Indications for sentinel lymph node biopsy in node-negative oral cancers.

BACKGROUND: We aimed to define the indications for sentinel lymph node biopsy (SLNB), the third option for cervical treatment in oral cancer with negative cervical lymph nodes. METHODS: The greatest depth of invasion (DOI) and long diameter (LD) of the primary site were used as exposures. SLN metastasis was considered the outcome. RESULTS: In three trials conducted between 2009 and 2016, 158 patients were eligible and reassigned to this study group. The scatterplot based on the respective values of DOI and LD would eventually be divided into three sections. In cases of sections T1, T2, and T3, the proportions of SLN metastasis positivity were 21.3%, 35.3%, and 51.2%, respectively. In certain cases of T1 with 2 mm < DOI ≤ 5 mm and 8 mm < LD ≤ 20 mm, the proportion of SLN metastasis positivity was 40.9%. CONCLUSIONS: SLNB-navigated or assisted neck dissection can be added as an effective procedure for N0 neck control.

Distribution pattern and pathologic analysis of metastatic sentinel and non-sentinel lymph nodes in lymphatic basin dissection for clinical T2/T3 oral cancer with clinical N0 status.

OBJECTIVE: The localization pattern of metastatic sentinel lymph node (SN) and non-SNs and pathologic analysis of metastatic lymph nodes in SN lymphatic basin dissection (SLBD) were investigated in patients with cT2/T3cN0 oral squamous cell carcinoma (OSCC). METHODS: This prospective multicenter trial involved 10 institutions nationwide in Japan. A total of 57 patients were enrolled. The lateral neck was divided into 5 lymphatic basins. The lymphatic basin containing SNs was defined as the SN lymphatic basin. All patients underwent SLBD with backup selective neck dissection (I-III) combined with primary tumor removal. When SNs were found outside of levels I-III, including in the contralateral neck, SLBD was performed by removing the compartments containing SNs separately. SN metastasis was classified as isolated tumor cells (ITCs), micrometastasis, or macrometastasis. ITCs are defined as a lesion no larger than 0.2 mm in largest dimension and are classified as pN0. RESULTS: SN metastasis was observed in 22 cases. All metastatic lymph nodes, including false-negative cases, were detected in the SN lymphatic basin. Isolated tumor cells in the SNs did not affect prognosis, whereas micrometastasis tended to have poor prognosis. After adjusting for other risk factors, a positive SN remained a significant predictor of poor 5-year overall survival in pT2-4 OSCC. CONCLUSION: SLBD for intraoperative SN biopsy is a sufficient therapeutic procedure and is valuable for determining pathologic nodal stage in OSCC. SN positivity was demonstrated to be an independent predictor of poor prognosis in patients with pT2-4 disease undergoing SLBD with backup selective neck dissection (I-III).

Neck Dissections Based on Sentinel Lymph Node Navigation Versus Elective Neck Dissections in Early Oral Cancers: A Randomized, Multicenter, and Noninferiority Trial.

PURPOSE: This study aimed to compare patients with early oral cavity squamous cell carcinoma (OCSCC) (tumor category [T] 1-2, node-negative, and no distant metastasis) treated with traditional elective neck dissection (ND) with those managed by sentinel lymph node biopsy (SLNB) using survival and neck function and complications as end points. METHODS: Sixteen institutions in Japan participated in the study (trial registration number: UMIN000006510). Patients of age ≥ 18 years with histologically confirmed, previously untreated OCSCC (Union for International Cancer Control TNM Classification of Malignant Tumors 7th edition T1-2, node-negative no distant metastasis), with ≥ 4 mm (T1) depth of invasion, were randomly assigned to undergo standard selective ND (ND group; n = 137) or SLNB-navigated ND (SLNB group; n = 134). The primary end point was the 3-year overall survival rate, with a 12% noninferiority margin; secondary end points included postoperative neck functionality and complications and 3-year disease-free survival. Sentinel lymph nodes underwent intraoperative multislice frozen section analyses for the diagnosis. Patients with positive sentinel lymph nodes underwent either one-stage or second-look ND. RESULTS: Pathologic metastasis-positive nodes were observed in 24.8% (34 of 137) and 33.6% (46 of 134) of patients in the ND and SLNB groups, respectively (P = .190). The 3-year overall survival in the SLNB group (87.9%; lower limit of one-sided 95% CI, 82.4) was noninferior to that in the ND group (86.6%; lower limit 95% CI, 80.9; P for noninferiority < .001). The 3-year disease-free survival rate was 78.7% (lower limit 95% CI, 72.1) and 81.3% (75.0) in the SLNB and ND groups, respectively (P for noninferiority < .001). The scores of neck functionality in the SLNB group were significantly better than those in the ND group. CONCLUSION: SLNB-navigated ND may replace elective ND without a survival disadvantage and reduce postoperative neck disability in patients with early-stage OCSCC.

Attempting to define sentinel node micrometastasis in oral squamous cell carcinoma.

OBJECTIVE: The aim of this supplemental study of a sentinel node (SN) biopsy (SNB) trial for oral squamous cell carcinoma (OSCC) was to assess the effectiveness in identifying micrometastasis and determining whether elective neck dissection (END) is necessary. MATERIALS AND METHODS: Twenty-three patients with pathologically positive SNs were included. The sizes of the metastatic lesions in positive SNs (SMSNs) were classified and the rates of occult metastasis of non-SNs were compared. RESULTS: The patients were divided according to the SMSN:<0.2 mm (group A, n=3);0.2 mm to <2.0 mm (group B, n=7);and ≥2.0 mm (group C, n=13). The rates of occult metastasis in groups A, B, and C were 0% (0/3), 14% (1/7) and 23% (3/13), respectively. CONCLUSION: Rare cancer cell distribution to nodes other than SNs was observed in the patients with SN metastatic lesions of at least smaller than 0.2 mm in size, suggesting the possibility of defining SN micrometastasis in N0 OSCC.

Long term-follow-up multicenter feasibility study of ICG fluorescence-navigated sentinel node biopsy in oral cancer.

In the current study, the utility of sentinel node (SN) identification using indocyanine green (ICG) was investigated for oral cancers in the clinical N0 stage. The current study was a prospective, multicentre, phase II clinical trial that was conducted in Japan. A total of 18 patients were included. Before surgery, the patients underwent lymphoscintigraphy to map the SNs. During surgery, radioactive isotope (RI) mapping was used to detect the SNs, and ICG was subsequently injected. ICG mapping of the SNs was then performed through the skin. The primary tumour was resected, and a neck flap was elevated for neck dissection, followed by SN biopsy (SNB) using RI or ICG mapping. With the RI method, a total of 63 SNs were detected. Among these SNs, 8 (12.7%) were positive for metastasis, including those with isolated tumour cells (ITCs). The median number of SNs per patient identified by SNB was 4. With the ICG method, a total of 67 SNs were detected. Among these SNs, 7 (10.4%) were positive for metastasis, including those with ITCs. The median number of SNs per patient identified by SNB was 4 (range, 1-6). The 5-year overall survival (OS) of all patients was 83.3%, and the 5-year disease-free survival (DFS) of all patients was 76.7%. The neck compression technique is a simple method that can be used to facilitate surgical procedures of ICG fluorescence navigated SNB for head and neck cancer.

Minimally invasive surgery for laryngopharyngeal cancer: Multicenter feasibility study of a combination strategy involving transoral surgery and real-time indocyanine green fluorescence-navigated sentinel node navigation surgery.

BACKGROUND: Sentinel node navigation surgery using indocyanine green (ICG-SNNS) can be performed in the operation room. The combination of minimally invasive transoral surgery (TOS) with ICG-SNNS can provide functional preservation options for both primary lesions and lymph node (LN) metastasis. This multicenter feasibility study of this strategy was conducted in Japan. METHODS: Patients with clinical T1 or T2, N0 oropharyngeal, hypopharyngeal, or supraglottic cancer were enrolled. The identification rate of sentinel nodes, delayed cervical LN metastasis in 2 years, and survival rate were assessed. RESULTS: Twenty-two patients (10 oropharynx, 8 hypopharynx, 4 supraglottic cancer) were enrolled. The identification rate was 100%. One case had delayed nodal metastasis. The accuracy was 95.5%, sensitivity was 75%, and specificity was 100%. The 5-year disease-specific survival was 100%, overall survival was 72.3%, and disease-free survival was 60.5%. CONCLUSIONS: The combination of TOS with ICG-SNNS is feasible as a minimally invasive strategy and has favorable oncological outcomes.

Sentinel node biopsy for oral cancer: A prospective multicenter Phase II trial.

OBJECTIVE: A recent study identified a survival benefit with prophylactic neck dissection (ND) at the time of primary surgery as compared with watchful waiting followed by therapeutic neck dissection for nodal relapse, in patients with cN0 oral squamous cell carcinoma (OSCC). Alternative management of cN0 neck cancer is recommended to minimize the adverse effects of ND, indicating the need for sentinel node biopsy (SNB) and limited neck dissection. We conducted a multicenter Phase II study to examine the feasibility of SNB for clinically N0 OSCC. METHODS: Previously untreated N0 OSCC patients (n=57) with clinical late-T2 or T3 tumors were enrolled across 10 institutions. SNB navigated with multislice frozen section analysis of sentinel nodes (SNs) and SNB supported sentinel node lymphatic basin dissection (SN basin dissection) were performed in a one-stage procedure. The endpoint was to investigate the rate of false-negative metastases after SN basin dissection and SNB alone. RESULTS: Most tumors were late-T2 lesions (n=50; 87.7%). SNs were identified in all patients. A total of 196 SNs were detected. Among these SNs, 35 (17.8%) were positive for metastasis (9 in level I, 12 in level II, 12 in level III, 1 in level V and 2 in the contralateral region of the neck). The false-negative rate of SNB supported by SN basin dissection and SNB alone was 4.5% and 9.1%, respectively. The concordance of the SN status in intraoperative frozen sections with the permanent histopathology was 97.4% (191/196). The sensitivity and specificity of intraoperative pathological evaluation were 85.7% (30/35) and 100% (30/30), respectively. The 3-year overall survival (OS) and disease-free survival was 89.5% and 82.5%, respectively. The OS of SN-negative patients was significantly longer than that of SN-positive patients (P=0.047). CONCLUSION: The current study verified that SN basin dissection was a useful back-up procedure for SNB performed as a one-stage procedure, showing a low false-negative rate. SNB alone is an appropriate staging method for patients with clinical N0 staging, and a reliable procedure to determine the appropriate levels for neck dissection.

Impact of Endoscopic Indocyanine Green Fluorescence Imaging on Superselective Intra-arterial Chemotherapy for Recurrent Cancer of the Skull Base.

BACKGROUND/AIM: For advanced paranasal sinus cancer, intra-arterial (I-A) chemotherapy has been applied for improving prognosis and organ preservation. While computed tomographic angiography (CTA) is useful for identifying the tumor-feeding artery, CTA cannot always detect the precise artery. The aim of this study was to assess the feasibility of endoscopic ICG (indocyanine green) fluorescence technique during I-A chemotherapy for recurrent skull-base cancer. PATIENTS AND METHODS: Seven patients with recurrent skull-base cancer were included in this study. Conventional CTA followed by ICG was administered. Additional information regarding tumor-feeding arteries attained via ICG was evaluated. RESULTS: Out of seven cases, the blood supply to the cancer was detected in three by CTA alone. By adding the endoscopic evaluation, the blood supply to the tumor was confirmed without difficulty in all cases. The information from endoscopic fluorescence imaging was helpful in making decisions concerning the administration of drugs for skull-base cancer. CONCLUSION: Endoscopic ICG fluorescence imaging combined with I-A chemotherapy compensated for deficiencies of CTA and generated more useful information about the feeders to tumors than was previously available.

Significant preservation of swallowing function in chemoradiotherapy for advanced head and neck cancer by prophylactic swallowing exercise.

BACKGROUND: Dysphagia is a serious complication of chemoradiotherapy (CRT) in patients with head and neck cancer. Approximately 20% to 30% of patients who have dysphagia require feeding tubes. The purpose of this study was to evaluate the impact of prophylactic swallowing exercises on swallowing function. METHODS: Fifty-one patients with advanced oropharyngeal, hypopharyngeal, and laryngeal cancers were included in this study. Twenty-one patients performed the Shaker exercise and 30 practiced traditional Mendelsohn maneuvers (control group). Before and after treatment, videofluoroscopy and swallowing motion were analyzed to establish movement of the hyoid bone, larynx, and aspiration scores. RESULTS: Average movement of the hyoid bone, thyrohyoid shortening, and upper esophageal sphincter opening were significantly better maintained in the Shaker group. Aspiration score of the Shaker exercise was significantly lower than control group. Feeding tube rates for the Shaker and control groups were 14% and 40% (p < .05). CONCLUSION: Shaker exercises as a prophylactic exercise contributed to preservation of swallowing function in patients with head and neck cancer.

Primary Tumor-Secreted Lymphangiogenic Factors Induce Pre-Metastatic Lymphvascular Niche Formation at Sentinel Lymph Nodes in Oral Squamous Cell Carcinoma.

OBJECTIVES: The objectives of this study were to evaluate the formation of lymphvascular niches in lymph nodes of patients with oral squamous cell carcinoma (OSCC), and investigate the roles of lymphangiogenic and angiogenic factors, such as vascular endothelial growth factor (VEGF)-A, VEGF-C, and VEGF-D, expressed in the primary tumors. MATERIALS AND METHODS: Forty-four patients with previously untreated clinically late T2 or T3 OSCC of cN0 were evaluated for primary tumors and 166 sentinel lymph nodes (SLNs). Primary tumors were immunohistochemically analyzed for expressions of VEGFs. Densities of lymphatic vessels (LVDpodoplanin) and high endothelial venules (HEVD) in the SLNs were also calculated using antibodies for each marker, podoplanin and MECA-79, respectively. RESULTS: In 25 patients, all lymph nodes were metastasis-negative, whereas, in 19 patients, metastasis was positive for at least one lymph node (either at SLN, non-SLN, or nodal recurrence). From the analyses of 140 SLNs without metastasis, LVDpodoplanin in 50 SLNs of metastasis-positive cases was significantly higher than that in 90 SLNs of metastasis-negative cases (p = 0.0025). HEVD was not associated with lymph node metastasis. The patients with VEGF-A-High or VEGF-D-High tumors had significantly higher LVDpodoplanin than patients with their Low counterparts (p = 0.0233 and p = 0.0209, respectively). In cases with lymph node metastasis, the VEGF-D-expression score was significantly higher than in those without lymph node metastasis (p = 0.0006). CONCLUSIONS: These results suggest that lymph node lymphangiogenesis occurs before metastasis in OSCC. VEGF-A and VEGF-D play critical roles in this process. VEGF-D is a potential predictive marker of positive lymph node metastasis in cN0 patients.

Massive myoepithelial carcinoma originating from the submandibular gland that was successfully treated with surgical excision, using a part of the lengthened skin as a local flap.

Myoepithelial carcinoma is rare and mostly originates from the major salivary glands. Sometimes, it is difficult to differentiate the benign from the malignant histologically, and its clinical behavior and histological features may vary. Here, we describe the case of a 55-year-old woman who presented with a massive myoepithelial carcinoma, which hung like a temple bell from her right side of the jaw, and she refused to go to the hospital for 3 years. Based on its size and location, we initially thought that, before surgical resection, neoadjuvant therapy would be necessary to reduce the tumor volume. However, after careful evaluation of the tumor characteristics (low-grade histology with outward expansion and little invasion of the adjacent tissues) and imaging findings, we decided that excision was possible. The tumor was encapsulated and had a clear border; it weighed 10.5 kg. By setting the incision line posterior to the equatorial plane and using the lengthened skin posterior to the tumor as a large local flap for the skin defect, we successfully reconstructed the skin defect without harvesting additional flap from other areas. No additional treatment was administered because a sufficient surgical margin was maintained, pathologically. She regained her daily life without recurrence or distant metastasis for 2 years. When treating a massive tumor, careful consideration of its characteristics and location is important, and in this case, we were able to use a simpler and less invasive treatment than we initially envisioned.

Cytological features of mammary analogue secretory carcinoma of the parotid gland in a 15-year-old girl: a case report with review of the literature.

Mammary analogue secretory carcinoma (MASC) is a recently recognized tumor of salivary glands characterized by the ETV6-NTRK3 fusion gene. This tumor is very rare in children and adolescents. We report a case of MASC in a 15-year-old girl, the fifth youngest case so far reported. The patient complained of a left infra-auricular mass that gradually enlarged for a year. Fine-needle aspiration cytology/imprint cytology showed individual tumor cells that had faintly eosinophilic granular cytoplasm with secretion granules sometimes seen adjacent to the tumor cells. These cytological features overlapped between those of zymogen granule-poor acinic cell carcinoma (AciCC) and MASC. In addition to the case report, we present a review of the related literature with a focus on the cytological features of MASC. The differential diagnostic clues are also discussed.

A novel procedure combining transoral resection and set-back tongue flap for oropharyngeal cancer.

Seven patients with advanced lateral oropharyngeal cancer (T3N2bM0, or T4N2bM0) underwent transoral lateral oropharyngectomy (TLO) with reconstruction performed through set-back tongue flap and polyglycolic acid (PGA) sheet. TLO was performed following en bloc resection of tumors using endoscopy. To cover the resulting defect in the lateral oropharyngeal wall, the set-back tongue flap was moved posteriorly and laterally to the area of the tongue base and lateral pharyngeal wall. The tip of the set-back tongue flap was sutured to the lateral pharynx to reconstruct the elevated tongue base and altered anterior pillar. The defect on the floor of the mouth was reconstructed using a PGA sheet. Following surgery, the mean observation period was 24 months. The mean operating time was 4 h and 2 min, with an average blood loss of 68.1 ml. All oral intake resumed on the first postoperative day via gastric tube. The mean gastric tube removal time was 1.6 postoperative days as a result of sufficient oral intake. None of the patients received postoperative radiotherapy or displayed evidence of tumor recurrence. We conclude that this novel procedure is highly effective for treating advanced oropharyngeal cancer as it demonstrates good prognostic and functional outcomes.

Advantages of superficial femoral vein grafts for carotid artery reconstruction following carotid artery resection in the treatment of head and neck cancer.

CONCLUSION: Reconstruction of the carotid artery using the superficial femoral vein (SFV) is very effective due to the ease in harvesting the vessel and its optimal size and length for carotid artery replacement. OBJECTIVES: To evaluate the effectiveness of carotid artery reconstruction using the SFV. METHODS: Ten patients with malignant tumors involving the carotid artery underwent carotid artery resection followed by reconstruction with the SFV. The SFV between the deep femoral vein and branches to the great saphenous vein and deep femoral vein at the popliteal region was used as a reconstructive vessel. RESULTS: The mean length and diameter of the grafted SFVs were 13.9 cm and 11.2 mm, respectively. The mean time for acquisition of SFV was 18 min. Ultrasonography measurements indicated that the mean lumen diameter of the common carotid artery was 8.37 mm. None of the patients experienced any permanent neurologic complications. The 2-year and 5-year overall survival rates were 60% and 40%, respectively. En bloc resection of the cancer and involved carotid artery followed by reconstruction with the SFV provides effective locoregional control. Our results indicated no postoperative vascular graft thrombosis and no donor site complications.

Volumetric comparison of positron emission tomography/computed tomography using 4'-[methyl-¹¹C]-thiothymidine with 2-deoxy-2-¹8F-fluoro-D-glucose in patients with advanced head and neck squamous cell carcinoma.

OBJECTIVE: We prospectively compared the diagnostic value of PET/computed tomography (CT) findings using the tracers 4'-[methyl-11C]-thiothymidine (11C-4DST) and 2-deoxy-2-18F-fluoro-D-glucose (18F-FDG) in patients with head and neck squamous cell carcinoma (HNSCC). PATIENTS AND METHODS: Thirty-eight patients with advanced HNSCC underwent 11C-4DST PET/CT and 18F-FDG PET/CT before treatment. Maximum standardized uptake values (SUVmax) were measured for both PET/CT studies; in addition, total lesion glycolysis (TLG) of 18F-FDG PET/CT and total lesion proliferation (TLP) of 11C-4DST PET/CT were measured. Absolute TLG and TLP values as well as values with various SUV thresholds were measured. All patients were followed up for 13.5±7.5 months (mean±SD) to monitor recurrence. RESULTS: A statistically significant correlation was observed between the primary tumor SUVmax for 11C-4DST PET/CT and 18F-FDG PET/CT (r=0.46, P<0.01). TLP values with SUV thresholds strongly correlated with TLG values relative to the same thresholds (r=0.60-0.92, P<0.001). Nine of the 38 patients with post-treatment recurrence were identified. Receiver operating characteristic curves for TLG3.0 and TLP2.5 showed the highest prognostic ability for recurrence; the sensitivity and specificity of TLG3.0 were 89 and 72%, respectively, and the sensitivity and specificity of TLP2.5 were 89 and 55%, respectively. CONCLUSION: In patients with advanced HNSCC, the TLP of 11C-4DST PET/CT strongly correlated with the TLG of 18F-FDG PET/CT. Although there were no large differences between these values, the receiver operating characteristic curves of the absolute TLG had slightly better prognostic ability for recurrence.

Relationship between insulin-like growth factor-1 receptor and human papillomavirus in patients with oropharyngeal cancer.

BACKGROUND: Human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (SCC) is associated with better prognosis than HPV-negative oropharyngeal SCC. The purpose of this study was to assess the expression of insulin-like growth factor-1 receptor (IGF-1R) in patients with oropharyngeal SCC, its relationship to HPV status and various clinical parameters, and its relationship with clinical outcome. METHODS: The study subjects were 59 patients with oropharyngeal SCC. IGF-1R expression was examined by immunohistochemistry in paraffin-embedded tumor tissues. HPV status was evaluated by in situ hybridization (ISH) in the same tissues. RESULTS: IGF-1R did not correlate with clinical parameters, but IGF-1R expression was more common in HPV-negative tumors than in HPV-positive tumors. The prognosis was poorer in patients of the IGF-1R-positive group than in the IGF-1R-negative group. CONCLUSION: The results suggested that IGF-1R expression in oropharyngeal SCC correlated with poor prognosis in HPV-negative patients. Treatment targeting IGF-1R could potentially improve the survival of patients with HPV-negative oropharyngeal SCC.

A novel procedure for transtracheal resection for recurrent thyroid cancer involving a trachea and esophagus.

BACKGROUND: Surgery remains the main treatment for locally advanced thyroid cancers invading the trachea, esophagus, and recurrent laryngeal nerve. However, extensive resection of such tumors can sometimes involve difficulties and may result in the deterioration of the patient's quality of life. The surgeon should consider not only the patient's prognosis but also the preservation of postoperative function. METHODS: This report describes a minimally invasive surgical procedure for recurrent poorly differentiated papillary thyroid carcinoma involving the trachea and esophagus. To decrease the potential for recurrent laryngeal nerve injuries and to preserve both the tracheal and esophageal blood supply, we adapted a transtracheal approach; the recurrent tumor was safely and completely removed without causing a dysfunction. After a tracheotomy to the right, the tumor was easily detected through the tracheostoma and delineated by palpation. The mucous membrane of the trachea was minimally incised along the right-hand border of the tumor and a mucosal flap was elevated. The left side of the trachea including the membranous wall and cartilage of the tracheal mucosa was maximally preserved, to maintain the vascular supply to the trachea. Finally, the membranous wall of the trachea was preserved to within one-third of the left-hand side. Furthermore, the risk of bleeding from major lateral vessels was reduced. A sternocleidomastoid muscle flap was elevated and inserted into the cavity resulting from the tumor resection and sutured between the esophagus and trachea. The membranous wall of the tracheal mucosa was also sutured submucosally. RESULTS: The tumor was removed completely with the muscular layer of the esophagus without injury to the intact recurrent laryngeal nerve and lateral major vessels. The patient started oral nutritional intake on the first postoperative day and was discharged without any significant postoperative complications. CONCLUSIONS: This new procedure for transtracheal resection for recurrent thyroid cancer involving the trachea and esophagus was useful and safe.

A novel procedure for reconstruction utilizing superficial femoral vein grafts following en bloc resection of carotid artery and head and neck malignant tumours.

OBJECTIVES: The objective of our study was to investigate the effectiveness of reconstructing the carotid artery using a superficial femoral vein (SFV). METHODS: Ten patients with malignant tumours involving the carotid artery underwent carotid artery resection and reconstruction with the SFV. We use the SFV between the deep femoral vein and perforator branches to the great saphenous vein or deep femoral vein at the popliteal region reconstructive vessel. RESULTS: The mean length and diameter of the grafted SFVs were 13.9 and 11.2 mm, respectively. The mean time for SFV acquirement was 18 min. The mean cerebral ischaemic period was 23.1 min. Nine patients did not experience any neurological complications. One patient experienced slight temporary hemiparesis. There was no postoperative vascular graft thrombosis. Donor site complications did not occur. CONCLUSIONS: Reconstructing the carotid artery using an SFV is very effective due to the ease in harvesting the vessel and its optimal size and length for carotid artery replacement.

Impact of removing mastoid process for advanced parotid cancer on facial nerve identification, preservation and reconstruction.

BACKGROUND: Advanced parotid cancers more than 4 cm are firmly fixed around the main trunk of the facial nerve that can be hardly detected in narrow working space between mastoid process and parotid cancer. Even though facial nerve was preserved, facial nerve stretching during surgery has significantly serious effect on postoperative facial palsy. OBJECTIVE: To evaluate usefulness of removing mastoid process in managing advanced parotid cancers to contribute identifying and preserving facial nerve. METHOD: The study was performed on 18 advanced parotid cancers which was more than 4 cm and invaded around the facial nerve. Thirteen cases were fresh cases and 5 were recurrent cases.According to a modified Blair incision, the sternocleidomastoid muscle is detached from the mastoid process with electrocautery. When the mastoid process is removed, the main trunk of the facial nerve can be observed from stylomastoid foramen.This procedure was evaluated based on the duration of surgery, working space, and postoperative facial nerve function. RESULTS: In eleven cases, facial nerves were sacrificed. Negative margins were achieved in 100% of the patients. The mean duration for removing of the mastoid process to identify facial nerves was 4.6 minutes. The mean size of the removed mastoid process was 2.1 cm in height and 2.3 cm in width, and 1.8 cm in depth. The extended mean working space was 16.0 cm3, and, as a result, the tumors could be resected without retraction. CONCLUSION: Removing the mastoid process for advanced parotid tumors facilitates identification of the facial nerve and better preservation of the facial nerve function.