Site of distant metastasis affects the prognosis with recurrent/metastatic head and neck squamous cell carcinoma patients treated with Nivolumab.

BACKGROUND: Nivolumab is approved for the treatment of recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC). However, the influence of the site of distant metastasis on the efficacy of immune checkpoint inhibitor in R/M HNSCC remains unclear. We investigated the prognosis of R/M HNSCC patients treated with nivolumab, focusing on the site of distant metastasis. METHODS: We reviewed the data of R/M HNSCC patients treated with nivolumab between April 2017 and June 2020 at Saitama Prefectural Cancer Center. The differences in the prognosis were evaluated according to the site of distant metastasis. RESULTS: Of the 41 patients enrolled, 26 (63.4%) had lung metastasis, 7 (17.1%) had bone metastasis, and 4 (9.8%) had liver metastasis. Ten patients (24.4%) had single-organ distant metastasis (lung metastasis in all cases). Univariate analysis identified lung metastasis alone (single-organ distant metastasis) was associated with a significantly better prognosis [HR0.37 (95% CI) 0.14-0.97 p = 0.04], while liver metastasis was associated with a significantly worse prognosis [HR3.86 (95% CI) 1.26-11.8 p = 0.02]. Multivariate analysis identified lung metastasis alone and liver metastasis as independent prognostic factors. While 7 patients (70%) with lung metastasis alone could be continued on nivolumab treatment or received subsequent chemotherapy, only 1 patient (25%) with liver metastasis received subsequent chemotherapy. CONCLUSION: The site of distant metastasis affects the prognosis of R/M HNSCC patients treated with nivolumab. Lung metastasis alone appears to be associated with a better prognosis, in that it allows easier transition to subsequent chemotherapy, while liver metastasis associates with a worse prognosis.

Analysis of various defects and reconstructive methods after invasive thyroid carcinoma resection.

OBJECTIVE: The thyroid gland adjoins the trachea, pharynx, esophagus, carotid artery and cervical skin. Most thyroid carcinomas have been treated at lower stages; however, in some cases the carcinomas have invaded the surrounding organs. After resecting invasive thyroid carcinomas, the defects vary depending on the invasion area and organs affected; subsequent reconstructive methods vary depending on the size of defect and its components. This study analysed the pattern of defects and the reconstructive methods used following invasive thyroid carcinoma resection. METHODS: From April 2011 to March 2021, 665 patients in Saitama Cancer Center (Saitama, Japan) were diagnosed with thyroid carcinoma and subsequently underwent thyroidectomies. In the 25 patients (3.8%), the thyroid carcinoma invaded surrounding organs and any reconstructive surgery-including end-to-end tracheal anastomosis and simple pharynx closure-was performed after thyroid carcinoma resection. The patients' records were retrospectively reviewed, and the defects and subsequent reconstructive methods were analysed. RESULTS: When our new classification system was applied to the defects, the number of cases for each type was totaled: Tr0: 1; Tr1a: 3; Tr2b: 5; Tr3a: 1; La-Tr3b+PE2: 7; La-Tr3b+PE2+S2: 1; PE1: 1; PE1+S1: 2; S1: 2; S2: 2. For Tr0, a tracheal fenestration was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr1a defect, a tracheal fenestration was performed with cervical skin after the tumor resection and the tracheal fenestration was closed with a deltopectoral flap or pectralis major musculocutaneous flap. In one recent patient, the tracheal fenestration was reconstructed using free forearm flap and cervical skin, and the fenestration was closed with a hinge flap. For Tr2b defect, free forearm flap and costal cartilage graft reconstruction was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr3a defect, end-to-end anastomosis was performed in one patient. For La-Tr3b+PE2 defect, total pharyngolaryngectomy with free jejunal flap reconstruction was performed. For PE1 defect, a simple closure was performed in one patient and a PMMC muscle flap was used for covering the suture line in two patients. For S1 and S2 defect, PMMC flap or DP flap was used. CONCLUSION: Our analysis of defects and reconstructive methods defines the complex defect patterns occurring after invasive thyroid carcinoma resection, describes the patterns of subsequent reconstructive methods.

Medial lingual lymph node metastasis in carcinoma of the tongue.

Lingual lymph node metastases are rarely seen in carcinoma of the tongue, and these nodes are not removed during neck dissection. Lingual lymph nodes are classified into medial and lateral groups, and metastasis to the former is extremely rare. A 55-year-old male with squamous cell carcinoma of the tongue, (stage T4aN0M0), underwent hemiglossectomy with neck dissection and free flap reconstruction. The lingual septum had a mass, 8 mm in size, which was diagnosed as medial lingual lymph node metastasis on histopathology. The patient developed multiple distant metastases and died of disease 18 months after the initial surgery. The presence of medial lymph node metastasis could result in contralateral neck metastases and worsen prognosis. Such cases may warrant more intensive therapy than recommended by current guidelines.

Clinical features of IgG4-related rhinosinusitis.

PURPOSE: IgG4-related disease is a systemic disease that affects various organs of the body. Aim of this study is to elucidate the clinical characteristics of IgG4-related rhinosinusitis. MATERIAL AND METHODS: Clinical features, laboratory findings, radiological and endoscopic findings, associated disease, treatment and prognosis were retrospectively examined in 10 patients with IgG4-related rhinosinusitis. RESULTS: The age was 59.1±11.3 years old and male-to-female ratio was 1:1. The chief nasal complaints were hyposmia (n=4), nasal obstruction (n=3), and nothing (n=3). Serum IgG4 levels were elevated in all patients and the value was 740.4±472.4mg/dl. Other IgG4-related diseases were associated in all 10 patients, including IgG4-related sialadenitis (n=6), IgG4-related dacryoadenitis (n=5), and autoimmune pancreatitis (n=5). Imaging findings on CT/MRI were obstruction of the way of elimination (n=10), thickening of the sinus mucous membrane (n=10), and fluid in the sinus (n=6). All of the cases had bilateral findings. Nasal endoscopic findings were chiefly deviated nasal septum (n=5), polyps (n=4), edema of the mucous membrane (n=3). Histologically, abundant infiltration of IgG4 positive plasma cell and lymphocyte and an elevated IgG4+/IgG+ cell ration was detected in all 8 patients and 5 patients, respectively. Endoscopic sinus surgery was performed in 8 patients. Eight patients were treated with steroid therapy for other associated IgG4-related diseases. Symptoms improved in all 6 patients after an initial treatment (endoscopic surgery (n=5) and steroids (n=1)), but one patient suffered relapse. CONCLUSIONS: IgG4-related rhinosinusitis is a distinct entity of IgG4-related disease, and is associated in patients with multiple IgG4-related diseases.

Tongue pressure in patients with tongue cancer resection and reconstruction.

OBJECTIVE: Assessment of tongue function following tongue reconstruction is important to evaluate patient status. To assess tongue function in patients who had undergone tongue reconstruction, the surgical team used a simple, hand-held tongue pressure measurement device to measure tongue power. METHODS: Tongue power of 30 patients (25 males, 5 females; average age: 53.6±15.0 years) was calculated using a hand-held tongue pressure measurement device, six months postoperation. The defects were classified into minimal glossectomy (MG) (n=8), near-half partial glossectomy of the mobile tongue (PG) (n=5), hemi-glossectomy (HG) (n=4), more than half partial glossectomy of the mobile tongue (SG-MT) (n=7), and subtotal glossectomy (SG) (n=6). As seen in other tongue assessments, a simple articulatory test, food evaluation, and speech intelligibility assessment were also performed; resulting correlations were statistically calculated using tongue pressure values. RESULTS: The tongue pressure values were 94.0±14.5% in MG, 48.5±13.2(a) % in PG, 40.4±18.7(a) % in HG, 19.3±7.7(a,b) % in SG-MT, and 15.3±5.6(a,b) % in SG (a: <0.05 vs. MG, b: <0.05 vs. PG). The Pearson r was 0.77, 0.67, and 0.74 when correlated with simple articulatory test, food evaluation, and speech intelligibility assessment, respectively. CONCLUSION: Tongue pressure measurement in patients with tongue cancer resection and reconstruction facilitated determination of patients' tongue function status.

Complex lower face reconstruction using a combined technique of Estlander flap and subscapular artery system free flaps.

When advanced mandibular carcinoma is resected, the defect may include lip and oral commissure. Free flap insertion is commonly used to reconstruct the lip defect. Although improvements in the oral reconstructive method via free flap use have been reported, functional and aesthetic results of the oral sphincter remain limited. This case report describes two individuals presenting with massive lower face defects, including a lower lip defect and a mandibular bone defect. Reconstruction was accomplished using the Estlander flap and free subscapular system of flaps. In both cases, the free subscapular artery system flap was elevated from the mandibular bone defect and other mucosal defect. The lower lip and oral commissure defect was reconstructed via Estlander flap. Free flaps survived 100% and both cases healed without complication. Patients regained good oral sphincter function with no reports of drooling. Thus, in cases involving massive lower face resection, including that of the lower lip and mandibular bone, this method of reconstruction when combined with lip-switch flap and subscapular artery system flap can prove to be useful.

Anatomical feature of the middle cranial fossa in fetal periods: possible etiology of superior canal dehiscence syndrome.

CONCLUSION: Different from adults, the superior semicircular canal (SSC) protrudes into the cranium during the fetal period. This might cause adhesion of the membranous labyrinth to dura as the bony labyrinth develops much later than the membranous labyrinth. This adhesion interferes with ossification and leads to a bony defect in the SSC. OBJECTIVES: The purpose of this study was to investigate a possible etiology of superior canal dehiscence syndrome (SCDS) from a view point of ontogeny. METHODS: Forty-two adult cadavers and 4 fetal cadavers were used for macroscopic observation of the middle cranial fossa (MCF). In addition, six fetuses underwent computed tomography (CT) examinations. The volume data of the CT obtained from four adults were also used for comparison. Using these CT data, we investigated the anatomic relationship between the MCF and SSC. RESULTS: The SSC and the cochlea in fetuses protruded into the cranium in macroscopic anatomy and CT examination. On the other hand, the SSC of all adults was completely or mostly buried in the temporal bone.

The approaches and outcomes of skull base surgery for pediatric sarcoma after initial therapy.

OBJECTIVE: Surgical removal of the residual pediatric sarcoma after initial therapy is common; however, that in the skull base area still presents a formidable challenge. We reviewed the approaches and outcomes of skull base surgery for pediatric sarcoma. METHODS: Thirteen patients with pediatric sarcoma who received skull base surgery were reviewed retrospectively. Tumor sites, surgical approach, complications, regional recurrence after surgery, and survival rate were analyzed. RESULTS: The residual tumor sites were the infratemporal fossa (8), nasal cavity and paranasal sinus (4) and orbit with anterior skull base invasion (1). Coronal skin incision (1), that with preauricular skin incision (7) and facial dismasking flap (5) were applied to patients as the skin preparation. Following skin preparations, anterior skull base surgery with frontal craniotomy (3), infratemporal fossa approach with temporal craniotomy (5), and anterior-lateral skull base with front-temporal craniotomy (1) were performed. Tumors were removed with a sufficient surgical field in all patients. Facial nerve palsy (9), facial deformity (4), orbital complications (diplopia, decreased visual acuity, narrowing of visual field) (2) and occlusal imbalance (1) occurred. However, facial palsy, diplopia and occlusal imbalance subsided gradually. Local recurrence occurred in 6 cases and distant metastasis was observed in 4 cases. The overall 5-years survival rate was 51.9% (Kaplan-Meier method). CONCLUSION: These tumors were safely removed with minimum morbidity. Skull base surgery is recommended to remove residual pediatric sarcoma after the initial treatment.

Parapharyngeal space tumors: anatomical and image analysis findings.

OBJECTIVE: The parapharyngeal space (PS) is defined as the deepest space in the neck and it consists of the pre- and post-styloid regions. PS tumors originating in these regions are thought to dislocate the carotid artery (CA) in either the posterior or anterior direction. To determine the precise anatomy of the PS and its relationship with the CA in diagnostic images, we conducted cadaveric and imagining analysis. MATERIALS AND METHODS: We examined the posterior and lateral aspects of the PS in three cadavers. We also examined 17 patients who suffered from PS tumors, in which the carotid artery was dislocated (CA), then compared the results with surgical and pathological findings. RESULTS: The anterior part of the PS was mainly composed of fatty tissue and is generally referred to as the pre-styloid region of the PS. In the posterior of this fatty region, blood vessels and nerves were tightly covered with muscles and adjacent fascias to form a compact musculo-fascial structure containing the CA, jugular vein, vagal, glossopharyngeal, accessory and sympathetic nerves, and a portion of the hypoglossal nerves. The hypoglossal nerves emerged from the hypoglossal canal posterior to this structure and coursed behind it, entering it at the upper third of the PS. These anatomical findings indicated that the PS was actually comprises of three regions. Image analysis showed that the CA was dislocated in the postero-lateral direction by a pleomorphic adenoma originating from the parotid gland and by a trigeminal schwannoma, both of which were pre-styloid tumors. On the other hand, the post-styloid tumors did not always dislocate the CA in the anterior direction. Tumors that developed within the musculo-fascial structure such as those of the carotid body tumor or sympathetic nerve schwannoma dislocated the CA from both the antero- to the postero-lateral directions. A hypoglossal nerve schwannoma originating from the most posterior part of the PS, which was behind the musculo-fascial structure dislocated the CA in the anterior direction. CONCLUSION: The present findings indicated that the post-styloid region of the PS is considered to consist of two regions. As the CA is a component of this musculo-fascial structure, tumors originating from it that are defined as post-styloid did not always displace the CA in the anterior direction. Such anatomical recognition is helpful for diagnostic imaging of PS tumors.

A novel permanent tracheostomy technique for prevention of stomal stenosis (triangular tracheostomy).

OBJECTIVE: Stenosis of a permanent tracheostoma after total laryngectomy lowers postoperative quality of life (QOL), and its prevention is clinically important. METHODS: From April 2003 to March 2009, the authors performed 87 permanent tracheostomies. For the purpose of prevention of tracheostomal stenosis, we had applied new technique from October 2005. RESULTS: The incidence of the tracheostomal stenosis was retrospectively reviewed. Until September 2005, conventional permanent tracheostomy was applied for 33 cases and tracheostomal stenosis developed in 6 cases (18.2%). On the other hand, stenosis did not develop in any of the 54 cases in which the new technique was used. The triangular method was significantly superior to the conventional method in preventing stenosis. Stomal recurrence did not develop in either technique. CONCLUSION: The key point of the new technique is as follows: at the upper end of trachea, the posterior part of tracheal cartilage is preserved and the anterior edge of the tracheostoma is made much lower. The shape of the tracheostoma approximates a triangle, and the area is greater than with other methods. From our experience, this technique is safe and effective for the prevention of tracheostomal stenosis.

Partial maxillary swing approach for removal of the tumors in the retromaxillary area.

OBJECTIVE: Removal of tumors around the pterygoid process poses difficult challenges. Our method for removal of tumors in this area using a modification of the maxillary swing approach is reported. METHODS: A retrospective study of five cases was performed using the partial maxillary swing approach. Like the "maxillary swing approach", the maxilla is swung laterally with the facial skin; however, only two-thirds of the anterior maxillary bone is swung. RESULTS: All tumors were safely removed using the partial maxillary swing approach alone, with the exception of one patient who needed an additional mandibular swing. No facial palsy, masticatory problems or necrosis of the maxilla were observed in any cases. CONCLUSIONS: The partial maxillary swing approach offers a wide surgical field of the lesion around the posterior part of the maxilla and pterygoid process without severe complications and is useful for removal of tumors in these areas.

Mechanical obstruction of the eustachian tube by the benign tumor of the parapharyngeal space does not cause otitis media with effusion.

OBJECTIVE: We are reporting on eustachian tube and middle ear pathologic findings in patients with parapharyngeal tumors. PATIENTS: Eleven cases of eustachian tube involvement as indicated by obstruction due to compression of the tumor were assessed in this study. MAIN OUTCOME MEASURES: Each patient underwent otoscopy, nasopharyngoscopy, a pure-tone hearing test, impedance audiometry, and sonotubometry. RESULTS: All of the tumors were diagnosed benign according to the histologic examination. In 9 of the 11 patients, the pharyngeal opening of the eustachian tube narrowed or was blocked by the tumor. None of the patients showed any response on the tumor side in the sonotubometry. Therefore, gas exchange was prevented through the eustachian tube by the tumor; however, they also showed an intact tympanic membrane and normal hearing tests. CONCLUSION: According to our data, if there is drainage of middle ear fluid through the eustachian tube and the exchange of gas in the middle ear is preserved, otitis media with effusion will not occur even in cases such as these.

Bony eminence on the middle cranial fossa corresponding to the temporomandibular joint.

We report a nameless bony eminence over the temporomandibular joint (TMJ) and its possible clinical significance. Forty-two half heads of 21 UK Caucasian cadavers (61-95 years old, mean 84.3 +/- 8.2 years, male:female = 11:10) were used to investigate the surface of the middle cranial fossa (MCF) over the TMJ. The thickness of the bony roof of the glenoid fossa was also measured. A bony eminence over the glenoid fossa was observed in half of the specimens. Some showed a complete oval bulge, which completely reflected the contour of the glenoid fossa. The others showed a bony bulge, which partially reflected that contour. The mean (+/-SD) thickness of the bone in the roof of glenoid fossa was 1.5 +/- 1.2 mm. The mean bony thickness of specimens showing the eminence was 0.8 +/- 0.5 mm, whereas it was 2.3 +/- 1.2 mm in specimens without an eminence. These differences were statistically significant (P < 0.01). The osteological features we describe may be relevant to certain clinical problems. Traumatic dislocation of mandibular condyle, for example, might relate to a weakness of the glenoid fossa.