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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

(2)

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

(3)

Chief Complaint

 Unhealed wound after extraction of tooth

46 at LDC in October, 102

(4)

102/11/19

(5)

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.

(6)

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

(7)

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

(8)

OMF Examination

 MMO : 40mm

 No malignant-like change in oral

mucosa

 Numbness(-)

 Pain(+)

 Swelling(+)

 Tenderness(+)

 LAP (-)

102/12/14

(9)

Image 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

(10)

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

(11)

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.

(12)

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

(13)

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

(14)

Image finding – EGD

(102/12/03)

 Comments :

H. Pylori test : Negative Reported

(15)

Image finding – Abdomen Echo

(102/12/02)

 Fatty liver

(16)

Image finding – Bone scan

 Impression:

Active bone lesions involving the above bony structures, especially in the mandible.

(17)

Differential Diagnosis

(18)

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

(19)

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

Neoplasm

(20)

Our case Benign Malignant Progressive rapid Slow Variable Swelling with intact epithelium - + -

Pain + +/- +/-

Mobility Fixed Movable Fixed

Sclerotic margin - - +

→Malignant

Benign

(21)

Working 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)

(22)

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

(23)

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)

(24)
(25)

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

(26)

Tentative Diagnosis

 Central SCC, right mandible,

cT4aN0M0,Stage IVA

(27)

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

(28)

Treatment Plan

 Wide excision + segmental resection+ R’t SND + free flap

 CCRT

(29)

Treatment course

Operation 102/12/16

 Routine GA procedures

 WE + segmental resection+ R’t SND +

free flap

(30)

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

(31)

Discussion I

•INTRABONY DEFECT

(32)

Intrabony lesion

Epithelial origin  central SCC

Fibrous origin  Fibrosarcoma

Bone origin  osteosarcoma

Lymphatic origin  Central lymphoma

Metastatic tumor in jaw bone

(33)

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

(34)

Fibrosarcoma

 Male : Female = 1:1

 Mean age 4th decade

 MandiblePremolar and molars area

 Painful enlarging mass

 Overlying mucosa : normal

(35)

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

(36)

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

(37)

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

(38)

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)

(39)

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.

(40)

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.

(41)

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)

(42)

 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

(43)

Case Report

(44)

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.

(45)

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 : (-)

(46)

X-ray finding

 Well-defined unilocular radiolucency around

the impacted 3rd molar, and there was no

complete radicular development

(47)

 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

(48)

 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

(49)

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

(50)

 P‘t f/u for 6 months, no sign of recurrence of the lesion in that period.

(51)

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

(52)

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

(53)

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

(54)

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

(55)

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

(56)

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%

(57)

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.

(58)

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

(59)

醫學倫理討論

(60)

 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)

(61)

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。

(62)

1.行善原則(Beneficence)

 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

(63)

臨床案例

 對病患的生活品質有所幫助?(雖然移除病

灶,但造成顏面損傷及失去咬合功能)

 做手術是否有減輕病人的疼痛?或是使病

人更不舒服?

 手術的介入時機是否恰當?

(64)

2.誠信原則(Veractity)

 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?

 對於病人疾病嚴重程度是否有誠實的通知,

盡到告知的義務?

(65)

3.自主原則(Autonomy)

 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

(66)

臨床案例

 在說明病情及治療計畫、風險之後,是否

有讓病人充分自主的選擇治療計畫?

 在做手術以前,是否有說明完整之後再請

病人自主的簽名同意?

(67)

4.不傷害原則(Non-maleficence)

 不殺害病人、不能侵害病人權益和福祉以

及平衡利害得失,使痛苦減到最低

 臨床意義

(1)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

(2)權衡利害原則→ 兩害相權取其輕

(3)保護病人的生命安全

(68)

臨床案例

 手術過程中,是否有造成不必要醫源性的

傷害?

 若詳實的說明治療計畫,並讓病人對於治

療計畫沒有疑問,使心理壓力不那麼大,

其實也可以算是一種不傷害原則

(69)

5.保密原則(Confidentiality)

 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

(70)

臨床案例

 對於病患病情的保密,已及他的資料是否

會被使用來研究用途是否有告知(是否要提

前告知病患,資料會做研究之用)

(71)

6.公義原則(Justice)

 強調資源合理分配、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及法律之前人人平等

(4)先來先服務與急重症優先

(72)

臨床案例

 術前術後照護有無不足之處?

 住院時間是否太短?太長?

 藥物使用的必要性?

(73)

醫學倫理總結

 在病例方面(病灶描述,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,須說明病情、治療計畫及

風險

 應在不違反醫學倫理的原則之下進行治療的

行為

(74)

Reference

 http://oralpathol.dlearn.kmu.edu.tw/

 žOral and maxillofacial pathology, 3rd edition, Neville

 Essentials of Oral Pathology, 3rd Edition

 Med Oral Patol Oral Cir Bucal. 2009 Apr

1;14 (4):E171-4.

(75)

Thanks for your attention

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