Case report
指導醫師：陳玉昆醫師暨口腔病理科全體醫師 報告者: Intern F組 楊忠祐、林沅醇、陳善婷、賴柏勳 報告日期: 102.01.28
General data
Name :OOO
Sex : Male
Age : 61y/o
Native : 高雄市
Marital status : 已婚
Attending V.S. : OOO 醫師
First visit : 102/11/19
102/12/14
Chief Complaint
Unhealed wound after extraction of tooth
46 at LDC in October, 102
102/11/19
Present Illness
This 61 y/o male felt discomfort over R’t
mandibular area, and had an extraction of
tooth 46 in LDC in October, 102. But the
wound was still unhealed, so he went to
LDC for help. The dentist found there is a
intrabony lesion and referred him to
KMUH OS dept for further examination.
Past history
• Past medical history
– Underlying disease: (+),DM under medication control, HBV(+), Fatty liver
– Hospitalization: (-)
– Surgery under GA: (-) – Allergy: (-)
• Past Dental History
– General routine dental treatment
• Attitude to dental treatment : co-operative
Personal History
Risk factors related to malignancy
Alcohol：(+), few
Betel quid：(+), 10-20 nuts/day, 7yrs, quit for 8 yrs
Cigarette：(+), 40 yrs, 2PPD, quit for 1 month
Special oral habits : denied
OMF Examination
MMO : 40mm
No malignant-like change in oral
mucosa
Numbness(-)
Pain(+)
Swelling(+)
Tenderness(+)
LAP (-)
102/12/14Image finding – Panorex
• Size: about 4.5 x 5.0 cm
• Radiolucence mixed with radiopaque ragged and poorly defined border
• Moth-eaten appearance
• Right mandibular canal walls destructed
102/11/19
Image finding – Occlusal film
• Size: 4.5 x 3.5 cm
• R-L mixed R-O
• Moth-eaten appearance
• Poor-defined
• Irregular border
• Tooth 44.45.47.48 involved
• No bone expansion
• Non-corticated
• Cortical bone (both lingual and buccal): destructed
102/11/19
Image finding – Chest PA
(102/11/26) Impression：
1) No radiological evidence of active cardiopulmonary disease.
2) Spondylosis and scoliosis of the T-, L-spine.
Image finding – Oral CT
(102/11/29)=======【口腔癌癌症分期統一報告格式(Based on RSROC20120412)】
=======
1. TNMStage: T4aN0MB
Stage group if no distant metastasis (M0): IVA
2. Tumor location / Size
■Measurable lesion-Size: 5.95 cm (largest diameter)
Laterality: right (Se/Im:3/21)
Tumor location: ■Lower gingiva
3. Tumor invasion
■Moderately advanced local disease: tumor invades
Lip:
Oral cavity: ■through cortical bone
4. Regional nodal metastasis (Lymph Node)
■No regional nodal metastasis
5. Distant metastasis (in this study)
■No or Equivocal
Image finding – EGD
(102/12/03) Comments :
H. Pylori test : Negative Reported
Image finding – Abdomen Echo
(102/12/02)
Fatty liver
Image finding – Bone scan
Impression：
Active bone lesions involving the above bony structures, especially in the mandible.
Differential Diagnosis
Our case
• Age and gender: 61 years-old, male
• Pain: (+)
• Tenderness: (+)
• Swelling: (+)
• Mobility: fixed
• Consistency: rubbery to firm
• Destruction of bone structures: (+)
• Development: moderately rapid-growing
Our case Inflammation Cyst Neoplasm
Fever /local heat - + - -
Duration 1+ months days to months years Months to years
Pain + + -/+ -/+
Consistency rubbery/firm rubbery/firm rubbery variable
Sclerotic margin - - + -
→ Neoplasm
NeoplasmOur case Benign Malignant Progressive rapid Slow Variable Swelling with intact epithelium - + -
Pain + +/- +/-
Mobility Fixed Movable Fixed
Sclerotic margin - - +
→Malignant
BenignWorking diagnosis
Intrabony malignant tumor
Central Squamous cell carcinoma
Osteosarcoma
Metastatic tumors in jaw bone
Others Reticulum cell
sarcoma Malignant minor salivary gland
tumor
Chondrosarcoma Ewing’s sarcoma Less
compatible Rare
10-60(avg. 37) Commonly firm exophytic lesion
and seldom ulcerate except as
a result of trauma
More maxilla Young age (5-24)
Central Squamous cell carcinoma
Our case Central SCC
Gender Male M:F≈2:1
Age 61 30-70(peak 57)
Site Mandible (premolar-molar region)
Md:Mx = 4.2:1
Paresthesia - +
Swelling + +
Radiography Ill-defined RL with ragged, irregular border
Ill-defined RL with irregular border
Teeth displacement /root resorption
- +
No apparent mucosal involvement
Osteosarcoma
Our case Osteosarcoma
Gender Male M>F
Age 61 10-40(peak 27)
Site Mandible (premolar-molar region)
Md:Mx = 2:1
(predominant: mandibular body)
Paresthesia - +(14%)
Swelling + +
Radiography Ill-defined RL with ragged, irregular border
Ill-defined, RL irregular border (sunburst appearance by
osteophyte)
Metastatic tumors in jaw bone
Our case Metastatic tumors in jaw bone
Gender Male M:F≈1:3
Age 61 40-60
Site Mandible (premolar-molar region)
Md:Mx=7:1 (Premolar-molar) Radiography Ill-defined RL with ragged,
irregular border
Ill-defined RL with ragged, irregular border
Denied tumor history Wide variety of symptoms
Tentative Diagnosis
Central SCC, right mandible,
cT4aN0M0,Stage IVA
Treatment course
• 102/11/19
– First visit to OS department – Intrabony incisional biopsy
– H-P report: SCC, alveolar ridge, lower right, grade 1
• 102/11/29
– Consult PS department for evaluation of free flap repair
• 102/12/02
– Arranged CT
• 102/12/04
– Arranged GA routine examination – Schedule Operation on 102/12/16
Treatment Plan
Wide excision + segmental resection+ R’t SND + free flap
CCRT
Treatment course
Operation 102/12/16
Routine GA procedures
WE + segmental resection+ R’t SND +
free flap
Treatment course
Histology report(102/12/16)
Pathologic diagnosis: Oral cavity, edentulous ridge, lower right, wide
excision, squamous cell carcinoma, grade 1 ( pT4pN0cM0, stage IV )
Bone, mandible right, segmental resection SCC, grade 1
Lymph node, neck, SND, right Reactive hyperplasia ( 0 / 36 )
Salivary gland,
submandibular SND, right Minimal histological change
Oral cavity, 31遠心牙齦 Excision Minimal histological changes
Neck, 下顎舌骨肌前緣 Excision Minimal histological
changes
Discussion I
•INTRABONY DEFECT
Intrabony lesion
Epithelial origin central SCC
Fibrous origin Fibrosarcoma
Bone origin osteosarcoma
Lymphatic origin Central lymphoma
Metastatic tumor in jaw bone
Central SCC
30~80 y/o
Mand. ,molars region
Surface epithelium appeared normal in appearance (before tooth extraction)
Most often irregular ill-defined radiolucency
Border shows osseous destruction and varying degree of extension
Male
Fibrosarcoma
Male : Female = 1:1
Mean age 4th decade
MandiblePremolar and molars area
Painful enlarging mass
Overlying mucosa : normal
Fibrosarcoma
Ragged, noncorticated, ill-defined, entirely radiolucency, with little internal structure
Destruction of inferior border of the jaw and corticles of the neurovascular canal are lost
Paresthesia
Periosteal reaction is uncommon
Usually entirely radiolucency
Osteosarcoma
Typically occur in 4th decade
Mandible, tooth-bearing area
Swelling, pain, tenderness, ulceration
Ill-defined radiolucency with little internal structure
Destruction of the neurovascular canal and inferior border of the mandible
Male :Female 2:1
Lymph node involvement is rare
Central lymphoma
Occur in all age groups but is rare in the 1st decade
Md (posterior area)
Pain, lymphadenopathy, sensorineural deficits
Radiolucency with ill-defined border
Destruction of cortex of the neurovascular canal
The lesion occurring outside lymph node in head &
neck are present in as much as 1/5
Metastatic tumor in jaw
Usually situated deep in the bone
70% in mandible--Premolar and molars area
Slight predilection for female (3:1)
Solitary, poorly defined radiolucency
Usually erodes rather than expands the adjacent cortical plates
There was no systemic symptom to suggest a primary tumor elsewhere (although there could been occult primary tumor)
Discussion II
Squamous cell carcinoma arising from an odontogenic keratocyst: A case report
Farnaz Falaki, Zahra Delavarian, Jahanshah Salehinejad, Shadi Saghafi
Med Oral Patol Oral Cir Bucal. 2009 Apr 1;14 (4):E171-4.
Squamous cell carcinoma
Arising from the wall of an odontogenic cyst (primary intraosseous carcinoma)
Extremely rare tumor that is limited to the jaws
More frequently in men, mean age of patients is 57 y/o.
Primary intraosseous carcinoma
WHO, classified as an odontogenic carcinoma (1972)
Definition: solid type carcinomas
carcinomas originating from keratocystic odontogenic tumor(OKC),
carcinomas arising from odontogenic cysts other than OKCs
Arise from the lining of an odontogenic cyst or de novo from presumed odontogenic cell rests (ex:
reduced enamel epithelium)
Various odontogenic cysts have been associated with odontogenic SCC:
1ST: residual cyst
2ND: dentigerous cyst
Calcifying odontogenic cyst, and lateral periodontal cyst…
WHO:
Odontogenic keratocyst ─ a specific odontogenic tumor
PIOC derived from it ─ a specific entity which is different to other PIOC’s derived from the odontogenic cysts
Case Report
Case Report
Patient
20-year-old man
CC: painful lesion and swelling in the right retro- molar region of the mandible which was first
noticed by the patient 25 days earlier with gradual increase in size and occasional bleeding.
Intra-oral examination
Painful sessile exophytic lesion with a verrucous surface,
approximate size of 2× 3 cm
Palpation: firm, bleeding was noticed from the posterior
gingival sulcus of the 2nd molar
No anaesthesia or paraesthesia in the area
Lymphadenopathy : (-)
X-ray finding
Well-defined unilocular radiolucency around
the impacted 3rd molar, and there was no
complete radicular development
Clinical diagnosis: SCC in the wall of an odontogenic cyst
Incisional biopsy
Malignant squamous epithelial islands (S) with keratin pearl formation (K) and
individual cell keratinization (I)
Microscopic examination
Chest radiograph and ultrasound examination
Examination of various organs and the possibility of metastasis was ruled out.
Surgical resection (radical surgery using the commando approach)
Surgical specimen reconfirmed initial diagnosis
Histopathologic findings
Microscopic view of the central lesion:
Dysplastic changes in epithelial lining of the cyst
Another microscopic view of the central lesion: An Odontogenic Keratocyst
P‘t f/u for 6 months, no sign of recurrence of the lesion in that period.
DICUSSION
Odontogenic carcinoma
Extremely rare tumor
First discribed by Loos in 1913 as a “Central Epidermoid Carcinoma” of the jaw
Long-standing chronic inflammation
Presence of keratinization in cyst lining
Malignant changed
Odontogenic carcinoma
Men > women
Mean age:57 years
Mandible > Maxilla
Most common symptoms
Pain and swelling
Paresthesia and numbness
May be asymptomatic with lesion on panorax
Odontogenic carcinoma
Radiographically
A unilocular or multicular lesion with well-defined or ill- defined border RL
Malignant changes
The radiolucent area has jagged or irregular margins with indentations and indistinct borders
Histopathologic
Consistent with diagnosis of SCC
Represent well differentiated keratinizing carcinoma
Odontogenic carcinoma
Three possible mechanism:
1) Pre-existing cyst become secondarily involved in a carcinoma of unrelated origin arising from adjacent epithelial structure or distant primary tumor
2) The lesion is a carcinoma from the outset, a part of which has undergone cystic transformation
3) The initial lesion is cyst, malignant changes taken place in the epithelial lining
Odontogenic carcinoma
PIOC must be considered in the differential diagnosis of malignant tumors of odontogenic epithelium
Ameloblastic carcinoma, intraosseous
mucoepidermoid carcinoma, clear cell odontogenic carcinoma, malignant variant of CEOT.
Metastatic SCC must be ruled out
Odontogenic carcinoma
Treatment
Surgery and/or radiation therapy
Prognosis is poor
Metastasis to cervical lymph nodes is observed in up to 50% of cases
Two year survival rate of patients has been reported in 53%
Odontogenic carcinoma
In this case PIOC occurred in 20 yr patient is unusual for SCC
Young age of the patient
Lesion perforated the cortex of the bone and appeared in the oral cavity, which has not been reported in the literature yet
It was possible that two different co-existing lesions,
An overlying mucosal scc and an odontogenic
keratocystic merged together with time, but SCC in a 20- year- old healthy person is not probable
Malignant histopathologic changes observed in the wall of the cyst confirmed diagnosis of odontogenic SCC.
Summary
The importance of careful examination and regular follow up of patients with impacted teeth.
Careful histopathological examination of apparently innocuous odontogenic cysts for the possibility of carcinomatous changes in their epithelial lining
醫學倫理討論
醫學倫理：一種道德思考、判斷和決策，
以倫理學的觀點出發，以期能做出對病人 最有利益、最能符合道德倫理規範的醫療 決策
醫病關係的轉變：醫師中心模式轉變為病
人中心模式 (physician-centered model
→ patient-centered model)
Tom Beauchamp & James Childress 六大原則- 1979
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。
誠信原則(Veractity)：醫師對其病人有「以誠信相對 待」的義務。
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
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。
保密原則(Confidentiality):醫師對病人的病情負有保 密的責任。
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。
