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A dermoid cyst is lined by an epidermis-like epithelium with dermal adnexal structures contained within the cyst wall. The “sac of marbles” sign is a characteristic image finding of a dermoid cyst but its pathogenesis is unknown. In this report, we aim to elucidate the cause of the sac of marbles using immunohistological studies. We report the case of a 39-year-old man with a dermoid cyst in the floor of the mouth with a “sac of marbles” sign that was revealed by magnetic resonance imaging. We analyzed the histology of the sac of marbles in dermoid cysts and performed an immunohistological analysis of keratin subtypes. Histopathologically, the sac of marbles contained a spherical accumulation of anucleated epithelial cells; immunohistochemistry revealed that it was positive for keratin1 and keratin 10 and was negative for keratin 15 and keratin 17, demonstrating the same direction of differentiation as the cyst-lining epithelium. The results of this study show that the sac of marbles originates from denatured keratin derived from the lining epithelium.

The aim of this study was to compare the estimated public medical care cost of measures to address metallic dental restorations (MDRs) for head and neck radiotherapy using high-energy mega-voltage X-rays. This was considered a first step to clarify which MDR measure was more cost-effective. We estimated the medical care cost of radiotherapy for two representative MDR measures: (i) with MDR removal or (ii) without MDR removal (non-MDR removal) using magnetic resonance imaging and a spacer. A total of 5520 patients received head and neck radiation therapy in 2018. The mean number of MDRs per person was 4.1 dental crowns and 1.3 dental bridges. The mean cost per person was estimated to be 121 720 yen for MDR removal and 54 940 yen for non-MDR removal. Therefore, the difference in total public medical care cost between MDR removal and non-MDR removal was estimated to be 303 268 800 yen. Our results suggested that non-MDR removal would be more cost-effective than MDR removal for head and neck radiotherapy. In the future, a national survey and cost-effectiveness analysis via a multicenter study are necessary; these investigations should include various outcomes such as the rate of local control, status of oral mucositis, frequency of hospital visits and efforts of the medical professionals.

Pyogenic granuloma (PG) is a granulomatous elevated lesion that occurs on the skin and mucous membranes. We herein report two cases of intra-oral PG that developed during the administration of ramucirumab for gastric cancer. Case 1 involved a 55-year-old man with a 6-mm tumor on the right tongue, and case 2 involved a 67-year-old man with a 5-mm tumor on the upper lip. The imbalance in angiogenesis caused by ramucirumab and the deterioration in the local oral environment were suggested to have caused the PG. Medical and dental collaboration is essential during the administration of ramucirumab.