翁長 龍太郎

6079 Background: Advances in perioperative systemic therapy for head and neck squamous cell carcinoma (HNSCC) (e.g., KEYNOTE-689) have increased the need to tailor postoperative management, balancing oncologic benefit against toxicity and resource constraints. Imaging-detected extranodal extension (iENE) has been incorporated as a potential prognostic factor in the UICC TNM 9th edition. However, the prognostic impact of iENE among patients without pathological extranodal extension (pENE) remains unclear. We evaluated the association between iENE status and clinical outcomes in pENE-negative HNSCC. Methods: We retrospectively reviewed patients with HNSCC of the oral cavity, oropharynx, hypopharynx, or larynx, radiologically suspected lymph node metastasis, and underwent primary surgery with neck dissection without adjuvant therapy, between 2012 and 2021. Eligible patients had pathologically confirmed lymph node metastasis, negative surgical margins, and no evidence of pENE. Preoperative iENE status was assessed by board-certified radiologists. Survival endpoints included event-free survival (EFS) and overall survival (OS). Patients were stratified into low-risk (non-candidates for adjuvant therapy) and intermediate-risk (candidates for postoperative radiotherapy alone) groups according to NCCN guidelines. Results: Of 3,771 screened patients, 133 met the eligibility criteria (low-risk: 20, intermediate-risk: 113), of whom 41 (30.8%) were iENE-positive. At a median follow-up of 60.6 months, iENE-positive patients demonstrated poorer outcomes than iENE-negative patients, including shorter EFS (5-year: 33.1% vs 55.4%; hazard ratio [HR], 1.69; p=0.029). The association between iENE positivity and inferior EFS was observed consistently across both risk strata. Overall survival also favored iENE-negative patients (5-year: 80.4% vs. 68.7%). On multivariate analysis, iENE positivity, ECOG Performance Status ≥1, and lower baseline serum albumin were independently associated with poorer EFS. Patients meeting none of the three factors had excellent outcomes despite omission of adjuvant therapy (5-year EFS: 69.8%, 5-year OS: 88.0%). Conclusions: iENE may help identify an unfavorable-prognosis subset among pENE-negative HNSCC patients. The study cohort predates the routine use of perioperative immunotherapy, and the generalizability of these findings in contemporary treatment settings requires prospective validation. Five-year EFS by iENE status: Overall and by risk group. <table> <tbody><tr> <th colspan="1" rowspan="1">Group</th> <th colspan="1" rowspan="1">iENE status</th> <th colspan="1" rowspan="1">5y-EFS</th> <th colspan="1" rowspan="1">HR (95% CI)</th> <th colspan="1" rowspan="1">P-value</th> </tr> </tbody><tbody> <tr> <td colspan="1" rowspan="1">ALL (n = 133)</td> <td colspan="1" rowspan="1">Positive</td> <td colspan="1" rowspan="1">33.1%</td> <td colspan="1" rowspan="1">1.69 (1.05-2.71)</td> <td colspan="1" rowspan="1">0.029</td> </tr> <tr> <td colspan="1" rowspan="1"></td> <td colspan="1" rowspan="1">Negative</td> <td colspan="1" rowspan="1">55.4%</td> <td colspan="1" rowspan="1">Ref.</td> <td colspan="1" rowspan="1"></td> </tr> <tr> <td colspan="1" rowspan="1">Intermediate risk (n = 113)</td> <td colspan="1" rowspan="1">Positive</td> <td colspan="1" rowspan="1">34.2%</td> <td colspan="1" rowspan="1">1.57 (0.94-2.63)</td> <td colspan="1" rowspan="1">0.08</td> </tr> <tr> <td colspan="1" rowspan="1"></td> <td colspan="1" rowspan="1">Negative</td> <td colspan="1" rowspan="1">51.9%</td> <td colspan="1" rowspan="1">Ref.</td> <td colspan="1" rowspan="1"></td> </tr> <tr> <td colspan="1" rowspan="1">Low risk (n = 20)</td> <td colspan="1" rowspan="1">Positive</td> <td colspan="1" rowspan="1">28.6%</td> <td colspan="1" rowspan="1">3.57 (0.85-15.04)</td> <td colspan="1" rowspan="1">0.06</td> </tr> <tr> <td colspan="1" rowspan="1"></td> <td colspan="1" rowspan="1">Negative</td> <td colspan="1" rowspan="1">76.9%</td> <td colspan="1" rowspan="1">Ref.</td> <td colspan="1" rowspan="1"></td> </tr> </tbody> </table>

Background Olfactory neuroblastoma (ONB) is a rare malignant tumor of the head and neck. Due to its rarity, standard systemic therapy for this condition has yet to be established. In particular, the use of immune checkpoint inhibitors (ICIs) for the recurrent or metastatic (R/M) ONB population remains unclear. Methods We retrospectively evaluated 11 patients with R/M ONB who received any systemic chemotherapy at two Japanese institutions (National Cancer Center Hospital East and Kyushu Medical Center) between January 2002 and March 2022 and analyzed outcomes by use of anti-PD-1 antibody (nivolumab or pembrolizumab) monotherapy. Results Of the 11 patients, 6 received ICI (ICI-containing treatment group) and the remaining 5 were treated with systemic therapy but not including ICI (ICI-non-containing treatment group). Overall survival (OS) was significantly longer in the ICI-containing group (median OS: not reached vs. 6.4 months, log-rank p-value: 0.035). The fraction of ICI systemic therapy in the entire treatment period of this group reached 85.9%. Four patients (66.7%) in the ICI-containing treatment group experienced immune-related adverse events (irAE), with grades of 1/2. No irAE of grade 3 or more was seen, and no patient required interruption or discontinuation of treatment due to toxicity. Conclusion ICI monotherapy appears to be effective and to contribute to prolonged survival in R/M ONB.

When pharmacological treatments are inadequate, facial nerve paralysis from various etiologies, including Bell's palsy, Hunt syndrome, and trauma, often requires surgical intervention. Facial nerve decompression surgery aims to relieve nerve compression and restore function, with preserving hearing function, especially in pediatric cases, being crucial. Conventional methods, like the transmastoid approach, risk affecting auditory function due to ossicle manipulation. Herein, we describe the case of a 12-year-old boy with left facial palsy diagnosed with zoster sine herpete (ZSH) syndrome. Despite medical treatment, the patient's condition did not improve, prompting facial nerve decompression surgery. Employing the intact transmastoid ossicle (ITO) swaying technique, we minimized ossicular manipulation, preserving auditory function while effectively achieving facial nerve decompression. The patient demonstrated improvement postoperatively in auditory and facial nerve functions. Furthermore, audiometric assessments demonstrated no substantial deterioration in hearing thresholds, and the facial nerve function improved from Grade V to Grade II on the House-Brackmann scale. The ITO technique provides a less invasive alternative compared to conventional approaches, lowering the chance of the ossicular chain and the risk of postoperative hearing loss. This case highlights the significance of customized surgical approaches in pediatric facial nerve decompression surgery, resulting in improved patient outcomes. Further research is required to validate the efficacy and safety of this method across various clinical contexts.

小児甲状舌管癌は頻度が少なく，再発症例はさらに稀である。今回2度再発を反復した症例を経験したので報告する。初発時12歳の男児。甲状舌管から右頸部にかけての乳頭癌に対し甲状腺右葉切除術，Sistrunk手術，頸部郭清術を併施した。右葉には原発巣を認めず甲状舌管癌と診断した。13歳時に頸部リンパ節再発し，頸部郭清術を施行した。今回，経過観察中の21歳時に甲状腺左葉へ乳頭癌の転移再発を認め，左葉切除術を施行した。甲状腺が原発巣であった可能性を完全には否定できないものの，超音波所見の推移から可能性は極めて低いと考える。初回治療の議論や左葉病変の臨床的及び病理学的な検討を含め考察する。

症例1(5歳女児)。生後7ヵ月時より左頸部の膿瘍形成を繰り返し、3歳時に当科へ紹介となった。消炎期の下咽頭食道造影検査にて左下咽頭梨状陥凹瘻と診断され、その後も頸部の感染を繰り返したため、今回、5歳時の消炎期に外切開法による瘻管摘出術を行う方針とした。症例2(2歳男児)。発熱、頸部の発赤を主訴に、前医の頸部CTにて頸部膿瘍を指摘され、当科へ紹介となった。CTで左梨状陥凹瘻と診断され、急性期に外切開排膿術を行う方針とした。いずれの症例も外切開により瘻管の同定・摘出に成功し、術後の経過は良好であった。