Yukinori Kimura

Burkitt's lymphoma involving the mandible: Report of a case and review of Japanese cases

A Japanese case of Burkitts lymphoma is presented. The intraoral and panoramic images showed alveolar bone destruction with an infiltrative border, displacement of lower molars, root resorption, and loss of lamina dura and the follicular cortex of a developing tooth, similar to descriptions in previous reports. Computed tomography revealed that a primary lesion occupied the mandible and extended to the muscles of facial expression and to the sublingual and submandibular spaces. Another soft tissue mass was evident in the contralateral parapharyngeal space. Results of a survey of the Japanese literature are also presented; they indicate differences in the clinical features between Japanese cases and African and American cases of Burkitts lymphoma.

Cytokeratin expression profiling is useful for distinguishing between primary squamous cell carcinoma of the lung and pulmonary metastases from tongue cancer

It can be difficult to distinguish between primary and metastatic squamous cell carcinoma (SCC) in the lung. Surgical specimens were obtained from two groups of patients, 26 lung SCC patients without histories of any other cancer (the definite primary group) and 17 patients who had undergone surgical removal of SCC emerging in the lung after surgery for tongue SCC (the unknown group). From the former, 26 primary lung SCC were obtained. From the latter, 17 lung tumors and 15 primary tumors of the tongue were obtained. Eleven of the 17 lung tumors from the unknown group were metastatic lung SCC. All specimens were immunostained with cytokeratin (CK)5/6, CK7, CAM5.2, CK19 and p63 antibodies. The frequency of CAM5.2 and CK19 expression was significantly higher in the lung SCC of the definite primary group (21 of 26, 81% and 20 of 26, 78%, respectively) than in the metastatic lung SCC (1 of 11, 9% (P < 0.001) and 2 of 11, 18% (P= 0.003), respectively) or primary SCC of the tongue (5 of 15, 33% (P= 0.002) and 2 of 15, 13% (P < 0.001), respectively). CAM5.2 and CK19 are useful for distinguishing between primary SCC of the lung and metastases from tongue cancer.

The pharyngeal mucosal, parapharyngeal, and retropharyngeal spaces

Mass lesions in the deep neck spaces cannot be examined directly but instead require sectional imaging examinations. This pictorial essay reviews cases of mass and/or mass-like lesions in the oral cavity and/or the pharyngeal region that were radiologically diagnosed at our department. The purpose of this paper is to introduce to oral radiologists several key points in the sectional imaging diagnosis of a variety of lesions of the pharyngeal mucosal space, parapharyngeal space, and retropharyngeal spaces. To help readers make full use of CT or MR image findings of lesions in these spaces, we provide actual images of common diseases that occur in either the oral cavity or the neck. By focusing on displacements of fat, vessels, muscles, and bony structures in each space, oral radiologists can narrow the range of possible differential diagnoses. Familiarity with not only the anatomy of these spaces but also with the diseases specific to them and, in turn, their radiological manifestations, can help oral radiologists reach an accurate diagnosis.Mass lesions in the deep neck spaces cannot be examined directly but instead require sectional imaging examinations. This pictorial essay reviews cases of mass and/or mass-like lesions in the oral cavity and/or the pharyngeal region that were radiologically diagnosed at our department. The purpose of this paper is to introduce to oral radiologists several key points in the sectional imaging diagnosis of a variety of lesions of the pharyngeal mucosal space, parapharyngeal space, and retropharyngeal spaces. To help readers make full use of CT or MR image findings of lesions in these spaces, we provide actual images of common diseases that occur in either the oral cavity or the neck. By focusing on displacements of fat, vessels, muscles, and bony structures in each space, oral radiologists can narrow the range of possible differential diagnoses. Familiarity with not only the anatomy of these spaces but also with the diseases specific to them and, in turn, their radiological manifestations, can help oral radiologists reach an accurate diagnosis.

Plasmablastic lymphoma of the maxillary sinus with intraoral manifestation caused by direct alveolar bone infiltration in an HIV‐negative patient

To the Editor: Plasmablastic lymphoma (PBL) of the oral cavity was first described by Delecluse et al. in 1997 as a new entity of a form of non-Hodgkin lymphoma (NHL) associated with human immunodeficiency virus (HIV) infection. They reported a series of sixteen highly malignant diffuse large B-cell lymphomas of the oral cavity with unique immunohistologic features. All their cases displayed morphologic features of diffuse large-cell lymphomas, but strikingly differed from them in that they showed minimal or absent expression of the leukocyte common antigen (CD45) as well as B-cell antigen CD20. Alternatively, the tumor cells showed constant expression of the characteristic plasma cell antigens (VS38c and CD38), frequent expression of CD79a, variable expression of cytoplasmic immunoglobulins and monoclonal rearrangement of the immunoglobulin heavy chain gene. PBL has been listed in the 2008 World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues as a non-Hodgkin B-cell lymphoma occurring predominantly in HIV-positive patients. PBLs account for approximately 2.6% of all HIV-related NHL. Here, we present a case of PBL of the maxillary sinus with intraoral manifestation caused by direct alveolar bone infiltration in an HIV-negative patient. A 50-year-old female had been treated with endodontologic management for spontaneous pain and increase of mobility of the left second molar of the maxilla for two months prior to tooth extraction, and thereafter, wound healing failed to occur. The patient was admitted to the Dental Hospital of Showa University for referral to oral surgery. On examination, a gingival ulcer, 15 × 12 mm in size, was found in the extraction site of the left second molar of the maxilla. Laboratory findings showed increases in lactate dehydrogenase (262 U/L), creatinine kinase (380 U/L) and γ-glutamic transferase (97 U/L), and revealed high thymol turbidity test (7.2 U). Complete blood count and differential peripheral white blood cell count were normal. All other laboratory data examined were within normal ranges. Computed tomography (CT) detected a lesion, 40 × 35 × 50 mm in size, occupying the left maxillary sinus, which partially destroyed the medial and posterior walls of the maxillary sinus, and extended into the nasal cavity with permeated pattern without definite central necrosis (Fig. 1a). Further, this lesion pressed against the left orbital floor, directly infiltrated into the alveolar bone of the left maxillary molar region, and caused intraoral manifestation (Fig. 1b). Nodal involvements were suggested in the left submandibular and cervical lymph nodes from diagnostic imaging. The patient had no history of autoimmune and lymphomatous diseases. There was no evidence of immunosuppression. Biopsy was performed from the gingival ulcer which showed that the lesion was composed of diffuse and cohesive monotonous proliferation of large atypical lymphoid cells with immunoblastic or plasmablastic features (Fig. 1c,d). The nuclei were usually oval with prominent nucleoli. Only a few plasmacytic-like differentiations were identified. Apoptotic cells and mitotic figures were frequently observed. A few tingible body macrophages were sporadically present. Immunohistochemically, the atypical lymphoid cells were positive for CD45 and partially positive for CD79a, but negative for CD20 (L26) (Fig. 2b) and PAX5. Regarding the expression of plasma cell-associated antigens in the atypical lymphoid cells, CD138 was sporadically positive and VS38c (Fig. 2a) was diffusely positive. These cells were also positive for MUM-1, and focally positive for EMA and CD30. Proliferation rate as assessed by Ki-67 staining was more than 90% (Fig. 2c). Definite immunoglobulin light chain restriction was not detected by assessment for immunoglobulin kappa and lambda light chain antibodies. In situ hybridization showed positivity for Epstein-Barr virusencoded RNA (EBER) (Fig. 2d). The atypical lymphoid cells were negative for Bcl2, Bcl6, Cyclin D1, CD3, CD5, UCHL-1, CD8, CD56, TIA-1, Granzyme B and HHV8 LNA. The diagnosis of PBL was made. The patient was referred to the Department of Hematology at another hospital for further examination and treatment. No other organ and bone marrow involvement was identified, and the patient was evaluated as Stage II (Ann Arbor staging system). Serological screening was negative for hepatitis B virus, hepatitis C virus and HIV. The patient was treated with four cycles of chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) and has been in complete remission. Recent examination of this patient at 9 months after chemotherapy showed no evidence of recurrence. To date, there have been four cases reported of PBL primarily arising in the maxillary sinus with HIV negativity, including the present case. Their ages ranged from 24 to 86 years, with a mean age of 51 years, and male-to-female ratio of 1:1. One patient died of disease at 4 months after diagnosis, while the other patients were all alive for more *Correspondence: Tarou Irié, e-mail: tarou@dent.showa-u.ac.jp Disclosure: No conflict of interest declared. †Contributed equally to this work. Pathology International 2014; 64: 588–590 doi:10.1111/pin.12212 bs_bs_banner

Hyoid bone position related to gender and aging using lateral cephalometric radiographs

Abstracts Purpose The purpose of this study was to assess hyoid bone position related to gender and aging using lateral cephalometric radiographs in 22 to 84 years old patient. Materials and methods Lateral cephalometric radiographs of 459 patients were reviewed retrospectively. The position of the hyoid bone was assessed in terms of horizontal position, rotation, and vertical position. Data were compared between age groups for both genders. Two-factor analysis of variance and Tukey’s honest significant difference (Tukey’s HSD) test were performed. Results Mean vertical distance in the 22–29-year age group and the 60–84-year age group was 0.2 mm and 9.7 mm, respectively, among males, and −4.3 mm and −0.3 mm, respectively, among females. There was a trend toward larger measurements in the vertical position in older males (P < 0.001). Among males, all measurements tended to increase significantly with age (P < 0.001). In the over 60-year age group, the posterior position and rotation of the hyoid bone were almost the same for males and females. Conclusion Age-related changes in hyoid bone position may decrease swallowing safety. Oral frailty, an early sign of orofacial muscle weakness and functional deterioration, negatively influences dental treatment and swallowing. The hyoid bone shifted to a posterior, rotated, and lower position with increasing age. Especially among males in the over 60-year age group, the hyoid bone had shifted significantly to a lower position. We should focus into the hyoid bone position in lateral cephalometric radiograph.

Evaluation of prevalence and characteristics of ponticulus posticus among Japanese adults: A comparative study between CBCT imaging and lateral cephalogram

Abstract Purpose Purpose of the study was to evaluate the prevalence and precise characteristics of ponticulus posticus (PP) among Japanese adults using CBCT, and to evaluate the accuracy of PP by using the lateral cephalogram. Materials and methods This retrospective study consisted of lateral cephalogram and CBCT scans of 204 subjects (46 Males and 158 Females) above the age of 20 years. Prevalence and characteristics of PP was assessed. Chi-square test was used for statistical analysis. Results 30 PP positive cases (14.7%) were defined by using CBCT. 12.7% subjects were assessed PP positive cases on lateral cephalogram. The accuracy of PP by using cephalogram was 0.89, sensitivity was 0.56 and specificity was 0.95.On CBCT assessment, there were 16 PP (7.8%) present on right side of Atlas whereas 23 PP (11.2%) were present on left side. Statistically significant difference was seen in the prevalence of left side PP. Among the 158 females 25 (15.8%) had PP whereas out of 46 males 5 (10.8%) had PP. No statistical significant differences were seen in gender and age groups. Conclusion PP is quite a common finding in Japanese adults. There were cases in which PP was not detected on lateral cephalogram compared with CBCT.

Lateral retropharyngeal node metastasis from squamous cell carcinoma of the upper gingiva: a report of three advanced cases and review of the reported Japanese cases

われわれの施設では, 2002年から2004年にかけて上顎歯肉扁平上皮癌進行例の3例に外側咽頭後リンパ節 (LRPN) 転移がみられた。断層画像では, 原発腫瘍は大臼歯部歯肉から硬口蓋へ浸潤し, また患側の後咽頭間隙内に各々, 10×10mm, 11×8mm, 9×5mmの大きさの転移性リンパ節が認められた。これら3症例と本邦における論文で報告されている, LRPN転移を生じた他の上顎歯肉癌7例を, 原因となったリンパ路と臨床的特徴に重点を置いて分析した。LRPN転移は, 2例では切歯管・鼻腔底―上咽頭側壁路あるいは5例で硬口蓋―口蓋帆挙筋内側路として輸入リンパ管に由来した可能性がある。他の3例では, 頸部郭清術や多発性頸部転移によって生じた通常はみられない逆行性リンパ流に, このような稀な転移が由来した可能性がある。頸部転移のあった8例中7例でLRPN転移が同側にみられた。これらの7例中4例で, 顎下部または上頸部リンパ節転移が同時にみられた。2例では初診時の断層画像でLRPN転移がみられ, 3例は初回治療終了直後にみられたが, これらの各々が進行癌: (r) T3-4であった。一方, (r) T1-2の4例ではLRPN転移は後発転移であった。よって, 上顎歯肉癌が生じた場合では常に, 外側咽頭後リンパ節は断層画像において関心を寄せるべきである。

Parotid Node Metastasis from Oral Mucosal Squamous Cell Carcinomas: a report of four cases

頭頸部領域の扁平上皮癌の耳下腺リンパ節転移は, 頸部への転移頻度と比較すると頻繁に生じるものではない。耳下腺リンパ節転移のリスクが高い癌がみられる原発領域は, 耳, 眼瞼, 頬後方部, 側頭部および前頭部の頭皮であると報告者によって記載されている。それ故に, 口腔粘膜の扁平上皮癌患者では耳下腺リンパ節は転移を生じうる部位としては見落とされる。口腔からの耳下腺リンパ節転移の症例は, 文献上でも報告が極めて少なく, どのような患者が耳下腺リンパ節転移に発展するリスクがあるのかについては殆ど知られていない。われわれの施設にて, 1990年から2003年の問に耳下腺転移性病変を生じた口腔癌患者の4例をレトロスペクテイブに評価した。そこで, このような症例をCT所見と共に報告し, この主題に関する文献を特に耳下腺リンパ節の解剖学とリンパの経路に重点を置いてレビューした。耳下腺内病変のrim-enhancementとcentral low density areaが耳下腺リンパ節転移の画像診断には有用であった。解剖学的研究によると, 耳下腺リンパ節ヘリンパ排出する口腔の部位は限られているが, 実際口腔のどの部位からも悪性病変の耳下腺リンパ節転移が報告されている。われわれの経験と文献のレビューから, 耳下腺リンパ節は上頸部リンパ節転移に対する頸部郭清術や放射線治療とも関連しているようである。それ故に, 断層画像で上頸部にリンパ節性病変が認められた場合には, 特に治療後においては耳下腺リンパ節への転移に関して耳下腺領域を注意深く検査するべきであろう。口腔扁平上皮癌が耳下腺リンパ節に転移するのは稀れではあるが, 経過観察においては実際的に考慮すべき余地を残している。

Buccinator lymph node metastasis from oral aud maxillary cancers suspected by imaging: Report of two cases.

Facial Lymph Nodesの1つで頬筋上にある頬リンパ節への顎口腔領域の癌の転移は非常に稀れである。頬リンパ節の転移性病変が画像診断された例は文献的には10例しかみられない。本報告では, 顎口腟癌からの転移の2例を紹介する。1例は84歳の女性で頬粘膜扁平上皮癌 (T2N1M0) であった。頬粘膜に粘膜下の硬結を伴うポリープ状腫瘤性病変を認め, CTでは, その病変の深部に位置する典型的な転移性リンパ節の所見を呈した別の腫瘤性病変を認めた。他の1例は51歳の男性で上顎洞扁平上皮癌 (T4N1M0) であった。CTとMRでは, 頬部の皮下組織層へ高度に浸潤した腫瘍とは離れて頬脂肪体内に典型的な転移性リンパ節の所見を呈した別の腫瘤を認めた。頬リンパ節転移は, Facial Lymph Nodesの中では最も転移が多くみられ (57%) , 頸部リンパ節転移を合併することは稀である (12%) 。自験例を含めた文献的考察によると頬リンパ節転移の原発部位は頬粘膜や上顎洞が最も多い。これらの結果から, 頬粘膜癌や上顎洞癌の症例では頬リンパ節の評価に断層画像を含めた注意深い検査を要することが示唆される。

Bilateral metastases to lateral retropharyngeal nodes from upper gingival and maxillary sinus cancers: report of two cases.

外側咽頭後リンパ節いわゆるルビエールリンパ節 (RN) への口腟癌の転移は非常に稀である。顎口腔領域の癌から両側性にRNへの転移をきたした2症例を報告する。1例は51歳の男性で, 上顎歯肉癌 (TINO) に対する上顎部分切除後に局所再発と両側頸部リンパ節転移を生じた。両側の頸部郭清術と上顎亜全摘を施行したが, 8か月後にCTで片側のRN転移がみられた。その後, 化学療法を繰り返したが, 約6か月後のCT検査で対側にも本リンパ節転移がみられた。よって, 両側のRN転移と診断した。他の1例は66歳の男性で, 上顎洞癌 (T3N1) であった。化学療法を同時併用した放射線治療後に, 上顎部分切除と上頸部郭清術を施行した。しかし, 術後9か月にCTで頸部リリンパ節転移とRN転移がみられた。頸部へ外照射を施行したが, 1か月にCTで対側のRN節転移がみられ両側転移と診断した。2例ともRN転移への治療効果がみられたが, 2か月前後で遠隔転移にて死亡し極めて予後不良であった。本転移の原因として, 頸部郭清術や腫瘍塞栓によるリンパ流が変化が考えられた。両側転移は, 対側からの転移や全身性に生じた遠隔転移の結果として成立したものと推測した。よって, 口腔癌と言えど症例によっては, RNの画像診断学が必要であると考えられた。