口腔病理診斷科 CASE REPORT

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口腔病理診斷科 CASE REPORT

實習D組:李翊豪許璧伃張淳涵余舜仁郭孝緯

指導醫師:林立民教授陳玉昆主任王文岑醫師陳靜怡醫師謝牧諺醫師

2010/01/25

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G ENERAL DATA

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GENERAL DATA

• Personal Data

– Name: 簡 x 輝 – Gender: Male – Age: 77

– Native: 台灣嘉義 – Occupation: 無

– First visit: 98/12/18

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• Chief Complaint:

– Referred from 陳慶長牙醫診所 for right maxillary edentulous ridge over tooth 17

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• Present illness

– The 77 y/o male went to 陳XX LDC for oral

examination. The dentist found a dark pigmented lesion over 17 edentulous area and suggested him to come to our OPD for further examination.

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• Past Medical History

– Diabetes mellitus

– Hospitalization history (-)

– Denied any food and drug allergy

• Past Dental History

– RPD, PFM crown, Metal C&B, Endo tx.

– General dental treatment

• Attitude to dental treatment

• Cooperative

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• Personal data

– Risk factor related to malignancy

• Alcohol: (-)

• Betel nut: (-)

• Cigarette: (-)

• Other Habit: unknown

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Intraoral examination

• Size: 1.5 cm X 1.5 cm

• Surface: smooth

• Color: Dark brown to black

• Shape: Irregular

• Pain: (-)

• Tenderness: (-)

• Fluctuation: (-)

• Induration: (-)

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Intraoral examination

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Intraoral examination

• Dental findings:

– Missing teeth: 13, 17, 18, 23, 24, 25, 26, 27, 28, 31, 32, 36, 38, 41, 42, 43, 46, 47, 48

– PFM Crown: 21

– Metal C&B: 34 35 X 37 – Residual Root: 15

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X -RAY FINDING

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• No special finding over 17 edentulus area

• There is a well-defined radiolucency with an uncorticated margin extending from tooth 22 distal to left premolar edentulus area and from maxilla bone to the incisal edge of tooth 33

measuring approximately 1x2 cm.

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Dental findings:

• Missing: 18, 17, 13, 23, 24, 25, 26, 27, 28, 38, 36, 32, 31, 41, 42, 43, 46, 47, 48

• Restoration: 15 , 21 metal crown, 34 35 x 36 C&B

• Endo: 15, 21, 34, 35

• Filling: 12, 16, 22

• Elongation: 16

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• There is a surface erosion over 17 edentulous ridge

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W ORKING DIAGNOSIS

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Working Diagnosis

• Disease origin :

1. Peripheral or intra-bony origin ？

2. Inflammation or cyst or neoplasm ？ 3. Benign or malignant ？

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1. Peripheral or intra-bony origin?

–Induration : (-)

–Bony destruction : (+) –Bony expansion : (-)

Peripheral origin

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2. Inflammation, cyst or neoplasm?

• Color : black and brown

• Fever or Local heat : (-)

• Lymphadenopathy : (+)

• Pus discharge : (-)

• Duration : unknown

• Fluctuation : (-)

Neoplasm

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3. Benign or malignant neoplasm?

• Pain : (-)

• Tenderness : (-)

• Ulceration: (-)

• Induration : (-)

• Lymphadenopathy : (+)

• Bone invasion : (+)

Malignant

(

but cannot rule out benign)

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Working Diagnosis : Neoplasm

Oral Melanoma

Oral Melanotic macule

Oral Melanocytic nevus

Oral Melanoacanthoma

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D

IFFERENTIAL DIAGNOSIS

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Oral Melanoma

Mucosal Lentiginous Melanoma Our case

Sex 2/3 male Male

Race Black Asian

Age 60~80 77

Size >6mm 15x15 mm

Shape Irregular Irregular

Surface may have ulceration and bleeding Smooth

Colour Darkly pigmented Brown to black

Pain Painless (except in ulcerated type) Painless

Site 4/5 hard palate& maxillary aveolus 17 edentulus area

Consistency Soft Unknown

Base Macule to nodule (flat at early stage) Flat

X-ray finding Irregular or moth-eaten Surface erosion

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Oral Melanoma Our case

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Melanotic macule

Melanotic macule Our case

Site Lip, buccal mucosa, gingiva, palate

17 edentulus area Age Any age, 43 y/o in average 77

Sex Not specified Male

Colour Tan to dark brown Dark brown to black

Symptom Asymptomatic Asymptomatic

Size 7x7 mm or smaller 15x15 mm

Shape Round or oval Irregular

Margin Well-demarcated Well-demarcated

Growth Remains constant Unknown

X-ray Normal Surface erosion

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Our case Melanotic Macule

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Melanocytic nevus

Acquired Melanocytic Nevus (intraoral melanocytic nevus)

Our Case

Site Palate , gingiva 17 edentulous area

Size less than 6 mm 15 X 15 mm

Colour brown or black ( more than 20%

lack pigmentation)

Brown to black

Surface Smooth Smooth

Age 35 years old 77 y/o

Sex 2/3 female male

Race White > Asians or black Asians

margin Well-demarcated Well-demarcated

X-ray Normal Surface erosion

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Our case Melanocytic nevus

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Melanoacanthoma

Melanoacanthoma Our case

Age 20-40 y/o 77 y/o

Gender Female > Male Male

Symptom No symptom, but enlarge rapidly No symptom Pain: (-)

Tenderness: (-)

Site Buccal mucosa 17 palatal tuberosity

18 edentulous ridge

Colour Dark brown to black Brown to Black

Surface Smooth, flat, or slightly raised Smooth Size Occasionally reach diameter of

several centimeters

1.5 x 1.5 cm

Racial Exclusively in black Asian

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Melanocanthoma Our case

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Impression:

Malignant Melanoma

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B

^IOPSY

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• Biopsy incised over 17 edentulous area on 98.12.18

• The specimen submitted consists of 1 soft tissue fragment in 1 bag, fixed in formalin, measuring 0.6x0.4x0.2 cm in size.

• Grossly, it is whitish in color and rubbery in consistency.

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• Microscopically, it is characterized by atypical melanocytes and pigments, the melanocytes invade connective tissue and epithelium.

• These cells show pleomorphism,

hyperchromatism, and abnormal mitosis.

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• Positive stainings for S-100 and HMB-45 for tumor cells are noted.

• Based upon the above findings, it shows melanoma.

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C

^{T IMAGE}

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CT image

(coronal view)

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(axial view)

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P

OSITRON EMISSION TOMOGRAPHY

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D

^ISCUSSION

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DISCUSSION

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 Melanoma

Most in white adult,50-55 years old(30~80)

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 clinicopathologic types:

1.Superficial spreading melanoma

2.Nodular melanoma 3.Lentigo maligna melanoma

4.Acral lentiginous melanoma

 Growth pattern:

1.radial growth phase 2.vertical growth phase

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‘ ABCD’ Clinical Features of Melanoma

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 Asymmetry (uncontrolled growth pattern)

 Border irregularity

 Color variegation

(brown,black,white,red,andblue,depending on the amount and depth of melanin pigmentation)

 Diameter greater than 6 mm

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Acral lentiginous melanoma

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 Most in black

 Acral lentiginous melanoma site: plams of hands, sole of the feet,

subungual area

Mucosal lentiginous melanoma

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 Mucosal lentiginous melanoma

site: mucosal membrane, 4/5 hard

palate, maxillary alveolus sex: 2/3 male

age:60~80 years old shape: flat-->nodular-->lateral

lobulated

surface: might have ulceration pain: no pain, except in

ulcerated lesions

consistency: soft to palpation radiographic: irregular, moth eaten

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Treatment and Prognosis

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 The prognosis for oral melanoma is extremely poor.

 survival rate:

1. five years: 45% --> ten years: 28%

2. the site of mucosal“not”to influence survival

3. younger one better than older 4. non-pigmented or amelanotic lesions

- particularly poor prognosis 5. usually die from distant metastasis rather

than from lack of local control

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 Treatment:

Radical surgical removal

If lesion invades the overlying

maxillary bone --- hemimaxillectomy

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口腔病理診斷科 CASE REPORT