Case Report

(1)

Case Report

Intern B組嚴崇文廖翊伶郭明樹陳依涵吳詠霞

指導老師陳玉昆醫師暨口腔病理科全體醫師

101/10/29

(2)

General data

Name:葉ＯＯ Sex:Female Age:58 y/o

Native:高雄市

Marital status:Married

Attending V.S.:陳中和醫師 First visit:101/10/03

(3)

Chief complaint

Swelling over upper left canine area about 2+ months

101/10/03

101/10/27

(4)

Present Illness

101/10/03

Refered from LDC for swelling mass over L’t canine space then received incisional biopsy

(5)

Past History

Past Medical History

Underlying disease : denied Hospitalization(+)

盲腸,結紮

Surgery under GA (+) : as above Drug allergies : denied

Past Dental History

Routine dental treatment

Attitude to dental treatment : cooperative

(6)

Personal History

Risk factor related to malignancy Alcohol:(-)

Betel nut : (-) Cigarette : (-)

special oral habits : Denied Irritation factor: Denied

(7)

OMF Examination

Size: 3cm x 1.5cm Color: whitish

Mobility: fixed Surface: smooth Pain (+)

Tenderness (+) Induration (+) LAP (-)

(8)

Image Finding (Panorex)

101/10/03

There is a ill defined unilocular irregular radiolucency without a cortical margin extending from the distal

side of tooth 28 to the apical of tooth 23 and invading the floor of the maxillary sinus, measuring

approximately 3.5X0.7cm.

(9)

Image Finding (Panorex)

101/10/03

Missing:teeth 27 Mesial tilting: 35

Restoration:11,21,38,37,47,48

(10)

CT(101/10/03)

• Impression：

• 1) An expansile soft tissue mass in left maxillary sinus with

• erosion over adjacent sinus walls and alveolar

process

• with invasion of right nasal cavity and soft palate.

Sinus

•

carcinoma could not be excluded.

• 2) No evidence of enlarged cervical adenopathy.

• 3) AJCC preliminary cancer staging: III (T3N0Mx).

• 4) Small bilateral submandibular and internal jugular l h d

( 1 )

(11)

Bone Scan

Impression：

•

(1) High probability of local bone invasion from maxillary

•

sinus cancer to the maxilla with low probability of distant bone metastasis.

• (2) X-ray exam & follow-up bone scan may be

• recommended.

(12)

Chest PA(101/10/17)

Impression：

Status post insertion of endotracheal tube and right subclavian line.

Suspect nipple shadows in the bilateral lower chest.

Mild spondylosis deformans of the L-spine.

•

(13)

Differential Diagnosis

(14)

Peripheral / intrabony

Size: 3cm x 1.5cm Color: whitish

Mobility: fixed Surface: smooth Pain (+)

Tenderness (+) fluctuation(+) Induration (+) LAP (-)

(15)

Peripheral / intrabony

CT:

An expansile soft tissue mass in left maxillary sinus with erosion over adjacent sinus walls and alveolar process

size:47.2x 39.2x 39.8 mm

Intrabony Lesion

(16)

Peripheral / intrabony

our case peripheral intrabony

mucosal lesion - + -

induration + + -

bony expansion + - ＋-

cotical bone

destruction + - + -

intrabony

(17)

Inflammation/Cyst/Neoplasm

our case inflammation

redness - +

swelling + +

local heat ? +

pain + +

(18)

Cyst/Neoplasm

our case Non-inflammation Cyst

Fluctuation + +

Well defined border - +

Bone expansion ＋ +

progression fast slow

sclerotic margin - +

(19)

Neoplasm

our case Benign Malignancy Border ill-defined well-defined ill-defined

Margin irregular smooth Irregular

Sclerotic margin - + -

Destruction of cortical

margin + + - +

Progressive fast slow fast

Swelling with intact

epithelium + + -

pain + - +

Induration + - +

Malignancy

(20)

Working Diagnosis

Osteosarcoma

Mixed tumor carcinosarcoma

Ewing’s sarcoma

(21)

our case Osteosarc- oma

Chondrosarc- oma

Ewing’s sarcoma

Age 58

10-20 Or older

than 50

Older than

50 20+

Sex predilection F M M/F

M Site and prevalance

Buccal mucosa

(Maxilla)

Maxilla or

Mandible Maxilla Mandible>

Maxilla Radiographic findings RL

RO or mixed

or RL

Mixed RL and

RO

Margins Ill-defined Ill-defined Ill-defined Ill-defined Border irregular irregular irregular irregular

Swelling

+

+ ^-

+

pain + + ⁺ +

(22)

Diagnosis

Left maxillary carcinoma,suggestive of neuroendocrine , ycT4a N0 M0 stage IV

(23)

Discussion

What is neuroendocrine carcinoma?

(24)

Neuroendocrine carcinoma

Neoplasms arise from cells of the endocrine &

nervous systems

Many NE tumors are benign,while some are malignant

Most commonly occur in intestine,lung,rest of the body

Many kinds of NETs , treated as a group of tissue cells of these neoplasms share common features special secretory granules/producing biogenic

amines & polypeptide hormones

(25)

Neuroendocrine system

Arise from various neuroendocrine cells NE cells are present in endocrine glands

throughout the body produce hormones , diffused in all body tissue.

(26)

History

1907

small intestinal neuroendocrine tumors were first distinguished from other tumors

named carcinoid tumors

slow growth was considered to be “cancer-like”

rather than truly cancerous 1938

some of these tumors could be malignant

(27)

Incidence

2.5~5 per 100000

2/3 carcinoid tumors ; 1/3 other NETs

(28)

WHO classification

well-differentiated NETs

benign tumor

with uncertain behavior

well-differentiated(low grade) NE carcinomas

Poorly differentiated(high grade) NE carcinomas

(29)

WHO classification

Depends on size

lymphovascular invasion mitotic counts

invasion of adjacent organs presence of metastases

whether produce hormones

(30)

Diagnosis-Imaging

CT-scans

95% of tumor > 3cm

generally not tumor < 1cm MRIs

sonography(ultrasound)

endoscopy(including endoscopic ultrasound)

Molecular imaging

(31)

Treatment

Symptomatic relief Surgery

CCRT

Hepatic artery

(32)

(33)

(34)

(35)

Treatment Plan

Frozen section

hemimaxillectomy

101/10/03 101/10/27

(36)

醫學倫理與全人照護

(37)

醫學倫理與全人照護

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)

(38)

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)

(39)

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

(40)

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

(41)

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

(42)

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

(43)

臨床案例討論

病人已了解自己的病狀 ,治療方法(f/u ,手術) 復發的可能性,併發症

•

自主原則(Autonomy)

(44)

臨床案例討論

預10/22行左胸動脈導管｀有胸靜脈導管植入，麻醉照會已完成，因上排牙齒搖晃建議照會牙科，經牙科醫師評估無需固定

行善原則(Beneficence): 預防傷害：應該預防傷害或惡行, 移除傷害：應該移除傷害或惡行

不傷害原則(Non-maleficence)

(45)

最後，整個治療過程不只是關心到病人的身體上的病狀，也包含病人生活上的品質與心理上的照顧，完美無缺的達到了全人照顧的要素

(46)

總述

經過執行的Treatment course可檢討到:

• 讓病人了解症狀的嚴重性，並持續的f/u，可能會減

少到手術範圍

(47)

Case Report

Case Report

Intern B組 嚴崇文 廖翊伶 郭明樹 陳依涵 吳詠霞

指導老師 陳玉昆 醫師暨口腔病理科全體醫師

101/10/29

General data

Chief complaint

101/10/03

101/10/27

Present Illness

Past History

Personal History

OMF Examination

Image Finding (Panorex)

Image Finding (Panorex)

CT(101/10/03)

process

Sinus

carcinoma could not be excluded.

( 1 )

Bone Scan

Impression：

(1) High probability of local bone invasion from maxillary

sinus cancer to the maxilla with low probability of distant bone metastasis.

Chest PA(101/10/17)

Impression：

Status post insertion of endotracheal tube and right subclavian line.

Suspect nipple shadows in the bilateral lower chest.

Mild spondylosis deformans of the L-spine.

Differential Diagnosis

Peripheral / intrabony

Peripheral / intrabony

CT:

size:47.2x 39.2x 39.8 mm

Intrabony Lesion

Peripheral / intrabony

our case peripheral intrabony

mucosal lesion - + -

induration + + -

bony expansion + - ＋-

cotical bone

destruction + - + -

intrabony

Inflammation/Cyst/Neoplasm

our case inflammation

redness - +

swelling + +

local heat ? +

pain + +

Cyst/Neoplasm

our case Non-inflammation Cyst

Fluctuation + +

Well defined border - +

Bone expansion ＋ +

progression fast slow

sclerotic margin - +

Neoplasm

our case Benign Malignancy Border ill-defined well-defined ill-defined

Margin irregular smooth Irregular

Sclerotic margin - + -

Destruction of cortical

margin + + - +

Progressive fast slow fast

Swelling with intact

epithelium + + -

pain + - +

Induration + - +

Malignancy

Working Diagnosis

Osteosarcoma

Mixed tumor carcinosarcoma

Ewing’s sarcoma

Age 58

10-20 Or older

than 50

Older than

50 20+

Sex predilection F M M/F

M Site and prevalance

Maxilla or

Intern B組嚴崇文廖翊伶郭明樹陳依涵吳詠霞

指導老師陳玉昆醫師暨口腔病理科全體醫師

+ ^-

pain + + ⁺ +