Reconstruction of esophageal stenosis that had persisted for 40 years using a free jejunal patch graft with virtual endoscopy assistance: A case report

In this report, we present a case in which good results were achieved by treatment using a free jejunal patch graft with virtual endoscopy (VE) assistance in a patient whose swallowing had failed to improve for 40 years after he mistakenly swallowed sulfuric acid, despite pectoralis major myocutaneous flap grafting and frequent balloon dilatation surgery. During the last 20 years, virtual computed tomography imaging has improved remarkably and continues to be used to address new challenges. For reconstructive surgeons, the greatest advantage of VE is that it is a noninvasive modality capable of visualizing areas inaccessible to a flexible endoscope. Using VE findings, we were able to visualize the 3-dimensional shape beyond the stenosis. VE can also help predict the area of the defect after contracture release.

Postoperative radiotherapy for squamous cell carcinoma of the maxillary sinus: analysis of local control and late complications

This retrospective study was conducted to analyze the local control and late complications in patients with squamous cell carcinoma of the maxillary sinus treated with postoperative radiation therapy following surgery. Between 1979 and 1998, 41 patients with squamous cell carcinoma of the maxillary sinus were treated with postoperative irradiation following partial or total maxillectomy. Tumor classification according to the TNM classification of the International Union Against Cancer (1997) was T2 in 6 patients, T3 in 21 patients, and T4 in 14 patients. Fourteen patients had negative surgical margins, 23 had microscopically positive margins, and 4 had grossly positive margins. Sixteen patients received preoperative intraarterial chemotherapy. The total dose to the primary tumor bed was 40-70 Gy (median: 54 Gy) with a fraction size of 2 Gy. The median follow-up time of the surviving patients was 93 months (range: 25-179 months). Local recurrence was observed in 17 patients (41%), and the 5-year actuarial overall survival and local control rates were 48% and 55%, respectively. In the univariate analysis, surgical margin status and total dose each had a statistically significant impact on local recurrence. For the patients with negative surgical margins, 8 of 9 (89%) patients achieved local control with a dose of 50-54 Gy, while 7 of 10 (70%) patients with microscopically positive margins achieved local control with a dose of 60-64 Gy. There were 11 late complications found in 9 patients; bone necrosis in 2, soft tissue necrosis in 2, trisumus: 2, cellulitis in 1, retinopathy in 1, and vision impairment in 3 patients. A total dose of 60 Gy or more was administered in all patients who suffered late complications except for 2 patients with vision impairment. These results indicated that an optimal dose of postoperative irradiation according to the surgical margin status was necessary to achieve local control for squamous cell carcinoma of the maxillary sinus following surgery. For patients with negative surgical margins, a total dose of 50-54 Gy in conventional fractionation was appropriate to achieve local control as well as to reduce late complications. On the other hand, a dose of 60 Gy or more was required for the patients with microscopic positive margins.

Hyperfractionated radiotherapy followed by adjuvant chemotherapy for nasopharyngeal cancer: report of seven cases

Cases of hyperfractionated radiotherapy and adjuvant chemotherapy for nasopharyngeal cancer are reported. Seven patients received hyperfractionated radiotherapy (76.8-81.6 Gy/64-68 fractions to primary tumor) and two cycles of cisplatin (80 mg/m2 i.v. on day 1) plus 5-FU (800 mg/m2 continuous infusion on days 2-6). Mucositis was the most frequent side effect in hyperfractionated radiotherapy. Moderate leukopenia was the major side effect of adjuvant chemotherapy. With a mean follow-up time of 34 months (range 25-48 months), five of the seven patients were locoregionally controlled. Two developed distant metastases. Two patients suffered late complications (posterior nasopharyngeal wall necrosis and brain necrosis). These results suggested that our regimen was almost well tolerated and might be of use in locoregional control of nasopharyngeal cancer. However, it carries some risk of late complications and might be inadequate for preventing distant metastases. A three-dimensional conformal boost irradiation technique and adequate dose intensity chemotherapy might be encouraged.

Site-specific localization of Epstein-Barr virus in pharyngeal carcinomas

In this study, the correlations of factors with Epstein-Barr virus (EBV)-association were investigated in 50 patients with nasopharyngeal carcinoma (NPC), 61 with oropharyngeal carcinoma (OPC), and 55 with hypopharyngeal carcinoma (HPC) in Okinawa and Osaka prefectures in Japan. The incidence of pharyngeal carcinoma in Okinawa was previously found to be higher than that in Osaka; the incidence of OPC was approximately 6 times higher and that of HPC was two times higher. The EBV genome was detected in the tumor cells of the present patients; 83% of the Okinawa and 92% of the Osaka NPC patients. The EBV genome was not detected in OPC or HPC. A univariate analysis showed that sex, the location of the tumor, histology, and the degree of lymphocytic infiltration correlated with the EBV-positive rate. A multivariate analysis revealed that only the location of the tumor was independently correlated with the EBV-positive rate. Histology and tumor size were factors affecting the prognosis of the patients with NPC. The NPC of poorly differentiated type frequently showed the EBV genome, and NPC with lymphocytic infiltration showed a more favorable prognosis compared to the other NPC types. These findings suggest that latent genes of EBV expressed in cancer cells might trigger a cytotoxic T cell reaction against the cancer.

Non-Hodgkin's lymphoma of Waldeyer's ring as a manifestation of lymphoproliferative diseases associated with human T-cell leukemia virus type 1 in southwestern Japan

Adult T-cell leukemia/lymphoma (ATL) usually presents with node- and/or cutaneous-based diseases, with a leukemic picture. It is not clear whether ATL initially manifests with lesions in Waldeyer's ring (WR) in an ATL-endemic area. In the present study, we examined distributions of immunophenotypes and the presence of human T-cell leukemia virus type 1 (HTLV-1) and Epstein-Barr virus (EBV) genomes in 62 cases of non-Hodgkin's lymphoma (NHL) of WR (NHL-WR) from two areas of Japan: Osaka, an ATL-nonendemic area (25 cases), and Okinawa, an ATL-endemic area (37 cases). In both areas, age ranged from 10 to 94 years (median, 64 yr), with a male-to-female ratio of 1.81:1. Twelve patients were in Stage I, 34 in Stage II, and 6 in Stage III; stage was unknown in 10. The 25 Osaka cases were B-cell type (16 diffuse immunoblastic type (DIB), 8 diffuse large cell predominantly noncleaved cell (DLNC), 1 cleaved cell (DLC)). Of the 37 Okinawa cases, 20 were B-cell type (3 DIB, 10 DLNC, 2 DLC, 5 other). The remaining 17 cases showed T-cell phenotype (4 DIB, 3 DLC, 3 diffuse large cell not otherwise specified, 7 other). There was a significant difference in the distribution of immunophenotypes between these two areas (P < .001). Combined studies of polymerase chain reaction (PCR) and in situ hybridization revealed the presence of EBV genome in 1 (4%) of 24 Osaka cases, 2 (13%) of 16 B-cell NHLs from Okinawa, and 3 (23%) of 13 T-cell NHLs from Okinawa. HTLV-1 proviral genome was found in 11 (85%) of 13 T-cell lymphomas from Okinawa but could not be detected in B-cell lymphomas from Osaka and Okinawa. Combined clinical, histologic, serologic, and PCR findings suggest that NHL-WR in an ATL-endemic area could be an initial manifestation of ATL.

A case report of carotid body tumor

A case of left carotid body tumor is presented. A 47-year-old female patient consulted our otorhinolaryngological clinic with a neck swelling that had persisted for 5 months. On physical examination, a movable and pulsating hard mass measuring 2 x 2.5 cm in size was found on the left side of her neck, near the angle of the mandible. Computed tomography, magnetic resonance image and angiography all demonstrated a well-circumscribed tumor mass showing high vascularity and located at the bifurcation of the left carotid artery. The tumor involved the left carotid artery, but the patency of the artery was preserved. The patient showed satisfactory temporary balloon occlusion test results without neurological complications. Since the tumor was strongly adherent to the carotid arterial wall, the tumor was resected together with the carotid artery. Histologically, the tumor was composed of organoid clusters of round cells with eosinophilic granular cytoplasm. Involvement of tumor cells was seen to the adventitia of the carotid artery, but only slight cellular atypia was seen. Ultrastructurally, two types of cells were observed in the central and marginal portion of the tumor; these were round chief cells with few cytoplasmic neurosecretory granules and spindle-shaped sustentacular cells. Immunohistochemically, the chief cells and sustentacular cells showed positive reaction for neuron-specific enolase and S-100, respectively. The ultrastructural findings suggested the benign nature of the tumor.

[High tissue concentration of 5-FU reduced local recurrence after administration of tegafur suppositories]

Forty-two patients with head and neck cancer were treated with tegafur suppository for 7 days preoperatively and clinical value of this treatment was assessed. In a group which indicated tumor tissue concentrations of 5-FU were more than 0.5 micrograms/g, local recurrence decreased in the period of postoperative observation for 42 months. A survival rate of this group was better than others. From these results, preoperative tegafur suppository treatment seemed to have a role in expectation of improvement of local control in head and neck cancer therapy.

[Tissue concentration of tegafur suppository in patients with head and neck cancer--concentration of 5-FU in cancer tissue]

Fifty patients with head and neck cancer were treated with tegafur suppository for 7 days preoperatively. The tissues were obtained during surgical operation and the concentrations of 5-FU in cancer tissue, normal tissue and blood were measured. It was revealed that a high concentration of 5-FU was seen in cancer tissue and then metastatic lymph nodes. The 5-FU concentration in cancer tissue was parallel with T stage of the patients. Subsites which showed a high concentration of 5-FU were nasal-paranasal cavity, tongue and mesopharynx. The tegafur suppository was useful because of the high concentration in cancer tissue and metastatic lymph nodes without any obvious side effects in the head and neck region.

Lethal midline granuloma in Okinawa with special emphasis on polymorphic reticulosis

Lethal midline granuloma (LMG) is a clinical term used to describe a condition which may be manifested histologically as Wegener's granulomatosis (WG), polymorphic reticulosis (PR), and malignant lymphoma (ML). WG is an inflammatory disease, and PR and ML are considered to represent a neoplastic proliferation of lymphoreticular cells. In this report, twenty-two cases of LMG in Okinawa were examined. The frequency of LMG per 100,000 outpatients of the ear, nose and throat clinic in Okinawa was 67, and the higher frequency of PR (27) and ML (34) in Okinawa than in other districts of Japan was characteristic. Polymerase chain reaction, in situ hybridization, and immunohistochemical studies showed that the proliferating cells in PR were CD43+ and simultaneously contained Epstein-Barr viral genome in their nuclei. The higher frequency of PR and ML in Okinawa is discussed in conjunction with a review of pertinent literature: multiple factors including genetic, viral environmental, and socioeconomic factors seem to affect the frequencies of these diseases.