Mitsunobu Otsuru

Determination of deep surgical margin based on anatomical architecture for local control of squamous cell carcinoma of the buccal mucosa

Of all oral squamous cell carcinomas, squamous cell carcinomas of the buccal mucosa (BSCC) are most associated with poorest prognosis. In particular, patients treated with surgery alone are reported to experience frequent local failures. This is considered to result from the surgeons determination of the deep surgical margin for resection based on palpation alone when performing BSCC surgery. Therefore, an objective system for classifying the depth of invasion of a tumor appears to be necessary in order to improve the results of BSCC treatment. While current general practice is to treat based on tumor thickness, we would like to emphasize the importance of how far down the cheek wall layer the tumor has invaded. We performed surgery by classifying the depths of tumor invasion in relation to the buccinator. Depth of tumor invasion was assessed mainly using ultrasonography (US). The tumor was defined as D1 when it extended to the mucosal (m) and submucosal layers (sm). In these cases, the tumor was resected, while the buccinator was spared. The tumor was defined as D2 when it extended to the buccinator, but, based on US, muscle continuity was preserved, and the tumor was resected to include the buccinator and its overlying fascia. When the tumor had spread to the buccinator or invaded subcutaneous or cutaneous tissue it was classified as D3 and resection included the skin. The disease-specific survival rate of BSCC when treated based on our classification was 73.7% and the local control rate was 89.5%. These results are superior to those based on surgery alone and this therapeutic modality was considered to be useful.

Postoperative follow-up strategy in patients with oral squamous cell carcinoma.

PURPOSE The duration of follow-up after treatment of oral squamous cell carcinoma and the frequency of routine visits are based on common usage rather than evidence-based practice. The purpose of this study was to determine the appropriate postoperative routine follow-up program in patients with oral squamous cell carcinoma. PATIENTS AND METHODS Three hundred four cases treated curatively mainly by surgery at Tokai University Hospital from 1994 to 2004 were analyzed. A secondary event was defined as a local recurrence, a regional recurrence, a distant metastasis, or a second primary cancer. To evaluate the follow-up program, data on the first tumor recurrence or first second primary tumor in the head and neck region or elsewhere in the body were used. Overall survival rate, disease-specific survival rate, relapse-free rate, and cumulative risk of developing a second primary cancer were estimated by the Kaplan-Meier product limit method. RESULT All relapse cases were detected within 3 years postoperatively, of which 86.3% were detected within 1 year. Most relapses were in the neck, and regional recurrences had a dismal salvage rate. Second primary cancers were constantly detected 1 to 10 years postoperatively. CONCLUSION Follow-up should be performed more frequently in the first year, with 2 weekly follow-ups with monthly ultrasound examinations, and should be continued after 3 years to exclude the development of second primary cancers.

A case of brain abscess extended from deep fascial space infection

A case of brain abscess in the temporal lobe caused by direct intracranial extension of deep neck abscess is described. The abscess also spread to the orbital cavity through infraorbital fissure. The possible etiology of this case might be dental surgery. The diagnostic imaging clearly showed the routes of intracranial and -orbital extension of parapharyngeal and masticator space abscesses. From the abscess specimens, oral streptococci, anaerobic streptococci, and anaerobic gram-negative bacilli were isolated. Antimicrobial susceptibility testing of isolates showed that some Prevotella and Fusobacterium strains had decreased susceptibility to penicillin, and these bacteria produced beta-lactamase. The bacteria from the deep neck abscess were consistent with those detected from the brain abscess. Proper diagnosis, aggressive surgical intervention, and antibiotics chemotherapy saved the patient from this life-threatening condition.

Intratumoral heterogeneity of HER2 protein and amplification of HER2 gene in salivary duct carcinoma

Salivary duct carcinoma (SDC) is an aggressive adenocarcinoma of the salivary glands, and accounts for 1–3% of all malignant salivary gland tumors, resembling morphologically invasive ductal carcinoma (IDC) of the breast. In contrast to IDC of the breast and gastric carcinoma (GC), the study of human epidermal growth factor receptor 2 (HER2) in SDC has not progressed. Therefore, we investigated the relationship between HER2 protein expression and amplification of the HER2 gene, and compared them in terms of intratumoral heterogeneity (ITH) in 13 cases of SDC using immunohistochemistry and dual color in situ hybridization. We found seven cases with protein overexpression (53.8%) and five cases with gene amplification (38.5%) in accordance with ASCO/CAP guidelines. ITH of HER2 protein expression was seen in seven cases (53.8%). Interestingly, the ratio of the HER2 gene showed homogenous distribution with or without the presence of ITH of HER2 protein expression. SDC tends to have more ITH of HER2 protein similarly to GC, in contrast to IDC of the breast. ITH of HER2 protein in SDC has no heterogeneity of the HER2 gene amplification. The mechanism of HER2 protein expression in SDC might proceed through a more complex pathway relative to that of IDC of the breast.

Prognostic and staging implications of mandibular canal invasion in lower gingival squamous cell carcinoma

A multi‐institutional study was undertaken to determine whether mandibular canal (MC) invasion and mandibular medullary bone invasion are independent factors in lower gingival squamous cell carcinoma (SCC). A total of 345 patients with lower gingival SCC were retrospectively reviewed. Mandibular bone invasion was categorized into three types; no bone invasion; invasion through cortical bone (medullary); and MC invasion. The overall survival rate and factors affecting local, regional, and distant failures were assessed by Cox proportional hazards regression analysis and Kaplan–Meier estimates. Bone invasion was present in 201 (58%) patients, of whom 107 (31%) had medullary invasion and 94 (27%) had MC invasion. Using the International Union Against Cancer (UICC) staging system and American Joint Committee on Cancer (AJCC) system, 171 (50%) patients were classified as T4a. When the bone invasion criteria were excluded from the UICC/AJCC system definition, 152 T4a tumors were downstaged and reclassified to T1 in 12 (3%), to T2 in 98 (28%), and to T3 in 42 (12%). In Cox multivariate analysis, MC invasion was an independent predictor of overall survival but medullary bone invasion was not. Medullary bone invasion was an independent variable for distant control. The current T staging system has restricted prognostic utility. The authors recommend a modified T staging system, whereby tumors with MC invasion instead of medullary bone invasion are classified as T4a, and tumors are first classified as T1 to T3 based on size and then upstaged by one T classification in the presence of medullary invasion.

Development of follicular lymphoma of the cervical lymph nodes in a postoperative patient with tongue cancer.

Patients with head and neck squamous cell carcinoma are at an increased risk of developing second malignancies. Most commonly, these second primary malignancies are squamous cell carcinoma of the head and neck region, but also noted are esophageal cancer or lung cancer. Hematologic malignancies are uncommon second malignancies. Diagnosis can be challenging, particularly when a patient suffers metastases of squamous cell carcinoma to the cervical lymph nodes in addition to synchronous or metachronous malignant lymphoma that originates in the cervical lymph nodes. This article describes a case of primary follicular lymphoma in the cervical region that was discovered during a postoperative follow-up after partial glossectomy and neck dissection for tongue cancer.

Huge Ameloblastoma Associated With Hypercalcemia, Leukocytosis, and Elevated Tumor Markers via Production of Parathyroid Hormone-Related Protein and Granulocyte Colony-Stimulating Factor

n h s e r s e i Ameloblastoma is one of the most common odontogenic tumors and is a lesion of odontogenic epithelial origin. These tumors may arise from nests of dental lamina, a developing enamel organ, epithelial lining of odontogenic cysts, or basal cells of the oral mucosa. The trigger or stimulus for neoplastic transformation of these epithelial residues is unknown. Ameloblastomas may occur anywhere in the mandible or maxilla, although they occur most frequently in the mandibular molar–ramus area. Lesions are usually asymptomatic and discovered either during routine radiographic examination or because of asymptomatic jaw expansion. If left untreated, they may grow slowly to

Significant prognostic factors affecting treatment outcomes of salivary gland carcinoma: a multicenter retrospective analysis

The purpose of this study was to investigate the prognostic factor in salivary gland carcinoma patients. Clinical and pathological data of 211 consecutive patients who treated with curative intent were analyzed. The overall survival (OS) rate, local control rate, and distant metastasis rate were calculated. To examine a prognostic factor in salivary gland carcinoma patients, a multivariate analysis was performed. The 5-year-OS rate was 84.0%, and 10-year was 69.2%. The 5-year-local control rate was 84.6%, and 10-year was 70.1%. The 5-year-distant metastasis rate was 16.9%, and 10-year was 21.1%. In a multivariate analysis, the OS rate was affected by pN(+), high-grade malignancy, and primary tumor size. The local control was affected by the primary tumor size, high-grade malignancy, and the status of the surgical margin. The primary tumor size and pN(+) were associated with the distant metastasis. The results of this study suggested that pN(+), malignancy grade, primary tumor size, and the margin status might affect the prognosis of salivary gland carcinoma patients. Postoperative radiotherapy and adjuvant chemotherapy were suggested the possibility of contribution to the good prognosis of salivary gland carcinoma patients.

Clinical investigation of 38 cases of oral mucosal melanoma: A multicentre retrospective analysis in Japan

The aim of the present study was to investigate treatment modalities and outcomes in oral mucosal melanoma.

Multi-center retrospective study of the prognosis and treatment outcomes of Japanese oral squamous cell carcinoma patients with single lymph node metastasis and extra nodal extension

Oral squamous cell carcinoma (OSCC) containing single lymph node metastasis (pN1) with extra nodal extension (ENE) is a rare clinical situation. Therefore, it is unclear whether pN1 with ENE is at high risk of recurrence among the OSCC population, or whether postoperative radiotherapy (RT)/concomitant chemoradiotherapy (CCRT) is effective in these cases.