CASE REPORT
Intern A:
游杰洺、蔡豐光、張儒豐、郭懿霆
指導醫師：口腔病理科全體醫師 2011/09/26
CHIEF COMPLAINT
100. 4.7
Recurrent tumor over right coronoid process for about 2 years.
PERSONAL DATA
Name：韓XX
No. of Chart ：1XXXXXX8
Gender：Female
Age：33 y/o
Marital status : 已婚
Address : 高雄市三民區
Date of first visit : 91/5/28
PHYSICAL EXAMINATION
Surface：Smooth
Pain : (-)
Tenderness : (-)
Right chin numbness, due to previous OP
No effect on facial profile
PRESENT ILLNESS
91.5.28
Swelling over right posterior mandible for 2 month.
O.E.: 2x2cm, smooth, firm, fixed, painless, tenderness(-)
Refer from 長庚H for biopsy and further treatment.
Panoramic findings: large radiolucency shadow over right posterior mandible extended into ramus (near sigmoid notch)
Incision biopsy was done, H-P result: Unicystic Ameloblastoma, desmoplastic, right mandible
Aspiration: (+) yellowish fluid
C-T image findings: compatible with ameloblastoma at right mandibular angle
91.6.18~91.9
Decompression with Penrose drain, N/S irrigation
O.P. on 91.10.4 : excision + bone trimming
91.8.7
91.6.18~91.9
Decompression with Penrose drain, N/S irrigation
O.P. on 91.10.4 : excision + bone trimming
91.9.4
• 91.6.18~91.9
– Decompression with Penrose drain, N/S irrigation – O.P. on 91.10.4 : excision + bone trimming
91.11.6
• 92.7.9~94.5.2
̶ Regular follow up , panoremic film: stationary
92.4.2
95.6.7
Panoramic film show: radiolucent lesion over right mandibular body and angle again.
96.4.20
Incision biopsy, H-P result: ameloblastoma, right mandibular OP on 96.5.16 : excision + Bone trimming
96.4.20
• OP on 96.5.16 : excision + Bone trimming
96.6.15
• 96.8.10
̶ Radiolucent lesion over posterior margin of the lesion with radiopacities
̶ Excision of the RO lesion, bone, H-P: osteomyelitis
96.8.10
• 96.12.7~98.2.12
̶ Regular follow up, Panoremic film: OK
96.12.7
• 96.12.7~98.2.12
̶ Regular follow up, Panoremic film: OK
97.2.15
• 96.12.7~98.2.12
̶ Regular follow up, Panoremic film: OK
97.8.8
• 98.2.12
̶ Panoremic film: subcoronoid lesions
98.2.12
• 98.5.14
̶ Panoremic film: radiolucent lesion over right coronoid process
• 100.4.7
̶ Panoremic film: radiolucent lesion over right coronoid process growing larger in diameter ( 15.9x19.0 mm )
̶ Arrange OP on 6/3
PAST MEDICAL HISTORY
Hospitalization: (+)
91.10 : O.S. ward, ameloblastoma, R’t mand., excision + bone trimming
96.5 : O.S. ward, ameloblastoma, R’t mand., excision + bone trimming
Surgery under GA: (+)
Allergy to Pentothal, Tracrium
Systemic disease: nil
PAST DENTAL HISTORY
Denture, general routine dental treatment
Attitude to dental treatment：cooperative
PERSONAL HABITS
Alcohol drinking (-)
Betel nut chewing (-)
Cigarette smoking (-)
Denied other specific habit
DIFFERENTIAL DIAGNOSIS
CLINICAL IMPRESSION
91年10月：
Ameloblastoma at right mandibular angle and body
96年5月：
Recurrent ameloblastoma at right mandibular angle and body
100年6月：
Recurrent ameloblastoma at right mandible coronoid process
Inflammation Cyst Neoplasm
Our case Inflammation Cyst Neoplasm
Color Normal Red Normal Variable
Discharge - + - -
Consistency Firm Rubbery Soft Firm
Pain - + - +/-
Ulceration - - - +/-
Mobility Fixed Fixed Fixed Fixed
Duration 1-2 Month(s) Days Years Months
Benign
Inflammation Cyst Neoplasm
Malignant
Our case Benign Malignancy
Surface Smooth Smooth Rough
Ulceration - - +
X-ray margin Well-defined Well-defined Poor-defined
Mobility Fixed Movable Fixed
LAP - - +
Duration 1-2 Month(s) years Months
Benign
Central Peripheral
Inflammation Cyst Neoplasm
Malignant
Our case Central Peripheral
Consistency Firm Firm Rubbery
Ulceration - +/- +/-
Induration - - +
X-ray border well-defined well-defined ill-defined Bony
expansion or perforation
+ +/- +
Mobility Fixed Fixed Fixed
Peripheral Benign
Central
Inflammation Cyst Neoplasm
Malignant
WORKING DIAGNOSIS
Recurrent ameloblastoma, right coronoid process
Odontogenic keratocyst
AMELOBLASTOMA
Without pain
20-70 y/o
80-85% posterior mandibular、cortical bone expansion、易造成牙根吸收
Multilocular RL、local invasive、易復發(50% - 90%)
Firm or fluctuant with straw colored fluid
COMPARISON
Our case Ameloblastoma
Gender F Both (M~F)
Age 24 20-50 (40)
Site Right posterior
mandible Mandible 80%
Posterior 70%
Pain - -
Ulcer - -
LAP - -
Consistency Firm Firm/Fluctuant
Shape Well-defined ill-defined
Ragged borders
Features Radicular, radiolucent, smooth contours
Multilocular, erode cortical plates
ODONTOGENIC KERATOCYST
10-40 y/o
Posterior mandible、較少造成bone expansion
Well defined unilocular RL，有時會有scallop- border 、multilocular、少造成牙根吸收
Firm fluctuant
易復發 (5% - 62%)
Cheesy, yellow substance
COMPARISON
Our case OKC
Gender F M=56.9%
Age 24 10-30(28)
Site Right posterior mandible Mandible 65%
3rd molar
Pain - -
Ulcer - -
LAP - -
Consistency firm firm
Shape Well-defined Well-defined
Scallop border Features Radicular, radiolucent,
smooth contours Hazy radiolecency
HISTOPATHOLOGIC DIAGNOSIS
Recurrent ameloblastoma (follicular type), right coronoid process
DISCUSSION
Ameloblastoma
HISTOPATHOLOGIC DIAGNOSIS
Recurrent ameloblastoma initial: desmoplastic type
1st recur: plexiform and acanthomatous type 2nd recur: follicular type
AMELOBLASTOMA
臨床上可分為三種類型:
Conventional (intraosseous): 86%
Unicystic: 13%
Peripheral (extraosseous): 1%
佔所有odontogenic tumor第2位
是種slow growing, local invasive的腫瘤
可能跟TNF-alpha, antiapoptotic protein, interface protein (FGF)過度表現有關
CLINICAL FEATURES
Sex predilection: none
Age predilection: 20~70歲平均分布
Racial predilection: none
Site predilextion:80~85%在mandible，特別是 molar-ramus area
Anterior Premolar Molar
Maxilla 6% 1% 6%
Mandible 10% 11% 66%
Symptom and sign:
Pain and parethesia並不常見
當tumor很大，造成cortical bone expansion，
觸診時有eggshell cracking的感覺
RADIOGRAPHIC FEATURES:
Mutilocular RL:呈現Soap bubble(肥皂泡)或 honeycombed(蜂窩狀)
Combine impacted tooth常見:多半是mandible 3rd molar
Buccal 和lingual 的bony expansion常見
鄰近牙齒的牙根常見吸收
但有一種特別的分類叫desmoplastic
ameloblastoma，好發在anterior maxilla區，因其 有很緻密的fibrous stroma，呈現RL+RO
HISTOPATHOLOGIC FEATURES
沒有capsule，或並不明顯
基本構造細胞有三種
Ameloblast-like cell:
High columnar (高柱狀) epithelial cell
Reversed polarity:核偏一邊，會遠離basal membrane，朝向stellate reticulum
Stellate reticulum
loosely arranged angular epithelial cell
Mature fibrous stroma:
是成熟，成束的fibroblast
是中胚層來源
顯微鏡下多變，有幾種分類的方式:
依island的形狀與細
胞排列方式 依stellate reticulum
的變化來分 依fibrous stroma的 緻密度來分
Follicular
Plexiform Acanthomatous type Granular cell type Basal cell type
Desmoplastic type
DIFFERENTIAL DIAGNOSIS
All type
follicular 團狀，最常見，microcyst
plexiform 索狀
acanthomatous Squamous metaplasia
Granular cell Granular cell, lysosome, young, more aggressive Basal cell 最少見，stellate reticulum 很少，basaloid cell desmoplastic Dense stroma, enamel-like island, RL+RO,上顎前
牙,transforming growth factor beta
TREATMENT AND PROGNOSIS:
具有局部侵犯性(local invasive)，實際病灶會 浸潤到周邊的bone，使真正的tumor size，比 起X-ray或臨床診斷的更大，故需要wide
resection
Recurrence rate高達50~90%
