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CASE REPORT

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(1)

CASE REPORT

報告者:Intern D組 朱翎毓 蔡凱全 楊謹禎 吳冠儒 指導醫師:陳玉昆主任 暨口腔病理科全體醫師

(2)

General Data

• Name: 陳O元

• Sex: Male

• Age: 71 y/o

• Native: 高雄市

• Marital status: Married

• Attending staff: OOO醫師

• First visit: 104/10/14 (口外)

(3)

Chief Complaint

• 2015/10/14 高醫口外初診

• A reddish swelling mass on hard palate for ten years

(4)

Present Illness

• 2015/10/14 高醫口外初診

• This 71 y/o male complained about swelling mass on hard palate s/p incisional biopsy at AT Hospital on 2009, the result was benign. The lesion recurred on 2015.09.XX,He went to AT Hospital again for CT, the result was still benign.

The doctor of AT Hospital referred him to CG Hospital, but he came to our OPD instead in 2015.10.14

(5)

Personal History – past medical history

• Underlying diseaseHypertension

• Hospitalization(+)

• Surgery under GA(-)

• AllergyDenied

• MedicationDenied

(6)

Personal History – past dental history

• General routine dental treatment

• Attitude to dental treatment: Co-operative

• Risk factors related to malignancy

− Alcohol drinking (-)

− Betel-quid chewing (-)

− Cigarette smoking (-)

(7)

RADIOGRAPHY FINDING

(8)

X-ray finding ‒ CT

• 2015.09.30

(9)

X-ray finding ‒ CT

• 2015.09.30

(10)

X-ray finding ‒ CT

• 2015.09.30

(11)

X-ray finding ‒ Panorex

• 2015.10.21

(12)

X-ray finding ‒ Panorex

• 2015.10.30

(13)

X-ray finding ‒ CT

• 2015.11.18

(14)

14

WORKING DIAGNOSIS

(15)

Working diagnosis

• Inflammation?

• Cyst or neoplasm?

• Benign or malignant?

(16)

Inflammation ?

Our case Inflammation

Redness + +

Swelling + +

Local heat - +

Pain - +

(17)

Cyst ?

17

Our case Cyst

Aspiration N/A +

Fluctuation - +/-

Well-defined

border - +

Bony expansion - +/-

(18)

Benign or Malignant ?

Our case Benign Malignant Border Ill-defined Well-defined Ill-defined

Sclerotic margin - + -

Destruction of cortical margin + +/- +

Pain - - +/-

Induration + - +

Swelling with intact epithelium - + -

Progress Slow Slow Slow/Fast

Metastasis - - +/-

→ Our case is a Malignant lesion

(19)

DIFFERENTIAL DIAGNOSIS

(20)

Differential diagnosis

• Mucoepidermoid carcinoma

• Polymorphous low-grade adenocarcinoma

• Adenoid cystic carcinoma

(21)

Mucoepidermoid carcinoma

Our case Mucoepidermoid Carcinoma

Gender Male Equal or

Slight female predominance

Age 71 y/o 15~86 y/o (wide range) V

Site Hard palate Parotid gland(common)

Minor salivary gland(Palate) V S/S Swelling, painless Usually asymptomatic,

swelling or pain if high-grade

V Size 2X2 cm in diameter Variable

Duration 6 years

(since 2009 found) Slow V

Clinical features

Pain(-) Tenderness(+)

Induration (+)

Pain(-) Tenderness(+)

Induration (+)

V

(22)

Polymorphous low-grade adenocarcinoma

Our case Polymorphous low-grade adenocarcinoma

Gender Male 2/3 female

Age 71 y/o 50~80 y/o V

Site Hard palate Minor salivary gland(common) (65% palate)

V

S/S Swelling, painless Swelling, painless V Size 2X2cm in diameter Not mention

Duration 6 years(since 2009 found) slow V Clinical

features

Pain (-) Tenderness (+)

Induration (+) Consistency: soft

Pain (-) Tenderness (+)

Induration (+) Consistency: firm

(23)

Adenoid cystic carcinoma

Our case Adenoid cystic carcinoma Gender Male Slight female predominance

Age 71 y/o Middle age adult

Site Hard palate Minor salivary gland, palate V S/S Swelling, painless Swelling, pain (common)

Slow growing, but aggressive Size 2 X 2 cm in diameter Not mention

Duration 6 years

(since 2009 found) slow V

Clinical features

Pain (-) Tenderness (+)

Induration (+)

Pain (+) Tenderness (+)

Induration (+)

(24)

Clinical impression

• Mucoepidermoid carcinoma over hard palate

(25)

TREATMENT COURSE

(26)

Treatment course

• 初診 2015/10/14 (OS department)

• Incision and biopsy

− The slide contains two identical groups of irregular- shaped soft tissue specimens. Microscopically, it shows mucoepidermoid carcinoma.

(27)

• 2015.10.21

• CT

• Bone scan

• Chest PA

• Abdominal eccho,

• Endoscope

• CEA, TPA, SCC marker

• Panorex

(28)

CT(104/10/21)

1.Imaging date

Date of examination (Y/M/D): 2015/10/14

Imaging modality

Imaging by CT scan

2.Tumor location / Size (TumorLocation, TumorSize)

■Measurable lesion

Size: 2.3 cm (largest diameter)

Laterality: bilateral (Se/Im:4/13)

Tumor location: ■Hard palate

3.Tumor invasion (Othe rOrgan Invasion)

■No regional invasion

4.Regional nodal metastasis (LymphNode)

■No regional nodal metastasis

5.Distant metastasis (in this study) (MetastaticOrgan)

■No or Equivocal

(29)

Chest PA (104/10/21)

(30)

Panorex (104/10/21)

(31)

Treatment course

• 2015/10/27 入院

• 2015/10/28 照會耳鼻喉科

• 2015/10/29 執行手術 - 術者:陳中和醫師

• 2015/11/04 出院

• 2015/11/11 consult 血液腫瘤科

• 2015/11/12 consult 放射腫瘤科

• 預計2015/11/18 開始放療

(32)

DISCUSSION

(33)

Mucoepidermoid Carcinoma (MEC)

• 1924 described by Masson and Berger

• Accounting for 5–10% of all salivary gland tumors

(34)

Etiology

• 來源為管腔上皮細胞與 myoepithelial cell

• Not well known

• Translocation of gene t (11;19)(q21;p13.1) as a possible abnormality

(35)

Clinical features

• Sex predilection:♂≥♀ (3:2)

• Age predilection:50 y/o

• Most common type of salivary gland malignancy in adults

• Found at distant and atypical sites, including the breast,

Eustachian tube of the ear, bronchi of the lungs, and thyroid

• Symptoms

− Tenderness, Otorrhea, Dysphagia, Trismus

• Intraoral tumors are often bluish-red and fluctuantqas

(36)

Histopathologic features

• The tumor is primarily made up of three cell types in widely varying proportions

− Myoepithelial cell

− Mucous-secreting cell

− Squamous cell

(37)

Treatment amd Prognosis

• Treatment:surgery combine RT

• Prognosis:good

(38)
(39)

Case report

• 45 y/o male

• Smoke for 25 years

• No system disease

• No food and drug allergy

• No family history

(40)

Intra-oral examination

• Right side of palate

• Well-defined ovoid ulcero-proliferative growth, 3.5 × 2.5 cm in size

• Extendedfrom the posterior-most rugae to the junction of hard and soft palate

• On palpation, non-tender, firm in consistency, fixed to the underlying bone

(41)
(42)
(43)
(44)
(45)

• CT, MRI, and ultrasonography (USG) are the standard imaging modalities for evaluation of saliva tumor

• Accuracy of FDG-PET for detecting lymph node

metastases is superior with a sensitivity and specificity of up to 90% and 94%, respectively, compared with CT

values of 82% and 85%, respectively, and MRI values of 88% and 79%, respectively

(46)

醫學倫理討論

(47)

Tom Beauchamp &James Childress 六大原則 - 1979

生命的神聖性(Sanctity of life)

1. 行善原則(Beneficence):醫師要盡其所能延長病人之生命且減輕

病人之痛苦。

2. 誠信原則(Veractity):醫師對其病人有「以誠信相對待」的義務。

3. 自主原則(Autonomy):病患對其己身之診療決定的自主權必須得到

醫師的尊重。

4. 不傷害原則(Nonmaleficence):醫師要盡其所能避免病人承受不必

要的身心傷害。

5. 保密原則(Confidentiality):醫師對病人的病情負有保密的責任。

6. 公義原則(Justice): 醫師在面對有限的醫療資源時,應以社會公平、

正義的考量來協助合理分配此醫療資源給真正最需要它的人。

(48)

生命的神聖性

• 強調尊重自己和他人的生命

• 尊重生命的價值

(49)

行善原則

• 做了Excision 後是否有減輕病人的疼痛感?或是使病人

更不舒服?

有完整去除病灶區域並拍照記錄術後情形

術前即告知病人術後傷口會疼痛,但傷口癒合後疼痛

會逐漸緩解

(50)

誠信原則

• 對於患者的疾病嚴重程度是否有確實地通知,盡到告

知的義務?

• 是否有清楚的向病人說明清楚疾病病程、治療計畫、

預後、風險?

皆已告知病人後,經同意才進行手術

(51)

自主原則

• 充分說明病情及治療計畫、風險之後,是否有讓病人

充分自主地選擇治療計畫?

病人及家屬選擇並同意醫師的建議

• 在做全身麻醉以前,是否有說明完整之後再請病人自

主的簽名同意?

已充分說明並與家屬溝通

(52)

不傷害原則

• 是否有先完整瞭解病人的病史?

治療前有完整蒐集病史資料,並與病患溝通後擬定

進一步的治療計畫

• 手術過程中,是否有造成不必要的醫源性的傷害?

沒有不必要醫源性傷害

(53)

保密原則

告知的對象

1. 本人為原則

2. 病人未明示反對時,亦得告知其配偶與親屬

3. 病人為未成年人時,亦須告知其法定代理人

4. 若病人意識不清或無決定能力, 應須告知其法定代理人、

配偶、親屬或關係人

5. 病人得以書面敘明僅向特定之人告知或對特定對象不

予告知

(54)

公義原則

• 手術的必要性?

Mucoepidermoid Carcinoma最佳的治療方式是手術l

excision,將病灶完整的清除(enucleation)才能將復

發率(recurrence rate) 降到最低。

(55)

醫學倫理總結

• 在病例撰寫方面(病兆描述,治療計畫,病人態度)應書寫

詳盡, 使治療過程有詳實的記錄及治療順利

• 在進行治療之前,須請病人簽署同意書

• 應在不違反醫學倫理的原則之下進行治療的行為

(56)

THANK YOU FOR YOUR ATTENTION!

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