Case report

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Case report

報告者: Intern Group D

蔡宜璋、張仁虎、黎育廷、林兆祥、

指導醫師:陳玉昆 主任 林立民 醫師

及口腔病理科全體醫師

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工作分配

General data+醫倫:張仁虎

CT:黎育廷

DD:林兆祥

Discussion:蔡宜璋

PPT製作:全體組員

報告:全體組員

統整:黎育廷 蔡宜璋

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General data

 Name : O O O

 Sex : Male

 Age : 65 y/o

 Native : 高雄市

 Marital status : married

 Attending staff : O O O

 First visit : 103/10/20

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Chief Complaint

Bleeding over L't maxilla

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Present Illness

This 65 y/o male suffered from discomfort over apical area of tooth 24~26,and bleeding over L't maxilla more than 10 days. He went to the OS dept. for treatment.

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Personal History

Past medical history

Underlying disease: (+)

hepatocellular carcinoma, T4N0M1, lung metastasis, HBV,HTN, DM

Hospitalization: (+) hepatocellular carcinoma, (96~103)

Surgery under GA: (+)

Allergy: denied:(-)

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Past Dental History

General routine dental treatment

 Attitude to dental treatment : co-operative

Risk factors related to malignancy

Alcohol:(-)

Betel quid:(-)

Cigarette:(-)

Special oral habits : denied

Irritation : denied

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Intraoral examination

 A nodule on L’t side of palatal opposed to teeth 24~26

 Size: 2.5X2.0cm

 Surface: smooth

 Consistency: soft to firm

 Color: pink

 Dome-shaped

 Sessile based

 Pain(+)

 Tenderness(-)

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Intraoral examination

 Ulcer over buccal gingiva of teeth

 Size: 0.5X0.5cm

 Surface: smooth

 Consistency: soft to firm

 Color: pink

 Pain(+)

 Tenderness(-)

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103/10/20

There is a well-defined irregular radioluence without corticated

margin over left posterior maxilla, extending from the distal side of tooth 24 to the mesial side of tooth 26 , and from the border of left maxillary sinus to the left maxillary alveolar crest of premolar area, measuring approximately 1.5x2.0 cm,It affected alveolar bone loss over 24~26.

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Image finding - Pano

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103/10/20

•Tooth missing:14,15,16,17,18,28,34,35,36,37,38,47,

•Prosthesis: 13-12-11-21-22-23-24-25,32-33X,46X48,

•filling: 31,41,43

•Endo: 11,13,21,23,25,42,45

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Image finding - Pano

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103/10/21

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Periapical film

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103/10/21

CBCT

103/10/20

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103/10/21

CBCT

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Poorly enhancing nodules in both hepatic lobe

Progression of hepatocellular carcinomas (HCCs)

in both hepatic lobe

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Multiple soft tissue nodules are noted in both lungs

multiple metastases in both lungs

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Metastases at the right 11th rib, adjacent soft tissues, adjacent

diaphragm, adjacent right

retroperitoneum and adjacent skin

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Metastases at T12 and previous pathological fracture

The height of the vertebral body of T12 is decreased.

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Suspect subsegmental atelectasis and/or fibrosis in both lungs.

The plate-like opacities are noted in both lungs.

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Cholelithiasis.

The plaque opacities are noted at gallbladder

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Athersclerosis of aorta, coronary arteries and the major branches of

aorta

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Liver cirrhosis and splenomegaly.

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Ascites

Fluid collection is noted in the peritoneal space

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Cysts in liver and left kidney

Hypodense cystic lesions are noted in the liver and left kidney.

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Spondylosis deformans of cervical spine, thoracic spine and lumbar spine

Spur is noted on the cervical spine, thoracic spine and lumbar spine

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Differential diagnosis

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Working diagnosis

Inflammation, cyst, or neoplasm?

Benign or malignant?

Intrabony or peripheral?

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Our case

• Age and gender: 65y/o, Male

• Pain(+)

• Tenderness(-)

• Swelling(+)

• Mobility: Fixed

• Consistency: soft to firm

• Destruction of bone structures(+)

• Development: Fast

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Inflammation,cyst or neoplasm

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Our case Inflammation Cyst Neoplasm

Color Pink Red Normal Variable

Fever - + - -

Consistency soft to firm Rubbery Soft Firm

Margin Irregular Irregular Regular Irregular

Discharge - + - +/-

Pain + + - +

Ulceration + - - +

Mobility Fixed Fixed Fluxuation Fixed

Duration >10 days Days Years Months

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Benign or malignant

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Our case Benign Malignant

Surface Smooth Smooth Rough

Ulceration + - +

X-ray margin Poor defined Well-defined Poor defined

Mobility Fixed Movable Fixed

Duration >10 days Years Months

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Intrabony or peripheral

Our case Intrabony Peripheral

Mucosal lesion + - +

Bone expansion - +/- -

Cortical bone

destruction + +/- -

Consistency Soft Hard Soft,firm,rubbe ry…..

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Working diagnosis

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Working Diagnosis

• 1. Metastatic Tumors

• 2. Squamous cell carcinoma

• 3. Mucoepidermoid Carcinoma

• 4. Non-Hodgkin’s Lymphoma

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Metastatic Tumors

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Factors Our case Metastatic Tumor

Age 65 Adults

Gender Male Both

Site Left Max. Post. area Jaw Bone,Oral soft tissue

Duration >10 days Growth slowly

(several months)

Color Pink Red

Shape Irregular Irregular

Surface Smooth Smooth

Mobility Fixed Fixed

Consistency Soft to firm Soft

Pain + +

Induration - -

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Squamous cell carcinoma

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Factors Our case SCC

Age 65 Increasing age

Gender Male Male

Site Left Max. Post. area 1. Buccal mucosa

2. Tongue 3. Gingiva

Duration >10 days 4~8 months

Color Pink Red/Yellow

Shape Irregular Irregular

Surface Smooth Rough

Mobility Fixed Fixed

Consistency Soft to firm Firm

Pain + -

Induration - +

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Mucoepidermoid Carcinoma

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Factors Our case Mucoepidermoid

Carcinoma

Age 65 Adults

Gender Male Both

Site Left Max. Post. area Parotid Gland

Duration >10 days Growth slowly

(several months)

Color Pink Red

Shape Irregular Irregular

Surface Smooth Smooth

Mobility Fixed Fixed

Consistency Soft to firm Soft

Pain + -

Induration - -

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Non-Hodgkin’s Lymphoma

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Factors Our case Non-Hodgkin’s Lymphoma

Age 65 Adults

Gender Male Male

Site Left Max. Post. area CNS(most) ; Oral(4%,

gingiva , tongue , palate)

Duration >10 days Growth slowly

(several months)

Color Pink Red

Shape Irregular Irregular

Surface Smooth Rough

Mobility Fixed Fixed

Consistency Soft to firm Soft

Pain + +

Induration - -

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Treatment course

103/10/20 OS

Bleeding over L't maxilla ,CBCT

103/10/21 OD

discomfort over apical area of tooth 24~26

103/10/22 OS

Incisional biopsy

103/10/23 oral- hp report:

Pathologic diagnosis:

Bone, maxilla, left, incision, hepatocellular carcinoma, metastatic

103/10/24 KMUER Fever

103/10/25~11/14 17ES Hospitalized

11/12 寎情惡化,11/14 病危自動離院〔critical AAD〕

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Discussion:

cancer metastasis to oral cavity

Metastases to jaw bones Metastases to soft tissue

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Metastases to jaw bones

Breast carcinoma

Prostate carcinoma

Lung carcinoma

Kidney carcinoma

Thyroid carcinoma

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Clinical features

Older patient

80% in mandible

Symptoms:pain,swelling,tooth mobility,mass,pareesthesia

Numb chin

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Radiographic features

Most Radiolucent

Well crcumscribed,ill-defined(moth eaten)

PDL widening

RO,mix RO-RL(breast/prostate)

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Histopathologic features

Poorly differentiated

Immunohistochemical reaction is needed

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Treatment and prognosis

Poor prognosis

Tx: excision and RT

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Metastases to oral soft tissue

Route:Batson’s plexus

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Clinical features

Site:gingiva(>50%)

Male(>40 y/o)

Nodular mass

Surface ulceration

In man:lung cancer> renal carcinoma>melanoma

In woman:breast cancer>genital

organ>lung>bone>kidney

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Histopathologic features

Resemble the tumor of origin

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Treatment and prognosis

Poor prognosis

Palliative treatment

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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):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):醫師對其病人有「以誠信相對待」的義務

3. 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。

4. 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。

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

6. 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

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行善原則

是否有減輕病人的疼痛感?或是使病人更不舒服?

→考量病人屬重症患者,面對家人擔心是meta tumor,

第一時間安排CBCT,及後續Biopsy ,減輕其焦慮。

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誠信原則

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Biopsy。

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自主原則

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?

ò→照會OD dept. 尋求 second opinion ,病人及家屬選擇並同意醫師的建議。

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不傷害原則

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

Biopsy手術過程中,是否有造成不必要的醫源性的傷害?

ò→沒有不必要醫源性傷害。

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保密原則

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

Biopsy手術的必要性?

→病人重症患者, Biopsy有助於病症診斷與後 續治療的進行,屬適當的醫療行為,符合公義 原則

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醫學倫理總結

在病例撰寫方面(病灶描述,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

更加了解放化療病患口腔照顧的重要性,一旦口腔出現病灶,

影響病人食慾,睡眠,身心健康大受影響。

安寧照護口腔照護的重要性,讓病人最後一程能好好的走。

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Reference

P.477~480,P.507~509,P.516~517,P.525~52 6,P.560~563,P.669~670 in Oral and

Maxillofacial Pathology, third edition

P.252,Wheater’s Functional Histology A Text and Colour Atlas

Diagnostic Challenge of a Deep Minor Salivary Gland Neoplasm

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THANK YOU FOR YOUR ATTENTION!

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