Satoshi Ebihara

Predictive markers for late cervical metastasis in stage I and II invasive squamous cell carcinoma of the oral tongue

Purpose: Patients with oral tongue carcinoma treated by intraoral excision only should be followed up carefully for cervical lymph node metastasis and salvaged immediately if found, because some patients have a more aggressive clinical course. The purpose of this study was to find useful markers for predicting late cervical metastasis in patients with stage I and II invasive squamous cell carcinoma of the oral tongue. Experimental Design: We investigated clinicopathologic factors and immunohistochemical biomarkers predicting late cervical metastasis in surgical specimens from 56 patients with T1–2N0M0 invasive squamous cell carcinoma of the oral tongue who did not undergo elective neck dissection. Histopathologic factors including tumor thickness, mode of invasion, Broders grade, total score of three different malignancy grading systems, eight other clinicopathologic parameters, and immunohistochemical expression of p53, cyclin D1, Ki-67, epidermal growth factor receptor, microvessel density, cyclooxygenase-2, MUC1, laminin-5 γ2, E-cadherin, and β-catenin were examined. All of the clinicopathologic factors and immunohistochemical expression of biomarkers were compared in terms of survival. Results: In the univariate analysis, tumor thickness (P = 0.009), Broders grade (P = 0.017), nest shape (P = 0.005), mode of invasion (P < 0.001), Anneroth score (P = 0.029), Bryne score (P < 0.001), and E-cadherin expression (P = 0.003) were correlated with late cervical metastasis. Multivariate analysis on late cervical metastasis revealed that tumor thickness >4 mm, mode of invasion grade 3 or 4, and E-cadherin expression were independent factors. Late cervical metastasis was the only prognostic factor for overall survival (P = 0.002). Conclusions: Our results indicate that patients with stage I and II invasive squamous cell carcinoma of the oral tongue with tumor thickness >4 mm, mode of invasion grade 3 or 4, and low expression of E-cadherin should be considered a high-risk group for late cervical metastasis when a wait-and-see policy for the neck is adopted.

Pharyngoesophageal reconstruction using a fabricated forearm free flap.

A new microsurgical alternative in reconstruction of the pharynx and cervical esophagus is reported. A trapezoidal forearm flap is fabricated into an inverted skin tube and placed in the pharyngoesophageal defect. Although microvascular anastomoses are required to revascularize the transferred forearm flap, the long and large nutrient vessels of the flap make anastomoses easy and reliable. None of our 12 patients demonstrated any necrosis of the transferred flap. This one-stage, less invasive operation for pharyngoesophageal reconstruction greatly benefits older persons, who are the more likely to be involved with pharyngoesophageal carcinomas.

Analysis of the Relations Between the Shape of the Reconstructed Tongue and Postoperative Functions After Subtotal or Total Glossectomy

Objectives/Hypothesis For reconstruction after subtotal or total glossectomy, both preserving the larynx and maintaining postoperative swallowing and speech functions can greatly improve quality of life; however, postoperative functional results are often unstable. Our experiences suggest that insufficient flap volume in the oral area and postoperative prolapse of the preserved larynx affect postoperative function. The objective was to investigate the relations of the shape of the reconstructed tongue to postoperative swallowing and speech functions.

Comparison of innervated and noninnervated free flaps in oral reconstruction.

Thirteen patients who had undergone ablative surgery for advanced squamous cell carcinoma in which more than half of the tongue had been resected underwent reconstruction in which the cutaneous nerve of a free flap was anastomosed to the stump of the transected lingual nerve. Eight of the patients underwent reconstruction with an innervated anterolateral thigh flap and five patients underwent reconstruction with an innervated rectus abdominis musculocutaneous flap. Sensory recovery of the flap at least 6 months postoperatively was compared in these 13 patients and in 16 additional patients who received noninnervated versions of the same flaps for the same defect. The degree of sensory recovery of innervated thigh flaps was significantly greater than that of noninnervated ones in all modalities and that of innervated rectus abdominis flaps was also greater than that of noninnervated flaps, except for hot and cold perception. These results indicate that sensory regrowth occurs in most areas through the surgically created pathways. However, results of Semmes-Weinstein testing showed that recovery did not reach the level of protective sensation in either type of innervated flap. Although these findings must be followed by additional objective and functional tests and the need for sensory reeducation should be considered, this simple operative procedure can improve postoperative intraoral function and should be attempted whenever possible after ablative surgery.

Neuroendocrine carcinoma of the paranasal sinus a morphological and endocrinological study

Four rare cases of small cell carcinoma of the paranasal sinuses were studied histologically, ultrastructurally, and endocrinologically. All tumors showed features of undifferentiated carcinoma with alveolar patterns but without acinar or squamous differentiation and contained cells possessing endocrine‐type small secretory granules, which were indistinguishable from non‐neoplastic neuro‐secretory granules. The three cases also possessed a small number of microtubules, and in one of these fine cytoplasmic filaments were observed. One case showed elevated plasma levels of cortisol and adrenocorticotropic hormone associated with adrenocortical hyperplasia and Crookes changes of the pituitary gland. Another case showed hypercalcemia with bone metastasis, hypercalcitonemia with a high content of calcitonin in the tumor tissue, calcitonin‐positive tumor cells, and C‐cell hyperplasia of the thyroid. It was concluded that all four cases should be called neuroendocrine carcinoma, which might be related to neoplasms derived from amine precursor uptake and decarboxylation cell series rarely encountered in the paranasal sinuses.

Analysis of thyroid carcinoma based on material registered in japan during 1977-1 986 with special reference to predominance of papillary type

Background. As geographic differences have been observed in the characteristics of thyroid carcinoma, an analysis was made on thyroid carcinoma in the iodine rich country of Japan.

Postoperative complications and functional results after total glossectomy with microvascular reconstruction

Microsurgical reconstruction after total glossectomy can greatly improve quality of life; however, postoperative functional results are often unstable, and the effectiveness of total glossectomy remains questionable. To determine the problems of reconstruction after total glossectomy with laryngeal preservation and to examine the functional results of swallowing and speech, 30 patients who had undergone total glossectomy and reconstruction with free flaps were reviewed for this study. The patients ranged in age from 20 to 73 years, and 23 of the 30 had undergone reconstruction with a rectus abdominis musculocutaneous flap. Wider and thicker flaps were designed and transferred and were sutured to suspend the larynx. To maintain physiologic swallowing function after surgery, the extent of laryngeal suspension and cricopharyngeal myotomy was limited. Of the 30 patients, 21 (70 percent) could be decannulated with laryngeal preservation; 20 of these 21 could tolerate a normal/soft/pureed diet, and 1 was limited to a fluid diet. Speech was intelligible in 16 of the 19 patients evaluated. In 9 of the 30 patients, laryngeal function could not be preserved. In four of these nine patients, additional resection combined with total glossectomy caused severe aspiration and recurrent pneumonia. Two patients with preoperative cerebral dysfunction were also poor candidates for laryngeal preservation. Additionally, the transferred flap’s lack of bulk in the oral cavity and the advanced age (73 years) of one patient and the poor motivation of another may have contributed to postoperative aspiration. Aspiration occurred in one patient because of local recurrence of a tumor. The presence of preoperative cerebral dysfunction (p = 0.025), resection of the epiglottis (p = 0.005), and postoperative orocutaneous fistulas (p = 0.04) were significantly associated with the failure of laryngeal preservation. However, because of the difficulty of enrolling a sufficient number of patients in the study and the inherent limitations of retrospective studies, multivariate analysis in this study showed that no factors, such as patient age, flap volume, and the type of neck dissection, were significant predictors of laryngeal preservation. Although prospective studies are necessary, the function of individual patients must be assessed so that the study experiences discussed here can be applied to subsequent patients.

Simple maxillary reconstruction using free tissue transfer and prostheses.

&NA; Prosthetic rehabilitation is essential for maintaining postoperative oral function after maxillary reconstruction. However, the maxillary prosthesis becomes unstable in some patients because of extensive palatomaxillary resection and drooping of the transferred flap. In such patients, maintaining sufficient oral function is difficult, especially if the patient is edentulous. To achieve prosthetic retention, the authors performed microvascular maxillary reconstruction with a slit‐shaped fenestration in the midline of the hard palate. Maxillary defects after subtotal or total maxillectomy were reconstructed with rectus abdominis musculocutaneous flaps in five patients. Defects of the nasal lining and palate were reconstructed with the single cutaneous portion of the flap, and a slitshaped fenestration was left between the cutaneous portion of the flap and the edge of the remaining hard palate. Postoperatively, patients were fitted with maxillary prostheses that had a flat projection for the palatal fenestration. In all patients, the prosthesis was stable enough for mastication and prevented nasal regurgitation. Speech function was rated as excellent on Hiroses scoring system for Japanese speech ability. The authors believe that their method of palatomaxillary reconstruction is both simple and reliable. (Plast. Reconstr. Surg. 111: 594, 2003.)

In Situ hybridization and immunohistochemical study of human papillomavirus infection in adult laryngeal papillomas

Routinely processed paraffin sections from 20 patients with adult laryngeal papillomas were examined for the presence of human papillomavirus type 11 (HPV‐11) DNA and its specific mRNA by in situ hybridization methods using 35S‐labeled RNA probes. Immunohistochemical techniques were also used to identify papillomavirus genus‐specific common antigen (pgsantigen). HPV‐11 DNA signals and/or papillomavirus genus‐specific common antigen were detected in all eight samples of multiple laryngeal papilloma. On the other hand, in 12 samples of single laryngeal papilloma, neither papillomavirus genus‐specific common antigen nor HPV‐11 DNA were detected. Four patients were positive for both HPV‐11 DNA and pgs‐antigen. In three of these four patients, HPV‐11 mRNA signals were also detected. These results provided direct evidence of the association of HPV and adult multiple laryngeal papilloma.

Usefulness of Narrow-band Imaging for Detecting the Primary Tumor Site in Patients with Primary Unknown Cervical Lymph Node Metastasis

Objective We sometimes experienced patients with primary unknown cervical lymph node metastasis. In such cases, if computed tomography, magnetic resonance imaging, laryngoscopy and gastrointestinal endoscopy cannot detect a primary site, there is no other effective method to identify a possible primary tumor. We investigated whether narrow-band imaging can detect a possible primary tumor in such. Methods Forty-six patients with primary unknown cervical lymph node metastasis were surveyed about primary tumors, from January 2003 to December 2006. All cervical lymph nodes were histologically proved to be squamous cell carcinoma by fine-needle aspiration cytology. Narrow-band imaging combined with magnifying endoscopy was used to identify the primary site in the head and neck region and cervical esophagus. Histological analysis was performed for all suspicious lesions by a biopsy specimen. Results Twenty-six lesions were suspected to be cancerous lesions by narrow-band imaging in the head and neck region. Sixteen lesions in 16 (35%, 16/46) patients were squamous cell carcinoma. Ten lesions were located in the hypopharynx and the remaining six lesions were located in the oropharynx. White light endoscopy could not point out any lesion. Conclusions Narrow-band imaging endoscopy can detect possible primary cancer in patients with primary unknown cervical lymph node metastasis.