Search

Pharyngolaryngectomy with total esophagectomy (PLTE) is often indicated for patients with synchronous head and neck cancer and thoracic esophageal cancer or those with head and neck cancer extending to the upper mediastinum. A long conduit is required for the reconstruction, and the blood flow at the tip of the conduit is not always sufficient. Thus, reconstructive surgery after PLTE remains challenging, and optimal reconstruction methods have not been elucidated to date. This analysis investigated 65 patients who underwent PLTE. The short-term outcomes among the procedures were compared to explore the optimal digestive reconstruction methods. We used a simple gastric conduit for 7 patients, a gastric conduit with microvascular anastomosis (MVA) for 10 patients, an elongated gastric conduit with an MVA for 20 patients, a gastric conduit combined with a free jejunum transfer (FJT) for 25 patients, and other procedures for 3 patients. Postoperatively, 17 (26.2%) of the patients experienced severe complications, classified as Clavien–Dindo grade 3b or higher, including graft failure for 3 patients (6.2%). Anastomotic leakage was found in six patients (9.2%), and all leakages occurred at the pharyngogastric anastomosis. The reoperation rate was 15.4% (n = 10), and three patients (4.6%) died of massive bleeding from major vessels. The patients who underwent simple gastric conduit more frequently had graft failure (P = 0.04), anastomotic leakage (P

Objectives Total pharyngolaryngectomy with free jejunal reconstruction is often performed in patients with hypopharyngeal carcinoma. However, postoperative speechlessness significantly decreases patient quality of life. We investigated whether Provox® insertion could preserve speech after total pharyngolaryngectomy with free jejunal reconstruction. Study Design Retrospective chart review. Methods A total of 130 cases of secondary Provox® insertions after total pharyngolaryngectomy with free jejunal reconstruction were analyzed. Communication outcomes were compared using the Head and Neck Cancer Understandability of Speech Subscale. Outcomes and complications associated with insertion site (jejunal insertion vs. esophageal insertion) and adjuvant irradiation therapy were also evaluated. Results Provox® insertion had favorable communication outcomes in 102 cases (78.4%). Neither the insertion site nor irradiation affected the communication outcome. Complications were observed in 20 cases (15.4%). Local infection was the most common complication. Free jejunal insertion, in which the resection range was enlarged, had a lower complication rate than did esophageal insertion, and its complication rate was unaffected by previous irradiation. For all patients, the hospitalization duration and duration of speechlessness were 13.4 days and 14.6 months, respectively. Patients receiving jejunal insertions had a significantly shorter hospitalization duration than did those receiving esophageal insertions. Unlike Provox®2, Provox®Vega significantly reduced the complication rate to zero. Conclusion For jejunal inserson of a Provox® prosthetic, a sufficient margin can be maintained during total pharyngolaryngectomy and irradiation can be performed, and satisfactory communication outcomes were observed. Provox® insertion after total pharyngolaryngectomy with free jejunal reconstruction should be considered the standard therapy for voice restoration. Level of Evidence 4.

Patients with advanced hypopharyngeal or cervical esophageal cancer have a comparatively high risk of also developing thoracic esophageal cancer. Pharyngolaryngectomy with total esophagectomy is highly invasive, and few reports about it exist. We examined the postoperative complications and respective countermeasures and prognoses of patients who underwent pharyngolaryngectomy with total esophagectomy.Case series with chart review.Department of Head and Neck Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Japan.We examined the postoperative complications and respective countermeasures and prognoses of 40 patients who underwent pharyngolaryngectomy with total esophagectomy in our hospital.Postoperative complications were observed in 23 patients (57.5%) and consisted of 8 groups: tracheal region necrosis in 5 patients; neck abscess formation/wound infection in 5; fistula in 4; tracheostomy suture leakage in 2; ileus in 2; lymphorrhea in 2; pulmonary complications in 2; and other complications, including hemothorax, tracheoinnominate artery fistula, temporary cardiac arrest due to intraoperative mediastinum operation, methicillin-resistant Staphylococcus aureus enteritis, and sepsis, in 1 patient each. A lethal complication-brachiocephalic vein hemorrhage due to tracheostomy suture leakage and hemorrhagic shock due to tracheoinnominate artery fistula-occurred in 2 (5%) patients. The crude 5-year survival rate was 48.6%.Serious postoperative complications were related to tracheostomaplasty. Although pharyngolaryngectomy with total esophagectomy is highly invasive, we believe that our outlined treatment method is the most appropriate for cases of advanced hypopharyngeal or cervical esophageal cancer that also requires concurrent surgery for esophageal cancer.

1980年1月から2010年12月までの30年間にがん研病院頭頸科で一次治療として手術を行った頭頸部原発粘膜悪性黒色腫40例の治療成績を検討した。男女比1：1，年齢は24～79歳（中央値62歳），観察期間は5～174ヶ月（中央値23ヶ月）であった。原発臓器は鼻副鼻腔：28例，口腔：9例，咽頭：3例。TNM分類（AJCC/UICC第7版）ではT3：8例，T4a：23例，T4b：9例でN0：36例，N1：4例，stage III：6例，stage IVA：25例，stage IVB：9例であった。Kaplan-Meier法による5年局所制御率，粗生存率，無再発生存率は70%，43%，29%であった。TNM分類は臨床的な予後とよく相関し，T4b，N1は予後不良であった。原発後方再発の制御が課題と考えられた。後発頸部リンパ節転移も高率にみとめ，頸部郭清が治療成績の維持に一定の効果を認めた。

当科における上顎癌の治療は1960年代後半から佐藤ら1）の三者併用療法をmodifiedした治療法を行い，その成績は1970年から1980年までの症例で5年粗生存率41.8%が得られていた2）。その後，さらなる成績向上を目指しCT，MRIによる画像診断を取り入れ，術前放射線療法の効果に応じた一塊切除を行なう方法に切り替えた。結果，1980年から2008年までの一塊切除136症例では5年粗生存率：62.1%，5年原発巣制御率75.2%が得られた。術前療法の効果では単独照射より動注照射の方が効果的であった。上顎近傍には眼球等の重要臓器があり顔面形態の保存を含めたQOLを考慮したさまざまな治療方法が示されているが，本稿では上顎扁平上皮癌に対する一塊切除法の成績について報告する。

頭頸部再建手術においては，切除側と再建側がお互いの要望するところを熟知し，協調性をもって計画的にチーム医療を実施することが大事である。切除側の注意点には，特に原発巣切除断端の良好な血流ならびに健常組織の保存，血管吻合の候補となる血管の愛護的操作と保存がある。一方再建側の注意点には，最適なvolumeを持ち血流の安定した皮弁の採取，術後機能を最大限に引き出し，かつ合併症を回避すべく工夫を施した再建が挙げられる。実際の手術が時間の点でも，人員配置の点でも継ぎ目なく有効に行われるためには，切除，再建の両者が要求する細かい部分までをよく熟知し，お互いが協調していく体制が必須である。

（目的）舌根の広範囲切除症例において，術後嚥下機能を評価することで最適な再建手術方法を検討する。（方法）癌研有明病院頭頸科で2007年1月から12月までに手術を行った口腔中咽頭癌症例のうち，舌根を半分以上切除しかつ喉頭を保存した症例5例を対象とした。再建については，まず残存舌根の能動的な動きを確認し，下端の粘膜を寄せて狭い咽頭腔を作成した後，ボリュームのある皮弁を咽頭腔に突出するように縫着した。全例，喉頭挙上術や輪状咽頭筋切断術は行っていない。これらの術後経過と嚥下機能を詳細に観察して検討した。（結果）5例全てにおいて経口摂取が可能であった。2例が術後早期に再発を生じていた。（結論）この方法によりある程度良好な嚥下機能が期待できると思われた。ただし予後の悪い症例もあるため術式選択や術後管理には十分注意すべきと思われた。

1999年から2003年までの5年間に癌研有明病院頭頸科で治療した下咽頭扁平上皮癌295例を検討し，治療成績の現状と，当科で行っているQOL向上の工夫について紹介した。295例中，根治治療を行ったのは245例（83%）であり，5年死因特異的生存率はStage I：100% II：88.8% III：80.8% IVa：53.8% IVb：28.6%であった。Stage IIIまでは満足いく結果であったが，全症例の67%を占めるStage IVの予後が不良であり，主な非制御部位は遠隔転移38%と頸部25%であった。予後向上のために当科では術後治療として病理学転移が4個以上の症例は術後放射線治療と化学療法（CDDP，5-FUもしくはTS-1）を中心として行っている。QOL向上の工夫は，喉頭摘出後の音声再建としてボイスプロステーシス（PROBOX2®）を用いた二期的シャント形成を積極的に行い，良好な結果を得ている。

Although in recent years there have been a tendency to choose partial hypopharyngectomy with laryngeal preservation in some cases of early stage hypopharyngeal cancer, the standard operation for advanced stage is still considered to consist primarily of total pharyngolaryngectomy. In this article, we report a case of an advanced T3 hypopharyngeal cancer with laryngeal preservation. The field of resection ranged from most of the piriform sinus to the epiglottis, aryepiglottic fold, paraglottic space, false vocal cord, and a part of the arytenoids. Although the resected area encompassed such a large area as described above, we succeeded in the reconstruction with several devices and attained good swallowing function by making the bulky rectus abdominal myocutaneous flap over-hang the supraglottic space and occupying the piriform sinus of the affected side with it. In conclusion, we believe that there is a possibility to perform partial hypopharyngectomy with laryngeal preservation even in T3 cases when movement of bilateral arytenoids and vocal cords are both intact.

1985年から1999年までに当科で根治治療を行った上歯肉，硬口蓋原発扁平上皮癌51例を対象として原発巣制御の治療成績を検討した。この時期における全体の原発巣制御率は70.6%であったが，治療法別では，手術のみ73.3%，根治照射71.4%，術前照射＋手術68%，T分類別ではT1：85.7%，T2：60%，T3：77.8%，T4：80%，術式別では上顎部切69.2%，上顎全摘80%であった。腫瘍の存在部位と原発巣制御の関係をみてみると，口腔前方に腫瘍が存在する場合，制御は良好であったが，後側方や正中に存在する場合で制御が不良であり，再発部位として側頭下窩深部や翼口蓋窩への再発が比較的多く認められた。このような例では救済手術が不可能で，直接的な死因となることが多いため，手術手技上，後方側方への深い浸潤がある例では，できるだけ良好な視野が得られるようなアプローチを充分計画することが大切と思われた。

頸動脈を含む周囲軟部組織に浸潤する頭頸部悪性腫瘍に対し, 局所制御の機会を得るため, 頸動脈を含む拡大合併切除が試みられてきた。当科で29年間に実施した血行再建, 非再建例を含む頸動脈切除症例を対象として, 頸動脈切除の合併症および頸動脈切除を含む頭頸部癌摘除術の術後成績について, 回顧的研究を行った。1984年以前は, 頸動脈切除例は全例結紮を行っていた。1996年以降は, 可及的に頸動脈の血行再建を行うこととしている。62例が調査可能であった。頸動脈切除後, 35例が結紮され, 27例が再建された。脳梗塞は13例に発症した。頭頸部扁平上皮癌症例34例を検討した結果, 50%疾患特異的生存期間は12ヶ月であった。5年無病生存率は13%であった。局所再発率は39%であった。手術治療をしない場合の病状の経過とのバランスを十分に考慮して手術適応を決めるべきである。

低侵襲な治療が望まれる近年の流れの中で, 当科の手術治療における工夫や注意点を挙げた。また今後の低侵襲手術の適応を考えるために, 遊離皮弁再建症例の合併症率や, 切除や再建を縮小せざるを得なかった高齢者の手術治療結果を検討した。その結果当科での2001年12月までの遊離皮弁再建症例全1,843例中, 全体の合併症率は24.3%, さらにその中で皮弁の全壊死率は2.7%であった。また80歳以上の高齢者で手術治療を中心に行ったものは85例あり, その中で遊離皮弁再建症例は15例あったが全例皮弁は生着した。高齢者は術後に重篤な合併症を起こす危険性があるが, 必要以上に再建手術を縮小すると創部の合併症や機能低下をきたすこともあることが示唆された。

Reconstruction of the tonsillar fossa and soft palate is sometimes troublesome, because of postoperative deglutition and speech disorder. In this study, we reviewed 84 patients who underwent reconstruction surgery of this area at our hospital during the period from 1977 to 1995. As a result, (1) wide resection causes poor postoperative quality, (2) patients after 1990 shows better function of eating and speaking than patients before 1990, (3) free flap reconstruction has more benefit than pedicled flap because trimming of the free flap is quite easy and it can fit any defect of the lesion. One of the most important things during surgery are not to injure the function of nasophayngeal closure and tongue mobility. In these couple of years, we routinely use rectus abdominis M - C flap after wide resection of the oropharyngeal cancer.

Paragangliomas are highly vascular tumors that arise from chief cells in extra-adrenal paraganglia of the autonomic nervous system. Vagal paragangliomas occur along the vagal nerve, usually located in the rostral portion of the vagus nerve in the vicinity of the gangliom nodosum. Actively functional vagal paragangliomas are rare. We report a patient with functioning vagal paraganglioma located in the infrahyoid carotid sheath. The patient had no history of hypertension and catecholamines were not measured before surgery. The findings of diagnostic imaging workup, including computed tomography, ultrasonography and magnetic resonance, were suggestive of paraganglioma. The blood pressure and pulse rates increased sharply intraoperatively during tumor manipulation, together with spikes in noradrenaline and dopamine. The tumor was removed with successful preservation of the vagus nerve trunk. The blood catecholamine levels returned to normal immediately after surgery. Head and neck surgeons should be aware of occult functioning paragangliomas and patients with such tumors should undergo full hormonal assessment.

For T2 tumors, surgery was indicated if functional preservation was possible. For T3/T4 tumors, the rate of primary disease control was not high and surgery frequently involved total laryngectomy. Points that surgeons must heed when performing such surgery were delineated.Because tumors originating from the base of the tongue are rare, few large-scale studies of such tumors have been performed. We reviewed treatments and outcomes at our department to establish effective future therapeutic plans.From 1971 to 2000, 84 patients with previously untreated and resectable squamous cell carcinoma of the base of the tongue were treated at the Head and Neck Department of the Cancer Institute Hospital, Tokyo. Treatment selection and results were investigated.The main treatment options were radiotherapy for primary lesionsor = T2 and surgery for primary lesionsor = T3. Overall disease-specific 5-year cumulative survival rate was 59.8%, but there was no significant difference in survival rate at each stage between the two treatments. Among patients who died of the primary disease, the area that was most difficult to control was the superior margin of the lateral wall of the oropharynx (n=7). The incidence of contralateral or retropharyngeal lymph node metastasis was low if tumors neither crossed the midline nor infiltrated the lateral wall. While total laryngectomy was performed on 48 patients, the larynx was operatively preserved in 5 T3 patients and one T4 patient.

Only 16 cases of bilateral chylothorax following neck dissection have been reported within 10 decades. In this paper, three cases of bilateral chylothorax which developed after neck dissection are reported. In all cases, conservative treatment resulted in resolution of the condition. Diagnosis may be delayed in those who are on total parenteral nutrition, and therefore particular attention should be paid to those patients. It may be difficult to treat cases of chylothorax that develop following neck dissection performed after radiotherapy.

We treated 9 patients with squamous cell carcinoma of the posterior oropharyngeal wall at the Cancer Institute Hospital, Tokyo. All were men averaging 64.1 years of age. One patient each was stage I, stage II or stage III, and 6 were stage IV. Cervical lymph node metastasis was seen in 6 at initial diagnosis. Retropharyngeal lymph nodes were involved in 4, while 5 had second primary cancer such as esophageal, gastric, head and neck cancer. Radical radiotherapy was done for 3 and surgery as initial treatment in 6. Five-year local control was 50% and 5-year disease-free survival was 22%. Total laryngectomy was done for 4 patients. Six died of oropharyngeal cancer and 1 of second primary cancer. Cancer of posterior pharyngeal wall is relatively rare and the prognosis is considered poorer than other types of oropharyngeal cancer for necessitating study to determine which modality may improve treatment results.