Surgical resection for parotid cancer often results in the loss of the facial nerve as well as creating both skin and soft tissue defects. An anterolateral thigh (ALT) flap with the vastus lateralis branch of the femoral nerve (VLFN) and the lateral femoral cutaneous nerve (LFCN) can be used for the immediate reconstruction of a defect associated with parotid cancer resection. From October 2003 to December 2008, 10 parotid cancer patients underwent VLFN and/or LFCN grafting for immediate reconstruction after cancer ablation. Five cases received non-vascularized nerve grafts and 5 cases received vascularized and non-vascularized nerve grafts. In 9 cases, an ALT flap was combined with a nerve graft to treat skin defects, and perifascial areolar tissue (PAT) was used in one case to treat a soft tissue defect.
The results were satisfactory, and facial animation returned in all but 2 patients.
Various tissues, such as nerves, muscle flaps, PAT, and fascia can therefore be used for facial nerve reconstruction after parotid cancer ablation.

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The aim of this research was to analyze how the occlusal status of oral and maxillofacial cancer patients reconstructed with free scapular combined flap affects their oral function.
Forty-seven patients treated in our hospital from 1988 to 2007 simultaneously underwent reconstructive surgery following mandibulectomy. Food intake was evaluated at least one year after treatment. The 47 patients were divided by means of Urken's classification. Most of the patients who underwent limited resection (B, BS) showed sufficient ability to eat without prosthetic dentures. Patients who became edentulous in a larger area as a result of mandibular resection demonstrated worse eating. Most of the patients who underwent wide mandibular resection (RBSSB, BSSB) could not use dentures because of poor retention even after reconstruction. The insertion of a dental implant into reconstructed bone improved denture stability, and the patients consequently showed better eating ability. Completely edentulous patients gained better eating ability by means of dentures without dental implant if an adequate shape of reconstructed bone with a thin skin paddle was employed. This study showed that suitable reconstruction had many advantages for the recovery of oral functions.
The patients reconstructed using a scapular combined flap successfully re-acquired the ability to eat.

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Complication rates for salvage surgery after concurrent chemoradiotherapy (CCRT) have been reported to be high. From 1995 to 2008, 131 patients with laryngeal cancer and 107 with hypopharyngeal cancer underwent CCRT at Hokkaido University Hospital, Japan. Of the 131 patients with laryngeal cancer, a local recurrence developed in 43 (33%), of whom 38 (88%) underwent salvage surgery. The local control rate after salvage surgery was 79% (30/38). On the other hand, a local recurrence developed in 30 (28%) of 107 patients with hypopharyngeal cancer, of whom only 10 (33%) underwent salvage surgery, the local control rate after which was 60% (6/10). In 34 patients who underwent salvage laryngectomy or laryngopharyngectomy in our hospital (laryngeal cancer 28, hypopharyngeal cancer 6), overall wound complications, major wound complications and pharyngocutaneous fistulas were observed in 53%, 29% and 26%, respectively. CCRT can cause difficulties in wound healing and wound complications, such as infection or pharyngocutaneous fistulas. To reduce the incidence of wound complications, we have taken steps including appropriate skin incisions, preservation of the strap muscles, thyroid glands and major veins, and pectoralis major myofascial flap transfer to reinforce the primary pharyngeal closure (pharyngeal interposition graft). High incidences of wound complications and poor wound recovery in patients undergoing salvage surgery following CCRT should be taken into account before the initiation of CCRT, and emphasis should be placed on taking steps to prevent wound complications associated with salvage surgery.

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Concurrent chemoradiation (CCRT) for advanced head and neck cancer is becoming more widely used. CCRT represents an effective treatment for patients with advanced head and neck cancer, and possibly improves survival. In the present study, all of 25 patients underwent planned neck dissection 6-8 weeks after the completion of radiation. Selective neck dissection was performed whenever possible. Radical neck dissection was carried out for patients with residual adenopathy that had invaded the surrounding structures and/or enclosed the carotid arteries. A complete response at the primary sites was achieved in all patients. Of the 25 cases, 7 (28%) showed viable cancer cells within their neck dissection specimens. Local and regional disease control was excellent after CCRT with neck dissection. Unfortunately, CCRT followed by neck dissection sometimes induces stomal infection and swallowing dysfunction. We have been performing additional surgery to improve the swallowing function and bilateral neck dissection simultaneously.

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Cervical cancer is initiated by infection with high-risk human papillomaviruses (HPVs). It has been suggested that the link between HPV and head and neck squamous cell carcinoma is specific to carcinoma of the tonsil. We systematically summarize HPV infection, carcinogenic mechanisms and detection of HPV in head and neck cancer. It will be necessary to develop preventive and therapeutic strategies aimed at reducing the incidence and mortality of HPV-associated cancers.

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Purpose: Human papillomavirus (HPV) has previously been reported to be associated with squamous cell carcinoma of the head and neck (HNSCC). Our objective was to investigate the presence and type of HPV infection in head and neck tumors and to determine whether infection was associated with patients and tumor characteristics. Experimental design: Fresh tumor samples were obtained from a series of 71 head and neck squamous cell carcinoma patients with newly diagnosed HNSCC in the Tokyo Medical Center from 2005 through 2009, including 62 men and 9 women. A PCR-based technique was used to detect and type HPV. Results: Of the 71 patients, 8 (11%) had detectable HPV in their tumor samples (HPV 16:7 cases, HPV 33:1 case). HPV was detected in 50% of oropharyngeal tumors. HPV-positive tumors are more likely than HPV-negative tumors to occur in nonsmokers and ex-smokers. Furthermore HPV-positive tumors were less likely to harbor p53 mutations than HPV-negative tumors. Conclusion: Our study supports the previous reports that suggest HPV 16 is associated with squamous cell cancers in the oropharynx. Carcinogenesis of HPV-positive HNSCCs is genetically quite different from that of HPV-negative HNSCCs, suggesting that novel treatment strategies are required for those tumors.

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We retrospectively analyzed cases with squamous cell carcinoma of the lower gingiva and alveolus who underwent a combination of alveolar ridge and soft tissue reconstruction using a vascularized fibular or hemi-radius graft following marginal mandibulectomy between April 1992 and August 2007, in order to evaluate the validity and indications. Our treatment strategy for mandibular reconstruction after marginal mandibulectomy is as follows: 1. If the vertical alveolar bone defect ranges within 1/3, neither alveolar bone reconstruction nor soft tissue reconstruction is performed, or soft tissue reconstruction alone is performed; 2. If the vertical alveolar bone defect is from 1/3 to 1/2 of the mandible, a combination of alveolar ridge and soft tissue reconstruction using a radial forearm free flap with hemi-radius is performed; 3. If the bone defect accounts for more than 1/2 of the mandible, a combination of alveolar ridge and soft tissue reconstruction using a vascularized fibular graft is performed. The subjects consisted of 24 cases with reconstruction of the alveolar bone and/or soft tissue and 22 cases without reconstruction. In the 24 cases, 17 cases were treated with soft tissue reconstruction alone and 7 cases with the combination of alveolar ridge reconstruction and soft tissue reconstruction. The period from the day of operation to hospital discharge was significantly shorter in the cases without reconstruction than with reconstruction. The period from the day of operation to the insertion of dental prosthesis was significantly shorter with the combination of alveolar ridge reconstruction than with soft tissue reconstruction.
In conclusion, we considered that the combination of alveolar ridge and soft tissue reconstruction using a vascularized fibular or hemi-radius graft following marginal mandibulectomy is a standard therapy for squamous cell carcinoma of the lower gingiva and alveolus.

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The medical records of 52 previously untreated patients with N1 squamous cell carcinoma of the tongue between 1983 and 2002 were reviewed. All patients underwent neck dissection as part of the initial treatment. Clinical cervical metastases of level I to III were found in all cases. The pathological sites of cervical metastasis and cervical recurrence were found to be almost level I to III. The T stage and the clinical sites of cervical metastasis were not correlated with the pathological sites of cervical metastasis. The appropriate area of neck dissection for patients with N1 tongue cancer is thought to be level I to IV.

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Organs with important functions for daily life are concentrated in the head and neck area, and maintaining post-treatment Quality-of-Life (QOL) is also important when treating cancers of the head and neck, in addition to improving survival rate. Free flap reconstruction techniques are expected to contribute to maintaining post-treatment QOL, but these techniques have not been adequately evaluated in Japan. We performed a cross-sectional analysis of QOL, using the Japanese version of the UWQOL (version 4) from the University of Washington in the United States, with 202 patients from 10 institutions who had undergone reconstructive surgery for tongue cancer. In addition to the survey form, we collected clinical information (age, sex, time since surgery, flap donor site, whether radiotherapy was administered, and other factors), and analyzed whether differences in postoperative QOL were seen depending on each of these factors and the hospital at which the surgery was performed. Although a relationship was found between QOL following reconstructive surgery for tongue cancer and the extent of resection, age and whether radiotherapy was administered, fairly good QOL was maintained overall.

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Laryngeal cancer is the most common type of head and neck carcinomas, and there are many reports on its treatment and results. Therefore, the treatment procedures and results are somewhat similar. However, the recent widespread use of concurrent chemoradiotherapy has resulted in differences in the larynx preservation rates in T2 and T3 cases among facilities.
Our facility administers concurrent chemoradiotherapy for advanced cancers in order to preserve organs and functions. In this paper, we report the results of a study on 35 laryngeal cancer cases, which were treated at our facility from April 2005 to December 2008.
The cumulative survival rates were 100, 100, 83.3, and 57.1% for stage I, II, III, and IV, respectively. The CR rate of the concurrent chemoradiotherapy (SN therapy) was 82.4%. The larynx preservation rate after SN therapy was 94.1%.

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This study reviewed the results of salvage surgery in patients with local recurrence of hypopharyngeal carcinoma after chemoradiotherapy. Between 1989 and 2008, 74 patients with hypopharyngeal carcinoma were treated with chemoradiotherapy. Ten of these patients underwent salvage surgery, and we analyzed postoperative complications and prognosis. Postoperative complications were found in 9 cases (90%). The survival rate after salvage surgery was 30%. These results suggest that accurate diagnosis of recurrence at an early stage is important for improving the outcome of salvage surgery.
The indication as well as operative risks of salvage surgery should be carefully determined.

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We started to use endoscopic laryngo-pharyngeal surgery (ELPS) from June 2007 for pharyngeal and laryngeal superficial carcinomas. Twenty patients treated by ELPS from June 2007 to June 2009 were retrospectively analyzed. The age of the patients was 40-82 (median: 67.4) years old. Nineteen were male and one was female. Eleven of 19 patients who had been suspected of cancer before the operation were pathologically diagnosed as carcinoma in situ or squamous cell carcinoma. Four patients were pathologically diagnosed as dysplasia. The lesions in 17 of the 20 patients were found by gastroenterological endoscopy in the internal medicine department. Only 3 patients were diagnosed by ENT doctors. Almost half of the patients (9 out of 17 cases) were diagnosed by gastroenterological endoscopy during follow-up of stomach or esophageal cancer. In terms of airway management of ELPS, a tracheostomy was done only for the first case; the other 19 cases were extubated on the same day. Only 2 patients could not eat on the day after the operation. The longest period until the patient was able to ingest orally was 13 days. All patients could eat orally within 2 weeks.

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To clarify radiotherapeutic factors related to the control of cervical lymph node metastases, we retrospectively reviewed 29 patients with N2-3 oro- and hypopharyngeal squamous cell carcinoma treated with chemoradiotherapy followed by planned neck dissection between April 2004 and March 2008. Pretreatment assessment of all patients revealed cervical metastases in a total of 63 neck levels. Planning target volume (PTV) was defined as lymph node metastases by neck level with a 5-mm margin, and a dose-volume histogram (DVH) was used to evaluate the maximum (PTV max), minimum (PTV min) and mean radiation dose to the PTV (PTV mean). Overall, 59% of the patients attained a pathologic complete response (pCR) in the neck. Evidence of residual pathologic tumor by neck level was found most commonly in Level V and retropharyngeal lymph nodes. On univariate analysis, primary site (oropharynx) and the effect of induction chemotherapy (partial response) were significant predictors of a neck disease specimen with negative pathology. PTV max and PTV mean in Level V were found to be significantly lower than those in Levels II and III. Furthermore, there was a significant association between radiation dose and pathologic status on the neck. Our data thus suggested that excellent dose coverage for cervical lymph nodes might lead to better regional control.

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Ultrasonography (US) is very useful for detecting cervical neck metastases in head and neck cancer. Recently, FDG-PET is used to investigate cervical lymph nodes metastases.
We evaluated the accuracy of US and FDG-PET for identifying lymph node metastases with histopathologic correlation.
In US findings, lymph nodes were considered metastatic if their shortest diameter exceeded 7 mm in level I and II or 6 mm in level III, IV and V, and if the ratio of their shortest to longest diameters exceeded 0.5 concurrently. In FDG-PET findings, lymph nodes were classified as metastatic if their standardized uptake value (SUV) was greater than 3.0.
Cervical lymph nodes were removed by neck dissection from 31 patients with head and neck squamous cell carcinoma. Nine patients underwent bilateral neck dissection, so we evaluated 40 sides of necks in 31 patients. A total of 74 lymph nodes were diagnosed histopathologically as metastatic. Of the 74 metastatic lymph nodes, 36 (48%) were diagnosed correctly by preoperative US findings and 38 (51%) were diagnosed correctly by preoperative FDG-PET findings. The accuracy of US and FDG-PET was 87% and 92%, respectively.
The accuracy of clinical N staging by FDG-PET was superior to that by US, especially N1 and N2a were diagnosed correctly. Comparing clinical N stage with pathological N stage, 31 of 40 cases were correctly diagnosed by FDG-PET findings, while 27 of 40 cases were correctly diagnosed by US.
US and FDG-PET have the limitation that they cannot detect all histopathological metastatic lymph nodes preoperatively. US is very useful and can determine clinical N stage quickly, however, FDG-PET provides more accurate clinical N staging than US. If neck dissection will be done, it is desirable that both US and FDG-PET are done.

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Objective and Subjects: To clarify the clinical features of multiple primary cancers (MPC) in the Ryukyu Islands, we investigated 218 head and neck squamous cell carcinoma cases newly and histologically diagnosed from February 2005 to August 2008 at our clinic.
Methods: Medical records were retrospectively reviewed for MPC development.
Results: 1. MPC were observed in 48 of 218 patients and consisted of 25 synchronous and 23 metachronous cancers during a mean follow-up period of 16.4 months. 2. MPC development was observed in 50.0% of middle ear cancer, 28.8% of mesopharyngeal cancer, 23.9% of hypopharyngeal cancer, 18.0% of laryngeal cancer, and 17.3% of oral cavity cancer cases. 3. The most common site for synchronous MPC development was the esophagus (16 lesions), followed by head and neck (4), lung (3), stomach (1) and rectum (1). 4. Metachronous MPC were divided into two groups according to the location of the first cancer, i.e. head and neck group (9 cases) and other cancer group (14 cases). The period between detection of first cancer and development of second cancer was significantly shorter in the head and neck group (40 months) than in the other cancer group (98 months). 5. Treatment results in patients with MPC were not significantly different from those in patients without MPC. 6. Significant risk factors in MPC development included a high alcohol intake, and mesopharynx and hypopharynx as tumor locations.
Conclusions: These results demonstrated the high incidence of multiple primary cancers in patients with head and neck squamous cell carcinoma, especially mesopharyngeal cancer. Long-term regular and repeated examinations of high-risk areas, i.e. the esophagus, head and neck, stomach, and lung, are important to detect MPC in the early clinical stage.

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Postoperative bed rest has been used for patients who underwent microsurgical head and neck reconstructions to avoid the risk of a thrombosis at the microvascular anastomosis. However, prolonged bed rest increases the risk of postoperative complications such as deep vein thrombosis, pneumonia, atelectasis and delirium.
We created a postoperative program in which early ambulation is started after microsurgery of head and neck reconstruction.
In the first period, from September 2002 to September 2003, 45 cases underwent bed rest for 4 days and started ambulation at 5 days after microsurgery. In the second period, from October 2003 to September 2004, 47 cases underwent bed rest for 1 day and started ambulation at 2 days. In the third period, after October 2004, 164 cases did not need bed rest and started ambulation on the day after operation. The thrombosis rates at the vessel anastomosis in the first, second and third periods were 2.2%, 2.1% and 1.8%, and postoperative delirium rates in each period were 29%, 23% and 7%, respectively.
We conclude that early ambulation decreased the postoperative delirium rate and did not affect the thrombosis rate after microvascular anastomosis for head and neck reconstruction.

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We clinically examined 9 patients with metastatic cancers to the head and neck from the thoracoabdominal viscera treated in our department during the 15-year period from March 1994 to February 2009. The patients were 6 males and 3 females with a mean age of 67.9 years (range 58-78 years). Primary lesions included those in the lung (4 cases), kidney (2 cases), liver (1 case), stomach (1 case), and colon (1 case) in order of frequency. Sites of metastasis in the head and neck region included 4 cases in the mesopharynx (3 in the palatine tonsil and 1 in the root of the tongue), 3 in the oral cavity, 2 in the nose or paranasal sinus, and 1 in the thyroid gland. One patient had double cancers originating in the palatine tonsil and the oral cavity. The interval between detection of the primary cancer and the metastatic head and neck cancer ranged between within one month and 10 years, and in three cases was more than five years. In one of nine cases (gastric cancer), pathologic findings for the metastatic lesion were helpful in detecting the primary site. All cases exhibited other distant metastases outside the head and neck region, and the bone (5 cases) was the most frequent site followed by the brain (3 cases), adrenal gland (3 cases), and lung (2 cases).
Although previous studies found that the most frequent metastatic cancer to the head and neck from the thoracoabdominal viscera was renal cell carcinoma in the nose or paranasal sinus, our review of the literature published between 1983 and 2009 has revealed that metastasis of lung cancer to the pharynx is the most frequent.

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Head and neck soft tissue sarcoma is a very rare disease in adults. We retrospectively analyzed 8 cases with head and neck soft tissue sarcomas treated at Shikoku Cancer Center from 1993 to 2006. They were pathologically classified as follows: 3 cases with rhabdomyosarcoma, 2 cases with liposarcoma, and one each of angiosarcoma, myofibroblasticsarcoma, and fibrosarcoma. All 3 cases of rhabdomyosarcoma were performed chemotherapy (VAC) and radiotherapy as the first treatment; the other 5 cases were performed wide excision as the first treatment. The disease-specific 5-year survival rate was 30.0%. After surgical treatment, it is worth considering radiotherapy for cases with a positive resection margin.

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Various hormones and cytokines produced by malignant tumors are known to cause paraneoplastic syndrome, but also a neutrophilic hematogenic factor, known as granulocyte colony stimulating factor (G-CSF), is another factor that induces paraneoplastic syndrome.
We report a case of an 82-year-old male who was diagnosed with a G-CSF producing carcinoma of the right nasal cavity. The pathology of the specimen from the biopsy revealed a well differentiated squamous cell carcinoma, and his blood/laboratory test on admittance showed a remarkable increase in WBC count of 23.7 × 10⁹/L, as well as an extremely high level of G-CSF of 480 pg/ml. The patient underwent partial maxillectomy whereby total resection was achieved, and post-operative radiotherapy of 50 Gy in doses was applied. The serum G-CSF concentration was seen to normalize after treatment.
From these clinical findings and immunohistological results (obtained by using polyclonal antibody against G-CSF to stain the tumor cells), the tumor was diagnosed as a G-CSF producing carcinoma. The prognosis of this carcinoma is said to be very poor, averaging around 3 months, but our case has shown no recurrence for over 2 years after treatment. The fact that we were able to totally resect the tumor surgically is likely to be the most significant factor of non-recurrence. There have been reports that an increase in WBC count may be a marker of recurrence, so we plan to continue following this case carefully.

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