野口 忠秀

Background: Melanotic neuroectodermal tumor of infancy (MNTI) is a very rare tumor, and case reports of orthodontic treatment for patients with MNTI may be previously unreported. This article describes the orthodontic treatment for a 7-year-old girl with MNTI in the mandible. Case: Her chief complaint was anterior crossbite. Although she had an MNTI diagnosis at the age of 8 months, it remained subclinical. Therefore, she has been regularly followed-up by computed tomography (CT) and magnetic resonance (MR) imaging without aggressive treatment. We had worried about the stimulation of MNTI on the mandible by changing her occlusal position with orthodontic treatment. Therefore, we sufficiently explained to her and her family that orthodontic treatment was at risk for worsening MNTI. However, they desired treatment that consisted of maxillary protraction and slow expansion to correct anterior crossbite and encourage the permanent tooth eruption. After 19 months of active orthodontic treatment, the anterior crossbite was improved, and the eruption of permanent teeth made good progress. No evidence of progression and exacerbation of MNTI has been found by both CT and MR imaging. As the observation period is still short, we need a careful and long-term follow-up of her occlusion and MNTI. Furthermore, when we encounter rare cases without previous experience and reports, informed consent was of particular importance.

縫合糸膿瘍は、頭頸部悪性腫瘍の術後にしばしば遭遇し、その臨床症状ならびに画像所見から局所再発やリンパ節転移との鑑別を要することがある。今回われわれは、口腔癌頸部郭清術後の創部に多発した縫合糸膿瘍の1例を経験したので報告する。患者は71歳、女性。右側口底部扁平上皮癌に対して両側肩甲舌骨筋上郭清術、口底部腫瘍切除術、血管柄付き遊離前腕皮弁による再建術を施行した。術後4ヵ月頃から両側顎下部に皮下膿瘍を認めるようになり、膿瘍の掻爬物中に縫合糸を認めたことから縫合糸膿瘍と診断した。その後も顎下部から中頸部に多発した皮下腫瘤を認めるようになり、CT、MR、FDG-PETでは頸部再発が疑われる所見であった。超音波検査では腫瘤は縫合糸膿瘍の可能性が示唆された。顎下部皮下腫瘤に対し摘除生検を施行したところ、腫瘤内には結紮に使用した絹糸が認められた。病理組織学所見でも縫合糸を取り囲むように限局した炎症性細胞浸潤、毛細血管増生からなる肉芽組織を認め、縫合糸膿瘍と診断した。経過観察中も頸部ならびに皮弁採取部の前腕部の皮下にも同様の所見を認めたため、腫瘤の摘除を行ったところ縫合糸膿瘍であった。本邦において血管結紮への吸収性縫合糸の転換はまだ課題が多く、適切な条件下でエナジーデバイスを有効利用することは、縫合糸膿瘍の形成リスクを減少させるための1つの方法に成り得ると考えられる。(著者抄録)

For doctors and other medical staff treating oral cancer, it is necessary to standardize the basic concepts and rules for oral cancer to achieve progress in its treatment, research, and diagnosis. Oral cancer is an integral part of head and neck cancer and is treated in accordance with the general rules for head and neck cancer. However, detailed rules based on the specific characteristics of oral cancer are essential. The objective of this article was to contribute to the development of the diagnosis, treatment, and research of oral cancer, based on the correct and useful medical information of clinical, surgical, pathological, and imaging findings accumulated from individual patients at various institutions. Our general rules were revised as the UICC was revised for the 8th edition and were published as the Japanese second edition in 2019. In this paper, the English edition of the "Rules" section is primarily presented.

骨髄移植後の合併症の一つとして移植片対宿主病が生じる。慢性GVHDに伴う口腔病変は癌を発生するリスクが高い。われわれは骨髄異形成症候群の骨髄移植後に、慢性GVHDに伴う口腔病変を発症し、その後、舌癌と診断し術後早期に再発した症例を経験したので、その概要を報告する。(著者抄録)

症例は59歳女性で、左側上顎前歯部歯肉の腫脹を主訴とした。局所麻酔下にて左上2歯根嚢胞摘出および抜歯術を施行し、欠損部にβ-リン酸三カルシウム(β-TCP)の填入を行った。しかし、填入から4ヵ月後にインプラント埋入目的でパノラマエックス線とCT撮影を行ったところ、埋入予定部位の骨不透過像が不均一になっていた。インプラント埋入時、左上2番相当部に填入したβ-TCPは概ね周囲骨と同化していないため、骨化していないβ-TCPを可及的に除去した。β-TCPを除去するとトンネル状の骨欠損を認めたため、インプラント埋入窩を形成し、インプラント埋入後に下顎枝より採取した自家骨をインプラント周囲に移植した。6ヵ月の免荷期間ののちにインプラント二次手術を施行、インプラント周囲の骨は骨化しており、インプラント体の露出は認められなかった。

Le Fort I型骨切り術(LI)単独と馬蹄形+LIを比較し、馬蹄形+LIによる上下顎移動術の有用性について検討した。当院で施行した上下顎移動術22症例のうち、馬蹄形+LI 4症例を対象とした。出血量については、馬蹄形+LIは約635mL、LIは約379mLとなり、馬蹄形+LIとLIの出血量には有意差が認められた。手術時間は馬蹄形+LIは約5時間24分、LIは約5時間2分であり、馬蹄形+LIとLIの手術時間には有意差は認められなかった。馬蹄形の予定上顎移動量と実際の上顎移動量の比較については、前方部の予定移動量は3.75mm、実際の上顎移動量は3.3mm、後方部の予定移動量は4.25mm、実際の上顎移動量は2.8mmとなった。後方部の実際の上顎移動量が予定の上顎移動量より少なくなった理由として、後方部は蝶形骨翼状突起をはじめ下行口蓋動脈周囲の骨の干渉が完全に取り除けていなかったことなどが考えられた。

症例は31歳男性で、左頬部腫脹および疼痛が出現し、アジスロマイシン、ロキソプロフェンナトリウムの投与を受けるも改善せず、当院紹介受診となった。検査結果より上顎左67根尖病巣を起因とする左側頬部蜂窩織炎と診断し、セフトリアキソンナトリウムの投与と切開排膿処置による消炎治療を開始した。第1病日より全身倦怠感、腹痛、嘔吐が著明となり再度問診したところ、数週間前から1日2000mlの清涼飲料水を飲用していたことが明らかになり、さらに、5ヵ月前から20kgの体重減少を生じていたことが判明した。糖尿病性ケトアシドーシスの診断を得て内分泌代謝科に転科し、食止となり持続インスリン療法が開始され、第3病日に全身状態が改善した。第16病日には経口血糖降下剤に移行され、第17病日には原因歯である上顎左678の抜歯を行った。その後も血糖値は良好にコントロールされ、歯性感染症の再燃なく第22病日に退院となった。

BACKGROUND: Osteosarcomas of the head and neck region are rare entities that comprise < 10% of all osteosarcomas. Multimodality treatment of patients with osteosarcoma is well-established for osteosarcoma in long bones, and the benefits of chemotherapy in long bones are clearly known. However, there is no consensus regarding the effects of chemotherapy in cases of head and neck osteosarcoma. The prognostic factor for head and neck osteosarcoma is complete tumor resection with negative margin, which is a radical surgery. However, a clear margin may be difficult to achieve in the head and neck region. CASE PRESENTATION: We present a case of a 69-year-old Japanese woman who developed osteosarcoma of the condyle within the masticator space and infratemporal fossa, which was treated with radical surgery using a modified preauricular and transmandibular approach. Although we recommended adjuvant treatment after surgery, the patient refused this treatment. There was no evidence of local recurrence or distant metastasis through 30 months of follow-up. CONCLUSIONS: Our modified preauricular and transmandibular approach allowed access to the masticator space and infratemporal fossa, thereby increasing complete resection of the tumor and resulting in minimal functional and cosmetic deficits.

BACKGROUND: This multicenter retrospective study aimed to determine whether elective neck dissection (END) can be performed for T1-2N0M0 tongue cancer. METHODS: Patients with T1-2N0M0 tongue squamous cell carcinoma who received treatment between January 2000 and December 2012 were enrolled at 14 multicenter study sites. The 5-year overall survival (OS) and 5-year disease-specific survival (DSS) were compared between the propensity score-matched END and observation (OBS) groups. RESULTS: The results showed that the OS rates among the 1234 enrolled patients were 85.5% in the END group and 90.2% in the OBS group (P = 0.182). The DSS rates were 87.0% in the END group and 94.3% in the OBS group (P = 0.003). Among the matched patients, the OS rates were 87.1% in the END group and 76.2% in the OBS group (P = 0.0051), and the respective DSS rates were 89.2% and 82.2% (P = 0.0335). CONCLUSION: This study showed that END is beneficial for T1-2N0M0 tongue cancer. However, END should be performed for patients with a tumor depth of 4-5 mm or more, which is the depth associated with a high rate of lymph node metastasis. The use of END should be carefully considered for both elderly and young patients.

The purpose of this study was to evaluate surgical outcomes in elderly patients who had undergone free fibula flap transfer for malignant head and neck tumours. A retrospective chart review was performed to identify patients who had undergone free fibula flap transfer for mandibular reconstruction after malignant tumour resection at Jichi Medical University Hospital between May 2009 and April 2015. Enrolled patients were divided into an elderly group (≥80 years old) and a younger group (&lt 80 years old). Seventeen patients met the inclusion criteria and were included in the elderly group. Age at surgery ranged from 80 to 92 years. Thirteen patients (76.5%) experienced postoperative complications. Surgical site complications occurred in seven patients. The success rate of free fibula flap transfer was 100%. Systemic complications occurred in nine patients, most commonly delirium (n = 6). No perioperative mortality was encountered. The overall 1-year survival rate was 94.1% (16/17). No patient reported gait disturbance as a donor site complication or any other major complication. The incidence of postoperative complications did not differ significantly between the elderly and younger groups. Almost no difference in postoperative course was seen between the groups. Elderly patients appear to tolerate free fibula flap reconstruction just as well as younger patients.

Vascularized iliac bone grafts are used for mandibular reconstruction, but the factors affecting graft maintenance are unknown. This study explored the postsurgical changes in vascularized iliac bone grafts in patients who had undergone mandibular reconstruction after segmental resection. The study involved 24 patients (16 men and eight women) with oral tumours or osteoradionecrosis. Thirteen patients required bare bone grafting (BBG) and 11 patients required reconstruction with soft tissue coverage (six with a skin paddle and five with direct closure). The bone graft maintenance rate (with regard to the height of the centre of the graft) was calculated immediately after surgery and at 3, 6, 12, 24, and 36months after surgery. The maintenance rate was significantly lower in the BBG group than in the soft tissue coverage group at 3, 6, 12, 24, and 36months, and in those who were fitted with dentures compared to those who were not at 6, 12, 24, and 36months. Local infection also influenced the maintenance rate, but not significantly so. These findings indicate that the reconstruction technique and denture use can affect the bone graft maintenance rate after mandibular reconstruction with vascularized iliac bone grafts.

乾燥剤の誤飲・誤嚥は、高齢者や小児で多く認められる。酸化カルシウムは、食品乾燥剤として多用されており、シリカゲルと比較して誤飲した場合に発熱とアルカリによる粘膜腐食作用により症状が重症化しやすい。今回、われわれは乾燥剤の誤食により広範囲な口腔粘膜化学損傷を生じた1例を経験した。患者は74歳、女性で酸化カルシウムを誤食し当院を受診した。広範囲に口腔粘膜の潰瘍と舌の腫脹、口腔乾燥を認めた。入院の上、口腔衛生管理と栄養管理を行い症状は改善し15日目に退院となった。乾燥剤の種類と摂取量に基づいた適切な処置を行うことが肝要である。(著者抄録)

Objective: This study aimed to retrospectively evaluate the efficacy and safety of laser treatment of oral vascular lesions using the multiple spot irradiation technique with a single-pulsed wave. Background data: In laser therapy for vascular lesions, heat accumulation induced by excessive irradiation can cause adverse events postoperatively, including ulcer formation, resultant scarring, and severe pain. To prevent heat accumulation and side effects, we have applied a multiple pulsed spot irradiation technique, the so-called "leopard technique" (LT) to oral vascular lesions. This approach was originally proposed for laser treatment of nevi. It can avoid thermal concentration at the same spot and spare the epithelium, which promotes smooth healing. The goal of the study was to evaluate this procedure and treatment outcomes. Patients and methods: The subjects were 46 patients with 47 oral vascular lesions treated with the LT using a Nd:YAG laser (1064 nm), including 24 thick lesions treated using a combination of the LT and intralesional photocoagulation. Results: All treatment outcomes were satisfactory without serious complications such as deep ulcer formation, scarring, bleeding, or severe swelling. Conclusions: Laser therapy with the LT is a promising less-invasive treatment for oral vascular lesions.

抜歯目的に受診した糖尿病患者で、初診時にHbA1cおよび血糖値が測定され抜歯後の経過観察が可能であった96例(男性64例、女性32例、平均67歳)を対象に、糖尿病の治療状況、糖尿病合併症の有無、抗菌薬の投与方法、術式などを後ろ向きに調査した。初診時のHbA1c中央値は7.0%、血糖値中央値は142.5mg/dlで、糖尿病治療状況は、経口血糖降下薬の内服85例、インスリン投与7例、食事療法のみ3例、未治療1例であった。糖尿病合併症を有していたものは90例であり、術前抗菌薬投与に関しては、経口投与74例、経静脈投与10例であり、術直後投与の平均期間は4.1日であった。抜歯術式は埋伏智歯抜歯9例、普通抜歯84例、難抜歯3例であった。また、抜歯後合併症は9例で生じた。

当科で行っている顎矯正治療システムについての概要を報告するとともに、最近5年間での当科における顎矯正手術症例の臨床統計の検討を行った。当科での顎変形症治療は、主に次の六つの段階に分けられる。検査・診断、術前矯正治療、術前診断、手術方法の選択、手術および周術期管理、術後矯正治療、保定。2012年1月～2017年8月までに当科にて手術施行となった顎変形症患者45例(男性19例、女性26例、平均23歳)を対象とした。診断では下顎前突症が最も多く、27例(60%)であった。術式のうち最も多かったのは上下顎骨切り術(2 Jaw surgery)の26例(58%)であった。平均出血量は下顎骨骨切り術で167.8ml、上下顎骨切り術で364.4ml、平均手術時間は下顎骨骨切り術で3時間42分、上下顎骨切り術で5時間18分であった。平均入院期間は下顎骨骨切り術で9.5日、上下顎骨切り術で10.1日であった。

Docetaxel, cisplatin plus fluorouracil (DCF) regimen is a useful chemotherapy, but is sometimes withdrawn due to severe adverse effects (AE). In this study, we examined whether the chronotherapy of DCF regimen could reduce the drugs-induced toxicities in clinical practice. Patients with oral squamous cell carcinoma were enrolled. Chemotherapy started at 10:30 (Morning-dosing) or 18:30 (Evening-dosing) for 5 days by a cross-over design. AE were assessed for 14 days after an initiation of each dosing. The grades of nausea, vomiting and neutropenia were smaller during Evening-dosing than during Morning-dosing. These data suggest that the chrono-chemotherapy might provide a merit for reducing the DCF regimen-related severe AE.

Ganglion cysts frequently occur on the dorsal side of the carpal joints, but rarely involve the temporomandibular joint. We encountered a 64-year-old woman with a chief complaint of swelling in the right cheek. Lipoma was observed in the right cheek on magnetic resonance imaging, along with a cystic lesion in the left temporomandibular joint. The cyst in the left temporomandibular joint was extracted under general anesthesia. Histological diagnosis was ganglion cyst. We report our experience with a case of ganglion cysts occurring on the temporomandibular joint with reference to the literature.

In this clinical report, we present the management of a brain abscess that was presumed to be caused by radiation osteomyelitis of the mandible. The patient underwent chemoradiotherapy for oropharyngeal carcinoma on the left side at the Department of Otolaryngology of our hospital in 2000. Local recurrence or metastasis did not occur post-treatment. In January 2009, the patient was diagnosed with radiation osteomyelitis of the mandible on the left side, complicated by a pathologic fracture. In July 2011, numbness occurred in the left upper extremity and the patient was transferred to the emergency center of our hospital. A computed tomography scan showed a tumor lesion in the brain that was diagnosed as a brain abscess by magnetic resonance imaging. Neurosurgeons performed burr hole drainage of the abscess, followed by administration of antibiotics. Although impaired fine movements of the left hand remain, progress has been relatively favorable with no recurrence of osteomyelitis or brain abscess post-surgery.

急性上腸間膜動脈閉塞症は、発症初期に臨床症状が乏しいため早期診断が難しく、また急速で広範囲に腸管虚血や壊死を来す極めて予後不良な疾患である。今回われわれは、口底癌術後に上腸間膜動脈閉塞症を発症した1例を経験したので報告する。患者は73歳の女性で、心房細動の既往がありワルファリンカリウムによる抗血栓療法を受けていた。口底部に難治性潰瘍を生じ、近医歯科を受診したところ当科紹介受診となった。精査の結果、口底扁平上皮癌の診断となり、ヘパリンブリッジで抗血栓療法を行いながら口底部分切除術を施行した。術後2日目に腹痛を生じ、消化器科に対診し経過を観察したが症状はさらに増悪した。腹痛出現3時間後、腹痛の精査目的にCTを施行したところ上腸間膜動脈の閉塞が認められた。ついで画像下治療(以下、IVR)が行われ、血栓吸引およびウロキナーゼ投与による血栓溶解による治療が施行された。治療3時間後には腹痛は消退し、血流は再開した。しかしウロキナーゼ投与中は、口腔の手術創からの持続的な出血を生じ気道閉塞のリスクがあった。急性腹症を起こしている心疾患を有する高齢者は、本症のハイリスク患者であることを認識することが重要である。また早期診断には腹部造影CTとIVRおよびD-dimerによるモニタリングが有用であると考えられた。ウロキナーゼ投与時は、口腔の手術創からの持続的な出血や血腫形成に伴う気道トラブルに留意することが肝要である。(著者抄録)

膿原性肉芽腫は皮膚や粘膜に生じる単発性の有茎性病変である。成因については不明確であるが、内分泌系の影響、感染、外傷等があげられる。今回われわれは、免疫抑制剤使用により舌縁に多発性に生じた膿原性肉芽腫を経験したので報告する。症例1:74歳、男性。腫瘍随伴性天疱瘡に対しステロイド療法中だった。舌縁に多発性に腫瘤状病変が出現した。症例2:42歳、男性。ホジキンリンパ腫に対し同種造血幹細胞移植後に移植片対宿主病(以下、GVHD)予防目的に免疫抑制剤を投与中に舌縁に多発性に腫瘤状病変が出現した。両症例とも切除生検の結果、病理組織学的に膿原性肉芽腫の診断であった。ステロイドあるいは免疫抑制剤による免疫力低下は、膿原性肉芽腫の発症につながる要因の1つである可能性が示された。(著者抄録)

Ghost cell odontogenic carcinoma (GCOC) is a rare malignant odontogenic tumor with aggressive growth characteristics. We report a case of GCOC of the maxilla in a 65-year-old Japanese man who was referred to our hospital with painful swelling of the left maxilla. Computed tomography showed a bone defect in the left upper jaw and the border with the surrounding tissue was indistinct in one area. Tumor resection was performed under general anesthesia, and the histopathological diagnosis was dentinogenic ghost cell tumor (DGCT). Ten months postoperatively, the tumor recurred in the same area, and partial resection of the maxilla was performed. Twelve months after reoperation, the tumor recurred a second time. The histopathological diagnosis this time was GCOC, as a secondary malignant manifestation of the benign DGCT.