Optimization of therapeutic strategy for p16-positive oropharyngeal squamous cell carcinoma: Multi-institutional observational study based on the national Head and Neck Cancer Registry of Japan.

BACKGROUND: Although the American Joint Committee on Cancer TNM classification has been amended to include human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) as an independent entity, to the authors' knowledge the optimized de-escalating treatment modality has not been established to date. METHODS: The authors conducted a retrospective, nationwide, observational study in patients with HPV-related OPSCC who were treated from 2011 to 2014 in Japan to determine the best treatment modality. RESULTS: A total of 688 patients who were newly diagnosed with HPV-related OPSCC who were treated with curative intent at 35 institutions and had coherent clinical information and follow-up data available were included in the current study. In patients with T1-T2N0 disease (79 patients), both the 3-year recurrence-free survival and overall survival (OS) rates were 100% in the group treated with radiotherapy (RT) as well as the group receiving concurrent chemoradiotherapy (CCRT). The 3-year OS rates were 94.4% (for patients with T1N0 disease) and 92.9% (for patients with T2N0 disease) among the patients treated with upfront surgery. In patients with stage I to stage II HPV-related OPSCC, the 5-year recurrence-free survival and OS rates were 91.4% and 92%, respectively, in the patients treated with CCRT with relatively high-dose cisplatin (≥160 mg/m2 ; 114 patients) and 74.3% and 69.5%, respectively, in the patients treated with low-dose cisplatin (<160 mg/m2 ; 17 patients). CONCLUSIONS: Despite it being a retrospective observational trial with a lack of information regarding toxicity and morbidity, the results of the current study demonstrated that patients with T1-T2N0 HPV-related OPSCC could be treated with RT alone because of the equivalent outcomes of RT and CCRT, and patients with stage I to stage II HPV-related OPSCC other than those with T1-T2N0 disease could be treated with CCRT with cisplatin at a dose of ≥160 mg/m2 .

[Survey on the Choice of the Treatment in Elderly Patients with Head and Neck Cancer].

The elderly population has been increasing, in Japan. With this increase, the incidence of elderly patients with head and neck cancer is likely to increase concomitantly. Therefore, a strategy for addressing this problem must be defined. In this study, a questionnaire for head and neck cancer specialists, certified by the Japanese Society of Head and Neck Surgery, is analyzed. The survey was conducted in 225 head and neck cancer specialists, and 122 answers were complete and bare analyzed in this study. Comorbidity was found to be the most important factor in decision making for head and neck cancer, even though it is subclinical. Especially important was the cognitive state, the dysfunction of which might decrease the feeling of struggle against the disease. These results indicate that we must choose the appropriate treatment based on the evaluation of the physical and emotional condition of the patients and their families, not only on their age. However, this suggestion includes some problems, such as the fact that the criteria are not definite and the choice of the treatment might be at risk of being judged by only one doctor.

Descending necrotizing mediastinitis associated with Lactobacillus plantarum.

BACKGROUND: Descending necrotizing mediastinitis (DNM), a severe infection with a high fatality rate, develops in mediastinal spaces due mainly to deep cervical abscesses. The majority of causative microbes of DNM are Streptococci and oral anaerobes. DNM associated with Lactobacillus-infection is rather rare. CASE PRESENTATION: A 69-year-old male with an unremarkable past medical history was referred to our hospital for surgical resection of advanced laryngeal cancer. Full examination revealed a neck abscess and DNM with a background of untreated diabetes mellitus. Initially, he was treated with meropenem. However, Lactobacillus plantarum was isolated from surgical drainage of a mediastinal abscess. Despite using antibiotics capable of eradicating all isolates with susceptibilities not differing significantly from those of the neck and mediastinal abscesses, we attributed DNM to the L. plantarum detected only in the mediastinal abscess. After DNM treatment, he underwent total pharyngolaryngectomy with bilateral neck dissection followed by reconstruction using free jejunum. He was discharged fully recovered. CONCLUSION: We concluded that L. plantarum as the sole cause of the mediastinal abscess in the present case cannot be ruled out. As the number of immunocompromised patients increases, we should be cautious regarding this "familiar" microbe.

Downhill Varices in the Hypopharynx of a Patient with a Large Thyroid Tumor: A Case Report.

Downhill varices are usually caused by superior vena cava (SVC) obstruction due to bronchogenic carcinoma or mediastinal tumors. These structures exhibit retrograde blood flow and are located in the proximal esophagus. Varices in the hypopharynx resulting from mediastinal thyroid tumor are extremely rare. A 70-year-old man with a 35-year history of a growing thyroid tumor on the right side of his neck visited a local hospital. Fine-needle aspiration cytology of the tumor revealed benign goiter. Contrast-enhanced computed tomography showed a huge tumor (13 × 10 × 5 cm) in the right to left lobe of the thyroid that extended into the mediastinum. A well-enhanced mass mimicking hypopharyngeal cancer was identified in the hypopharynx. Endoscopic examination showed varices in the postcricoid region, so biopsy was contraindicated. The preoperative diagnosis was adenomatous goiter and hypopharyngeal varices caused by obstruction of the internal jugular and brachiocephalic vein by the goiter. Total thyroidectomy was performed and the hypopharyngeal varices had disappeared by the next day. The histopathological diagnosis of the thyroid tumor was poorly differentiated carcinoma. Mediastinal thyroid tumor rarely causes downhill varices due to SVC obstruction. However, signs of SVC obstruction were absent in this case, and varices were present in the hypopharynx, not in the upper esophagus. Obstructed venous flow from the thyroid plexus might circulate via the superior laryngeal vein and cause varices in the postcricoid region. When a patient with a large mediastinal tumor has a tumor-like lesion in the hypopharynx, downhill varices should be considered before scheduling a biopsy.

Head and neck small-cell carcinoma: A multicenter study of 39 cases from 10 institutions.

Objective: Basal information of head and neck small-cell carcinoma (HNSmCC) including epidemiology, primary site, treatment, and prognosis remains sparse due to its rarity. We report here a multicenter retrospective study on the diagnosis, treatment, and outcomes of patients with HNSmCC. Materials and methods: This study involved 47 patients with HNSmCC from 10 participating institutions. Eight patients were excluded for whom no pathological specimens were available (n = 2) and for discrepant central pathological judgements (n = 6). The remaining 39 patients were processed for data analysis. Results: As pretreatment examinations, computed tomography (CT) was performed for the brain (n = 8), neck (n = 39), and chest (n = 32), magnetic resonance imaging (MRI) for the brain (n = 4) and neck (n = 23), positron emission tomography-CT (PET-CT) in 23 patients, bone scintigraphy in 4, neck ultrasonography in 9, and tumor markers in 25. Primary sites were oral cavity (n = 1), nasal cavity/paranasal sinuses (n = 16), nasopharynx (n = 2), oropharynx (n = 4), hypopharynx (n = 2), larynx (n = 6), salivary gland (n = 3), thyroid (n = 2), and others (n = 3). Stages were II/III/IV-A/IV-B/IV-C/Not determined = 3/5/16/6/5/4; stage IV comprised 69%. No patient had brain metastases. First-line treatments were divided into 3 groups: the chemoradiotherapy (CRT) group (n = 27), non-CRT group (n = 8), and best supportive care group (n = 4). The CRT group included concurrent CRT (CCRT) (n = 17), chemotherapy (Chemo) followed by radiotherapy (RT) (n = 5), and surgery (Surg) followed by CCRT (n = 5). The non-CRT group included Surg followed by RT (n = 2), Surg followed by Chemo (n = 1), RT alone (n = 2), and Chemo alone (n = 3). The 1-year/2-year overall survival (OS) of all 39 patients was 65.3/53.3%. The 1-year OS of the CRT group (77.6%) was significantly better compared with the non-CRT group (31.3%). There were no significant differences in adverse events between the CCRT group (n = 22) and the Chemo without concurrent RT group (n = 9). Conclusion: Neck and chest CT, neck MRI, and PET-CT would be necessary and sufficient examinations in the diagnostic set up for HNSmCC. CCRT may be recommended as the first-line treatment. The 1-year/2-year OS was 65.3%/53.3%. This study would provide basal data for a proposing the diagnostic and treatment algorithms for HNSmCC.

A Completely Unique Branching Pattern of the Facial Artery.

This case report describes a recent case where a patient with hypopharyngeal cancer underwent resection and reconstruction with a free jejunum flap and the surgeons found a rare variation in the branching pattern of the common carotid artery. Specifically, the left facial artery arose directly from the common carotid artery, whereas the left superior thyroid artery arose from the facial artery. This branching pattern has not been reported previously. Although this is a hitherto unique case, head and neck and reconstructive surgeons should be aware of the possibility that this branching pattern may be present because it could complicate the outcomes of both neck dissection and reconstruction by free tissue transfer.

A Novel Tube-Drainage Technique of Negative Pressure Wound Therapy for Fistulae after Reconstructive Surgery.

BACKGROUND: Patients with head and neck or esophageal cancer who undergo resection and reconstructive surgery sometimes develop fistulae that exhibit delayed wound healing. We developed a novel negative pressure wound therapy (NPWT) that employs a Penrose drain. This case series report describes its effect on the wound healing and treatment duration of cancer patients with postoperative fistulae. METHODS: This consecutive case series consisted of all patients from February 2014 to February 2017 who underwent resection and reconstruction for head and neck or esophageal cancer and who then developed a fistula that was treated with either NPWT or a second flap that did not resolve the fistula or led to fistula recurrence and was then treated with NPWT. A Penrose drainage tube was inserted into the fistula, and a NPWT device was applied. RESULTS: Eleven patients (10 males, 1 female; mean age, 67.4 years) underwent NPWT for fistulae that arose after tumor resection and reconstruction (n = 6) or after fistula reconstruction (n = 5). The resection was for esophageal (n = 4), laryngeal (n = 3), oral (n = 2), and hypopharyngeal (n = 2) cancer. In 9 cases, 1 week of NPWT led to rapid and complete wound healing. In 2 cases, complete healing occurred after 3-4 weeks of NPWT. CONCLUSIONS: Our NPWT applies continuous negative pressure inside the fistula only and dramatically promoted fistula healing. This approach may work by cleaning the fistula and promoting mucosal surface adhesion. It is particularly effective when the tissue surrounding the fistula is soft due to fresh tissue transfer.

Carcinosarcoma ex Pleomorphic Adenoma of the Submandibular Gland in a 64-Year-Old Man: A Case Report.

Carcinosarcoma (CS) is a rare tumor, consisting of both carcinomatous and sarcomatous components. In this paper, we present a case of CS arising from a pleomorphic adenoma (PA) of the submandibular gland. A 64-year-old Japanese man presented with a left submandibular mass that had developed for 20 years with complaints of pain for the last 3 months. Magnetic resonance imaging showed a lesion involving the left submandibular gland. The patient underwent total dissection of the left submandibular gland and left cervical lymph nodes. Upon gross examination, the mass appeared completely covered by fibroadipose tissue measuring 46×42×45 mm; sectioning revealed a solid-white nodule with central bleeding and necrosis, invading into the surrounding adipose tissue. Microscopically, the presence of carcinomatous and sarcomatous components in the fibro-myxomatous stroma was detected, suggestive of pre-existing PA. The carcinoma component was diagnostic of salivary adenocarcinoma, not otherwise specified, whereas the sarcomatous component exhibited features of osteosarcoma characterized by formation of osteoid. As the border between the carcinomatous and sarcomatous components was not evident, CS may have occurred via transformation of the carcinoma into sarcoma. Tumor metastasis was detected in the cervical lymph nodes. Immunohistochemically, AE1/AE3 expression was noted in the carcinomatous component, but not in the osteosarcoma component. Both components were diffusely positive for vimentin. Four months after the operation, the patient developed a metastatic CS lesion in the lung, suggesting tumor aggression.

Phlegmonous gastritis associated with advanced esophageal cancer.

Phlegmonous gastritis is a rapidly progressive bacterial infection of the stomach wall. It has a high mortality rate and aggressive treatment, either with antibiotics or surgical resection, is required. Here, we report an extremely rare case of phlegmonous gastritis associated with advanced esophageal cancer. A 65-year-old Japanese man was urgently admitted to the hospital due to pyrexia and gastrointestinal symptoms. Abdominal computed tomography revealed widespread diffuse thickening of the gastric wall. On endoscopic examination, an ulcerative mass was detected at the lower thoracic esophagus, and a markedly elevated submucosal lesion was present in the middle of the stomach body. Biopsy specimens taken endoscopically from the esophageal tumor confirmed a diagnosis of squamous cell carcinoma. Gastric biopsy cultures were positive for Streptococcus viridans, leading to a diagnosis of phlegmonous gastritis associated with esophageal cancer. After the patient's condition improved with preoperative antibiotic administration, we performed a thoracoscopic esophagectomy, a total gastrectomy and a reconstruction of the gastrointestinal tract using a pedicled right colon. Histological examination of the resected specimen confirmed that the gastric mass was compatible with a phlegmon.

A comparison of microsurgical venous anastomosis techniques.

BACKGROUND: Successful vascular anastomosis is essential for the survival of transferred free tissue. Arterial anastomosis is typically uncomplicated because the lumen is easily maintained and the vessel walls have elasticity. Venous anastomosis, however, is more time consuming because the vessel walls are thin and extensible. This article describes, reviews, and compares 3 currently used venous anastomosis techniques. METHODS: From April 2012 through January 2014, free tissue transfer and supercharging pedicled tissue transfer were performed in 107 and 10 patients, respectively, at our hospital. According to the anastomotic technique used, patients (83 men and 34 women; mean age, 60.6 years) were divided into interrupted suture, continuous suture, and microvascular anastomotic coupling device (MACD) groups. Medical records were reviewed, and postoperative results were analyzed. RESULTS: The diameter of anastomosed veins did not differ significantly among the groups. However, among the interrupted suture, continuous suture, and MACD groups, there were significant differences in vascular anastomosis time (51, 43.9, and 29.5 minutes, respectively) and transferred tissue ischemic time (151.9, 139.1, and 117.5 minutes, respectively). Surgical site infection occurred in 9 patients, and flap necrosis occurred in 2 patients. However, complication rates did not differ significantly among the 3 groups. CONCLUSIONS: The venous anastomosis technique does not affect the complication rate but does affect anastomosis time and flap ischemia time. On the basis of these results, we believe that the continuous suture and MACD techniques are easier and safer for venous anastomosis than is the traditional interrupted suture technique.

Use of free flaps for reconstruction in head and neck surgery: a retrospective study of 182 cases.

OBJECTIVE: In order to clarify the factors affecting the survival of flaps, we performed a retrospective study on free flaps (187) used for reconstruction in head and neck surgery in 182 patients. METHODS: Free jejunum flaps were used on 68 occasions, rectus abdominus myocutaneous flaps on 67, radial forearm flaps on 49, scapular osteocutaneous flaps on 2 and latissimus dorsi myocutaneous flap on ones occasion, during the period from May 1996 to April 2003. Post-operative circulatory complications at the recipient site were analyzed mainly in relation to a history of previous surgery, radiotherapy and chemotherapy. RESULTS: Circulatory crisis was observed in seven cases and circulation was restored in two of them after emergency exploration, whereas the other five flaps failed to survive. The overall failure rate of free flaps was 2.7%. Wound infection at the recipient site was frequent in patients with a history of previous local cervical surgery. Flap failure was significantly more frequent in patients with a history of previous surgery and infection, except for 2 patients in whose case the microsurgical technique was inadequate. Flap failure was not observed in those patients whose irradiation field could be analyzed, or in the patients who received chemotherapy. Although the incidence of circulatory crisis as a consequence of inadequate microsurgical technique was observed in the early period of this retrospective study, their frequency has diminished in the last 2 years. CONCLUSION: The survival of flaps was affected by a history of previous surgery following wound infection, although a history of irradiation and chemotherapy would have no effects on flap failure. The appropriate choice of vessels and surgical skill are crucial for the success of free flaps from our experience. Emergency exploration was also crucial for the survival of the flap in the case of circulatory crisis.

Malignant fibrous histiocytoma of the hypopharynx: a case report in a young adult.

This is the first case report of malignant fibrous histiocytoma of the hypopharynx in a young adult with preservation of the larynx. Although the initial histopathological diagnosis of the biopsy was benign fibrous histiocytoma, subsequent histopathological evaluation of the surgical specimen was malignant fibrous histiocytoma. Thereafter, re-excision of the histiocytoma with a wide margin was performed coupled with reconstruction of the hypopharynx while preserving the larynx. We also report the good long-term survival of this case of low-grade type of malignant fibrous histiocytoma.

Significance of preserving the posterior branch of the great auricular nerve in parotidectomy.

OBJECTIVE: Sensory disturbance due to excision of the great auricular nerve in patients who have undergone parotidectomy sometimes causes discomfort to the patients. In order to reduce the postoperative discomfort of the pinna, we tried to preserve the posterior branch of the great auricular nerve. METHODS: Forty patients with parotid tumor were included in this study. Twenty-one of these patients had pleomorphic adenoma, 16 had adenolymphoma and 3 had a low grade malignant tumor. Sensations of the pinna and the quality of life (QOL) after parotidectomy were evaluated using a 0-100 Visual Analogue Scale (VAS) assessed at 2 weeks, 1 month, 2 months, 3 months and 6 months after parotidectomy. RESULTS: The posterior branch of the great auricular nerve was preserved in 26 out of 40 patients (65%). No difference was observed in the incidence of complications except sensory disturbance of the pinna with this surgical procedure as compared to the surgical technique where the great auricular nerve was excised. The VAS score for the sensation was significantly higher in the group of patients whose great auricular nerve was preserved at 2 months (35.0+/-20.8 vs. 18.5+/-9.2), 3 months (64.4+/-18.3 vs. 26.4+/-13.8) and 6 months (66.9+/-16.2 vs. 26.6+/-11.4) after parotidectomy. The VAS score for the QOL was also significantly higher in the group of patients whose great auricular nerve was preserved at 2 months (50.3+/-21.8 vs. 35.1+/-14.5), 3 months (69.5+/-27.5 vs. 45.9+/-22.6) as well as 6 months (71.9+/-24.1 vs. 45.7+/-19.1) after parotidectomy. CONCLUSION: Preservation of the posterior branch of the great auricular nerve during parotidectomy is valuable in order to reduce the postoperative sensory disturbance of the pinna that follows conventional surgery. It further helps to improve the QOL of these patients after parotidectomy.

Reconstruction after resection of malignant parapharyngeal space tumor.

Primary malignant tumor of the parapharyngeal space (PPS) is rare. After surgical resection, primary closure could be considered if the oropharynx mucosa remains. This report describes two patients who underwent reconstruction by free tissue transfer after the resection of PPS tumors. This report was presented at the 56th annual meeting of the Japanese Society of Plastic and Reconstructive Surgery, 4 April, 2013.

Surgical management of tongue cancer during pregnancy.

There are ethical dilemmas in managing head and neck cancers during pregnancy. Diagnostic and treatment modalities need to be carefully determined. We herein describe 3 cases of tongue cancer during pregnancy. The details of the management would contribute to the daily practices for head and neck cancers. All three patients were Japanese female patients, two of them were 29 years old and one was 26 years old. All patients were admitted to the Nippon Medical School Hospital during pregnancy, complaining of oral pain and/or discomfort. Case 1 was diagnosed as tongue cancer stage T3N0M0, however, the tumor was superficial and controllable by partial glossectomy. Case 2 was stage T2N0M0 with deep invasion with ulcer, and the hemi-glossectomy with neck dissection and the reconstruction was thought to be the standard modality. However, she underwent partial glossectomy in order to reduce the stress of the fetus. Case 3 could not be diagnosed on admission by biopsy and she underwent partial glossectomy after delivery. In case 3, the pathological diagnosis was pT1 tongue cancer. In case 1 and case 3, the patient and baby were healthy. In case 2, however, the patient died of recurrence at the primary site. In decision making of the strategy, the most important factors are not only oncological evaluation but also ethical and emotional factors.

Three cases of carcinoma of the hypopharynx developing as metachronous second primary cancers after total laryngectomy with radiotherapy for carcinoma of the larynx.

We describe 3 cases of metachronous hypopharyngeal cancer developing after laryngeal cancer had been treated with both radiotherapy and total laryngectomy. All 3 patients were men, 2 were 89 years old, and 1 was 65 years old. All patients had undergone total laryngectomy and radiotherapy for cancer for the glottis more than 20 years earlier. All patients underwent total hypopharyngectomy with jejunal free flap reconstruction. Surgery was complicated by scars from previous cancer treatment, and highly sophisticated surgical skills are needed, especially for preparing the recipient vessels. The postoperative period was largely uneventful and without fatal complications, however, 2 of the 3 patients died of distant metastasis 22 months and 31 months after surgery.