論文

多形腺腫由来癌は主に耳下腺などの大唾液腺に生じ，その癌腫成分は腺癌（NOS）や唾液腺導管癌が多い。今回われわれは，頰部の小唾液腺由来の筋上皮癌を主体とする多形腺腫由来癌の1例を経験したので報告する。症例は74歳，女性で，左側頰部の腫脹を主訴に受診した。MRIでは左側咬筋前縁を取り囲む分葉状の腫瘤性病変を認めた。生検では，多形腺腫と癌腫成分が混在した所見を認め，多形腺腫由来癌の診断を得た。全身麻酔下に腫瘍切除術，肩甲舌骨筋上頸部郭清術，血管柄付き前外側大腿皮弁移植による再建術を実施した。術後経過は良好であったが，術後約5か月経過時に他病死の転帰となった。多形腺腫由来癌は小唾液腺ではまれな疾患であり，多施設からの症例の蓄積による術前診断法および治療法の確立が望まれる。

アミロイドーシスは，アミロイド蛋白がさまざまな臓器や組織に沈着し，機能障害をきたす原因不明の疾患である。 今回われわれは，多発性骨髄腫に合併した口唇アミロイドーシスの一例を経験した。症例は50歳男性。初診時，上下唇に結節があり，生検にてアミロイドの沈着が確認された。初診より9年経過し，口唇病変に変化は無い。本邦における報告の検討では口腔に生じるアミロイドーシスは舌が多く，口唇での発症はまれであった。

＜文献概要＞処方のポイント　●発症時期や所見から口腔粘膜炎であることを確認して薬を処方する.●使用感と疼痛を随時確認し,薬の剤形や種類を柔軟に変更する.

多形腺腫由来癌は主に耳下腺などの大唾液腺に生じ,その癌腫成分は腺癌(NOS)や唾液腺導管癌が多い。今回われわれは,頬部の小唾液腺由来の筋上皮癌を主体とする多形腺腫由来癌の1例を経験したので報告する。症例は74歳,女性で,左側頬部の腫脹を主訴に受診した。MRIでは左側咬筋前縁を取り囲む分葉状の腫瘤性病変を認めた。生検では,多形腺腫と癌腫成分が混在した所見を認め,多形腺腫由来癌の診断を得た。全身麻酔下に腫瘍切除術,肩甲舌骨筋上頸部郭清術,血管柄付き前外側大腿皮弁移植による再建術を実施した。術後経過は良好であったが,術後約5ヵ月経過時に他病死の転帰となった。多形腺腫由来癌は小唾液腺ではまれな疾患であり,多施設からの症例の蓄積による術前診断法および治療法の確立が望まれる。(著者抄録)

© 2018 by The Keio Journal of Medicine. Radical esophagectomy for thoracic esophageal cancer is invasive and frequently results in postoperative pulmonary complications. Postoperative pneumonia is the most common such complication and affects hospital mortality and survival rates. Oral care has been very effective in reducing pneumonia. In Japan, preoperative professional oral care is highly recommended. However, there are few studies on the effect of preoperative improvements in oral hygiene as a result of intervention on the incidence of postoperative pneumonia. The primary end-point of this retrospective study was the incidence of postoperative pneumonia after radical esophagectomy. The oral health levels of 46 patients were individually categorized, and then patients were grouped according to whether they maintained or improved their oral hygiene. At the first dental examination, oral health levels were classified as good in 22 patients and bad in 24. Of the 46 patients studied, 39 patients maintained or improved their oral hygiene (good control group), whereas 7 showed no improvement (bad control group). Postoperative pneumonia occurred in eight patients: four in the good control group and four in the bad control group. Statistical analysis with postoperative pneumonia as a dependent variable showed a significant effect of oral hygiene improvement on the incidence of pneumonia. Logistic regression analysis with this factor as an independent variable demonstrated that the risk of postoperative pneumonia was reduced in the good control group (OR 0.086, 95% CI 0.014-0.529). Therefore, preoperative professional oral care may improve oral hygiene and oral health, which may in turn reduce the incidence of postoperative pneumonia.

Diffuse sclerosing osteomyelitis of the mandible (DSOM) is a nonsuppurative osteomyelitis mainly characterized by recurrent local mandibular swelling and pain. Because of the unknown pathophysiological mechanism underlying DSOM, treatment can be challenging. Reported treatment options include long-term analgesic medication, non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics, corticosteroids, hyperbaric oxygen, and surgical treatment. However, these treatments cannot reliably lead to a long-lasting reduction of complaints. Recently, bisphosphonates has been reported effective in managing DSOM. We herein report a case of DSOM with a favorable response to a single infusion of zoledronate without prior treatment of other bisphosphonates. The patient was a 19-year-old woman who visited our hospital complaining of swelling and remarkable spontaneous pain in the right mandibular angle region. Under the diagnosis of osteomyelitis of the mandible, the clinical symptoms were improved by administering an antimicrobial agent and anti-inflammatory analgesic, but computed tomography (CT) showed exacerbation of bone resorption. A biopsy showed fibrosis between the bone tissue and trabeculae, a finding consistent with post-inflammatory changes. 99mTc scintigraphy showed an abnormal accumulation in the right mandibular ramus. Based on these results, she was diagnosed with DSOM. As a result of discussing with the physician in charge of internal medicine, it became the policy of the bisphosphonates and the intravenous administration of zoledronate 4 mg was enforced. Her bone sclerosis and bone resorption showed an improving trend on CT three months after the zoledronate administration, and there have been no symptoms or exacerbation of findings in three years since the administration.

Objectives: Indigo naturalis, a herbal medicine effective against ulcerative colitis, exhibits anti-inflammatory effects and induces interleukin-22-mediated antimicrobial peptide production. Anti-inflammatory activity and the prevention of secondary infection are essential for the management of chemotherapy-induced oral mucositis (CIOM); therefore, we developed an indigo naturalis ointment to be administered topically for CIOM and evaluated its feasibility. Methods: We performed a single-centre, open-label, prospective feasibility study from March 2017 to December 2018. The key eligibility criteria for the subjects were as follows: (1) receiving chemotherapy for a malignant tumour; (2) grade 1 or 2 CIOM and (3) receiving continuous oral care. The treatment protocol comprised topical indigo naturalis ointment application three times a day for 7 days. The primary endpoint assessed was feasibility. The secondary endpoints assessed were the changes in oral findings, oral cavity pain and safety. Results: Nineteen patients with CIOM were enrolled. The average feasibility (the proportion of prescribed applications that were carried out) observed in this study was 94.7%±8.9% (95% CI 90.5% to 99.0%), which was higher than the expected feasibility. The revised oral assessment guide scores of the mucous membrane domain and total scores were significantly improved. All patients reported a reduction in oral cavity pain, with a median pain resolution duration of 6 days. No serious adverse events were observed. Conclusions: The indigo naturalis ointment was feasible, and showed the potential for efficacy and safety. Larger randomised controlled trials are needed to further assess the efficacy and safety of indigo naturalis compared with a placebo. Trial registration number: UMIN000024271.

© 2018 Asian AOMS(+) ASOMP(+) JSOP(+) JSOMS(+) JSOM(+) and JAMI Myelodysplastic syndrome is an acquired hematopoietic disorder showing symptoms of pre-leukemia and refractory anemia. In the tooth extraction process of such cases, bleeding tendency due to pancytopenia, infection etc., becomes a problem. As such, a cautious approach is required. We have confirmed platelet transfusion refractoriness prior to tooth extraction in a myelodysplastic syndrome patient, and hereby report a case of tooth extraction following human leukocyte antigen (HLA)-compatible concentrated platelet transfusion. The patient was a 55-year-old female who was examined at our department due to a request for the extraction of tooth No. 36. Following consultation at the Hematology Department, platelet transfusion was performed as a pretreatment upon hospitalization. Increased body temperature, chills, shivers, and feelings of discomfort in the pharynx were observed. A close examination was performed due to a lack of increase in platelet count, and revealed platelet transfusion refractoriness caused by anti-HLA antibodies. Therefore, the patient was re-hospitalized and transfused with a platelet concentrate-HLA preparation. One hour later, an increase in platelet count was confirmed and the tooth extraction was performed. There was no evidence of bleeding or infection following extraction, and the prognosis was good.

Objectives: We aimed to evaluate the clinical value of an entire-circumferential intraoperative frozen section analysis (e-IFSA) for the complete resection of superficial squamous cell carcinoma (SCC) of the tongue. Materials and Methods: A total 276 specimens from 51 patients with pT1-2, N0, mucosal or submucosal invasion SCC were analyzed to evaluate the diagnostic accuracy of the e-IFSA and the added value of the e-IFSA to iodine staining. The e-IFSA results were compared with the final histologic results obtained using permanent sections. All specimens for the e-IFSA were taken over the entire circumference 5 mm outside from the iodine unstained areas. The outline of the main resected specimen after taking these outer mucosal specimens were defined as the surgical margins determined by iodine staining alone. Results: The e-IFSA results were in excellent agreement with final histological results (Cohen's kappa value: 0.85) and the e-IFSA showed high sensitivity (100%) and high negative predictive value (100%). The actual complete resection rate with an e-IFSA was 100% (51/51), and no patient required additional resection after surgery. In contrast, 10/51 patients (20%) patients showed residual atypical mucosal epithelium at or beyond the margin determined by iodine staining alone; this difference was statistically significant (P = 0.002). The 5-year local control rate and 5-year overall survival rate after this procedure were both 100%. Conclusion: An e-IFSA has additional value when performed in conjunction with iodine staining. An e-IFSA would be useful for achieving complete resection of superficial SCC of the tongue.