cystic carcinoma（DACC）consists of a conventional neoplastic component with a highly-malignant transformed component. We present a case of DACC manifested in the palate. A 62-year-old woman visited our hospital with a complaint of contact pain on the left side of the palate. A 10-mm ulcer was seen at the left side of the hard palate. Enhanced CT revealed a tumor-like image extending into the nasal and paranasal cavity with destruction of bone. A biopsy specimen showed DACC. Metastases to the ipsilateral superior internal jugular and contralateral lateral retropharyngeal（Rouviere）lymph nodes and lung were revealed. Although concomitant chemoradiotherapy controlled the primary lesion and lymph node metastases, multiple metastases developed to the lung, liver and bone, resulting in death. The clinical and biological behavior of DACC is still unknown and so it is necessary to accumulate and analyze cases of DACC.

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Airway management is often difficult in patients with severe obesity. Approach to the trachea is interfered with by thickened adipose tissue during tracheotomy and there is a risk of dislocation of the tracheal cannula from the tracheal stoma at the flexion and extension site of the neck. We report here a case of airway management in a patient with severe obesity using tracheotomy combined with lipectomy in the perioperative period of advanced lower gingival cancer.
The patient was a 43-year-old man. The purpose of his visit was treatment of lower gingival cancer diagnosed previously at a local dental clinic. He presented with the complication of severe obesity （height 171cm; body weight 108kg; body mass index 36.8）. CT scan showed that the distance from the skin surface to the trachea was about 5cm at the level of the second tracheal cartilage ring. After the clinical examination, the patient was diagnosed as left lower gingival cancer （T4aN2bM0）. We performed tracheotomy, segmental resection of the mandible, modified radical neck dissection, and finally reconstructed the mandible with a titanium plate and anterolateral thigh flap. Medial tracheotomy was carried out with transverse incision and lipectomy to prevent dislocation of the tracheal cannula during the operation. After surgery, we used an adjustable tracheal cannula to fit the insertion length. On the fifteenth day after surgery, we terminated the airway management with tracheotomy because the patient’s condition had improved significantly.

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We report a case of tongue carcinoma for which the pathological diagnosis reported no metastasis even though some images strongly indicated metastasis. A 60-year-old woman with a left tongue border ulcer was referred to our outpatient clinic. She had a 2×3mm ulcer with a whitish lesion on the left tongue border that contacted the lingual malposed left lower second premolar. We performed excisional biopsy and tooth extraction under general anesthesia. Pathological diagnosis showed differentiated squamous cell carcinoma with clear margins. After 4 years and 2 months, she developed lymphadenopathy in the left submandibular region. Contrast computed tomography （CT） images showed a 10 mm lymphadenopathy in the left submandibular region. Lymphadenopathy in the left submandibular and superior internal jugular regions was also detected by contrast magnetic resonance imaging. The lymphadenopathy was further identified by positron emission tomography–CT （PET–CT）, with average standardized uptake values （SUV） of 3.71 and 3.44, respectively. Because neck ultrasonography indicated a collapsed or constricted hilum of the lymph nodes, we diagnosed neck metastasis from tongue cancer as the lymphadenopathy. Under informed consent, we performed a left radical neck dissection; 31 lymph nodes in the dissected tissue showed no cancer but rather lymphadenitis.

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We report a case of terminal stage mandibular gingival cancer treated with Mohs’ paste for chemosurgery under ambulatory care. An 84-year-old woman with lower gingival squamous cell carcinoma （T2N2bM0） had refused surgery, so chemoradiotherapy （S-1: 80 mg/day for 42 days, total dose of radiation: 60 Gy/30 fr） was administered. Post-treatment evaluation indicated complete remission. However, 18 months later, local recurrence of the tumor was confirmed in the same region. Two years and nine months later, the tumor infiltrated into the right mandibular skin and formed a pedicle. Additionally, blood and exudate were generated from the surface. Chemosurgery using Mohs’ paste under ambulatory care was planned and implemented. We applied Mohs’ paste to the tumor and removed the fixed part of the tumor without anesthesia after 24 hours. A similar operation was repeated until the tumor was reduced. Bleeding and exudate were controlled, and gauze replacement was reduced to once daily. However, her general condition gradually worsened, and she died at her home 3 months later. Chemosurgery with Mohs’ paste is useful for palliative care during the terminal stage and it seems to be useful for ambulatory and home medical care.

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