 This 57 y/o male is a victim of pleomorphic adenoma over left cheek, tracing his history:

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指導老師:口腔病理科全體醫師 報告組別:實習E組

報告人員:林建明 吳宗勳 李惠娜 陸弘志 報告日期:101.01.30

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General Data

Name: 呂XX

Chart number: 2xxxxxx81

Gender: male

Age: 57 y/o

Native: Kaohsiung

Marital status: Married

Birthday: 43.12.10

First visit: 97.3.19

Attending VS:陳中和

(3)

Chief Complaint

民國一百年:Swelling in left face for 2 weeks.

(4)

Present Illness

 This 57 y/o male is a victim of pleomorphic adenoma over left cheek, tracing his history:

 97.03.04 (at 小港 H )

HP: epithelial hyperplasia , L’t BM

 97.04.02

HP: fibrous tissue, left BM , cutaneous tissue

 97.04.10

Water’s view :

1.left chronic maxillary sinusitis

2.suspecicous left chronic mastoidits

(5)

Present Illness

 97.04.10 CT scan :

consider a benign mass in left masticator space

and infratemporal fossa with compression of posterior wall of left maxillary sinus .

Sized 6.0 * 4.2 * 5.0 cm3

 97.04.17 OP:excision

HP: pleomorphic adenoma, left buccal subcutanous

tissue

(6)

Present Illness

 97.10 ~ 100.10

lost f/u until p’t found a mass over left cheek got lager and lager in these 2 weeks

 100.12.08 CT scan:

enlargement of the mass (pleomorphic adenoma) in the left masseter and buccal space with invasion to left maxillary sinus and zygomatic arch, malignant

transformation needs to be excluded

 100.12.29

Arrange OP (frozen section examination and excision

or WE + partial maxillectomy)

(7)

Past History

Past medical history

 Denied any systemic disease

 Denied any drug and food allergy

 Pleomorphic adenoma over left cheek (S/P tumor excision at 97/04/17)

 Gastrorrhagia and duodenal ulcer

Past dental history

 Prosthesis fabrication

 OD treatment

 Scaling

 Extraction

(8)

Personal History

Oral risk factors:

 Alcohol drinking: (+) seldom

 Betel nut chewing: (+) 10 顆over 10 years, now quit

 Cigarette smoking: (+) ½ PPD

Denied other specific oral habits

Attitude toward dental treatment: uncooperative

(9)

Extraoral Examination

Swelling over left face

– Size: 5x5 cm

– Consistency: rubbery and hard – Pain: (+)

– Tenderness: (+)

(10)

Intraoral Examination

– Size: 5x4 cm

– Consistency: rubbery and hard – Fluctuation: (-)

– Induration(-) – Pain: (+)

– Tenderness: (+)

(11)

Intraoral Examination

Missing : tooth 14.15.46.48

Residual root : tooth 18

(12)

Dental Examination

Missing: tooth 26,27,46,48

Caries: tooth 28,38

Residual root: tooth 18

Crown and bridge: tooth 21-X-23

(13)

Radiographic Examination (2008,03,19)

There is an ill-defined radiolucence over left maxillary, extending form distal side of tooth

25 to mesial side of tooth 28, and from alveolar crest to the floor of left maxillary sinus,

measuring approximately 2.5 cm X 1.5 cm.

(14)

Radiographic Examination (2011,12,21)

There is an ill-defined radiolucence over left maxillary, extending form apex of tooth 23 to mesial side of tooth 28, and from alveolar crest to the left maxillary sinus,

measuring approximately 4.0 cm X 5.0 cm. The left maxillary sinus seems cloudy

compared to right maxillary sinus, and the floor of left maxillary sinus is extremely thin,

and the left zygomatic arch is invaded.

(15)

Radiographic Examination (2011,12,30)

(16)

CT Examination(2011.12.08)

• There is an enlarging soft tissue mass in the left masticator and buccal space with invasion of left maxillary sinus and zygomatic arch. The size is about 6.0x4.2x5.0 cm 3 .

• Calcification

(17)

CT Examination(2011.12.08)

• The bilateral mastoid aeration is decreased.

(18)

CT Examination (2011.12.08)

• No enlarged lymph node can be identified.

• Impression

- Enlargement of the mass (pleomorphic

adenoma) in the left masticator and buccal

spaces with invasion of left maxillary sinus and left zygomatic arch. Malignant transformation needs to be excluded.

- Decreased bilateral mastoid pneumatization.

(19)

Differential Diagnosis

Inflammation, cyst or neoplasm?

Benign or malignant?

Peripheral or intrabony?

(20)

Inflammation, Cyst or Neoplasm?

 Pain: (+)(1-2/10)

 Tenderness (+)

 Swelling: (+)

 Duration: (2weeks)

 Texture: (Firm)

 Redness: (-)

 Fixed

Neoplasm

(21)

Benign or Malignant?

 Pain (+)(1-2/10)

 Tenderness (+)

 Duration: (2weeks)

 Lymphadenopathy (-)

 Ulceration (-)

 Induration (-)

 Paresthesia(-)

Benign but maybe malignant change

(22)

Peripheral or Intrabony?

On the left check mucosa

No bony expansion

Peripheral Peripheral Neoplasm

(23)

 Carcinoma ex mixed tumor

 Pleomorphic adenoma

 Ossifying fibroma

 Chondrosarcoma

 Mucoepidermoid carcinoma

 Acinic cell adenocarcinoma The List(more possible→less)

Working diagnosis

(24)

Our Case Carcinoma ex mixed tumor

Gender male Female>Male (slightly)

Age 57 y/o 15 year older than PA 60-80 y/o

S / S Painless swelling(dull pain) Recent rapid growth with associated pain or ulceration(Not all)

Site Left masticator and buccal spaces with invasion of left maxillary

sinus and left zygomatic arch

80% in the major salivary gland , especially in parotid gland Features irregular shape ,Smooth surface,

firm, fixed Dome or nodular,smooth or ulceration,firm,fixed

Size 6x4x5cm Variable

Others Zygomatic arch perforation , sinus

involve Risk for malignant change in a PA increases with the duration

Carcinoma ex mixed tumor

(25)

Our Case Carcinoma ex mixed tumor

Image

Carcinoma ex mixed tumor

(26)

Our Case Pleomorphic adenoma

Gender male Female>Male (slightly)

Age 57 y/o 30-60 y/o

S / S Painless swelling(dull pain) Usually painless swelling,progression time is many months or years Site Left masticator and buccal spaces

with invasion of left maxillary sinus and left zygomatic arch

Most common salivary gland tumor 53-77% parotid gland tumor Features irregular shape ,Smooth surface,

firm, fixed firm ,movable at beginning

Size 6x4x5cm Variable

Others Zygomatic arch perforation , sinus involve

Pleomorphic adenoma

(27)

Our Case Pleomorphic adenoma

Image

Pleomorphic adenoma

(28)

Our Case Ossifying firbroma

Gender male Female>male (slightly)

Age 57 y/o 30-50

S / S Painless swelling(dull pain) Painless swelling Site Left masticator and buccal spaces

with invasion of left maxillary

sinus and left zygomatic arch Mandible premolar and molar area Features irregular shape ,Smooth surface,

firm, fixed Fixed ,firm ,smooth

Size 6x4x5cm Variable

Others

Ossifying firbroma

(29)

Our Case Ossifying fibroma

Image

Ossifying fibroma

(30)

Our Case Chondrosarcoma

Gender male

Age 57 y/o any age but has a peak incidence in the

30- to 40-year-old age Group

S / S Painless swelling(dull pain)

Lesions are expansile masses. Pain and paresthesia may occur. In the anterior maxilla: nasal obstruction and

breathing difficulties

Site Left masticator and buccal spaces with invasion of left maxillary sinus

and left zygomatic arch jaws, usually of the anterior maxilla Features irregular shape ,Smooth surface,

firm, fixed Dome,smooth surface,fixed

Size 6x4x5cm Variable

others Zygomatic arch perforation , sinus

involve Widening of the periodontal membrane of associated teeth

Chondrosarcoma

(31)

Our Case Mucoepidermoid carcinoma

Image

Mucoepidermoid carcinoma

Chondrosarcoma. Computed tomography of large lesion of left maxilla containing flecks of radiopacities.

(32)

Our Case Mucoepidermoid carcinoma

Gender male Female>Male (slightly)

Age 57 y/o Wide range (20~70 y/o)

S / S Painless swelling(dull pain) usually asymptomatic swelling(but pain may develop),progress time<1year Site Left masticator and buccal spaces

with invasion of left maxillary sinus and left zygomatic arch

Most common in parotid gland (preauricular & cheek) Features irregular shape ,Smooth surface,

firm, fixed Dome,smooth surface,firm,

Fluctuation(not all),fixed

Size 6x4x5cm Variable,smaller than 4 cm in diameter

others Zygomatic arch perforation , sinus

involve If distant metastasis : Lymphadenopathy

Mucoepidermoid carcinoma

(33)

Our Case Mucoepidermoid carcinoma

Image

Mucoepidermoid carcinoma

(34)

Our Case Acinic cell adenocarcinoma

Gender male Female>Male (60 %)

Age 57 y/o Wide range (20~70 y/o) mean 40

S / S Painless swelling(dull pain) Slowly growing mass, mostly asymptomatic

Site

Left masticator and buccal spaces with invasion of left

maxillary sinus and left zygomatic arch

Most common in parotid gland (85%) Minor salivary gland (9%)

Submandibular gland (2.7%~4%)

Features irregular shape ,Smooth surface,

firm, fixed Large,firm

Size 6x4x5cm variable

others Zygomatic arch perforation ,

sinus involve Better Prognosis

Acinic cell adenocarcinoma

(35)

Our Case Acinic cell adenocarcinoma

Image

Acinic cell adenocarcinoma

(36)

Clinical impression

 Carcinoma ex mixed tumor

over

the left buccal mucosa

 Pleomorphic adenoma

over

the left buccal mucosa

(37)

Salivary gland tumor treatment

1.Depend on frozen :

Benign → excision biopsy。

Malignant → Wide excision and RT 2. Prophylactic neck LND:

a) Not for parotid gland tumor (Seldom meta)。

b) Usually for submandibular gland (Much easier lymph node meta)。

c) AND high-grade mucoepidermoid carcinoma、malignant mixed tumor、adenocarcinoma、squamous cell

carcinoma、 facial skin cancer。

(38)

Radiotherapy

• Radiotherapy:

• 1. Benign:

encase nerve、recurred、tumor unclear。

• 2. Malignant:

low-grade or low-stage do not need RT。

(39)

Chemotherapy

• Chemotherapy:

• 1. High-grade mucoepidermoid carcinoma 和 un-differentiated tumor。 (5-FU; CDDP; MTX)

• 2. Metastasis adenoid cystic carcinoma

(40)

Treatment Plan

Impression : pleomorphic adenoma ,left masseter and buccal space with invasion to left maxillary sinus and zygomatic arch

Treatment plan :Weber-Ferguson incision + Wide excision + sinus debridement

(41)

醫學倫理討論

(42)

病人安全

• 2008/07/24 12:00 華視新聞 地區:新竹市報導

• 新竹市開整形診所的醫師,曾鼎昌,今年五十六歲,已經執業 二十多年,跟別的醫師不一樣的是,他用是存證信函來催促病 人回診。日前就有一名台商,左胸長了惡性腫瘤,在診所進行 局部切除後,台商就說傷口已經好了,打電話也不接,曾醫師 只好寄出存證信函,內容寫著,憂慮傷口變化,如要到其他醫 院治療或要回診,請告知,好讓本人放心。還有一名三歲小妹 妹,在樓梯摔倒,上唇裂傷,曾醫師交代縫合後一定要來換藥,

一星期後拆線,但一樣沒看到人,曾醫師擔心之下,又寄出存 證信函,希望家長趕快帶小妹妹回診檢查,以免延誤病情。

其他曾醫師的病患,也都說沒碰過這麼積極熱心的醫生。

為了病患好,擔心會有後遺症,曾醫師以嚴謹的態度,寄存證 信函追蹤回診,讓病患及家屬感受到醫師關心病人的責任感。

(記者莊明憲報導)

(43)

病人安全

• 【2006/08/11 民生報】

• 林太太疑似罹患乳癌,醫師建議做電腦斷 層和磁振造影檢查,由於醫事人力不足,

排檢時間長,加上病患自己未準時回診,

所有檢查拖了半年才完成,癌症從二期拖

到三期。

(44)

病人安全

• 病人沒有回診,醫護人員需要主動聯繫嗎?

• 是否有方法可以提高病人回診率?

(45)

病人安全

• Oral care experiences with 181

nasopharyngeal carcinoma patients receiving radiotherapy in a Taiwanese hospital.

- Wang WC, Chen YK, Lin LM

• Fluoride tray deliver vs follow up period

With Without

3~6 months 61.8% 18.8%

6~12 months 5.3% 1.9%

Lost follow up 32.8% 72.9%

Auris Nasus Larynx. 2008 Jun;35(2):230-4.

(46)

病人安全

• 製備手術後張口練習器

• 押金,回診後退款 - 是否符合法規

- 增加醫事人力成本

• 存證信函

(47)

病人安全

• 隨時追蹤身體狀況,有不舒服立刻反應。回應 醫師的問題才能寶貝自己的身體,因為沒好好 把握健康可是會稍縱即逝。

• 行政院衛生署與財團法人醫院評鑑暨醫療品質

策進會推動本項病人安全活動,推廣對象也由

醫療機構與醫護專業人員延伸至民眾端,期將

手術安全的觀念深植於民眾,建立醫護人員及

民眾對於手術安全的自我意識,呼籲民眾掌握

三「應」原則(響應、回應、反應),讓自己

也成為照護自己健康的團隊成員之一,為自己

的就醫安全把關。

(48)

病人安全

• 隨時追蹤身體狀況,有不舒服立刻反應。回應 醫師的問題才能寶貝自己的身體,因為沒好好 把握健康可是會稍縱即逝。

• 行政院衛生署與財團法人醫院評鑑暨醫療品質 策進會推動本項病人安全活動,推廣對象也由 醫療機構與醫護專業人員延伸至民眾端,期將 手術安全的觀念深植於民眾,建立醫護人員及 民眾對於手術安全的自我意識,呼籲民眾掌握 三「應」原則(響應、回應、反應),讓自己 也成為照護自己健康的團隊成員之一,為自己 的就醫安全把關。

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