Mitsuhiko Nakahira

Posttreatment CT and MR imaging in head and neck cancer: what the radiologist needs to know.

In patients with head and neck cancer, posttreatment imaging can be complicated and difficult to interpret because of the complexity of the surgical procedures performed and the postirradiation changes, but such imaging is critical for the evaluation of (a) the response to therapy and (b) tumor control. Posttreatment changes are affected by the type of surgery performed, reconstruction, neck dissection, and radiation therapy. Three types of flaps are used for reconstruction in the head and neck region: (a) the local flap, with geometric repositioning of adjacent tissue; (b) the pedicle flap, with rotation of donor tissue and preservation of the original vascular system; and (c) the free flap, with transfer of tissue that is revascularized by using microvascular surgical techniques. The posttreatment imaging findings in patients with head and neck cancer can be divided into four groups: altered anatomy secondary to surgical reconstruction, tumor recurrence, potential postsurgical complications, and possible postirradiation changes. Potential postsurgical complications are wound infection, abscess, fistula, flap necrosis, hematoma, chylous fistula, and serous retention. Possible postirradiation changes include mucosal necrosis, osteoradionecrosis, radiation-induced vasculopathy, radiation pneumonitis, radiation lung fibrosis, radiation-induced brain necrosis, and radiation-induced secondary malignancies. A familiarity with the imaging characteristics of posttreatment changes and of the potential complications caused by surgery and irradiation and an ability to differentiate these findings from tumor recurrence are essential for posttreatment surveillance and follow-up management of patients with head and neck cancer.

Quantitative diffusion-weighted magnetic resonance imaging as a powerful adjunct to fine needle aspiration cytology for assessment of thyroid nodules.

OBJECTIVES The purpose of this study was to assess the value of the apparent diffusion coefficient (ADC) in the differential diagnosis between benign and malignant thyroid nodules, particularly those found to have indeterminate cytology with fine needle aspiration (FNA). METHODS Thirty-eight patients with 42 thyroid nodules underwent neck magnetic resonance imaging consisting of T1-, T2-, and diffusion-weighted imaging. The final diagnosis of all nodules was confirmed by surgery, revealing 23 with benign and 19 with malignant lesions. Preoperative FNA cytology was performed in 38 of 42 nodules, including 15 of indeterminate cytology. The mean ADC values in benign and malignant groups were compared. RESULTS There was a significant difference between mean ADC values in benign and malignant nodules and between mean ADC in benign and malignant nodules of indeterminate cytology. A cutoff value for malignant nodules of 1.60 × 10(-3) mm(2)/s yielded sensitivity, specificity, and accuracy of 94.73%, 82.60%, and 88.09%, respectively. CONCLUSION The present study revealed that ADC measurements could potentially quantitatively differentiate between benign and malignant thyroid nodules, even those of indeterminate cytology. We propose that diffusion-weighted imaging evaluation should be used for the assessment of thyroid nodules in addition to FNA cytology.

Primary aspergillosis of the larynx associated with CD4+ T lymphocytopenia

The purpose of this study was to report the first case (to our knowlege) of primary laryngeal aspergillosis in a patient with underlying CD4(+) T lymphocytopenia. Laryngeal involvement of Aspergillus is more commonly seen as a part of a wider infection involving the respiratory system in an immunocompromised host. However, primary infection of the larynx is extremely rare. Although there were 12 cases of primary laryngeal aspergillosis previously reported in healthy subjects, there is no known study describing immunological findings in detail. We report a case of primary laryngeal aspergillosis in a healthy 79-year-old male. The examination of his immunity subsequently revealed that there was a marked decline in the number of CD4(+) T lymphocytes and a decrease in the ratio of CD4(+) to CD8(+). It is suggested that it is essential to examine the defence mechanisms, specifically cell-mediated immunity in a patient showing primary laryngeal aspergillosis.

Bumetanide-induced Enlargement of the Intercellular Space in the Stria Vascularis Requires an Active Na + -K + -ATPase

OBJECTIVE Loop diuretics such as bumetanide and furosemide cause an acute enlargement of the intrastrial space of the stria vascularis, with an associated decline in the endocochlear DC potential (EP). The aim of this study was to determine the role played by the Na+-K+-ATPase in the bumetanide-induced enlargement of the intrastrial space, and to examine the importance of the balance between the activities of the Na+-K+-2Cl- cotransporter and the Na+-K+-ATPase to the physiological function of the stria vascularis. MATERIAL AND METHODS Albino guinea pigs were used in experiments involving perilymphatic perfusion, EP measurement and electron microscopy. The effects of bumetanide on the stria vascularis were examined following inhibition of the Na+-K+-ATPase by ouabain. Ouabain was administered to the perfusate and, when the EP reached 0 mV, both ouabain and bumetanide were administered. RESULTS Although there was no enlargement of the intrastrial space, vacuoles were apparent in marginal cells. The vacuolar change in marginal cells was similar to that caused by ouabain alone. CONCLUSION This study indicates that the enlargement of the intrastrial space requires not only the blockade of the Na+-K+-2Cl- cotransporter but also normal activity of the Na+-K+-ATPase, and suggests that the bumetanide-induced enlargement of the intrastrial space resulted from the imbalance between the activities of the Na+-K+-2Cl- cotransporter and the Na+-K+-ATPase.

Immunohistochemical Analysis of Oral Dysplasia: Diagnostic Assessment by Fascin and Podoplanin Expression

The aim of this study was to investigate fascin and podoplanin expression in oral dysplasia and carcinoma in situ (CIS) immunohistochemically, and to evaluate their relationship to histopathological diagnosis based on architectural and cytological features. Fascin and podoplanin expression patterns were analyzed immunohistologically in 26 specimens of oral lesions, including benign disease (hyperplasia, papilloma, and others), intraepithelial neoplasia/borderline disease (dysplasia), and malignant disease (CIS, invasive squamous cell carcinoma). Fascin expression was scored into four original categories, and podoplanin expression was scored into five previously established categories. The relationship between the immunohistochemically determined scores of fascin and podoplanin expression and the architectural and cytological features in the hematoxylin-eosin-stained slides was analyzed statistically. The immunostaining scores for fascin and podoplanin were significantly higher in dysplasia and CIS than in benign disease (p=0.0011, p=0.00036), and they were significantly higher in dysplasia than in benign disease (p=0.0087, p=0.0032). In all cases of invasive SCC, fascin was expressed mainly in the cytoplasm of the tumor cells and fascin expression extended from the destruction of the basal layer of the epithelium to the upper layer of the epithelium and podoplanin was expressed in the cytoplasm and membrane of the tumor cells. This was the first report of up-regulation of fascin in oral dysplasia. Our results suggest that it would be helpful for improving the diagnostic accuracy of oral dysplasia and CIS to assess the expression of fascin and podoplanin immunohistochemically.

Intraosseous hemangioma of the vomer: a case report.

We describe an unusual case of intraosseous hemangioma of the vomer. The lesion had a characteristic radiographic appearance, especially on the computed tomographic scan. The two most interesting points in this case were the rarity as a site for the occurrence of hemangioma and the successful extirpation of the tumor via the Le Fort I osteotomy approach without embolization of the feeding vessels. The benefits of this approach included the wide surgical field afforded deep in the midface region, which was important for controlling bleeding, as well as the complete extirpation of the tumor.

Validation of Nomogram-based Prediction of Survival Probability after Salvage Re-irradiation of Head and Neck Cancer

OBJECTIVE Treatment outcomes after salvage re-irradiation in patients with recurrent head and neck cancer vary widely due to heterogeneous patient characteristics, and it is difficult to evaluate optimal re-irradiation schedules. This study aimed to validate a nomogram, originally developed by Tanvetyanon et al., used to predict the survival probability of patients with recurrent head and neck cancer after re-irradiation. METHODS Twenty-eight patients with recurrent head and neck cancer who underwent salvage re-irradiation between June 2007 and November 2011 were evaluated. The median total dose used for initial radiotherapy was 60 Gy (range, 22-72). Re-irradiation sites included the nasopharynx or Rouvieres node (n = 14), external ear (n = 4), neck lymph node (n = 3) and other sites (n = 7). Overall survival after re-irradiation was calculated using the Kaplan-Meier method, and the 2-year survival probability was estimated using Tanvetyanons nomogram. RESULTS Twenty-two patients were treated with stereotactic body radiotherapy using a median total dose of 30 Gy (range, 15-40) in 1-7 fractions and six patients were treated with conventional external beam radiotherapy using 45 Gy (range, 23.4-60) in 10-30 fractions. The 2-year overall survival was 21.7% (95% confidence interval: 9.3-41.3), and the 2-year survival probability was 16.8% (95% confidence interval: 9.9-23.6). The 2-year overall survival in 20 patients with unfavorable prognosis (median 2-year survival probability, 5.5%) and in 8 patients with favorable prognosis (median 2-year survival probability, 45%) were 11.0 and 45.7%, respectively (P = 0.05). CONCLUSIONS Our findings show that Tanvetyanons nomogram accurately estimates the survival probability in patients with recurrent head and neck cancer after re-irradiation.

Monophasic synovial sarcoma of the nasopharynx.

Synovial sarcomas are rare, aggressive malignant neoplasms, and less than 10% of cases involve the head and neck. Cases that involve the nasopharynx are even more exceptional and little information is available concerning their diagnosis and management. We report the third case of synovial sarcoma of the nasopharynx, which was diagnosed as a monophasic type and was successfully treated with a complete surgical excision followed by irradiation. The present case indicates that appropriate immunohistochemical and cytogenetic analysis are essential for accurate diagnosis of monophasic synovial sarcoma in unusual locations. A review of the literature indicates that synovial sarcoma of the nasopharynx exhibits an improved prognosis following tumor resection and postoperative adjuvant radiation unless it invades adjacent bones, even though the tumor is larger than 4 cm.

Waveform changes in antidromic facial nerve responses in patients with Bell's palsy.

We repeatedly tested the antidromic facial nerve response within 7 days after onset of paralysis in patients with Bells palsy. None of 109 patients showed the triphasic waveform that reflects normal conduction of the facial nerve action potential. The waves recorded from patients showed biphasic, monophasic, or flat waveforms. Eighty-two of 88 patients with complete recovery showed biphasic waves, whereas half of the patients with nerve degeneration had monophasic or flat waves. Most patients with complete recovery maintained biphasic waves, but in patients with incomplete recovery, the waveforms changed to monophasic or flat, except in 1 case. The presence of monophasic or flat waves with a low facial score strongly suggests nerve degeneration. The antidromic facial nerve response is recommended as a method of diagnosing paralysis and monitoring the progression of intratemporal facial nerve damage during its early stages.

Free jejunal transfer for a 15-year-old girl with synovial sarcoma of the hypopharynx *

INTRODUCTION Synovial sarcomas are rare, aggressive malignant soft-tissue tumours. Approximately 85-90% of synovial sarcomas occur in the extremities, with only 3% arising in the head and neck region. The hypopharynx as a site of occurrence has only rarely been reported. We describe herein our experience of free jejunal transfer for an adolescent patient with synovial sarcoma of the hypopharynx. CASE REPORT A 15-year-old girl presented with a 2-month history of swallowing difficulties and hoarseness. Laryngoscopy revealed a mass filling the hypopharynx, almost occluding the larynx. Histological diagnosis obtained by biopsy was synovial sarcoma. The patient underwent total pharyngo-laryngo-oesophagectomy and reconstruction with a free jejunal graft. Postoperative chemotherapy and radiotherapy was performed. She has been free of recurrence or metastases for 2 years and 6 months. The patient can take a normal diet without dysphagia. DISCUSSION Synovial sarcomas are rare, malignant, soft-tissue tumours primarily affecting the extremities, with only 3% arising in the head and neck region. The cornerstone of treatment for synovial sarcomas is complete surgical resection. Recently, total pharyngo-laryngo-oesophagectomy and free jejunal transfer have become the standard technique for patients with malignancies confined to the hypopharynx because of the minimal morbidity and mortality, favourable functional outcome and low incidence of complications associated with the donor site. CONCLUSION We report the case of a 15-year-old girl with synovial sarcoma of the hypopharynx. We performed a total pharyngo-laryngo-oesophagectomy and reconstruction with a free jejunal graft. The postoperative course and the functional outcome were satisfactory.