Locally advanced papillary thyroid carcinoma (PTC) with invasion of the airway and major vessels presents a significant therapeutic challenge. Although multikinase inhibitors (mTKIs) are effective for unresectable thyroid carcinoma, their antiangiogenic effects may increase the risk of life-threatening hemorrhage in patients with major vessel invasion or intraluminal airway exposure. Recent advances in BRAF-directed therapy have suggested a potential role for conversion surgery in selected patients with advanced thyroid carcinoma. A 75-year-old man presented with PTC with extensive intraluminal tracheal invasion causing severe airway stenosis, suspected common carotid artery involvement, and pulmonary metastases. The tumor was considered initially unresectable, and lenvatinib was avoided because of the risk of hemorrhagic complications. Following identification of a BRAF V600E mutation, treatment with dabrafenib plus trametinib was initiated. Dyspnea and wheezing resolved rapidly, and computed tomography demonstrated improvement of airway stenosis and restoration of a clear tissue plane between the metastatic lymph node and common carotid artery. Conversion surgery consisting of total thyroidectomy, circumferential tracheal resection, and bilateral neck dissection was subsequently performed. The postoperative course was uneventful. BRAF-directed therapy may represent a useful strategy for achieving conversion surgery in selected patients with locally advanced PTC.

BackgroundRecent advances in artificial intelligence have facilitated the automatic diagnosis of middle ear diseases using endoscopic tympanic membrane imaging.AimWe aimed to develop an automated diagnostic system for middle ear diseases by applying deep learning techniques to tympanic membrane images obtained during routine clinical practice.Material and methodsTo augment the training dataset, we explored the use of generative adversarial networks (GANs) to produce high-quality synthetic tympanic images that were subsequently added to the training data. Between 2016 and 2021, we collected 472 endoscopic images representing four tympanic membrane conditions: normal, acute otitis media, otitis media with effusion, and chronic suppurative otitis media. These images were utilized for machine learning based on the InceptionV3 model, which was pretrained on ImageNet. Additionally, 200 synthetic images generated using StyleGAN3 and considered appropriate for each disease category were incorporated for retraining.ResultsThe inclusion of synthetic images alongside real endoscopic images did not significantly improve the diagnostic accuracy compared to training solely with real images. However, when trained solely on synthetic images, the model achieved a diagnostic accuracy of approximately 70%.Conclusions and significanceSynthetic images generated by GANs have potential utility in the development of machine-learning models for medical diagnosis. (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic).(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic).(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic), (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic) (GAN) (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic), (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic).2016 (sic)(sic) 2021 (sic)(sic)(sic), (sic)(sic)(sic)(sic)(sic) 472 (sic)(sic)(sic)(sic)(sic)(sic), (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic): (sic)(sic),(sic)(sic)(sic)(sic)(sic),(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic).(sic)(sic)(sic)(sic)(sic)(sic)(sic) InceptionV3 (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic), (sic)(sic)(sic)(sic) ImageNet (sic)(sic)(sic)(sic)(sic)(sic)(sic).(sic)(sic), (sic)(sic) StyleGAN3 (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic) 200 (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic).(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic), (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic).(sic)(sic), (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic), (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic) 70%.(sic)(sic)(sic)(sic)(sic)(sic)GAN (sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic)(sic).

We report a rare case of cervical vagal schwannoma in which we had difficulty in evaluating the vocal fold movements. The patient was a 52-year-old man diagnosed as having a cervical vagal schwannoma. We found it difficult to evaluate the vocal fold movements in this patient because he had a history of having undergone surgery for laryngotracheal injury sustained in a traffic accident. As the tumor increased in size, with consequent worsening of the pharyngeal discomfort reported by the patient, we performed intracapsular resection of the tumor. Intraoperative vagus nerve stimulation showed elicited no vocal cord response. However, the patient developed hiccups and bradycardia during the surgery, which suggested that the main afferent tract of the vagus nerve was still preserved. Therefore, the tumor was removed while taking care to preserve the vagus nerve, and no obvious neurological deficit was observed after the surgery. Thus, particular attention needs to be paid selection of the appropriate treatment strategy in such patients because of the risk of perioperative complications.

Nivolumab is approved for the treatment of recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC). However, the influence of the site of distant metastasis on the efficacy of immune checkpoint inhibitor in R/M HNSCC remains unclear. We investigated the prognosis of R/M HNSCC patients treated with nivolumab, focusing on the site of distant metastasis. We reviewed the data of R/M HNSCC patients treated with nivolumab between April 2017 and June 2020 at Saitama Prefectural Cancer Center. The differences in the prognosis were evaluated according to the site of distant metastasis. Of the 41 patients enrolled, 26 (63.4

光学技術の進歩による内視鏡画像の高精細化は拡大された明瞭な鼓膜写真の撮影を可能とした. しかし鼓膜所見から診断を正確に下すことは必ずしも容易とはいえず, 多くの経験を必要とする. 今回われわれは, 外来診療によって収集した鼓膜の内視鏡画像を用いて, 機械学習による中耳疾患の自動診断を行うプログラムの作成を試みた. 2016年4月～2021年10月に記録された鼓膜の内視鏡画像データを収集した. それぞれの鼓膜所見を, 診療を担当した耳鼻咽喉科医の診断に基づき, 正常, 急性中耳炎, 滲出性中耳炎, 慢性穿孔性中耳炎, 真珠腫性中耳炎の5種類の診断に分類した. 続いて, SONY が提供する Neural Network Console® を用いて画像データの管理と学習を行い, その精度を評価した. 学習モデルには VGG-11, InceptionV3 を採用した. 544枚の画像を収集し, 5種類の診断で精度74%のプログラムが作成された. われわれの検討では, VGG-11 のファインチューニングを行わなかったモデルが最も高い精度を記録した. さらなる精度の向上のためには, より多くの画像が必要と思われる.

Clear cell carcinoma is a low-grade salivary gland tumor that is indolent and rare. We report a case of clear cell carcinoma arising from the base of the tongue. The patient was a 64-year-old man with a tumor at the base of the tongue incidentally detected during an upper gastroendoscopy. Computed tomography and magnetic resonance imaging revealed a 17-mm tumor arising from the base of the tongue. A biopsy indicated either a clear cell carcinoma arising from a minor salivary gland or metastasis from renal carcinoma ; the latter was ruled out by abdominal examination. The tumor was successfully removed by intraoral median glossotomy. After the surgery, fluorescence in situ hybridization analysis revealed that the tumor cells were positive for EWSR1-ATF1 rearrangement, establishing the definitive diagnosis of clear cell carcinoma. No local recurrence or distant metastasis was observed 9 months post-surgery. Esthetics were maintained by the minimally invasive procedure, and the patient’s recovery progressed without any functional impairment such as dysphagia or dysarthria.

Hiccups are common reflexes and many treatment methods have been reported. Chlorpromazine is a known treatment option for hiccups, but its efficacy under general anesthesia remains unclear. We report the case of a patient with vagal schwannoma who developed hiccups while under general anesthesia. Muscle relaxants were not used because the patient was under neuromonitoring. The depth of anesthesia was deepened; however, the hiccups did not disappear. The hiccups were relieved by intravenous chlorpromazine administration (total; 5 mg), which allowed for surgery under neuromonitoring. This case indicates that chlorpromazine may be effective to treat hiccups under general anesthesia.

下咽頭癌症例では特に食道癌との重複が多い。同時重複癌症例では治療の選択が難しく，先行・後続治療が予定通り行えない場合もある。そこで2011–2014年の4年間で治療を行った下咽頭癌152例を検討した。重複癌は84例（55％）で認め，食道癌が最も多かった。5年全生存率（OS）は下咽頭癌単独症例54％，下咽頭食道癌重複例80％と有意差をもって重複症例が良好で，上部消化管内視鏡検査で下咽頭癌が早期で発見されたことが理由と考えられた。同時重複癌症例のOSは，下咽頭–食道どちらも早期癌症例で100％，進行癌症例で63％，早期–進行癌で75％，進行–早期癌で56％であった。早期食道癌が後続治療で，早期に治療が開始できない場合，先行治療で化学療法を行うべきと考えられた。下咽頭早期癌が後続治療の場合，先行治療の化学療法を行い不明瞭化しても，厳重な経過観察もしくは治療を行うべきと考えられた。

頸部リンパ節腫大を契機に発見されるものの，様々な術前検査を施行しても甲状腺内に原発巣を認めない甲状腺乳頭癌症例が稀に存在する。これは甲状腺内に原発巣がないものであるか，術前検査にて描出できないほど原発巣が小さなものであるかのどちらかである。 2010年1月から2017年12月にかけて当科で手術治療を行った甲状腺乳頭癌216例のうち，術前検査にて頸部外側区域リンパ節への転移を認めたものの甲状腺内に原発と考えられる腫瘤を認めなかった5症例を対象とした。どの症例も，一次治療として甲状腺片葉切除，患側D2b郭清を施行した。5例中1例は甲状腺内に原発巣となる病変を認めなかった。3例は多発の腺内転移を認めた。 術前検査にて甲状腺内に原発巣を認めない乳頭癌症例において，根治性，機能温存の双方を考慮した場合，甲状腺内の腺内転移の有無に関わらず患側の甲状腺片葉切除も選択肢になると考えられた。

下咽頭扁平上皮癌においてN2c症例は遠隔転移の高リスク群であり予後不良である。N2c群の中にも， 原発が片側にとどまるN2c群（原発片側群）と，原発が両側に拡がるN2c群（原発両側群）を認めるが，両者に 遠隔転移の状況や予後で差異があるのか後方視的に検討した。対象は，2008年から2016年に下咽頭扁平上皮癌新鮮例のうち，下咽頭喉頭全摘術および両側頸部郭清術を施行し，病理学的N2cが証明された41例とした。解析結果では，全生存率，疾患特異的生存率では両者に有意差は認めなかったが，無遠隔転移生存率は5年時点で原発片側群で40％，原発両側群で75％であり有意差を認めた。N2c症例で，原発が片側にとどまる症例はより遠隔転移を来すリスクが高い可能性が示唆された。

Head and neck cancer metastasizing to the small intestine is very rare. Here we report a case of cancer of the mandibular gingiva metastasizing to the small intestine. The patient was an 82-year-old man who had squamous cell carcinoma of the mandibular gingiva staged as T2N2bM0. Two months after surgery, he presented with lower abdominal pain accompanied by signs of peritoneal irritation. Urgent abdominal surgery was performed, during which a crater-shaped perforation was noted on the wall of the ileum. Microscopic findings at this site confirmed a diagnosis of metastatic squamous cell carcinoma in the small intestine from the mandibular gingiva. To our knowledge, this is the first case report of oral cancer metastasizing to the small intestine. If gastrointestinal symptoms appear in a patient with advanced oral cancer, a differential diagnosis of metastasis to the gastrointestinal tract should be kept in mind.

2017年に改訂されたUICCのTNM分類第8版についてその内容と臨床上の問題点を自験例で検討した。転移性頸部リンパ節から扁平上皮癌が検出されp16免疫染色が陽性であればp16陽性中咽頭癌にEBER-ISHが陽性であれば上咽頭癌に分類され，それ以外の残りが新分類上の原発不明頸部転移扁平上皮癌となった。自験例では従来のおよそ7割が新分類の原発不明頸部転移癌，3割がp16陽性中咽頭癌に相当した。節外進展を強力な予後因子として考慮したN分類が提唱され，病期はⅢ期およびⅣ期に分類された。cN病期はpN病期に比して過小評価される傾向が高く，両者の解離による生存曲線の大きな違いが臨床上の問題点と思われた。

下咽頭癌は早期にリンパ節転移を来すこともあり，明らかなリンパ節転移を認めない場合でも予防的に両側の頸部リンパ節郭清術を行うことが多い。術前検査にて健側頸部リンパ節に明らかな転移を認めていない下咽頭梨状陥凹癌において原発巣が正中を超えない症例と，梨状陥凹癌ながら正中を超えて進展する症例の2群，および原発巣が梨状陥凹に限局する症例と，限局せずに他部位へ進展する症例の2群に分け，健側頸部リンパ節転移の頻度を比較，検討した。下咽頭梨状陥凹癌において，腫瘍が健側に進展していない症例，もしくは腫瘍が梨状陥凹に限局する症例においては健側外側頸部郭清術を省略できる可能性があると考えられた。一方，腫瘍が正中を超えて進展する場合，もしくは腫瘍が梨状陥凹に限局せずに他部位へ進展する場合は両側の外側頸部郭清術，気管傍郭清術が必要と考えられた。

多発性対称性脂肪腫症は，頸部，肩，上腕や体幹部に，多発性，対称性に被膜を有さない脂肪組織の沈着を来す疾患で，日本での報告は極めて稀である。今回われわれは，両側顎下部からおとがい下部にかけて発生した多発性対称性脂肪腫症に対し，整容目的で切除術を行い，患者の高い満足が得られた症例を経験したので報告する。症例は63歳男性。4年前からの頸部腫脹で受診された。緩徐な経過で増大し，シャツの着用が困難となったため，整容目的で手術治療を行う方針となった。皮膚切開は横切開とし，広頸筋の浅層と深層に分けて脂肪組織の郭清を行った。術後6か月時のMRIにて再発なく経過しており，高い整容性が維持されている。

甲状腺癌の気管浸潤例の治療は腫瘍の浸潤範囲から喉頭温存の可否と気管合併切除時の再建法について評価することが重要である。喉頭温存には健側の反回神経の確実な温存が重要である。気管再建については手術侵襲や周術期の安全性の面から気管部分切除し気管皮膚瘻を作成する2期的再建が適しているとされる。今回われわれは甲状腺癌の気管浸潤例について気管を部分切除したが，初回手術で肋軟骨と前腕皮弁を移植し膜様部から側壁の再建する気管枠組み手術をしたのちに2期的に気管皮膚瘻閉鎖を行った。これにより安全かつ良好な喉頭機能温存が可能であった。甲状腺癌気管浸潤例の治療について改めて考察し，本法の有用性について報告する。

varying degrees of respiratory impairment. We report a male neonate with CNDC. The CNDC was surgically resected using an intranasal endoscopic approach. He presented with respiratory impairment just after birth and was treated with continuous positive airway pressure. An intranasal mass was located on the left inferior meatus. Computed tomography and magnetic resonance imaging showed an enlarged lacrimal sac and a nasolacrimal duct with the mass on the inferior meatus. Because his respiratory impairment became progressively more severe, an intranasal endoscopic marsupialization was performed with a microdebrider to improve his obstructed nasal respiration. Under general anesthesia, direct visualization of the left nasal cavity was performed using a straight telescope with an outside diameter of 2 . 7 mm. Endoscopic observation and iodine injection excluded the presence of right nasolacrimal duct cysts. Before marsupialization, the patency of the nasolacrimal duct was confirmed by iodine injection into the lacrimal punctum. The procedure with the microdebrider was carefully performed to prevent injury to the surrounding tissue. Nasal packing to prevent bleeding was not necessary. Although his respiratory state was not fully restored postoperatively, his obstructed nasal respiration was relieved, and no instances of recurrence or complications were noted. Nasal endoscopic marsupialization with a microdebrider represents a safe and effec-tive method for the treatment