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口腔病理科 病例報告

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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

(2)

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

(3)

Chief complaint

• Painful mass over right lower posterior

lingual gingiva, near alveolar ridge for 2~3 months

(4)

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.

(5)

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.

(6)

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

(7)

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

(8)

Past Medical History

• HCV

• HTN (Under-control)

• Allergy : (-)

(9)

Past Dental History

• Endodontics treatment

• Prosthodontics treatment

• Periodontics treatment

(10)

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 : (-)

(11)

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

(12)

Intra-Oral Findings

• Other:

> Slightly fibrotic and white change over oral mucosa

(13)

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)

(14)

• 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

(15)

• 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

(16)

Working diagnosis

(17)

Peripheral or intrabony

(18)

Peripheral or intrabony

(19)

Peripheral or intrabony

Case Peripheral Intrabony Lesion on

radiography - - +

Bony

expansion - - +/-

Bony

destruction - +/- +/-

Soft tissue

lesion + + +/-

(20)

Inflammation,cyst,neoplasm

• Inflammation

Our case Inflammation

Redness - +

Swelling + +

Local heat - +

Pain + +

Multifocal - -

(21)

Inflammation,cyst,neoplasm

Our case Benign Malignant

Pain + + ─

Induration + ─ +

lymphadenopathy + ─ +/-

Progress Fast Slow Fast

• Neoplasm

(22)

Inflammation,cyst,neoplasm

• Cyst

Our case Cyst

Aspiration - +

Fluctuation - +

Well-defined

border + +

Bone expansion

- +

Closed lesion + +

(23)

Working diagnosis Malignant soft tissue

neoplasm

(24)

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)

(25)

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

(26)

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

(27)

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

(28)

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

(29)

Tentative Diagnosis

• Squamous cell carcinoma

• Rhabdomyosarcoma

• Neurogenic sarcoma

• Leiomyosarcoma

• Fibrosarcoma

(30)

Pathologic Diagnosis – 2013.02.02

• Fibrosarcoma (Tooth 44,45 lingual gingiva)

(31)

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

(32)

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

(33)

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.

(34)

Lab Data -2013.02.06

(35)

DISCUSSION-

Fibrosarcoma

(36)

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

(37)

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

(38)

Clinical Features

(39)

Clinical Features

(40)

Clinical Features

(41)

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

(42)

Histopathology

(43)

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

(44)

Histopathology

(45)

Histopathology

(46)

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

(47)

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

(48)

Thank you for your

attention!!!

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