Advanced hypopharyngeal cancer with amyotrophic lateral sclerosis

We present a case of advanced hypopharyngeal cancer occurring in a patient with amyotrophic lateral sclerosis (ALS). A 58-year-old man diagnosed with ALS 2 years previously noticed a mass in his neck and dysphagia. We diagnosed him as having hypopharyngeal squamous cell carcinoma with the left cervical lymph node metastases (T3N2bM0) and treated with concurrent chemoradiotherapy. During and after the treatment, his neurological symptoms showed no worse signs. The patient has been cancer-free for 13 months after concurrent chemoradiotherapy. The influence of ALS on the patients’ quality of life (QOL) and/or prognosis had to be taken into consideration when determining an appropriate treatment for the hypopharyngeal cancer. To the best of our knowledge, this may be the first case with ALS who was treated for hypopharyngeal cancer.     

Cardiac metastasis by hypopharyngeal carcinoma. Case report

The patient was a 63-year-old Japanese male who came to the hospital with a chief complaint of a sore throat. Hypopharyngeal carcinoma (T4N2bM0, stage IVA) was diagnosed, and at the strong request of the patient he was treated by chemoradiotherapy. The tumor markedly decreased in size, but atrial fibrillation was detected when an ECG was performed in preparation for planned a scheduled re-biopsy of the hypopharynx. The echocardiography findings and result of a myocardial biopsy led to a diagnosis of cardiac metastasis by the hypopharyngeal carcinoma. Metastasis by head and neck malignancies is rare, and it is extremely rare for a confirmed diagnosis to be made while the patient is still alive. The case is described together with some discussion of the published literature.     

Nivolumab for recurrent/metastatic hypopharyngeal squamous cell carcinoma in a liver transplant recipient

Nivolumab administration to patients with organ transplantation history requires careful management. Herein, we report the case of a living-donor liver-transplant recipient, a 52-year-old man, with recurrent and metastatic hypopharyngeal cancer treated with nivolumab. He was diagnosed with T2N2bM0 stage IVA hypopharyngeal squamous cell carcinoma. While using oral immunosuppressants (cyclosporine and mycophenolate mofetil), the patient underwent right neck dissection followed by radiotherapy as an initial treatment. Three months after radiotherapy, positron emission tomography scans revealed multiple bone metastases. We administered two courses of the EXTREME regimen, comprising cisplatin, 5-fluorouracil, and cetuximab, as the first-line treatment for distal metastasis, but the patient presented with progressive disease. The patient was administered nivolumab as the second-line treatment. The programmed death-ligand 1 (PD-L1) expression level in a biopsy specimen of the primary hypopharyngeal tumor and resected specimen of the cervical lymph node metastasis was 40% and 10%, respectively. PD-L1 expression was not detected in hepatocytes of the liver biopsy sample obtained before nivolumab introduction. The patient received four courses of nivolumab 240 mg. Although liver dysfunction was alleviated by adjusting the dose of the hepatoprotective agent and cyclosporine, the progressive disease status persisted after completing nivolumab courses. The patient died of hypopharyngeal cancer progression.     

Cancer of the mandibular gingiva metastasizing to the small intestine

Head and neck cancer metastasizing to the small intestine is very rare. Here we report a case of cancer of the mandibular gingiva metastasizing to the small intestine. The patient was an 82-year-old man who had squamous cell carcinoma of the mandibular gingiva staged as T2N2bM0. Two months after surgery, he presented with lower abdominal pain accompanied by signs of peritoneal irritation. Urgent abdominal surgery was performed, during which a crater-shaped perforation was noted on the wall of the ileum. Microscopic findings at this site confirmed a diagnosis of metastatic squamous cell carcinoma in the small intestine from the mandibular gingiva. To our knowledge, this is the first case report of oral cancer metastasizing to the small intestine. If gastrointestinal symptoms appear in a patient with advanced oral cancer, a differential diagnosis of metastasis to the gastrointestinal tract should be kept in mind.     

Carotid blowout—a rare but fatal complication of endoscopic submucosal dissection of superficial hypopharyngeal carcinoma after radiotherapy

Endoscopic submucosal dissection (ESD) has gained wide acceptance as a minimally invasive and curative surgery for superficial head and neck carcinoma. However, the safety of ESD for superficial pharyngeal carcinoma after radiotherapy has not been elucidated. Superficial hypopharyngeal carcinoma of the left pyriform sinus developed in a 76-year-old man who had undergone concurrent chemoradiotherapy for T2N2bM0 pyriform sinus carcinoma on the opposite side 12 months before. He underwent ESD without complications. Because tumor invasion into the muscular layer was a concern, the muscular layer was partially resected with the tumor. Twelve days after discharge, he presented with a sore throat and difficulty in swallowing. Endoscopy and computed tomography revealed necrosis due to wound infection with abscess formation around the left carotid artery. The common carotid artery subsequently ruptured. Although the surgical intervention was performed, he passed away 46 days after ESD due to carotid blowout. ESD is a minimally invasive treatment for superficial head and neck carcinoma, but carotid blowout can occur in cases after radiation. Prior radiotherapy and deeper dissection into the muscular layer may hamper wound epithelization, resulting in infection-induced necrosis and carotid blowout. Diligent monitoring of wound healing is essential in patients who have previously undergone irradiation.     

Minocycline-induced black thyroid with black pigmentation of the thyroid cartilage,cricoid cartilage,and trachea found during reconstructive surgery for hypopharyngeal cancer

Black thyroid is characterized by a rare pigment change observed almost exclusively in patients taking minocycline. We present the case of a 72-year-old man diagnosed with T3N3bM0 stage IVB hypopharyngeal squamous cell carcinoma who had been taking minocycline for approximately 18 months as a treatment for prurigo chronica multiformis. Initial treatment consisted of total pharyngolaryngoesophagectomy, bilateral neck dissection, total thyroidectomy, pharyngeal reconstruction using a free jejunal autograft, and creation of a permanent tracheostoma. During surgery, black discoloration of the thyroid and trachea was observed. Postoperative histological findings confirmed the black discoloration, with deposits of dark-brown, melanin-like granules observed in the thyroid, trachea, thyroid cartilage, and cricoid cartilage. Therefore, the black discoloration of the thyroid associated with the use of minocycline can extend to the thyroid cartilage, cricoid cartilage, and trachea. This information is important for surgeons to recognize in order to prevent unnecessary resection due to misdiagnosis.     

Secondary placement of a voice prosthesis after total pharyngolaryngectomy with colon interposition: voice restoration in colon interposition

We present a patient treated by a total pharyngolaryngoesophagectomy and postoperative radiotherapy for a hypopharyngeal T4N2bM0 squamous cell carcinoma. The upper digestive tract was reconstructed with a pedicled left colon interposition through the posterior mediastinum. A voice prosthesis was placed 9 months after the initial treatment, following measurement of the tracheo-neopharyngeal wall thickness by sonography. Fifteen months after the total pharyngolaryngectomy, the patient remains free of recurrent disease and has successfully resumed speaking with the voice prosthesis.     

A new option for hypopharyngeal reconstruction with transverse cervical artery perforator flap: A case report

We report a case of a 61-year-old man with T2N2M0 hypopharyngeal carcinoma. In this case, the right vertical hemipharyngolaryngectomy (VHPL) and the right radical neck dissection were performed. At the same time, flap was taken from the superficial branch of transverse cervical artery for hypopharyngeal reconstruction. Postoperative wound healed smoothly. The patient resumed normal oral intake and was free of the tracheal tube at the 12th and 15th days after surgery, respectively. The superficial branch of transverse cervical artery flap is a new option to successfully reconstruct hypopharynx and has many advantages, such as no additional incision, a thin shape, local transfer, and a reliable blood supply.     

Using the larynx as a last resort for oral intake in a hypopharyngeal cancer patient

We present a new oral intake route in a hypopharyngeal cancer patient with severe complications. A 64-year-old man was diagnosed as having T2N0M0 squamous cell carcinoma of the posterior wall of the hypopharynx. He had previously undergone radiotherapy for laryngeal cancer and tricuspid valve replacement surgery, and also had atrial flutter and renal dysfunction. We performed surgery with curative intent. The hypopharynx was primarily closed after tumor resection. Laryngotracheal separation and tracheoesophageal diversion with end-to-end anastomosis of the trachea to the esophagus was performed. After surgery, complete oral feeding was achieved using the new pathway created. The larynx, contradictory to its typical role, can be used as a pathway to the esophagus using our revolutionary technique.     

Promoting healing with recombinant human platelet-derived growth factor--BB in a previously irradiated problem wound

OBJECTIVES/HYPOTHESIS: Persistent, poorly healing wounds are a significant clinical problem in patients who have had previous irradiation. Despite current treatments, refractory nonhealing soft tissue wounds persist. The study described one of the earliest reported uses of recombinant human platelet-derived growth factor-BB (rhPDGF) gel to improve the healing of a previously irradiated refractory dermal wound to the neck that had been present for 12 years. STUDY DESIGN: Case report and literature review. METHODS: Review of local healing management of previously irradiated wounds and review of patients chart one year after follow-up treatment. RESULTS: A 47-year-old man had a 12-year history of a persistent, painful, nonhealing full-thickness dermal wound on the left side of his neck after radiation therapy and chemotherapy for a T2N2bM0 nasopharyngeal carcinoma. He had been tumor free for 12 years. Despite multiple modalities of therapy over a 1-year period (including moist hydrogel dressings, topical and oral antibiotics, serial debridement, and hyperbaric oxygen), the wound did not heal. After 6 months of topical rhPDGF gel treatment, sufficient granulation tissue developed within the dermal wound that a split-thickness skin graft was successfully performed. Symptomatically, the patient's continuous pain at the neck resolved after rhPDGF treatment. Serial histological biopsy specimens before and after rhPDGF treatment confirmed the wound transformation from a chronic state to a short-term healing state. CONCLUSION: In previously irradiated tissue, rhPDGF can be useful in helping refractory wounds to heal by inducing further granulation formation. If such treatment is planned, the patient should be informed of the possible theoretical risks of its use when it is in proximity to a previously treated neoplastic site.     

Surgical management of tongue cancer during pregnancy

There are ethical dilemmas in managing head and neck cancers during pregnancy. Diagnostic and treatment modalities need to be carefully determined. We herein describe 3 cases of tongue cancer during pregnancy. The details of the management would contribute to the daily practices for head and neck cancers. All three patients were Japanese female patients, two of them were 29 years old and one was 26 years old. All patients were admitted to the Nippon Medical School Hospital during pregnancy, complaining of oral pain and/or discomfort. Case 1 was diagnosed as tongue cancer stage T3N0M0, however, the tumor was superficial and controllable by partial glossectomy. Case 2 was stage T2N0M0 with deep invasion with ulcer, and the hemi-glossectomy with neck dissection and the reconstruction was thought to be the standard modality. However, she underwent partial glossectomy in order to reduce the stress of the fetus. Case 3 could not be diagnosed on admission by biopsy and she underwent partial glossectomy after delivery. In case 3, the pathological diagnosis was pT1 tongue cancer. In case 1 and case 3, the patient and baby were healthy. In case 2, however, the patient died of recurrence at the primary site. In decision making of the strategy, the most important factors are not only oncological evaluation but also ethical and emotional factors.     

Diagnosis of nasopharyngeal carcinoma metastatic to mediastinal lymph nodes by endoscopic ultrasonography-guided fine-needle aspiration biopsy

We report the case of a patient with nasopharyngeal carcinoma who was diagnosed as having metastasis in mediastinal lymph nodes and successfully underwent systemic chemotherapy without surgery. A 61-year-old male with a history of nasopharyngeal carcinoma presented with odynophagia. Examination revealed two palpable lymph nodes in the right neck. Pharyngoscopy showed a mass in the left inferior pharyngeal mucosa, and upper gastrointestinal endoscopy showed only chronic gastritis, with no sign of esophageal disease. Chest CT confirmed the presence of a non-enhancing 20-mm soft tissue mass in the paraesophageal area, with increased attenuation compared with the adjacent esophagus. To evaluate this lesion we applied endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNA). Two passes were made with a 21-gauge fine needle and the patient tolerated the procedure well, without complications. Cytological findings were compatible with metastatic squamous cell carcinoma from a nasopharyngeal tumor, and the clinical stage was determined as T3N2bM1 (stage IVC) because of mediastinal lymph node metastasis. We thus determined the nodal status of a head and neck tumor by means of EUS-FNA. In conclusion, EUS-FNA is a safe and reliable technique for evaluation of mediastinal lymphadenopathy, and is especially valuable for head and neck tumors with suspected metastasis.     

Diagnosis of nasopharyngeal carcinoma metastatic to mediastinal lymph nodes by endoscopic ultrasonography-guided fine-needle aspiration biopsy

We report the case of a patient with nasopharyngeal carcinoma who was diagnosed as having metastasis in mediastinal lymph nodes and successfully underwent systemic chemotherapy without surgery. A 61-year-old male with a history of nasopharyngeal carcinoma presented with odynophagia. Examination revealed two palpable lymph nodes in the right neck. Pharyngoscopy showed a mass in the left inferior pharyngeal mucosa, and upper gastrointestinal endoscopy showed only chronic gastritis, with no sign of esophageal disease. Chest CT confirmed the presence of a non-enhancing 20-mm soft tissue mass in the paraesophageal area, with increased attenuation compared with the adjacent esophagus. To evaluate this lesion we applied endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNA). Two passes were made with a 21-gauge fine needle and the patient tolerated the procedure well, without complications. Cytological findings were compatible with metastatic squamous cell carcinoma from a nasopharyngeal tumor, and the clinical stage was determined as T3N2bM1 (stage IVC) because of mediastinal lymph node metastasis. We thus determined the nodal status of a head and neck tumor by means of EUS-FNA. In conclusion, EUS-FNA is a safe and reliable technique for evaluation of mediastinal lymphadenopathy, and is especially valuable for head and neck tumors with suspected metastasis.     

Positron emission tomography scan to determine the need for neck dissection after chemoradiation for head and neck cancer: timing is everything

We present a case of a negative positron emission tomography (PET) scan in a patient with pathologic viable cancer at neck dissection. STUDY DESIGN: Case Report. METHODS: A 69-year-old man presented with clinical stage T2N2c squamous cell cancer of the left tonsil and was treated with definitive chemoradiation. Left-sided adenopathy decreased but remained palpable after therapy. RESULTS: PET scan performed 23 days after completion of treatment showed no suspicious uptake in the left neck. Neck dissection performed at 2 months post-therapy revealed viable tumor in left cervical nodes. CONCLUSIONS: Persistent adenopathy after chemoradiation for head and neck cancer remains a clinical dilemma. A negative PET scan is accurate but only if the scan is performed 3 to 4 months after therapy.     

改良负压封闭引流装置在难治性咽瘘治疗中的应用

目的 探讨改良负压封闭引流(VSD)装置在难治性咽瘘治疗中的应用。 方法 两例患者诊断分别为下咽癌(环后区, T2N2M0)和喉癌(声门区, T1N0M0),年龄为48岁和62岁,行下咽肿瘤切除术和支撑喉镜下二氧化碳激光声带部分切除术,术后下咽癌患者行放化疗,喉癌患者行放疗,分别于同步放化疗后5 d、放疗后146 d出现难治性咽瘘,应用自制改良VSD装置治疗,对两例患者咽瘘愈合过程进行观察。 结果 2例患者使用改良VSD装置治疗后分别于第6天、第3天瘘口红肿消退,第58天、第38天创面明显缩小,后行咽瘘修补术,第74天、第63天咽瘘愈合。 结论 经过改良的VSD装置可以根据创面情况灵活应用,有助于头颈部肿瘤治疗后并发的难治性咽瘘的治疗。     

Endoscope-assisted intra-oral resection of the external thyroglossal duct cyst

Objective

Surgical removal of a thyroglossal duct cyst (TGDC) and its tract is usually accomplished through an external neck incision, including the removal of the middle part of hyoid bone and a block of tissues extending to the foramen cecum. However, this procedure inevitably results in neck scarring. We implemented a modified approach to TGDC removal in a 28-year-old woman through the floor of the mouth using an endoscope system.

Case report

Here, we describe the detailed procedure of the endoscope-assisted intra-oral resection for TGDC. The total operative time was 130 minutes. The patient complained of swelling and pain in the floor of the mouth for 2 days, but did not require any intervention. Follow-up imaging studies confirmed no recurrence (18 months) without any sequelae, and the patient was satisfied with her surgical outcome.

Conclusion

The intra-oral approach through the floor of the mouth is a technically feasible alternative surgical option that allows for complete removal of a TGDC without the neck scar.     

Pyogenic spondylodiscitis after transoral surgery for oropharyngeal cancer

We report the case of a patient with pyogenic spondylodiscitis after transoral surgery for oropharyngeal cancer. The patient was a 66-year-old man with a history of hepatic cell carcinoma, alcoholic cirrhosis, and chronic pancreatitis. The tumor was resected via a transoral approach with concurrent bilateral elective neck dissections. Although the initial postoperative course was uneventful, the patient experienced severe cervical pain because of which he revisited the hospital. The patient was diagnosed with pyogenic spondylodiscitis, according to the results of magnetic resonance imaging. Continuous treatment with parenteral antibiotics and a cervical brace was required for 2 months before all his symptoms and signs diminished. To the best of our knowledge, this is the first reported case of pyogenic spondylodiscitis as a complication of transoral resection for head and neck cancer.     

头颈部恶性肿瘤咽后间隙淋巴转移的诊断和手术治疗

目的探讨头颈部恶性肿瘤咽后间隙淋巴转移的临床表现、手术方法及其疗效。方法总结伴咽后间隙淋巴结肿大的6例头颈恶性肿瘤患者的临床表现。其中，声门上型喉癌（T3N2M0）2例（高、中分化鳞癌各1例）、下咽中分化鳞癌（T3N2M0）、口咽中分化鳞癌（T2N2M0）、鼻腔恶性黑色素瘤（TXN2M0）及甲状腺乳头状癌（TXN2M0）各1例。由CT和（或）MRI影像测得咽后间隙肿大淋巴结的直径为1．5～2．5cm，在控制原发灶和颈部转移淋巴结的基础上行咽后间隙淋巴清扫，并单独送病理检查。结果6例咽后间隙清扫标本均见转移，均为单发。其中1／2者4例，1／3者2例，且均伴颈内静脉链淋巴转移，分别为3／15，3／17，4／19，5／19，6／20和6／23。无颅神经损伤和咽瘘发生。下咽癌患者2年后死于肺转移；鼻腔恶性黑色素瘤者第3次手术后14个月复查时无复发，后失访；口咽癌患者术后18个月局部复发，2年后死亡。其余3例患者随访2～4年均无瘤生存。结论CT和MRI是诊断咽后间隙淋巴转移的主要手段，该处淋巴清扫是比较安全的。     

Acute mesenteric ischemia and rhinopharyngeal carcinoma

This work is a part of a pharmacovigilancy survey. OBJECTIVES: To determine the links between radiation therapy, chemotherapy, nasopharyngeal carcinoma and mesenteric ischemia. MATERIAL AND METHODS: A case of 69 year old man with a nasopharyngeal carcinoma, treated by radiation therapy and chemotherapy, who developed a lethal mesenteric ischemia is described. Etiology of mesenteric ischemia was unknown. A review of literature had been made on Pubmed with terms: "Mesenteric ischemia" and cisplatin, 5-FU or fluorouracil, radiation therapy, cancer or neoplasm, "head and neck cancer" or "carcinoma of the nasopharynx. RESULTS: In our case, the origin of the mesenteric ischemia is not atheromatous. Chimiotherapy with 5-fluorouracile and cisplatine, radiation therapy and morphine were suspected. According to literature, responsibility of morphine and radiation therapy is uncertain. In opposition, the 5-FU and the cisplatine can be incriminated. CONCLUSION: Mesenteric ischemia is an uncommon adverse effect of a treatment with cisplatin and 5-FU. It's the second case of mesenteric ischemia associated with a treatment with 5-FU and cisplatin in a patient with a nasopharyngeal carcinoma. ENT physicians must be aware of this complication.