中村 雅美¹, 河崎 正³, 大西 さゆり¹, 雪本 幸美¹, 辻 悦生², 中村 芳久², 横澤 保⁴, 宮内 昭⁴, 畑中 信良⁵, 仲原 正明⁵

Masami NAKAMURA¹, Tadashi KAWASAKI³, Sayuri OONISHI¹, Satimi YUKIMOTO¹, Etsuo TSUJI², Yoshihisa NAKAMURA², Tamotsu YOKOZAWA⁴, Akira MIYAUTI⁴, Nobutaka HATANAKA⁵, Masaaki NAKAHARA⁵

¹河崎内科病院超音波検査室, ²河崎内科病院放射線検査室, ³河崎内科病院内科, ⁴隈病院外科, ⁵大阪警察病院外科

¹Ultrasonographic Laboratory, Kawasaki Naika Hospital, ²Radiographic Laboratory, Kawasaki Naika Hospital, ³Department of Internal Medicine, Kawasaki Naika Hospital, ⁴Department of Surgery, Kuma Hospital, ⁵Department of Surgery, Osaka Police Hospital

キーワード : ADF image, anaplastic thyroid carcinoma, F-3D image, Levovist, total laryngectomy

症例は, 1ヵ月前に近医にて前頚部腫瘤を指摘された72歳, 女性, 嗄声, 血痰, 呼吸困難を主訴として救急入院した. 入院時所見では, 前頚部に約5 cm大の腫瘤と右側頚部に無痛性の鶏卵大のリンパ節を触知した. 頚部のX線撮影とCTスキャンでは, 腫瘤の浸潤による気管の圧排像と著明な狭窄像を認めた. 頚部の超音波検査では, 甲状腺右葉の腫瘍内に石灰化を有する, 境界不明瞭, 内部不均一の低エコー腫瘤と気管右側から気管内部に直接浸潤を強く疑う腫瘤による狭窄像を声帯下方に認めた. Advanced Dynamic Flow法では, 右葉内にブルーミングの少ない腫瘍血流と増大した腫瘤から 気管内部に流入する2本の細い動脈血流が描出された. レボビストをボーラス注入後の造影Fusion 3D像では, 右総頚動脈の腫瘤による圧排像と気管内部に流入する微細な腫瘍内血流が明瞭に描出された. 超音波ガイド下穿刺吸引細胞診の結果は, 大型で異型性を有する甲状腺未分化癌を示した. その後, 血痰や呼吸困難が増悪してきたため, 緊急で甲状腺腫瘍を含めた喉頭全摘出術を施行した. 病理組織所見は, 扁平上皮癌から転化した未分化癌であった. 超音波検査における ADF法やレボビスト造影Fusion 3D法は, 甲状腺腫瘍内外の微細な血管構築を明瞭に描出でき, 今後, 腫瘍の質的診断やPEIT前後の治療効果判定に充分寄与できると思われる.

A 72-year old woman was brought to the emergency room because of hoarseness, hemosputum, and dyspnea. Her health had been stable until 1 month earlier, when a physician discovered a mass in the anterior region of her neck. Further examination showed the mass to be about 5 cm in diameter and a painless lymph node the size of an egg was discovered by palpation in the right side of her neck. A roentgenogram and a computed tomographic scan of the neck showed external compression and marked stenosis of the trachea resulting from intratracheal invasion by a tumor. Ultrasonographic examination of the neck revealed a hypoechoic mass with an unclear margin and heterogeneous internal echogenicity, and a calcification in a mass in the right lobe of the thyroid gland. Additionally, remarkable stenosis of the trachea, thought to be directly invasion of the mass, was found immediately below the vocal cords. Ultrasonography using advanced dynamic flow (ADF) imaging showed intratumoral blood flow with little blooming, and two small arteries carrying blood from the enlarged tumor into the intratracheal space. After a bolus injection of a contrast agent (Levovist), Fusion Three Dimensional (F-3D) imaging showed compression of the right common carotid artery by the tumor and minute intratumorous vessels communicating with the trachea at the right lobe of the thyroid gland. Echo-guided aspiration needle biopsy disclosed an anaplastic thyroid carcinoma with atypical, large-type cells. Total laryngectomy was performed, because of deterioration in dyspnea and hemosputum. The microscopic findings demonstrated a thyroid anaplastic carcinoma that had developed from a squamous carcinoma. ADF imaging and F-3D imaging using the contrast agent depicted the intratumoral and extratumoral vasculature of the thyroid tumor. These techniques might contribute to the qualitative diagnosis of masses and estimation of the therapeutic effect of percutaneous ethanol injection therapy for thyroid tumor.