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General data

• Name: 陳XX

• Chart no.: 1xxxxxx4

• Gender: Female

• Age: 58 y/o

• Native origin: 屏東

• Martial status: 已婚

• Attending doctor: 吳崇維

• First visit: 101.04.11

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Chief complaint

• A swelling over L’t posterior mandible for 1 week

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Present illness

• This 58 y/o female accepted periodontal tx at 署屏Hospital for several months. Last week, the dentist found out that there is a swelling mass over L’t posterior mandible, and

suggested her to come to our OPD for further examination. On 101.04.11, she came to our OPD for examination and tx

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Medical and dental history

Past Medical History

– Hospitalization: (-) – Surgery under GA: (-) – Hypertension(+)

• Not under medical control

• 140-150mmHg on 101.04.11

– Denied any food or drug allergies

Past Dental History

– General routine dental treatment

Attitude towards dental treatment: co-operative

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Medical and dental history

• Risk factor related to malignancy – Alcohol:(-)

– Betel quid: (-) – Cigarette: (-)

• Special oral habits : Denied

• Bite irritation : Denied

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Dental examination

• Missing: Tooth 16, 18, 26, 27, 28, 36, 37, 46

• Crown and bridge: 15x17, 25, 34, 35xx38, 45x47

• Caries: Nil

• Calculus: Generalized deposition

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Intraoral findings

• Size: 0.7 x 0.5 cm

• Color: pink

• Surface: smooth

• Base: sessile

• Shape: dome

• Consistency: rubbery

• Fluctuation: (-)

• Mobility: fixed

• Pain: (-)

• Tenderness: (-)

• Paresthesia: (-, lip tongue)

101.05.02

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Radiographic Examination

There is a well-defined multilocular irregular shaped radiolucence with corticated margin, contains fine radiopaque except superior border over left posterior

mandibular area . The lesion extends from the distal root of tooth 38 up to half of left ramus area, and from left retromolar area down to mandibular body, measuring about 3.0 x 2.0 cm in diameter. The lesion suspect involved to mandibular canal.

101/04/11

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Radiographic Examination

There is a well-defined multilocular irregular shaped radiolucence with corticated margin, contains fine radiopaque except superior border over left posterior

mandibular area . The lesion extends from the distal root of tooth 38 up to half of left ramus area, and from left retromolar area down to mandibular body, measuring about 3.0 x 2.0 cm in diameter. The lesion suspect involved to mandibular canal.

101/05/23

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CT report

• Image finding:

– There is a marked artifact from dental prosthesis.

– The oral cavity cannot be well evaluated in this study.

– There is a suspicious soft tissue nodule at the left retromolar area.

– An indentation at adjacent mandible is present.

• Impression:

– Suspect a soft tissue nodule at the left retromolar

area with bony indentation.

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Inflammation, cyst or neoplasm?

Our case Inflammation Cyst Neoplasm

Color Pink Red Normal Variable

Fever - + - -

Consistency Rubbery Rubbery Soft Variable

Discharge - + - +/-

Pain + + - +/-

Duration weeks Days Years Months

Cyst or neoplasm

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Benign or malignant?

Our case Benign Malignant

Surface Smooth Smooth Rough

Ulceration - - +

X-ray margin Well-defined Well-defined Poor-defined

LAP - - +

Duration week Years Months

Benign

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Peripheral or intrabony?

Our case Peripheral Intrabony

Consistency Rubbery Rubbery Firm

X-ray margin Well-defined Poor-defined Well-defined Bony destruction or

expansion

+ - +

Intrabony

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Working diagnosis

Intrabony benign tumor or cyst

Benign Tumor

Odontogenic

• Calcifying Epithelial Odontogenic Tumor(CEOT), Pindborg Tumor

• Adenomatoid Odontogenic Tumor

• Ameloblastic Fibroodontonma

• Ameloblastoma (Desmoplastic)

Cyst

• Calcifying Odontogenic Cyst (Gorlin Cyst)

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Working diagnosis

• The List(more possible → less)

1. Calcifying Epithelial Odontogenic Tumor (CEOT), Pindborg Tumor

2. Calcifying Odontogenic Cyst (Gorlin Cyst) 3. Adenomatoid Odontogenic Tumor

4. Ameloblastic Fibroodontonma

5. Ameloblastoma

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Calcifying Epithelial Odontogenic Tumor(CEOT), Pindborg Tumor

• Etiology

– A tumor of odontogenic origin – Arises possibly from

• Dental lamina remnants

• Statum intermedium of enamel organ

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Calcifying Epithelial Odontogenic Tumor(CEOT), Pindborg Tumor

Our case CEOT

Gender Female Both

Age 50 y/o 30-50 y/o

Site Right retromolar area Most on posterior mandible(57%) Symptom/Sign Swelling and pain Slow-growing swelling

Painless

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Calcifying Epithelial Odontogenic Tumor(CEOT), Pindborg Tumor

Radiographic features Our case CEOT

Density R/O + R/L R/O + R/L

Border Well-defined with

corticated margin

Well-defined

20% corticated margin (20% Ill-defined)

Scalloped

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Ameloblastic Fibroodontonma

• Etiology

– Mixed odontogenic tumor

• Epithelial (enamel) and Mesenchymal tissue (dentin , pulp) inductive

– Arises possibly from

• Dental papilla , immature fibrous tissue

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Ameloblastic Fibroodontonma

Our case Ameloblastic

Fibroodontonma

Gender Female none

Age 50 y/o 10 y/o

Site Right retromolar area Mandible posterior (54%) Symptom/Sign Swelling and pain Asymptomatic and painless

swelling of the affected bone in large lesion

Effect Bony destruction and

expansion

(23)

Ameloblastic Fibroodontonma

Radiographic features Our case Ameloblastic

Fibroodontonma

Density R/O + R/L R/O + R/L

Border Well-defined with

corticated margin

Well-defined circumscribed RL

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Ameloblastoma

• Etiology

– A tumor of odontogenic epithelium

• Ameloblastoma (Desmoplastic type)

– Dense fibrous stroma

– Radiographic features : R/L+R/O

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Our case Ameloblastoma (Desmoplastic type)

Gender Female Both

Age 50 y/o 20~70 y/o

Site Right retromolar area Anterior maxilla Symptom/Sign Swelling and pain Rare pain or parethesia

Ameloblastoma

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Ameloblastoma

Radiographic features Our case Ameloblastoma (Desmoplastic type)

Density R/L+R/O R/L+R/O

(Dense fibrous septa) Border Well-defined with

corticated margin

Scalloped, well-defined, well-corticated

(27)

Calcifying Odontogenic Cyst (Gorlin Cyst)

• Etiology

– uncommon lesion among odontogenic cysts

• Clinical behavior

– Variable, some were regarded as neoplasms (infiltrative or malignant)

– May be associated with AOT or ameloblastoma

(28)

Calcifying Odontogenic Cyst (Gorlin Cyst)

Our case Calcifying Odontogenic Cyst (Gorlin Cyst)

Gender Female No predominant

Age 50 y/o Diagnosed between 20-

30y/o, average 33 y/o Site Right retromolar area Most on Incisors and

Canine areas (65%)

Symptom/Sign Swelling and pain Unspecific

(29)

Radiographic Features Our case Calcifying Odontogenic Cyst(Gorlin Cyst)

Density R/L + R/O R/L + R/O

Border Well-defined with corticated margin

Well-defined

Calcifying Odontogenic Cyst

(Gorlin Cyst)

(30)

Adenomatoid Odontogenic Tumor

• Etiology

– Uncommon lesion among odontogenic cysts

• Clinical behavior

– Variable, some were regarded as neoplasms (infiltrative or malignant)

– May be associated with AOT or ameloblastoma

(31)

Adenomatoid Odontogenic Tumor

Our case AOT

Gender Female Both , male : female 2:1

Age 50 y/o 10~20 y/o

Site Right retromolar area Most on lower Incisors and upper Canine

areas(53%)

Symptom/Sign Swelling and pain Asymtomatic swelling

(32)

Radiographic Features Our case AOT

Density R/L + R/O R/L + R/O

Border Well-defined with corticated margin

Well-defined

Adenomatoid Odontogenic Tumor

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Clinical Impression

• Calcifying Epithelial Odontogenic Tumor (CEOT), Left mandible

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Histological Pathologic Report

• Pathological diagnosis:

– Bone, mandible, left, retromolar,incision, calcifying epithelial odontogenic tumor, clear type

• Gross Examination :

– The specimen submitted consisted of 2 soft tissue fragments in 1 bottle, measuring up to 0.7 x 0.4 x 0.2 cm, fixed in formalin. Grossly, they are brown in color and rubbery in consistency

送檢時間:101/05/03 報告時間:101/05/09 送檢醫師:吳崇維醫師

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• Microscopic Examination :

– Microscopically, it is characterized by clusters of

round ,clear or faintly eosinophilic cell together with sheets, or strands of pleomorphic, slightly eosinophilic epithelial cells within a connective tissue stroma. Also homogeneous hyaline areas suggestive of amyloid-like materials are seen.

– Immunohistochemical staining of pan-keratin :

• clear cell (+) ,epithelial tumor cells (+) .

• PAS (-) ,PASD (-) , mucicarmine stain (-) .

• Based upon the above finding, it shows calcifying

epithelial odontogenic tumor, clear cell type.

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TREATMENT PLAN

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Treatment procedure

• 101.04.11

– Pano finding: Mild radiolucent image over 37 distal side, size 1.2x1.8 cm

– Imp: Odontogenic tumor, left mandible – Arrange CT exam and check BUN/Cr

• 101.05.02

– CT Imp(101.04.25):

Suspect a soft tissue nodule over left retromolar area with bony indentation

– Incisional biopsy

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Treatment procedure

• 101.05.09

– HP report:

Calcifying epithelial odontogenic tumor (clear cell type), left retromolar region of mandible, bone

Special stain :

• Congo red: (+)

• Mucin stain/ PAS /PASD: (-)

– Arrange OP on 101.06.01

―OP: Excision+ Bone trimming + 37 & 48 extraction

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Treatment plan

• It was originally believed that CEOT had about the same biologic behavior as the

ameloblastoma.

– Experience indicated that is tends to be less aggrssive.

• Tx.: concervation local resection to include a narrow rim of surrounding bone appears to be the treatment of choice.

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醫學倫理討論

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Tom Beauchamp &James Childress 六大原則- 1979

1. 行善原則(Beneficence),亦即醫師要盡其所能延長病人之 生命且減輕病人之痛苦。

2. 誠信原則(Veractity),亦即醫師對其病人有「以誠信相對 待」的義務。

3. 自主原則(Autonomy),亦即病患對其己身之診療決定的自 主權必須得到醫師的尊重。

4. 不傷害原則(Nonmaleficence),亦即醫師要盡其所能避免 病人承受不必要的身心傷害。

5. 保密原則(Confidentiality),亦即醫師對病人的病情負有保 密的責任。

6. 公義原則(Justice),亦即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。

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行善原則(Beneficence)

• 手術的介入對於陳女士來說是否是一個較 佳的治療方式?

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誠信原則(Veractity)

• 醫師對於陳女士是否有以誠信相對待?

• 病況與治療的急迫性?

• 治療方式(excision. resection )?預後?風險?後 續的治療?

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自主原則(Autonomy)

• 在說明清楚病情,各種治療方式及其預後與 風險之後,是否有讓陳女士自主選擇所要的 治療方式?

• 手術同意書與麻醉同意書一式兩份,由醫

療機構人員先行完成「基本資料」之填寫。

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不傷害原則(Nonmaleficence)

• 在治療(手術)的過程應與陳女士同意的治療 方式相符合,醫師須盡自己所能減量減少對 於病人的傷害

• 另外在詳細說病情時也不應給予病人過多 的心理壓力

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保密原則(Confidentiality)

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

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公義原則(Justice)

• 合理分配醫療資源 1. 手術的必要性?

2. 藥物的需求是否合理?

3. 住院的時間?

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醫學倫理總結

• 在病例方面(病兆描述,治療計畫,病人態度) 應書寫詳盡

• 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

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