口腔病理科 病例報告
Intern F 組
劉鏗全 賈媮如 郭哲豪 廖官瑄 鄭宜文 2013/2/26
指導醫師 : 陳玉昆 醫師暨口腔病理全體 主治醫師
Personal Data
• Name : O O O
• Sex : Male
• Age : 43 y/o
• Native : 高雄市
• Marital status : 已婚
• Attending V.S. : O O O醫師
• First visit : 2013/01/12
Chief complaint
• Painful mass over right lower posterior
lingual gingiva, near alveolar ridge for 2~3 months
Present Illness
• This 43 y/o male found a gumboil-like
nodule over near his right lower premolar teeth 3 months ago. He pressed the lesion with his finger and made the lesion
ruptured and bleeding was noted.
However, the lesion did not heal and became larger and with ulceration
increased gradually simultaneously.
Present Illness
• He visited ENT O O O in 101.10.22 and incisional biopsy was done; the
pathological report showed epithelial
dysplasia. Topical medication was applied but the lesion still did not subside, so he
visited ENT Dr. O O O in 101.12.31 again.
, biopsy was done again and the report still showed epithelial dysplastic lesion. Dr.郭
文烈 suspect eddental problem, and referred him to our OPD for further evaluation.
Intra-Oral Findings
An exophytic mass over lingual gingiva of teeth 44 & 45 extending to mouth floor
with ulceration and indurated white rolled border
2013.1.19
Intra-Oral Findings
• The mass:
> Shape: Dome
> Base: Sessile
> Fixation: Fixed
> Surface: Rough, border was covered by removable, 2cm in diameter in size white patches
> Consistency: Rubbery to firm
> Color: Mixed
(white, red & dark brown)
> Dimension: 1.5 cm in diameter
> Pain: (+) when eating
> Tenderness: (+)
> Induration: (+)
2013.1.19
Past Medical History
• HCV
• HTN (Under-control)
• Allergy : (-)
Past Dental History
• Endodontics treatment
• Prosthodontics treatment
• Periodontics treatment
Oral Habits
• Alcohol : (+) 約10+年
• Betel nut : (+) 約10+年, 5包/天, 目前無吃
• Cigarette : (+) 約20年, 目前有抽, 15支/天
• Other oral habits : (-)
Intra-Oral Findings
• Tooth
>
> Generalized tooth wear and heavy stains > Generalized gingival inflammation and
swelling, plaque and calculus deposition Percussion Mobility
44 (-) Grade 0
45 (-) Grade I
Intra-Oral Findings
• Other:
> Slightly fibrotic and white change over oral mucosa
Radiography Findings – Pano 2013.01.12
• Main findings (related to clinical findings):
1. No particular finding was noted over tooth 44 & 45 surrounding structures (no PAP or related bony
pathologic change)
• Dental findings :
1. Missing teeth : 18,26,27, 31,32,37,38,41,42,46,47 2. Crown & bridge : Tooth 11,21,36
3. Endodontic treated : 21
4. Generalized horizontal bony defect
5. Calculus deposition : 11,17,21,28,33,48
Radiography Findings – Pano 2013.01.12
• Other findings :
There is a well-defined, cloudy image over left maxillary sinus, extending from anterior wall of sinus to tooth 28 in horizontal dimension, and from maxillary sinus roof down to 2/3 sinus space, approximately 8X9.5cm in size.
Radiography Findings – Pano 2013.01.12
Working diagnosis
Peripheral or intrabony
Peripheral or intrabony
Peripheral or intrabony
Case Peripheral Intrabony Lesion on
radiography - - +
Bony
expansion - - +/-
Bony
destruction - +/- +/-
Soft tissue
lesion + + +/-
Inflammation,cyst,neoplasm
• Inflammation
Our case Inflammation
Redness - +
Swelling + +
Local heat - +
Pain + +
Multifocal - -
Inflammation,cyst,neoplasm
Our case Benign Malignant
Pain + + ─
Induration + ─ +
lymphadenopathy + ─ +/-
Progress Fast Slow Fast
• Neoplasm
Inflammation,cyst,neoplasm
• Cyst
Our case Cyst
Aspiration - +
Fluctuation - +
Well-defined
border + +
Bone expansion
- +
Closed lesion + +
Working diagnosis Malignant soft tissue
neoplasm
Squamous cell carcinoma
Our case Squamous cell ca.
Gender Male Male
Age 43 Risk increases with
age
A,B,C + +
Pain + +
Tenderness + +
Induration + +
Surface Rough
Secondary ulceration
Rough,irregular, Ulcerated surface
Site Lingual gingiva Buccal mucosa(Asian)
Rhabdomyosarcoma
Our case Rhabdomyosarcoma
Gender Male Male
Age 43 2~5% in adults(rare >45)
Pain + Often painless
Progress Grow rapidly Grow rapidly Occurrence in
head and neck
35%
Intra-oral site Lingual gingiva Palate,maxillary sinus
Neurogenic sarcoma
Our case Neurogenic sarcoma
gender Male No predilection
Age 43 Young adults
Symptom/sign Pain
Tenderness Induration
Enlarging mass
Pain or nerve deficit
Progress Grow rapidly Grow rapidly sometimes Occurrence in
head and neck
10~15%
Site Lingual gingiva Mandible, lip, BM
Leiomyosarcoma
Our case Leiomyosarcoma
gender Male No predilection
Age 43 No predilection
Symptom / sign Pain
Tenderness Induration Secondary ulceration
Pain(+/-)
Enlarging mass Secondary
ulceration Occurrence in
head and neck
Rare
Intra-oral site Lingual gingiva Jaw bone
Size 2.5X1 cm
Fibrosarcoma
Our case Fibrosarcoma
gender Male No predilection
Age 43 Young age , child
Symptom / sign Pain
Tenderness Induration Secondary ulceration
Slow-growing
(reach considerable size before pain)
Occurrence in head and neck
10%
Intra-oral site Lingual gingiva Nose and paranasal sinuses
Tentative Diagnosis
• Squamous cell carcinoma
• Rhabdomyosarcoma
• Neurogenic sarcoma
• Leiomyosarcoma
• Fibrosarcoma
Pathologic Diagnosis – 2013.02.02
• Fibrosarcoma (Tooth 44,45 lingual gingiva)
Radiography Findings – CT – Coronal dissection 2013.02.02
1. Poor enhanced lesion about 12X7mm in size in the lower right lingual soft tissue
2. Adjacent bony structure was intact
Radiography Findings – CT – Coronal dissection 2013.02.02
1. Non-specific small lymph nodes (<1cm) in the submental, bilateral submandibular,
jugulodigastric, and posterior cervical spaces
Radiography Findings – CT – Coronal dissection 2013.02.02
1. A well-defined ovoid-shaped tissue density suspended in the left maxillary sinus, approximately 6.7X6.8 mm in
size.
Lab Data -2013.02.06
DISCUSSION-
Fibrosarcoma
Definition
• Malignant spindle cell tumor showing a herringbone or interlacing fascicular
pattern and no expression of other connective tissue cell markers
– actin, S-100, epithelial membrane antigen, keratin, or desmin
• Genes in 2q14-22 region
Clinical Features
• Young adults and children, extremities
– 10% head and neck
• Rare, infiltrative neoplasm
– Slow growing, pain til considerable size
– Proliferation of malignant mesenchymal cells at the site of origin
– Secondary ulceration
– More of a locally destructive than a metastatic problem
Clinical Features
Clinical Features
Clinical Features
Histopathology
• Well-differentiated fibrosarcomas
– Malignant-appearing fibroblasts, typically in a herringbone or interlacing fascicular pattern – Collagen may be sparse and mitotic figures
frequent
– Ill defined border
Histopathology
Histopathology
• Poor-differentiated fibrosarcomas
– Cells are less organized and may appear rounder or ovoid
– Mild pleomorphism, more frequent mitotic activity
– Produce less collagen than well-differentiated fibrosarcomas
Histopathology
Histopathology
Prognosis & Treatment
• Wide surgical excision
• Recurrence rate : 50%
• Metastasis is infrequent
– Bone lesion are more likely to meta via the bloodstream
• 5-year survival rate: 30-50%
• Well differentiated lesion and primary lesion in soft tissue have a better prognosis
References
• Essentials of Dental Radiography and Radiology 4th edition – Eric Whaites
• Oral and Maxillofacial Pathology 3rd edition – Neville, Damm, Allen, Bouquot
• Pocket Atlas of Oral Diseases 2nd edition - G. Laskaris