Masataka Kojima

A feasibility study of NIR fluorescent image-guided surgery in head and neck cancer based on the assessment of optimum surgical time as revealed through dynamic imaging

Background In order to minimize surgical stress and preserve organs, endoscopic or robotic surgery is often performed when conducting head and neck surgery. However, it is impossible to physically touch tumors or to observe diffusely invaded deep organs through the procedure of endoscopic or robotic surgery. In order to visualize and safely resect tumors even in these cases, we propose using an indocyanine green (ICG) fluorescence method for navigation surgery in head and neck cancer. Objective To determine the optimum surgical time for tumor resection after the administration of ICG based on the investigation of dynamic ICG fluorescence imaging. Methods Nine patients underwent dynamic ICG fluorescence imaging for 360 minutes, assessing tumor visibility at 10, 30, 60, 120, 180, and 360 minutes. All cases were scored according to near-infrared (NIR) fluorescence imaging visibility scored from 0 to 5. Results Dynamic NIR fluorescence imaging under the HyperEye Medical System indicated that the greatest contrast in fluorescent images between tumor and normal tissue could be observed from 30 minutes to 1 hour after the administration of ICG. The optimum surgical time was determined to be between 30 minutes to 2 hours after ICG injection. These findings are particularly useful for detection and safe resection of tumors invading the parapharyngeal space. Conclusion ICG fluorescence imaging is effective for the detection of head and neck cancer. Preliminary findings suggest that the optimum timing for surgery is from 30 minutes to 2 hours after the ICG injection.

Significant preservation of swallowing function in chemoradiotherapy for advanced head and neck cancer by prophylactic swallowing exercise

Dysphagia is a serious complication of chemoradiotherapy (CRT) in patients with head and neck cancer. Approximately 20% to 30% of patients who have dysphagia require feeding tubes. The purpose of this study was to evaluate the impact of prophylactic swallowing exercises on swallowing function.

Relationship between insulin-like growth factor-1 receptor and human papillomavirus in patients with oropharyngeal cancer

Human papillomavirus (HPV)‐positive oropharyngeal squamous cell carcinoma (SCC) is associated with better prognosis than HPV‐negative oropharyngeal SCC. The purpose of this study was to assess the expression of insulin‐like growth factor‐1 receptor (IGF‐1R) in patients with oropharyngeal SCC, its relationship to HPV status and various clinical parameters, and its relationship with clinical outcome.

Significant improvement in superselective intra-arterial chemotherapy for oral cancer by using indocyanine green fluorescence

BACKGROUND Recent advances in indocyanine green (ICG) fluorescence imaging have enabled the visualization of the blood supply to tissues. For advanced head and neck cancer, intra-arterial chemotherapy has been applied for organ preservation and improvement of the prognosis. To identify the tumor-feeding artery, through which the intra-arterial chemotherapy should be administered, CT angiography has been shown to be useful. However, the precise evaluation for oral cancer patients depends on the oral environment, that is, whether they have been treated with dental metal. OBJECTIVES To assess the feasibility of the ICG fluorescence technique during intra-arterial chemotherapy for advanced oral cancer. MATERIAL AND METHOD Twenty-five patients with oral cancer who were treated by intra-arterial chemotherapy were included in this study. Conventional CT angiography followed by 5mg of ICG injection was performed to confirm the areas in which the drug had dispersed. Intra-arterial chemotherapy was administered at 75 mg/m(2) of CDDP. Additional information about the arteries feeding the tumors provided by ICG was evaluated. RESULTS Out of 25 cases, in 15 (56%) the blood supply to the cancer was clearly detected by CT angiography. Using the infrared ICG evaluation, the blood supply to the tumor was confirmed easily in all cases. The information obtained from fluorescence imaging was helpful for making decisions concerning the administration of chemo-agents for oral cancers. CONCLUSION ICG fluorescence imaging during intra-arterial chemotherapy compensated for the deficiencies of CT angiography, especially for oral cancer. ICG fluorescence provided us clearer and more useful information about the feeders to tumors.

Impact of intra-arterial chemotherapy including internal carotid artery for advanced paranasal sinus cancers involving the skull base

Background:The most significant problem of intra-arterial chemotherapy for advanced paranasal sinus carcinomas and residual cancers supplied by internal carotid artery (ICA) and involving the skull base is the lack of salvage therapies.Objective:The objective of the study was to evaluate the usefulness of intra-arterial chemotherapy including ICA infusion for treating advanced paranasal sinus carcinomas, which have invaded the skull base.Methods:Forty-six patients with advanced paranasal sinus carcinomas supplied by ICA were treated by intra-arterial chemotherapy using CDDP and sodium thiosulphate (STS) as a neutraliser of CDDP toxicity. After evaluating CT angiography, 150 mg m−2 of CDDP was superselectively administered weekly to each feeding artery including ICA four times.Results:The 10-year overall survival rate and progression-free survival rate were 70.7 and 60.2%, respectively. Compared with control group without infusing ICA, recurrences at anterior skullbase or anterior ethomoid sinus were significantly diminished. Of 32 patients in which the orbital apex had been invaded, 29 patients were treated with successful preservation of orbital contents. The CT angiography could efficiently determine all feeding arteries supplying the cancers. Consequently, chemotherapy could be administered on schedule, and side effects were minimal and acceptable.Conclusions:This new method has promising applications in the treatment of advanced paranasal sinus carcinomas involving the skull base.

Atypical Lemierre syndrome, thrombophlebitis of the facial vein.

A young man complained of fever and left-sided neck pain. Computed tomography (CT) scan of the neck showed a round low-density areawith enhancement at themargin.We suspected a deep neck abscess, and the antibiotic treatment was started. After 3 days, CT scan showed that the oval low-density area extended to its junction with the left internal jugular vein. We diagnosed him as having Lemierre syndrome of the facial vein thrombosis. CT scan of the chest showed multiple pulmonary embolisms. The patient started to receive intravenous anticoagulant therapy. The swelling and tenderness of the neck gradually resolved, and the patient improved without complications. Lemierre syndrome is potentially fatal. Prompt diagnosis and appropriate therapy are needed. Radiographic findings are characteristic and facilitate the diagnosis of Lemierre syndrome. A positive scan typically shows a filling deficit representing occlusive thrombus in the internal jugular vein. In this case, it was difficult to diagnose because the patient had thrombus involving only a facial vein. Recently, cases of Lemierre syndrome have increased, so it is necessary to know Lemierre syndrome of the facial vein thrombosis. In November 2011, a 23-year-old man presented with a 1-week history of sore throat and 3-day history of left-sided neck pain without improvement after outpatient antibiotic therapy from the general hospital. He had no medical history. Initial examination revealed fever (38.4°C), swelling and tenderness in the left side of the neck, and flare and swelling of the bilateral palatine tonsils with pus. Laboratory tests showed a leukocyte count of 15.9 × 109/L (neutrophils, 87.7%); Ddimer, 4.38 μg/mL; and C-reactive protein, 8.5 mg/dL. Computed tomography (CT) scan of the neck showed a round low-density area (diameter, 7 mm) anterior of the left internal jugular vein with enhancement at the margin of the area. We suspected a small, deep, neck abscess. The antibiotic treatment was started using cefepime and clindamycin on an inpatient basis. Three days after hospitalization, inflammatory parameters continually dropped, swelling and tenderness in the ☆ Grants or financial support: None. 0735-6757/

Impact of middle and lower jugular neck dissection on supraclavicular lymph node metastasis from endometrial carcinoma

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Impact of removing mastoid process for advanced parotid cancer on facial nerve identification, preservation and reconstruction

Supraclavicular lymph node metastasis from endometrial carcinoma is considerably rarer than metastasis from uterine cervical cancer. To date, there have been no reported cases regarding systematic neck dissection as a salvage treatment. In this report, we describe the neck dissection procedure carried out on a 74-year-old woman with supraclavicular lymph node metastasis. Our objective was to histologically determine the origin of the metastasis while simultaneously providing appropriate treatment. The patient’s past medical history included two prior cases of cancer: rectal cancer 7 years earlier and endometrial adenocarcinoma 4 years earlier. We determined that middle and lower jugular neck dissection was appropriate in treating this case based on the results of our preoperative FDG-PET and tumor markers. This surgery provided histological evidence that metastasis occurred from endometrial carcinoma. Middle and lower jugular neck dissection was expected to improve the patient’s prognosis without impacting the patient’s active daily life. We have continued to monitor the patient closely over an extended period.

Successful application of intra-arterial chemotherapy for advanced lacrimal sac carcinoma: a report of two cases

BackgroundAdvanced parotid cancers more than 4 cm are firmly fixed around the main trunk of the facial nerve that can be hardly detected in narrow working space between mastoid process and parotid cancer. Even though facial nerve was preserved, facial nerve stretching during surgery has significantly serious effect on postoperative facial palsy.ObjectiveTo evaluate usefulness of removing mastoid process in managing advanced parotid cancers to contribute identifying and preserving facial nerve.MethodThe study was performed on 18 advanced parotid cancers which was more than 4 cm and invaded around the facial nerve. Thirteen cases were fresh cases and 5 were recurrent cases.According to a modified Blair incision, the sternocleidomastoid muscle is detached from the mastoid process with electrocautery. When the mastoid process is removed, the main trunk of the facial nerve can be observed from stylomastoid foramen.This procedure was evaluated based on the duration of surgery, working space, and postoperative facial nerve function.ResultsIn eleven cases, facial nerves were sacrificed. Negative margins were achieved in 100% of the patients. The mean duration for removing of the mastoid process to identify facial nerves was 4.6 minutes. The mean size of the removed mastoid process was 2.1 cm in height and 2.3 cm in width, and 1.8 cm in depth. The extended mean working space was 16.0 cm3, and, as a result, the tumors could be resected without retraction.ConclusionRemoving the mastoid process for advanced parotid tumors facilitates identification of the facial nerve and better preservation of the facial nerve function.

Antegrade Bipedicled Submental Island Flap for Anterior Oropharyngeal Defect Reconstruction after Ablative Surgery

Objectives: Malignant lacrimal sac tumors are rare. The therapeutic methods are decided depending on the tumor status and general condition. A multidisciplinary approach may be needed. When necessary, orbital exenteration may be performed. To maintain the quality of life in patients, we applied intra-arterial infusion chemotherapy for locally advanced lacrimal sac squamous cell carcinoma cases. Patients and methods: Two patients with lacrimal sac squamous cell carcinoma who were treated by intra-arterial chemotherapy were included in this study. Intraarterial chemotherapy was administered at 150 mg/m2 of CDDP and 15 mg/m2 of DTX. Radiotherapy in combination with intra-arterial chemotherapy was performed for one patient. A Cyberknife was used for the other patient. Result: In both cases, the tumor was considered to have disappeared judging from the PET scan. Furthermore, the eyes of these patients were spared and the visual function was preserved. Conclusion: Multidisciplinary management should be applied for malignant lacrimal sac tumor. Intra-arterial chemotherapy can play an important role in organ preservation therapy for locally advanced lacrimal sac squamous cell carcinoma. Correspondence to: Dr. Shinichi Ohba, Department of OtorhinolaryngologyHead and Neck Surgery, Juntendo University Faculty of Medicine, Tokyo, Japan; Tel:+ 81-3-3813-3111; Fax: 81-3-5840-7103; E-mail: sooba@juntendo.ac.jp Received: September 30, 2016; Accepted: October 31, 2016; Published: November 03, 2016 Introduction Malignant lacrimal sac tumors are rare. The most common malignant tumors are of epithelial origin, with squamous cell carcinoma. The management of malignant tumors includes local resection or extensive wide resection with orbital exenteration followed by adjuvant therapy. However, orbital exenteration decreases the quality of life in such patients. This is the first report describing the application of superselective intra-arterial chemotherapy for locally advanced lacrimal sac carcinoma. This procedure could be a useful treatment for functional preservation of the orbit. Patients and methods Two patients with locally advanced lacrimal sac squamous cell carcinoma were treated with superselective intra-arterial chemotherapy. In these patients, 150 mg/m2 of CDDP and 15 mg/m2 of DOC were superselectively administered weekly to each feeding artery including the internal carotid artery. CT angiography was performed to confirm that the entire tumor was stained by contrast agents via the femoral approach. The one patient was treated with concomitant chemo-radiation and the other subsequently underwent Cyber knife treatment. Results Case 1 A 72 year-old female presented with right exophthalmous and diplopia. She had been treated for dacryocystitis for two years. On clinical examination, she was noted to have a firm mass inferior to the right medial canthas. The tumor was also easily visible in the right inferior nasal meatus (Figure1A). CT of the sinuses revealed an enhanced mass in the right lacrimal sac extensively involving the right orbit. There was also extension of the mass into the nasal cavity, the ethomoid sinus (Figure1B). Transnasal biopsy revealed moderately differentiated squamous cell carcinoma. Figure 1A. A tumor was confirmed in the right inferior nasal meatus (arrows). Trans nasal biopsy was performed, which revealed moderately differentiated squamous cell carcinoma. Hibiya R (2016) Successful application of intra-arterial chemotherapy for advanced lacrimal sac carcinoma: a report of two cases Volume 2(1): 128-130 Otorhinolaryngol Head Neck Surg, 2016 doi: 10.15761/OHNS.1000132 To avoid orbital exenteration, intra-arterial chemotherapy with concurrent radiotherapy was conducted five times. All of the cancer area was enhanced by contrast agent in the CT angiography, not only the external carotid artery but also the internal carotid artery (Figure 2). 200 mg of cisplatin and 20 mg of docetaxel were administered weekly five times. During the infusion of CDDP, sodium thiosulphate (STS) at 200 fold the dose of CDDP was injected to the brachiocephalic vein to neutralize the CDDP. The procedure was performed weekly for five times. The primary tumor was irradiated for a total 60Gy in 30 fractions. Two months after the treatment, MRI and 18F-FDG PET/CT showed no evidence of residual disease (Figure 3A and 3B). There were no complications related to the ICA infusion. The visual acuity was unchanged after treatment and the diplopia was also improved. Case 2 A 68-year-old-man was referred to our hospital with a hard mass in the left medial canthus and tearing. He had been diagnosed with maxillary sinus cancer at the age of 40 years and received chemoradiotherapy followed by partial maxillectomy at that time. He had also undergone coronary artery bypass surgery. Physical examination revealed a firm and fixed mass in the left internal canthus. An otolaryngologic rigid nasal/sinus endoscopy showed a firm mass under the normalappearing mucosa just in front of the uncinate process (Figure 4A). Transnasal biopsy revealed moderately differentiated squamous cell carcinoma that was considered to be a radiation-induced cancer. A sinus CT demonstrated a massively enlarged left lacrimal sac with bone loss. There was also extension of the mass into the orbit (Figure 4B). The patient’s visual acuity was 20/20 and 20/20. The patient was treated with super-selective intra-arterial chemotherapy followed by Cyberknife therapy (an-image guided, robotic radiotherapy) as an organ preservation technique. Most of the tumor was fed by the internal carotid artery (ICA) (Figure 5). 125 mg of CDDP and 10 mg of DOC were administered weekly four times (day 1,8,15 and 22) via the superficial temporal artery. The cyberknife therapy (3 treatments; maximum dose, 3703 cGy) was performed a month after the chemotherapy. The post treatment PET scan taken after 2 months revealed there was no residual tumor (Figure 6). There was no adverse event related to the ICA infusion and the visual acuity was preserved at 20/20 and 20/20. Discussion A variety of neoplasms may affect the lacrimal drainage system, with approximately 70% malignant in nature [1]. The most common type of cancer is squamous cell carcinoma followed by transitional cell carcinoma [2,3]. Lacrimal sac carcinoma is often mistaken for Figure 1B. Appearance of tumor on CT scan: axial CT scan shows enhancement of this lesion extending to the right orbit; coronal CT revealing the enhanced mass widely involving the orbit with bone destruction. Figure 2. CT angiographies of the right internal carotid artery. The cancer area that was not stained by the maxillary artery was covered by infusion of the right internal carotid artery. A B Figure 3. CT scan [Figure 3A] and FDG-PET/CT [Figure 3B] at two months after treatment showing no significant accumulation in the right lacrimal sac.