Case Report

(1)

Case Report

報告者： Intern E 組呂兆煜吳迪峰陳鈺文陳韻婷 指導醫師：陳玉昆主任林立民教授暨口腔病理科全體醫

師

(2)

General Data

• Name : O O O

• Sex : Female

• Age: 36y/o

• Native: 高雄

• Marital status: 單身

• Attending staff: O O O 醫師

• First visit : 2015/11/25

(3)

Chief Complaint

• Mass over upper anterior labial side for 20 days

2015/12/02

(4)

Present Illness

• This 36 y/o female patient found a mass and felt pain over upper anterior labial side for 20 days . She went to Tatung ear-nose-throat department for help and was given dexaltin and antibiotics. The mass has alleviated and pain relieved. She came to our OPD for further examination and treatment

(5)

Past History

• Past Medical History

– Systemic disease: denied – Hospitalization (+)

– Surgery under GA (+)

– Drug and food allergy: denied

• Past Dental History

– General routine dental treatment

• Attitude to dental treatment: co-operative

(6)

Personal Habits

• Risk factors related to malignancy

– Alcohol (+), quit, socially – Betel quid (-)

– Cigarette (+), for 20 years, 0.5 pack/day – Denied any other dental oral habits

(7)

OMF Examination

• MMO: 57mm

• Site: Upper right lip

• Size: 2.0 cm

• Color: whitish-yellow surrounded with pink

• Induration (+)

• Pain (+)

• Tenderness (+)

• Surface: smooth

• Base: sessile

• Shape: dome

• Mobility: fixed

• Consistency: firm

• Fluctuation (-)

• Skin adhesion (-)

• LAP (-)

2015/12/02

(8)

Panorex (2015/12/02)

(9)

RATIONALE FOR DIFFERENTIAL

DIAGNOSIS

(10)

Inflammation?

Cyst or neoplasm?

Benign or malignant?

Working diagnosis

(11)

Inflammation, cyst, or neoplasm ？

Our case Inflammation Cyst Neoplasm

Color Pink to red Red Normal Variable

Fever - + - -

Consistency Firm Rubbery Sof Variable

Shape Irregular Irregular Regular Irregular

Discharge - + - +/-

Pain + + - +/-

Ulceration - - - +/-

Mobility Fixed Fixed Fluctuation Fixed

Duration 20 days Days Years Months

(12)

Benign or Malignant ?

Our case Benign Malignant

Border Clear Clear Unclear

Surface Smooth Smooth Rough, smooth

Ulceration - - +/-

Induration + - +

Pain + - +/-

Metastasis - - +/-

Mobility Fixed Movable/fixed Fixed

Duration 20 days Years/Months Months

(13)

Intrabony or peripheral ？

→ Our case is a

Our case Intrabony Peripheral Bone

expansion

- + -

Bony destruction

- + -

Consistency firm Hard Sof, firm,

rubbery…

peripheral malignant neoplasm

(14)

• Malignant minor salivary gland tumor

- Mucoepidermoid carcinoma - Adenoid cystic carcinoma

WORKING DIAGNOSIS

Most possible

Least possible

• Malignant mesenchymal tumor

- Fibrosarcoma

(15)

Differential Diagnosis

(16)

Mucoepidermoid carcinoma

(17)

Adenoid cystic carcinoma

(18)

fibrosarcoma

(19)

Clinical impression

• Mucoepidermoid carcinoma over right upper lip

(20)

Treatment course

(21)

Treatment course

2015/11/25

Incisional biopsy

HP report

Oral cavity, upper lip, middle right, incision, adenoid cystic carcinoma

2015/12/02

Arrange CT, bone scan, chest PA, abdominal eccho, endoscope, CEA, TPA, SCC marker, panorex

Arrange operation under general anesthia on 2015/12/31.

(22)

Chest PA(2015/12/03)

Impression ：

No imaging evidence of active cardiopulmonary disease.

(23)

EKG(2015/12/03)

EKG Diagnosis: 　　　　　　

■ Low voltage (chest ) 　　　

(24)

EGD(2015/12/08)

• Assessment :

. Reflux esophagitis, Grade A . Superficial gastritis at antrum

. ECA survey : WL(-), NBI(-), no LVL, group A 　　　

(25)

Abdomen echo(2015/12/07)

DIAGNOSIS ： No liver metastasis 　　　　

　

(26)

Treatment Plan

• WE+ Terudermis (12/31)

2015/12/02

(27)

DISCUSSION

(28)

Adenoid Cystic Carcinoma(ACC)

• 3

^rd

most common salivary malignancies

• Commonly in head and neck

• Other sites: trachea, lacrimal gland, breast, skin, and vulva

• Distinctive histologic appearance

• Metastasis rate is high: bone and lung

Oral and Maxillofacial Pathology 3^rd edition, p.495-497

(29)

Clinical and Radiographic Features

• Sex predilection: ≥ (3:2) ♀ ♂

• Age predilection: middle-aged,

rare younger than 20 y/o

• Site : 50-60% in minor salivary glands, palate

• Features:

- Pain, Slow growing mass

- Facial nerve paralysis if in parotid gland

- Bone destruction showed in radiograph if in palate or maxillary sinus

(30)

Histopathologic Features

• Mixture of myoepithelial and ductal cell

• Three major patterns, usually combination

– Cribriform, Swiss cheese – Tubular

– Soild

(31)

Treatment and Prognosis

• Recurrence and metastasis

→ Surgical excision, adjunct RT may improve survival rate in some cases

• Survival rate

– 5-year : 70%

– 10-year : 50%

– 20-year : 25%

(32)

(33)

(34)

TNM stage at diagnosis (P=0.03), Histological subtype (P=0.023),

Combined surgery and radiotherapy (P=0.03),

were significant factors of improved 5-year overall survival.

(35)

“ 使用人工真皮 (Terudermis) 真的有比較好嗎？

”

醫學倫理討論

35

(36)

Tom Beauchamp & James Childress 六大原則 _{- 1979}

生命的神聖性 (Sanctity of life) 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。

(37)

Jonson 架構

醫療現況

(Medical indication for intervention) 病人選擇

(Patient’s preference) 生命品質

(Quality of life) 社會脈絡

(Contextual issues)

37

Jonsen, Siegler and Winslade; Clinical Ethics:

A Practical Approach to Ethical Decisions in Clinical Medicine (3rd edition McGraw-Hill 1992 )

(38)

生命的神聖性 (Sanctity of life)

強調尊重自己和他人的生命尊重生命的價值

38

(39)

行善原則 (Beneficence)

做了 wide excision 後是否有盡可能減輕患者的不適與疼痛感？

A: 術前預先告知病人術後可能會有的疼痛感，若有需要則搭配藥物的使用，並提醒病人相關的術後照護方式

39

(40)

誠信原則 (Veractity)

手術前是否有詳細告知病人，使用人工真皮的優點與缺點？

A: 自體植皮手術和人工真皮的差別

對於人工真皮的材料和組成是否有清楚的和病患做解釋

？

A: 需和病患解釋，人工真皮為取自於小牛的真皮，利用其膠原網狀纖維以及額外覆蓋的矽膠層所組成

相關人員是否有向病患甚至是其家屬，清楚說明治療計劃與癒後？

A: 應於告知病人且回答病人或家屬相關問提後，方才執行手術

40

(41)

自主原則 (Autonomy)

在詳細解釋治療計劃以及風險後，是否有讓病患完全自主的選擇治療計劃？

A: 除了清楚闡述相關治療計劃的優缺點和比較之外，應避免使用主觀的用詞，來影響或左右病人之選擇

41

(42)

不傷害原則 (Nonmaleficence)

術前是否有先完整瞭解病人的病史及是否適合使用人工真皮？

A: 需清楚病人是否有任何系統性疾病，以及相關的醫療紀錄，並評估使用人工真皮的可行性和風險

手術過程中是否有造成不必要的傷害？

A: 手術中應盡可能避免人為疏失，並在術前先了解病人的狀況，搭配良好的術後照護

，將病人的傷害降到最低

42

(43)

保密原則 (Confidentiality)

告知的對象本人為原則

病人未明示反對時，亦得告知其配偶與親屬病人為未成年人時，亦須告知其法定代理人

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

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

43

(44)

公義原則 (Justice)

以病人的情況來說，是不是真的需要使用到人工真皮？

A : 若傷口涵蓋的範圍較大，或病人不適合使用自體皮移植手術時，在評估病人的條件適合後，建議使用

44

Case Report

Case Report

General Data

• Name : O O O

• Sex : Female

• Age: 36y/o

• Native: 高雄

• Marital status: 單身

• Attending staff: O O O 醫師

• First visit : 2015/11/25

Chief Complaint

• Mass over upper anterior labial side for 20 days

Present Illness

Past History

Personal Habits

• Risk factors related to malignancy

OMF Examination

Panorex (2015/12/02)

RATIONALE FOR DIFFERENTIAL

DIAGNOSIS

Inflammation?

Cyst or neoplasm?

Benign or malignant?

Benign or malignant?

Working diagnosis

Inflammation, cyst, or neoplasm ？

Benign or Malignant ?

Intrabony or peripheral ？

• Malignant minor salivary gland tumor

- Mucoepidermoid carcinoma - Adenoid cystic carcinoma

WORKING DIAGNOSIS

• Malignant mesenchymal tumor

- Fibrosarcoma

Differential Diagnosis

Mucoepidermoid carcinoma

Adenoid cystic carcinoma

fibrosarcoma

Clinical impression

Treatment course

Treatment course

Chest PA(2015/12/03)

EKG(2015/12/03)

EKG Diagnosis:

■ Low voltage (chest )

EGD(2015/12/08)

Abdomen echo(2015/12/07)

DIAGNOSIS ： No liver metastasis

Treatment Plan

DISCUSSION

Adenoid Cystic Carcinoma(ACC)

• 3

most common salivary malignancies

• Commonly in head and neck

• Other sites: trachea, lacrimal gland, breast, skin, and vulva

• Distinctive histologic appearance

• Metastasis rate is high: bone and lung

Clinical and Radiographic Features

• Sex predilection: ≥ (3:2) ♀ ♂

• Age predilection: middle-aged,

• Site : 50-60% in minor salivary glands, palate

• Features:

Histopathologic Features

• Mixture of myoepithelial and ductal cell

• Three major patterns, usually combination

Treatment and Prognosis

• Recurrence and metastasis

→ Surgical excision, adjunct RT may improve survival rate in some cases

• Survival rate

醫學倫理討論

Tom Beauchamp & James Childress 六大原則 - 1979

Jonson 架構

醫療現況

(Medical indication for intervention) 病人選擇

(Patient’s preference) 生命品質

(Quality of life) 社會脈絡

(Contextual issues)

生命的神聖性 (Sanctity of life)

行善原則 (Beneficence)

做了 wide excision 後是否有盡可能減輕患者 的不適與疼痛感？

A: 術前預先告知病人術後可能會有的疼痛 感，若有需要則搭配藥物的使用，並提醒 病人相關的術後照護方式

EKG Diagnosis: 　　　　　　

■ Low voltage (chest ) 　　　

DIAGNOSIS ： No liver metastasis 　　　　

Tom Beauchamp & James Childress 六大原則 _{- 1979}

做了 wide excision 後是否有盡可能減輕患者的不適與疼痛感？

A: 術前預先告知病人術後可能會有的疼痛感，若有需要則搭配藥物的使用，並提醒病人相關的術後照護方式

手術前是否有詳細告知病人，使用人工真皮的優點與缺點？

A: 需和病患解釋，人工真皮為取自於小牛的真皮，利用其膠原網狀纖維以及額外覆蓋的矽膠層所組成

相關人員是否有向病患甚至是其家屬，清楚說明治療計劃與癒後？

A: 應於告知病人且回答病人或家屬相關問提後，方才執行手術

在詳細解釋治療計劃以及風險後，是否有讓病患完全自主的選擇治療計劃？

A: 除了清楚闡述相關治療計劃的優缺點和比較之外，應避免使用主觀的用詞，來影響或左右病人之選擇

術前是否有先完整瞭解病人的病史及是否適合使用人工真皮？

A: 需清楚病人是否有任何系統性疾病，以及相關的醫療紀錄，並評估使用人工真皮的可行性和風險

A: 手術中應盡可能避免人為疏失，並在術前先了解病人的狀況，搭配良好的術後照護

告知的對象本人為原則

病人未明示反對時，亦得告知其配偶與親屬病人為未成年人時，亦須告知其法定代理人

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

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

以病人的情況來說，是不是真的需要使用到人工真皮？

A : 若傷口涵蓋的範圍較大，或病人不適合使用自體皮移植手術時，在評估病人的條件適合後，建議使用