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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
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
Chief Complaint
民國一百年:Swelling in left face for 2 weeks.
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
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
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)
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
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
Extraoral Examination
Swelling over left face
– Size: 5x5 cm
– Consistency: rubbery and hard – Pain: (+)
– Tenderness: (+)
Intraoral Examination
– Size: 5x4 cm
– Consistency: rubbery and hard – Fluctuation: (-)
– Induration(-) – Pain: (+)
– Tenderness: (+)
Intraoral Examination
Missing : tooth 14.15.46.48
Residual root : tooth 18
Dental Examination
Missing: tooth 26,27,46,48
Caries: tooth 28,38
Residual root: tooth 18
Crown and bridge: tooth 21-X-23
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.
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.
Radiographic Examination (2011,12,30)
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
CT Examination(2011.12.08)
• The bilateral mastoid aeration is decreased.
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.
Differential Diagnosis
Inflammation, cyst or neoplasm?
Benign or malignant?
Peripheral or intrabony?
Inflammation, Cyst or Neoplasm?
Pain: (+)(1-2/10)
Tenderness (+)
Swelling: (+)
Duration: (2weeks)
Texture: (Firm)
Redness: (-)
Fixed
NeoplasmBenign or Malignant?
Pain (+)(1-2/10)
Tenderness (+)
Duration: (2weeks)
Lymphadenopathy (-)
Ulceration (-)
Induration (-)
Paresthesia(-)
Benign but maybe malignant changePeripheral or Intrabony?
On the left check mucosa
No bony expansion
Peripheral Peripheral Neoplasm
Carcinoma ex mixed tumor
Pleomorphic adenoma
Ossifying fibroma
Chondrosarcoma
Mucoepidermoid carcinoma
Acinic cell adenocarcinoma The List(more possible→less)
Working diagnosis
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
Our Case Carcinoma ex mixed tumor
Image
Carcinoma ex mixed tumor
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
Our Case Pleomorphic adenoma
Image
Pleomorphic adenoma
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
Our Case Ossifying fibroma
Image
Ossifying fibroma
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
Our Case Mucoepidermoid carcinoma
Image
Mucoepidermoid carcinoma
Chondrosarcoma. Computed tomography of large lesion of left maxilla containing flecks of radiopacities.
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
Our Case Mucoepidermoid carcinoma
Image
Mucoepidermoid carcinoma
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
Our Case Acinic cell adenocarcinoma
Image
Acinic cell adenocarcinoma
Clinical impression
Carcinoma ex mixed tumor
overthe left buccal mucosa
Pleomorphic adenoma
overthe left buccal mucosa
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。
Radiotherapy
• Radiotherapy:
• 1. Benign:
encase nerve、recurred、tumor unclear。
• 2. Malignant:
low-grade or low-stage do not need RT。
Chemotherapy
• Chemotherapy:
• 1. High-grade mucoepidermoid carcinoma 和 un-differentiated tumor。 (5-FU; CDDP; MTX)
• 2. Metastasis adenoid cystic carcinoma
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