Histopathologic analysis of bone marrow and bone metastasis in murine neuroblastoma

To elucidate the development of bone metastasis in human neuroblastoma, bone marrow and bone metastases were analysed histologically in a hematogeneous metastasis model of murine neuroblastoma. The bone marrow metastasis occurred initially in the bone marrow sinusoid where tumor cells adhered and extravasated to bone marrow parenchyma, resulting in the formation of nodular lesions in the medullary cavity. The nodular lesions eventually progressed to diffuse lesions segmentally occupying the medullary cavity. During the establishment of the diffuse lesions, tumor cells invaded cancellous bone and/or bone cortex, resulting in bone metastasis. Such nodular or diffuse bone marrow metastatic lesions occurred sporadically in a variety of bones. To improve the results of treatment for neuroblastoma, the characteristics of the bone marrow and the bone metastases demonstrated in this study should be considered in the diagnosis and treatment of this disease.

Diagnosis and treatment of complications after oesophagoplasty

OBJECTIVE

To find out the optimal method for diagnosing and treating anastomotic leaks and necrosis of the organs used for reconstruction after resection of oesophageal cancer and oesophagoplasty.

DESIGN

Retrospective study.

SETTING

University department, Japan.

SUBJECTS

481 patients who underwent resection of oesophageal cancer and subsequent oesophagoplasty (including 47 postoperative anastomotic leaks and 10 cases of necrosis of the organs used for reconstruction).

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

Of 47 patients with anastomotic leaks 2 died during their hospital stay as did 3 (30%) of 10 patients with necrosis. Necrosis was most common in cases in which the colon had been harvested by the presternal route (4/13, 31%). Secondary reconstruction with a free jejunal graft was successful in 3/4 cases.

CONCLUSION

Most anastomotic leaks were cured by conservative treatment. In cases of necrosis of the organs used for reconstruction, early drainage and secondary reconstruction with free jejunal grafts yielded the best results.

Collagen types I and III localization by in situ hybridization and immunohistochemistry in the partially obstructed young rabbit bladder

PURPOSE

The objective of the study was to investigate the alteration of collagen expression patterns at the transcription and translation levels during partial outlet obstruction and to compare changes in collagen types I and III gene expression, and protein deposition during early and subacute phases of obstruction.

MATERIALS AND METHODS

Following 1, 2, 7, 14 and 21 days of partial bladder obstruction in 2-week-old rabbits bladder tissues were evaluated for collagen types I and III messenger ribonucleic acid localization by in situ hybridization and for protein localization by immunohistochemical study.

RESULTS

There is up regulation of collagen types I and III gene expression after obstruction. Up regulation of collagen gene expression immediately after obstruction is within the lamina propria and the message moves into the muscular layer as obstruction progresses. Protein deposition for both collagen types is analogous to that of gene expression.

CONCLUSIONS

Up regulation of collagen types I and III gene expression, and increased protein deposition after partial obstruction demonstrate that the alteration in collagen synthesis is at least partially transcription regulated. This alteration starts from superficial layers of the bladder wall and becomes deeper as the pathological process progresses.

Identification of the functional region on the superantigen Yersinia pseudotuberculosis-derived mitogen responsible for induction of lymphocyte proliferation by using synthetic peptides

Yersinia pseudotuberculosis-derived mitogen (YPM) is the unique Gram-negative bacillary superantigen known. In order to identify the regions on the YPM molecule involved in its superantigenic activity, seven overlapping peptides of the entire YPM molecule were synthesized and tested to evaluate their effects on the YPM-induced proliferation of human peripheral blood lymphocytes. A peptide corresponding to the N-terminal amino acid sequence (1-23) was found to inhibit YPM-induced lymphocyte proliferation in a concentration-dependent manner. The N-terminal peptide was found to show no inhibition of the proliferation induced by the other superantigen (staphylococcal enterotoxin B) or the other T-cell mitogen pertussis toxin, indicating that the inhibition is specific to YPM-induced proliferation. Thus, we have identified the N-terminal region (1-23) of the YPM as one of the functional regions responsible for its superantigenic activity.

Multiple primary esophageal and concurrent upper aerodigestive tract cancer and the aldehyde dehydrogenase-2 genotype of Japanese alcoholics

BACKGROUND

Multiple intraesophageal primary cancer and upper aerodigestive tract (UADT) cancer associated with esophageal cancer are common diseases, especially in heavy drinkers. They are often explained by the concept of field cancerization, which suggests a similar etiology. However, little is known about the nature of the hypothesized etiology.

METHODS

Among 901 Japanese male alcoholics systematically screened by upper gastrointestinal endoscopy (with esophageal iodine staining), 33 had squamous cell carcinoma of the esophagus. The multiplicity of their esophageal carcinoma and their concurrent UADT cancer was compared with their genotype for aldehyde dehydrogenase-2 (ALDH2), the major determinant of blood acetaldehyde concentration after drinking.

RESULTS

Of 17 patients with inactive ALDH2, 13 (76.5%) had multiple primary carcinoma of the esophagus, whereas 5 of 16 (31.3%) with active ALDH2 had multiple carcinomas (P < 0.01). The prevalence of concurrent UADT cancer was 29.4% in those patients with inactive ALDH2, compared with 6.3% in those patients with active ALDH2.

CONCLUSIONS

Inactive ALDH2 is a risk factor for multiple carcinoma of the esophagus in alcoholics. Acetaldehyde, a recognized animal carcinogen, appears to play a critical role in field cancerization.

Multiple primary esophageal and concurrent upper aerodigestive tract cancer and the aldehyde dehydrogenase-2 genotype of Japanese alcoholics

BACKGROUND

Multiple intraesophageal primary cancer and upper aerodigestive tract (UADT) cancer associated with esophageal cancer are common diseases, especially in heavy drinkers. They are often explained by the concept of field cancerization, which suggests a similar etiology. However, little is known about the nature of the hypothesized etiology.

METHODS

Among 901 Japanese male alcoholics systematically screened by upper gastrointestinal endoscopy (with esophageal iodine staining), 33 had squamous cell carcinoma of the esophagus. The multiplicity of their esophageal carcinoma and their concurrent UADT cancer was compared with their genotype for aldehyde dehydrogenase-2 (ALDH2), the major determinant of blood acetaldehyde concentration after drinking.

RESULTS

Of 17 patients with inactive ALDH2, 13 (76.5%) had multiple primary carcinoma of the esophagus, whereas 5 of 16 (31.3%) with active ALDH2 had multiple carcinomas (P < 0.01). The prevalence of concurrent UADT cancer was 29.4% in those patients with inactive ALDH2, compared with 6.3% in those patients with active ALDH2.

CONCLUSIONS

Inactive ALDH2 is a risk factor for multiple carcinoma of the esophagus in alcoholics. Acetaldehyde, a recognized animal carcinogen, appears to play a critical role in field cancerization.

Hereditary deficiency of lactate dehydrogenase H-subunit

We report herein the fifth family of hereditary deficiency of lactate dehydrogenase (LDH) H-subunit with an autosomal recessive inheritance including two cases of complete deficiency. Their LDH activities were low both in the serum and in the red blood cells (RBC). Electrophoretic analysis revealed that the patients with the complete deficiency had only the LDH5 isozyme. The complete deficiency was associated with marked elevation of fructose-1, 6-diphosphate (FDP) and dihydroxyacetonephosphate (DHAP) and a less marked rise in glyceraldehyde-3-phosphate (GA3P) among glycolytic intermediates in the RBC. Furthermore, hemolysis was observed in the present cases, but this finding was not included in the other reports.

Inactive allele-specific methylation and chromatin structure of the imprinted gene U2af1-rs1 on mouse chromosome 11

The imprinted U2af1-rs1 gene that maps to mouse chromosome 11 is predominately expressed from the paternal allele. We examined the methylation of genomic sequences in and around the U2af1-rs1 locus to establish the extent of sequence modifications that accompanied the silencing of the maternal allele. The analysis of HapII or HhaI sites showed that the silent maternal allele was hypermethylated in a block of CpG sequences that covered more than 10 kb. By comparison, the expressed paternal allele was unmethylated from a CpG island upstream of the transcribed region through 2 kb. An analysis of DNaseI hypersensitivity of a putative promoter of U2af1-rs1 showed an open chromatin conformation only on the unmethylated, expressed paternal allele. These results suggest that allele-specific hypermethylation covering the gene and its upstream CpG island plays a role in maternal allele repression of U2af1-rs1, which is reflected in altered chromatin conformation of DNaseI hypersensitive sites.

[A clinical study of squamous cell carcinoma of the tongue base]

Between 1979 and 1992, 27 previously untreated patients with squamous cell carcinoma involving the base of the tongue underwent treatment with curative intent. Seven patients were in Stage I, II (26%) and 20 patients were in stage III, IV (74%). Seventeen patients (63%) presented clinically with neck metastasis. The patients were followed for a minimum of two years or until death or recurrence. Primary tumors treated with surgery or radiotherapy showed control rates of 80% (12 of 15 tumors) and 88% (7 of 8 tumors), respectively. The overall survival was 59 percent at 5 years. For the patients with exophitic primaries, local control with radiotherapy produced excellent results, whereas for advanced or deeply invasive tumors, surgery enhanced local control. Radiation therapy successfully controlled early neck disease (N0, N1). Patients with advanced neck disease (N2, N3) had poor regional control with radiotherapy, necessitating subsequent neck dissection. Forty-three percent of the N2b or N3 patients were found to have contralateral occult metastasis. Results obtained in the present study show that patients with T3, T4 or N2, N3 should undergo surgery. Prospective trials are necessary to compare surgery versus definitive radiotherapy with respect to patient survival and quality of life.

Successful screening for early esophageal cancer in alcoholics using endoscopy and mucosa iodine staining

BACKGROUND

Epidemiologic studies have provided evidence that alcohol abuse is an important risk factor for esophageal carcinoma. However, no systematic screening program has been established yet in the early detection of esophageal cancer in high risk populations of heavy drinkers.

METHODS

A cohort of 629 male alcoholics (54 +/- 8 years old) were consecutively and systematically screened by endoscopy combined with iodine staining and targeted biopsy at the National Institute on Alcoholism (Kanagawa, Japan). For mucosal carcinomas, endoscopic esophageal mucosal resection (EEMR) was used to serve confirmatory diagnostic and therapeutic purposes.

RESULTS

Iodine-unstained lesions, distinctly demarcated, white, and 5 mm or larger in greatest dimension, were observed on the esophageal wall in 162 patients (25.8%). Thirty-six such unstained lesions in 21 of 629 patients, with an unexpectedly high rate of 3.3%, turned out to be squamous cell carcinomas of the superficial type. According to some established criteria, EEMR was performed in 17 of these patients, 3 of whom were given additional irradiation. Esophagectomy was performed in two patients, chemotherapy combined with irradiation in one, whereas still another was followed endoscopically. The cancer invasion was confined within the epithelium in eight patients, to the proper mucosal layer in nine, and to the submucosa in four. Multiple logistic regression revealed that the risks for distinct iodine-unstained lesions and superficial esophageal carcinoma increased independently for users of stronger alcoholic beverages, i.e., whiskey or shochu (odds ratio [OR] = 1.47 and 2.94, respectively) compared with lighter beverages, i.e., sake or beer and 30+ cigarettes/day (OR = 1.68 and 3.85, respectively).

CONCLUSION

Routine application of this program for these high risk individuals yielded an unusually high rate of detection of esophageal carcinoma.

Transforming growth factor beta-1 and beta-2 in human tear fluid

PURPOSE

To evaluate human tear fluid for transforming growth factor beta isoforms 1 and 2 (TGF-beta1 and TGF-beta2).

METHODS

To accomplish this, human tears were evaluated for TGF-betas by quantitative antibody sandwich ELISA (sELISA), mink lung epithelial cell (MLEC) growth inhibition bioassay and western blotting. Various physical and chemical treatments were used to activate TGF-beta in these assays.

RESULTS

TGF-betas could not be detected in untreated or heated tears by sELISA; however, mean TGF-beta1 concentrations of 2.32 ng/ml were detected in acid-activated tears by sELISA. Furthermore, 10.54 ng/ml of TGF-beta1 and 2.98 ng/ml of TGF-beta2 were detected in tears treated with the mucolytic agent, acetylcysteine. Total TGF-beta bioactivity in human tears measured by the MLEC assay was found to be 13.04 ng/ml in untreated tears and 24.85 ng/ml in acid-activated tears. Approximately one-half TGF-beta in tear specimens was biologically active (mean = 52%, range 39-71%). Total tear TGF-beta bioactivity could be completely neutralized by recombinant human TGF-beta1 latency associated peptide (rh TGF-beta1 LAP). Mean neutralization of tear TF-beta bioactivity was 83% by TGF-beta1-specific antisera, and was 13% by TBF-beta2-specific antisera. Immunoreactive TBF-beta bands at approximately 12.5 and 95 kD were observed in immunoblots of reduced acidified tears. A high molecular weight (MW) TGF-beta band (>203 dD) was noted in untreated tears; however, this band disappeared following treatment with acetylcysteine.

CONCLUSIONS

The results of these studies indicate that TGF-beta1 and TGF-beta2 are present in human tear fluid, and TGF-beta1 is the predominant isoform. There appear to be factors in human tears capable of binding TGF-beta.

Production and secretion of transforming growth factor beta (TGF-beta) by the human lacrimal gland

PURPOSE

Transforming growth factor beta (TGF-beta) isoforms 1 and 2 have recently been detected in stimulated human tear fluid. The purpose of this study was to determine if these TGF-sbeta are produced and secreted by the lacrimal gland.

METHODS

To accomplish this, reverse transcriptase polymerase chain reaction (RT-PCR) was used to detect expression of TGF-beta1 and TGF-beta2 mRNAs in normal human and rabbit lacrimal gland biopsies. Northern blot analyses were used for comparing the relative levels of expression of these TGF-beta mRNAs in rabbit lacrimal glands. Human lacrimal gland biopsies were evaluated by immunohistochemistry for production of TGF-beta1, TGF-beta1 latency associated peptide (LAP), and TGF-beta2 proteins. Supernatants of unstimulated and carbachol-stimulated human lacrimal gland explant cultures were evaluated for secretion of TGF-beta1 and TGF-beta2 by ELISA:

RESULTS

TGF-beta1 and TGF-beta2 mRNA expression was found in all human and rabbit lacrimal gland specimens by RT-PCR. A greater level of expression of TGF-beta1 than TGF-beta2 mRNA in the rabbit lacrimal gland was noted by Northern blot. In human lacrimal gland biopsies, TGF-beta1 and TGF-beta1 LAP were detected in acinar and ductal epithelia by immunohistochemistry. TGF-beta2 specific antibodies stained a small percentage of acinar and ductal epithelia, as well as material within the lumens of tubulo-acinar complexes in one-third of these glands. TGF-beta1 was detected in supernatants of human lacrimal gland explants, and the concentration of TGF-beta1 increased by an average of 280% after carbachol-stimulation (p = 0.004). TGF-beta2 could not be detected in unstimulated or stimulated human lacrimal gland supernatants.

CONCLUSIONS

The results of these experiments indicate that TGF-beta1 and TGF-beta2 are produced by and TGF-beta1 is secreted by the human lacrimal gland. They also suggest that the lacrimal gland may be one source of TGF-beta in human tear fluid.

Multiple primary esophageal and concurrent upper aerodigestive tract cancer and the aldehyde dehydrogenase-2 genotype of Japanese alcoholics

BACKGROUND

Multiple intraesophageal primary cancer and upper aerodigestive tract (UADT) cancer associated with esophageal cancer are common diseases, especially in heavy drinkers. They are often explained by the concept of field cancerization, which suggests a similar etiology. However, little is known about the nature of the hypothesized etiology.

METHODS

Among 901 Japanese male alcoholics systematically screened by upper gastrointestinal endoscopy (with esophageal iodine staining), 33 had squamous cell carcinoma of the esophagus. The multiplicity of their esophageal carcinoma and their concurrent UADT cancer was compared with their genotype for aldehyde dehydrogenase-2 (ALDH2), the major determinant of blood acetaldehyde concentration after drinking.

RESULTS

Of 17 patients with inactive ALDH2, 13 (76.5%) had multiple primary carcinoma of the esophagus, whereas 5 of 16 (31.3%) with active ALDH2 had multiple carcinomas (P < 0.01). The prevalence of concurrent UADT cancer was 29.4% in those patients with inactive ALDH2, compared with 6.3% in those patients with active ALDH2.

CONCLUSIONS

Inactive ALDH2 is a risk factor for multiple carcinoma of the esophagus in alcoholics. Acetaldehyde, a recognized animal carcinogen, appears to play a critical role in field cancerization.

Studies on selectin blockers. 2. Novel selectin blocker as potential therapeutics for inflammatory disorders

As a part of our studies of selectin blockers, we prepared 1-(2-tetradecylhexadecyl)-3'-O-sulfo Le(X) 1 and 1-(2-tetradecylhexadecyl) sLe(X) 2 and examined their inhibitory activities against natural ligand (sLe(X)) binding to E-, P-, and L-selectins. Compounds 1 and 2 were 2 times more potent than the sLe(X) tetrasaccharide toward E-selectin binding and up to 4 times more potent than sLe(X) toward P- and L-selectin binding. Interestingly, compound 1 provided dose-dependent protective effects against an immunoglobulin E-mediated skin reaction in mouse ears. This protective effect was associated with diminished tissue accumulation of neutrophils in the ear (as assessed by myeloperoxidase). These findings indicate that the modification of sLe(X) or 3'-O-sulfo Le(X) with a "branched anchor", a 2-tetradecylhexadecyl group, is useful in the design of a more potent selectin blocker, which has broad inhibitory activities toward all selectins.

Absence of imprinting in U2AFBPL, a human homologue of the imprinted mouse gene U2afbp-rs

The mouse gene U2 auxiliary factor binding protein related sequence (U2afbp-rs) has previously been shown to be genomically imprinted with monoallelic expression from the paternal allele. To determine if the human homologue is imprinted and contains conserved structural features which regulate imprinting, we isolated genomic clones from a human P1-derived artificial chromosome (PAC) library that map to human chromosome 5q22-31, a region syntenic to the proximal portion of mouse chromosome 11 where U2afbp-rs resides. A genomic subclone was isolated which contained an open reading frame with high homology to the mouse gene. This subclone also maintained the intronless character of the mouse gene. A KpnI polymorphism within the open reading frame of the gene was found to occur in 21% (8/38) of the alleles tested from human placental tissue samples. RT-PCR analysis of human placentas using the KpnI polymorphism to determine the parental origin of the alleles indicates biallelic expression of the human chromosome 5 U2AFBPL gene.

[Treatment of bilateral neck metastases in laryngeal cancer]

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

[Modified surgery for early gastric cancer]

Based on the sufficiently accumulated results of early gastric cancer (EGC), particularly the diagnostic accuracy regarding the depth of cancerous involvement in the gastric wall, lymph node metastasis, pattern of recurrence etc., the modified surgery has been induced for the treatment of EGC since late 1970's. The modification is as follows depending on the depth and location of EGC: constriction of size of gastric resection; narrowing of the extent of lymphadenectomy; preserving omentum, pancreas, spleen, pylorus, vagal nerve, lower esophageal sphincter etc; sparing thoracotomy. This kind of surgery has resulted in remarkable reduction of blood loss during surgery, reduced operation time and hospital stay, which have brought improved QOL to the patients as well as satisfactory survival rate after surgery.

Studies on selectin blocker. 1. Structure-activity relationships of sialyl Lewis X analogs

As part of our studies of selectin blockers, we prepared 1-deoxy-3'-O-sulfo LeX analogs (1-3), 1-deoxy-3'-O-phosphono LeX analogs (4), and 1-deoxy sLeX analogs (5-7), and examined their inhibitory activities against natural ligand (sLeX) binding to E-selectin, P-selectin, and L-selectin. The 1-deoxy sLeX 5 was up to 20 times more potent an inhibitor than the sLeX tetrasaccharide toward P- and L-selectin binding. This indicates that the modification of the 1 or 2 position of sLeX is useful in the design of a more potent selectin blocker.

Demonstration of monoclonal origin of human parotid gland pleomorphic adenoma

BACKGROUND

Parotid gland pleomorphic adenoma is histologically comprised of epithelial and mesenchymal elements. It remains to be established whether this neoplasm arises from epithelial and mesenchymal elements, or solely from the epithelial element.

METHODS

In an attempt to resolve this issue, we have conducted clonal analysis on five pleomorphic adenomas. The method for clonal analysis was based on the trinucleotide repeat polymorphism of the x-chromosome-linked androgen receptor gene and on random inactivation of this gene by methylation. The epithelial and mesenchymal elements were obtained separately from the paraffin sections of the pleomorphic adenomas using a microdissection technique and then subjected to clonal analysis.

RESULTS

Clonal analysis revealed that both epithelial and mesenchymal elements were monoclonal. In addition, the same allele of the androgen receptor gene was inactivated in both elements in every case.

CONCLUSIONS

It is unlikely that the epithelial and mesenchymal elements of different origin happen to inactivate the same allele of the androgen receptor gene in all five tumors. Rather, it is more reasonable to consider that these two elements have a common single cell origin.

[Treatment of head and neck cancer: radiation therapy]

Radiation therapy is an effective modality for curative treatment with organ preservation, palliative treatment for pain control and combined/prophylactic treatment for local-regional control after surgery in head and neck cancer. For early lesions, 70-90% of local control may be expected in radiation therapy. However, some hurdles must be cleared with regard to advanced lesions. We reviewed the prospective randomized controlled trials (phase III trial) concerning adjuvant chemotherapy and multiple fractions per day of radiotherapy for advanced head and neck cancer. Adjuvant chemotherapy may be used in three ways in the treatment, i.e., induction therapy, concomitantly with radiotherapy and maintenance therapy. We reviewed the former two treatments because no "pure" phase III trial could be found in maintenance therapy after radiotherapy. As for multiple fractions per day of radiation therapy, the following definition is used. Hyperfractionation: Total dose is increased; dose per fraction is reduced; fractian number is increased,; overall time is relatively unchanged. Accelerated fractionation: Overall time is reduced; number of fraction total dose, and dose per fraction are either unchanged or somewhat reduced, depending on the extent of overall time reduction. Adjuvant chemotherapy combined with radiotherapy and multiple fractions per day of radiotherapy have been attempted to increase local-regional control and survival in a few randomized studies. However, these survival results were disappointing despite good local control. We need a more effective chemotherapy regime, fractionation schedule and also to clarify the indications for these treatments by analyzing the prognostic factors.