Idiopathic spinal cord herniation associated with intervertebral disc extrusion: a case report and review of the literature.

STUDY DESIGN: A case of idiopathic spinal cord herniation is reported, and the literature is reviewed. OBJECTIVE: To report a case of thoracic spinal cord herniation with a ventral dural defect, probably caused by thoracic disc extrusion. SUMMARY OF BACKGROUND DATA: Recently, reports of spinal cord herniation have been increasing. This increase can be attributed to the development of magnetic resonance imaging and increased awareness of this entity. However, the cause of the ventral dural defect remains unknown. METHODS: A 54-year-old woman had experienced Brown-Séquard syndrome for 2 years. Magnetic resonance imaging demonstrated an S-shaped anterior kinking of the spinal cord, with dilation of the dorsal subarachnoid space. RESULTS: After incision of the dural sac and gentle retraction of the spinal cord, a dural defect was recognized into which the spinal cord had herniated. An extruded disc was visualized through the defect at T3-T4. The ventral dural defect and the dorsal incision of the dural sac were repaired with a fascial graft from the thigh. CONCLUSIONS: Intraoperative findings suggest that the thoracic disc herniation in the current case was the probable cause of the ventral dural defect. Surgical reconstruction using double fascial graft under careful spinal cord monitoring resulted in a satisfactory neurologic recovery.

Low frequency of HLA-A*0201 allele in patients with Epstein-Barr virus-positive nasal lymphomas with polymorphic reticulosis morphology.

Lymphoproliferative diseases of the nasal cavity and paranasal sinuses occur frequently in Asian countries and are histologically categorized as monomorphic ordinary lymphoma and polymorphic reticulosis (PR) with apparent inflammatory cell infiltration. The large atypical cells in PR show natural-killer cell nature and frequently contain Epstein-Barr virus (EBV) DNA. Among the EBV genes involved in latent infection, those encoding EBV latent membrane proteins are frequently expressed in PR. Several cytotoxic T-lymphocyte (CTL) defined epitopes have been mapped to latent membrane proteins restricted with HLA-A2, -A11 or -A24 antigens. Thus, the HLA-A allele may affect the development of PR. To examine this possibility, HLA-A alleles of 25 patients with EBV(+) PR were determined with low-resolution polymerase chain reaction-based typing using HLA-A locus sequence-specific primer combinations. The frequency of HLA-A alleles including HLA-A2 and -A24 antigens in PR patients was lower than that in the normal Japanese population, but the difference was not significant. Since HLA-A2-restricted CTL responses are well delineated at the A2-subtype level, the A2-subtype of PR cases with HLA-A2 antigen was further determined by high-resolution genetic typing. The frequency of HLA-A*0201 in PR was significantly lower than in the normal population (p=0.0314). The HLA-A*0201-restricted CTL responses may thus function in vivo to suppress the development of overt lymphoma.

Larynx preservation in surgical treatment of cervical esophageal cancer--combined procedure of laryngeal suspension and cricopharyngeal myotomy.

From July 1994 to July 1998, a larynx-preserving procedure was performed on 10 out of 22 (45%) patients in the surgical treatment of hypopharyngeal and cervical esophageal cancer. At first, all 10 patients were treated with concurrent radiochemotherapy with cisplatin (10 mg/m2/day), 5-fluorouracil (500 mg/m2/day) and radiation (2 Gy/day) five times per week for 4 weeks. After preoperative radiochemotherapy, the larynx-preserving procedure, combining laryngeal suspension and cricopharyngeal myotomy, was performed. The operative and hospital mortality rate was 0%. The incidence of post-operative morbidity with minor complications was 70% in the present study. Laryngeal speech and oral food intake were preserved in all patients after this procedure. The new larynx-preserving procedure combining laryngeal suspension and cricopharyngeal myotomy for cervical esophageal cancer is a favorable operative method for retaining intelligible laryngeal speech and good food intake.

Correlation of epidermal growth factor receptor and radiosensitivity in human maxillary carcinoma cell lines.

To determine the relationship between epidermal growth factor receptor (EGFR) and radiosensitivity, we immunostained cells from three maxillary carcinoma cell lines with an anti-EGFR antibody. The intensity of staining reactivity, determined by means of an image analysis system, was expressed as grey value (0-black to 255-white). The mean grey values for cell lines IMC-2, IMC-3, and IMC-4 were 181, 210, and 222, respectively, and differed significantly (p < 0.001). This indicates that IMC-2 had the highest number of EGFR, followed by IMC-3 and IMC-4. The cells were then irradiated at 1, 2, 4, or 6 Gy, and cell survival was assessed by means of a standard colony-forming assay. IMC-2 had the highest survival rates at 1, 2 and 4 Gy, followed by IMC-3 and IMC-4. Therefore, the survival rates for IMC-2, IMC-3, and IMC-4 after irradiation increased in proportion to the amount of EGFR in each cell line. These results support the findings of previous clinical studies which showed that increased expression of EGFR was associated with higher recurrence rates of glottic and maxillary sinus carcinoma in patients treated with radiation therapy. The amount of EGFR in cells may therefore be associated with their radiosensitivity.

Laryngeal necrosis after combined chemotherapy and radiation therapy.

Post-radiation necrosis of the larynx is a major complication after irradiation and has become rare. Recently, combined chemotherapy and radiation therapy has been introduced for head and neck tumours. The authors report a case of laryngeal necrosis after combination therapy for a patient with cervical lymph node metastases of nasopharyngeal carcinoma and review the literature on late laryngeal necrosis. Although radiation-induced laryngeal necrosis has become a rare complication, the combination of chemotherapy and radiation therapy may increase its incidence. We should always consider it as a possible late complication and treat it appropriately.

Lymph node and distant metastases in patients with sinonasal carcinoma.

A retrospective analysis of 34 cases of sino-nasal squamous cell or undifferentiated carcinoma in patients admitted between 1984 and 1992 was undertaken. Multimodality therapy incorporated radiation, surgery and chemotherapy. The five-year survival rate was 53 per cent. The local control rate was 82 per cent. Patients died of local failure (six), distant metastases (six), lymph node metastases (one) and other causes (three). Twenty-eight patients with local control were separated into groups: G1-2 (well and moderately differentiated) and G3-4 (poorly differentiated and undifferentiated) and evaluated to find the association between differentiation and metastasis. Lymph node metastasis was not related to the degree of differentiation. Distant metastasis was significantly related to the degree of differentiation (Fisher's exact test: p = 0.007). The result of the combination therapy is poor for patients with poorly differentiated or undifferentiated carcinoma because of distant metastases. Adjuvant chemotherapy may be necessary for them to prevent distant metastasis.

[Evaluation of the method of treating non-Hodgkin's lymphoma].

Forty-two patients with non-Hodgkin's lymphoma were treated between October 1983 and December 1992 in the department of Otolaryngology, Kagawa Medical School Hospital. The twenty-six of these patients whose tumor originated in Waldeyer's ring and who were diagnosed as Stage I or II have been reviewed. In principle, method of treatment was a combination of chemotherapy and radiotherapy. Between 1983 to 1987, COP was primarily used (9 cases) as combination chemotherapy, and after 1988 CHOP was used (17 cases). VAMA was used to treat the poor response and recurring cases. The five-year estimated overall survival rates calculated by the Kaplan-Meier method were 33.3% and 94.1% in the COP and CHOP groups, respectively. We investigated age, stage, cell type and grade, as factors related to recovery, but except for cell type, there were no significant differences in overall survival. The most serious side effect was decreased leucocyte count, but we prescribed G-CSF and were able to continue treatment.

[A correlation between metastasis and histopathological differentiation in patients with carcinoma of the nasal cavity and paranasal sinuses].

The aim of this retrospective study was to investigate a correlation between histopathological differentiation and metastasis in patients with carcinoma of the nasal cavity and paranasal sinuses to improve the survival. Between 1984 and 1992, 52 cases of sino-nasal malignant tumors were treated at Kagawa Medical School Hospital. Squamous cell carcinoma was evaluated in 29 patients and undifferentiated carcinoma in five patients. Treatment in most cases consisted of radiotherapy, 50 Gy/25 fr/5 weeks, continuous intra-arterial infusion of 5-FU 2000 mg/4 weeks, and an extensive Denker's operation 2-3 weeks after the completion of radiotherapy. The 5-year survival rate was 53%, and the local control rate was 82%. Patients died of local failure (six), distant metastases (six), lymph node metastases (one) and other causes (three). Twenty-eight patients with local control were classified into G1-2 (well- and moderately-differentiated) and G3-4 (poorly-differentiated and undifferentiated) groups. Lymph node metastasis was unrelated to the degree of differentiation, but distant metastasis was significantly correlated to the degree of differentiation (P = 0.014). The 5-year survival rates in lymph node metastasis (n = 7), non-lymph node metastasis (n = 21), distant metastasis (n = 7), non-distant metastasis (n = 21), and the G1-2 (n = 17) group and the G3-4 group (n = 11) with local control were 57%, 63%, 14%, 78% (P = 0.002), 72% and 44% (P = 0.0384), respectively. The results of combination therapy were poor in patients with poorly-differentiated or undifferentiated carcinoma because of distant metastasis, and adjuvant chemotherapy may be necessary in such patients to prevent distant metastasis.

[A comparative clinical study on the treatment of head and neck tumors by adjuvant chemotherapy with HCFU--Second Study by Kinki Head and Neck Tumor Study Group].

In the first study by the "Kinki Head and Neck Tumor Study Group," we performed a comparative study to investigate intergroup difference between a control group consisting of patients given radical treatment only, and a HCFU group consisting of patients receiving long-term administration of HCFU after radical treatment. We earlier reported that subsequent observations by stratification revealed a favorable tendency in the cumulative disease-free rate in Stage II and Stage III patients in the HCFU group. In the second study, the same methods of treatment as in the first study were compared in a prospective control study. No differences were found between the two groups in Stage II patients. In Stage III patients, however, the disease-free rate tended to increase significantly in the HCFU group as in the first study.

[Immunohistological study of dendritic cells and macrophages in sino-nasal lesions--distributions in metaplastic squamous epithelium and squamous cell carcinoma].

Dendritic cells, macrophages and lymphocytes infiltrating the epithelia of sino-nasal lesions were investigated immunohistochemically using antibody S-100 protein for dendritic cells, Ki-M1P for macrophages, MT1 for T-cells and L26 for B-cells, respectively. Seventy-five specimens of sino-nasal mucosae involving 51 cases of metaplastic squamous epithelium (MSE), 12 of inverted papilloma, 1 of atypical hyperplasia and 11 of squamous cell carcinoma (SCC) were studied. Dendritic cells were observed in 12 cases of MSE (23.5%), in 4 of inverted papilloma (33.3%), and in 6 of SCC (54.5%). More dendritic cells were found infiltrating MSE of the infective and fibrotic types than of the mild and edematous types, histopathologically. Furthermore, infiltration correlated with the degree of squamous differentiation in MSE, but not in SCC. The number of macrophages was significantly smaller in MSE than in columnar ciliated epithelium, while that in SCC was significantly greater than that in MSE. With dendritic cell infiltration macrophages in MSE as well as SCC and T-cells in and around the carcinoma were often increased. These findings suggest that dendritic cells may be attracted to maturative squamous epithelium, and may play an important role in the immunologic defence mechanisms of MSE. Dendritic cells, in contrast, may play a role in the cellular immune response of T-cells against the carcinoma.

Pigmented squamous cell carcinoma of the alveolar ridge in the oral mucosa.

The clinical and morphologic features of a pigmented squamous cell carcinoma of the alveolar ridge in an 81-year-old Japanese woman are reported. The tumor was typical, well-differentiated squamous cell carcinoma but had many melanin-containing cells within it. Electron microscopy showed melanosomes in macrophages, melanocytes, and neoplastic squamous cells. Those in the neoplastic squamous cells seemed to have been excreted from the cytoplasmic processes of melanocytes.

The contact Nd-YAG laser for oral and oropharyngeal malignant tumors.

Nine oral and oropharyngeal squamous cell carcinomas were removed with a contact Nd-YAG laser. Clinical and morphological studies on wound healing and effects of the Nd-YAG laser were performed. The wounds were not sutured and patients did not complain of any severe symptoms. The wound healing was prolonged to 3-6 weeks. Cells and glands degenerated at a depth of 2-3 mm by the direct effects of the laser. The epithelium exhibited acantholysis 5 mm from the site of laser injury. Scanning electron microscopy showed no coagulation or other coated material in the wound created by a surgical knife, while the wound surface by laser consisted of carbonization, well-coated and non-coated areas. These findings varied with the laser power. The coagulation and thermal effects of the Nd-YAG laser resulted in autolysis of tumor cells at least within 5 mm of the cutting surface. The contact Nd-YAG laser was useful for the removal of the malignant tumor in the oral cavity and oropharynx where it is difficult to maintain a generous safety margin.

A correlation of argyrophilic nucleolar organizer regions with prognoses in patients with maxillary sinus squamous cell carcinoma.

Argyrophilic nucleolar organizer regions (AgNORs) were determined by a semiautomatic image analyzer in a group of 28 patients with T2 or T3 maxillary sinus squamous cell carcinoma. The group was separated into recurrent and non-recurrent groups, metastatic and non-metastatic groups, as well as groups strongly or weakly positive for epidermal growth factor receptor (EGFR). The mean number and area of AgNOR dots per nucleus and the mean size of each dot were calculated. The mean number and area were significantly greater than those in normal cells (P < 0.001), but not in recurrent and non-recurrent groups, metastatic and non-metastatic groups and groups separated by EGFR. There was also no difference found in the mean sizes of tumor and normal cells. These results suggest that AgNOR is related to malignant transformation, but not prognosis.

[Appropriate administration of granulocyte colony stimulating factor for malignant lymphoma of the head and neck].

The effects of granulocyte colony stimulating factor (G-CSF) were evaluated in 9 patients with malignant lymphoma of the head and neck. The effects of 31 cycles of cytotoxic chemotherapy were treated with G-CSF. G-CSF was given by one of the following three routes: 1) administration before or with cytotoxic chemotherapy, 2) administration after cytotoxic chemotherapy with leukocyte counts of more than 2000/mm3, and 3) administration after leukocyte counts had dropped to less than 2000/mm3. The first group consisted of one cycle of CHOP therapy and 2 cycles of VAMA therapy. The second group consisted of 10 cycles of CHOP therapy. The third group consisted of 13 cycles of CHOP therapy and 5 cycles of VAMA therapy. Leukocyte nadirs occurred on around day 14 for CHOP therapy and around day 21 for VAMA therapy without G-CSF treatment. In the first group, the leukocyte nadirs occurred earlier with G-CSF treatment. Additional G-CSF treatments were given in two of the three cycles. In the second group, the leukocyte counts did not drop below 2000/mm3 in three of the ten cycles. Additional G-CSF treatments were given in five of the remaining seven cycles. The two other cycles went without additional treatment. The mean volume of G-CSF was 305 +/- 86 micrograms. In the third group, the leukocyte counts increased to more than 2000/mm3 immediately after G-CSF administration in CHOP therapy. The mean volume was 227 +/- 78 micrograms, significantly less than that of the second group. The leukocyte counts also exceeded 2000/mm3 3-5 days after G-CSF administration in 5 cycles of VAMA therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Extracranial meningioma in the parapharyngeal space.

A case of extracranial meningioma in the parapharyngeal space is reported. A 24 year old woman presented with swelling and tenderness of the parapharyngeal region. A tumor was palpable in this region, and the tumor was surgically removed. Macroscopically the tumor occurred from the portion between the axis and atlas. Histologically the tumor cells, which had oval nuclei and a slightly eosinophilic cytoplasm, proliferated in fibrous connective tissues to form small nests. As the cell borders were not clear, the tumor structure appeared to be syncytium-like. Immunohistochemically the tumor cells were positive for anti-vimentin antibodies, anti-S-100 protein antibodies and anti-epithelial membrane antigen (EMA) antibodies in part. Electron microscopically the tumor cells had complex interdigitations of their adjacent plasma membranes. These were studded with many desmosomes. Bundles of intermediate filaments were visible in the cytoplasm. On the basis of the clinical, histological, immunohistochemical and electron microscopical features, the tumor was diagnosed as extracranial meningotheliomatous meningioma. The parapharyngeal space is an extremely rare location for extracranial meningioma, and our case is the first in Japan as far as we know.

Nucleolar organizer regions in human maxillary sinus squamous cell carcinoma.

A silver colloid technique for nucleolar organizer regions (AgNOR) was applied to paraffin sections of maxillary sinus squamous cell carcinomas (MSSCC) of 25 patients. The patients were divided into two groups, one with MSSCC recurring in the primary lesion after treatment with radiotherapy, chemotherapy and/or surgery and one without recurrence. Notable differences between the numbers of NOR in neoplastic epithelia and the normal mucosa were observed (P = 0.0001), but there were no differences between the numbers of NOR in the recurrent and non-recurrent carcinomas. This investigation found no prognostic importance in the number of AgNOR in MSSCC.

Prognostic significance of epidermal growth factor receptor in squamous cell carcinoma of the maxillary sinus.

The expression of epidermal growth factor receptor (EGFR) was determined immunohistochemically in two groups of maxillary sinus squamous cell carcinomas, one with recurrences at the primary site after combination therapy with radiotherapy, chemotherapy and/or surgery and one without local recurrences. Using a four-graded scale (-, +, + +, + + +), 9 of the 10 recurrent carcinomas had a staining intensity and proportion of stained cells of + + or more. A comparable staining intensity was found in 9 of the 18 non-recurrent carcinomas. This difference is statistically significant (Fisher's exact probability test, P < 0.05). These results indicate that an increased expression of EGFR may influence the recurrence rate of squamous cell carcinoma of the maxillary sinus after combined therapy.

[Enophthalmos following radical operation of the maxillary sinus and ethmoidal sinus].

Enophthalmos is usually a consequence of orbital trauma resulting in a blowout fracture of the orbital floor. We report here the case of a 35-year-old male who had a radical operation of the maxillary sinus and the ethmoidal sinus, and 2 months after the operation, developed spontaneous enophthalmos and ocular pain. The left orbit was enophthalmic by 5mm according to Hertel enophthalmometry. Surgical correction was performed under general anesthesia. The left orbit was explored through a transcutaneous incision of the left lower lid which revealed marked periosteal adhesions and absence of the bony floor of the orbit. A rib cartilage graft was used to reconstruct the floor of the orbit, and the globe was brought forward by means of retrobulbar placement. Enophthalmos and ocular pain disappeared postoperatively.

Spontaneous pain in patients with maxillary sinus carcinoma in relation to T-classification and direction of tumour spread.

Spontaneous pain was one of many complaints on initial examination of 845 patients with maxillary sinus carcinoma. The pain was analysed; cheek, teeth, head and eye pain were compared with the T-classification and the anterior-posterior direction of invasion. The incidence of the cheek, teeth, head and eye pain was 48, 39, 29 and 23 per cent respectively. The incidence of both the cheek and teeth pain was increased according to the advancement of T-classification and invasion towards the posterior. Head and eye pain was often referred. In the localized posterior group which tend to be diagnosed late, spontaneous pain occurred in 15 to 48 per cent of the patients. Maxillary sinus carcinoma should always be a differential diagnosis in patients with unclear cheek, teeth, head and eye pain. A careful investigation should be performed in order to diagnose malignant diseases as early as possible.

[A comparative clinical study of adjuvant chemotherapy of tumors in the head and neck areas by means of HCFU].

In order to evaluate the efficacy of HCFU as an adjuvant chemotherapy agent for squamous cell carcinoma of the head and neck areas, a randomized comparative study was performed with cooperative facilities. 191 patients who had undergone radical therapy were randomly assigned to the following two groups: Group A was the control group, which underwent radical therapy only, and Group B was a group which received long-term HCFU administration (300-600 mg/day x 12 weeks or more). In the comparison of non-recurrence rate in both groups, Group B had better results among patients who were at the advanced clinical stages such as N1 through N3, Stage II (p = 0.0583) and Stage III (p = 0.0970). The adverse reactions to HCFU included pollakiuria, feverishness, and digestive symptoms, but these were mild and the recovery was possible.