游雅婷 黃宣銘 郭乃嘉 陳佳伶
指導醫師: 口腔病理科全體醫師 報告日期: 2010.06.28
Name : 鄭X廷
Gender : male
Age : 26
First visit : 99.5.5
職業 : 學生
Progressive generalized swollen masses
over bilateral axilla, both sides for neck for 3 weeks.
This 26-year old man suffered from
generalized swollen lymph nodes
for the past 3 weeks. According to the patient, he first noticed swollen lymph nodes over left groin area(鼠 蹊部)which was not painful and he did not suffer from fever, leg pain nor swelling or ulcer or wound.
After that, he noticed generalized swollen
lymph nodes over both axilla, neck glands
associated swollen gingiva within the past 2 weeks. He visited 義大 hospital on
2010-4-30 and
then was admitted and undergone series of investigations and chest and abdomen CT scan were also done and showeddiffuse
lymphadenopathies(淋巴結病) over bilateral
submandibular, posterior triangle of neck,submental, axillary, left supraclavicular,
pretracheal mediastinal(氣管前縱隔), celiac(
腹腔) axis, hepatic hilum(肝門), paraaortic, mesentary(腸繫膜), pelvic(骨盆) wall and bilateral inguinal regions, consistent with
lymphoma, multiple alveolar(肺泡) nodular
densities
over bilateral lung fields, cannot rule out metastasis. He was also diagnosed as pulmonary edema and was given treatment there for 4 days.
Since the condition did not improve and he noticed subconjunctival(結膜下) swelling
over left eye
last 2 days, he requesteddischarge and then came to our hema OPD today.
He denied chest pain, palpitations(心悸), fever, chills, recent weight loss, passage of tarry stool(黑便), easy bruising(瘀血) or
hemorrhage, joint swelling in these days but he complained of easily fatiguable and
breathlessness on exertion(用力),
paroxysmal(陣發性) nocturnal(夜間性) cough without abdominal pain, burning
sensation of chest. With the tentative(暫時性) diagnosis of
malignant lymphoma, he was admitted for
further investigations and management. Medical history : 鼻中隔手術
Drug allergy : denied
Food allergy : denied
Dental history : unknown
Travel history : 目前在大陸讀書
Hepatic carcinoma
Patient Cared by 在大陸的親戚朋友
Alcohol : 偶爾喝
Smoking : 1天抽20~24支, 抽了2年
Betel nuts : nil
Body height: 165.6 cm
Body weight: 69.5 kg (no recent weight loss)
Temperature:37.4 ℃
Pressure: 99/68 mmHg
Heart rate: 75 bpm
Respiratory rate: 18 次/分
Diffuse lymphadenopathies
over bilateral submandibular, posterior triangle of neck, submental, axillary, left superaclavicular,pretracheal mediastinal, celiac axis, hepatic hilum, paraaortic, mesentary, pelvic wall and bilateral inguinal regions
Iatrogenic ecchymosis over right forearm
Reddish thread-like nodule
over left conjunctiva No facial deformity
Size: 6*3cm (main lesion)
Surface: smooth
Base: sessile
Shape: dome
Color: reddish, purple, brownish
Consistency: unknown
Fluctuation: unknown
Mobility: fixed
Pain: (-)
Tenderness: unknown
Induration: unknown
Lymphadenopathy：(+)
Loss of 11
Gingival enlargement
Bleeding easily when lightly touch
Associated teeth mobility: unknown
Chest, PA & LA
Nothing particular in heart size, great
vessels, hila, mediastinum, thoracic cage.
Multiple nodules are noted in the both lungs. Suspected
metastatic tumors or lymphomas.
Consider right
pleural effusion.
Chest, PA & LA
Nothing particular in heart size, great
vessels, hila, mediastinum, thoracic cage.
Multiple nodules are noted in the both lungs. Suspected
metastatic tumors or lymphomas.
Consider right
pleural effusion.
chest CT scan
Infiltration along the bronchovascular bundles, small nodules and patches in both lungs become
more prominent.
Enlarged lymph nodes in the submental,
bilateral mandibular, posterior cervical,
supraclavicular, hilar mediastinal regions,
mediastinum
Fluid accumulation in the right pleural space is recognized.
The heart and great vessels are unremarkable.
No focal osteolytic lesion is noted.
Chest, AP
Nothing particular in heart size, great vessels, hila, mediastinum, thoracic cage.
Multiple nodules are noted in the both lungs.
Suspected metastatic tumors or lymphomas.
Consider right pleural effusion.
Consolidation is noted in
both lungs. Suspected
superimposed infection
Oral, Pano
Right sinus is enlarged.
Missing teeth:11 38
Impaction teeth: 48
Periodontal condition:
angular bony defect of 43 44
Oral, Pano (cont.)
Missing teeth:11 38
Impaction teeth: 48
Periodontal condition:
angular bony defect of 43 44
RBC:3.67 *106 uL (<4.5~5.9)
HGB:10.2 g/dL (<14~17.5)
HCT:29.6 %
MCV:80.6 fl
MCH:27.9 Pg
MCHC:34.6 %
RDW: 14.7 %
WBC:7.9
* 103 μL (4.4~11.3)
NEUT:56%
EOSIN:6%
BASO:0.4%
LYMPH:25.1%
MONO:12.5%(>1~10)
Blast: 0 %
Promyelo: 0 %
Myelo:0 %
Meta:0 %
Band:2 %
Seg:61 %
Eosin:4 %
Mono:6 %
Lymph:20 %
Baso atypical:3%
Normobl:0%
PLT:53
*103/μL (<172~450)
PT: 11.5
INR 1.06
PTT: 28
HBs Ag: 132.87 IU/mL reactive
HBs Ab: 0.22 mIU/mL nonreactive
HBc IgG: reactive
HCV IgG: nonreactive
Bone marrow cell
Consult 血液腫瘤科
Aspiration from posterior iliac bone
Megakaryocyte: mild hyperplasia
Bone marrow blast: normal range 1.6 (0~5)
Diagnosis: nearly normal marrow
Chromosome
Done by 細胞遺傳室
Diagnosis: no chromosome abnormality
Immunophenotypic analysis
Done by 分子細胞功能實 驗室
Diagnosis: normal
distribution of bone marrow cells
Serum analysis
Suspected leukemia
Myeloid marker
CD13 : 1.3%
CD33 : 2.2%
CD15 : 26.5%
B-lineage marker
CD19 : 27%
CD20 : 26.1%
CD10 : 4.7%
T-llinage marker
CD5 : 66.2%
CD7 : 69.2%
lineage non-specific marker
HLA-DR : 52.8%
CD34 : 0.6%
CD56 : 24%
HLA-DR: 52.8%
CD10: 4.7%
CD7: 69.2%
CD19: 27%
CD33:2.2%
CD15: 26.5%
CD13: 1.3%
CD34: 0.6%
CD5: 66.2%
CD56: 24
CD20:26..1%
CD4: 13.7 (<800~1000)
CD4/CD8: 0.29 (<0.8~3)
EBV IgM(-) IgG(+)
CMV IgM(-) IgG(+)
HIV viral load: <40
HIV(-)
細菌黴菌血清學檢驗、抗酸菌直接鏡檢、寄生蟲檢
查、結核桿菌基因檢查、細菌培養:(-)
Working diagnosis
Lesion
Inflammation Cyst Neoplasm
benign malignant
Our case Inflammation Cyst Neoplasm
Color Red,
purple, brown
Red Normal Variable
Fever - + - -
Consistency Unknown Rubbery Soft Firm
Discharge - + - +/-
Pain - + - +
Ulceration + - - +
Mobility Fixed fixed Fixed Fixed
Duration 3 weeks Days Years Months
Lesion
Inflammation Cyst Neoplasm
Benign Malignant
Our case Benign Malignant Surface Rough Smooth Rough
Ulceratio
n + - +
X-ray
margin unknown Well-
defined Poor- defined Mobility Fixed Movable Fixed
LAP + - +
Duration 3 weeks Years Months
lesion
inflammation Cyst neoplasm
benign malignant
Central Peripheral
Our case Peripheral Central Consistency unknown Rubbery Firm
Ulceration + +/- +
Induration unknown + -
X-ray border unknown Ill-defined smooth Bony expansion
or perforation - + -
Mobility fixed Fixed Fixed
Peripheral or
Intrabony
Epithelial Lymphatic Hematologic Bone
SCC
Kaposi’s Sarcoma Non-Hodgkin’s
lymphoma
Leukemia
Angiosarcoma Metastatic tumor to jaw
Hodgkin’s
lymphoma
Our case SCC
Gender Male Male
Age 26 Older male
Site Upper ant. labial
gingiva B.M. and tongue
Size 6CM*3 CM variable
Base sessile sessile
Shape Dome variable
Color Reddish, purple,
brownish White, red
Surface Rough, ulceration Ulcerative
Consistency Firm firm
Pain/tenderness -/unknown +/+
Mobility - -
Induration Unknown +
LAP + +
Differential Diagnosis
Our case Kaposi’s sarcoma
Gender Male Male
Age 26 Late adult
Site Upper ant. labial
gingiva Extraoral lesion
>>hard palate
Size 6CM*3 CM Variable
Base Sessile Sessile
Shape Dome Variable
Color Reddish, purple,
brownish Red, purple, brown, or black
Surface rough Smooth
Consistency Firm Firm to hard
Pain/tenderness -/unknown -
Mobility - -
Induration unknown +
LAP + +
Differential Diagnosis
Our case Kaposi’s sarcoma Symptom/sign Persistent
generalized
lymphadenopathy
Persistent generalized lymphadenopathy,
Kaposi’s Sarcoma,
Non-Hodgkin’s lymphoma, Klebsiella pneumoniae,
Pneumocystic carinii pneumonia, Cryptococcus neoformans
Oral and esophageal Candidiasis
CD4 13.7 <200/ml
CD4/CD8 0.29 <0.59
Differential Diagnosis
Our case Non-Hodgkin’s lymphoma
Age 26 Adult
Site Upper ant. labial
gingiva Buccal vestibule, post. hard palate, gingiva, jaw
Base Sessile Sessile
Shape Dome Dome
Color Reddish, purple,
brownish Red, purple
Surface Rough + ulceration rough / ulceration
Consistency Firm Solid
Pain - +
LAP + +
Differential Diagnosis
Our case Non-Hodgkin’s lymphoma
Symptom/sign LAP LAP soft → firm
Bone expansion
Gene arrangement Normal Abnormal
Immunologic cell
surface marker normal Abnormal
Differential Diagnosis
Our case Hodgkin’s lymphoma
Age 26 15–40 and over 55
Site Upper ant. labial
gingiva Any lymph node
group
Base Sessile Sessile
Shape Dome Dome
Color Reddish, purple,
brownish
Surface Rough + ulceration smooth
Consistency Firm firm
Pain - +
LAP + +
Differential Diagnosis
Our case Non-Hodgkin’s llymphoma
Symptom/sign LAP Itching,weight
loss,fever,night sweat
Gene arrangement Noraml Abnormal
Immunologic cell
surface marker normal Abnormal
Differential Diagnosis
Our case Leukemia
Gender Male Male
Age 26 AML 20~30
Site Upper ant. labial
gingiva Gingiva
Base Sessile Sessile
Color Reddish, purple,
brownish Dark red
Surface Rough + ulceration Rough + ulceration
Differential Diagnosis
Our case Leukemia Symptom/sign Fatigue
PGLHBV infection
Fatigue, dyspnea, Perirectal infection, Hepatic infection, Oral Candidiasis
Spleen/liver size Normal enlarged
LAP + +
Blood examination RBC↓, PLT↓ 1.WBC↓, RBC↓, PLT↓
Easy bleeding + +
Immunophenotypic
analysis Peripheral異常
Bone marrow正常 Large porpotion in peripheral blood and bone marrow
Bone marrow biopsy Most normal, Hyperplasia of megakaryocyte
>20% abnormal 血球母細 胞
Differential Diagnosis
Differential Diagnosis
Our case Angiosarcoma
Gender Male No sex prediletion
Age 26 Elder
Site Upper ant. labial
Gingiva Mandible
Size 6*3 cm Variable
Base Sessile
Shape Dome Nodular
Color Reddish, purple,
brownish
Surface Rough + ulceration Ulcerative
Differential Diagnosis
Our case Metastatic tumor to jaw
Gender Male
Age 26 Elderly
Site Upper ant. labial
Gingiva Vertebrae, ribs, skull
>>mandible
parasthesia - +
Pain/tenderness -/unknown +/+
Widening of PDL - +
Angiosarcoma
Kaposi’s sarcoma
Leukemia
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
SCC
Matastasis to the jaw
Highly compatible
Low compatible
Consult OS for biopsy of gingival swelling on 99.5.8
According to Dr. 陳裕豐’s opinion, upper
anterior gingival black and reddish swelling masses were found, the same at right buccal mucosa.
But lab data of patient’s platelets is quite low(53000/μl), suggest incisional biopsy while platelets arise.
On 99.5.11
術者:陳中和 醫師
麻醉方式:局麻
99.5.18
組織名稱：Gingiva, lower
臨床診斷：Secondary and unspecified malignant neoplasm of lymph nodes of head,face,and neck.
口腔病理診斷：Angiosarcoma, compatible with
Kaposi’s sarcoma
Kaposi’s sarcoma over upper ＆ lower anterior area.
