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A male patient in his 70s who had undergone a regular upper gastrointestinal endoscopy noted a flat, erythematous area on the right soft palate of the oropharynx 9 months after his treatment of oropharyngeal cancer. Six months after noticing the lesion, endoscopy revealed that the lesion had rapidly developed into a thick, erythematous, bump. Endoscopic submucosal dissection was performed. Pathological analysis of the resected tissue found a squamous cell carcinoma with a thickness of 1400 μm invading the subepithelial layer. There are few reports on the growth speed of pharyngeal cancer and it remains unclear. In some cases, the growth of the pharyngeal cancer may be rapid, and it is important to follow up the patient in a short period of time., (© 2023. Japanese Society of Gastroenterology.)

Over the past 20 years, the therapeutic concepts for the treatment of head and neck cancer have evolved and non-surgical treatment strategies have gained in importance. However, despite improved organ preservation protocols and primary chemoradiation, tumor recurrence is still frequent. Under these conditions, salvage surgery if often the only remaining curative treatment option. Over the past 30 years, advancements in plastic-reconstructive surgery have broadened the surgical spectrum in the head and neck area, offering new treatment options for salvage surgery in recurrent cancer of the pharynx and larynx. Survival after salvage surgery mainly depends on the primary treatment modality as well as the localization and tumor stage at the time of initial diagnosis and local recurrence. For the reconstruction of defects after salvage surgery, pedicled flaps and microvascular free flaps may be utilized. The most frequently used flaps in these situations are the pectoralis major island- or the myocutaneous latissimus dorsi island flap. The radial forearm and the ALT-flap are potentially applicable free flaps. With the use of these flaps, vital tissue is transferred into the previously irradiated area, hereby allowing for reconstruction and functional preservation of the resected area and preventing complications such as fistulas. The expected morbidity and the likelihood of surgical success must be assessed thoroughly in every individual case prior to performing salvage surgery. This review aims to support decision making in these situations., (© Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: In parapharyngeal space dissection, significant complications such as dysphagia and carotid artery rupture have been reported. In order to resect tumours safely in narrow parapharyngeal space, we propose indocyanine green (ICG) florescence image for navigation surgery., Objective: To evaluate the usefulness of ICG fluorescent image-guided surgery for parapharyngeal space tumours., Methods: 0.5 mg/kg of ICG was injected via the cephalic vein. Observation of the fluorescent image was performed with HEMS (HyperEye Medical System) at 10-30 min after injection. At first, the position of the tumour was marked over pharyngeal mucosa according to ICG fluorescence imaging with HEMS. We also confirmed submucosal tumours hidden under fascia using HEMS imaging again and resected them., Results: All tumours displayed bright fluorescence emissions which clearly contrasted with the normal structures. Even with the submucosal tumour covered with and obscured by fasciae, we could observe the tumour clearly under HEMS imaging. Tumours behind the carotid artery and lower cranial nerves also were displayed bright fluorescence emissions and were clearly detected. As a result, we could completely remove the tumour safely and noninvasively to preserve pharyngeal functions., Conclusion: ICG fluorescence imaging is effective for the detection and resection of the parapharyngeal space tumours with preserving functions., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Recent advances now permit resection of many pharyngeal tumors through the open mouth, an approach that can greatly reduce the morbidity of surgical exposure. These transoral techniques are being rapidly adopted by the surgical community and hold considerable promise. On November 6-7, 2011, the National Cancer Institute sponsored a Clinical Trials Planning Meeting to address how to further investigate the use of transoral surgery, both in the good prognosis human papillomavirus (HPV)-initiated oropharyngeal cancers, and in those with HPV-unrelated disease. The proceedings of this meeting are summarized., (Copyright © 2012 Wiley Periodicals, Inc.)

Purpose: To prospectively analyze patterns of failure in patients with head-and-neck squamous cell carcinoma treated with definitive high-precision radiotherapy with a focus on location of failure relative to target volume coverage., Methods and Materials: Sixty patients treated with three-dimensional conformal radiotherapy or intensity-modulated radiation therapy were included. Locoregional failure volume was defined on the planning data set at relapse, and dose received was analyzed by use of dose-volume histograms., Results: Thirteen patients were deemed to have had locoregional failures, of which two did not have any viable tumor on salvage neck dissection, leaving eleven patients with proven persistent or recurrent locoregional disease. Of these, 9 patients had in-field failure, 1 marginal failure, and 1 both in-field and marginal failures. Overall, only 2 of 11 patients (18%) with relapse had any marginal failure. Of the 20 sites of locoregional failure, 15 (75%) were in-field and 5 (25%) marginal. Distant metastases were detected in 3 patients, whereas a second new primary developed in 3 others. With a median follow-up of 26 months (interquartile range, 18-31 months) for surviving patients, the 3-year local control, locoregional control, disease-free survival, and overall survival rates were 75.3%, 74%, 67.2%, and 60.5%, respectively., Conclusions: Locoregional relapse remains the predominant pattern of failure in head-and-neck squamous cell carcinoma treated with high-precision definitive radiotherapy with the majority of failures occurring "in-field" within the high-dose volume. Marginal failures can occur, particularly in the vicinity of the spared parotid gland. The therapeutic index of high-precision conformal radiotherapy is largely dependent on adequate selection and delineation of target volumes and organs at risk., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Unresectable carcinomas of the oropharynx and hypopharynx still have a poor long-term prognosis. Following a previous phase II study, this phase III multicenter trial was conducted between November 1997 and March 2002., Methods: Nontreated, strictly unresectable cases were eligible. Twice-daily radiation: two fractions of 1.2 Gy/day, 5 days per week, with no split (D1-->D46). Total tumor doses: 80.4 Gy/46 day (oropharynx), 75.6 Gy/44 day (hypopharynx). Chemotherapy (arm B): Cisplatin 100 mg/m2 (D1, D22, D43); 5FU, continuous infusion (D1-->D5), 750 mg/m2/day cycle 1; 430 mg/m2/day cycles 2 and 3., Results: A total of 163 evaluable patients. Grade 3-4 acute mucositis 82.6% arm B/69.5% arm A (NS); Grade 3-4 neutropenia 33.3% arm B/2.4% arm A (p < 0.05). Enteral nutrition through gastrostomy tube was more frequent in arm B before treatment and at 6 months (p < 0.01). At 24 months, overall survival (OS), disease-free survival (DFS), and specific survival (SS) were significantly better in arm B. OS: 37.8% arm B vs. 20.1% arm A (p = 0.038); DFS: 48.2% vs. 25.2% (p = 0.002); SS: 44.5% vs. 30.2% (p = 0.021). No significant difference between the two arms in the amount of side effects at 1 and 2 years., Conclusion: For these unresectable cases, chemoradiation provides better outcome than radiation alone, even with an "aggressive" dose-intensity radiotherapy schedule.

Objective: To compare the long-term, health-related quality-of-life outcomes in patients with advanced head and neck cancer (HNC) treated with surgery and postoperative radiation therapy (SRT) or concurrent chemotherapy and radiation therapy (CRT)., Design: Matched-pair study comparing patients with advanced HNC treated with SRT or CRT at least 12 months after treatment. Patients completed 2 validated surveys addressing HNC-specific outcomes and depressive symptoms and provided information on employment and tobacco and alcohol use. Results for the 2 groups were compared using paired-sample t test and chi2 analysis., Setting: University-based study., Patients: Patients with stage III or IV squamous cell carcinoma of the oropharynx, hypopharynx, and larynx who underwent SRT or received CRT., Main Outcome Measures: Head and neck cancer-specific health-related quality of life from the Head and Neck Cancer Inventory and level of depressive symptoms from the Beck Depression Inventory., Results: The matching process resulted in 27 patients in each treatment group. The HNC-specific domain scores (with higher scores representing better outcomes) for CRT vs SRT were eating, 37.8 vs 40.8 (P = .69); speech, 65.1 vs 56.0 (P = .23); aesthetics, 80.3 vs 69.2 (P = .14); and social disruption, 69.7 vs 70.6 (P = .90). Overall health-related quality of life was 64.0 with SRT and 55.0 with CRT (P = .142). For the Beck Depression Inventory (with higher scores representing worse outcomes), patients who underwent SRT had a mean score of 9.6 compared with 11.6 for patients who received CRT (P = .42)., Conclusion: As nonsurgical means of treating HNC have become more aggressive and surgical techniques have become more focused on function preservation and rehabilitation, the overall health-related quality of life resulting from these different approaches is similar.

Purpose: To determine whether, in the postoperative setting, accelerated fractionation (AF) radiotherapy (RT) yields a superior locoregional control rate compared with conventional fractionation (CF) RT in locally advanced squamous cell carcinomas of the oral cavity, oropharynx, larynx, or hypopharynx., Methods and Materials: Patients from four institutions with one or more high-risk features (pT4, positive resection margins, pN >1, perineural/lymphovascular invasion, extracapsular extension, subglottic extension) after surgery were randomly assigned to either RT with one daily session of 2 Gy up to 60 Gy in 6 weeks or AF. Accelerated fractionation consisted of a "biphasic concomitant boost" schedule, with the boost delivered during the first and last weeks of treatment, to deliver 64 Gy in 5 weeks. Informed consent was obtained. The primary endpoint of the study was locoregional control. Analysis was on an intention-to-treat basis., Results: From March 1994 to August 2000, 226 patients were randomized. At a median follow-up of 30.6 months (range, 0-110 months), 2-year locoregional control estimates were 80% +/- 4% for CF and 78% +/- 5% for AF (p = 0.52), and 2-year overall survival estimates were 67% +/- 5% for CF and 64% +/- 5% for AF (p = 0.84). The lack of difference in outcome between the two treatment arms was confirmed by multivariate analysis. However, interaction analysis with median values as cut-offs showed a trend for improved locoregional control for those patients who had a delay in starting RT and who were treated with AF compared with those with a similar delay but who were treated with CF (hazard ratio = 0.5, 95% confidence interval 0.2-1.1). Fifty percent of patients treated with AF developed confluent mucositis, compared with only 27% of those treated with CF (p = 0.006). However, mucositis duration was not different between arms. Although preliminary, actuarial Grade 3+ late toxicity estimates at 2 years were 18% +/- 4% and 27% +/- 6% for CF and AF, respectively (p = 0.10)., Conclusion: Accelerated fractionation does not seem to be worthwhile for squamous cell carcinoma of the head and neck after resection; however, AF might be an option for patients who delay starting RT.

Surgery of locoregional failures is mainly represented by salvage surgery after radiotherapy. Due to progress of radiotherapy, especially modification of fractionation and association with chemotherapy, the problem of salvage surgery is nowadays emphasized. Despite the reduction of postoperative mortality and morbidity by the use of myocutaneous flaps the complications are still frequent and the rehabilitation long and difficult. Oncologic results are disappointing too, especially in salvage surgery for oropharyngeal and hypopharyngeal tumors with less than a half of patients being candidates for salvage surgery and 5 year survival rates inferior to 30% in these patients. Laryngeal tumors are more favorable for salvage surgery but in the majority of the cases recurrences after radiotherapy require a total laryngectomy. The poor postoperative, functional and oncologic results after salvage surgery, especially in pharyngeal tumors must be taken into account for the decision of primary treatment. Regarding the important locoregional aggressivity of squamous cell carcinomas of the upper aerodigestive tract, these results must be kept in mind when preservation protocols are in question.

Unresectable forms of HNSCC relapses occurring in a previously irradiated area are relatively common and may be difficult to manage from a therapeutic point of view. Full dose re-irradiation with concomitant chemotherapy constitutes an alternative to palliative chemotherapy. Indeed, the feasibility of this approach has been shown, and may be associated with a curative potential in a relatively low proportion of these relapses.

Objective: To evaluate the results of an induction chemotherapy protocol with Vinorelbine, UFT and Cisplatin (UFTVP)., Methods: 93 patients with laryngo-pharyngeal squamous cell carcinoma in stage III or IV were prospectively entered into a protocol to receive four cycles of UFTVP. Responders followed definitive radiation therapy. Nonresponders underwent conventional surgery with postoperative radiation., Results: Following chemotherapy nodal response (complete in 28% and partial in 33%) was less than that the primary site (complete in 60% and partial in 30%), p = 0.002. With a median follow-up of 62 months, the Kaplan-Meier 5-year survival was 45%. Successful larynx preservation was achieved in 50% of patients with laryngeal cancer and in 29% of patients with hypopharyngeal cancer. Lymph node metastases and pharyngeal localization were found to be significant negative factors with regards to survival., Conclusions: UFTVP is an active regime of chemotherapy in advanced squamous cell carcinoma of the pharynx and larynx. Results differ according to the localization, having significantly better rates of survival and organ preservation in the laryngeal cancers that in those of the pharynx.

The choices for practical monitoring of free jejunal transfer have been quite limited because of its own characteristics, such as buried form, lack of skin surface, and the structure of a hollow viscous tract. Physiologically, it is known that tissue hypoxia caused by compromised perfusion leads to an increase of partial pressure of carbon dioxide (PCO2). Because of its physiological properties, the diffusion of carbon dioxide is always equilibrated between the mucosa of a hollow viscous organ and its lumen. The intramucosal PCO2 (PiCO2) of the gastrointestinal tract can therefore be determined indirectly from the intraluminal PCO2, which is measured with the aid of the tonometer catheter. To develop an optimal monitoring method for free jejunal transfer, the authors proposed the application of PiCO2 measurement by a modified use of a tonometer catheter. Since May of 1999, the authors performed postoperative PiCO2 monitoring on 20 cases of reconstructed pharyngoesophageal tracts in 18 patients who underwent radical tumor resection and one-stage reconstruction at the Shizuoka Red Cross Hospital. All 20 cases were safely monitored by PiCO2 measurement without any complications associated with the use of the tonometer catheter. In the 17 cases that succeeded uneventfully, the mean values of PiCO2 were kept lower than 40 mmHg throughout the monitoring period. On the other hand, the other three cases (15 percent) needed reexploration due to development of vascular complications, which was alerted by an abrupt increase of PiCO2 in each case (229, 130, and 99.6 mmHg). Two of the patients were fortunately successfully treated by immediate reexploration, leading to a 95 percent overall success rate. No false-negative or false-positive cases were observed. The authors' experience suggests that PiCO2 measurement using a tonometer catheter can provide the surgeon with reliable information for evaluating the perfusion and viability of a free jejunal transfer. Simplified manipulation and the objectivity of the numerical data allow stable measurement of PiCO2 and prompt judgment of the adequacy of the perfusion, which could minimize the burden and anxiety of the surgeon, particularly in the early postoperative period.

Purpose: To study locoregional tumor control in postoperative radiotherapy (PRT) for head-and-neck cancer in relation to the position and duration of treatment gaps, duration of the interval surgery-radiotherapy, and to the other potentially prognostic variables., Methods and Materials: The retrospective study included 868 patients with cancer of the larynx, oral cavity, oropharynx, and hypopharynx treated in Gliwice between 1980 and 1997. Mean total radiation dose, dose per fraction, overall radiation treatment time (OTT), and the interval surgery-PRT were 62.8 Gy, 2.1 Gy, 45 days, and 63 days, respectively. No interruptions during PRT (except for weekend breaks) appeared in 30% of patients, whereas 19% had more than 5 days of gap. The actuarial locoregional recurrence-free survival (RFS) has been examined using multivariate Cox regression model, and the ultimate locoregional tumor control probability using a logistic model., Results: Increased duration of treatment gaps, positive resection margins, pathologically proven metastases to the neck nodes, and extralaryngeal site of cancer were significantly related to a decrease in RFS. The duration of time interval surgery-PRT appeared, by contrast, only borderline significant for RFS. The relative risk of locoregional recurrence was approximately the same for the gaps in days 1-21 as for the "late" gaps (days >21), except in a subgroup of patients with positive clinical margins. The logistic analysis revealed a significant time-related displacement of the dose-response curves for PRT. The detriment from the protraction of OTT appeared to be larger than the benefit from the equivalent shortening of OTT., Conclusions: Although the conclusions from this study must be regarded as only hypothesis-generating, we assume that a highly significant adverse influence of radiation treatment gaps on the rate of tumor control is consistent with rapid repopulation of cancer clonogenes during PRT. Lack of significant effect of the position of gaps on locoregional tumor control after radical surgery may suggest that a lag time for the onset of repopulation in PRT is short. A less likely explanation is that the total amount of regeneration during OTT is the same, regardless of the timing of the gap, even if all the repopulation occurred late. The magnitude of the detriment in tumor control from prolonged interval surgery-PRT indicates that repopulation of cancer cells between surgery and radiotherapy is not as fast as between the fractions of radiotherapy.

Purpose: To evaluate dose concepts in postoperative irradiation of carcinomas of the upper aerodigestive tract according to the radicality of resection., Patients and Methods: In a retrospective analysis, the charts of 257 patients with histologically-proven carcinoma of the upper aerodigestive tract (40 T1, 80 T2, 53 T3, 84 T4 tumors, with nodal involvement in 181 cases) were reviewed according to the radicality of resection and dose of irradiation administered. Sixty-four patients had tumor-free resection margins (> 3 mm), 66 patients had close resection margins (< 3 mm), and 101 patients had R1 resections, and 26 patients had R2 resections. A median dose of 56 Gy was applied to the primary tumor bed and the cervical lymphatics (2 Gy/fraction, 5 fractions/week). In cases of R1 or R2 resection, or of close margins (< 3 mm), the tumor bed or, respectively, tumor residuals were boosted with doses up to a median of 66 Gy. Locoregional tumor control and survival was investigated by uni- and multivariate analyses according to T-, N-stage, grade of resection, total dose of radiation, and presence or absence of extracapsular tumor spread and lymphangiosis carcinomatosa., Results: An overall 3- and 5-year survival rate of 60% and 45%, respectively, was achieved. Rates for freedom from locoregional recurrence were 77% and 72% at 3 and 5 years, respectively. The survival rates according to the grade of resection at 5 years were 67% for patients resected with tumor-free margins, 59% for patients resected with close margins, 26% for patients with R1 resection, and 27% for patients with R2 resection. Within a median follow-up period of 4.7 years for living patients, a total of 67 recurrences (26%) were observed (in 9% of patients resected with tumor-free margins, in 27% with close margins, in 37% of R1 resected, and in 19% of R2 resected patients). Freedom from locoregional recurrence at 3 years was achieved in 100% of the patients resected with tumor-free margins, in 92% of patients resected with close surgical margins, in 87% of R1 and 69% of R2 resected patients. In multivariate Cox-regression analysis, the variables grade of resection (p = 0.00031) and total dose of irradiation (p = 0.0046) were found as factors influencing locoregional control. Variables influencing survival according to multivariate analysis are T-stage (p = 0.0057), N-stage (p = 0.024), grade of resection (p = 0.000015), total dose of irradiation (p < 0. 000000). Extracapsular tumor spread and lymphangiosis carcinomatosa are factors of borderline significance (p = 0.055, p = 0.066)., Conclusion: In postoperative radiotherapy of head and neck carcinomas, doses adapted to the risk of locoregional recurrent disease should be applied. Patients with R1 and R2 resections should be treated with doses of more than 68 Gy (2 Gy/fraction, 5 fractions/week) (with close margins [< 3 mm] more than 66 Gy) to achieve an improvement in locoregional control and survival.

Background: Management of the suspected N0-neck (sonography and CT) in squamous cell carcinoma (SCC) of the head and neck is discussed controversially. The question arises whether the sentinel node (SN) concept as it is performed in different areas of clinical oncology is applicable to ear, nose, and throat medicine., Methods: Nine male patients with SCC were studied (4 oropharynx, 2 hypopharynx, and 3 larynx) in whom different lymph node status was diagnosed clinically (5 x N0, 2 x N1, 2 x N2c). After intraoperative scintillation probe detection, the histological examination of the SN with neck dissection (ND) specimen followed., Results: In 7 of 9 cases SN detection was successful. In 4 of 5 cases of clinical N0 status, SN, and ND specimens were free of tumor histologically, while in one patient radiolabel-identified SN showed tumor cells in histological examination. In 2 patients with clinical N1 neck, SN, and ND were histologically tumor-free in one patient and contained one single tumor metastasis located in the SN in the other patient. In 2 patients with clinically and histologically proven N2c neck, lymph nodes located in regions II and III showed metastasis including capsular rupture. In both cases no lymph node radioactivity was detectable during the operation., Conclusions: The results suggest that sentinel lymphonodectomy may be suited for ear, nose, and throat medicine. Before it is applied to clinical practice, further problems must be resolved. These include the short distance between the primary injection side and lymph nodes and the influence of intranodal tumor metastasis on the uptake of the radiolabeled tracer.

Sixteen cases of schneiderian-type mucosal papillomas arising in the nasopharynx and oropharynx are reported. The patients include 11 men and 5 women ranging in age from 45 to 79 years (median 62 years). In 12 patients, the papilloma was discovered as an incidental finding, and 2 patients complained of nasal airway obstruction. In the remaining 2 cases, information regarding the cause that led to discovery was unavailable. None of the patients had a prior or concurrent history of sinonasal (schneiderian) papillomas. Histologically, all of the tumors were identical to sinonasal inverted papillomas. Transnasal or transoral surgical excision was the treatment of choice. In 4 of the patients, recurrent tumor occurred within 6 months of initial resection, necessitating additional surgery. Extended follow-up information was available in 9 cases. Eight of the 9 patients are alive and have been free of disease over periods ranging from 15 to 201 months (median 114 months) from diagnosis. One patient was found to have a separate nasopharyngeal squamous cell carcinoma 14 months after the diagnosis of the schneiderian-type papilloma. This patient died secondary to the squamous cell carcinoma 30 months after his initial evaluation.

Background: Reestablishing good swallowing function after resection and reconstruction of head and neck tumors is very important for our patients' well-being. Today many different surgical concepts for reconstruction after tumor surgery are in common use. It is necessary to establish a good diagnostic procedure for postoperative assessment of the swallowing function. High-speed cineradiography at a minimum of 50 frames per second is well established for evaluating swallowing problems in head and neck patients., Methods: Thirty-six patients divided into three groups were examined using high speed cineradiography after surgical treatment of pharyngeal and oral cavity cancer. Group 1 (n = 12) included patients with a subtotal or total tongue resection and reconstruction with infrahyoid myofascial flap and jejunal flap; Group II (n = 8), patients with total resection of the oropharynx soft palate and velum and reconstruction with a free radial forearm flap; Group III (n = 15), patients with total laryngopharyngektomy and reconstruction with jejunal flap and siphon and with or without repair of the digastric muscle., Results: Group I: All patients with tongue reconstruction were able to swallow normally from the oral cavity into the pharynx. All patients had normal bolus propulsion because of a good tongue volume and tongue motility. There was only one case of aspiration after total glossectomy with the larynx left in place. All patients could swallow with the head and neck in a normal position. Group II: All patients with reconstruction of the soft palate and velum were able to initiate proper bolus propulsion without nasal regurgitation or rhinolalia aperta. Only one patients suffered from chronic aspiration after hemiresection of the oropharynx and hypopharynx. Group III: All patients with pharynx reconstruction had no problems with bolus transfer through the reconstructed pharynx. Aspiration into the reconstructed pharynx was a major problem for those patients without repair of the digastric muscle (5/8 = 63%). Better results were observed in the patients who underwent repair of the digastric muscle. There was only one case (13%) of aspiration., Conclusions: By using high-speed cineradiography it is possible to make a detailed description of the swallowing function after extensive surgical treatment of pharyngeal and oral cavity cancer. We think that high-speed cineradiography is a very sensitive diagnostic procedure capable of detecting all functional aspects of swallowing. High-speed cineradiography should be one of the standard diagnostic studies performed surgery of the oral cavity and pharynx.

Fifty-three patients who underwent laryngopharyngeal cancer surgery were examined with a sequential computer manometry system using 4-channel pressure probes. Swallowing coordination is largely independent of the oropharyngeal pressure thrust nor of the pharyngeal transit time and depends mainly on initiation of swallowing. The points of interest are the pharyngeal entrance and outlet. The topographic correlates are the base of the tongue and the upper esophageal sphincter. Resections of the base of the tongue decrease the volume available for pressure generation reducing the driving force of the tongue. Thus, reconstruction at the base of the tongue must provide more bulky-tissue coverage (i.e. myocutaneous flaps) in order to avoid cranial release of pressure and to bring about initiation of swallowing. Resections of the pharyngoesophageal segment cause circular defects that affect the sphincter, reducing hypopharyngeal suction. Thus, the resistance to bolus flow is generally increased, but can be compensated for by an increased driving force of the tongue. Additional pharyngeal and/or lingual resections increase the lumen discontinuity between the wide pharynx and the narrow esophagus, exceeding any compensatory possibilities. Plastic reconstructions therefore have to compensate for different lumina distally. In the region of the upper esophageal sphincter, softer and smoother tissue coverage is warranted in order to facilitate bolus transfer or passive bolus flow if necessary. For that purpose we modified the myofascial pectoralis-major-flap. It covers defects where a soft lining is required. The resistance to bolus flow is reduced, alleviating the need to increase the driving force of the tongue which would otherwise increase to compensate for the defect.

Standard procedures for temporary mandibulotomy are medial or the lateral osteotomy. Median mandibulotomy is associated with destruction of anatomical structures in the floor of the mouth and with lateral osteotomy no preservation of the nervus alveolaris inferior is possible. Therefore, a modification of mandibulotomy is described with wide-field exposure, minimal functional defects and reduction of osteotomy-related complications. The first osteotomy is carried out vertically before the foramen mentale on the buccal compacta of the mandible. A second vertical osteotomy is placed on the lingual compacta posterior to the musculus myohyoideus. Horizontal osteotomies on the alveolar ridge and the basal ridge of the mandible are connected with the vertical osteotomies. Using a chisel, the lingual and the buccal part of the mandible are split sagittally with preservation of the nervus alveolaris inferior located in the buccal fragment of the mandible. The two parts of the mandible are divided to provide access to the oropharynx. Surgical approach to the fossa pterygopalatina and the parapharyngeal space is reached with dissection of the mucosa along the ascending mandible, subluxation in the mandibular joint and reflection of the mandible cranially and posteriorly. The wide access offers a lot of advantages especially in combination with a microvascular flap reconstruction. Fixation of the mandible is carried out with two titanium miniplates at the anterior vertical osteotomy. The wide areas of the split bone marrow, resulting from sagittal splitting, achieved an exact adaptation of the mandibular parts and an easy and sure fixation via miniplates. Therefore, post-operative radiation therapy can be started two weeks after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective review of 57 patients, who had received frozen-section diagnoses, was performed both to ascertain the accuracy of diagnosis and to evaluate its usefulness in assessing tumor surgery. Except for 2 cases, each with a parotid gland tumor, the frozen-section diagnoses were consistent with the final diagnoses using permanent paraffin sections. Fifteen cases with either T1 or T2 squamous cell carcinoma of the oral cavity and 2 cases with malignant salivary gland tumor, showing tumor-free surgical margins by frozen-section examination, were followed. A local recurrence of the carcinoma was observed in 1 case during the follow-up period. Prior to neck dissection, lymph node metastases were examined using frozen sections. Ten cases, which were diagnosed as negative for metastasis, showed no subsequent development of cervical node metastasis.

Osteoradionecrosis of the mandible following primary or adjuvant radiotherapy of progressive oral and oropharyngeal malignancy is, for the affected patient, a feared and sometimes vitally threatening complication. In the authors' experience, the incidence rate of osteoradionecrosis between 1973 and 1987 was 4.1%, which makes the necessity of the prophylactic efforts described in the present study evident.

A retrospective review of 333 previously untreated patients from 1965 to 1986, with primary squamous cell carcinoma of the oropharynx or hypopharynx, was undertaken to ascertain the prevalence of neck node metastases by neck level. The 333 patients underwent 344 classical radical neck dissections. Patients were grouped by clinical neck status at the time of neck dissection: elective dissection in the N0 neck (N = 71), and immediate therapeutic dissection in the N+ neck (N = 259). Detailed analysis was performed for each group based on the specific primary site. This revealed a predominance of neck node metastases in levels II, III, and IV for both oropharyngeal and hypopharyngeal primaries. Isolated "skip" metastases outside of levels II, III, or IV occurred in only 1 patient (0.3%). Otherwise, level I or V involvement was always associated with nodal metastases at other levels (ie, N2 disease). These data support the trend toward selective limited neck dissection (anterior modified) in N0 patients. Furthermore, they provide the foundation for planning of future prospective trials to assess the efficacy of modifications in the extent of neck dissection for carcinomas of the oropharynx or hypopharynx.

Reconstruction of defects after tumor ablation has been accomplished by a variety of different techniques. The platysma musculocutaneous flap for reconstruction is outlined and the surgical technique described. It provides 8 x 10 cm of flap coverage. The donor site is closed primarily without cosmetic defect. Forty of 48 patients on whom this flap was used healed without complication.

Analysis of 113 typical (within the same anatomical area) surgeries has helped define the indications for such interventions in stage-III squamous cell carcinoma, of the moving part of the tongue and cheek first of all. Clinical indications are dissemination of the tumor within one anatomical area, exophytic or ulcerous form of its growth, a higher than 50 percent realization of the effect of previous conservative therapy, no regional metastases; morphologic indications include the presence of a clear-cut borderline, manifest lymphoplasmacytic reaction of the adjacent tissues.

The authors present conservative transmandibular lateral pharyngectomy (CTLP) as a substitute for BPTM operations in cancers of the tonsillar region. The mandible is sectioned along the symphyses and the oropharynx is widely exposed through an incision of the pelvilingual sulcus. The authors propose a primary operability criterion that allows to salvage the mandibular angle, which is usually sacrificed. This can be assessed peroperatively by testing the possibility to cleave and spread inwardly the pharyngomandibular region following detachment of the pterygoid muscles. The functional and cosmetic benefits of this method are obvious and should commend its more frequent utilization.

In this article, the multidisciplinary approach to the management of carcinomas of the tongue and oropharynx has been emphasized. The decision for the primary mode of therapy will depend on the multiple factors discussed herein. However, a surgeon skilled in the management of head and neck tumors, including major reconstructive techniques, should lead the team. Most patients with head and neck carcinoma present with lesions that are relatively far advanced, and the combination of surgical excision and radiation therapy has proved to be the best method of controlling this disease. Even when cure is unlikely, the palliation of the patient by proper resection and immediate reconstruction, followed by adequate radiation therapy, can provide significant palliation and, it is hoped, avoid the horribly painful and agonizing death that ensues from massive local recurrence in the head and neck. Modern reconstructive techniques allow for reasonable aesthetic and functional restoration, which can be performed in a single stage at the time of the ablation of the tumor. Healing with these well-vascularized flaps is predictable and allows the patient to get to the radiation therapist within the early postoperative period. A full tumoricidal dose of radiation therapy can then be instituted with the expectation that the reconstruction with the vascularized tissue will withstand the irradiation well. This avoids the increased complication rates associated with operating in irradiated fields and gives the radiation therapist a better chance for effective therapy with a markedly reduced tumor load. These tumors remain one of the most obstinate problems that surgeons face today. However, an aggressive approach to control local disease remains the best therapy and offers the patient the only chance for cure. These are difficult patients to manage from many aspects. I believe that the statement made by Dr. Charles Mayo in 1905 remains timely: "A large part of abdominal work is recreational as compared with the work of what might be called the heavy surgery of the neck."

This historically controlled study evaluates radiation therapy in 119 patients--with squamous cell carcinomas of the head and neck--who underwent surgery alone (SA) or surgery plus radiation (S + R). The primary tumor control and nodal control, in patients with negative surgical margins who had surgery alone (SA), were 63% in the oral cavity, 60% in the oropharynx, and 67% in the hypopharynx. The same rates for S + R group and negative surgical margins were 100%, 73%, and 100%. Combining the patients with negative and positive surgical margins, control of the tumor and nodal control were the same in the oral cavity for both treatment groups (41% for SA and 44% for S + R) and increased with the addition of radiation in the oropharynx (30% for SA to 65% for S + R) and hypopharynx (33% for SA to 86% for S + R), in spite of higher percentages of T3 and T4 tumor and positive lymph nodes in the S + R group. The lower control rate in patients who had surgery alone could be due (in part) to inadequate surgery at the primary site (42% local excision) and lack of neck dissection (35% for SA vs. 77% for S + R). Postoperative radiation therapy to the primary site and neck is shown to effectively reduce local recurrence in patients with oral cavity and oropharynx cancer, regardless of surgical margins.

A new technique of closure of the oral-oropharyngeal defects after tumour surgery in selected cases, using the masseter cross-over flap, has been described.

In our centre, the vast majority of patients with oropharyngeal tumours are treated by irradiation. Over a period of 10 years, between 1976 and 1986 we treated 305 patients with squamous carcinomas of the oropharynx. The mean age was 58.2 years. There were 24 women and 281 men. 59% of the patients had advanced tumours, classified as T3 or T4, 54% of the patients showed the presence of adenopathy at the first examination. All patients received radiation therapy. 69 patients had surgical treatment of the tumour or glands. 21 patients had implant therapy (most often combined with transcutaneous irradiation). 165 patients had induction chemotherapy. Local tumour control was obtained in 124 patients (41%), i.e. 82, 56, 31 and 4% for T1, T2, T3 and T4 respectively. The 5 years survival rate of the overall population was 28%. The principle causes of failure were local progression for T3 and T4 tumours and metastases and second cancers in patients with T1 or T2 tumours. The prognostic factors were gland involvement and general health. The site of the tumour, sex and histological type were not prognostic factors. Induction chemotherapy did not improve the results of treatment.

After resection of the ascending ramus of the mandible, the temporalis muscle is rendered functionless. It represents a viable and versatile bulk of tissue covered by stout fascia, which can be used in oral and oropharyngeal reconstruction after extensive excisional surgery. The surgical effort is reasonable, owing to the vicinity of the defect. The fascia, which resists the saliva, is left uncovered; epithelization is completed after 2 to 3 weeks. The cosmetic result is acceptable. Skin incisions are invisible because they are covered by hair; the flattening of the temporal fossa will be smoothed out by scarring after several months. The postoperative course was uneventful in 11 patients but for minor problems. The flap remained viable in all subjects. The temporalis muscle flap seems to be a valuable alternative among the techniques of oral and oropharyngeal reconstruction.

Thirty patients with Stages I, II and III squamous cell carcinoma of the oral cavity and oropharynx (6, 12 and 12 patients, respectively) were entered into a combined modality protocol using preoperative chemotherapy, followed by resection with or without radical neck dissection and radiotherapy. None of the patients received prior treatment and all had good performance status. Primary sites included alveolar ridge (in nine patients), buccal mucosa (in eight), tongue (in six), floor of mouth (in five), and hard palate and tonsillar fossa in one each. Chemotherapy was given as a neoadjuvant debulking procedure using two courses of the Price-Hill regimen (5FU, methotrexate with citrovorum rescue, vincristine, bleomycin, and hydrocortisone) followed in 10 to 14 days by local resection for Stage I-II patients and radical neck dissection plus radiotherapy for Stage III patients. Response to chemotherapy alone was observed in 70% (21 of 30), with 17% (5 of 30) complete responders. Responses were seen in 100% of Stage I, 75% of Stage II, and 50% of Stage III patients. Age greater than 80 years was a poor prognostic indicator. Both men and women responded equally well. Of the 25 patients not entering CR with chemotherapy, a further 75% (11 of 15) did so after local resection and 50% (5 of 10) after local resection, radical neck dissection, and radiotherapy. Overall salvage rate post chemotherapy was 64% (16 of 25). All five patients in CR with chemotherapy alone are alive at a median follow-up time of greater than or equal to 43 months; full survival data are discussed. Toxicity was minimal and did not affect change in treatment course in any patient. These results show that further investigations on the use of neoadjuvant chemotherapy in early-stage and locally advanced squamous cell carcinoma of the oral cavity and oropharynx are indicated.

Nasopharyngeal teratomas are rare neoplasms, often presenting as neonatal airway obstruction. A case is presented of a full-term neonate with a mass which filled the oropharynx, nasopharynx and the entire left nasal cavity and extended through the left nares. Airway obstruction necessitated orotracheal intubation immediately after delivery. Cerebrospinal fluid rhinorrhea was suggested and computerized tomography was initially interpreted as a nasoethmoidal encephalocele. After a craniotomy failed to reveal a dural defect, the mass was completely removed via the nose and nasopharynx. The infant was extubated and had an uneventful recovery. This case illustrates the problem of confusing a teratoma for an encephalocele and demonstrates a pitfall in the interpretation of computerized tomography of these lesions.

A musculocutaneous flap from pectoralis major was used for reconstruction after widespread excision for cancer of the oral cavity and oropharynx in 54 cases, the method of choice being transposition as islets. Necrosis in 6 cases (11%), was partial in 5 patients and was limited to the skin layer only. The advantages of the musculocutaneous flap from pectoralis major when compared with other reconstructive procedures, particularly deltopectoral and temporofrontal flaps, are discussed.

We have reviewed our experience with 120 selected patients who had pharyngeal tumors resected through a median mandibulotomy approach with paralingual extension (mandibular swing). Clinical findings, technique, and complications are discussed. Results were gratifying in terms of salvage, patient appearance, and function. We believe that this surgical approach, in combination with postoperative radiotherapy when appropriate, offers an attractive alternative to high dose radiotherapy alone in patients with oropharyngeal carcinoma.

Reliability has become a foremost requirement in pharyngoesophageal reconstruction because of the disastrous consequences after a failure. Our institution has achieved a 97 percent success rate using the free bowel autograft. We believe that this represents a significant accomplishment and designates the free bowel autograft as the reconstructive method of choice after pharyngoesophageal resection.

Squamous cell carcinoma of the oral cavity and oropharynx can invade the mandible requiring an "en bloc" or composite resection. With this procedure alone, reported local control rates for advanced stage tumors have been suboptimal suggesting the need for adjuvant therapy. The treatment records of 35 patients were reviewed who were treated with composite resection alone, composite resection plus radiotherapy, or composite resection as a salvage procedure for a primary treatment failure. Combined irradiation and composite resection resulted in a higher local control than patients receiving composite resection alone (72% vs. 43%). There was no difference in complication rates between these two treatment groups. Composite resection as a salvage procedure resulted in local control in 38% of patients through this was associated with a 64% rate of complications. This data and a review of the literature suggest that tumors of the oral cavity and oropharynx with extension to the mandible requiring composite resection probably represent a category of tumors with a high risk of local recurrence and may benefit from adjuvant irradiation.

Recent progress in myocutaneous and free flaps has facilitated the primary closure of various complex defects resulting from ablative surgery of head and neck cancers. The musculocutaneous flap (such as the pectoralis major flap or the latissimus dorsi flap) has in particular proved its greater versatility. The forearm free flap for intraoral defects can provide thin and pliable skin and has great potential in the reconstruction of oropharyngeal defects. Between November 1982 and August 1985, we achieved 74 free forearm flap transfers for patients with head and neck cancers. Herein we present several clinical applications of the free forearm flap and discuss its advantages and disadvantages, especially hand morbidity after flap elevation.

The authors report their experience in the management of a series of 52 patients treated in Nantes for repair of loss of substance in the bucco-pharyngeal cavity, using a free antebrachial flap. Its fundamental value is to provide a very fine, supple cutaneous sheet of large surface area, which is particularly adapted to bucco-pharyngeal cancer surgery by limiting as much as possible the anatomical and functional sequelae and thereby allowing much larger resections to be carried out. After a review of the anatomy, a study of the indications, precautions and results obtained in this series is presented.

1. Drinkers and cigarette smokers are at very high risk for the development of upper aerodigestive tract and lung squamous carcinomas. 2. The floor of the mouth, the ventrolateral tongue, and the soft palate are high-risk sites within the oral cavity and oropharynx. 3. Mucosal erythroplasia rather than leukoplakia is the earliest visual sign of oral and pharyngeal carcinomas. 4. Areas of mucosal abnormality, especially redness or inflammation in high-risk sites, that persist for more than 14 days without obvious etiology or resolution should be biopsied. 5. Asymptomatic, erythroplastic lesions should not be regarded merely as precancerous changes. The evidence indicates that these lesions in high-risk sites should be considered to be invasive carcinoma or at the very least carcinoma in situ, unless proven otherwise by biopsy. 6. Toluidine blue staining is a useful diagnostic adjunct, particularly as a method of ruling out false-negative clinical impressions. It may also be used as a screening rinse in high-risk patients to encompass the entire oral mucosa after a negative clinical examination and as a guide to improve biopsy yields. 7. If oral or pharyngeal cancer is identified, evaluations of the larynx, hypopharynx, esophagus, and lungs should be performed to rule out second primary cancers. Yearly aerodigestive surveillance should be continued after satisfactory treatment of the index cancer.

In collaboration with the Radiotherapeutic Hospital, 87 patients with squamous cell carcinomas of the oral cavity and the oropharynx were treated by combined pre-irradiation and surgical intervention at the University ORL Hospital of Cologne. The study was supposed to improve the five-year survival of patients suffering from advanced carcinomas of the head and neck area. The male and female patient's ratio was 4.5 to 1. Half of the patients had squamous cell carcinomas of the oropharynx, 21 patients had tumors of the floor of the mouth, and another 21 had tumors of the anterior two thirds of the tongue. The tumor and lymph node status was classified according to the UICC regulations (1979). In the pre-irradiation, 40 to 50 Gy were applied to the primary tumor and the regional lymph nodes. Surgery was executed generally four weeks after pre-irradiation. The tumor remission following to pre-irradiation was very good. 27% of the patients showed little or moderate post-operative disturbances in wound healing. An osteoradionecrosis was found in 4.6%. Almost 25% of the patients developed local recurrences. The cumulated five-year survival of all patients is 32%. In dependence on TNM stages, the three-year survival rates are as follows: stage I and II 80%, stage III 44%, and stage IV 40%.