報告者： Intern Group A 指導醫師：陳玉昆 主任 林立民 醫師
及口腔病理科全體醫師
General data+醫倫：蕭博元
DD：楊秉倫、陳育苹
Disscussion：郭俊成
PPT製作：全體組員
報告：全體組員
統整：楊秉倫
Name: 郭O O
Sex: Male
Age: 73 y/o
Native: 高雄市
Marital status: Married
Attending staff: O O O
First visit: 103/05/28
Referred from ENT Dept. due to a mass over R’t palatal area by self-palapation found in 103/05/10
This 73 y/o male found a mass over R’t hard
palatal area by self-palapation in 103/05/10 and went to ENT dept. for treatment. He received a
biopsy at 103/5/19 and the H-P report’s diagnosis was odontogenic tumor. Therefore, ENT Dr
referred the P’t to OS for further treatment
103/05/10
• A mass over R’t hard palate was found 103/05/19 ENT
• Received a biopsy
• H-P report: squamous odontogenic tumor , ameloblastoma 103/05/28 OS
• Referred from ENT for treatment. 由於病人目前剛接受心臟手術2
個月,且有服用抗凝血劑,建議6個月後再考慮手術,並要求協助複
製O O醫院病歷資料提供全身麻醉以及手術過程參考。
• Panorex taking
103/07/05
病人與兒子帶來O O醫院心臟科醫師的評估報告,證明藥物
coumadin 已停止使用 (from103/06/26~now)
Patient found the mass was growing up and asked for OP arrangement
Arrange OP(WE+ stent fixation +Terudermis) on 103/7/18
GA routine
Past medical history
Underlying disease (+)
HTN, valvular heart disease and severe aortic root dilatation
Hospitalization (+) aortic valve replacement 、
coronary revascularization、 ascending aortic reconstruction (103/03)
Surgery under GA (+)
Allergy: Denied
Past Dental History
General routine dental treatment
Attitude to dental treatment : co-operative
Risk factors related to malignancy
Alcohol drinking: (-)
Betel quid chewing: (-)
Cigarette smoking: (+)
Special oral habits: Denied
Irritation: Denied
Facial asymmertry (+)
MMO=55mm
A nodule on R’t side of palatal opposed to teeth 25,26,27
Size: 2.5X2.0cm
Surface: Smooth
Consistency: Soft to firm
Color: Pink
Dome-shaped
Sessile based
Pain (-)
Tenderness (-)
Central erosive surface
(biopsy site:0.3 x 0.3cm) 103/07/05
11
103/05/28
• Tooth missing: 34,46
• Prosthesis: 45X47, 33X35 36
• Restoration: 13, 14, 15, 22
There is a homogeneous, well enhanced soft tissue lesion at the right hard palate.The neck anatomical spaces are essentially clear and preserved.
The trachea is patent without foreign body.
The bony structure is intact.
No regional lymph node enlargement could be identified
Impression:
A soft tissue tumor at the right hard palate without bony erosion.
(pathology: odontogenic tumor)
Impression:
1) Cardiomegaly
2) Atherosclerosis of tortuous and dilated aorta 3) Thoracolumbar spondylosis
4) S/P sternotomy and cardiac valve replacement
竇性心博過緩
Working Diagnosis
Intrabony or peripheral?
Inflammation, cyst, or neoplasm?
Benign or malignant?
Our case Intrabony Peripheral
Mucosal lesion + - +
Bone expansion - +/- -
Cortical bone
destruction - +/- -
Consistency Firm Hard Soft, firm,
rubbery…..
→Our case is a peripheral lesion
Our case Inflammation Neoplasm
Regress or progress Progress Regress Progress
Symptom - + +/-
Growth rate Months, years Hours, days, weeks Weeks, months, years
Lymph node
enlarge - + +/-
Tenderness - + -
Fluctuation - + -
→Our case is not an inflammation, but a neoplasm.
Our case Benign Malignant
Boreder Well defined Well defined Poor defined
Destruction of
cortical margin - - +
Pain - - +
Induration - - +
Swelling with intact
epithelium + + -
Progress Slow Slow Fast
Metastasis Unknown - +
Lymphadenopathy - - +
Lesion could be come from
1.
Epithelium (surface deffirentiation→X)
2.
Blood vessel (redness,young→X)
3. Connective tissue
4. Minor salivary gland
5. Nerve
Differential diagnosis
Our case Pleomorphic adenoma
Age 73 y/o 30~60 y/o X
Gender M Slight F V
Site Hard palate 50% minor salivary
gland,hard palate V
Surface Smooth Smooth V
Shape Sessile, dome-shape
Sessile,
Dome-shape V
Symptom Painless Painless V
Tenderness Soft to firm Firm V
Our case Fibroma
Age 73 y/o 40~60 y/o X
Gender M M V
Site Hard palate Buccal mucosa,
anywhere V
Surface Smooth Smooth V
Shape Sessile, dome-shape
Sessile, Nodule
V X
Symptom Painless Painless V
Tenderness Soft to firm Firm V
Color Pink Pink V
Our case
Palisaded encapsulated
neuroma
Age 73 y/o 50~70 y/o X
Gender M - V
Site Hard palate Palate V
Surface Smooth Smooth V
Shape Sessile,
dome-shape Nodule X
Symptom Painless Painless V
Tenderness Soft to firm Firm V
Our case Oral focal muconosis
Age 73 y/o Young age X
Gender M F X
Site Hard palate 1st Gingiva (3/4)
2nd Hard palate V
Surface Smooth Smooth V
Shape Sessile, Dome-shape
Sessile, Nodule
V X
Symptom Painless Painless V
Tenderness Soft to firm Unknown X
Pleomorphic adenoma,
right hard palate
Surgery
1. Routine patient identification check and time out
2. Patient was put in supine position, GA with NETT intubation
3. Routine aseptic and OMS draping procedures were done
4. Prophylactic antibiotic: Cefazolin(1g) 1 vial + Aq- dest 20 ml IV was injected.
5. Throat pack in and OP started
6. Excision of right palate soft tissue tumor
Surgery
7. Copious N/S and antibiotic irrigation (Cefazolin(1g) 1 vial + Aq-dest 20 ml)
8. Palatal stent try-in and adjustment
9. Terudermis(2.5x2.5) repair, suture with vicryl 4-0
10. Soft-liner dressing,compression with palatal stent
11. Palatal stent fixation with #24 wire over tooth 15,17,24,26
12. Copious N/S irrigation
13. Throat pack out and OP ended.
Pre-OP Post-OP
臨床診斷： Benign neoplasm Pathologic diagnosis:
Oral cavity, hard palate, right, excision, pleomorphic adenoma Gross Examination:
The specimen submitted consists of 1 soft tissue fragment in 1 bag, measuring 3.0 x 2.0 x 1.2 cm in size,
in fresh state. Grossly, it is white brown in color and firm in consistency.
All for section. Jar 0.
Microscopic Examination:
The slide contains two identical groups of irregular-shaped soft tissue specimens.
Microscopically, it shows pleomorphic adenoma.
103/7/26
Wound condition: stable
Explained H-P report
Reinforce home care 103/8/2
Wound condition: stable
Local treatment with remove palatal stent
Reinforce home care
Case Report
Diagnostic Challenge of a Deep Minor Salivary Gland Neoplasm
Wagner VP et al., Case Reports in Otolaryngology 2014; 608267
Salivary gland tumors
unusual oral conditions that generated considerable interest due to their heterogeneous histology, grade of malignancy, and clinical behavior.
Accurate preoperative diagnosis
adequate treatment and open biopsy followed by
histopathological analysis
Fine-needle aspiration cytology (FNAC) and Core needle biopsy (CNB) have gained
widespread popularity for tissue sampling in order to achieve a definitive diagnosis as they both represent less invasive and inexpensive techniques
Fine-needle aspiration cytology (FNAC)
21- to 27-gauge needles
Safer and less traumatic
clusters of cells
High false negative rate
Difficulty to diagnosis (cytopathologist)
Core needle biopsy (CNB)
14- to 17-gauge needles
Safer and less traumatic
Automated biopsy gun
Pieces of tissue
High accuracy
A 60-year-old Caucasian female patient
presented with a painless swelling in the soft palate, breathing and swallowing difficulties, and suffocation feeling.
Clinical examination revealed that the lesion was located mostly in the right side, extending from the limit between the hard and soft palate and continuing to the oropharynx
Clinical and imaging aspects- a hypothesis of
benign X malignant salivary gland tumor
Incisional biopsy and histopathological examination is - normal mucosa
otorhinolaryngologist team was consulted and the decision was made to perform a CNB.
The histopathological analysis of the sample revealed pleomorphic adenoma
Salivary gland tumors - most heterogeneous
and usually misdiagnosed
salivary gland malignancy- increases in inverse
proportion to the size of the gland Unlike major salivary gland tumors, the majority of minor salivary gland tumors are malignant
Open biosy CNB FNAC
Advantage Gold standard to diagnosis
Cheaper ,
high accurate , can use in deep lesion
Cheaper,
can use in cystic content
Disadvantage Difficulty in deep lesion expensive
Difficulties in cystic content and small lesion (less than 1cm)
Less accurate
In major salivary glands, open biopsy is no longer justified due to the
1. High risk of tumor seeding
2. Facial nerve injury
3. Facial scarring
4. Fistula formation
Capacity of supplying a specific diagnose in head and neck tumors
The study showed that CNB of salivary gland lesions
(only major salivary gland)
CNB FNAC
Correct accuracy 90% 66%
True salivary glands neoplasms
Malignancy in salivary glands
Positive predictive
100% 98%
Open biopsy remains the gold standard for minor salivary gland lesions
However, the purpose for the diagnosis of tumors situated in greater depth of tissues.
CNB represents a safe technique and at the present case was able to supply a correct
diagnose, confirmed in the surgical specimen.
1. 生命的神聖性(Sanctity of life)：
2. 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。
3. 誠信原則(Veractity):醫師對其病人有「以誠信相對待」的義務。
4. 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。
5. 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。
6. 保密原則(Confidentiality):醫師對病人的病情負有保密的責任。
7. 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。
做了Excision 後是否有減輕病人的疼痛感？
或是使病人更不舒服？
→有完整去除病灶區域並拍照記錄術後情形。
並告知術後傷口會疼痛，但持續癒合後疼痛 會逐漸緩解
對於患者的疾病嚴重程度是否有確實地通知，
盡到告知的義務？
是否有清楚的向病人說明清楚疾病病程、治
療計畫、預後、風險？
→皆以已告知病人後，經同意才進行手術。
充分說明病情及治療計畫、風險之後，是否 有讓病人充分自主地選擇治療計畫？
→病人及家屬選擇並同意醫師的建議。
在做全身麻醉以前，是否有說明完整之後再
請病人自主的簽名同意？
→已充分說明並與家屬溝通。
是否有先完整瞭解病人的病史?
→治療前有完整蒐集病史資料，並與病患溝 通後擬定進一步的治療計畫
手術過程中，是否有造成不必要的醫源性的
傷害？
→沒有不必要醫源性傷害。
告知的對象 1. 本人為原則
2. 病人未明示反對時，亦得告知其配偶與親屬 3. 病人為未成年人時，亦須告知其法定代理人 4. 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
5. 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
手術的必要性？
→pleomorphic adenoma最佳的治療方式 是sugical excision，將病灶完整的清除
(enucleation)才能將復發率(recurrence rate) 降到最低。
在病例撰寫方面(病兆描述,治療計畫,病人態 度)應書寫詳盡， 使治療過程有詳實的記錄及 治療順利。
在進行治療之前,須請病人簽屬同意書
應在不違反醫學倫理的原則之下進行治療的
行為
P.477~480, 507~509, 516~517, 525~526 in Oral and Maxillofacial Pathology, third edition
P. 252, Wheater’s Functional Histology A Text and Colour Atlas
