島根大学 医学部 医学科 4年次生 チュートリアル講義 ∼口腔顎顔面頸部の口腔がん手術 再建外科手術∼に必要な 臨床局所解剖学 歯科口腔外科学講座 (主任：関根浄治教授) 辰巳 博人 口腔癌 (上顎洞) ＋ 唾液腺(大唾液腺, 小唾液腺） 口唇 TNM classification 口唇および口腔 T −原発腫瘍 TX T0 Tis T1 T2 T3 原発腫瘍の評価が不可能 原発腫瘍を認めない 上皮内癌 最大径が 2 cm以下の腫瘍 最大径が 2 cmをこえるが 4 cm以下の腫瘍 最大径が 4 cmをこえる腫瘍 T −原発腫瘍 T4a T4a T4b 口唇：骨髄質，下歯槽神経，口腔底，皮膚（顎ま たは外鼻）に浸潤する腫瘍 口腔：骨髄質，舌深層の筋層/外舌筋（オトガイ舌 筋，舌骨舌筋，口蓋舌筋，茎突舌筋），上顎洞， 顔面の皮膚へ浸潤する腫瘍 口唇および口腔：咀嚼筋間隙，翼状突起，または 頭蓋底に浸潤する腫瘍，または内頚動脈を全周 性に取り囲む腫瘍 Nー所属リンパ節 NX 所属リンパ節転移の評価が不能 N0 所属リンパ節の転移なし N1 同側の単発性リンパ節転移で最大径が 3 cm以下 N2 N2a 同側の単発性リンパ節転移で最大径が 3 cmを こえるが 6 cm以下 N2b 同側の多発性リンパ節転移で最大径が 6 cm以下， N2c 両側性あるいは対側のリンパ節転移で最大径が 6 cm以下 N3 最大径が6 cmをこえるリンパ節転移 Mー遠隔転移 MX 遠隔転移の評価が不可能 M0 遠隔転移なし M1 遠隔転移あり 病期分類 0期 I期 II期 III期 IV A期 IV B期 IV C期 Tis T1 T2 T1,2 T3 T1, T2, T3 T4a T4b Tに関係なく T, Nに関係なく N0 N0 N0 N1 N0,N1 N2 N0, N1, N2 Nに関係なく N3 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 日本口腔外科学会、口腔がん診療ガイドライン、2013年版 口腔癌原発巣の治療 I．外科療法 A．切除術 口腔癌は，舌，口底，頰粘膜，上顎歯肉，下顎歯肉，硬口蓋など 解剖学的構造の異なった部位に発生するために，癌の病態や進 展様式は発生部位によって大きく異なる。そのため治療法も部位 によって異なってくる。口腔癌の外科切除では，咀嚼および摂食・ 嚥下，発音などの機能面ならびに顎顔面領域の審美面に及ぼす 影響も大きいため，術後の患者のQOLを重視した治療体系が望ま れ，欠損部についての再建を配慮した外科療法を行う必要がある。 日本口腔外科学会、口腔がん診療ガイドライン、2013年版 １．舌 癌 a．舌の切除方法 （1）舌部分切除：舌可動部の一部の切除，あるいは半側に満たない切除（図4-1）。 （2）舌可動部半側切除：舌可動部のみの半側切除。 （3）舌可動部（亜）全摘：舌可動部の半側を越えた（亜全摘），あるいは全部の切除。 （4）舌半側切除：舌根部を含めた半側切除（図4-2）。 （5）舌（亜）全摘：舌根部を含めた半側以上の切除（亜全摘），あるいは全部の切除（図4-3,4） b．T分類と切除法の原則 T1：舌部分切除 earlyT2：舌部分切除，ただし深部浸潤の程度によっては舌可動部半側切除を適用。 lateT2：表在型は舌部分切除，腫瘍浸潤の深い症例は舌可動部半側切除。 T3： 表在型は舌部分切除術，腫瘍浸潤の深い症例は舌（可動部）半側切除術，さらに深い症例は舌（可動部）亜全摘出術を行う。 T4：舌（可動部）亜全摘出術あるいは全摘出術を行う。 c．口底・下顎骨進展に対する切除術 舌癌の下顎骨進展あるいは口底に進展し下顎骨に接している症例は，口底・下顎骨を同時に切除して，安全域を確保する15）,16）。腫瘍 が顎舌骨筋を越えていなければ，下顎辺縁切除を行う（図4-5）。腫瘍が顎舌骨筋を越える場合は，切除を確実にするために下顎区域 切除を行う9）（図4-6）。 d．舌根進展例に対する切除術 舌縁後方で舌根に浸潤した症例は，舌根，口蓋舌弓，扁桃窩を切除する17）。 舌半側切除 舌部分切除 舌全摘 下顎辺縁切除 （口底進展・下顎近接） 舌亜全摘 下顎区域切除 （下顎骨進展） 下顎歯肉癌の切除方法 ２．口底癌 ３．頬粘膜癌 ４．下顎歯肉癌 (社）日本口腔腫瘍学会・ガイドラインより http://www.jsot.org/ 切除範囲の模式図 ５．上顎歯肉癌・硬口蓋癌 付属 気管切開術 原発巣の切除範囲が広い場合，両側の頸部郭清術を行った場合，および気道 閉塞が長期間に及ぶ可能性がある場合には同時に気管切開を行う。 口腔がん頸部リンパ節転移巣の手術治療 口腔癌における頸部郭清術の分類 日本口腔外科学会、口腔がん診療ガイドライン、2013年版 頸部リンパ節のレベル分類 日本口腔外科学会、口腔がん診療ガイドライン ： オトガイ下リンパ節（Level IA）， 顎下リンパ節（Level IB） Level II ： 上内頸静脈リンパ節 （Level IIA：副神経より前方，Level IIB：副神経より頭側） Level III ： 中内頸静脈リンパ節 Level IV ： 下内頸静脈リンパ節 Level V ： 副神経リンパ節（Level VA），頸横リ ンパ節，鎖骨上窩リンパ節（Level VB） Level VI ： 前頸部リンパ節 Level I I．外科療法 B．再建術 口腔癌治療において再建術を行う目的は，手術などにより生じた組織欠損を修復するとともに，術後 の機能障害をできるだけ軽減しQOLを向上することにある。さまざまな再建方法，再建材が報告され ているが，長期的予後を含め，安全性が高く，機能回復の優れた方法が望まれる。 口腔癌切除による組織欠損は軟組織，硬組織（顎骨），あるいはその両方に生じ，さまざまな再建 方法が報告されている。再建術を行う時期には，腫瘍切除と同時に行われる即時再建（一次再建）と 切除後に行われる二次再建がある。再建方法，再建時期の決定には患者の年齢，全身状態，社会 生活なども考慮して検討されるべきである 口腔癌切除後欠損 に対する再建方法 日本口腔外科学会、口腔がん診療ガイドライン、2013年版 有茎皮弁 DP 皮弁 Deltopectoral flap 内胸動脈肋間穿通枝により栄養されるが deltoid portionは皮膚穿通枝により栄養される 大胸筋皮弁 Pectoralis major myocutaneous flap 胸肩峰動脈系により栄養される 遊離皮弁 前腕皮弁 腓骨部皮弁 There are typically 206 bones in the body, though there may be up to about 226. Of these there are 22 bones of the Skull, which include: 8 Cranial Bones: 1 x Ethmoid Bone 1 x Frontal Bone 1 x Occipital Bone 2 x Parietal Bones 1 x Sphenoid Bone 2 x Temporal Bones 14 Facial Bones: 2 x Inferior Nasal Conchae 2 x Lacrimal Bones 1 x Mandible 2 x Maxillae (pl.); Maxilla (sing.) 2 x Nasal Bones 2 x Palatine Bones 1 x Vomer 2 x Zygomatic Bones The other bone also included in this section is the hyoid bone, which is located in the neck . Other bones that may also be required knowledge and other similar therapies include: 33 Spinal Bones: 33 x Vertebrae, including: 1 x Atlas (1st Vertebra), and 1 x Axis (2nd Vertebra). Other Bones: 2 x Clavicle 2 x Humerus 2 x Scapula 1 x Sternum AO-CMF, http://www.ivy-rose.co.uk/HumanBody/Skeletal/Bones_CranialandFacial.php より改変引用 The right lateral view and anterior view of the skull's bones http://www.cliffsnotes.com/sciences/ より改変引用 Dissection Platysma Cutaneous nerves and superficial veins Lesser occipital n. External jugular vein Greet auricular n. Transverse nerve of neck Anterior jugular vein Supraclavicular n. Submendibular gland Digastric Accessory n. Hypoglossal n. Superior thyroid a. Ansa cervicalis Sternothyroid Sternohyoid Vagus n. Cervical plexus Phrenic n. Omohyoid Hypoglossal n. Vagus n. Internal branch Superior thyroid a. Vertebral a. External branch Inferior thyroid a. The muscles of neck • Superficial group • • Platysma 広頚筋，a thin sheet-like muscle of facial expression Sternocleidomastoid 胸鎖乳突筋 • Suprahyoid muscles • Digastric 顎二腹筋 • Stylohyoid 茎突舌骨筋 • Mylohyoid 顎舌骨筋 • Geniohyoid オトガイ舌骨筋 Elevate (raise) hyoid bone and depress mandible. • Infrahyoid muscle • • • • Sternohyoid 胸骨舌骨筋 Sternothyroid 胸骨甲状筋 Thyrohyoid 甲状舌骨筋 Omohyoid 肩甲舌骨筋 Depress hyoid or larynx after elevation • Deep group • Lateral • • • • Scalenus anterior 前斜角筋 Scalenus medius 中斜角筋 Scalenus posterior 後斜角筋 Medial • • longus capitis 頭長筋 longus colli 頸長筋 Flex the head, bends the neck forward The arteries of neck Common carotid artery 総頸動脈 • Origin (arises from) • Brachiocephalic trunk on the right • Aortic arch on the left • Ascends in neck to upper border of thyroid cartilage; bifurcates into internal and external carotid arteries • Carotid sinus 頸動脈洞 (baroreceptor), located at a localizes dilation of terminal part of common carotid artery or beginning of internal carotid artery, sensitive to blood pressure changes • Carotid glomus 頸動脈小体 (chemoreceptor), lies posterior to the point of bifurcation of common carotid artery, senses changes in blood carbon dioxide (oxygen) levels Branches of external carotid a. • Superior thyroid a. 上甲状腺動脈－ descends to supply upper pole of thyroid gland and larynx • Lingual a. 舌動脈 • Facial a. 顔面動脈 • Occipital a.後頭動脈 • Posterior auricular a. 後耳介動脈 • Maxillary a. 顎動脈 • Superficial temporal a. 浅側頭動脈 Subclavian artery 鎖骨下動脈 • Origin (arises from) • Brachiocephalic trunk on right • Aortic arch on left • Becomes axillary artery at lateral border of first rib • Branches • Vertebral a. 椎骨動脈 • Internal thoracic a. 内胸動脈 • Thyrocervical trunk 甲状頸動脈 • Inferior thyroid artery 下甲状腺動脈－ supplies inferior pole of thyroid gland • Costocervical trunk 肋頸動脈 Veins Draining the neck Internal jugular vein 内頸静脈 • Begin at jugular foramen, descending to join the subclavian vein to form brachiocephalic vein • Lies lateral first to internal and then to common carotid a. within carotid sheath • Chief extracranial tributaries • • • • • Common facial vein 総顔面静脈 Lingual v. 舌静脈 Pharyngeal v. 咽頭静脈 Superior thyroid v.上甲状腺静脈 Middle thyroid v. 中甲状腺静脈 Subclavian vein • It is an continuation of axillary vein at the lateral border of first rib • Joins internal jugular vein to form the brachiocephalic vein. Angle of union is termed venous angle 静脈角 External jugular vein 外頸静脈 • Formed behind angle of mandible by union of posterior auricular, posterior branch of retromandibular and occipital vein • Crossing sternocleidomastoid to enter subclavian vein Anterior jugular vein 前頸静脈 • Drains submandibular and anterior neck regions • Descends near midline, runs posterior to sternal end of sternocleidomastoid to drain into external jugular vein or subclavian vein Lymph nodes of neck Anterior cervical lymph nodes • Superficial anterior cervical lymph nodes • Deep anterior cervical lymph nodes Lateral cervical lymph node • Superficial lateral cervical lymph nodes－lie along the external jugular vein Deep lateral cervical lymph nodes • Extend along the internal jugular vein from the base of skull to the root of neck, divided into superior deep lateral cervical lymph nodes and inferior deep lateral cervical lymph nodes • Receive lymphatic vessels from head, neck, tongue, larynx, cervical parts of esophagus and trachea, thyroid gland, upper parts of the thoracic wall and breast • Efferent vessels form the jugular trunk－ the left jugular trunk joins the thoracic duct and right may joint the right lymphatic duct Superior deep lateral cervical lymph nodes Jugulodigastric lymph node : lies at the junction of posterior belly of digastric and internal jugular vein Inferior deep lateral cervical lymph nodes Juguloomohyoid lymph node : lies at the junction of the intermediate tendon of omohyoid and internal jugular vein Supraclavicular lymph nodes : lie along the subclavian artery Right lymphatic duct 右リンパ総管 • Formed by union of right jugular, subclavian, and bronchomediastinal trunks • Ends by entering the right venous angle • Receives lymph from right half of head, neck, thorax and right upper limb Thoracic duct 胸管 • At the roof of the neck, it turns laterally and arches forwards and descends to enter the left venous angle • Just before termination, it receives the left jugular, subclavian and bronchomediastinal trunks Cervical plexus Formation: formed by anterior rami of C1-C4 spinal nerves Position: lies in front of the origin of levator scapulae and scalenus medius and deep to the superior part of the sternocleidomastoid Branches • Cutaneous branches: emerge around middle of posterior border of sternocleidomastoid, to supply skin of neck and scalp between auricle and external occipital protuberance • Lesser occipital n. 小後頭神経 • Greet auricular n. 大耳介神経 • Transverse nerve of neck 頸横 神経 • Supraclavicular n. 鎖骨上神経 • Muscular branches: supply the deep muscles of neck • Phrenic nerve 横隔神経 (anterior rami of C3-C5) • Lies on anterior scalene, deep to fascia • To diaphragm (motor and sensory) • Ansa cervicalis 頸神経ワナ: • Hypoglossal nerve gives off superior root of ansa (descendens hypoglossi), composed of fibers picked up from nerve C1 • Joins inferior root of ansa (descendens cervicalis, C2and C3) to form a loop, the ansa cervicalis, which supplies infrahyoid muscles Vagus nerve (Ⅹ) 迷走神経 • Leaves skull via jugular foramen • Descends in the neck in carotid sheath between internal (or common) carotid artery and internal jugular vein Accessory n. (Ⅺ ) 副神経 • Deep to posterior belly of digastric • Supplies sternoclidomastoid and trapezius muscle Hypoglossal n.(Ⅻ) 舌下神経 • Descends between internal carotid a. and internal jugular v., hooks around external carotid a., to lie on the hyoglossus before entering tongue • Supplies muscles of tongue Cervical part of sympathetic trunk 交感神経管 • Formed by superior , middle and inferior cervical ganglia and interganglionic branches • Superior cervical ganglion: largest, situated in front of transverse processes of C1~C3 vertebra • Middle cervical ganglion: smallest, is at level of transverse processes of C6 vertebra • Inferior cervical ganglion: situated at level of C7 vertebra, and may be fused with first thoracic ganglion to form cervicothoracic ganglion Anterior region of neck • Suprahyoid region 舌骨上 • Submental triangle 顎下三角 • Submandibular triangle オトガイ下三角 • Infrahyoid region • Carotid triangle • Muscular triangle 舌骨下 頸動脈三角 胸鎖三角 Lateral region of neck • Occipital triangle 後頸三角 • supraclavicular triangle 鎖骨上三角 (greatsupraclavicular fossa) Superficial fascia • Consists of fat and connective tissue • Contents • Platysma • Superficial veins • Anterior jugular v. • External jugular v. • Cutaneous nerves • • • • Lesser occipital n. Greet auricular n. Transverse nerve of neck Supraclavicular n. • Cervical branch of facial n. Cervical fascia 頸筋膜－three layers Superficial layer (investing fascia 浅頸筋膜) • Encloses trapezius, sternocleidomastoid, posterior belly of digastric and parotid and submandibular glands • Attached to bony landmarks of upper and lower boundaries of neck and zygomatic arch of face Prevertebral layer 気管前頸筋膜 • Encloses viscera of neck: pharynx, larynx, trachea, esophagus, thyroid gland and parathyroid glands • Completely surrounds thyroid gland, forming a sheet for it, and bind the gland to larynx • Extends from hyoid bone to fibrous pericardium of superior mediastinum Prevertebral layer 椎前葉頸筋膜 • Lies anterior to bodies of cervical vertebrae and prevertebral muscles; extends from base of skull downward into the superior mediastinum, continuous with anterior longitudinal lig. and endothoracic fascia • Covers subclavian vessels and roots of brachial plexus • Extends into upper limb as axillary sheath 頸動脈鞘 • Formed by components of all three layers of deep cervical fascia • Contains common and internal carotid arteries, internal jugular vein, and vagus nerve • Ansa cervicalis located on its anterior surface Carotid sheath Pretracheal space 気管前間隙 • Lies between pretracheal layer and cervical part of trachea • Contains arteria thyroidea ima, inferior thyroid v., unpaired thyroid venous plexus, brachiocephalic trunk and left brachiocephalic v. Retropharyngeal space 咽後間隙 • Lies between prevertebral layer and buccopharyngeal fascia Prevertebral space 椎前間隙 • Lies between prevertebral muscles, cervical part of vertebral column and prevertebral layer Suprahyoid region Submental triangle オトガイ下三角 • Lies below the chin and is bounded laterally by anterior bellies of digastric, and inferiorly by the body of hyoid bone • Covered by skin, superficial fascia and investing fascia • Floor－mylohyoid muscles • Contents－submental lymph nodes Submandibular triangle 顎下三角 • Bounded by anterior and posterior bellies of digastric and lower border of the body of the mandible • Covered by skin, superficial fascia, platysma and investing fascia • Floor－ mylohyoid, hyoglossus and middle constrictor of pharynx • Contents－submandibular gland, facial a., v., hypoglossal n. and v., lingual n., submandibular ganglion and submandibular lymph nodes Infrahyoid region Carotid triangle 頸動脈三角 • Bounded by anterior border of sternocleidomastoid, superior belly of omohyoid and posterior belly of digastic muscles • Covered by skin, superficial fascia, platysma and investing fascia • Floor－prevertebral fascia and lateral wall of pharynx • Contents－common carotid a. and its branches, internal jugular v. and its tributaries, hypoglossal n. with its descending branches, the accessory and vagus nerves, and part of the chain of deep cervical lymph nodes Posterior belly of digastic muscle • Superficial－great auricular n., retromandibular v., cervical branch of facial n. • Deep－internal and external carotid a., internal jugular v., Ⅹ～Ⅻ cranial n. and cervical part of sympathetic trunk • Superior－posterior auricular a., facial a. and glossopharyngeal n. • Infeior－occipital a. and hypoglossal n. Sternocleidomastoid region 胸鎖乳突筋下 • Covered by sternocleidomastoid • Contents • • • • Ansa cervicalis Carotid sheath Cervical plexus Cervical part of synpathetic trunk Triangle of the vertebral a. 椎骨動脈三角 • Boundaries • • • • • Medially－longus colli Laterally－scalenus anterior Inferiorly－first part of subclavian a. Apex－transvese procss of C6 Posteriorly－cupula of pleura, transvese procss of C7, anterior rami of C8 spinal nerves, costal neck of 1st rib • Anteriorly－carotid sheath, phrenic n. and arch of thoracic duct (left) • Contents • • • • Vertebral a. Inferior thyroid a. Cervical part of sympathetic trunk Cevicothoracic ganglion Occipital triangle 後頸三角 • Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and superior border of inferior belly of omohyoid • Covered by skin, superficial fascia, and investing fascia • Floor－prevertebral fascia and scalenus anterior, scalenus medius, scalenus posterior, splenius capitis and levator scapulae • Conents • Accessory n.－emerges above the middle of the posterior border of sternocleidomastoid and crosses the occipital triangle to trapezius • Cervical and brachial plexuses Supraclavicular triangle 鎖骨上三角 • Bounded by posterior border of sternocleidomastoid, inferior belly of omohyoid and middle third of clavicle • Covered by skin, superficial fascia, and investing fascia • Floor－prevertebral fascia and inferior parts of scalenus • Conents • Subclavian v. and venous angle • Subclavian a. • Brachial plexus
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