報告組別：

報告組別：Intern Group C 報告日期 : 101.11.26

指導醫師：林立民醫師、陳玉昆醫師、

王文岑醫師、陳靜怡醫師

組員：邱筠太、蕭智謙、陳品元、危薇、郭乃綺

General Data

 Name : XXX

 Sex : Female

 Age : 56 y/o

 Native : 高雄

 Marital status : 已婚

 Attending V.S. : XXX醫師

 First visit : 101.10.05

Chief Complaint



Referred from 小港H. for oral examination due to a swelling mass over left palate for 3 years.

101.10.24

Present Illness

 This 56 y/o female suffered from a swelling mass over left palate for 3 years near the

midline, and about 1 year ago she noticed the mass was increasing in size.

 101.09.27

• Received incisional biopsy by Dr.許 at 小港H.

H-P report : Adenoid cystic carcinoma

Present Illness

101.10.05

 Referred to our OMS dept. for further treatment

 Pre-op examination

OMF Examination

 Size : 3 x 2 x 1 cm

 Color : Pinkish with areas of bluish color

 Mobility : Fixed

 Shape : Well-defined;

 Dome shaped

 Consistency : Firm

 Pain (-)

 Tenderness (-)

 Induration (-)

 Ulceration (-)

 Facial paralysis (-)

 LAP : (-)

101/10/24

Past History

 Past Medical History

 Underlying diseases : Hepatitis C

 Urticaria history

 Hospitalization :

○ Hysterectomy at 台東馬偕H. in 1994

○ Adenocarcinoma, breast s/p operation

 Surgery under GA : as above

 Drug or food allergies : denied

 Past Dental History

 Routine dental treatment

 Attitude to dental treatment : cooperative

Personal History



Risk factors related to malignancy

 Alcohol : (+), social

 Betel quit : (+), 1 grain in few months , quit 30+ yrs

 Cigarette : (-)



Special oral habits : Denied



Irritation : Denied

Image finding - Panorex

There is no significant finding in panorex.

Image finding - Panorex

Dental finding :

• Caries : Nil

• Periodontal condition : Horizontal bony resorption of lower anterior teeth

• Calculus : Tooth 15, 41, 43

• Missing tooth : Tooth 18, 28, 38

• Prosthesis : Nil

Water’s View - 101/10/05

1. The calvarium is intact

2. The bony structures of the orbits and sinuses are intact

3. The bilateral maxillary sinuses are slightly cloudly

4. No nasal septal deviation is noted

5. The visible soft tissue also appears unremarkable

CT – 101/10/12

CT report：Invasion to palate bone and may be extent to nasal cavity

Working Diagnosis



Our case features :

 Site : Hard palate

 Gender : Female

 Age : 56

 Consistency : Firm

 Progressive : Slow and sudden spurt

Our case Inflammation Neoplasm Cyst Color

: Pinkish with areas of bluish color

Red Variable Yellow or

white Fever or

local heat

(-) (+) (-) (-)

Consistency Firm Rubbery Variable Rubbery

Ulceration (-) (-) (-)/(+) (-)

Duration 3 years Days to Months Months to years Years Mobility Fixed(in palate) Fixed(in palate) Fixed (in palate) Fixed(in

palate)

Pain (-) (+) (-)/(+) (-)

Inflammation ? Neoplasm ? Cyst ?

Neoplasm!

Our case Benign Malignance

Progressive Slow, then sudden spurt

Slow Variable

Pain - +/- +/-

Induration (in palate) - Hard to defined Hard to defined

Mobility(in palate) Fixed Fixed Fixed

Benign or Malignance ?

Benign and malignant tumor should be

considered

Working Diagnosis



(1) Pleomorphic adenoma



(2) Mucoepidermoid carcinoma



(3) Adenoid cystic carcinoma



(4) Polymorphous low-grade adenocarcinoma



(5) Malignant mixed tumor

Pleomorphic adenoma

Our case Pleomorphic adenoma

Gender Female Female

Age 56 30-60

Site Hard palate Parotid gland (most common)

minor gland (especially palate)

Pain （－） （－）

Ulcer （－） （－）

Consistency Firm Variable

Fluctuation Unknown unknown

Duration 3 years Many years

Rate - 45-75 %

Pleomorphic adenoma

Our case Pleomorphic adenoma

Mucoepidermoid carcinoma

Our case Ｍucoepidermoid carcinoma

Gender Female None

Age 56 10-60

Site Hard palate Parotid gland > minor gland (especially palate)

Pain （－） （－）

Ulcer （－） （－）

Consistency Firm Variable(low-grade: soft

High-grade: firm)

Fluctuation Unknown Low-grade(+)

High-grade(-)

Duration 3 years 1 year or less

Rate - 22.9 %

Mucoepidermoid carcinoma

Our case Mucoepidermoid carcinoma

Adenoid cystic carcinoma

Our case ACC

Gender Female None

Age 56 Middle-aged

Site Hard palate Minor salivary gland

Pain （－） （＋）

Ulcer （－） （－）

Consistency Firm Firm

Feature No significant finding Bone destruction

Duration 3 years Slowly growing

Rate - 6.4 %

Adenoid cystic carcinoma

Our case Adenoid cystic carcinoma

Polymorphous low-grade adenocarcinoma

Our case PLGA

Gender female 2/3 female

Age 56 70-90

Site Hard palate Minor salivary gland

Pain （－） （－）

Ulcer （－） （＋）／（－）

Consistency Firm Variable

Duration 3 years Slowly growing

Feature No significant finding Infiltrate the underlying bone

Rate - 5.1 %

Polymorphous low-grade adenocarcinoma

Our case

Polymorphous low-grade adenocarcinoma

Malignant mix tumor

Our case MMT

Gender Female Female

Age 56 Around 70

Site Hard palate 68% in Parotid gland

18% in minor salivary gland

Pain （－） ^{( + )}

Ulcer （－） ^{( + )}

Consistency Firm Firm

Duration 3 years Variable

0.4 %

Clinical Impression



Pleomorphic adenoma, left hard palate



Adenoid cystic carcinoma, left hard palate



Mucoepidermoid carcinoma, left hard palate

101.10.24

Treatment procedure



101/09/27

 Received biopsy by Dr.許 at 小港H

 H-P report : adenoid cystic carcinoma, grade 1, left hard palate



101/10/05

A swelling mass over left palate for 3 years

Arrange Bone scan and Water’s view

Treatment procedure

 101/10/05 - Water’s view

1. The calvarium is intact

2. The bony structures of the orbits and sinuses are intact

3. The bilateral maxillary sinuses are slightly cloudly

4. No nasal septal deviation is noted

5. The visible soft tissue also appears unremarkable

 Suspect bilateral maxillary sinusitis

Treatment procedure



101/10/09

 Bone scan



The hot spots over Maxillofacial bones showed abnormal

active bone lesions.

Bone scan – 101/10/09

Imaging findings :



Tc-99m MDP whole body bone scan



There are increased radioactivity in：

1. Hot spots in maxilla and mandible, which may be due to certain dental problem. However,

metastatic bone disease should be carefully ruled out.

2. Diffusely in calvarium, and slightly in L3, which may be due to certain degenerative change.

3. Mildly in bilateral shoulder, knee joints and tarsal bones, which may be due to certain arthritis.

Bone scan – 101/10/09

Impression :



Active bone lesions involving the above bony structures, especially in facial

bones.



Although the probability of local bone invasion from palate cancer to facial bones is not considerably high, and certain dental problem should be

considered first, X-ray exam & follow-up

bone scan may be recommended.

Treatment procedure



101/10/12

 CT report：Invasion to palate bone and may be extent to nasal cavity.

 Suggest surgical tx.

 Referred to Dr. 陳中和 for further treatment



101/10/24

 Arrange op at 101/10/29 下午

 Pre-operative examination

 Take Chest-PA

Treatment procedure



101/10/24 - Chest PA

1. The heart size is enlarged

2. The aorta is dilated

3. Both lungs are free of any infiltrative or active consolidative lesion

4. The hila and mediastinum are also unremarkable

5. There are spurs of the T-spine & L-spine

 Cardiomegaly

 Dilated aorta

 Spondylosis of the T-, L-spine

Treatment procedure

 101/10/29

 OP under GA with NETT

 Wide excision + Partial maxillectomy + Terudermis repair + Extraction of tooth 25 + Palatal stent fixation

Treatment procedure

 101/11/02

 Take panorex

 Remove NG tube

The panorex showed that the surgery area was extending from distal side of tooth 24 to the end of left maxilla and from the height of root apex of tooth 24 down to the top of maxillary alveolar crest. Left maxillary sinus was not involved. Besides, there were three splinting tooth 11, 16, 23 and we can also found ghost image of NG tube.

Treatment procedure

 101/11/06

 HP report : ACC, grade 2

 Microscopic invasion :

- Bone of maxilla (tumor thickness : 1.2cm)

 Perineural invasion : present

 Bone invasion : present

 Surgical margin : involved

 Frozen sections : negative of malignancy

 101/11/08

 Fever, Consult INF, Take chest PA film

Treatment procedure

 101/11/08 - Chest PA

 This study is compared with previous exam dated 101/10/24

 The lungs reveal free of active consolidation or infiltration

 The cardiac size is not enlarged

 The costophrenic angles are sharp

 The mediastinum and hila are remarkable

 The bony thorax remains unremarkable

 No radiological evidence of active cardiopulmonary disease

Treatment procedure

 101/11/09

 Consult 肝膽胰內科 for pre-CT, arrange

abdomional echo on 11/15, add silymin 1# TID for impaired liver function

 101/11/15

 Discharge

Adenoid Cystic Carcinoma

Clinical & Radiographic



Minor gland:50%~60%,palate the most



Major gland: Parotid ＝ Submandibular



Parotid gland : 2%~3%



Submandibular gland: 12%~17%



Middle age , >20 years



Male=Female

Clinical & Radiographic



Slowing growing



Pain,noticeable swelling



Constant,low-grade,dull ache



May paralysis facial nerve



Palate & maxillary sinus show bone

destruction

Clinical & Radiography



Palate & maxillary sinus show bone destruction

Histopathology



Myoepithelial cells + Ductal cells

Histopathology



3 patterns:

(1) Cribriform type:

 Basaloid epi. + multiple cylindrical → Swiss chess

 Space : Basophilic mucoid material,

hyalinized eosinophilic, mucoid-hyalinized appearance

 Cell : small, cuboidal, basophilic nuclei, little cytoplasm, rare mitotic

Histopathology

Histopathology

(2) Tubular pattern

 Small ducts or tubules within a hyalinized stroma

(2) Solid variant

 Rare duct or cyst formation

 Focal necrosis in the tumor island

Histopathology



Perineural invasion : swirling



Also seen in polymorphous low-grade adenocarcinoma



CD43,c-kit(CD117) → Positive

Treatment & Prognosis



Surgical excision , adjunct RT



Late recurrence & distant metastasis



Survival rate:

 5 years→70%

 10 years→50%

 20 years→25%



Poorest prognosis :

 Solid type / maxillary sinus / submandibular gland

Treatment & Prognosis



DNA ploidy : diploid better than aneupolid



Palate/maxillary sinus may invade base of brain



Distant metastasis : Lung & bone

醫學倫理與病人安全

• 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

醫學倫理原則

 由Tom Beauchamp & James Childress在1979提出

 自主原則(Autonomy)

 不傷害原則(Non-maleficence)

 行善原則(Beneficence)

 公義原則(Justice)

自主原則(Autonomy)

• 原則：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

不傷害原則(Non-maleficence)

• 源自希波克拉底之醫師誓約，即醫師之職責：

「最首要的是不傷害」

• 原則：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

行善原則(Beneficence)

• 原則：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

公義原則(Justice)

• 原則：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, 法律之前人人平等 (4) 先來先服務與急重症優先

臨床案例討論



該如何告知病患罹患惡性癌症，解釋病情

和說明預後?

病情告知--YES



病患本有「知」的權利



無法隱瞞：對自己的身體，每個人都有自

知之明



病情得知後，才好溝通且較願意配合醫療



病情告知後可以自行安排各種事



尊重生命：給予病人機會，能安祥地離開，

這也是一項很重要的人權



有助於往後的哀傷輔導

病情告知--NO



害怕病人精神負擔太重，病情會惡化



家屬願意負擔責任，對病患的治療有決

策權



反正病人已很嚴重，何必再告知？



告知的時機、地點不對



對告知者無信心，或告知者本身告知技

巧還不成熟

技巧



有能力且充份地評估病人與家屬各種事項：

如求醫經過、人生觀、對疾病與死亡的認知，

情緒狀態、宗教信仰、支持系統....等等



衡量告知的利弊：注意自主原則、行善原則、

及個人差異性



建立良好的信任、醫病關係



掌握合適的時機告知：做完檢查時、病人主

動詢問時



告知者該有的準備：了解病情、預知情緒變

化、接納病人的情緒及如何處理情緒變化

技巧

 何人來告知：由病人最信任的人，如主要負責照顧的

醫師，其他如親人、好友或教友

 何時來告知：掌握適當的時機，最好在病人有充份準

備時告知，而且不能告知後馬上走人，要留點時間給 病人

 何地來告知：選擇隱密性、讓病人及家屬覺得安全、

寬心且可以表達情緒的地方，如討論室、會談室 等

 如何告知病情：坐下來、專心地、目光平視、語氣委

婉，同理病人情緒反應、分辨認知問題或情緒反應；

用病人可以理解的字語來解釋；隨時觀察病人可以接 受的程度，澄清病人所了解的訊息

 告知什麼：確定病人想知道的範圍

總結



與其一味以隱瞞、扭曲、矯飾心態，不如坦

誠相對，積極賦予病人餘存生命意義，提供

改善病人生活品質的希望，這才是病情告知

的真正意涵，而掌握時機與良好溝通技巧是

病情告知的不二法門。

Thanks for your attention !!