報告日期: 102.12.24

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指導醫師:陳玉昆醫師暨口腔病理科全體醫師

報告者: Intern E組

報告日期: 102.12.24

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Name : OOO

Sex : Male

Age : 17 y/o

Native : 高雄市

Marital status : Unmarried

Attending V.S. : OOO醫師

First visit : 102/10/26

(3)

A swelling mass over left TMJ area for 3 months since 102/7

102/11/23

(4)

This 17 y/o male found a swelling mass over left TMJ area for 3 months since 102/7. When he was playing basketball, he was hinted by basketball and then found there is a mass over his left ear side. He has no other symptom or signs and infection. According to his statement, the lesion grew

gradually, so he came to our OPD for further treatment.

(5)

Past Medical History - Seizure

- Hospitalization (-) - Surgery under GA (-)

- Denied any drug/food allergies

- Denied any other systemic problem

Past Dental History

- General routine dental treatment

Attitude to dental treatment: Co-operative

(6)

Risk factors related to malignancy - Alcohol: (-)

- Betel quid: (-) - Cigarette: (-)

Special oral habits: Denied

(7)

102/11/23

Mass over left pre-auricular area

Size: 2 x 2cm

Skin surface: Smooth

Tenderness: Mild

Consistency: rubbery to firm

Mobility: Movable

(8)

102/10/26

No lesion over left TMJ area

Malposition: Tooth 38, 48

Restoration: Tooth 16(O),26(O),46(O)

(9)

Impression:

No imaging evidence of active cardiopulmonary disease.

(10)

Impression:

Left parotid nodule (3.31 x 1.85 x 2.20 cm).

◦ Nature to be determined.

◦ Malignancy cannot be completely excluded.

Enlarged lymph node (1.65 cm) in the left level IB.

◦ DDx: reactive lymphadenopathy, metastasis.

Non-specific small lymph nodes (<1cm) in the submental, the bilateral submandibular, jugulo-digastric, and the

posterior cervical spaces.

Right frontal, ethmoid, and bilateral maxillary sinusitis.

(11)
(12)
(13)

EKG diagnosis:

Sinus arrhythmia

APCs

LVH

Others: suspect early repolarization ectopic P waves

(14)
(15)

Age and gender: 17 years-old, male

Pain: (-)

Tenderness: Mild

Swelling: (+)

Mobility: Movable

Consistency: Rubbery to firm

Destruction of bone structures: (-)

Development: Progressive

(16)

→ Neoplasm Neoplasm

Our case Inflammation Cyst Neoplasm

Fever/local heat - + - -

Duration 3 months Days to months Years Months to years

Pain - + -/+ -/+

Consistency Rubbery/firm Rubbery/firm Soft Variable

Sclerotic margin - - + -

(17)

→benign Benign

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

Pain - +/- +/-

Mobility Movable Movable Fixed Sclerotic margin - - +

(18)

Pleomorphic adenoma

Warthin’s tumor

Basal cell adenoma

Mucoepidermoid carcinoma

(19)

特徵 Pleomorphic Adenoma Our case Age &

gender

Most commonly 30-50 y/o, slight female predilection

17 y/o, M

Site Parotid, submandibular gland regions

Left pre-auricular region

Paresthesia Pain and nerve involvement are rare

Painless

Swelling Progressive swelling Progressive swelling

(20)
(21)

特徵 Warthin’s Tumor Our case Age &

gender

Older adults 60-70 y/o, male predilection(historically)

17 y/o, M

Site Tail of Parotid, near angle of mandible, Sometimes bilaterally, metachronously

Left pre-auricular region

Paresthesia Painless Painless

Swelling Slowly growing and swelling Progressive swelling

(22)
(23)

特徵 Basal cell adenoma Our case Age & gender Any age, commonly

50-70 y/o, female predilection

17 y/o, M

Site Superficial lobe of parotid gland Left pre-auricular region

Paresthesia Painless Painless

Swelling Slowly growing and progressive swelling

Progressive swelling

(24)
(25)

特徵 Mucoepidermoid Carcinoma Our case Age & gender 20-70 y/o, slight female

predilection

17 y/o, male

Site Parotid gland, minor glands(palate) Left pre-auricular region

Paresthesia Painless, however pain and facial palsy may develop

Painless

Swelling Progressive swelling Progressive

swelling

(26)
(27)

Pleomorphic Adenoma

102/11/23

(28)

Pre-auricular incision with temporal extension

Submandibular approach for lymphadectomy

(29)

102/10/26

- First visit to our OPD

- Arranged Parotid Gland CT scan

102/11/07

- Advise P’t to undergo tumor excision

102/11/14

- found mass growing rapidly - Arranged MRI

- Arranged GA routine examination - Arranged OP on 102/11/27

(30)

Operation 102/11/27

Routine GA procedures

Excision of mass on pre-auricular area

(31)

Histology report(102/12/4)

Pathologic diagnosis: Pleomorophic adenoma (Left pre-auricular area, parotid gland region)

(32)

Clinicopathologic analysis of 493 cases of salivary gland tumors

Southern Brazilian population Vol. 114 No. 2 August 2012 (Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:230-239)

(33)

Salivary gland tumor(SGT)

Heterogeneous lesions with complex clinicopathologic characteristics and distinct biological behavior

3% to 10% of the neoplasms of the head and neck region

WHO

0.4 to 13.5 cases per 100 000 inhabitants

Geographic variation

(34)

Numerous epidemiologic studies of SGTs

Origin of the study (medical or dental centers)

Divergences in the histologic classification

Restriction to a specific population

Anatomical location

Tumor type

Our study: distribution and clinicopathologic features

(35)

Determine the distribution and demographic features of salivary gland tumors (SGTs) in a large Brazilian

population

Review the characteristics of 493 SGTs from a general pathology laboratory and an oral pathology service

Evaluate the clinicopathological differences between these two samples

(36)

493 cases

Private general pathology service in Cascavel, Paraná State

Department of Oral Pathology of the Piracicaba Dental School

11-year period

Medical 2001-2009

Dental 2002-2011

Data concerning

Age, gender, tumor location

(37)

Benign Malignant

Case number(2.9:1) 369 124

Mean age 48.2

range 8~88

46.3 54

Male: Female (0.8:1) 0.7:1 1.1:1

Location

parotid gland 42.3%

palate 19.2%

lip 7.7%

submandibular gland6.8%

Parotid gland>palate>lip Palate>parotid gland

>cheek>submandibular gland

Most common Pleomorphic adenoma(PA) 63.6%

Warthin’s tumor 7.3%

Mucoepidermoid carcinoma(MEC)31.4%

Adenocarcinoma26.6%

Adenoid cystic carcinomas17.7%

(38)

Major: minor= 1.5:1

Benign: malignant Major 6.1 : 1 (higher) minor 1.6 : 1 (lower)

Benign Malignant

Major Pleomorphic adenoma

Warthin’s tumor Adenocarcinoma, NOS Adenoid cystic carcinoma

Minor PA

Canalicular adenoma MEC PLGA

(39)

332 salivary gland tumors

Benign 84.6%

Malignant 15.3%

Mean age 47.7

M:F=0.8:1

Location(major salivary gland 72.5%)

Parotid gland 62.6%> submandibular gland10.5% > palate2.7%

Benign: Pleomorphic adenoma(PA)72.5%>Warthin’s tumor10.8%

Malignant: Adenocarcinoma 8.1%> Adenoid cystic carcinoma(ACC)3%

(40)

161 salivary gland tumors

Benign 54.1%

Malignant 45.9%

Mean age 48.9

M:F=0.7:1

Location(minor salivary gland 86.9%)

Palate53.4%>lip20.4%>cheek9.3%

Benign: Pleomorphic adenoma(PA)45.3%>canalicular adenoma5.5%

Malignant: Mucoepidermoid carcinoma(MEC)21.7%>polymorphous low- grade adenocarcinoma(PLGA)8.6%> adenoid cystic carcinomas 7.4%

(41)

Sex (similar)

Male: female 0.8:1(♀>♂)

Benign tumor 0.7:1(♀>♂)

Malignant tumor 1.1:1(♂>♀)

Age (similar)

Mean age 48.2(range 8~88 y/o)

Malignant tumors are about 10 years older than benign tumors

Affected site

Parotid gland>palate>lip(similar)

Benign 74.8%>malignant 25.1%(similar)

Benign tumor: parotid gland (similar)

Malignant tumor: Palate>parotid gland(different!)

(42)

Benign (similar)

Pleomorphic adenoma

The most common benign tumor, both in major and minor gland

Female patients in the fourth decades

Warthin’s tumor

The second most common benign tumor

(43)

Malignant (similar)

Mucoepidermoid carcinoma

The most common malignant tumor

Female in the fifth decades

Adenocarcinoma NOS

The second most common malignant tumor

Parotid gland of male in the sixth and seventh decades

Adenoid cystic carcinoma

The third most common malignant tumor

Submandibular and palatal gland

Equal gender distribution in the seventh decades

(44)

Main difference between medical and dental samples was related to tumor distribution preferentially

affecting major or minor salivary gland

Most common site

Medical sample: major gland

Dental sample: minor salivary gland

Most epidemiologic studies suffer this bias

PA, canalicular adenoma: most common benign neoplasia

MEC, ACC, PLGA: most common malignancy

Benign/malignant ratio: Medical > dental

Gender, mean age: no significant difference

(45)

PA and MEC are the most common benign and malignant SGTs

It is important to consider that differences in tumor types may be influenced by whether a tumor derives from a medical or a dental service

(46)
(47)

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。

(48)

在本案例中病人尚未成年,在手術同意書簽署方面 遇到不同狀況時我們應該怎麼做?不同的作法又和 醫學倫理以及法律層面有何相關?

(49)

新北市陳小姐日前罹患濕疹,到永和區一家地區型醫 院就診,醫師告知須做雷射手術,但因陳小姐未滿20 歲,醫護人員特別囑咐陳女手術當天,須請親友陪同 作為手術見證人。 陳小姐投訴,手術當天她請男友陪 同前往醫院,兩人遵照醫護人員指示,出示身分證件 供核對,不料正要簽同意書時,卻被醫護人員制止,

對方告知其男友未滿20歲,即使簽名也不能施作手術,

質疑醫護人員惡意刁難,「已依指示帶親友陪同,為 何不能施作手術?」報導╱投訴組(2013.08.05)

(50)

專家意見

新北市衛生局醫事管理科代理股長吳彥毅說,依規 定手術當事人滿20歲可免手術見證人,若未成年則須 有見證人,可找法定代理人、配偶、親屬或關係人簽 具,但須滿20歲才可,因此未成年確實不能當見證人,

本案醫護並非惡意刁難。

簽手術同意書須知

.詳讀同意書內容,了解術後可能併發症等資訊

.病患本人滿20歲,可免手術見證人

.未成年須先由成年的法定代理人、配偶、親屬或關

係人簽署

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(52)

病人本身害怕手術,不願意進行手術,但父母親同 意進行並且簽署同意書,那是否要進行手術呢?

(53)

以病人本身的意見為主,若病人感到害怕且不願意 進行手術,即使家屬已簽署手術同意書,亦不進行 手術。

遵照自主原則(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。

遵照不傷害原則(Nonmaleficence):醫師要盡其 所能避免病人承受不必要的身心傷害。

違反行善原則(Beneficence)醫師要盡其所能延

長病人之生命且減輕病人之痛苦。

(54)

家屬支持進行手術並且簽署同意書後,即使病人本 身不願意,仍進行手術治療

遵照行善原則(Beneficence)醫師要盡其所能延

長病人之生命且減輕病人之痛苦。

違反自主原則(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。

違反不傷害原則(Nonmaleficence):醫師要盡其所

能避免病人承受不必要的身心傷害。

(55)

病人與父母親口頭上皆同意進行手術,但父母親無 法立即親自簽署同意書,是否要等待父母親簽署後 才能進行手術?

(56)

務必等到父母親簽署後再進行手術,即使有可能拖 延到病情,亦不進行手術。

遵照自主原則(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。

違反不傷害原則(Nonmaleficence):醫師要盡其 所能避免病人承受不必要的身心傷害。

違反行善原則(Beneficence)醫師要盡其所能延

長病人之生命且減輕病人之痛苦。

(57)

不必等待父母親簽署同意書,直接進行手術治療,

以免拖延病情

遵照行善原則(Beneficence)醫師要盡其所能延

長病人之生命且減輕病人之痛苦。

遵照不傷害原則(Nonmaleficence):醫師要盡其所 能避免病人承受不必要的身心傷害。

違反自主原則(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。

(58)

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