[A successful case of advanced nasal adenocarcinoma treated with tumor dormancy therapy with S -1 alone].

We report a 65-year-old female case of low-grade non-intestinal type adenocarcinoma of the nasal cavity with bilateral metastases to the cervical lymph nodes(T3N2cM0: Stage IV A). Chemoradiotherapy administered as first-line therapy yielded only a partial response in the primary tumor and metastatic lesions, and subsequent chemotherapy with S-1(at a dose of 80 mg per day)alone was applied as tumor dormancy therapy(TDT)on an outpatient basis. Adverse events during S-1 medication were limited to a decrease in leukocyte count and hemoglobin level, both of which were grade 1. The tumor has not enlarged, and the patient has survived 29 months since the beginning of chemotherapy with S-1 alone without any decrease in quality of life. Although the effectiveness of S-1 for adenocarcinoma of the head and neck has not been fully demonstrated, S-1 might be useful in patients with advanced head and neck adenocarcinoma for the purpose of TDT.

[Tracheal cartilaginous sleeve in craniosynostosis].

Tracheal cartilaginous sleeve (TCS) is a congenital malformation involving fusion of the tracheal arches that may be isolated to a few tracheal arches, include the entire trachea, or extend beyond the carina into the bronchi. Tracheotomy was required in 9 of 23 craniosynostosis cases undergoing gradual distraction at Osaka City General Hospital from March 2002 to April 2006. TCS was diagnosed in 5 of 9 cases-four Pfeiffer patients and one Crouzon patient. Diagnosis was made intraoperatively during tracheotomy or at autopsy. 3D-CT was not useful in diagnosing TCS. Aggressive management of respiratory infection and pulmonary secretion, selection of appropriate tracheostomy tubes, and endoscopic evaluation are very important to care in managing TCS patients.

Evaluation of diagnostic abilities of Ga-SPECT for head and neck lesions.

OBJECTIVE: Single-photon emission computed tomography (SPECT) using gallium (Ga) has been frequently used for diagnosing head and neck tumors in patients. Although the usefulness of Ga-SPECT is well known, the degree of the increase in diagnostic ability with Ga-SPECT for head and neck tumors has not been reported. We compared the ability of the planar images of Ga scintigraphy, SPECT images of Ga scintigraphy, and CT images to diagnose head and neck primary tumors and neck metastases. METHODS: The subjects of this study were 167 patients with malignant head/neck lesions. For Ga scintigraphy, Ga-67-citrate (74 MBq) was injected via a cubital vein. Planar and SPECT images were taken 72 h after the Ga-67-citrate injection. The rate of detection of the primary lesions was compared first between SPECT and planar images then between SPECT and CT images. The rate of detection for each stage of disease according to the TNM classification was also analyzed. RESULTS: The rate of detection of primary lesions was 50% with planar imaging and 69% with SPECT. And similarly, regarding the rate of detection of lymph node metastases, there was a significant difference between planar imaging and SPECT. The rate of detection of primary lesions was 70% for both CT and SPECT. At T stage, the rates of detection of primary lesions with each imaging technique were 11% with planar imaging and 39% with SPECT, and 22% with CT for stage T1. CONCLUSIONS: This study revealed the marked superiority of SPECT images over planar images in terms of the ability to detect primary tumors and tumor metastasis to cervical lymph nodes. Furthermore, the primary T1 tumor detection rate of SPECT images was higher than that of CT images. On the basis of these results, the concomitant use of SPECT is highly recommended when Ga scintigraphy is performed to check for malignant head/neck tumors.

Laryngeal myxoma.

Myxoma is a rare benign tumor, and occurs most commonly in the mandible and maxilla in the head and neck region. Myxoma of the larynx is extremely rare and is frequently misdiagnosed as a vocal polyp. We present the first female case of myxoma on a vocal cord and review the literature on this subject. The patient was 74 years old. She had undergone laryngomicrosurgery for a vocal cord polyp 20 years previously, but did not know the histological diagnosis. We performed laryngomicrosurgery for bilateral edematous vocal cords. Microscopic laryngoscopy demonstrated a mass in the submucosal space of the right vocal cord. The pathologic diagnosis of the mass was myxoma. Myxoma is a connective tissue tumor composed of multinucleate stellate cells suspended in an edematous, mucopolysaccharide-rich stroma. Since myxomas may infiltrate surrounding tissue, they have a high incidence of local recurrence. To prevent recurrence, myxoma should be surgically excised with surrounding normal tissue. Although no local recurrence has been detected, as myxoma is characterized by a slow growth rate, long-term follow-up is needed in this case.

Detection of local residual tumor after laryngeal cancer treatment using FDG-PET.

OBJECTIVE: Fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) is sometimes used as a means of follow-up after diagnosis and treatment of cancers of the head and neck region. The present study was undertaken to evaluate the ability of FDG-PET to detect local residual tumor after treatment of laryngeal cancer. METHODS: Thirty-six patients with laryngeal cancer underwent FDG-PET before and after initial treatment. Of these patients, 20 received FDG-PET before treatment and 28 received it after treatment. The relationship between standardized uptake values (SUV) and the presence or absence of local residual tumor was investigated by setting the cut-off value of the SUV using the receiver operating characteristics (ROC) curve. RESULTS: When the pre-treatment SUV threshold for laryngeal cancer was set at 7.20, the detection of local residual tumor after treatment using FDG-PET had a sensitivity of 77.78%, specificity of 81.82%, false positive rate of 18.18%, false negative rate of 22.22%, accuracy of 80% and a p value of 0.02. When the post-treatment SUV threshold for the larynx was set at 3.35, the test had a sensitivity of 93.75%, specificity of 91.67%, false positive rate of 8.33%, false negative rate of 6.25%, accuracy of 92.86% and a p value of 0.0001. CONCLUSIONS: FDG-PET was found to be useful for determining the presence of local residual tumor after treatment of laryngeal cancer.

Carotid artery pseudoaneurysm as a rare sequela of surgery for laryngeal cancer.

Formation of carotid artery pseudoaneurysm is uncommon after intensive treatment for head and neck cancer. We encountered a case of postoperative formation of pseudoaneurysm at the left carotid bifurcation in a diabetic man. The risk factors for carotid artery pseudoaneurysm in the patient included diabetes mellitus, previous radiotherapy to the neck, neck dissection, and postoperative Staphylococcus aureus infection secondary to accidental pharyngocutaneous fistula. We successfully obliterated this pseudoaneurysm using a Smart stent and detachable coils without neurological deficits. The possibility of vascular injury after treatment for head and neck cancer must be considered, especially in patients with risk factors for it due to previous treatment.

Intramasseteric schwannoma in a child.

Schwannoma arising in muscle is rare. We treated a very unusual case of schwannoma originating in the masseter muscle in a 12-year-old boy, who presented with a 1-year history of a painless left cheek mass. CT and MRI revealed that the mass existed in the masseter muscle. It was extirpated under general anesthesia without postoperative sequelae. The whitish mass was solid and encapsulated, and pathologic examination confirmed the diagnosis of schwannoma consisting of Antoni A and Antoni B areas. Definitive diagnosis of schwannoma before surgery is usually difficult; hence, histological examination during or after surgery is, in most cases, decisive. However, schwannoma should be considered in the preoperative differential diagnosis of intramuscular tumor, despite its rare occurrence, since postoperative neurological sequelae may occur.

Outcome of preoperative concurrent chemoradiotherapy and surgery for resectable lingual squamous cell carcinoma greater than 3 cm: the possibility of less extensive surgery.

We present the outcome of treatment with preoperative concurrent chemoradiotherapy and surgery for resectable lingual squamous cell carcinoma more than 3 cm in its greatest dimension. Twenty patients were enrolled in this study between June 2001 and August 2004. Concurrent chemoradiotherapy included intraarterial pirarubicin (THP) (5 mg/day), intravenous continuous 5-FU, and radiation, usually followed by surgery. Complete response rate was 100%. Notably, 8 of 12 patients who underwent surgery exhibited pathologically complete response, though three patients developed recurrence or distant metastasis. The main adverse effects were mucositis (13/20) and leucopenia (9/20), both of which were acceptable. Although long-term results should be considered, our treatment method appears very useful for lingual squamous cell carcinoma greater than 3 cm, with a remarkably high rate of pathological local control and acceptable adverse events.

Improvement of the radial forearm donor site by compression with hydrocolloid dressing and adhesive sponge.

CONCLUSIONS: With our method, general improvement is obtained as compared with traditional split-thickness skin grafting of the radial forearm flap donor site. As our method is simple and easy, the same results can be obtained wherever and by whomever it is performed. OBJECTIVE: The radial forearm flap is associated with complications of graft take and a poor aesthetic appearance despite its usefulness in reconstructing the oral cavity and oropharynx. We describe a simple technique for improvement of the radial forearm donor site. PATIENTS AND METHODS: We studied 12 patients who underwent reconstruction with radial forearm free flaps following resection of oral or oropharyngeal tumors. We covered the donor site defect using traditional split-thickness skin grafts and performed aftercare with a hydrocolloid dressing and an adhesive sponge to retain moisture and apply compression. After the treatment series, color matching, texture matching, depressive deformity, and hypertrophic scar were evaluated. RESULTS: The results of comprehensive evaluation of the two patients with premature discontinuation of compression were good. One patient was assigned only 1 point for hypertrophic scar, and another only 1 point for color match. The evaluation of the other 10 patients was excellent.

Application of modified transmastoid approach methods to congenital atresia of the external ear canal with middle ear infection.

OBJECTIVE: To present our surgical technique for congenital atresia of the external ear canal with middle ear infection. METHODS: A modified transmastoid approach to congenital atresia of the external ear canal with middle ear infection was applied. Our method is to visualize the landmarks of the mastoid cavity such as the antrum, sinodural angle and digastric ridge by the canal-open method to avoid facial nerve injury and then prepare a relatively large external ear canal with reconstruction of the posterior wall of the external ear canal. RESULTS AND CONCLUSION: This method is suitable not only for treating congenital atresia of the external ear canal with middle ear infection, but also for avoiding facial nerve injury and postoperative complications such as re-stenosis of the new ear canal and postoperative middle ear infection.

Concurrent chemoradiotherapy with pirarubicin and 5-fluorouracil for resectable oral and maxillary carcinoma.

OBJECTIVE: We present the response rate and adverse effects of our regimen of concurrent chemoradiotherapy with pirarubicin (THP) and 5-fluorouracil (5-FU) for oral and maxillary carcinoma. PATIENTS AND METHODS: Fifteen patients with oral (10 cases) or maxillary (5 cases) squamous cell carcinoma who underwent our concurrent chemoradiotherapy with the combination of intraarterial pirarubicin, intravenous continuous 5-fluorouracil, and radiation between March 2001 and February 2003 in our department were entered in this study. THP (5 mg/day) was infused into the lingual or maxillary artery one hour before radiation on days 1-5 and 8-12, while intravenous 5-FU (150 mg/m2/day) was instilled continuously on days 1-5, 8-12, 15-19, and 22-26 in accordance with the radiation schedule (2 Gy/day). Consequently, total doses of THP, 5-FU, and radiation were 50 mg, 3000 mg/m2 and 40 Gy, respectively. After the treatment series, response rate and adverse effects were evaluated. RESULTS: Response rate achieved 100% (12 cases exhibited a complete response and the remaining 3 a partial response). Notably, all 10 patients with oral carcinoma exhibited complete response. The main adverse effects were leucopenia (6/15) and mucositis (6/15), both of which were acceptable. CONCLUSIONS: This concurrent chemoradiotherapy is very useful for oral and maxillary carcinoma as a preoperative modality with remarkably high response rate and acceptable adverse events.

Accelerated hyperfractionated irradiation with concomitant boost for stage II laryngeal cancer and locally advanced head and neck cancer.

OBJECTIVE: This study was conducted to evaluate the efficacy and feasibility of our accelerated hyperfractionation with concomitant boost for stage II laryngeal cancer and stages III-IVb locally advanced head and neck cancer. PATIENTS AND METHODS: From January 2000 to October 2001, eight patients with AJCC 1998 stage II laryngeal cancer and 11 patients with AJCC 1998 stages III-IVb locally advanced head and neck cancer underwent accelerated hyperfractionated radiation therapy. For the stage II laryngeal cancer, radiation was delivered at a 2.0 Gy fraction a day, 5 fractions per week for the first 3 weeks, then 2 fractions (1.8 and 1.2 Gy) a day, 5 times a week for 2.5 weeks, with total dose of 69 Gy. For stages III-IVb head and neck cancer, radiation was given at a 1.8 Gy fraction a day, 5 fractions per week for 6 weeks and a boost was added up to 70.5 Gy with 1.5 Gy as a second daily fraction during the last 2.2 weeks. Among the patients, 16 (84%) received concomitant chemotherapy, mainly with low-dose carboplatin. Acute toxicity based on RTOG criteria and tumor response at 1 month post-treatment were estimated as initial effects. RESULTS: The overall response rate was 100% in patients with stage II laryngeal cancer and 91% in patients with stages III and IVb head and neck cancer. The incidence of grade 3 or worse acute effects was 47%. Eighteen patients (95%) completed radiation therapy without interruption related to acute side effects, while one had prolongation of the treatment for more than 1 week because of neutropenia. CONCLUSIONS: Our results demonstrated that accelerated hyperfractionation, mostly combined with concomitant chemotherapy, had a good overall response rate with acceptable toxicity in stage II laryngeal cancers and stages III-IVb head and neck tumors.

A possible case of Werner syndrome presenting with multiple cancers.

The treatment of a man with six metachronous primary cancers is described. The primary lesions were in the soft palate, both edges of the tongue, the hard palate, the esophagus, and the right ureter. Pathologically, all of the first five tumors in the head and neck and esophagus were proven to be squamous cell carcinoma with various grades of differentiation, and the last one was transitional cell carcinoma. The cancers were found in the early clinical stage, and were completely controlled one by one except for the ureteral tumor under treatment. His characteristic medical history and physical findings, i.e. bilateral cataracts, short stature, baldness, diabetes mellitus, high-pitched voice, and multiple malignancies, met the clinical criteria for possible Werner syndrome, a genetic premature aging disorder, though the possibility of phenocopy of this syndrome has not been ruled out. We have followed him carefully because he might be vulnerable to malignant tumor formation.

The syndrome of inappropriate antidiuretic hormone secretion associated with chemotherapy for hypopharyngeal cancer.

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterized by hyponatremia and the plasma hypoosmolality induced by water retention attributable to persistent antidiuretic hormone (ADH) release. It has been reported that SIADH may occur due to various factors in patients with malignant tumor. We report a case of hypopharyngeal cancer complicated by SIADH following chemotherapy. A 72-year-old woman with hypopharyngeal cancer was treated by oral administration of S-1 and intravenous administration of low-dose cisplatin following radiation therapy. General fatigue and coma occurred during the third course of this chemotherapy, using S-1 and low-dose cisplatin. We believed that she had SIADH because of the results of examinations including hyponatremia, serum hypoosmolality and increasing serum ADH level. We treated her by fluid restriction and intravenous administration of hypertonic saline and furosemide, and she recovered. Unfortunately, her hypopharyngeal cancer gradually progressed and she died of acute pneumonia three months later.

A case of simultaneous primary carcinomas of the tongue.

Reports of multiple primary cancers are increasing, but simultaneous primary cancers are not frequently reported especially originated in the same organ. We encountered a 71-year-old female who had two simultaneous carcinomas at both edges of the tongue. Histologically, the carcinoma of the right edge was a well-differentiated squamous cell carcinoma, while that on the left edge was a moderately-differentiated squamous cell carcinoma. No other tumors were detected on other examinations, including gallium-67 scintigraphy, CT scan of the chest, upper gastrointestinal fiberscopy and so on. She underwent surgical treatment without other induction treatments such as radiotherapy and chemotherapy. Her postoperative radiotherapy and chemotherapy were also uneventful because of her age. Fourteen-month follow-up revealed neither recurrence nor metastasis.

[Metastatic carcinoma of the neck from unknown primary sites].

Encountering a metastatic carcinoma of the neck from an unknown primary site is not unusual, despite intensive examinations of the entire body. In previous reports, the pathological diagnosis of these carcinomas was usually squamous cell carcinomas and rarely adenocarcinoma. We treated eight patients with metastatic carcinoma of the neck from unknown primary sites, including 4 cases of squamous cell carcinoma, 2 cases of adenocarcinoma, one case of small cell carcinoma, and one case of clear cell carcinoma, during a 10-year period from January 1992 to December 2001. We clinically examined these eight cases, and focusing on the two cases of metastatic cervical adenocarcinoma from unknown primary sites. The 8 cases consisted of 5 cases of N2 and 3 cases of N3 disease. Three of the 5 N2 patients underwent a neck dissection, but all three of the N3 cases were judged to be inoperable. Disease-free survival was achieved in all 3 patients who underwent surgery. In this paper, we review 36 reports on metastatic carcinomas of the neck from unknown primary sites and statistically analyze 1454 cases. Pathologically, the majority of them (81.1%) were squamous cell carcinoma; adenocarcinomas accounted for only 7.6% of the cases. Notably, 65.0% of the patients with cervical metastatic adenocarcinomas were confirmed to have primary lesions outside the head and neck region. The prognosis of primary unknown metastatic cervical adenocarcinoma is reportedly poor, and the optimal treatment is still unclear, although surgery is recommended for primary unknown metastatic cervical squamous cell carcinoma. However, we suggest that intensive treatment, including surgery, radiotherapy, and chemotherapy, of metastatic lesions of the neck may play a key role in improving patient prognosis.

[Preoperative concurrent chemoradiotherapy with intra-arterial infusion of pirarubicin and continuous intravenous instillation of 5-fluorouracil for resectable advanced head and neck squamous cell carcinoma].

Eight cases (4 of the maxillary sinus, 3 of the tongue, and one of the oral floor) of resectable advanced head and neck squamous cell carcinoma were treated preoperatively by means of concurrent chemoradiotherapy with combination of pirarubicin (THP), 5-fluorouracil (5-FU), and radiation between March 2001 and April 2002. THP (5 mg/day) was infused into the maxillary or lingual artery through a catheter placed in the superficial temporal artery one hour before radiotherapy on days 1-5 and 8-12. In addition, continuous intravenous instillation of 5-FU (150 mg/m2/day) was performed on days 1-5, 8-12, 15-19, and 22-26 in accordance with the radiotherapy schedule (2 Gy/day). The total doses of THP, 5-FU, and radiation were 50 mg, 3,000 mg/m2 and 40 Gy, respectively. Five out of 8 patients showed a complete response and the remaining 3 a partial response, for a 100% response rate. In particular, all 4 cases of tongue and oral floor carcinoma showed a complete response. All patients were able to undergo this series of therapy as scheduled without any severe adverse effects. We conclude that this concurrent chemoradiotherapy is feasible for preoperative therapy in view of the good locoregional control rate and the negligible adverse effects.