Search

縦隔内に進展する甲状腺癌と術前に診断された胸腺癌の1例を経験した。症例は61歳男性。6年前からの前頸部腫瘤にて当科を受診となる。MRIにて甲状腺左葉下極を中心に縦隔へ進展する腫瘍を認め，穿刺吸引細胞診では“suggestive of papillary carcinoma”であった。甲状腺乳頭癌の縦隔進展と考え手術を施行した。術後の永久病理診断では，胸腺癌とCarcinoma showing thymus like differentation（CASTLE）両方の可能性があったが，腫瘍と甲状腺の境界が明瞭であることから胸腺癌と診断された。切除断端は陰性のため後治療は行っていないが，現在再発を認めず外来にて経過観察中である。

耳下腺腫瘍における深葉腫瘍の占める割合は低いが，術後顔面神経麻痺が生じやすく，手術の難易度が高くなる。当科にて2006年1月から2008年12月までの3年間に初回手術加療を行った耳下腺良性腫瘍は100例で，そのうち深葉腫瘍は13例（13%）であった。これら13例の術後顔面神経麻痺の発症率は61.5%（8/13例）と浅葉腫瘍例と比し高率で，有意に高く全枝麻痺を認めた。しかし永久麻痺はなく全例一過性で，3週間から6か月以内に完全回復した。腫瘍の大きさが40mm以上で有意に麻痺が発症していた。また術前診断にて浅葉か深葉かを判断することには限界があり，13例中4例は術中に深葉由来であることが判明した。

Systemic air embolism, a very rare clinical condition, has many causes. We report a case of multiple air embolisms following laryngopharyngoesophagectomy salvage surgery for hypopharyngeal residual cancer after concurrent chemoradiotherapy. Cervical infection arose from a fistula caused by postoperative suture failure in which the 56-year-old man suddenly lost consciousness and went into shock. A few days post operation, an air embolism happened and caused in the brain, pulmonary, myocardiac and cerebral infarction. The man died two months after initial occurrence. We suspect that air entered through the ruptured left internal jugular vein via infection due to aspiration at the injury site. Air embolisms are associated with different medical maneuvers, and it is necessary to recognize that they may become a serious perioperative complication.

In this paper, we show that spatial correlation of renewable energy outputs greatly influences the robustness of the power grids against large fluctuations of the effective power. First, we evaluate the spatial correlation among renewable energy outputs. We find that the spatial correlation of renewable energy outputs depends on the locations, while the influence of the spatial correlation of renewable energy outputs on power grids is not well known. Thus, second, by employing the topology of the power grid in eastern Japan, we analyze the robustness of the power grid with spatial correlation of renewable energy outputs. The analysis is performed by using a realistic differential-algebraic equations model. The results show that the spatial correlation of the energy resources strongly degrades the robustness of the power grid. Our results suggest that we should consider the spatial correlation of the renewable energy outputs when estimating the stability of power grids.

Tumors arising in the parapharyngeal space are rare. We reviewed 13 cases of parapharyngral space tumors that had been operated on between 1999 and 2004, and investigated the preoperative diagnosis, method of operation, and complications after surgery. Computed tomography, magnetic resonance imaging and fine-needle aspiration cytology were very useful for preoperative diagnosis, judging the extent of involvement and localization, and assessing the pathology of the tumor in the parapharyngeal space. The pathological diagnosis of these tumors was pleomorphic adenoma (6 cases), neurilemmoma (5 cases), ganglioneuroma (1 case), and malignant pleomorphic adenoma (1 case). The cervical approach was the most common, and was used in seven cases. Other surgical approaches included the cervical approach with mandibulotomy (2 cases), cervical-parotid approach (2 cases), and parotid approach (2 cases). First bite syndrome (FBS) has recently been reported as a complication after surgical removal of parapharyngeal space tumors. We experienced 4 cases of FBS. Since FBS was very difficult to treat in these patients, it is necessary to be aware of this syndrome.

中咽頭癌において上側壁が切除された場合，術後にしばしば鼻呼吸，嚥下，構音障害をきたす。著者らはこのような欠損における再建にGehanno法を用い，術直後より良好な術後機能を得ている。今回Gehanno法の長期的成績について評価をおこない，同法の有用性につき検討をおこなった。1997年より現在までに33例に対しGehanno法を施行し，今回8例に対して，術後機能評価を行うことができた。それらの症例については概ね順調に術後機能の維持ができていると思われるが，前腕皮弁使用例の一部において，術後徐々に機能が悪化してくる症例があった。元来前腕皮弁は柔軟性に優れており，中咽頭のような複雑な形態の再建に適しているとされていたが，Gehanno法による再建材料としては，周囲組織の瘢痕による形態的変化を受けやすい可能性が示唆され，皮弁の第一選択としては腹直筋皮弁が推奨されると思われた。

Objective: Chemoradiation based on S-1, a novel oral antitumor agent of fluorinated pyrimidines, is the treatment for T2N0 glottic carcinoma; however, the optimal scheduling and dosing have still not been established. A phase I study was conducted to determine the maximum tolerated dose of S-1 with radiotherapy of 2 Gy/day for 5 days a week to a total dose of 60 Gy. Endpoints of this study were to examine the toxicity profile of this regimen and to determine the recommended dose of S-1. Methods: Concomitant administration with the above-mentioned radiotherapy of S-1 once a day for 2 weeks, beginning on the day therapy was started, followed by 2 weeks off the drug and 2 weeks on the drug with the dose escalating from S-1 60 mg/body (level 1) to 80 mg/body/day (level 2), and then to 100 mg/body/day (level 3). Results: Twenty-one patients were valid for safety. Eighteen patients were enrolled in the dose-escalation phase. In all patients, S-1 was administered. The maximum tolerated dose was determined to be 100 mg/body/day and the dose-limiting toxicity was indicated by the onset of grade 3 chemoradiation dermatitis. Therefore, the determined recommended dose of S-1 was 80 mg/body/day. Objective response according to Response Evaluation Criteria in Solid Tumors were observed in 20 of 21 patients who had measurable disease (95.2%). Conclusion: Concurrent S-1 and radiotherapy was feasible and well tolerated, and was suggested to produce a worthwhile response in T2N0 glottic carcinoma. These results warrant further investigation, and a phase II has already been started.

We present a patient with metastastic renal cell carcinoma to the ethmoid sinus. A 68-year-old male consulted with complaints of left epistaxis and nasal cavity tumor. His status was post left total nephrectomy for renal cell carcinoma. The histological diagnosis was renal cell carcinoma (clear cell type). We performed skull base surgery for total ethmoid sinus resection. We report on this case and discuss metastasis of renal cell carcinoma to the head and neck region.

With the population over age 70 growing, treatment for head and neck cancer in the elderly has increased. We retrospectively evaluated their management and outcome.Subjects numbered 121-83 men and 38 women from 70 to 94 years old-initially treated at our hospital. We classified them into 2 groups by age-the aged at 70-79 years (55 men and 26 women) and the very old at 80 years and older (28 men and 12 women), We also evaluated a younger control group aged 50-59 years (37 men and 19 women).Primary tumor sites were the oral cavity (28.1%), larynx (28.1%), paranasal sinus (15.8%), and hypopharynx (9.9%). Preoperative geriatric disease was seen in 54% of controls. 74% of the aged. and 93% of the very old. Cardiovascular and respiratory diseases were most common. Surgical treatment and irradiation were essential for cancer treatment. Postoperative complications, including pneumonia, delirium, renal and cardiovascular hypofunction occurred in 56.5% of controls, 18.2% of the aged, and 17.8% of the very old. The frequency of postoperative complications correlated significantly with the American Society of Antsthesiologist classification of physical status (ASA) and preoperative performance status (PS). The complications of irradiation including pneumonia, dehydration, and feeding disturbance occurred in 53% of the very old.Cures were achieved in 83.9%, of controls, 81.5% of the aged, and 65.0% of the very old. Cause specific 5-year survival in those cured was 85.2% of controls, 84.5% of the aged, and 80.0% of the very old. Median survival in those not cured was 4 months in control, 9.6 months in the aged, and 5 months in the very old.We concluded that Curative treatment is important in the elderly, and the success of curative treatment and the prevention of complications depend on careful assessment of systemic disease, PS, ASA, and mental activity.

当教室では, 術後のQOLの向上を考慮し, 近年頸部郭清術の際, 症例に応じて頸神経を温存する術式を行ってきた。しかしながら, 頸神経の詳細な役割については不明な点が多い。今回, 23例に対し術中神経刺激を行うことにより頸神経の運動機能を検討し, また検査しえた術後1ヶ月の19例と, 術後1年以降の28例に対し肩周囲の感覚機能について評価し, 頸神経の役割, 温存の意義について検討を行ったので報告する。術中の電気刺激による検討では, 副神経刺激では全症例で僧帽筋の収縮を認めたが, 頸神経刺激では全症例に筋の収縮は見られなかった。術後の肩甲部の感覚機能における検討では, 頸神経温存により感覚機能が保存され, 頸神経は, 知覚神経としての機能を有するものと推察された。また長期に観察すれば, 頸神経切断例においても, 感覚機能が改善する可能性が推察された。

We report a case of deep vein thrombosis after surgery for mesopharyngeal cancer (T4N3M0). The patient showed swelling of the thigh on the right side and was diagnosed as deep vein thrombosis using RI venoscintigraphy. Heparin as an anticoagulant was effective for the disease. The number of cases of the disease may increase in the field of otorhinolaryngology and head and neck surgery. We emphasize the importance of selection of high risk patients and preventive treatment for these patients as well as early detection and therapy for deep vein thrombosis.

In the cases of arteriosclelosis, post-radical radiotherapy and without good arteries to anastomose because of re-operation, it is possible to occur flap necrosis in free microvascular tissue transfers. It is very important to select artery with good flow and to anastomose intima precisely. On the one hand, most of the venous thrombus is mainly due to a twist, to be oppresssed by surrounding tissue and setting of indwelling drain. Furthermore, to be improved success rate for free tissue transfers, main technique we introduced is internal jugular vein end-to-side anastomosis, anticoagulative therapy and carotid artery end-to-side anastomosis. As a result, we succeeded in expanding indication for difficult cases of microvascular anastomosis.

Surgical procedures for tumor with high vascularity in the head and neck regions is complicated by massive hemorrhage. Superselective embolization method has widely been accepted as the first choice to controle hemorrhage during operation of vascular tumors. This method was apllied for sinonasal hemangioma and epipharygeal angiofibroma preopera-tively. The hemorrhage during the operations was 5 to 1200ml in these cases. The superselective embolization was found to be effective in our series.

肩甲下動静脈茎複合皮弁を用いて頭蓋顎顔面骨の硬性再建を行い, モアレ法を併用した術後顔面形態の検討から肩甲下動静脈茎複合皮弁の有用性を示した。上顎全摘出術および頭蓋内外合併到達法による前頭蓋底手術には角枝を温存した分割肩甲骨皮弁で, 前中頭蓋底拡大切除には肩甲骨皮弁と広背筋 (皮) 弁を複合させた肩甲下動静脈茎複合皮弁を用いて上顎再建を行った。分割肩甲骨皮弁による上顎再建は角枝により栄養される肩甲下角骨と骨枝により栄養される外側縁骨による眼窩下壁および頬部～顔面口蓋骨の同時骨再建である。前中頭蓋底手術では前述の上顎再建に加えて広背筋弁で頭蓋底再建を行った。一方, 下顎を切除した舌・口腔咽頭癌に肩甲骨皮弁による下顎硬性再建を施行した。2カ所の骨弁内骨切りの必要な下顎彎曲部再建では骨枝と角枝の二重血管茎とした。顎顔面硬性再建症例の術後長期の形態維持は良好であるので, QOLを考慮し積極的に硬性再建を行うべきである。

Mucoepidermoid carcinoma of the maxillary sinus is a rare neoplasm. We describe diagnostic difficulties in a case of low grade mucoepidermoid carcinoma of a cystic pattern in a 72-year-old man. The patient complained of double vision and nasal bleeding. CT findings indicated a shadow in the unilateral maxillary sinus as well as bony destruction of the maxilla on the same side. Although biopsies and maxillary operations were repeatedly performed over a period of 7 years, the histopathological diagnoses were chronic sinusitis with necrotic characteristics or squamous cell carcinoma.Several cases of mucoepidermoid carcinoma have been similarly misdiagnosed as squamous cell carcinoma because mucoepidermoid carcinomas contain epidermoid cell components similar to squamous cell carcinomas. Tumor necrosis in our case were extensive and the mucous discharge secreted by mucous cell components in this type of carcinoma may increase pressure inside the cystic tumor causing tumor necrosis. The significance of a differential diagnosis between mucoepidermoid carcinoma and chronic inflammation or squamous cell carcinoma in the maxillary sinus should be emphasized.

Mediastinal tracheostomas have poor tissue separating the tracheal skin suturing area and the mediastinum and therefore, infection occurring in the suture area readily extends to the mediastinum. In addition, there is the risk of rupture of the brachiocephalic artery due to mediastinitis or tracheal necrosis. To avoid this postoperative complication, we have performed an operative technique in which the mediastinal tracheostoma and the surrounding area are covered using a pectoralis major muscle flap for separation of the tracheostoma from mediastinal major blood vessels. In this study, we evaluated 6 patients who underwent mediastinal tracheostomy at our department between 1998 and 2003. No fatal complications such as tracheal necrosis, f istulation between the trachea and brachiocephalic artery, or mediastinitis were observed in any patient.

Resection of the superior or lateral wall of the cancer-affected oropharynx can often lead to disturbed nasal breathing, dysphagia, and dysarthria. The authors used the Gehanno method to reconstruct these surgical defects and achieved favourable functional recovery soon after surgery. The present study was undertaken to analyze the long-term outcome and usefulness of this method. Reconstruction was carried out using the Gehanno method in 36 patients during the 10-year period between 1997 and 2007. Both short-term and long-term evaluations of the postoperative function were performed in 12 of the 36 cases. The postoperative function was favourably maintained in all 12 cases, but gradual deterioration was noted in some cases in which the forearm flap had been used for reconstruction. Conventionally, the forearm flap is considered suitable for the reconstruction of complex structures such as the oropharynx because of its excellent flexibility. The results suggest that if the forearm flap is used for reconstruction using the Gehanno method, the surrounding tissue is likely to undergo change over time. The rectus abdominis myocutaneous flap should be considered as the first-choice flap for reconstruction using the Gehanno method.

The purpose of this study was to improve the survival and phonatory rates in patients with advanced hypopharyngeal carcinoma.Seventy-two consecutive patients with advanced hypopharyngeal carcinoma were treated with pre- and postoperative radiotherapy (RTS), or preoperative concomitant chemoradiotherapy (CCRTS). Surgical procedures, including total laryngectomy plus partial pharyngectomy (TLPP) to preserve the posterior pharyngeal wall offering a functional neoglottis for esophageal or tracheoesophageal shunt phonation postoperatively, were conducted for patients who did not achieve CR.A significantly higher survival rate at 5 years (93.3%) was observed for N0-2b stage patients in the CCRTS group (n=16) than the RTS group (n=34; 41.5%) (p.005). The distant metastasis-free rate was 92.9% (CCRTS group) versus 55.4% (RTS group) (p.05) in these patients. In the CCRTS group, the 5-year survival rate with laryngeal or esophageal and/or tracheoesophageal shunt phonation was 22.2%.It is suggested that the CCRTS protocol and TLPP procedure may improve the survival rates without deterioration of phonatory rates in patients with N0-2b advanced hypopharyngeal carcinoma.

Malignant lymphomas arising in the salivary glands are very uncommon. The vast majority of these lesions are classified as extranodal non-Hodgkin's lymphoma. Clinical presentation, management, histopathology, and outcome in 11 cases of non-Hodgkin's lymphomas of the parotid gland region were reviewed. The ages of the patients ranged from 25 to 80 years (average 56.0 years) and the male to female ratio was 5:6. Presenting symptoms were painless masses (10 cases) and a painful mass (1 case) in the parotid gland region. None of the patients had facial nerve paralysis. It seems to be difficult to diagnose malignant lymphomas of the salivary glands preoperatively, because an open biopsy of the salivary glands is generally contraindicated. We failed to diagnose malignant lymphoma in the parotid gland preoperatively. The clinical stages were stage I in 5 cases, stage II in 5 cases, and stage III in 1 case. There was no patient with stage IV. Three of the stage I tumors were diagnosed as MALT (mucosa-associated lymphoid tissue) lymphomas. Eight of the tumors were treated surgically and an open biopsy of the parotid gland tumor was performed in 1 case and open biopsy of a neck lymph node in 2 cases for the purpose of diagnosis. After the diagnosis, these cases were followed up with or without radiotherapy and chemotherapy. Follow-up ranged from 6 to 109 months. The 5-year-survival rate was 60%. The outcome for this group was found to be as good as that reported by others.