General data General data

Case Report Case Report

Intern E

Intern E 組 組

蔡億霖 蔡億霖 李幸芸 李幸芸 楊俊泓 楊俊泓 楊宗維 楊宗維 楊念珊 楊念珊

General data General data

„

„ Name : Name : 盧盧X XX X

„„ Sex : FemaleSex : Female

„„ Age : 70 y/oAge : 70 y/o

„„ Native :Native :高雄市高雄市

„„ Martial status : 已婚Martial status : 已婚

„„ Attending V.S.: 陳中和醫師Attending V.S.: 陳中和醫師

„„ First visit :95/09/13First visit :95/09/13

Chief Complaint Chief Complaint

„„ A swelling mass over right side of mouth floor A swelling mass over right side of mouth floor for one year, with painful sensation for 1 month for one year, with painful sensation for 1 month

Present illness Present illness

„„ A swelling mass over right side of A swelling mass over right side of

mouth floor was found one year ago mouth floor was found one year ago

and didn

and didn’’t make her uncomfortable. t make her uncomfortable.

She didn

She didn’’t go for help. t go for help.

„„ One month ago, she felt painful One month ago, she felt painful sensation of the mass, went to

sensation of the mass, went to 第一門第一門 診診 and wasand was referred her to our OPD . referred her to our OPD .

Present illness Present illness

„„ Besides, she didn’Besides, she didn’t feel uncomfortable of t feel uncomfortable of right

right submandibularsubmandibular region during meal region during meal time.

time.

„„ The patient had lost all teeth 28 years The patient had lost all teeth 28 years ago . The latest CD was fabricated at ago . The latest CD was fabricated at 苓苓 雅門診雅門診 5 years ago. When the CD was 5 years ago. When the CD was

delivered and adjusted, the patient didn delivered and adjusted, the patient didn’’t t

felt uncomfortable when wearing denture.

felt uncomfortable when wearing denture.

Past history Past history

„„

Past Medical History Past Medical History

–– Left breast cancer: operation at veterans hospital Left breast cancer: operation at veterans hospital 802H

802H 10 years ago without C/T and R/T. F/U for 3 10 years ago without C/T and R/T. F/U for 3 years.

years.

–– Stroke 2 years ago: routine medication with Stroke 2 years ago: routine medication with Aspirin

Aspirin

–– Denied any drug or food allergyDenied any drug or food allergy

„„

Past Dental History Past Dental History

–– OD, Endo, ExtractionOD, Endo, Extraction

–– Wearing CD from 42 y/oWearing CD from 42 y/o

Personal history Personal history

„„ Risk factors related to malignancyRisk factors related to malignancy

–– AlcoholAlcohol：：((--))

–– Betel quidBetel quid：：((--)) –– CigaretteCigarette：：((--))

„„ Other oral habits: avoid sour foodsOther oral habits: avoid sour foods

OMF Examination OMF Examination

„„ A swelling mass over right A swelling mass over right side of mouth floor

side of mouth floor

-- 1.5 cm x 2.5 cm1.5 cm x 2.5 cm -- RedRed

-- Mild depression of central Mild depression of central portion

portion

-- Tenderness(+)Tenderness(+) -- FirmFirm

-- fixed to underlying tissuefixed to underlying tissue

„

„ Saliva secretion of WhartonSaliva secretion of Wharton’s ’s duct: clear

duct: clear

„

„ No paresthesiaNo paresthesia of right side of right side of tongue border

of tongue border

Image finding

Image finding – – Panorex Panorex

Panorex

Panorex image finding image finding

„„ This This panorexpanorex shows edentulous alveolar ridge shows edentulous alveolar ridge with general horizontal

with general horizontal resorptionresorption, especially in , especially in maxilla (only basal bone left) and the

maxilla (only basal bone left) and the trabeculartrabecular density of maxilla decrease.

density of maxilla decrease.

„

„ There is an elevated dome shape soft tissue There is an elevated dome shape soft tissue image over

image over rr’’tt mandible, extending from the mandible, extending from the posterior

posterior ½½ of mandible body to the anterior of mandible body to the anterior region of

region of ramusramus, measuring approximately , measuring approximately 2.8cm in diameter.

2.8cm in diameter.

„„ Sinus: NPSinus: NP

„„ CondyleCondyle: NP : NP

Peripheral or

Peripheral or Intrabony Intrabony Origin Origin

„„ Bony destruction (Bony destruction (--))

„„ Mucosal lesion (+)Mucosal lesion (+)

Peripheral Origin

Inflammation, Neoplasm or Cyst Inflammation, Neoplasm or Cyst

„„ Fever or local heat (Fever or local heat (--) )

„„ Fluctuation (Fluctuation (--))

„„ LymphadenopathyLymphadenopathy ((--) / (+)) / (+)

„„ IndurationInduration ((--) )

„„ Long duration (1 year)Long duration (1 year)

Neoplasm

Benign or Malignant Benign or Malignant

„„ Pain (+)Pain (+)

„„ Tenderness (+)Tenderness (+)

„„ IndurationInduration ((--))

„„ LymphadenopathyLymphadenopathy (+)/((+)/(--))

„„ WellWell--defined margindefined margin

„„ Ulceration(+)Ulceration(+)

Benign or low grade malignant

Differential Diagnoses

Mescenchymal Metastasis Salivary gland

Fibroma Rhabdomyoma

Lipoma

Breast cancer

Mucoepidermoid ca.

Mixed tumor

Acinic cell adenocarcinoma

Teachers’ comments: We suggest the differential diagnosis should only

include malignance without considering whether it is of low-grade (this is a matter of histology). So, the malignancies of mesenchymal origin such as fibrosarcoma, rhabdomyosarcoma, etc should be considered. For salivary gland origin, PLGA, adenocystic carcinoma should be included

Working diagnosis Working diagnosis

„„ MucoepidermoidMucoepidermoid carcinoma carcinoma

„„ PleomorphicPleomorphic tumortumor

„„ AcinicAcinic cell cell adenocarcinomaadenocarcinoma

„„ FibromaFibroma

„„ RhabdomyomaRhabdomyoma

Mucoepidermoid

Mucoepidermoid carcinoma carcinoma

Our case

Our case MucoepidermoidMucoepidermoid carcinomacarcinoma

ageage 7070 20-20-7070

gender

gender ^{femalefemale femalefemale}

frequency

frequency Most common salivary gland malignanciesMost common salivary gland malignancies

sitesite L`tL`t mouth floormouth floor Parotid gland, minor salivary glandParotid gland, minor salivary gland

Growth rate

Growth rate 1 year1 year 1 year1 year

大小大小 1.5*2.51.5*2.5 < 3cm< 3cm

color

color redred Blue or redBlue or red

mobility

mobility fixed to underlying tissuefixed to underlying tissue movablemovable

painpain ++ ++

induration

induration -- --

LAPLAP -- --

P.SP.S Lower lip, floor of mouth, tongue, retromolarLower lip, floor of mouth, tongue, retromolar pad中pad中最常見的最常見的salivary tumorsalivary tumor

Mixed tumor Mixed tumor

Our case

Our case Mixed tumorMixed tumor

ageage 7070 30-30-5050

gender

gender femalefemale femalefemale frequency

frequency Most commonMost common

sitesite L`tL`t mouth floormouth floor Parotid gland, Parotid gland, submandibularsubmandibular Growth

Growth

raterate 1 year1 year Slow, months to yearsSlow, months to years consistency

consistency firmfirm firmfirm

mobility

mobility fixed to underlying fixed to underlying tissue

tissue Movable,Movable,變大變大ÆÆless mobilityless mobility

painpain ++ --

induration

induration -- --

LAPLAP -- --

Acinic

Acinic cell cell adenocarcinoma adenocarcinoma

Our case

Our case AcinicAcinic cell adenocarcinomacell adenocarcinoma

ageage 7070 20-20-7070

gender

gender femalefemale femalefemale frequency

frequency Much lessMuch less

sitesite L`tL`t mouth floormouth floor Parotid gland,Parotid gland, SubmandibularSubmandibular glandgland 速度速度 一年一年 Slow, months to yearsSlow, months to years

大小大小 1.5*2.51.5*2.5 < 3 cm< 3 cm mobility

mobility fixed to underlying tissuefixed to underlying tissue movablemovable

painpain ++ +/ +/ --

tendernes tendernes

ss ^{++ +/ +/ --}

Fibroma Fibroma

Our case

Our case fibromafibroma

ageage 7070 4040-60-60

gender

gender femalefemale femalefemale

sitesite L`tL`t mouth floormouth floor Anywhere in mouth,Anywhere in mouth, BuccalBuccal mucosamucosa Growth rate

Growth rate 一年一年 slowslow

大小大小 1.5*2.51.5*2.5 < 1.5 cm< 1.5 cm surface

surface SmoothSmooth smoothsmooth

basebase sessilesessile sessilesessile color

color redred pinkpink

consistency

consistency firmfirm firmfirm

mobility

mobility fixed to underlying tissuefixed to underlying tissue fixedfixed

painpain ++ +/ -+/ -

tenderness

tenderness ++ --

induration

induration -- --

LAPLAP -- --

Rhabdomyoma Rhabdomyoma

Our case

Our case rhabdomyomarhabdomyoma

ageage 7070 Middle-Middle-aged and older aged and older p`tp`t gender

gender femalefemale malemale

sitesite L`tL`t mouth floormouth floor Pharynx, oral cavity, laynxPharynx, oral cavity, laynx (Mouth floor, soft palate, (Mouth floor, soft palate,

base of tongue) base of tongue) consiste

consiste

ncyncy firmfirm

painpain ++ ++

Biopsy Biopsy

„„ 9/13 arrange to Oral Surgery for biopsy9/13 arrange to Oral Surgery for biopsy

„„ IncisionalIncisional biopsy was performed over right biopsy was performed over right mouth floor

mouth floor

Before going into biopsy, a clinical impression should be provided, such as Clinical impression: Mucoepidermoid carcinoma, right posterior mouth floor

ㄧ般血液檢驗

ㄧ般血液檢驗

項目項目 結果值結果值 參考標準值參考標準值 單位單位

WBCWBC 5.355.35 4.0-4.0-10.010.0 *1000/ul*1000/ul RBCRBC 3.893.89 4.0-4.0-5.55.5 *10*6*10*6次方次方//ulul

HgbHgb 12.012.0 12-12-1616 g/dlg/dl

HctHct 38.238.2 37-37-4747 %%

MCVMCV 98.298.2 79.0-79.0-101.0101.0 flfl MCHMCH 30.830.8 26.0-26.0-35.035.0 PgPg MCHCMCHC 31.431.4 31.0-31.0-37.037.0 g/dlg/dl

PLTPLT 233233 130.0-130.0-500.0500.0 *1000/ul*1000/ul NEUTNEUT 59.259.2 37.0-37.0-75.075.0 %%

EOSIN

EOSIN 1.71.7 0.0-0.0-4.04.0 %%

BASOBASO 0.40.4 0.0-0.0-1.01.0 %%

LYMPH

LYMPH 35.335.3 12.0-12.0-50.050.0 %%

MONOMONO 3.43.4 0.0-0.0-10.010.0 %%

RDW-RDW-CVCV 12.012.0 11.5-11.5-14.514.5 %% RDW-RDW-SDSD 42.942.9 36.0-36.0-46.046.0 flfl

ㄧ般生化檢驗

ㄧ般生化檢驗

項目項目 結果值結果值 參考標準值參考標準值 單位單位

Protein

Protein 7.57.5 6.0-6.0-8.38.3 gm/dlgm/dl Bil(Total

Bil(Total)) 1.561.56 0.2-0.2-1.01.0 mg/dlmg/dl GOT(AST)

GOT(AST) 1616 10-10-4242 IU/LIU/L

GPT(ALT)

GPT(ALT) 1313 10-10-4040 IU/LIU/L

ALPALP 6161 32-32-9292 IU/LIU/L

UNUN 9.19.1 7.0-7.0-18.018.0 mg/dlmg/dl Creatinine

Creatinine 0.70.7 0.6-0.6-1.31.3 mg/dlmg/dl NANA 141141 136136-145-145 mmolmmol/L/L KK 4.24.2 3.5-3.5-5.15.1 mmolmmol/L/L CLCL 109109 98-98-107107 mmolmmol/L/L

GGTGGT 1111 7-7-6464 U/LU/L

Sugar

Sugar 9191 70-70-105105 mg/dlmg/dl

Albumin

Albumin 4.234.23 3.5-3.5-5.05.0 gm/dlgm/dl A/GA/G 1.31.3 1.50-1.50-2.012.01

Image finding

Image finding – – CT of Oral CT of Oral Cavity

Cavity

„„ A focal oval homogeneous tumor (2.32cm x A focal oval homogeneous tumor (2.32cm x

1.92cm x 2.75cm) with mild ring enhancement is 1.92cm x 2.75cm) with mild ring enhancement is

found in the right aspect of the mouth floor.

found in the right aspect of the mouth floor.

„„ No regional lymph node enlargement could be No regional lymph node enlargement could be identified.

identified.

„„ The adjacent bony structure is essentially intact.The adjacent bony structure is essentially intact.

„„ The visible portion of brain parenchyma is The visible portion of brain parenchyma is unremarkable.

unremarkable.

„„ Low attenuation soft tissue component is found Low attenuation soft tissue component is found within the sphenoid sinus.

within the sphenoid sinus.

Image

Image – – CT of Oral Cavity CT of Oral Cavity

(95/09/22) (with contrast) (95/09/22) (with contrast)

Axial Coronal

Image finding

Image finding – – CT of Oral CT of Oral Cavity

Cavity

„„ Impression :Impression :

1.1. homogeneous tumor (2.32cm x homogeneous tumor (2.32cm x

1.92cm x 2.75cm) in the right aspect 1.92cm x 2.75cm) in the right aspect of mouth floor, consistent with mixed of mouth floor, consistent with mixed

tumor.

tumor.

2.2. Sphenoid sinusitis.Sphenoid sinusitis.

Image finding

Image finding – – Chest PA View Chest PA View

(95/09/22) (95/09/22)

„„ The heart size enlarged.The heart size enlarged.

„„ Atherosclerotic plaque of Atherosclerotic plaque of aorta is visualized.

aorta is visualized.

„„ Mild linear increased Mild linear increased

densities in upper lungs densities in upper lungs

are present.

are present.

„„ bony density decreased.bony density decreased.

„„ PeribronchialPeribronchial thickening thickening at lower lungs are also at lower lungs are also

present.

present.

„„ ThoracolumbarThoracolumbar spurs.spurs.

Image finding

Image finding – – Chest PA View Chest PA View

(95/09/22) (95/09/22)

„„ Impression :Impression :

1.1. CardiomegalyCardiomegaly and atherosclerosis of and atherosclerosis of aorta.

aorta.

2.2. Suspect chronic bronchitis in lower Suspect chronic bronchitis in lower lungs.

lungs.

3.3. Mild Mild postinflammatorypostinflammatory fibrosis at upper fibrosis at upper lobes.

lobes.

4.4. ThoracolumbarThoracolumbar degenerative degenerative spondylosis

spondylosis..

Image finding

Image finding – – Skull PA, Lat and Skull PA, Lat and Waters' Views

Waters' Views

„„ Mild mucosal thickening at bilateral maxillary Mild mucosal thickening at bilateral maxillary sinuses is identified.

sinuses is identified.

„

„ Mild nasal Mild nasal septalseptal deviation is also present.deviation is also present.

„„ The nasal The nasal turbinatesturbinates are prominent.are prominent.

„

„ The The calvariumcalvarium appears intact.appears intact.

„„ There is teeth defect.There is teeth defect.

Image finding

Image finding – – Skull PA, Lat Skull PA, Lat and Waters' Views

and Waters' Views

„„

Impression : Impression :

1. 1. R/O chronic rhinitis and mild R/O chronic rhinitis and mild maxillary sinusitis.

maxillary sinusitis.

2. 2. Nasal Nasal septal septal deviation. deviation.

Biopsy Biopsy

„„ 9/28 arrange to Oral Surgery for wide 9/28 arrange to Oral Surgery for wide excision

excision

„„ Wide excision was performed over right Wide excision was performed over right mouth floor

mouth floor

Thanks for your attention !

Thanks for your attention !