頭頚部腫瘍性病変で失神/社会疫学ＤＡＹ２

・だいたひかる風（わかる人が、現在どれだけいる？）に「私だけ？、失神の原因検索に苦労するのは？」ということで、↓の論文のような論文を読みました。頭頚部の腫瘍でも失神発作が起こります。（本文を読もうとする人は、手術中の写真がちょっとエグイ？？ので要注意）

失神発作を惹起したと考えられた大きな下顎骨中心性粘表皮癌の1例

日本口腔外科学会雑誌　64巻（2018）9号

【抄録】（本文は日本語です）

https://www.jstage.jst.go.jp/article/jjoms/64/9/64_545/_article/-char/ja

 

Central mucoepidermoid carcinoma is an uncommon tumor, accounting for 2% to 3% of all mucoepidermoid carcinomas. Meanwhile, a head and neck tumor rarely causes an attack of syncope. We describe a case of syncope considered to be caused by a large central mucoepidermoid carcinoma in the mandible. A 66-year-old man was referred to our clinic to receive treatment for a right mandibular lesion and to determine the cause of repeated attacks of syncope. Computed tomography showed that the right side of the mandible was remarkably expanded, and the parapharyngeal space was compressed by an expanded right mandibular tumor. Tumor biopsy was performed, and a mucoepidermoid carcinoma of the mandible was definitively diagnosed. No evidence of metastasis was evident on positron emission tomography. With the patient under general anesthesia, we performed a right hemimandibulectomy, right neck dissection, and immediate reconstruction using a pectoralis major myocutaneous flap and a reconstruction plate with condyle. We found no evidence of local recurrence or regional and distant metastasis at the 4-year postoperative follow-up. In addition, no attack of syncope occurred after the operation.

 

・本文の抜粋↓

下顎骨中心性悪性腫瘍が失神発作を生じたという報告は， 渉猟し得た範囲ではないものの， 頭頸部領域の腫瘍性病変 が， まれに失神発作を誘発することがある．悪性腫瘍 での報告が多いが良性腫瘍での報告例もある．失神発 作の作用機序は， 腫瘍が舌咽神経や総頸動脈にある頸動脈 洞を圧迫したり浸潤することによって， 交感神経の抑制と 副交感神経（ 迷走神経） の興奮が惹起され， 低血圧， 徐脈も しくは心停止が生じることによると考えられている

cf.　上記論文が引用している文献の一つ

AJNR Am J Neuroradiol  2002 Aug;23(7):1257-60.

Syncope as a sign of occult malignant recurrence in the retropharyngeal and parapharyngeal space: CT and MR imaging findings in four cases.

http://www.ajnr.org/content/23/7/1257.long

Abstract

Although rare, syncope may result from metastasis to the retropharyngeal or parapharyngeal space and involve or invade the glossopharyngeal nerve or internal carotid artery. We report the CT and MR imaging findings in four patients with syncope that preceded the diagnosis of recurrent squamous cell carcinoma in the pericarotid region. These findings suggest that recurrent carcinoma should be ruled out when a patient with head and neck malignancy and syncope is postoperatively examined.

・もう一つ引用文献↓（これは、freeでは読めないようなので、抄録のみ）

J Neurooncol. 1983;1(3):257-67.

Syncope from head and neck cancer.

Abstract

We have examined 17 patients suffering from recurrent syncope caused by carcinoma of the head and neck. The tumor originated in the mouth in seven, larynx in six, nasopharynx in three and parotid gland in one, and involved cervical lymph nodes at diagnosis in 12. Sixteen patients had previously had radical neck dissections and 12 had had radiation therapy. Recurrent carcinoma was present in 16. Spells resolved spontaneously in four, improved with treatment in 11 and continued in two. The syncope was spontaneous in 15 and induced only by suctioning or carotid sinus massage in two. Suctioning also produced attacks in four others, as did carotid sinus massage in five of ten tested. Acute severe unilateral head or neck pain preceded spontaneous syncope in 11. Sixteen patients had both profound bradycardia and hypotension during most spells, but ten had syncope with hypotension only, either spontaneously or following cardiac pacing or atropine to prevent bradycardia. Seizure activity accompanied syncope in eight. Anticholinergics improved 7/12, carbamazepine 2/5, carotid ligation 1/1 and intracranial sectioning of the glossopharyngeal nerve 1/1. Local radiation may have helped 4/10. Cardiac pacing was ineffective in 3/3 due to the development of pure vasodepressive syncope. Autopsy in 2/2 showed tumor involving the glossopharyngeal and vagus nerves. Syncope in these patients is under-recognized, frequently is due to vasodepression, and suggests recurrent carcinoma.

 

以下日記

・本日11/20（火）は、5時1分まえに起床。身支度して病院へ。途中セブンイレブンによってサンドイッチと肉まん買って病院着。医局で朝食摂りながら電子カルテで情報チェックして病棟へ。重症の患者さんを診て、岡大医学部へ。9時から17時前まで、イチロー・カワチ先生の社会疫学講義2日目。本日のメインは、人種と差別の話。一般の人が聞いたらいろいろ驚くべき話をされておりました。Social Epidemiology second editionにあった　"Discrimination and Health inequities"の章は、日本語訳の『社会疫学』のテキストでは省略されていたので、ちょっと性根入れて読まないといけないと思いました。（英語のテキストは自分が訳した1章ともう1章しか読んでおりません）

・お昼休みがちょっと長かったので、久々に散髪。散髪屋のＴＶで、日産のゴーン会長の逮捕のことをワイドショウでやっておりました。これで、株価が下落して逮捕に腹立てるひともいるんでしょうね。人の価値観はいろいろでしょうが、まずは社会正義（最低法律守ること）でしょうと、私なんかは思うのですが。（株を持っていないもののかんかくですかね）

・帰宅は、18時20分頃。すぐお風呂入ってから録画の「月曜から夜ふかし」観ながら夕食。で、スダチをいれたジントニックもどき。スダチがなくなるまでアルコール摂取はつづくでしょう。

・明日は、社会疫学集中講義の最終日。明日も早起きするので、早く寝ましょう。