Akiko Sakakibara

Risk Factors Associated with Distant Metastasis in Patients with Oral Squamous Cell Carcinoma

Objective The purpose of this study was to retrospectively evaluate the incidence of distant metastasis (DM) after curative surgical treatment and assess the multivariate relationships among various risk factors for DM in patients with oral squamous cell carcinoma (OSCC). Study Design Case series with chart review. Setting Tertiary referral center. Subjects and Methods The medical records of all patients with OSCC without DM who underwent curative surgery with or without postoperative adjuvant chemoradiation between January 2001 and February 2014 at our institution were retrospectively reviewed. There were a total of 451 patients, including 271 men and 180 women, with a mean age of 65.9 ± 13.5 years. Results Of these patients, 30 (6.7%) developed DM. During the follow-up period, the 5-year overall survival rate was 76.2%. Sites of DM comprised the lungs (80.0%), skin (13.3%), liver (10.0%), bone (6.7%), and brain (3.3%). We found the T classification and N classification as well as the histologic grade to be significant risk factors associated with the development of DM in the univariate analysis only (P = .003), whereas locoregional failure (odds ratio [OR], 4.03), multiple lymph node metastases (more than 4 positive nodes; OR, 3.32) and positive extracapsular spread (OR, 3.06) were identified to be significant risk factors associated with the development of DM in the multivariate analysis. Conclusion We demonstrated multivariate relationships among various risk factors for DM in OSCC patients. Clinicians should consider these risk factors and pay special attention to detecting DM early during the postoperative management of OSCC patients with these risk factors.

Preoperative MR angiography for free fibula osteocutaneous flap transfer

Introduction: Magnetic resonance angiography (MRA) is currently considered the most useful test to evaluate the vascular anatomy of the lower leg prior to free fibula osteocutaneous flap transfer. This study aimed to confirm the validity of preoperative MRA. Methods: In 19 patients underwent free fibula osteocutaneous flap transfer for maxillary and mandibular reconstruction, the MRA and intraoperative findings and the postoperative complications were retrospectively analyzed. The location and number of distal septocutaneous perforators (dSCPs) that were preoperatively identified and harvested with flaps were documented. Results: Preoperative MRA detected dSCPs with 100 % sensitivity. MRA findings also revealed the diversity of vascular structures, such as the tibio‐peroneal bifurcation location and the anatomical relationship between the peroneal vessels and the fibula. No patients suffered postoperative ischemic complications in the donor leg. The total flap survival rate was 95 %. Conclusions: Preoperative MRA effectively excluded large vessel anomalies and peripheral vascular disease, and precisely identified the septocutaneous perforators. Additionally, preoperative MRA contributed to a safer fibular osteotomy by predicting the anatomical relationship between the peroneal vessels and the fibula.

Risk factors associated with postoperative delirium after surgery for oral cancer

OBJECTIVE The purpose of this study was to retrospectively investigate the multivariate relationships among the various risk factors for postoperative delirium in patients undergoing oral cancer surgery. MATERIAL AND METHODS The medical records of all patients with oral cancer who underwent curative head and neck surgery between April 2011 and March 2013 at our institution were retrospectively reviewed. There was a total of 188 patients, including 110 males and 78 females. RESULTS We found that older age, extensive surgical procedure, longer operation, excessive hemorrhage, blood transfusion, longer postoperative management in the intensive care unit, longer postoperative hospital stay, lower albumin level in the preoperative blood test, and lower total protein, albumi, n and hemoglobin levels and a higher C-reactive protein (CRP) level in the postoperative blood tests were significant variables in the univariate analysis (p < 0.05). We also determined that an older age (odds ratio [OR] = 6.83), intraoperative lower hemoglobin levels (OR = 6.82), and excessive hemorrhage (OR = 3.62) during surgery were significant variables in the multivariate analysis. CONCLUSION Clinicians should pay special attention to preventing delirium during the postoperative management of older patients with these risk factors. Furthermore, increasing the hemoglobin levels during surgery may be able to prevent postoperative delirium.

Transcutaneous Carbon Dioxide Induces Mitochondrial Apoptosis and Suppresses Metastasis of Oral Squamous Cell Carcinoma In Vivo

Squamous cell carcinoma (SCC) is the main histological type of oral cancer. Its growth rate and incidence of metastasis to regional lymph nodes is influenced by various factors, including hypoxic conditions. We have previously reported that transcutaneous CO2 induces mitochondrial apoptosis and decreases lung metastasis by reoxygenating sarcoma cells. However, previous studies have not determined the sequential mechanism by which transcutaneous CO2 suppresses growth of epithelial tumors, including SCCs. Moreover, there is no report that transcutaneous CO2 suppresses lymphogenous metastasis using human cell lines xenografts. In this study, we examined the effects of transcutaneous CO2 on cancer apoptosis and lymphogenous metastasis using human SCC xenografts. Our results showed that transcutaneous CO2 affects expressions of PGC-1α and TFAM and protein levels of cleavage products of caspase-3, caspase-9 and PARP, which relatives mitochondrial apoptosis. They also showed that transcutaneous CO2 significantly inhibits SCC tumor growth and affects expressions of HIF-1α, VEGF, MMP-2 and MMP-9, which play essential roles in tumor angiogenesis, invasion and metastasis. In conclusion, transcutaneous CO2 suppressed tumor growth, increased mitochondrial apoptosis and decreased the number of lymph node metastasis in human SCC by decreasing intra-tumoral hypoxia and suppressing metastatic potential with no observable effect in vivo. Our findings indicate that transcutaneous CO2 could be a novel therapeutic tool for treating human SCC.

Long-term follow-up study of radial forearm free flap reconstruction after hemiglossectomy.

AbstractPrevious studies on postoperative long-term results in patients who underwent reconstructive free flap transfer following hemiglossectomy had some issues, including the heterogeneity of the patient population and the observation period. The present study aimed to evaluate changes of reconstructed tongues in patients who underwent radial forearm free flap (RFFF) after hemiglossectomy with long-term follow-up. We enrolled 23 patients who underwent RFFF after hemiglossectomy with a postoperative follow-up of 5 years or more. Postoperative status (eating, speech, sensation function) was assessed by concise medical inquiries. Morphological changes of flaps were evaluated by reviewing clinical photographs. Hemiglossectomy involving the base of the tongue was performed in 4 cases (17.4%) and was limited to the mobile tongue in 19 cases (82.6%). The mean follow-up was 85.4 months (range, 60–122 months). All patients experienced gradually improved postoperative status. The most significant improvement was found between 1 and 5 years after surgery (P = 0.007), but not between 1 and 3 years (P = 0.075) or between 3 and 5 years (P = 0.530). In almost all of the flaps, there were few morphological changes throughout the follow-up period. Postoperative status in patients who underwent reconstructive RFFF following hemiglossectomy improved sequentially.

Risk Factors and Surgical Refinements of Postresective Mandibular Reconstruction: A Retrospective Study

Background. Postresective mandibular reconstruction is common in cases of oral and mandibular tumors. However, complications such as infection, plate exposure, or plate fracture can occur. We identified several significant risk factors of complications after reconstructive surgery and compared the effectiveness of different surgical techniques for reducing the incidence of complications. Methods. This study is a retrospective analysis of 28 oromandibular cancer cases that required reconstructive surgery between January 1999 and December 2011 at Kobe University Graduate School of Medicine in Japan. All cases were classified using Hashikawas CAT and Eichners classification methods. Then, we determined whether these classifications and different treatment or surgical methods were significantly related to complications. Results. Complications after mandibular reconstruction occurred in 10/28 patients (36%). Specifically, five patients had plate fractures, four had plate exposures, and one had an infection. Radiation therapy and closure without any flaps were significantly related to infection or plate exposure. The wrap-around technique of securing reconstruction plates was used in 14 cases, whereas the run-through technique was used in two cases. Conclusions. The success of mandibular reconstruction depends on both mechanical and biological factors, such as the location of defects, presence of occlusions, and the amount of vascularization of the flap.

Sequential evaluation for bone union of transferred fibula flaps in reconstructed mandibles: panoramic X-ray versus computed tomography

The purpose of this study was to sequentially evaluate bone union of fibular grafts in mandibular reconstruction. Patients who underwent routine follow-up computed tomography (CT) and panoramic X-ray imaging during a period of ≥2 years were enrolled. On panoramic X-ray images, bone union was scored as 0 (absent callus formation) or 1 (complete callus formation). On CT images, a scale of 0 to 2 was used (0, absent callus formation; 1, complete callus formation only on the labial side; 2, complete callus formation on both the labial and lingual side). A total of 56 bone junctions were evaluated in 20 patients. Five of 56 junctions (9%) in four of 20 patients (20%) showed radiological non-union (panoramic X-ray score=0, CT score=0 or 1) at 2 years after surgery. All bone junctions with radiological non-union were located at the mandibular angle. No categorical values, including diabetes mellitus and radiation therapy, were significantly associated with radiological non-union. In conclusion, assessing at least two sides (i.e. labial and lingual sides) on CT images is adequate to evaluate bone union in transferred fibula flaps. Careful fixation at the mandibular angle may improve the rate of bone union.

Three-dimensional venous visualization with phase-lag computed tomography angiography for reconstructive microsurgery.

BACKGROUND Most free flap reconstruction complications involve vascular compromise. Evaluation of vascular anatomy provides considerable information that can potentially minimize these complications. Previous reports have shown that contrast-enhanced computed tomography is effective for understanding three-dimensional arterial anatomy. However, most vascular complications result from venous thromboses, making imaging of venous anatomy highly desirable. METHODS The phase-lag computed tomography angiography (pl-CTA) technique involves 64-channel (virtually, 128-channel) multidetector CT and is used to acquire arterial images using conventional CTA. Venous images are three-dimensionally reconstructed using a subtraction technique involving combined venous phase and arterial phase images, using a computer workstation. RESULTS This technique was used to examine 48 patients (12 lower leg reconstructions, 34 head and neck reconstructions, and 2 upper extremity reconstructions) without complications. The pl-CTA technique can be used for three-dimensional visualization of peripheral veins measuring approximately 1 mm in diameter. CONCLUSION The pl-CTA information was especially helpful for secondary free flap reconstructions in the head and neck region after malignant tumor recurrence. In such cases, radical dissection of the neck was performed as part of the first operation, and many vessels, including veins, were resected and used in the first free-tissue transfer. The pl-CTA images also allowed visualization of varicose changes in the lower leg region and helped us avoid selecting those vessels for anastomosis. Thus, the pl-CTA-derived venous anatomy information was useful for exact evaluations during the planning of free-tissue transfers.

Facial emphysema after sinus lift.

An 80-year-old man with a history of en bloc resection of squamous cell carcinoma of the hard palate (T4aN0M0) was performed a lateral-window sinus lift of the edentulous area of the left maxillary molar region to facilitate future placement of dental implants. Two hours after the surgery, the patient complained of sudden malar swelling. Marked swelling was present from the left infraorbital region to the buccal region. The swelling was associated with air pockets at the alar base and in the angulus oculi medialis region and subcutaneous malar tissue. Emphysema appeared after the patient blew his nose. Therefore, the mucous membrane of the maxillary sinus might have had a small hole, and air might have entered the subcutaneous tissue via the bone window when the air pressure in the maxillary sinus increased with nose blowing. It is important to advise patients to avoid increasing the intraoral pressure after sinus-lift procedure.

Postoperative abnormal response of C-reactive protein as an indicator for infectious complications after oral oncologic surgery with primary reconstruction

BackgroundC-reactive protein (CRP) screening has been reported to be reliable for detection of infectious complications. Postoperative abnormal response of CRP can predict wound infection in colorectal surgery. This study aimed to determine the efficacy of CRP monitoring to detect infectious complications in oral oncologic surgery.MethodsOne hundred patients who underwent oral cancer resection with primary reconstruction were enrolled. Postoperative kinetics of CRP were classified into a normal or abnormal response.ResultsA normal CRP response after surgery was observed in 61 patients and an abnormal response was observed in 39. There were postoperative infectious complications in 21 patients, with surgical site infections in 13 patients (early onset in six and late onset in seven). Non-wound infections were found in nine patients. Sensitivity, specificity, the positive predictive value, and the negative predictive value for abnormal CRP response as a predictor for early infectious complications were 100%, 70.1%, 35.9%, and 100%, respectively.ConclusionPostoperative serial CRP screening is a useful test as an indicator of infectious complications in oral oncologic surgery. Normal CRP responses can rule out almost all early infectious complications.