95年度口腔病理科十大病例報告

(1)

95年度口腔病理科十大病例報告

報告者: 陳靜怡第二年住院醫師 指導醫師: 林立民教授

陳玉昆主任

王文岑主治醫師 報告日期: 2007.05.31

(2)

Case 1

•

Name : 王 X X

•

Gender : Female

•

Age : 25

•

First visit : 96.01.02

• Chief complaint

A white mass over anterior right tongue border for 4 months

• Present Illness

This 25 y/o female found a painless white nodule over her anterior right tongue tip for 4 month.

The lesion became larger recently, so she came to OM OPD for further evaluation.

(3)

Past History

• Past medical history

1. Systemic disease: Denied 2. Hospitalization: Nil

3. Drug allergy: Denied

• Past dental history

: NP

• Oral habits: Nil

(4)

Intra-oral Findings

•

A dome-shaped, painless nodule over anterior R’t tongue border

1. Dimension:0.5x0.3 cm 2. Color: whitish

3. Surface: smooth

4. Consistency: rubbery 5. Sessile

6. Tenderness(-) 7. Induration(-)

(5)

Treatment course

•

96.01.02

Clinical impression: Fibroma, R/O other

mesenchymal benign tumors over right tongue border

Referred to OS -- excisional biopsy, sent for histopathological exam.

•

96.01.09 and 96.01.13 -- post-op follow up.

(6)

Microscopic Examination – 1

Pseudoepitheliomatous hyperplasia – acanthosis, basal layer hyperplasia, hyperparakeratosis

(7)

Microscopic Examination – 2

Granular cells – polygonal cells with granular eosinophilic cytoplasm, mixing with muscle fibers.

(8)

Immunohistochemical Stain

S‐100(+)

(9)

Final Diagnosis

• Granular cell tumor

Oral cavity, Tongue border, Right anterior, Excision

(10)

Discussion

•

Immunohistochemical stain: S-100(+), suggest

originating from Schwann cells or their precusors.

•

Clinical features

1. 50% in head and neck region; 60% in tongue 2. Predilection for female and blacks

•

Prognosis: good

•

Recurrence: rare

(11)

Case 2

•

Name : 沈 X X

•

Gender : Male

•

Age : 52

•

First visit : 95.10.20

• Chief complaint

Bilateral swelling mass over mouth floor for about one year.

(12)

Present Illness

•

This 52 y/o male found bilateral swelling masses over mouth floor for about one year. He went to a hospital in Australia and biopsy was done. The

histopathological report indicated that the lesion may originated from endocrine (protein) problem.

He was suggested to accept further evaluation and treatment so he came to OS OPD on 95.10.20.

(13)

Past History

• Past medical history

1. Systemic disease: HCV 2. Hospitalization: 中耳炎 3. Drug allergy: Denied

• Past dental history

: NP

• Oral habits: A(-), B(?), C(-)

(14)

Intra-oral Findings

•

Bilateral painless dome- shaped mass over mouth floor (sublingual gland) 1. Dimension: 6x5 cm 2. Color: white

3. Surface: smooth 4. Consistency: firm 5. Sessile

6. Tenderness(-)

7. Lymphadenopathy(-)

(15)

Treatment Course

•

95.10.20

Clinical impression

: Salivary gland tumor induced by systemic problem, left mouth floor

Incisional biopsy and sent for histopathological exam.

•

95.10.27 -- post-op follow up and HP report.

(16)

Microscopic Examination – 1

Rete ridge atrophy of stratified squamous epithelium, hyperorthokertosis

(17)

Microscopic Examination – 2

Large amount of amorphous, acellular, eosinophilic, homogeneous substance depositing in the fibrous connective tissue

(18)

Histochemical Stain

Congo red (+), amyloid indicated

(19)

Final Diagnosis

• Amyloidosis

Oral cavity, Mouth floor, Left, Excision

•

Referred to 血液腫瘤內科 for further evaluation and treatment.

1. R/O multiple myeloma

2. Lab survey to determine type

(20)

Discussion

•

Oral manifestations – macroglossia, amyloid nodules

•

Amyloidosis – extracellular deposition of amyloid Organ-limited – rare in oral soft tissue

Systemic

1. Primary

2. Myeloma-associated

3. Secondary – a result of chronic inflammatory condition, eg: tuberculosis, osteomyelitis

4. Hemodialysis-associated 5. Heredofamilial (遺傳)

(21)

Case 3

•

Name : 楊X X

•

Sex : 男

•

Age : 34 y/o

•

First visit :95.01.16

• Chief Complaint

Pain and skin

perforation over lower loeft face, left

mandible exposure

(22)

Present Illness -- 1

• 95.01.16

This 34 y/o male

suffered from trismus and painful white

lesion over lower left buccal gingiva for 2 months. He came to OS OPD and incisional biopsy was performed.

(23)

Incisional Biopsy

• Epithelial displasia with hyperkeratosis

Oral cavity, Gingiva,

Lower left, Incision

•

P’t refused to accept further treatment and lost follow up.

(24)

Present Illness -- 2

• 95.07~95.12

The lesion persisted and the patient went to 阮 綜合hospital for help in 95.07. Biopsy was

performed and the HP report was squamous cell carcinoma over left buccal mucosa. Then he accepted R/T and C/T in 阮綜合 hospital.

• 96.02.07

The patient came to our OPD due to left buccal skin perforation and mandible exposure.

(25)

Past History

• Past medical history

1. Systemic disease: Denied 2. Hospitalization: Nil

• Past dental history

: NP

• Oral habits:A(-), B(+), C(+)

(26)

OMF Findings

• Ulcerative lesion and perforation over left

buccal skin with mandible exposure, about 6x4 cm in dimension, Pain(+),

Induration(+)

• Two ulcerative lesions

over lower border of right mandible with bone

exposure

• Severe Trismus

(27)

X-Ray Findings -- Panorex

(28)

Treatment Course

• 96.02.07

Clinical impression: Squamous cell carcinoma over

left buccal mucosa s/p R/T and C/T

Osteoradionecrosis over right mandible

• 96.05.04

– Operation

1. Wide excision + segmental resection 2. Free flap reconstruction

(29)

Microscopic Examination -- 1

Keratin pearl formation, pleomorphism, hyperchromatism, abnormal mitosis, individual cell keratinization

(30)

Microscopic Examination -- 2

Fat tissue invasion (+) Perineural invasion (+) Perivascular invasion (+) Bone invasion (+)

(31)

Final diagnosis

• Squamous cell carcinoma, grade I, T4N0M0, stage IV

Oral cavity, Buccal, Left, Excision

Bone, Mandible, left, Segmental resection

(32)

Case 4

•

Name : 林X X

•

Sex : 男

•

Age : 25 y/o

• • Chief Complaint

A mass over left side of maxilla was

accidentally found via CT exam of head

(33)

Present Illness

•

This 25 y/o male patient was hospitalized in plastic ward due to traffic accident on 95.08.16. A large mass occupied his left maxillary sinus and maxilla was accidentally found via CT exam. The biopsy was consulted by plastic department under

general anesthesia on 95.08.18.

•

According to his family’s statement, he had

allergic rhinitis but never had the experience of discomfort over left side of maxilla and nose.

(34)

Past History

• Past medical history

1. Systemic disease: Denied

2. Hospitalization: left supraorbital rim fracture 3. Drug allergy: Denied

• Past dental history

: NP

• Oral habits: Nil

(35)

OMF Findings

•

Extra-oral findings

Slightly swelling over left infraorbital area with

ecchymosis

•

Intra-oral findings 1. Bone expansion(+)

2. Covering mucosa: intact 3. Pain(-)

5. Pus or discharge(-)

(36)

X-Ray Findings -- Panorex

(37)

CT Findings

(38)

Treatment Course

•

95.08.18

Consulted by plastic dept., -- incisional biopsy under GA, sent for histopathological exam

•

95.08.30

OS OPD for further management, arrange OP on 95.09.28

(39)

Microscopic Examination -- 1

Cyst Formation

(40)

Microscopic Examination -- 2

Mucous producing cells Epidermoid cells

(41)

Immunohistochemical Stains

Cytokeratin(+) EMA(+)

Mucicarmine(+)

(42)

HP Report -- Incisional

• Mucoepidermoid carcinoma, low grade

Sinus, Maxillary, Left, Incision

Minimal histological change Bone, Maxilla, Left, Incision

•

95.09.28

Hospitalization and operation -- partial maxilloectomy

(43)

Final Diagnosis

• Mucoepidermoid carcinoma, low grade

Sinus, Maxillary, Left Partial maxilloectomy

• Criteria of pathological grading

1. Cyst formation ( ) 2. Relative numbers of

mucous cells ( ) , epidermoid cells

and intermediate cells 3. Cellular atypia ( )

(44)

Discussion

•

Origin – de novo formation, mucous cells of

sinus lining

•

Site: parotid gland > minor salivary gland

(palate > tongue or buccal mucosa > retromolar

> lip)

Rarely

it may arises as primary jaw tumor or as a laryngeal, lacrimal, nasal, paranasal, tracheal or pulmonary tumor

•

Prognosis: depending on grade and stage

(45)

Case 5

•

Name : 林 X X

•

Gender : Male

•

Age : 60

•

First visit : 95.05.29

• Chief complaint

Throbbing pain over lower right posterior area for 2 months

(46)

Present Illness

•

This 60 y/o male suffered from the above episode for 2 months. He had been to LDC and received endodontic treatment of 48 but in vain. He didn’t feel better and numbness of R’t lower lip was

noted about 1 week ago.Then he went to another LDC. Radiolucent lesion was noted over R’t

mandible opposed to 45, 46 area (edentulous) and then he came to OM OPD for further evaluation.

(47)

Past History

• Past medical history

Systemic disease: Denied

Hospitalization: facial bone fracture due to T/A on 89/02/29, s/p ORIF Drug allergy: Denied

• Past dental history

1. 45, 46 lost 30 yrs ago 2. OD, Endo 3. Extraction

(48)

Personal History

• Oral habit

Alcohol: (+) 1 BOT/day for 40 yrs

Betel nut chewing: (+) socially for 5 yrs, quit for 2 yrs

Cigarette: (+) 3PPD for 40 yrs Others(-)

• Family history

NP

(49)

OMF Findings

• Extra-oral

Slight swelling over right lower face

• Intra-oral

Slightly elevated mass over lower right edentulous ridge

1. Dimension: 2x2cm 2. Surface: smooth 3. Color: pink

4. Covering mucosa: NP 5. Pain(+), throbbing

6. Tenderness(+) 7. Induration(-) 8. Lymphadenopathy(-)

(50)

X-Ray Findings -- Panorex

(51)

Treatment Course

•

95.05.29 –

Clinical impression: Osteomyelitis, right mandible

R/O malignancy

Referred to OS -- incisional biopsy and 48

odontectomy, sent for histopathological exam.

(52)

Microscopic Examination ‐‐ 1

Spindle-shaped cells arranging in interlaced bundles and

whorled appearance Highly cellular, basophilic

wavy fibrous tissue

(53)

Microscopic Examination ‐‐ 2

Abnormal mitosis Pleomorphism,

hyperchromatism, axon-like structure

(54)

Immunohistochemical Stains

NSE(+) NFP(+)

S-100(+) CD34(-) Ki67(+)

(55)

HP report -- Incisional

• Neurofibrosarcoma

Bone, Mandible, Right, Incision

•

95.06.07 – arrange PET and bone scan

•

95.07.01– arterial port implantation and 1st IAIC

•

95.07.18 – hospitalization and operation 1. wide excision + segmental resection 2. free flap reconstruction by plastic

surgeon

•

96.01.08 ~96.04.19 -- IAIC

(56)

Microscopic Findings of Excisional Specimens

•

Microscopic findings the same as incisional biopsy

•

Immunohistochemical stain: the same result as incisional biopsy

•

Frozen section: free

•

Lymph node: free

•

Margin: free

(57)

• Neurofibrosarcoma

Bone, Mandible, Right, Segmental resection

Final Diagnosis

(58)

Discussion

• Neurofibrosarcoma (Malignant peripheral nerve sheath tumor) – 5~10 % soft tissue tumors

• Origin

1. Peripheral nerve – brachial plexus, 32%

( this cases: inferior alveolar nerve)

2. Malignant transformation from previous existed neurofibroma – associated with neurofibromatosis, 24~50%

3. Malignant transformation from previous existed shwannoma, rare

• Prognosis: poor when associated with neurofibromatosis, 5 yr survival rate: 15%

(59)

Case 6

•

Name : 楊 X X

•

Gender : Male

•

Age : 51

• • Chief complaint

Massive ulcer over lower left posterior area and upper

anterior palatal area for 2 to 3 weeks

(60)

Present Illness

•

The 51 y/o male found two ulcerative lesions over lower left posterior and upper anterior palatal area 2 to 3 weeks ago. Patient did not recall any previous oral soft tissue trauma history. The ulcerative lesions became larger gradually, so he came to OS OPD for further examination.

(61)

Past History

• Past medical history

1. Systemic disease: HTN under medications heart disease

2. Hospitalization: skeletal trauma 3. Drug allergy: Acetaminophen

• Past dental history

: Wearing upper RPD for more than a decade

• Oral habits: A(-), B(+), C(+)

(62)

Intra-oral Findings -- 1

•

An ulcerative, crater‐like lesion over gingiva from teeth 13‐23, bone

exposure

1. Dimension: 2x2 cm 2. Color: white & red

3. Consistency: rubbery 4. Pain: (‐)

5. Tenderness: (+) 6. Induration: (+)

(63)

Intra-oral Findings -- 2

•

An ulcerative, crater‐

like lesion over

gingiva from 35‐38

1. Dimension: 3x2.5 cm 2. Color: white & red 3. Consistency:

rubbery to firm 3. Pain: (+)

4. Tenderness: (+) 5. Induration: (+)

(64)

X-ray Findings -- Panorex

(65)

Microscopic Examination– 1

Lesion of anterior maxilla -- immature lymphoid cell proliferation, diffuse small basophilic cells

(66)

Microscopic Examination – 2

Lesion of 35-38 area -- immature lymphoid cell proliferation, diffuse small basophilic cells

(67)

Immunohistochemical Stains

LCA(+) Lamda(-) Kappa(-)

T cell(-) B cell(+)

(68)

Final Diagnosis

• B cell lymphoma, small, diffuse type

Bone, Maxilla, Anterior, Incision Bone, Mandible, Left, Incision

•

Referred to Hema. Dept., chemotherapy accepted

(69)

Discussion

• Non-Hodgkin’s lymphoma, small B-cell diffuse type Æ low-grade, extra-nodal

• Common site in oral cavity:

1. jaw bone – ill-defined radiolucency

2. buccal vestibule, gingiva and posterior hard palate -- non-tender, diffuse swelling with or without

ulceration

• Treatment and prognosis: depending on grade and stage, RT + CT, or CT alone, response good but tend to recur in older adults (survival rate without treatment: 8~10 yrs)

(70)

Case 7

•

Name : 林 X X

•

Gender : Male

•

Age : 17

• • Chief complaint

Painless swelling over upper left

gingiva for more than one week

(71)

Present Illness

•

The 17 y/o male patient didn’t have uncomfortable experience of oral cavity before. On 95/09/16, his aunt found that a mass occupied on his upper left gingiva. The mass didn’t make him painful or

uncomfortable. Then he was brought to XX內兒科 診所 for help. After clinical examination, the

doctor referred him to OS OPD for further treatment.

(72)

Past History

• Past medical history

1. Systemic disease:

-- Enuresis with medication at our urological department for 5 years

-- Depressive disorder with medication at our psychological department for 2 years 2. Hospitalization: Nil

• Past dental history

: NP

• Oral habits: (-)

(73)

Intra-oral Findings

• A dome-shaped swelling mass over left side of maxilla

opposed to teeth 21~25, buccal gingiva, vestibule and palatal gingiva

1. Dimension: 6x5 cm 2. Color: pink

3. Consistency: firm

6. Pus or discharge(-)

(74)

X-ray Findings --Panorex

(75)

X-ray Findings – Occlusal

(76)

Treatment Course

•

95.09.19

Clinical impression: Dentigerous cyst, impacted 23

Incisional biopsy, sent for histopathological exam

•

95.10.12

Hospitalization and operation -- cyst enucleation + bone graft

(77)

HP Report -- Incisional

• Dentigerous cyst

Bone, Maxilla,

Impacted 23, Incision

Cyst wall

Epi.

Cystic space

Epi.

(78)

Gross – Hemisection

Cystic

part Solid

mass

Tooth 23

(79)

Radiograph -- Gross -- Slide

Tumor

(80)

Microscopic Examination

AOT Tooth

Odontoma- like area

Solid mass -- AOT

(81)

Final Diagnosis

• Adenomatoid odontogenic tumor ex dentigerous cyst

Bone, Maxilla, Impacted 23, Enucleation

(82)

Discussion

• Lesions arising from dentigerous cyst

1. Non-aggressive odontogenic benign tumor – AOT

2. Aggressive odontogenic benign tumor – Ameloblastoma 3. Malignant tumor – SCC, mucoepidermoid ca.

• Lesions associated with AOT 1. COC

2. CEOT

• AOT ex DC in English language literatures – total 6 cases

• Incisional biopsy 的結果會受到切片位置的影響

• X-ray image:當包圍牙冠的R/L lesion 向牙根方向推進超過 CEJ時, Tumor的可能性較高

(83)

Case 8

•

Name : 高 X X

•

Gender : Female

•

Age : 42

•

First visit : 95.06.08

• Chief complaint

Referred from LDC due to a radiolucent lesion over left

mandible

(84)

Present Illness

•

This 42 y/o female suffered from toothache

over upper left posterior area for 1 day and she came to LDC for treatment. After x-ray

examination, an abnormal image over left

mandible was found, and then she was referred to OS OPD. According to patients’s statement, she felt pain over left mandible when palpation.

The symptom lasted for a period of time.

(85)

Past History

• Past medical history

1. Systemic disease: Denied 2. Hospitalization: Nil

3. Drug allergy: Denied

• Past dental history : NP

• Oral habits: A(+), B(-), C(-)

• Family history: NP

(86)

Intra-oral Findings

• Mild buccal & lingual bony expansion over tooth 37 and retromolar area

1. Dimension: 3x2 cm 2. Color: pink

5. Tenderness(+) 6. Induration(-) 7. Vitality of 37(+)

8. Numbness of left lower lip(-)

(87)

X-ray Findings --Panorex

(88)

Treatment Course

•

95.06.08

Clinical impression– ameloblastoma, left mandible

Incisional biopsy, sent for histopathological exam.

•

95.08.04

Hospitalization and OP

(89)

Microscopic Examination ‐‐ 1

Odontogenic epithelial islands

Amyloid-like deposition

(90)

Immunohistochemical Stain

Congo red (+),

amyloid indicated

Cytokeratin(+)

(91)

HP Report – Incisional

•

Odontogenic tumor, suggestive of calcifying

epithelial odontogenic tumor

Bone, Mandible, Left, Incision

(92)

Final Diagnosis

• Calcifying epithelial odontogenic tumor

Bone, Mandible, Left, Excision

(93)

Case 9

•

Name : 胡 X X

•

Gender : Female

•

Age : 30

•

First visit : 95. 12.30

• Chief complaint

A huge mass over

lower right edentulous area for 4 months

(94)

Present Illness

•

This 30 y/o female patient suffered from above episode for 4 months. She felt mild pain at first and found the lesion getting larger and larger gradually. Then she came to LDC for treatment and was referred to our OS OPD for further

evaluation and management on 95.12.30.

(95)

Past History

• Past medical history

1. Systemic disease: asthma, uterine myoma, HCV

2. Hospitalization: uterine myoma 3. Drug allergy:Denied

• Past dental history : NP

• Oral habits: A(+), B(-), C(-)

(96)

Intra-oral Findings

• An exophytic firm mass over 45 to 47 edentulous ridge

• Tooth 45 was shift to lingual side by the mass

• Indentation could be seen over lingual side of the 1. Dimension: 4 X 4 cm 2. Color: Red＆white 3. Surface : Ulcerative 4.Mild pain

5.Tenderness(-) 6.Induration(+)

(97)

X-Ray Findings -- Panorex

(98)

CT Findings

(99)

Treatment Course

• 95.12.30

Clinical impression: Odontogenic tumor over lower right edentulous ridge

Incisional biopsy, sent for histopathological exam.

• 96.01.09

Arrange operation on 96.01.18, delay due to high GOT, GPT, referred to 肝膽內科.

• 96.04.10

Hospitalization and operation

(100)

Microscopic Examination -- 1

(101)

HP Report -- Incisional

• Odontogenic fibroma

Oral cavity, Edentulous ridge, Lower right, Incision

(102)

Microscopic Examination -- 2

(103)

Immunohistochemical Stains

Ki67 (+) Cytokeratin(+)

(104)

Final Diagnosis

• Odontogenic fibroma, peripheral

Oral cavity, Edentulous ridge, Lower right, Excision

(105)

Case 10

•

Name : 王 X X

•

Gender : Male

•

Age : 68

•

First visit : 95. 09.04

• Chief complaint

Swelling over left buccal mucosa for 1 week

(106)

Present Illness

•

This 68 y/o male patient suffered from above

episode for 1 week. He felt pain and swelling over left buccal mucosa. So, he came to OM OPD for further treatment.

•

According to her daughter, two weeks ago, he

went to 大同hospital due to osteophyte and fever.

He also had dry cough during this period.

(107)

Past History

• Past medical history

1. Systemic disease:Denied 2. Hospitalization: Nil

3. Drug allergy:Denied

• Past dental history : NP

• Oral habits: A(+), B(+), C(+)

(108)

Intra-oral Findings

• A swelling mass extending from left mouth angle to molar region.

1. Dimension: 4x3.5 cm 2. Color: red and white 3. Surface: rough

4. Consistency: firm 5. Pain(+)

6. Tenderness(+) 7. Induration(+)

8. Lymphadenopathy(+)

(109)

Treatment course

•

95.09.04

Clinical impression: oral cancer, left buccal

Referred to OS -- incisional biopsy, sent for histopathological exam

(110)

Microscopic Examination

Granulomatous inflammation (tubercle)

Multinucleated giant cells (Langhan cells) , caseous

necrosis, epithelioid histiocytes

(111)

Histochemical Stain

Acid fast stain(+)

(112)

Final Diagnosis

• Tuberculosis, secondary

Oral cavity, Buccal, Left, Incision

•

Referred to 胸腔內科

95.09.11 -- 抗酸菌直接鏡檢 (sputum): (++++) 建議病患住院或在家隔離

Improved after medications

96.05.14 -- 抗酸菌直接鏡檢 (sputum): (-)

(113)

Chest X-Ray

• 96.05.14: post-inflammatory pulmonary emphysema,

fibrosis and bronchiectasis

• 95.09.1: inflammatory or metastatic disease

(114)

Discussion

• Oral TB lesions:

Secondary TB: 0.5-1.5% (primary: lung)

Primary: rare

(115)