Successful detection of a minute tonsillar cancer lesion on transoral examination with narrow band imaging: A report of 2 cases.

BACKGROUND: The improvement of optical enhancement devices, such as narrow band imaging (NBI), has enabled us to visualize lesions that cannot be seen upon macroscopic examination. NBI is useful for detecting subtle lesions, including the primary sites of occult primary cancer. METHODS AND RESULTS: We describe 2 cases of tiny tonsillar cancer with positive p16 staining. Case 1 was as an occult primary cancer, and case 2 had a foreign body sensation of the pharynx. With transoral examination using a flexible video-laryngoscope with NBI, we successfully detected tonsillar cancer. These patients were treated with surgery, and the patients are currently alive with no evidence of disease more than 1 year posttreatment. CONCLUSION: We detected a small primary lesion in the palatine tonsil through transoral examination with NBI, which is a simple and noninvasive method. This approach may be useful to detect subtle lesions, especially in patients with human papillomavirus (HPV)-related tonsillar cancer. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2421-E2424, 2016.

The predictive role of infiltrative growth pattern in early pharyngeal cancers.

CONCLUSION: The infiltrative growth pattern may predict tumor depth and lymph node metastasis. INF-a seems to fall into a low-risk category, and no additional treatment may be required immediately. OBJECTIVES: Tumor depth is a predictor of lymph node metastasis in early pharyngeal cancers. An infiltrative growth pattern is also a prognostic factor in other cancers. This study aimed to elucidate the predictive role of infiltrative growth pattern in early pharyngeal cancers. METHODS: Thirty-eight lesions from 37 patients who had undergone trans-oral resection of pharyngeal cancers were included. According to the Japanese Classification of Esophageal Cancer, infiltrative growth pattern was classified into three groups; INF-a, INF-b, and INF-c. The correlation between infiltrative growth pattern and tumor depth, cervical lymph node metastasis was analyzed. RESULTS: Of the 38 lesions, 25 were INF-a, nine were INF-b, and four were INF-c lesions. Lymph node metastasis was observed in three INF-b and one INF-c lesions. In contrast, no INF-a had lymph node metastasis. All INF-a lesions showed shallow invasion of the sub-epithelium; INF-b and INF-c lesions had significantly greater depth than INF-a.

The potential risk of vessel infiltration and cervical lymph node metastasis in hypopharyngeal superficial squamous cell carcinoma: a retrospective observational study.

CONCLUSION: The depth of hypopharyngeal superficial cancer may predict vessel infiltration and potential risk of cervical lymph node metastasis. OBJECTIVES: To elucidate the histopathological predictors of vessel infiltration and the risk of regional lymph node metastasis in hypopharyngeal superficial cancer. METHODS: This study included 31 lesions from 30 patients who had undergone transoral en bloc resection in the hospital. Patients with intraepithelial neoplasia or muscular invasion were excluded. Patient characteristics, nodal status, state of vessel infiltration, state of perineural invasion, histopathological parameters, and post-operative cervical lymph node recurrence were retrospectively examined. The histopathological parameters measured were tumor diameter and the following three parameters: tumor thickness, depth from the mucosal surface, and depth from the basement membrane. Correlations between histopathological parameters and state of vessel infiltration were statistically analyzed. RESULTS: Of the 31 lesions examined, four had vessel infiltration. Three of the four lesions with vessel infiltration had regional lymph node metastasis as well as subsequent lymph node metastasis. Lesions with vessel infiltration were significantly deeper than those without. In contrast, there was no significant difference in lesion diameters. In addition, there was no correlation between the depth and the diameter of the lesion.

Intratumoral heterogeneity of HER2 protein and amplification of HER2 gene in salivary duct carcinoma.

Salivary duct carcinoma (SDC) is an aggressive adenocarcinoma of the salivary glands, and accounts for 1-3% of all malignant salivary gland tumors, resembling morphologically invasive ductal carcinoma (IDC) of the breast. In contrast to IDC of the breast and gastric carcinoma (GC), the study of human epidermal growth factor receptor 2 (HER2) in SDC has not progressed. Therefore, we investigated the relationship between HER2 protein expression and amplification of the HER2 gene, and compared them in terms of intratumoral heterogeneity (ITH) in 13 cases of SDC using immunohistochemistry and dual color in situ hybridization. We found seven cases with protein overexpression (53.8%) and five cases with gene amplification (38.5%) in accordance with ASCO/CAP guidelines. ITH of HER2 protein expression was seen in seven cases (53.8%). Interestingly, the ratio of the HER2 gene showed homogenous distribution with or without the presence of ITH of HER2 protein expression. SDC tends to have more ITH of HER2 protein similarly to GC, in contrast to IDC of the breast. ITH of HER2 protein in SDC has no heterogeneity of the HER2 gene amplification. The mechanism of HER2 protein expression in SDC might proceed through a more complex pathway relative to that of IDC of the breast.

A new technique to expose the hypopharyngeal space: The modified Killian's method.

OBJECTIVE: Recent remarkable progress in endoscopic technology has enabled the detection of superficial cancers that were undetectable in the past. However, even though advanced endoscopic technology can detect early lesions, it is useless unless it can provide wide exposure of an area. By modifying the Killian position, it is possible to observe a wider range of the hypopharyngeal space than is possible with conventional head positions. We report a revolutionary method that uses a new head position to widely open the hypopharynx. The technique is named "the Modified Killian's method." METHODS: The patient is initially placed in the Killian position and then bent further forward from the original position (i.e., the modified Killian position). While in this position, the patient's head is turned and the Valsalva maneuver is applied. These additional maneuvers constitute the Modified Killian's method and widely expands the hypopharyngeal space. RESULTS: The conventional head position cannot open the hypopharyngeal space sufficiently; however, the Modified Killian's method opens the hypopharyngeal space very widely. CONCLUSION: The Modified Killian's method enables observation of the entire circumference of the hypopharyngeal space and the cervical esophageal entry. The Modified Killian's method may become an indispensable technique for observing the hypopharynx and detecting hypopharyngeal cancers.

Optimal postoperative treatment for composite laryngeal small cell carcinoma.

Small cell carcinoma (SmCC) most commonly occurs in the lung and rarely arises from the head and neck region. Further, composite SmCC is extremely rare. Therefore, no postoperative treatment strategy has been established. We report a 59-year-old male patient referred to our outpatient clinic for further examination and treatment of a laryngeal tumor. Biopsy from the tumor revealed squamous cell carcinoma (SCC). The preoperative diagnosis was supraglottic SCC (T3N2bM0), and total laryngectomy and bilateral neck dissection were performed. Pathological examination revealed 2 individual cancer components: SmCC and SCC. Postoperative chemoradiotherapy (2 courses of cisplatin (CDDP) and etoposide (VP-16)) was indicated. Following the postoperative chemoradiotherapy, 2 courses of adjuvant chemotherapy were administered. The patient is currently alive with no evidence of disease at 36 months following the completion of therapy. Postoperative chemoradiotherapy and adjuvant chemotherapy are optimal treatment strategies for laryngeal composite SmCC.

Localized or diffuse lesions of the submandibular glands in immunoglobulin g4-related disease in association with differential organ involvement.

OBJECTIVES: The purpose of this study was to assess the relationship between the sonographic characteristics of the submandibular glands and organ involvement at the initial presentation in patients with immunoglobulin G4 (IgG4)-related disease. METHODS: We conducted a retrospective study that included 15 patients who had bilateral swollen submandibular glands and elevated serum IgG4 levels between January 2005 and December 2010. RESULTS: In all 15 patients, sonography revealed the involvement of both sides of the submandibular glands. The sonographic appearance of each gland was classified into two types: localized tumor-forming and diffuse focal types. On the basis of this typing, all 15 patients were classified into two groups: a group with the localized tumor-forming type observed on one or both sides of the glands (n = 10) and a group with the diffuse focal type present on both sides (n = 5). All 10 patients in the former group had lesions in local exocrine organs, such as the lacrimal and parotid glands, with regional lymphadenopathy. In contrast, all 5 patients in the latter group had lesions in abdominal organs, such as autoimmune pancreatitis and sclerosing cholangitis. CONCLUSIONS: The sonographic patterns of the submandibular glands in patients with IgG4-related disease can be divided into two types: localized tumor-forming and diffuse focal. The distinctive patient groups defined by the sonographic patterns in both glands were associated with differential organ involvement and thus could be used as indicators of the disease extension and specific organ involvement.

Evaluating the significance of level IIb neck dissection for hypopharyngeal cancer.

BACKGROUND: This study evaluated cervical lymph node metastases at level IIb in cases of hypopharyngeal cancer and analyzed the possibility of preservation of level IIb during neck dissection. METHODS: In total, 34 patients (51 neck sides) with hypopharyngeal cancer that underwent neck dissection from April 2008 to April 2011 were retrospectively analyzed. We evaluated the distribution of metastatic lymph nodes at various levels (particularly level IIb) in cases treated with therapeutic neck dissection and elective neck dissection. RESULTS: The incidence of metastases in level IIb was 13.3% (4 of 30 patients) for therapeutic neck dissection and 0% (0 of 21 patients) for elective neck dissection. All the level IIb metastases were found on the ipsilateral side in the cases treated with therapeutic neck dissection. CONCLUSIONS: The results suggest that preservation of level IIb during neck dissection was possible in N0 cases of hypopharyngeal cancer.

Transoral en bloc resection of superficial laryngeal and pharyngeal cancers.

BACKGROUND: The objective of this study was to evaluate the efficacy and safety of minimally invasive transoral en bloc resection of superficial pharyngeal and laryngeal cancers. METHODS: Forty-one superficial lesions (from 35 patients) were resected transorally under a surgical microscope using a monopolar cautery. Quality of life (QOL) was assessed using a questionnaire European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Cancer Module (EORTC QLQ-H&N35) 1 year after the surgery. RESULTS: Twenty-eight hypopharyngeal, 5 oropharyngeal, and 8 laryngeal cancers were operated on using this method. The surgical field was widely exposed with a wide-caliber scope or extending laryngoscope. A bimanual procedure under a surgical microscope enabled us to achieve en bloc resection. The local control rate was 98%. No postoperative dyspnea or dysphagia was observed. Postoperative QOL scores were favorable. CONCLUSIONS: Our transoral en bloc resection technique can be easily adopted, and it effectively maintained QOL after treatment.

Prevention of wound complications in salvage pharyngolaryngectomy by the use of well-vascularized flaps.

CONCLUSIONS: We successfully reduced the incidence of pharyngocutaneous fistulas (PCFs) in high-risk patients undergoing surgery by using pectoralis major myocutaneous flaps (PMMCFs) and deltopectoral flaps (DPFs) to cover suture lines. OBJECTIVES: We used coverage of suture lines with PMMCFs and DPFs in patients with high risk of PCFs undergoing total laryngectomy (TL) or total pharyngolaryngectomy (TPL) to determine whether coverage of suture lines during salvage surgery can reduce the incidence of PCFs. METHODS: This retrospective study was based on a review of 52 patients who underwent salvage TL or TPL between 2001 and 2011; we have been using PMMCFs or DPFs during salvage surgery since 2008. Details of postoperative complications including PCFs were analyzed. RESULTS: The incidence rate of PCF was lower in the flap group (7.7%) than that in the non-flap group (30.1%). No carotid ruptures were observed in the flap group (0%) as contrasted with patients in the non-flap group (7.7%).

Multivariate analysis of wound complications after surgery for laryngeal and hypopharyngeal cancers.

PURPOSE: The aim of this study was to identify the factors leading to postoperative complications following surgical management of laryngeal and hypopharyngeal cancers. PROCEDURES: Between 2001 and 2008, the medical records of 107 laryngeal and hypopharyngeal cancer patients requiring laryngectomy or pharyngolaryngectomy at our hospital were reviewed. The incidence of wound complications and correlation of complications with clinicopathological factors were investigated by univariate and multivariate analysis. RESULTS: The overall incidence of wound complication was 33.6%. The complication incidence was 35.2, 21.7 and 46.2% for the primary surgery, radiation and chemoradiation groups, respectively. Diabetes mellitus and bilateral paratracheal node dissection were significantly correlated and were independent risk factors according to multivariate analysis. Bleeding from a large vessel occurred in 4 patients, and there were significant correlations with chemoradiation. CONCLUSION: Preoperative chemoradiation was not a significant risk factor for wound complication in this study. However, once postoperative wound complications occurred, they tended to produce lethal outcomes.

A survey of head and neck malignancy at Tokai University Hospital.

Patients with head and neck malignancy who visited Tokai University Hospital over seven years were statistically surveyed. Six hundred and eighty-three patients were newly registered in this period. The most frequent primary lesion was the larynx (29.3%), followed by the hypopharynx (20.6%), oral cavity (11.9%), oropharynx (11.9%), and nose and paranasal sinus (8.6%). About two-thirds of the patients had advanced cancers. The patients were referred from adjacent regions, most frequently from the Shonan area. Referred patients with malignancy were increasing each year. The trends in head and neck cancers and the treatment modality were discussed. After the opening of a new hospital building in 2006, a further increase in the number of referred patients and operations is expected.