Munenaga Nakamizo

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.

Solitary Fibrous Tumor of the Cervical Esophagus

Solitary fibrous tumors (SFTs), so-called localized fibrous tumors or fibrous mesotheliomas, are rare tumors originating from the mesenchymal tissue, and were first described as a distinct entity in 1931 by Klemperer and Rabin [1]. SFT has received different names, such as subpleural fibroma and benign or localized (fibrous) mesothelioma because of controversy surrounding its histogenesis (mesothelial versus submesothelial). About 700 cases of SFTs were described from 1942; in 85–90% of cases they arose from the pleura, but have also been described in other locations in the body, including the pelvic cavity, nasal cavity, pulmonary parenchyma, meninges, kidney, lung, mediastinum, retroperitoneum, temporal region, neck, groin, buttock, and thigh [2–16]. We report a case with an SFT arising from the cervical esophagus accidentally discovered by endoscopic examina-

Ultrasonographic demonstration of retropharyngeal lymph nodes: Preliminary report

The aim of this study was to describe the results of ultrasonography of upper retropharyngeal lymph node (RPN) metastasis in patients with pharyngeal carcinomas. A total of 10 patients with metastatic RPN were examined using percutaneous ultrasound (US) with 3.5-MHz probes. Primary cancer sites were the nasopharynx in two patients, the oropharynx in three and the hypopharynx in five. Metastatic RPNs lay in the level of occipital bone in five patients, C1 in nine, and C2 in five. US images were compared with previously obtained computerized tomography (CT) images based on size and depth. In all of the 10 patients, metastatic RPNs were ultrasonographically demonstrated as hypoechoic masses. Nodal sizes ranged from 1.5 cm to 3.5 cm both in CT and in US. Depths of the RPN centers were from 3.5 cm to 7.0 cm in CT, and from 3.5 cm to 6.5 cm in US. Differences of sizes and depths between CT and US were from -0.5 cm to 0.5 cm and from 0.0 cm to 1.0 cm, respectively. RPNs that are 1.5 cm or more in size can be demonstrated with percutaneous US using CT guidance. This technique should be utilized for the purpose of monitoring in a radiation therapy setting.

Short-time ultrasound of head and neck squamous cell carcinoma under radiotherapy.

To evaluate the efficacy of ultrasonography for patients with head and neck squamous cell carcinoma before and during radiotherapy (RT), consecutive patients with macroscopic lesions were examined before and during RT. Each scan was performed percutaneously in a short time (less than 5 min). The demonstration rate of primary tumors and the largest node of previously known metastatic cervical nodes were measured. Of all 190 patients, 91 primary tumors were detected (47.9%). Primary tumors in oral cavity, oropharynx, hypopharynx and cervical esophagus were determined in over 70% and, for those of nasopharynx and larynx, the demonstration rates were 30% or less. Nodal metastases were visualized in 78 of 80 patients with regional metastases (97.5%). Using the above information, 73 patients (38.4%) received the benefit of radiation therapy. Short-time sonography is a valuable modality for patients with selected sites of head and neck cancers.

Descending necrotizing mediastinitis associated with Lactobacillus plantarum

BackgroundDescending necrotizing mediastinitis (DNM), a severe infection with a high fatality rate, develops in mediastinal spaces due mainly to deep cervical abscesses. The majority of causative microbes of DNM are Streptococci and oral anaerobes. DNM associated with Lactobacillus-infection is rather rare.Case presentationA 69-year-old male with an unremarkable past medical history was referred to our hospital for surgical resection of advanced laryngeal cancer. Full examination revealed a neck abscess and DNM with a background of untreated diabetes mellitus. Initially, he was treated with meropenem. However, Lactobacillus plantarum was isolated from surgical drainage of a mediastinal abscess. Despite using antibiotics capable of eradicating all isolates with susceptibilities not differing significantly from those of the neck and mediastinal abscesses, we attributed DNM to the L. plantarum detected only in the mediastinal abscess. After DNM treatment, he underwent total pharyngolaryngectomy with bilateral neck dissection followed by reconstruction using free jejunum. He was discharged fully recovered.ConclusionWe concluded that L. plantarum as the sole cause of the mediastinal abscess in the present case cannot be ruled out. As the number of immunocompromised patients increases, we should be cautious regarding this “familiar” microbe.

A Comparison of Microsurgical Venous Anastomosis Techniques

BACKGROUNDnSuccessful vascular anastomosis is essential for the survival of transferred free tissue. Arterial anastomosis is typically uncomplicated because the lumen is easily maintained and the vessel walls have elasticity. Venous anastomosis, however, is more time consuming because the vessel walls are thin and extensible. This article describes, reviews, and compares 3 currently used venous anastomosis techniques.nnnMETHODSnFrom April 2012 through January 2014, free tissue transfer and supercharging pedicled tissue transfer were performed in 107 and 10 patients, respectively, at our hospital. According to the anastomotic technique used, patients (83 men and 34 women; mean age, 60.6 years) were divided into interrupted suture, continuous suture, and microvascular anastomotic coupling device (MACD) groups. Medical records were reviewed, and postoperative results were analyzed.nnnRESULTSnThe diameter of anastomosed veins did not differ significantly among the groups. However, among the interrupted suture, continuous suture, and MACD groups, there were significant differences in vascular anastomosis time (51, 43.9, and 29.5 minutes, respectively) and transferred tissue ischemic time (151.9, 139.1, and 117.5 minutes, respectively). Surgical site infection occurred in 9 patients, and flap necrosis occurred in 2 patients. However, complication rates did not differ significantly among the 3 groups.nnnCONCLUSIONSnThe venous anastomosis technique does not affect the complication rate but does affect anastomosis time and flap ischemia time. On the basis of these results, we believe that the continuous suture and MACD techniques are easier and safer for venous anastomosis than is the traditional interrupted suture technique.

Carcinosarcoma ex Pleomorphic Adenoma of the Submandibular Gland in a 64-Year-Old Man: A Case Report

Carcinosarcoma (CS) is a rare tumor, consisting of both carcinomatous and sarcomatous components. In this paper, we present a case of CS arising from a pleomorphic adenoma (PA) of the submandibular gland. A 64-year-old Japanese man presented with a left submandibular mass that had developed for 20 years with complaints of pain for the last 3 months. Magnetic resonance imaging showed a lesion involving the left submandibular gland. The patient underwent total dissection of the left submandibular gland and left cervical lymph nodes. Upon gross examination, the mass appeared completely covered by fibroadipose tissue measuring 46×42×45 mm; sectioning revealed a solid-white nodule with central bleeding and necrosis, invading into the surrounding adipose tissue. Microscopically, the presence of carcinomatous and sarcomatous components in the fibro-myxomatous stroma was detected, suggestive of pre-existing PA. The carcinoma component was diagnostic of salivary adenocarcinoma, not otherwise specified, whereas the sarcomatous component exhibited features of osteosarcoma characterized by formation of osteoid. As the border between the carcinomatous and sarcomatous components was not evident, CS may have occurred via transformation of the carcinoma into sarcoma. Tumor metastasis was detected in the cervical lymph nodes. Immunohistochemically, AE1/AE3 expression was noted in the carcinomatous component, but not in the osteosarcoma component. Both components were diffusely positive for vimentin. Four months after the operation, the patient developed a metastatic CS lesion in the lung, suggesting tumor aggression.

Crystalloid Granuloma of Parotid Gland: A Case Report With Review of the Literature

Crystalloid granuloma (CG) of salivary gland is an extremely rare inflammatory disease, and only 6 cases have been reported in the English literature. CG is histologically characterized by a granulomatous reaction to amylase crystalloid deposition. A 73-year-old woman presented with a painful left neck mass. Computed tomography depicted a mass located in the lower pole of the left parotid gland, suspicious for a tumoral lesion. Preoperative fine needle aspiration cytology found amylase crystalloid deposition with a few inflammatory cells. Surgical sections of the mass revealed formation of a granuloma containing abundant eosinophilic but glassy and transparent amorphous crystalloids, suggestive of α-amylase crystalloid. No neoplastic elements were detected. The case was eventually diagnosed with CG in the parotid gland. Our findings suggest that when we identify amylase crystalloids in fine needle aspiration cytology smears from the salivary gland, CG should be considered even if neoplasm is clinically or radiographically suspected.

Phlegmonous gastritis associated with advanced esophageal cancer.

Phlegmonous gastritis is a rapidly progressive bacterial infection of the stomach wall. It has a high mortality rate and aggressive treatment, either with antibiotics or surgical resection, is required. Here, we report an extremely rare case of phlegmonous gastritis associated with advanced esophageal cancer. A 65-year-old Japanese man was urgently admitted to the hospital due to pyrexia and gastrointestinal symptoms. Abdominal computed tomography revealed widespread diffuse thickening of the gastric wall. On endoscopic examination, an ulcerative mass was detected at the lower thoracic esophagus, and a markedly elevated submucosal lesion was present in the middle of the stomach body. Biopsy specimens taken endoscopically from the esophageal tumor confirmed a diagnosis of squamous cell carcinoma. Gastric biopsy cultures were positive for Streptococcus viridans, leading to a diagnosis of phlegmonous gastritis associated with esophageal cancer. After the patient’s condition improved with preoperative antibiotic administration, we performed a thoracoscopic esophagectomy, a total gastrectomy and a reconstruction of the gastrointestinal tract using a pedicled right colon. Histological examination of the resected specimen confirmed that the gastric mass was compatible with a phlegmon.

Extranodal Natural Killer/T-Cell Lymphoma, Nasal Type, with Primary Manifestation as an Upper Eyelid Swelling.

Extranodal natural killer/T-cell lymphoma (ENK/TCL) is most often in the nose or the nasopharynx but can present elsewhere. We report a rare case of ENK/TCL that presented as swelling of an upper eyelid without ocular involvement. A 76-year-old man visited our hospital with a swollen lesion of the left upper eyelid which had appeared 2 months earlier. A biopsy of the upper eyelid revealed slight perivascular and periadnexal infiltration of mononuclear cells with dermal edema. Treatment with oral prednisolone at a dosage of 20 mg/day decreased the eyelid swelling. However, 5 months later, exacerbation of the swelling and nasal congestion were observed. A second biopsy of the upper eyelid revealed a diffuse dermal infiltrate composed of mononuclear cells with an angiocentic growth pattern. Immunohistochemical studies and in situ hybridization showed natural killer-lineage antigens (CD56, granzyme B, and T-cell intracellular antigen 1) with expression of Epstein-Barr virus. These findings lead to the diagnosis of ENK/TCL. We treated the patient with radiation therapy (50 Gy) and 3 courses of a regimen including dexamethasone, carboplatin, etoposide, and ifosphamide. This case suggests that ENK/TCL can present with swelling of an upper eyelid as the primary sign of the skin lesion. Swelling of an upper eyelid should be considered in the differential diagnosis of ENK/TCL.