 First visit: 101.10.XX  Attending V.S: XXX 醫師  Marital status: 已婚  Age: 55 Y/O  Sex: Female  Name: XXX



Name: XXX



Sex: Female



Age: 55 Y/O



Marital status:已婚



Attending V.S: XXX醫師



First visit: 101.10.XX



Ask for oral mass over L’t upper buccal

mucosa evaluation



This 55 Y/O female suffered from pain

over L’t buccal mucosa for several days.

She went LDC for help, the dentist there

suggested her to come to our OS OPD

for further examination and treatment.

 Site: L’t buccal mucosa

 Dimension: 1.0 x 1.0 cm

 Shape: Dome

 Color: Normal mucosa

 Surface: Smooth

 Base: Sessile

 Consistency: Firm

 Ulceration (-)

 Fluctuation (-)

 Mobility: Fixed

 Pain (+)

 Tenderness (+)

 Lymphadenopathy:(-)

 No obvious bony lesions on left side of posterior maxilla



Hospitalization (-)



Systemic diseases: Denied



Drug or food allergy: Denied



General routine dental treatment



Attitude to dental treatment



Risk factors related to malignancy

› Alcohol: (-)

› Betel quid: (-)

› Cigarette: (-)



Other specific oral habits : Denied



Bite irritation : Denied



Missing: Tooth 28 37 38 48



Caries: Tooth 12 23



C&B: Tooth14 15 16 24 25 26 35 36 44 45

46



Panorex taking



Left posterior buccal mucosa near

buccal vestibule opposed to tooth 27



1x1cm, firm consistency, smooth surface, sessile base, dome shape, pink color,

fixed



Pain (+)



Tenderness (+)



No bony lesion & destruction

→ peripheral lesion

Our case Peripheral <Intrabony>

Mucosal lesion + + -

Bony expansion - - +/-

Cortical bone destruction

- - +/-

→ Peripheral

Our case Inflammation

Redness - +

Swelling + +

Local heat - +

Pain + +

Our case cyst

Fluctuation - +/-

Well + defined border Unknown +

Due to intraoral examination:

a mass of no local heat, firm consistency

→ neoplasm

Our case <benign> Malignance

progressive Unknown Slow Fast

Swelling with intact epithelium

+ + -

Pain + - +

Induration - - +

lymphadenopathy - - +

Benign tumor or low-grade malignancy



Pleomorphic adenoma



Warthin tumor



Mucoepidemoid carcinoma, low grade



Polymorphous low grade adenocarcinoma



Acinic cell adenocarcinoma



Fibroma

Our case Pleomorphic adenoma

Gender female female

Age 40 30~60

Site Buccal mucosa Palate (54%), upper lip (18%), buccal mucosa (11%)

pain + -

swelling + +

drainage - -

Shape Smooth, dome shape Firm single nodular

Duration Unknown Slow

Our case Warthin tumor

Gender Female Male

Age 40 60~70

Site Buccal mucosa

The tail of the parotid gland near the angle of

the mandible

Pain + -

Swelling + +

Drainage - -

Shape Smooth, dome shape Firm or fluctuant, bilateral but may not metachronous

Duration Unknown Slow

Our case Mucoepidermoid carcinoma

Gender female Slight male

Age 40 20~70

Site Buccal mucosa Lower lip, floor of mouth, tongue, retromolar pad area

Pain + Early stage: -

Swelling + +

Drainage - -

Shape Smooth, dome shape Firm or hard

Duration Unknown Slow

Our case Polymorphous low grade adenocarcinoma

Gender Female Female

Age 40 60~70

Site Buccal mucosa Palate

Pain + -

Swelling + +

Drainage - -

Shape Smooth, dome shape Firm, indolent

Duration Unknown Slow

Our case Acinic cell carcinoma

Gender Male Equal

Age 40 40

Site Buccal mucosa Parotid gland

Pain + -, sometimes + or tenderness

Swelling + +

Drainage - -

Shape Smooth, dome shape Smooth surface

Duration Unknown Slow

Our case Fibroma

Gender Male Equal

Age 40 40~60

Site Buccal mucosa Buccal mucosa

Pain + -

Swelling + +

Drainage - -

Shape Smooth, dome shape Pedunculated, round shape

Duration Unknown Slow



Pleomorphic adenoma over left

posterior buccal mucosa



101-10-17

Painful mass on left posterior buccal mucosa near maxillary buccal vestibule opposed to tooth 27.

Firm, smooth surface, tender (+), 1X1 cm L’t submandibular LN: < 1cm



Tx plan:



101-10-24

H-P report



Pathologic Dx:

 Dx: Mucoepidermoid carcinoma on left posterior buccal mucosa, cT1N0M0, stage I



Tx plan:



101-10-26

Appointment for H-P reaport



Pathologic imp:

 Dx: Mucoepidermoid carcinoma on left posterior buccal mucosa, cT1N0Mo, stage I



Tx plan:



101-10-26

TC-99 whole body bone scan

 Warm spots in maxilla and mandible, which my due to certain dental

problem rather than metastatic bone disease

 Impression:

Low probability of bone metastasis from buccal cancer



101-10-27



Tx plan:



101-10-31

 Collect GA routine data



101-11-01 MRI

small nodule (1.5 X 1.31 X 1.03cm), left retromolar trigone

 Multiple small visible LN (<1cm) are found in the submental, submandibular, and posterior cervical

 Impression:

TNM stages: T1N1MB (Stage grouping if no distant metastasis M0)



101-11-01

MRI



101-11-09

 OP under GA with NETT

 Wide excision + left lymphadenectomy + buccal fat pad repair



101-11-12

 H-P report:

Mucoepidermoid carcinoma, low grade

 Microscopic invasion :

- Limited to submucosa (tumor thickness : 1.2cm)

 Lymph-vascular invasion: not identified

 Perineural invasion : present

 Surgical margin : involved

Frozen sections : negative of malignancy



101-11-19

 Discharge



101-11-24

 OPD F/U of operation wound

 向病人解釋於切片病理報告內側上緣仍有腫瘤侵 犯。因臨床在內側緣(soft palate)手術前無明顯 病灶，已安排口腔癌多專科討論是否再次手術或 是接受RT



101-12-01

 Arrange operation under GA on 101- 12-21

預掛ENT for evaluation of laryngeal



101-12-08

 Collect GA routine data



101-12-15

 Impression for fabrication of surgical stent.

 One of the most common salivary gland malignancies.

 Major clinical features

- Wide age range (2^nd-7^th decades) - Parotid gland

- Major and minor salivary gland

( Major: 1-2 to10 %, Minor: 9% to 15-23% ) - Asymptomatic swelling

Histopathologic grades

1. Amount of cyst formation 2. Degree of cytologic atypia 3. Relative number of mucous,

epidermoid, and intermediate cell

Low grade:

Prominent cyst formation, minimal cellular

atypia, relatively high porportion of mucous cell.

 Location

 Histopathologuc grade

 Clinical stage: subtotal or total parotidectomy?

 Prognosis depends.

- Low grade: 90-98%

- High grade: 30-54%

 Submandibular gland with poor outlooks 

 Tongue and mouth floor 

 全人照護（Holistic Health Care）：不僅強調生病後提 供以病人為中心之醫療照護，也要在生病前提供正確有 效的預防方法。

 而「全人健康照護體系」指提供全人（包括生理、心理、

社會及心靈層面）、全民（每一個人都可以得到）基本 保健醫療（包括預防保健、疾病診治、長期照護及安寧 照護）的照護系統 （從基層至二、三級醫療的整合）。

需持以「病人為中心」之整合性預防、保健、醫療為導 向，提供以個人為中心，家庭為單位，社區為範疇之整 合性、協調性、持續性的預防保健及醫療照護，暨以良 好互動之醫病關係，進而達到落實執行『全人健康照護』

的理念。

• 倫理？

• Ethics，源自希臘字ethike 和 ethos，原意為道 德、習慣、習性和行為； 所要探討的是有關人類 行為「善」與「惡」的性質，是一種統御個人行 為的價值體系

• 醫學倫理是運用倫理學的理論及研究架構，來探 討醫學領域中所有的倫理問題；以解除醫學科技 與人性需求的衝突，作為人類深思內省的依據。

• 臨床醫學倫理係指運用醫療適應症、病人喜好、

生命品質、外在的道德原則等道德指標加以權衡 實際個案，以判斷倫理原則應用在臨床醫療照護 時，何者孰輕孰重？以使醫療人員能做出對病人 最有利也最能符合道德倫理規範的醫療決策。

Beauchamp & Childress (1979)

 Autonomy 自主

 Non-maleficence 不傷害

 Beneficence 行善

 Justice 公義

• 原則：一位具理性思考能力的病人，在完全瞭 解醫療處置方針的利弊得失下，有權決定自己 的行為，包括決定及選擇醫療專業人員和治療 方式

• 臨床意義

(1) 病人之自主行為不應遭受他人之操控或干預

(2)指醫療人員應提供充分且適當之資訊，以促成 病人針對診療方式主動作一抉擇

 完全自主

 代理決定(surrogate decision making)

- 民法第七十六條:「無行為能力的人由法定代理 人代為意思表示，並代受意思表示。」

- 民法第七十七條:「限制行為能力人為為意思表 示及受意思表示，應得法定代理人的允許，但 純獲法律上之利益或依其年齡及身分日常生活 所必須者，不在此限。 」

希波克拉底誓約--

to benefit, or at least do no harm

行善是做對病人有益，不做對病人有害的事；在

照護過程中， 為避免傷害應處處以病人的利益著想，

以病人的福址為優先考慮。

 醫療上是必須的，或是屬於醫療適應症範圍,因所 施行的各種檢查或治療而帶來的傷害應符合不傷害 原則

• 原則：行善原則包括不傷害原則的反面義務(不應 該做的事)和確有助益的正面義務(應該做的事)，

包括維護和促進病人的健康、利益和福祉，為基 本倫理原則，也是醫護人員的基本義務

• 臨床意義

(1) 勿施傷害：不得故意對他人施予傷害或惡行 (2) 預防傷害：應該預防傷害或惡行

(3) 移除傷害：應該移除傷害或惡行

(4) 維持善行：應該致力於行事或維持善行

• 原則：資源合理分配、賞罰分明以及合乎正義之 事。醫療上公平原則指基於正義與公道，以公平 合理的態度來對待病人、病人家屬和受影響的社 會大眾

• 臨床意義

(1) 公平地分配不足的資源 (2) 尊重病人的基本權利

(3) 尊重道德允許的法律,法律之前人人平 等 (4) 先來先服務與急重症優先

醫學界採用的公平原則

 平等 大眾的權益

 先來先服務 (first come, first helped)

 急症與重症優先



www.ilanh.ym.edu.tw



www.kmuh.org.tw/www/clireser/5.htm



Oral and maxillofacial pathology, 3rd

edition, Neville