We retrospectively reviewed nine cases of olfactory neuroblastoma in Keio University School of Medicine from 2010 to 2015. The surgical approach was the endoscopic endonasal approach, either alone or in combination with craniotomy, performed by a team of head and neck surgeons and a neurosurgeon. The distribution of patients according to the modified Kadish classification （A/B/C/D） and Dulguerov classification （T1/T2/T3/T4） was 1/4/4/0 and 1/4/2/2. Tumors of six cases were removed by the endoscopic endonasal approach alone; three cases needed craniotomy to resect intra-dual tumors. Three-layered skull base reconstruction using fascia, pericranial flap and nasoseptal flap was used for five cases. None of the cases experienced cerebrospinal fluid leakage postoperatively. Seven patients received postoperative radiotherapy. Three cases experienced tumor recurrence, and underwent salvage surgery or radiotherapy. All cases remained alive, though the average observation time was less than 3 years. Recent reports have demonstrated that the endoscopic endonasal approach has a comparable control rate to the open approach for olfactory neuroblastoma. We believe that endoscopic endonasal skull base surgery should play a key role in the treatment of olfactory neuroblastoma in the years ahead.

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Olfactory neuroblastoma （ONB） is a rare nasal malignancy. Because of its rarity, established treatments are lacking. The present retrospective study investigated the efficacy of CADO-CVP against ONB in 31 patients initially treated in the Department of Head and Neck at the Cancer Institute Hospital between 1992 and 2012. We have previously administered CADO-CVP as induction chemotherapy, achieving a high response rate. Five-year overall and disease-free survival rates were 82％ and 53％, respectively. Disease-free survival rates differed significantly between the groups with and without induction chemotherapy. Four patients showed recurrence at over 5 years after initial treatment. We therefore consider that long-term follow-up is important for patients with ONB.

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Primary lacrimal sac tumor is relatively rare and is often misdiagnosed as chronic dacryocystitis, thereby delaying its treatment. We encountered a patient who underwent partial maxillectomy, orbital clearance, parotidectomy, modified neck dissection, and reconstruction with rectus abdominis flap. A multidisciplinary treatment comprising surgery, chemotherapy, and radiotherapy is generally recommended for primary lacrimal sac tumor. In addition, the primary lacrimal sac tumor needs to be treated according to various histological types such as squamous cell carcinoma, undifferentiated carcinoma, and transitional cell carcinoma. Because tumor recurrence is often observed after a long time, long-term follow-up is considered necessary. When examining patients with lacrimation or swollen lacrimal sac, we recommend that primary lacrimal tumor should be considered in differential diagnosis for early diagnosis.

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Most patients with early-stage oral tongue cancer（T1/T2N0M0）can be cured with intraoral resection alone. However， previous reports have found the rate of patients who are at high risk for distant metastasis to be 20-40％. We performed a clinical study of 48 patients undergoing surgery for early-stage tongue cancer and classified the tumors in order to identify prognostic factors according to the mode of invasion（YK classification）. Seven patients had YK-1， 8 had YK-2， 18 had YK-3， 13 had YK-4C， and 2 had YK-4D. Twenty-nine patients had no recurrence（NR）during the follow-up period. Six patients developed local recurrence（LR）， and 17 patients developed late cervical metastasis（LCM）. Eight patients died. LCM， distant metastasis（DM）， and the mode of invasion（YK-4 classification）were found to be significantly associated with a poor prognosis. In particular， the mode of invasion（YK-4 classification）was also associated with incidence of LCM. Thus it could be argued that the mode of invasion is the most useful prognostic factor among the clinical and pathological factors， which could be assessed after the initial surgery for early-stage oral tongue carcinoma. Therefore， it is necessary to promptly perform elective neck dissection after the initial surgery in patients with a mode of invasion classified as YK-4.

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The nasopharynx is located in the mid-facial portion and is difficult to access in surgery. In the trans-cervical approach, surgery is performed from the submandibular region through the parapharyngeal space. However, no report has explained the procedure in detail, especially when the mandibular bone is preserved. In this report, a case of T3 oropharyngeal posterior wall cancer extending into the nasopharynx is presented with a detailed description of the surgical procedure. In the operation, dissection proceeded from the submandibular region along the styloid diaphragm and the fascia covering the medial pterygoid muscle. The muscles associated with the styloid process （stylohyoid, styloglossus and stylopharyngeus muscles）, ones with auditory tube （levator veli palatine, tensor veli palatine） and the pharyngobasilar fascia were sequentially identified. After the lateral wall of the pharynx was widely exposed, the tumor was resected en bloc. The mucosal defect was reconstructed with free jejunal flap. The laryngeal framework was removed and subglottic mucosal closure was performed to maintain oral intake. The postoperative course was uneventful except for facial palsy which resolved without intervention. The trans-cervical approach to the nasopharyngeal space can be performed in systematic fashion and is a useful method for resecting oropharyngeal cancer extending into the nasopharynx.

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Objective: The aim of this study was to clarify the safety and suitability of endoscopic pharyngolaryngeal surgery （ELPS） for local recurrence after cetuximab combination radiation therapy （bio-radiation therapy: BRT）.
Materials and methods: We retrospectively evaluated by chart review the treatment results and complications for five hypopharyngeal cancer patients who underwent ELPS as salvage surgery after BRT, from April 2013 to October 2014.
Result: One of the five cases died due to local recurrence of the disease, another case remains alive with disease, and the remaining three cases have no recurrence and can take food normally. The local recurrence case had a deep part positive surgical margin according to the results of postoperative pathology. Two cases included surgical site infection, which were improved by conservative medical treatment.
Conclusion: ELPS as salvage surgery after BRT is useful for local control and larynx preservation, but it is necessary to prescribe precisely its adaptation.

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The prognosis of unresectable hypopharyngeal carcinoma is extremely poor. We have recently compiled data on the treatment process for unresectable hypopharyngeal carcinoma. A tumor was defined to be “unresectable” on the basis of the following criteria: 1）invasion into the internal carotid artery or common carotid artery, 2）notable invasion into the prevertebral muscle or vertebra, 3）invasion into the soft palate or epipharynx, 4）invasion into the brachial plexus, and 5）invasion into the cranial base. The present study included“unresectable hypopharyngeal carcinoma”cases without distant metastasis. Of 529 patients who visited our hospital between September 2002 and December 2015 for the treatment of hypopharyngeal carcinoma, 26 patients with unresectable carcinoma without distant metastasis（approximately 5％）were selected: 25 men and 1 woman, with a mean age of 64 years. The performance status（PS）was PS0 in 3 patients, PS1 in 1, PS2 in 4, PS3 in 7, and PS4 in 1. The treatment was chemoradiotherapy（CRT）in 16 patients, induction chemotherapy followed by CRT in 5, radiotherapy in 4, and best supportive care in 1. The outcomes were death due to the original disease in 19 patients, disease-free survival in 5, and death due to other diseases in 2. The survival period of the patients who died of the original disease ranged from 2.5 months to 3 years and 2 months（median: 6.4 months）, and the observation period for disease-free survival ranged from 10 months to 10 years（median: 3 years and 6 months）. The overall survival for all the patients was 20.7％. Compared with patients with“resectable hypopharyngeal carcinoma”, many of the patients with unresectable hypopharyngeal carcinoma had poorer PS with the possibility of serious adverse events during treatment, while some patients had a long disease-free survival period. Accordingly, it may be difficult to make exact assessments before starting treatment. Therefore, it is important to give detailed explanations to these patients and obtain their consent prior to treatment.

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Invasive micropapillary salivary duct carcinoma （SDC）, a subtype of SDC, is reported to be particularly aggressive.We report a case of invasive micropapillary SDC.A 44-year-old man was referred to us due to swelling of the left parotid gland.Radiological findings showed parotid gland tumor with multiple cervical lymph nodes.Fine needle aspiration cytology （FNA） of the tumor showed ‘Class V, adenocarcinoma suspected’.Extended total parotidectomy with radical neck dissection was performed, and the facial nerve was sacrificed due to adhesion to the tumor.Comedo necrosis and papillary structures were found in the specimen.The papillary structures were absent from the fibrovascular core and had clear spaces around themselves.Immunohistochemical analysis of MUC1 highlighted cells rimming the papillary structures.The tumor was diagnosed as invasive micropapillary SDC.Postoperative chemoradiotherapy was performed, but he died of multiple distant metastasis within one year from the first visit.

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Although adenoid cystic carcinoma （ACC） is characterized by a high incidence of distant metastasis, choroidal metastasis is extremely rare. Here, we present a patient with choroidal metastasis from ACC of the submandibular gland at around 11 years after initial treatment. Due to simultaneous lung metastasis, radiation therapy alone （40Gy/20fr） was administered for choroidal metastasis, and it resulted in tumor reduction and improvement of visual acuity without any adverse events. Thus, radiation therapy for choroidal metastasis of ACC may be considered as a palliative treatment for improvement of quality of life.

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Salivary duct carcinoma （SDC）, which originates mainly from the parotid gland, is liable to develop distant metastasis at an early phase. It is an extremely malignant cancer occurring on the head and neck, for which radiotherapy and chemotherapy are generally not effective. One characteristic is its expression of the androgen receptor （AR）; endocrine therapy targeting the AR would be effective for SDC. Although therapy targeting the AR is used for prostate cancer, it is not indicated for head and neck cancer. In our department, maximal androgen blockade therapy （MAB; usually used for prostate cancer） has been adopted since 2012 for cases of AR-positive advanced SDC for which first-line chemotherapy and radiotherapy were ineffective. MAB therapy showed three complete responses, one partial response and one disease progression as the best response of the target lesion in SDC patients with distant metastasis. Further, the therapy may contribute to the extension of life prognosis. MAB therapy is safe and effective for advanced SDC.

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We retrospectively analyzed 81 patients who were diagnosed with pathological N2c（pN2c）squamous cell carcinoma of the head and neck between January 2001 and December 2013 at Kurume University Hospital or other facilities. Patients comprised 74 males and 7 females, with a median age of 62（range, 29-89）years. Primary sites included the oral cavity（n＝22）, oropharynx（n＝8）, larynx（n＝13）, and hypopharynx（n＝38）. Age, gender, primary sites, T classification, degree of differentiation, neoadjuvant chemotherapy, adjuvant chemotherapy, surgical margin, neck metastasis to level 4, extracapsular spread, size of positive nodes, and number of positive nodes were selected as affected factors for consideration as locoregional, distant metastatic, and prognostic factors. Multivariate analysis identified surgical margin, number of positive nodes and T classification, and number of positive nodes as locoregional, distant metastatic, and prognostic factors, respectively. Patients with pN2c squamous cell carcinoma experienced distant metastasis and poor prognosis based on the increase in the number of positive nodes. We believe that adjuvant therapy was necessary for those high-risk patients.

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Small cell carcinoma of the head and neck is a rare tumor that carries a poor prognosis. We report six cases of small cell carcinoma of the head and neck in our hospital, four of which occurred in the paranasal sinus. The treatment modalities were very inconsistent. As the initial treatment, surgery was performed in two cases, radiotherapy in three, and best supportive care in one. The surgery cases died within one year because of tumor progress with distant metastasis in spite of postoperative radiotherapy. All radiotherapy cases remain alive, with two cases surviving for a long time （56 months, 102 months）. Two cases in the radiotherapy group received concurrent chemotherapy （Cisplatin and Etoposide）. Brain metastasis appeared in only one of the six cases. These results suggest that treatment for pulmonary small cell cancer in the head and neck region is reasonably effective, but because strong treatment is required, careful follow-up of adverse events is required.

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Squamous cell carcinoma of the thyroid gland is a rare disease. Although several mechanisms have been proposed, the pathogenesis of the disease is not known. A majority of cases are at an advanced stage at the time of diagnosis and the clinical course is extremely aggressive. This is because the tumor often invades directly into neighboring organs, metastasizes, and is refractory to conventional treatments. As a result, a clinically effective therapy is not established for this biologically aggressive tumor with extremely poor prognosis.
From January 2000 to December 2012, there were three cases of squamous cell carcinoma of the thyroid gland, accounting for 1.1％ of all thyroid cancers treated in our department.
Two patients who were treated with radical surgery plus chemoradiotherapy developed distant metastases. One of them died at 20 months after the initial treatment, while the other remained alive with metastatic tumor for 44 months. One inoperable patient died 5 months after CRT. For operable cases, multimodality treatment with radical surgery may be preferable, leading to longer survival.

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Carcinoma of the external auditory canal （EAC） is a very rare disease. Although a relationship between frequent ear-picking and EAC carcinoma has been suspected, no statistical analysis has been reported. We retrospectively reviewed ear-picking habit in patients with carcinoma of EAC and in healthy Japanese people and statistically analyzed the data. As a result, in the “younger （under 50 years old）” group, both “frequency” and “materials” showed a significant difference between the patients and the healthy population （p=0.0021 and p=0.0012, respectively）. Ear-picking more than once a day and with hard materials might be risk factors for carcinoma of EAC in the younger generation.

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In cases with advanced head and neck cancers, bony metastases cause skeletal-related events （SRE）, such as pathological fracture, spinal cord injury, and pain, affecting performance status （PS）. Previously, the treatments for SRE were surgery, radiation therapy and administration of bisphosphonate formulation with anti-tumor effects. However, in Japan in 2012, denosumab, a fully human monoclonal antibody against the receptor activator of nuclear factor-kB ligand （RANKL）, was approved and expected to be used as a new medication for the treatment of bony metastasis. Anti-bony metastasis medications have been used for the prevention and alleviation of SRE and not for their anti-tumor effects. Recently, reports about the anti-tumor effects of denosumab have increased. Here we report a clinical presentation of the significant effects of denosumab in a case of olfactory neuroblastoma with bony metastasis.

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Objective: Severe mucositis during bioradiotherapy （BRT） with Cetuximab for locally advanced squamous cell carcinoma of the head and neck （LA-SCCHN） sometimes causes interruption of the treatment. The aim of this study was to evaluate the pattern of dysphagia following BRT.
Materials and Methods: This retrospective study included 21 patients with BRT and 19 patients with CDDP-RT following induction chemotherapy （ICT） as an initial treatment from April 2009 to March 2016. We examined the frequency and risk factors of aspiration pneumonia.
Results: During BRT, aspiration was observed in the descending stage of the larynx and it occurred more frequently in LA-SCCHN compared to that in early stages. Aspiration as an acute adverse event was more common in the BRT treated group than in the CDDP-RT treated group following ICT. However, dysphagia as late toxicity tended to be higher in the CDDP-RT treated group than in the BRT treated group following ICT. Further, many BRT treated patients experienced aspiration at an earlier time of the treatment, compared to CDDP-RT treated patients.
Conclusion: When selecting BRT for LA-SCCHN, it is important to pay attention to aspiration pneumonia as an acute adverse event.

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The purpose of this study was to estimate compensatory movement of the posterior oropharyngeal wall after tongue reconstruction.This study involved 13 patients who underwent tongue resection and reconstruction for tongue cancer between November 2011 and February 2015.We measured the distance between the anterosuperior point of the second cervical vertebrae and the posterior oropharyngeal wall in the resting position and during the swallowing phase using videofluorography.The ratio of these numbers （motor ratio） was calculated in the early postoperative period （within 6 months after surgery） and middle period （more than 6 months）.Thirteen patients （7 males and 6 females） with an average age of 62.7 years consisted of 6 half resections, 6 subtotal resections and 1 total resection and they were reconstructed with 9 abdominal flaps, 1 anterolateral thigh flaps and 3 forearm flaps.The average motor ratio was 2.53 within 6 months post-surgery and 3.03 over 6 months post-surgery.Compensatory function was not needed when the residual tongue worked well and had enough volume.On the contrary, compensatory function increased when the residual tongue function and volume were not enough.In the cases of tongue resection with lateral oropharyngeal wall, there were cases that compensatory function did not work.The residual tongue function and compensatory function should be considered when planning reconstructive surgery as it will likely contribute to improvement of the swallowing function after surgery.

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Since the Clinic for Maxillofacial Prosthetics, Tokyo Medical and Dental University Dental Hospital was established in 1979, maxillofacial prostheses for defects and appliances for treatment were fabricated for over 6,000 cases in cooperation with surgeons. Among various types of prostheses, an immediate surgical obturator （ISO） was also fabricated for more than 200 cases and applied to the patient after the surgical operation in order to cover the surgical area to enhance healing and improve the functional impairments caused by the surgical operation. This article introduces the fabrication procedures and our concept of ISO in order to share knowledge of ISO with surgeons. Before conducting surgical operation, surgeons refer the patient to us, then we carry out an examination and diagnosis, explain to the patient the objective of ISO, and take an impression. In order to avoid occusal pressure that would prevent the healing process, artificial teeth are not set in the ISO. The ISO is applied soon after the surgical operation in order to improve the functional impairments and to train the patient to wear the prosthesis, and is expected to be widely used in the surgical field.

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