Feasibility and Safety of Microvascular Anastomoses Within Previously-Dissected Neck Regions.

The selection of appropriate recipient vessels is important for the success of head and neck reconstruction. Vessels located outside of previously-dissected neck regions tend to be more frequently selected due to relative ease of preparation. However, some advantages are offered regarding dead space filling and formation by using vascular anastomoses within regions previously dissected, or reusing former free flap pedicle due to their proximity to the defect. We analyzed microsurgical anastomoses in patients requiring oral reconstruction who had previously undergone neck dissection. Contralateral vascular anastomoses were preoperatively planned in 10 cases of which 9 could be successfully performed (achievement rate, 90%). Ipsilateral side anastomoses were planned in 28 cases, with 26 anastomosed as planned (achievement rate, 92.9%). There was no statistically significant difference between the two groups. Vascular anastomosis within the scar region can be performed safely, based on preoperative planning and intraoperative judgment.

Multi-center rater-blinded study of early intervention with the Hand Incubator for breast cancer-related lymphedema (the BEAT-EDEMA trial): Proposal of a research protocol.

Postoperative lymphedema is considered irreversible once it has developed, and significantly lowers the patient's quality of life. However, lymphatic function has recently been clarified, and it is possible that lymphedema can be cured if early treatment is started. This two-arm randomized clinical trial (UMIN000026124) will prospectively evaluate 24 patients with early-stage breast cancer-related lymphedema at the Nagoya University Hospital and Aichi Cancer Center Hospital. The eligibility criteria will be patients who are diagnosed with stage 0-1 breast cancer-related lymphedema, as defined by the International Society of Lymphology, within 12 weeks after breast cancer surgery. The diagnosis of lymphedema will be confirmed using a bioimpedance spectroscopy device (L-Dex®). Participants will be randomized 1:1 into the intervention and control groups. The physicians and patients will be aware of their group assignment, although treatment efficacy will be evaluated by raters who are blinded to the group assignments. The intervention group will complete grasping exercises in the Hand Incubator device for 4 weeks. The primary outcome will be the change in the affected upper limb's volume after the intervention, as measured using the water displacement method. This study may help establish a standard treatment for postoperative lymphedema.

Innovative Approach for Interim Facial Prosthesis Using Digital Technology.

Despite the important role of facial prosthetic treatment in the rehabilitation of head and neck cancer patients, delay in its implementation can be unavoidable, preventing patients from receiving a prompt facial prosthesis and resuming a normal social life. Here, we introduce an innovative method for the fabrication of an interim facial prosthesis. Using a 3D modeling system, we simplified the fabrication method and used a titanium reconstruction plate for facial prosthesis retention. The patient received the facial prosthesis immediately after surgery and resumed a normal social life earlier than is typically observed with conventional facial prosthetic treatment.

[A Case of Intrascrotal Liposarcoma].

A 69-year-old man was referred to our hospital with the chief complaint of a painless right scrotal swelling gradually increasing in size during the past 10 years. Testicular tumor markers were within the normal range. Ultrasonography showed an intrascrotal homogeneous mass. Computed tomography and magnetic resonance imaging revealed an inguinal mass, which mainly consisted of fat signal area and partially well enhanced in vascular density. Pre-surgical diagnosis was liposarcoma of spermatic cord estimated by radiographic examination and resection of the right intrascrotal tumor with high inguinal orchitectomy was performed. Histopathological diagnosis revealed well-differentiated liposarcoma. No recurrence phenomenon has been observed after 12 months without any adjuvant therapy. This case is the 129th report of intrascrotal liposarcoma in the Japanese literature.

Salvage surgery and microsurgical reconstruction for recurrence of skull base osteosarcoma after carbon ion radiotherapy.

Carbon ion radiotherapy has recently emerged as an alternative choice of treatment for malignant tumors of the head and neck. However, it is still in the infant stages and its influence on subsequent salvage surgery remains unclear. Here we report the case of a 43-year-old woman who underwent salvage surgery for left frontal bone osteosarcoma recurrence following carbon ion radiotherapy. Tumor resection was performed with a wide margin including the tissue considered to have been damaged by carbon ion radiotherapy. The dural defect was reconstructed using a fascia lata graft and pedicled galeal pericranial flap. The soft tissue defect was reconstructed using an anterolateral thigh flap anastomosed to the ipsilateral neck interposed by the radial forearm flap. As the patient developed no postoperative wound complications, she was able to initiate adjuvant chemotherapy early. Carbon ion radiotherapy is useful for its focused distribution and strong biological effects. Although the affected field may be limited, its high potency may severely damage adjacent normal tissue and lead to serious postoperative complications. Despite these concerns, satisfactory results were achieved in this case.

Free jejunal flap transfer for pharyngoesophageal reconstruction in patients with intestinal malrotation: two case reports.

Intestinal malrotation results from failure of intestinal rotation and fixation during fetal life. We report two cases of esophageal reconstruction with free jejunal flaps following total laryngopharyngectomy of hypopharyngeal and cervical esophageal carcinoma in which intestinal malrotation was detected during the jejunal flap harvesting. In both cases, the ligament of Treitz was absent, and the laparotomy incision was thus extended to identify the jejunum. In case 1, harvesting an adequate length of the vascular pedicle of the flap was impossible because of the abnormal position of the pancreas; thus, a jejunal flap of maximal length was harvested for optimal pedicle positioning in the recipient site. In case 2, Ladd's ligament prohibited the release of the jejunum from the ascending colon and required its dissection. Both patients underwent successful reconstruction. When the ligament of Treitz is absent during jejunal flap harvesting, investing the whole bowel by extended laparotomy incision is recommended. When anatomical abnormality caused by intestinal malrotation is detected, releasing an adhesion of the jejunum from circumferential organs and identifying the adequate vascular pedicle of a jejunal flap are necessary. If harvesting the long vascular pedicle is impossible, a jejunal flap of maximal length should be harvested for optimal positioning for vascular anastomosis at the shortest distance in the recipient site.

Surgical site infection in clean-contaminated head and neck cancer surgery: risk factors and prognosis.

Since new treatment strategies, such as chemoradiotherapy, have been introduced for head and neck cancer, a higher number of unknown factors may be involved in surgical site infection in clean-contaminated head and neck cancer surgery. The aim of the present study was to clarify the risk factors of surgical site infection in clean-contaminated surgery for head and neck cancer and the prognosis of patients with surgical site infection. Participants were 277 consecutive patients with head and neck cancer who underwent clean-contaminated surgery for primary lesions at the Aichi Cancer Center over a 60-month period. A total of 22 putative risk factors were recorded in each patient and statistically analyzed to elucidate surgical site infection related factors. Surgical site infection was observed in 92 (32.1 %) of 277 cases. Univariate analysis indicated that alcohol consumption, T classification, neck dissection, reconstructive procedure, and chemoradiotherapy were significantly associated with surgical site infection. Multiple logistic regression analysis identified two independent risk factors for surgical site infection: reconstructive surgery (p = 0.04; odds ratio (OR) 1.77) and chemoradiotherapy (p = 0.01; OR 1.93). In spite of surgical site infection, the five-year overall survival rate of patients with surgical site infection was not significantly different from those without surgical site infection. Although surgical site infection did not impact the overall survival of patients with surgical procedures, head and neck surgeons should pay attention to patients with previous chemoradiotherapy as well as to those with a high risk of surgical site infection requiring reconstructive surgery.

Hypothyroidism After Using Superior Thyroid Artery as A Recipient Artery.

OBJECTIVE: Superior thyroid artery (SThA) is a common recipient artery in free tissue transfer even after total pharyngolaryngoesophagectomy (TPLE) with hemithyroidectomy. The aim of this study was to evaluate whether the use of SThA as a recipient vessel affect thyroid function in patients undergoing TPLE with hemithyroidectomy. METHODS: From 2011 to 2020, 91 patients who underwent free jejunum transfer after TPLE with hemithyroidectomy were divided into two groups. In Group1 (n = 47), the contralateral SThA was used for the anastomosis. In Group2 (n = 44), other vessels were used. Retrospective chart review was performed comparing postoperative thyroid function between two groups. RESULTS: In group1, 17 patients presented hypothyroidism, 21 presented latent hypothyroidism and 9 presented no thyroid dysfunction comparing 15, 19, and 10 respectively in group 2. There were no significant differences between the two groups. CONCLUSION: Even after hemithyroidectomy, with inferior thyroid arteries are preserved, the SThA can be used as a recipient vessel. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:557-561, 2023.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan.

BACKGROUND: There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction. METHODS: This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence. RESULTS: Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15. CONCLUSION: The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Effect of Incision Negative Pressure Wound Therapy on Donor Site Morbidity in Breast Reconstruction with Deep Inferior Epigastric Artery Perforator Flap.

Background: The usefulness of closed incision negative pressure wound therapy (ciNPWT) has been well documented in many surgical sites, except for the donor site of the deep inferior epigastric artery perforator (DIEP) flap. The aim of this study was to evaluate the effect of ciNPWT on microsurgical breast reconstruction using a DIEP flap. Methods: Fifty-six cases of breast reconstruction with DIEP flap were included and divided into two groups based on post-surgical wound management: the ciNPWT group received ciNPWT at the donor site, while the conventional group received conventional wound management. The primary outcomes were the incidence of seroma, wound dehiscence, and surgical site infection, and secondary outcomes were the time to drain removal and amount of drainage. The breast reconstruction risk assessment (BRA) score was used to evaluate the comprehensive risk in each case. Results: Among the patient and surgical characteristics, only the BRA score (P=0.02) and the time to elevate the flap (P=0.02) were significantly higher and longer in the ciNPWT group, respectively. The incidence of seroma, dehiscence, and wound infection showed no significant difference between the two groups. In the subgroup analysis of patients with body mass index ≥ 25, the primary outcomes did not differ, while the secondary outcomes were significantly lower in the ciNPWT group (drainage volume, P = 0.04; time to drain removal, P = 0.04). Conclusion: ciNPWT can potentially reduce the incidence of donor site complications of DIEP flaps, especially if the comprehensive risk for post-surgical complications is considered.

Immediate one-stage implant-based breast reconstruction without the use of acellular dermal matrix in Japanese breast cancer patients.

BACKGROUND: In immediate one-stage implant-based breast reconstruction, acellular dermal matrix (ADM) is widely used around the world due to its ability to cover the outside part of the pectoralis major muscle. Unfortunately, ADM has not yet been approved in Japan. Consequently, in our institution, we have performed safe one-stage implant-based breast reconstruction without ADM by employing several unique techniques and have obtained excellent results. METHODS: The data of 186 patients were reviewed. In each case, we performed three unique steps to determine which cases were suitable for one-stage implant-based breast reconstruction as follows. First, ICG fluorescence imaging was performed to confirm the blood flow of the skin after mastectomy. Next, a serratus anterior muscle/fascial and external oblique fascial flap was elevated to completely cover the implant together with the pectoralis major muscle. We used a sizer to confirm the skin tension and the form of the breast. After confirming correct size, shape and coverage, we selected cases in which implant could be safely performed. We evaluated the final cosmetic outcome based on three measurements: the inframammary fold position, and the bilateral balance of both breast size and form. RESULTS: The rate of immediate one-stage implant-based reconstruction was 85.7%. An implant was removed in one case because of complications, and infection developed in five cases. Among all patients, the overall cosmetic evaluation of the final outcome was evaluated as good, fair and poor in 84.3%, 13.5% and 2.2% of cases, respectively. CONCLUSIONS: Immediate one-stage implant-based breast reconstruction without ADM can be a useful and safe procedure, based on our unique techniques in breast cancer patients who hope for immediate prosthetic breast reconstruction in Japan.

Recurrent ameloblastoma with both hypercalcemia and BRAF mutation: A case report.

This case report describes a mandibular ameloblastoma with both BRAF V600E mutation and rare hypercalcemia. The patient without distant metastasis underwent subtotal mandibulectomy using double flaps of fibula and anterolateral thigh. A whole body computed tomography scan taken 69 months after surgery revealed neither recurrence nor metastasis.

Prediction of decannulation, oral intake recovery, overall survival and lung metastasis following oral malignant tumor resection and reconstruction.

The present study investigated whether tongue base and mandibular bone defects were associated with the rate of decannulation and oral intake recovery, and survival time, including overall and lung metastasis-free survival time, in patients that underwent oral malignant tumor (OMT) resection with reconstruction. A total of 105 patients that underwent OMT resection with laryngeal preservation and reconstruction were recruited. The extent of defects was classified according to Urken's classification. The rates of decannulation and oral intake recovery were assessed with the Kaplan-Meier method. It was identified that 4-5 section segmental mandibulectomy (SM) and total glossectomy (TG) were significantly associated with a lower rate of decannulation and oral intake recovery by univariate and multivariate analysis using a Cox's proportional model. Patients in the high risk group (4-5 sections or TG) were significantly less likely to achieve decannulation and unaided oral intake. Patients in the high risk group exhibited a significantly shorter overall and lung metastasis-free survival time. Following multivariate analysis adjusted for the clinical stage (IV/I-III), past history of or postoperative radiotherapy (yes/no) and age (per year), the high risk group was associated with a significantly rate of decannulation and unaided oral intake. In conclusion, TG or wide SM is a prognostic parameter for functional and survival outcomes, including lung metastasis, in OMT.

Feasibility study of contralateral risk-reducing mastectomy with breast reconstruction for breast cancer patients with BRCA mutations in Japan.

BACKGROUND: Contralateral risk-reducing mastectomy (CRRM) for breast cancer patients with BRCA mutations has been reported to not only reduce breast cancer incidence but also to improve survival. The National Comprehensive Cancer Network guidelines recommend providing CRRM to women with BRCA mutations who desire CRRM after risk-reduction counseling. However, in Japan, CRRM cannot be performed generally because it is not covered by health insurance. Thus, we conducted a feasibility study to confirm the safety of CRRM. METHODS: CRRM with bilateral breast reconstructions were performed for breast cancer patients with BRCA mutations. The primary endpoint was early adverse events within 3 months, and secondary endpoints were late adverse events. RESULTS: Between August 2014 and November 2016, ten patients were enrolled. The median age was 37.5 years, and five of the patients had the BRCA1 mutation while five had the BRCA2 mutation. Six patients received neoadjuvant chemotherapy. Eight patients selected silicone breast implants, and two patients selected transverse rectus abdominis myocutaneous flap reconstruction. Pathological findings showed no evidence of occult breast cancers in any of the patients. At a median of 25.5 months follow-up time, CRRM-related early adverse events were hematoma (subsequently removed by re-operation; grade 2, n = 1), wound infection (grade 2, n = 1), skin ulceration (grade 1, n = 2) and wound pain (grade 1, n = 1). Overall, there were no grade 3 or more severe adverse events. CONCLUSION: Our results confirm that CRRM with reconstruction could be performed safely.

Prediction of chemosensitivity using multigene analysis in head and neck squamous cell carcinoma.

AIMS: The main purpose of the current study was to find predictive biomarkers that can be routinely used for the response to chemotherapy in head and neck squamous cell carcinoma (HNSCC). METHODS: From this standpoint, we selected the histoculture drug response assay (HDRA) to assess in vitro chemosensitivity, and real-time reverse transcription polymerase chain reaction to investigate the gene expression profile of individual tumors as available predictive biomarkers. Using both surgery and biopsy specimens, we analyzed their gene expression profiles using the 18 markers that we thought were likely predictors of the response to anti-cancer agents. RESULTS: Statistically significant associations were found between 5-fluorouracil (5-FU) sensitivity in HDRA and HER-2 mRNA expression level (p = 0.0030). Moreover, HER-2 expression was significantly associated with cisplatin sensitivity (p = 0.0089). Cisplatin sensitivity in HDRA was also demonstrated to have a significant association with epidermal growth factor receptor (EGFR) expression in which the group with cisplatin resistance tended to have a higher expression level than the sensitive group (p = 0.0385). CONCLUSION: HER-2 and EGFR may be possible reliable predictive biomarkers for anti-cancer therapy, and might help in the decision-making process for individual patients with HNSCC.

Evaluation of optimal drug concentration in histoculture drug response assay in association with clinical efficacy for head and neck cancer.

Induction chemotherapy or concomitant chemoradiotherapy has been used increasingly to improve survival, organ preservation and function in patients with head and neck cancer (HNC). However, this regimen encounters significant side effects with potential adverse reactions causing many disadvantages for patients. Therefore, reliable chemosensitivity assays are needed to accurately predict the response to chemotherapy and guide the selection and treatment of patients with HNC. The main purpose of this study was to examine the optimal drug concentrations for evaluating in vitro chemosensitivity using the histoculture drug response assay (HDRA). The tested tumor specimens included 7 from oral cavities (14.3%), 12 from oropharynx (24.5%), 10 hypopharynx (20.4%), 3 larynx (6.1%), 5 sinonasal (10.2%), 2 salivary glands (4.1%), and 10 from metastatic lymph nodes (20.4%), respectively. Histopathologic types of all 49 specimens were squamous cell carcinoma. We investigated the optimal drug concentrations in HDRA searching at doses of 4-100 microg/ml for cisplatin and 60-1500 microg/ml for 5-FU. We considered the concentration of 20 microg/ml to be appropriate for evaluating cisplatin sensitivity in HNC among the tested dosages. As for cisplatin sensitivity in vitro, the 50% cut-off inhibition index (I.I.) was found to have a significant association with the clinical response to chemotherapy, with an accurate prediction rate of 77.8%. The HDRA shows a predictive value for chemosensitivity in HNC patients using the optimal drug concentration cut-off with this site specificity.

Analysis of salvage operation in head and neck microsurgical reconstruction.

In this study, we examined salvage operations after reexploration in head and neck reconstruction and analyzed ways to solve problems. Free flap reconstruction of the head and neck lesion was carried out for 513 cases in our hospital over the past 12 years. Twenty-one cases of reexploration were caused by postoperative thrombosis (4.1%). We could only salvage seven cases (33.3%) of 21 cases from flap thrombosis. All seven cases were included in the category of venous thrombosis, and they were undertaken within 3 days postoperatively. Our results have shown that once thrombosis occurs, there is little possibility of flap salvage, particularly 3 days after operation and in infectious cases. When no flow phenomena are observed and no flap salvage is deemed possible, aggressive treatment such as a second free flap or next pedicle flap should be chosen as soon as possible to avoid any delay in postoperative treatment.

Selection of recipient vessels for free flap following intra-arterial chemoradiotherapy.

OBJECTIVE: This study aims at selecting recipient vessels for free flap following intra-arterial chemoradiotherapy. At present, many centers combine intra-arterial chemotherapy and concomitant radiotherapy for treating head and neck cancer with favorable results. However, some patients develop recurrent, residual disease/complications after completing treatment protocols and thus require free-flap surgery. The feasibility of microsurgery following intra-arterial chemoradiotherapy remains unclear. STUDY DESIGN AND METHODS: We retrospectively analyzed 730 patients who underwent free-flap surgery for managing treatment-related complications/defects following head and neck surgery from January 1999 to February 2012. All patients were categorized into two groups according to the presence (group A)/absence (group B) of a history of intra-arterial chemotherapy. Microvascular revision rates were compared between the groups. In group A, the correlation between catheterization sites and recipient vessels used for microsurgery was assessed. RESULTS: A total of 769 free flaps were created in 730 patients and comprised 36 and 733 flaps in groups A and B, respectively. Microvascular revision rates were 2.8% (1/36) and 4.2% (31/733) in groups A and B, respectively, with no significant difference observed between the groups. No statistically significant difference was observed when only cases of arterial thrombosis were included. Vessels used for recipient anastomoses were not directly exposed to intra-arterially injected agents. CONCLUSION: Preoperative intra-arterial chemoradiotherapy does not significantly increase the risk of microvascular revisions, particularly artery-related revisions, if vessels selectively catheterized and perfused with chemotherapeutic agents during intra-arterial chemotherapy are avoided as recipient vessels.

Prognostic factors and outcomes for salvage surgery in patients with recurrent squamous cell carcinoma of the tongue.

AIM: Recurrence rates of oral cancer following primary treatment have been reported in the range of 25-48%. However, salvage therapy remains a critical challenge to improving outcomes. Here, we investigated prognostic factors and outcomes for salvage surgery in patients with recurrent oral tongue squamous cell carcinoma (OTSCC). METHODS: We retrospectively reviewed patients who were referred to Aichi Cancer Center, Japan, for the treatment of recurrent OTSCC. All patients included in the present study had undergone salvage surgery. Data to identify the predictive value of prognostic factors were available from 69 patients. Prognostic factors were assessed using Cox's proportional hazards regression analysis. Differences in overall survival between groups of patients were assessed by the log-rank test. RESULTS: In all, 36 patients (52%) developed second recurrence or died, of which 21 (58%) occurred within 12 months of salvage surgery. Univariate analysis indicated that survival was significantly worse in patients with recurrent stage III or IV tumors, two or more positive cervical lymph nodes, levels IV or V positive cervical lymph nodes, extracapsular spread (ECS) of positive cervical lymph nodes and a disease-free interval from initial treatment of less than 12 months. On multivariate analysis, ECS was an independent prognostic factor for overall survival after salvage surgery. CONCLUSION: Neck status at the time of salvage surgery, particularly ECS is a significant prognostic factor for surgical salvage. Survival was also influenced by the stage of the recurrent tumor and disease-free interval, suggesting that the biological features of recurrent tumors might impact on prognosis.

Loss of p21WAF1/CIP1 expression in invasive fronts of oral tongue squamous cell carcinomas is correlated with tumor progression and poor prognosis.

The clinicopathological significance of cell-cycle proteins has remained unclear in oral tongue squamous cell carcinomas (OTSCC). In the current study, we evaluated several cell-cycle proteins in relation to clinicopathological parameters and disease outcome for OTSCC. A total of 123 previously untreated patients with OTSCC, who underwent surgical treatment, were enrolled. Tumor specimens were examined for expression of p21, p27, p16, p53, and p63 using immunohistochemistry, with reference to clinicopathological factors and disease outcome. It is noteworthy that differences in p21 immunoreactivity were evident between the shallow region and invasive front of tumors within the same specimens. Loss of p21 expression in invasive fronts was found to be associated with clinicopathological factors of tumor progression and poor prognosis. p21 expression in invasive fronts is a significant indicator for impact on survival. Moreover, p21 is one of the important factors that regulate the progression of malignant cells in OTSCC.