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We report a case of functional recovery following incisional cheiloplasty for the management of lower labial edema that developed after bilateral neck dissection with preservation of the one-side internal jugular vein and postoperative chemoradiotherapy. An 81-year-old woman underwent partial maxillectomy for the treatment of maxillary gingival cancer(squamous cell carcinoma, cT1N0M0, Stage Ⅰ)in April 2013. In July 2013, she underwent bilateral neck dissection(right, modified; left, radical)for bilateral cervical lymph node recurrence with an extra-nodal spread and received postoperative chemoradiotherapy( CDDP 75 mg/m2×3 course and total radiotherapy dosage of 66 Gy). Thereafter, the patient's condition progressed without recurrence or metastasis; however, the lower labium became edematous, and severe labial dysfunction was observed. Therefore, lower labial incisional cheiloplasty was performed under local anesthesia in October 2020. An excision area of 160×14 mm was determined on the inner side of the lower labium, and excision was performed with a steel blade scalpel. Lip closure became possible one week after the operation. Seven months after the operation, the patient recovered labial function and was satisfied with the outcome.

Oral leukoplakia is the most common premalignant and potentially malignant lesion of the oral mucosa. Several studies have reported that the prevalence of oral cancer in young people is increasingly rapidly. The patient in this report was a 47- year-old man who complained of left tongue discomfort. At the first visit, the clinical diagnosis was oral leukoplakia, and a follow-up examination was planned with a view to partial resection. However, at the follow-up, biopsy revealed squamous cell carcinoma. He underwent partial resection. Two months after the surgery, metastasis to the lymph node was detected. The patient underwent radical neck dissection and concurrent chemoradiotherapy. At the 3-years follow-up, there was no sign of recurrence or metastasis.

This case showed shoulder impairment due to paralysis of the trapezius and sternocleidomastoid muscles, swelling of the right hand, and dysphagia after undergoing endoscopic oropharyngeal cancer resection and cervical dissection for the posterior wall of the oropharynx. The rehabilitation and dysphagia treatment including electrical stimulation and repetitive facilitative exercises were performed for paralysis of the trapezius and sternocleidomastoid muscles. Consequently, improvements in paralysis of the trapezius and sternocleidomastoid muscles and swallowing function were obtained. The patient recovered from the functional decline caused by postoperative radiation therapy within 2 weeks and was discharged. The patient did not develop post-operative secondary sarcopenia despite being hospitalized for 152 days.

In recent years, the opportunity to treat oral cancer in elderly patients has been increasing because of the increased lifespan of individuals. Standard treatment for advanced tongue cancer involves reconstruction of the tongue with a free vascularized flap. However, this may not always be suitable for elderly patients because the procedure is lengthy and invasive and also because of their medical history. We report 2 cases of elderly patients undergone oral floor reconstruction with digastric muscle bipedicle flap for advanced tongue cancer. In case 1, an 86-year-old woman underwent pull-through ablation surgery with partial glossectomy and modified radical neck dissection for the treatment of left-sided tongue cancer(well-differentiated squamous cell carcinoma, cT3N2bM0, Stage ⅣA). In case 2, a 93-year-old man underwent pull-through ablation surgery with hemiglossectomy and suprahyoid neck dissection for treatment of right-sided tongue cancer(verrucous carcinoma, cT3N0M0, Stage Ⅲ). In both patients, the flap was sutured to the mandibular border, mandibular periosteum and surrounding tissue, and the intraoral mucosa and neck were isolated. Compared to the reconstruction of the tongue with a free vascularized flap, the procedure used in these 2 cases was shorter and caused less bleeding. Moreover, the patients exhibited no postoperative dysfunction, and clinical outcome remained favorable. We believe that oral floor reconstruction with digastric muscle bipedicle flap at the bottom of the mouth was effective in reducing surgical stress and restoring oral function in very elderly patients.

We present a case of cervical lymph node metastasis from an unknown primary cancer that was controlled with immunotherapy, chemotherapy, and surgery. The patient, a 61-year-old man, was referred to our department for treatment of a lesion in the left cervical lateral area. At the initial visit, the mass was covered by reddened skin and was elastic, hard, and immobile on palpation. The presence of a malignant disease such as malignant lymphoma or lymphadenitis because of infection by tubercle bacillus or Epstein-Barr virus was suspected on the basis of the clinical and magnetic resonance imaging findings. Biopsy and resection of the cervical mass was performed under general anesthesia. Because the pathological diagnosis during surgery indicated squamous cell carcinoma, the surgical approach was changed to neck dissection. Head, neck, and thoracic computed tomography and other examinations were performed to locate the primary cancer, but its origin remained unknown. Postoperative therapy consisted of chemotherapy and immunotherapy. The patient has been followed up for 4 years and 10 months without any evidence of recurrence.

In the case of oropharyngeal carcinoma, patients may present with symptoms similar to cervical lymphadenopathy, and the primary lesion may only be diagnosed after cervical mass extirpation/biopsy. We retrospectively analyzed the clinical course in 11 oropharyngeal carcinoma patients that were diagnosed after cervical mass extirpation/biopsy between 1998 and 2013. Before the diagnosis was made of oropharyngeal carcinoma, a cervical lymph node biopsy was performed in six patients; the lymph node was extirpated due to an initial diagnosis of lateral cervical cyst in four patients; and neck dissection was performed due to an initial diagnosis of primary unknown carcinoma in one patient. The primary tumor site in the oropharynx was the palatine tonsil in six patients and the lingual tonsil in five patients. Five of six patients with palatine tonsil carcinoma and three of five patients with lingual tonsil carcinoma were found to be positive for human papillomavirus (HPV). The duration from cervical lymph node extirpation/biopsy to final diagnosis was 1 to 13 months. All patients finally underwent radiation therapy or chemoradiotherapy, and they had no recurrence or metastasis. As the incidence of HPV-related oropharyngeal carcinoma increases, the number of oropharyngeal carcinomas assumed to be cervical lymphadenopathy due to the presenting symptoms may increase. It is important to investigate the oropharynx thoroughly so as to adequately differentiate the possibility of oropharyngeal carcinoma from that of cervical lymphadenopathy. Metastatic lymph nodes might present as cysts in cases of oropharyngeal carcinoma, it is therefore necessary to take the potential for metastatic lymph nodes in the oropharyngeal cancer into consideration when differentiating this disease from cervical cyst-shaped lesions.

A nerve reconstruction was performed in 20 patients whose spinal accessory nerve was resected during total neck dissection. Re-anastomosis or a cable graft was performed between both cut ends of the accessory nerve in 14 patients (accessory nerve reconstruction group), and between the peripheral cut end of the accessory nerve and the central cut end of the cervical nerve (C2 or C3) in 6 patients (cervical/accessory nerve reconstruction group). There was no difference in the postoperative shoulder functions between the reconstruction groups, and both groups were significantly better than the group without reconstruction (n = 13), although they tended to be poorer than the nerve preservation group (n = 41).

We report a case of papillary carcinoma of the thyroid gland and cervical lymph node metastases with concurrent tuberculous lymphadenitis that was diagnosed preoperatively. A 35-year-old woman presented with multiple lymph node swellings and an anterior neck mass. No findings suggesting the coexistence of pulmonary tuberculosis were present. The patient underwent a total thyroidectomy with bilateral neck dissection together with medication. Measures to prevent tuberculosis were undertaken during the perioperative period. The histopathological diagnosis was papillary carcinoma with both metastatic and tuberculous lymphadenitis of the lymph nodes in the neck. The possible coexistence of tuberculous lymphadenitis must be ruled out when lymph node swellings are observed in patients with head and neck cancer, including thyroid carcinoma.

Accessory parotid gland tumors are relatively rare; hence, adequately detailed clinical analyses of these tumors are difficult to perform at a single institution. In this report, we describe the findings for 65 patients [29 men, 36 women; median age, 51 (9-81) years] with accessory parotid gland tumors, consisting of 4 cases documented by us and 61 cases previously reported by other Japanese authors. Approximately 50% of the patients were treated in an otolaryngology department, while the remaining patients were treated in plastic surgery, oral surgery, or dermatology departments. In 4 patients, the results of preoperative fine-needle aspiration cytology indicated that the tumor was benign; however, the postoperative histopathology results revealed malignant tumors. The frequencies of malignant and benign tumors were 44.6% (n = 29) and 55.4% (n = 36), respectively. Mucoepidermoid carcinoma and pleomorphic adenoma were the most frequent types of malignant and benign accessory parotid gland tumors, respectively. Among the various surgical methods that were used, such as direct cheek and intraoral incisions, a standard parotidectomy incision was the most preferred treatment approach for these tumors. Recently, an endoscopic approach has also been found to yield satisfactory results. An optimal approach should be selected after evaluating the advantages and disadvantages of these methods. No definite guidelines are available regarding the choice of elective neck dissection and postoperative radiation therapy for malignant accessory parotid gland tumors. Although tumor resection (plus elective neck dissection) and postoperative radiation therapy have been frequently performed for various kinds of malignant accessory parotid gland tumors to date, additional studies are needed regarding the criteria for selecting elective neck dissection and postoperative radiation therapy. Since the malignancy rate for accessory parotid gland tumors is higher than that for parotid gland tumors, the possibility of malignancy (especially mucoepidermoid carcinoma and carcinoma ex pleomorphic adenoma) should be considered when resecting accessory parotid gland tumors, even if the results of preoperative fine-needle aspiration cytology indicate that the tumor is benign.

The unilateral bolus passage through the upper esophageal sphincter (UES) is often observed in swallow evaluations of patients following neck dissection. Head rotation toward the paretic side was reported to be useful to prevent aspiration; however, we often encounter cases of head and neck surgical patients in which the bolus passes through the non-surgical side. Therefore, we investigated UES flow after head and neck surgery to evaluate the laterality to find an effective treatment technique after a head and neck operation. Videofluoroscopic swallowing studies (VFSS) were conducted in 23 oral cancer patients who underwent unilateral neck dissection but not tongue resection. Patients comprised 12 males and 11 females, with a mean age of 62 (SD=14) years. Preoperative VFSS showed that none had a predominant side for UES flow. The laterality of the bolus flow through the UES was predominantly on the side of neck dissection in post-operation. Lateral VFSS showed elevation of the hyoid and the larynx on the non-dissected side was greater compared to the dissected side. Therefore, head rotation toward non-dissected side can be effective for head and neck surgical patients.

A 76-year-old man who had previously undergone unilateral radical neck dissection (RND) was scheduled for contralateral radical neck dissection and reconstruction of the internal jugular vein (IJV) with the saphenous vein due to local recurrence of thyroid carcinoma infiltrating the IJV Reconstruction of the IJV was not necessary, however, because the preserved IJV was large enough to drain venous return after partial resection of the tumor-infiltrated part of the IJV. Reports of anesthetic management for bilateral RND are very rare. In this report, we discussed anesthetic management of bilateral RND including physiological changes and complications after bilateral IJV ligation and monitoring methods for disturbances of cerebral venous circulation.

Well differentiated thyroid carcinoma (WDTC) consists of papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). Although both cancers are excellent prognosis, there are different in carcinogenesis by some genes, criteria of pathological diagnosis and transforming pattern between PTC and FTC. So the strategy for surgical treatment of them should be discussed separately. The patient with PTC less than 45 years old whose tumor is localized in a unilateral lobe without extra thyroidal invasion, lymph node metastasis and distant metastasis should be performed a unilateral lobectomy with central node dissection (D1). PTC patient over 45 years old except micro PTC case (T1a N0, M0) is recommended total thyroidectomy with modified radical neck dissection (D2 or D3). Encapsulated FTC is not necessary prophylactic lymph node dissection and only preformed unilateral lobectomy. If this patient has vascular invasion after lobectomy, completion thyroidectomy will be recommended for monitoring by serum Tg and whole body 123I scan.

According to our previous data on papillary thyroid cancer (PTC), recurrences are related to lymph node ratio (number of metastatic lymph nodes/number of dissected nodes) and lymphatic spread of PTC is more symmetrical than previously thought. Therefore, neck dissection should be performed symmetrically. Our basic procedure for clinically evident PTC is total thyroidectomy with central neck dissection. For the cases with jugular chain adenopathy and/or T3, T4 tumor, bilateral lateral neck dissection should be added. Surgical clearance of malignant tissue is important for curability. For micro PTC (T<1 cm), lobectomy with ipsilateral central neck dissection or careful observation are proposed. Meticulous maneuver of parathyroid glands and recurrent laryngeal nerves is essential for above-mentioned procedure.

The incidence of thyroid cancer clinically detected is increasing, mainly due to the technical progress in thyroid sonography. There are many problems and questions regarding the management of patients with thyroid tumors, including how to distinct thyroid follicular cancer from adenoma (no definite method is available except for the histological examination of the tissue specimen at surgery), how to treat patients with unproved thyroid tumor (thyroidectomy or observation ?), how to define "poorly differentiated thyroid cancer" (different definition between WHO and Japan) and how to treat patients with differentiated thyroid cancer (total thyroidectomy or subtotal thyroidectomy, with or without prophylactic neck dissection, with or without postoperative remnant ablation by radioactive iodine, with or without postoperative TSH suppression by thyroid hormone, thyroidectomy or observation for micro-carcinoma). Several guidelines for management of thyroid tumors have recently been published from western thyroid associations. Their basic policy how to manage differentiated thyroid cancer is considerably different from, at least, the traditional treatment in Japan. An evidence-based guideline should be published soon in

Traditional treatment for papillary thyroid carcinoma confined in one lobe was subtotal thyroidectomy with ipsilateral modified neck dissection in Japan. Several guidelines reported from western countries differ in many aspects from Japanese traditional practice. They recommend total or near total thyroidectomy except for a small solitary cancer without nodal metastasis and modified neck dissection only if nodes are clinically involved. They also recommend ablation of remnant thyroid with radioactive iodine and TSH suppression with variable indications and intensities. According to the recent improvements in surgical techniques and change in medical and economical situations, we currently perform total thyroidectomy more frequently and hemithyroidectomy for a small cancer. We abandoned subtotal thyroidectomy basically. We still consider prophylactic neck dissection valuable in reducing nodal recurrence in selected patients.

We reported a case of acute respiratory distress syndrome (ARDS) induced by docetaxel in treating lung metastases from oral cancer. The patient was an 84-year-old man who had undergone partial mandibulectomy and radical neck dissection for lower gingival carcinoma. The patient developed ARDS after docetaxel administration (40 mg/body) for multiple lung metastases.

Therapeutic performance of the esophageal cancer has improved rapidly. Now in the decision of therapeutic strategy not only life prognosis but also treatments-related morbidity and late term quality of life should be considered. The most important factor of the improvement of esophageal cancer treatment is a progress in early detection of esophageal cancers and active use of treatment methods such as endoscopic mucosal resection. In addition,the role of radiotherapy and chemotherapy has improved as an arm of multidisciplinary therapy,and the establishment of chemoradiotherapy as one of the standard therapy for esophageal cancer is also very important. This shows that surgical and non-surgical approach has been getting more interactive and the relationship to one another should always be considered. Surgical therapy is very effective in patients with localized esophageal tumor and the patient's satisfaction is high. However, many problems are remained, and the improvement of diagnosis for metastasis and lessening surgical invasiveness and early/late complications are expected. Moreover,the chemoradiotherapy as an esophagus preserving method will establish more important standpoint and the salvage surgery will be applied more actively. On the other hand, a new strategy such as chemoradiotherapy immediate after esophagectomy for the patients with possible residual tumor for improving therapeutic results may be considered under the status of reliable surgical procedures.

Small oropharyngeal carcinomas with advanced neck metastases (stage N2 or greater) are common. Patients with small T with large N oropharyngeal carcinoma have high rates of local control but lower rates of regional control when treated with chemoradiotherapy. Clinical assessment after chemoradiotherapy cannot ensure the absence of neck disease. In the last 5 years, we have treated patients with T1-2 with N2-3 oropharyngeal carcinoma with weekly docetaxel radiotherapy followed by planned neck dissection (PND). Our objectives were to clarify the pathologically complete response (CR) rate of neck metastasis after weekly docetaxel radiotherapy, to identify the clinical predictor of residual neck disease, and to determine the mobidity of planned neck dissection. After chemoradiotherapy, all 12 patients had a complete response at the primary site. We conducted 15 neck dissections. Of these, 6 (40%) had positive nodes. The pathological CR rate of neck metastasis was 58.3%, whereas overall 2-year neck control rate was 91.7%. These findings lend support to the role of PND after chemoradiotherapy in N2-3 neck disease. After chemoradiotherapy, clinical parameters including TN status, feasibility of chemoradiotherapy, largest lymph node size or size reduction in MRI, did not identify patients with residual neck disease. We conducted selective neck dissection (SND) in 80% of patients. SNI) as PND appears to be appropriate in this group of patients because of the low incidence of complications. A further cohort study including the comparison of PND nonenforcement group is necessary to clarify the validity of the addition of PND in weekly docetaxel radiotherapy.

We reviewed the records of 10 patients with malignant skin tumors of the forehead and face who underwent neck lymph node dissection at Kurume University Hospital between 2000 and 2004. Two patients underwent selective neck dissection (SND), 5 patients underwent SND and superficial parotidectomy (SP) and 3 patients underwent modified radical neck dissection and SP. Lymph node metastasis to the upper jugular group was found in 3 patients, and metastasis to lymph nodes of the parotid region was found in 3 patients. In a patient with malignant melanoma of the forehead, the patent blue dye was injected intradermally around the tumor and blue-stained lymph nodes were identified in the upper jugular group and parotid region. From these results, we consider that the sentinel lymph nodes of frontal and facial malignant tumors are located in the upper jugular group and parotid region. Thus, in malignant skin tumor patients, SND and SP might be mandatory.

A 53-year-old man underwent partial glossectomy for tongue cancer on the right side (well-differentiated squamous cell carcinoma T 1 N 0 M 0). One and 9 months later, cervical lymph node metastasis was observed bilaterally. After bilateral radical neck dissection, 2 courses of NDP/5-FU combined chemotherapy were administered. However, 2 metastatic lung cancers were observed 14 months after initial treatment. Stereotactic radiation therapy of 50 Gy in 5 fractions and 6 courses of docetaxel/cisplatin/5-FU chemotherapy were administered. As a result, no recurrence was observed, and a complete response was obtained for 41 months after lung metastasis.

We experienced a 49-year-old man with cancer of the lower lip (squamous cell carcinoma, T1N2cM0). We planned surgical treatment including bilateral neck dissection and started a new TS-1 administration method as a neo-adjuvant chemotherapy. One course of this chemotherapy consisted of 3 weeks'administration including 5-day administration and 2-day termination following 1 week rest. TS-1 was given at 120 mg/day. After the first course of chemotherapy, the primary tumor disappeared, and the neck lymph node metastases were markedly reduced. There was no obvious side effect except mild stomatitis. Since we assumed that the lymph node palpated in left neck was a residual tumor, we performed left neck dissection. Histopathological examination revealed that there was no cancer cell but hyalinization in the removed specimen of lymph node, suggesting that the effect of the chemotherapy was a pathologically complete response. We concluded that our novel TS-1 administration method was extremely effective for head and neck squamous cell carcinomas with high potential and without any severe side effects.

We evaluated the usefulness and limitations in ultrasonography (US) for diagnosing neck lymph node metastases in patients with hypopharyngeal cancer by comparing the results of preoperative US examinations with postoperative pathological findings following neck dissection. Seventy-five previously untreated patients with hypopharyngeal squamous cell carcinoma underwent a curative procedure that included neck dissection. Preoperatively, all patients were examined by palpation, computed tomography (CT), and US. Postoperatively, all dissected neck lymph nodes were submitted for pathological examination. Results of pre-and postoperative examinations were then compared. US accuracy for each lymph node was 93.9%, while sensitivity was 78.0%, since hypopharyngeal cancer metastasizes early and easily to the neck lymph nodes, and it is difficult to detect small, pathologically positive nodes. Nine of 75 cases showed latent neck recurrence, and two of these were underestimated by US. The major cause for neck recurrence was considered to be the high rate of metastases in such cases, rather than a reduced dissection field. It is not rare to find very small, pathologically positive lymph nodes that US cannot detect in hypopharyngeal cancer. Efforts must therefore be expanded to improve the accuracy of US diagnosis. Care must also be taken when selecting cases for no or limited neck dissection.

We assessd the feasibility and problems associated with sentinel lymph node (SLN) study in 13 cases of oral and pharyngeal squamous cell carcinoma (SCC) that were neck-node-negative clinically. The primary sites were the tongue (n = 10), other sites in the oral cavity (n = 2), and the mesopharynx (n = 1). The day before surgery, tracer was injected into the submucosa around the tumor, and scintigraphic images were acquired 2 hours later. The SLN was identified intraoperatively with a handheld gamma probe, and neck dissection, including the SLNs, was performed. Radioactivity within the nodes was confirmed with a well type scintillation counter, and all resected lymph nodes were histologically examined for metastasis. The SLN was identified in every case. There were regional lymphnode metastases in 4 cases, and metastasis to the SLNs was present in all of 4 cases. Thus, the SLN concept was valid for head and neck SCC, sentinel node navigation surgery (SNNS) was thought to be applied in stage NO SCC of the head and neck. If SNNS is performed, about 70% of patients do not require neck dissection. SNNS is feasible and cost-effective in these cases. We used two different tracers: phytate and tin colloid, and found that phytate was more useful. To avoid the effects of the shine-through phenomenon, it was thought that some directions of lymphoscintigram should be taken. For intraoperative identification of the SLNs, care should be taken to the angle of gamma probe. SLN study leads to clarify each patient's lymphoid flow mapping, and it is also useful to determine the dissection area of selective neck dissection.

No consensus for papillary carcinoma of the thyroid exists on the preoperative diagnosis of lateral cervical lymph node metastasis, indications, or range of neck dissection, so we studied the usefulness and limits of ultrasonography and sufficient dissection by comparing preoperative ultrasonographic and postoperative histopathological diagnosis. Subjects were 45 patients (51 affected sides) with lateral cervical lymph node metastasis of papillary carcinoma of the thyroid who underwent modified neck dissection between July 1997 and July 2003. Preoperative ultrasonographic and postoperative histopathological diagnosis were compared. Specimens excised by neck dissection contained 1,325 lymph nodes. Of these, 198 (15%) detected by preoperative ultrasonography were selected for investigation of diagnostic criteria for metastasis-positive lymph nodes. The best criterion for the diagnosis of metastasis-positive lymph node was 0.5 or greater [minor axis/major axis] with 6 mm or greater minor axis at levels III, IV, or V (7 mm or greater at level II), and sensitivity, specificity, and accuracy were 78%, 100%, and 84% respectively. The lateral cervical lymph node metastasis rate obtained by this diagnostic criterion was 41%. Regional histopathological metastasis positivity was investigated in the lateral cervical region, and high positivity rates were obtained: 57% at level II, 71% at level III, and 84% at level IV. Considering these findings and the preoperative ultrasonographic diagnosis rate of 41%, sufficient dissection at levels II-IV may be necessary for patients in whom lateral cervical metastasis is observed before surgery. The metastasis rate was 10% at level V, but dissection should always be done in lateral cervical metastasis-positive patients because: 1) No trend was observed in age, gender, the number of metastatic lymph nodes, or regional metastasis rate; 2) no anatomical boundary is present between levels II, III, IV and level V; 3) no functional disorder due to preservation of the accessory nerve occurred; 4) the prognosis of patients with advancement to the accessory nerve was poor; and 5) improvement of the prognosis of papillary carcinoma of the thyroid by modified radical neck dissection has been reported.

Papillary thyroid carcinoma (PTC) may metastasize to cervical lymph nodes. It is, however, uncommon for a palpable neck node alone to lead to the diagnosis of this disease when it is not apparent at presentation. Standard treatment for such cases has not yet been established. We retrospectively analyzed clinical courses in 8 patients with thyroid papillary carcinoma presenting with palpable lymph node metastasis at Hokkaido University Hospital between 1990 and 2003. Three had high thyrogloblin in cervical cystic lesions, leading to the diagnosis of PTC with lymph node metastasis. In 4, PTC was diagnosed by pathological examination of cervical lymph nodes initially diagnosed as lateral cervical cysts. Preoperative examination did not indicate PTC within the gland in any case. All 8 were alive at the last visit after follow-up from 23 to 150 months (mean: 78 months). Total thyroidectomy was done on 4 and thyroid lobectomy on 3. Pathological examination of resected thyroid glands confirmed multifocal papillary carcinoma from 4 mm to 15 mm in diameter. Six underwent unilateral neck dissection and 1 chose bilateral dissection. The other patient received no additional surgery on either the thyroid or neck after the single enlarged lymph node initially diagnosed as a lateral cervical cyst was resected. Postoperative radioiodine treatment was done in 2 undergoing total thyroidectomy. Recurrence in the cervical area were observed in 1 whose neck dissection was insufficient. Based on these observations, we concluded that patients who undergo thyroid lobectomy and adequate neck dissection may enjoy longer survival than those treated with total thyroidectomy without sacrificing thyroid and parathyroid function. We therefore propose a prospective study on the effectiveness of thyroid lobectomy with neck dissection including positive nodes in patients with occult PTC presenting with lymph node metastasis.

The treatment results of 65 patients with hypopharyngeal carcinomas treated at our institute between 1995 and 2000 were analyzed. In general, concurrent radiochemotherapy (RCT), consisting of intravenous 5-FU injection, intra-muscular vitamin A injection, and radiation (FAR therapy) was used as an initial treatment for advanced hypopharyngeal carcinomas and early hypopharyngeal carcinomas. Tumor responses were evaluated at the time of radiation doses of 30Gy. Patients who showed a complete response (CR) subsequently received curative radiation doses of 60 to 70Gy. Patients who did not show a CR underwent radical surgery consisting of pharyngo-laryngo-cervical esophagectomy, neck dissection for positive cervical nodes and/or the primary tumor sides, and reconstruction using a free jejunum flap. The disease-specific 5-year survival rates were 92%, 55%, 35% and 49% for stage I/II, III, IV and all cases, respectively. Eight out of 9 patients with stage I/II disease who showed a CR after receiving 30Gy of RCT survived with an intact larynx after definitive RCT. All the patients with stage II/III disease who underwent radical surgery after receiving 30Gy of RCT did not have a recurrence, whereas the 5-year survival rate of patients with stage IV disease who underwent RCT and radical surgery was 45%. Seventeen out of 19 patients with clinically negative cervical nodes on the opposite side of their primary tumors showed no nodal metastasis after RCT without neck dissection. This result suggests that elective neck dissection after RCT is not necessary. To improve the treatment results for hypopharyngeal carcinomas, early detection of this disease is prerequisite. In addition, the clinical diagnosis of highly malignant cases and new molecular-targeted therapies based on an analysis of distant metastasis mechanisms should be developed to overcome the poor prognosis of advanced hypopharyngeal carcinomas.

Management of the cervical lymph nodes is one of the most important factors in controlling head and neck carcinoma. The clinical treatment strategy for managing the N0 neck in oral cancer is still under debate. Recently, the accuracy and feasibility of sentinel lymph node biopsy (SNB) have been investigated in many studies. An application of the technique to the area of oral cancer was therefore obvious. We reported the technique and accuracy of SNB in our center, and have reviewed the preliminary reports indicating that sentinel node identification is technically feasible in oral and pharynx cancer stages T1 and T2 with clinical N0. However, a multi-institutional trial is needed to determine whether SNB should become a standard procedure.

We treated 4 patients with hypopharyngeal cancer, each of whom had a complete response after 2 cycles of chemotherapy with docetaxel, cisplatin, and 5-FU followed by radiation and/or neck dissection. Twenty-one months to 2 years after this therapy, 3 patients had no recurrence and no metastasis with their laryngeal framework and function preserved. Chemotherapy including docetaxel, cisplatin, and 5-FU is a useful treatment for early head and neck cancer.

A patient who had parotid gland carcinoma with hepatic metastasis (T4N2bM1) underwent 3 cycles of neoadjuvant chemotherapy with docetaxel, cisplatin and fluorouracil (TPF). After this treatment, the patient showed a PR in the primary site and a CR in the hepatic metastasis. Left total parotidectomy and modified radical neck dissection were then performed followed by postoperative irradiation of 40 Gy. No recurrence in the primary site or the neck was seen, but in the metastatic site a recurrence was observed at 8 weeks after the first chemotherapy. The same chemotherapy is now applied in an outpatient setting. Toxicities with neutropenia, nausea and vomiting of CTC Grade 3 were observed, but these toxicities were mild and manageable. TPF is considered to show clinical activity for advanced parotid gland carcinoma, and we consider further investigation necessary.

The indication and preferred dissection field for prophylactic neck dissection for submandibular gland cancer are controversial and have not been standardized. We reviewed 27 patients who underwent a definitive operation for previously untreated submandibular gland cancer. The 27 patients consisted of 13 patients with adenoid cystic carcinoma, 6 patients with mucoepidermoid carcinoma, 6 patients with adenocarcinoma, and 2 patients with squamous cell carcinoma. The diagnostic accuracies of malignancy and histology with fine needle aspiration cytology were 86% and 56%, respectively. In sixteen out of 21 cases without neck lymph node metastasis, a prophylactic neck dissection was performed and pathological neck lymph node metastases were detected in five cases. On the other hand, in five cases that did not receive a prophylactic neck dissection, latent neck lymph node metastasis was observed in 2 cases. In both cases of neck lymph node metastasis, pathological positive lymph nodes were observed in only level 2 or level 3. The rates of occult neck lymph node metastasis according to the T stage were 0% in T1, 33.3% in T2, 57.1% in T3 and 100% in T4. The rates of occult neck lymph node metastasis according to the histopathology were 46.2% in adenoid cystic carcinoma, 50% in mucoepidermoid carcinoma, 50% in adenocarcinoma, and 50% in squamous cell carcinoma. In conclusion, we believe that supraomyohoid neck dissection is suitable for N0 cases of submandibular gland cancer because of four reasons: 1) rate of occult neck lymph node metastasis in submandibular gland cancer is high, 2) pathological neck lymph node metastasis in N0 cases and latent neck lymph node metastasis were observed in level 2 and level 3, 3) the prognosis of cases with neck lymph node metastasis was poor, and 4) same skin incision can be used not only for the primary resection but also for the neck dissection.

We retrospectively evaluated clinical profiles and prognoses in 152 patients with thyroid papillary carcinoma treated at Fukui Medical University between 1986 and 2000. As standard treatment, 106 (70%) underwent hemithyroidectomy to preserve the normal thyroid lobe. Subtotal thyroidectomy or total thyroidectomy was conducted on 40 cases (23%). Regional lymphnodes were extirpated in 104 (68%) with pathological N0, and radical or conservative neck dissection for 46 cases (30%) with pathological N1. Overall survival for 10 years, estimated using the Kaplan-Meier method, was 100% in both stage I and II, and 95% in stage III. Of 152 thyroid papillary cases, 22 (14%) had tumor recurrence. Of 51 in stage III, 14 (27%) had tumor recurrence. The 14 recurrent in stage III showed local extrathyroidal invasion. Note that 5 of 10 (50%) T4N1 treated with hemithyroidectomy had tumor recurrence in the residual thyroid lobe. Of 11 T4N0 cases who underwent hemithyroidectomy, none had tumor recurrence in the residual thyroid lobe. Results suggest that patients with T4N1 should be treated by total thyroidectomy and neck dissection at initial treatment. Tumor size, cervical lymphnodal metastasis, and distant metastasis may be prognostic factors for thyroid papillary carcinoma.

Encountering a metastatic carcinoma of the neck from an unknown primary site is not unusual, despite intensive examinations of the entire body. In previous reports, the pathological diagnosis of these carcinomas was usually squamous cell carcinomas and rarely adenocarcinoma. We treated eight patients with metastatic carcinoma of the neck from unknown primary sites, including 4 cases of squamous cell carcinoma, 2 cases of adenocarcinoma, one case of small cell carcinoma, and one case of clear cell carcinoma, during a 10-year period from January 1992 to December 2001. We clinically examined these eight cases, and focusing on the two cases of metastatic cervical adenocarcinoma from unknown primary sites. The 8 cases consisted of 5 cases of N2 and 3 cases of N3 disease. Three of the 5 N2 patients underwent a neck dissection, but all three of the N3 cases were judged to be inoperable. Disease-free survival was achieved in all 3 patients who underwent surgery. In this paper, we review 36 reports on metastatic carcinomas of the neck from unknown primary sites and statistically analyze 1454 cases. Pathologically, the majority of them (81.1%) were squamous cell carcinoma; adenocarcinomas accounted for only 7.6% of the cases. Notably, 65.0% of the patients with cervical metastatic adenocarcinomas were confirmed to have primary lesions outside the head and neck region. The prognosis of primary unknown metastatic cervical adenocarcinoma is reportedly poor, and the optimal treatment is still unclear, although surgery is recommended for primary unknown metastatic cervical squamous cell carcinoma. However, we suggest that intensive treatment, including surgery, radiotherapy, and chemotherapy, of metastatic lesions of the neck may play a key role in improving patient prognosis.

Postoperative cervical lymphorrhea is a complication uncommonly encountered following neck dissection for which several treatment modalities have been described in the literature. We managed 8 cases of lymphorrhea after neck dissection by injecting Minocycline through a drainage tube. We attempted this procedure for lymph discharge that had continued despite pressure dressing and systemic management with nutritional modification for about 1 week. This treatment rapidly resolved lymph discharge in 6 of the 8 cases. No patient required surgical intervention. Minocycline sclerotherapy has typically been used to treat pleural effusion, ascites, pneumothorax, and other cystic diseases of the liver, pancreas, and kidney. In many cases, this therapy brings rapid resolution. This inefficiency is due to the acidity and toxicity of Minocycline. No major adverse effects have been reported. We believe that Minocycline sclerotherapy is effective for rapidly resolving lymphorrhea following neck dissection and use of this therapy should be attempted before surgical intervention.

We evaluated the effects of surgical invasion and vascular injury on hemostatic abnormalities in seventeen ASA I-II patients undergoing prolonged surgeries of eight hours or more consisting of tumor excision, radical neck dissection and free flap reconstruction in the maxillofacial region. As molecular markers of blood coagulation and surgical invasion, prothrombin fragment 1 + 2 (F 1 + 2), interleukin-6 (IL-6), tissue-type plasminogen activator (tPA), thrombomodulin (TM) and plasmin alpha 2-plasmin inhibitor complex (PIC) were measured during surgery and on the first and second postoperative days. The F 1 + 2 values increased significantly during surgery and decreased postoperatively, and reached the maximum at the end of surgery. Changes in IL-6 and tPA were similar to those of F 1 + 2, and there was a correlation in the levels of F 1 + 2 and IL-6 (r = 0.54), tPA (0.41) and PIC (0.30) at each measurement time. PIC and TM, however, did not show statistically significant changes intra- and postoperatively, nor was there any correlation between F 1 + 2 and TM values. From these results, we conclude that inflammatory mediators and endothelial stimulation activated by surgical invasion may influence hypercoagulability. Vascular injury, however, did not act as the main coagulation factor during prolonged maxillofacial surgery.

Surgery is not always necessary for micro cancer (less than 1.0 cm in diameter). In surgery of micro cancer, we recommended to dissect only the central compartment (pretracheal [II]/paratracheal [III] area). In patient with cancer (more than 1.0 cm in diameter), lymph nodes in the central compartment, ispirateral supraclavicular area, and jugulocarotid chain (V and VI) should be dissected. Even in incomplete surgery, lymph node dissection of the central compartment is warranted in patients with papillary cancer, because recurrence in the central compartment results in dyspnea and/or hemosptum, lowering the quality of life.

The purpose of this study is to ascertain the role of neck surgery and radiation therapy for cervical lymph node metastasis in oropharyngeal cancer patients. We reviewed 217 previously untreated patients with squamous cell carcinoma of the oropharynx who were treated at the Cancer Institute Hospital in Tokyo between 1971 and 1995. The N stage distribution was; N0: 83(38.2%), N1: 42(19.4%), N2a: 23(10.6%), N2b: 27(12.4%), N2c: 33(15.2%), and N3: 9(4.2%). A predominance of cervical node metastases in level II and III was revealed and there were no skip metastases outside of level II and III. The control rate of cervical metastasis for each N stage was; N0: 96.9%, N1: 90.0%, N2a: 76.5%, N2b: 62.5%, N2c: 50.0%, and N3: 0%. Definitive irradiation provided sufficient treatment for small nodes, when the primary tumor growth was well controlled by radiation therapy. Neck dissection was necessary for more advanced neck metastases. Selective limited neck dissection (level II and III) is recommended for N0 and N1 patients, and modified or classical RND is considered to be better for most cases with N2 and N3.

A statistical analysis was performed on 40 patients with squamous cell carcinoma of the tongue and mouth floor, which could be followed for 6 months or more after initial treatment in the Department of Otorhinolaryngology, School of Medicine, Keio University during the 14 years from 1983 to 1996. The 5-year survival rate determined by the Kaplan-Meier method for each stage was 100% for Stage I, 77.8% for Stage II, 60.0% for Stage III and 44.4% for Stage IV. Thirteen suffered a relapse after initial treatment and patients with relapses among them have all survived after the subsequent salvage surgery. In contrast, in nine patients with cervical relapse, however, the 5-year survival rate was 11.1% with an unfavorable prognosis. This confirmed that suppressing cervical relapses is important for treating tongue and floor mouth cancers. The treatment strategy in our department is characteristic of positive enforcement of prophylactic neck dissection in the surgery and introduction of neoadjuvant chemotherapy (NAC) in the chemotherapy. Prophylactic neck dissection was performed in the 17 patients and no relapse was observed on the side of prophylactic neck dissection. NAC was performed on 26 patients in consideration of suppressed minute metastases and preserved function and 24 determinable cases were statistically analyzed. Among patients who had received NAC, the oral function was successfully preserved without surgical intervention in six patients both patients who showed complete response (CR) and four out of 14 patients who had a partial response (PR) following NAC. This may indicate that the oral function could be preserved in those patients who exhibited CR following NAC, but that preservation could be difficult in patients who exhibited PR. In addition, concerning the accumulated 5-year survival rate in relation to the effect of NAC, responders (CR + PR) accounted for 90.9% and non-responders (no change + progressive disease following NAC) for 15.0% with a very good outcome noted in the responder group. These figures suggest that responders may have a significantly good prognosis in the multivariant analysis including additional background factors before treatment as well. Accordingly, the present therapeutic measures for non-responders must be reexamined and performed more carefully and accurately as compared with those for responders.

Carcinoma of the hypopharynx has a great tendency to metastasize to the neck. In addition it often metastasizes to the upper retropharyngeal lymph nodes (Rouviere's lymph nodes) and to the paratracheal lymph nodes. In this study, in order to determine the pattern of lymph node metastasis, 112 patients with carcinoma of the hypopharynx who had undergone bilateral radical neck dissection, bilateral paratracheal dissection, bilateral dissection of retropharyngeal nodes as an initial treatment between January 1982 and June 1997 in the Kurume University Hospital, were retrospectively reviewed in detail. Special attention was paid to retropharyngeal nodes and paratracheal lymph nodes. In N0 cases neck metastases were seen in more than one-quarter of the patients. Metastasis to retropharyngeal lymph nodes and to the paratracheal lymph nodes was seen in 5.4% and 12.5% of the patients, respectively. The frequency of metastasis to paratracheal lymph nodes had a significantly close relationship with that to the upper and lower jugular lymph nodes. The frequency of metastasis to retropharyngeal lymph nodes also had significantly close relationship with that to paratracheal lymph nodes, while having no relationship with that to other neck lymph nodes. These results suggest the following: 1) In patients with T1 or T2 PS type carcinoma of the hypopharynx, in which the lesion is confined unilaterally and is presumed to have been successfully treated by laser surgery prior to radiotherapy, unilateral neck dissection alone will be sufficient. In all the other patients with carcinoma of the hypopharynx bilateral neck dissection must be performed. 2) In all patients retropharyngeal lymph nodes and paratracheal lymph nodes should be dissected as much as possible and postoperative irradiation to both areas will be necessary.

In order to determine the reasonable lymph node dissection for T2 or T3 midthoracic esophageal cancer with cervical lymph node metastasis, a retrospective study was carried out on 106 patients receiving resection between 1983 and 1996. Metastasis to cervical lymph node was obtained in 27.4% (29/106) of patients with T2 or T3 midthoracic esophageal cancer. Within 29 patients, metastasis in cervical node only, in two fields and in three fields occupied 17.2%, 41.4% and 41.4%, respectively. And according to the histologic examination of dissected lymph nodes, metastatic sites spreaded from neck to perigastric region. Five-year survival rate of 23 patients receiving curative operation was 33.0%, and that of 13 patients excluding 3-field metastasis was 51.9%. But the main sites of nodal recurrence were cervical or superior mediastinal nodes along the bilateral recurrent laryngeal nerves, and the rate of nodal recurrence was 47.8%. These results of actual state of lymph node metastasis and prognostic benefit of aggressive dissection suggest that 3-field lymph node dissection is mandatory for T2 or T3 midthoracic esophageal cancer with cervical lymph node metastasis. And we should endeavor to upgrade the precise dissection in order to decrease the nodal recurrence.

The frequency and distribution of metastatic lymph node of submucosal cancer (sm) located in mid-thoracic esophagus were investigated retrospectively to evaluate the significance of cervical lymph node dissection, so-called "radical neck dissection". In the further investigations of lymph node dissection in sm cancer located only in mid-thoracic esophagus, cervical lymph node metastasis was found only in 2 cases of 19 mid-thoracic esophageal sm cancer, which were both at paraesophageal area, resectable from the thoracic approach. Comparison of the survival cases receiving esophagectomy for sm cancer located in mid- and lower esophagus, with cervical lymph node dissection (n = 26) and without (n = 16) showed no significant differences. Therefore cervical lymph node dissection can be omitted in cases of mid-thoracic esophageal sm cancer.

We report the case of a 46-year-old woman with cancer of the tongue. She underwent interstitial high-dose-rate brachytherapy of 50 Gy in 10 fractions for 5 days following telecobalt therapy of 20 Gy in 10 fractions for 2 weeks. Seven applicators were percutaneously implanted into the tongue. Radical neck dissection was carried out because a tumor rapidly developed on the neck 2.5 months after the treatment. Pathological examination revealed tumor seeding to the soft tissue of the neck where applicators were placed. To the best of our knowledge, there have been no reports presenting tumor seeding through percutaneous applicators of interstitial brachytherapy for head and neck tumor.

The charts of 319 consecutive patients who underwent total laryngectomy at the Cancer Institute Hospital from 1971 to 1994 were reviewed in order to clarify the relationship between pharyngo-cutaneous fistula formation and age, the dose of pre-operative radiation and radical neck dissection, as well as the need for subsequent surgical repair. The patients did not need to undergo reconstruction by flaps at the time of laryngectomy. Radiation sources were limited to X ray radiotherapy and Cobalt 60. Of the 319 patients 204 (63.9%) underwent neck dissection. Both radical neck dissection and modified radical neck dissection were classified as neck dissection. The chi-square test was used to construct a table of the three parameters age, dose of radiation and neck dissection. With respect to age, the incidence of fistula formation was 13.4% (16 patients of 119) in patients at the age of 59 and below, 5.9% (7/118) in those from 60 to 69, and 8.5% (7/82) in those at 70 years and above. Our analysis reveals that the age at the time of surgery is not a predisposing factor for fistula formation in the three age groups (59 and below, between 60 and 69, and 70 and above). Similarly the need for subsequent surgical repair is also not age-related. With respect to radiation, the incidence of fistula formation was 8.0% (4/50) for patients who received radiotherapy less than 20 Gy, 6.3% (2/32) in those who received between 20 and 40 Gy, 2.6% (2/77) in those who received between 40 and 60 Gy, 13.2% (20/152) in those who received between 60 and 80 Gy and 25.0% (2/8) in those who received over 80 Gy. When the preoperative dose of radiation was divided into three classes, that is, less than 40 Gy, 40 to 60 Gy and over 60 Gy, we observed that the incidence of fistula formation increased significantly in the patients who received over 60 Gy. Surgical repair was also indicated more frequently for those patients who received over 60 Gy than for those who received less than 60 Gy. With respect to neck dissection, the incidence of fistula formation was 12.2% (14/115) for the patients who did not undergo neck dissection or those who underwent only lymphadenectomy, 7.8% (9/115) for the patients who underwent unilateral neck dissection, and 7.9% (7/89) for those who underwent bilateral neck dissection. These data reveal that neck dissection, whether unilateral or bilateral, dose not increase the incidence of fistula formation, nor the need for subsequent surgical repair. Fistulae were present in 30 patients (9.4%) for 24 years, and 14 of these 30 patients did not need subsequent surgery. In these 30 patients with fistulae, we did not find patients with systemic disease such as diabetes mellitus prior to the surgery. When the period of 24 years was divided into 4 periods, the incidence of fistula formation was 19.0% (from 1971 to 1976), 6.9% (from 1977 to 1982), 10.3% (from 1983 to 1989) and 2.6% (from 1989 to 1994), that of the latest period was the lowest with gradual improvement. The average dose of preoperative radiation was 57.7 Gy (from 1971 to 1976), 50.8 Gy (from 1977 to 1982), 39.6 Gy (from 1982 to 1988) and 45.7 Gy (from 1989 to 1994) and reduction in dose of radiation seemed to be one of the reasons for the lower frequency of fistula. Several surgeons performed the operations for different patients, but the procedure of laryngectomy was recently directed by an experienced surgeon. The study also indicates that the risk of fistula formation is reduced not only by the dose of radiation but also by improved surgical skill.

Laryngeal cancer is one of the most curable malignancies. One of the reasons is that most of them are in the early stage. However, the prognosis of advanced bilateral neck metastases is still poor. Based on loco-regional failure and cause of death, the effective procedure of neck dissection and the efficacy of postoperative irradiation were investigated retrospectively. A total of 1022 patients with laryngeal squamous cell carcinoma were registered in our hospital between 1979 and 1991, 58 of them (5.7%) had bilateral neck metastases. Clinical N2c cases accounted for 52% (32/58). In the other patients, the metastatic nodes were revealed by elective neck dissection for a clinically negative neck. The T stages of the 58 cases were as follows; T2 in 14 cases, T3 in 22 and T4 in 22. Forty-nine of the patients treated curatively by bilateral neck dissection were analyzed, 48 with total laryngectomy and 1 with partial laryngectomy. The remaining 9 patients were excluded because of radical irradiation in 3, distant metastases found the diagnosis in 3, unresectable recurrent neck metastases treated in other hospitals in 2 and no treatment because of severe myocardial infarction in 1. Cumulative crude and cause-specific 5-year survival rates for the 49 patients were 32.2% and 52.2%, respectively. Nineteen patients died of their disease; 10 of them of an uncontrolled neck lesion. From a comparison of the surgery alone group (28 cases) with a surgery plus irradiation group (21 cases) which consisted of preoperative irradiation in 2 and postoperative in 19, addition of irradiation may be effective for loco-regional control. Eight patients died of an uncontrolled neck lesion in the surgery alone group, while there were only 2 deaths in the postoperative irradiation group. Nevertheless there were no significant differences in survival: the cumulative crude and cause-specific 5-year survival rates in the surgery alone group were 34.4% and 56.2%, respectively, while those in the surgery plus irradiation group were 28.6% and 46.3%, respectively. It is obvious that the procedure of neck dissection influenced the loco-regional control. Excluding the recurrence-free patients who died of intercurrent diseases within 2 years, recurrence in the ipsilateral neck was found in 1 of 12 patients with radical neck dissection (RND), in 1 of 3 with modified radical neck dissection (MRND), in 2 of 15 with lateral neck dissection (lateral ND) and in 9 of 11 with regional neck dissection (regional ND). Recurrence is the contralateral neck were found in none of 2 with RND, of 3 with MRND and of 20 with lateral ND, but in 6 of 16 with regional ND. These results suggest that regional ND was insufficient to accomplish loco-regional control in those patients and that lateral ND or MRND or RND may be required bilaterally. Since 1986, all patients except 1 were treated by more extensive maneuvers than lateral ND bilaterally, so that loco-regional recurrence was found in only 1 case, in spite of the fact that the surgery alone group accounted for 73% (19/26). Cumulative crude and cause-specific 5-year survival rates for the patients prior to 1985 (23 cases) were 26.1% and 32.6%, respectively, while those for the patients since 1986 (26 cases) were 38.5% and 76.9%, respectively. There was no significant difference (p = 0.73) in cumulative crude 5-year survival rates between the 2 groups, but the difference in their cause-specific 5-year survival rates was statistically highly significant (p = 0.0032). It was concluded that lateral ND, MRND or RND should be required bilaterally for the patients with bilateral neck metastases and that addition of irradiation is not always indispensable for patients treated by curative neck dissection, such as lateral ND, MRND or RND.

A case of lung cancer with skip metastasis to supraclavicular lymph nodes is described. The patient had undergone radical resection for gastric cancer about nine years ago. For about one year, chemotherapy had been done by Tegafur (600 mg/day) after operation. Radical resection for lung cancer (p/d squamous cell carcinoma) was performed about seven years ago. Pathologically, mediastinal lymph node metastasis could not be detected. The needle aspiration biopsy of supraclavicular lymph node revealed metastasis. Then, radical neck lymph nodes dissection involving supraclavicular lymph nodes and radiation therapy were added. There has been no sign of recurrence so far.

A 52-year-old woman of diffuse malignant mesothelioma of the right pleura with metastasis to right supraclavicular lymph nodes underwent extended extrapleural right pneumonectomy and neck dissection. For this resection we selected the new approach: median sternotomy with hemi-collar incision. Through this approach systematical dissection of the cervical-mediastinal lymph nodes was performed together with resection of the right lung, parietal pleura, the pericardium and the diaphragm. As a result of this en bloc resection, she is alive without recurrence for one year after the operation.