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
1
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
3
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
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
11Image finding - Pano
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
Poorly enhancing nodules in both hepatic lobe
Progression of hepatocellular carcinomas (HCCs)
in both hepatic lobe
Multiple soft tissue nodules are noted in both lungs
multiple metastases in both lungs
Metastases at the right 11th rib, adjacent soft tissues, adjacent
diaphragm, adjacent right
retroperitoneum and adjacent skin
Metastases at T12 and previous pathological fracture
The height of the vertebral body of T12 is decreased.
Suspect subsegmental atelectasis and/or fibrosis in both lungs.
The plate-like opacities are noted in both lungs.
Cholelithiasis.
The plaque opacities are noted at gallbladder
Athersclerosis of aorta, coronary arteries and the major branches of
aorta
Liver cirrhosis and splenomegaly.
Ascites
Fluid collection is noted in the peritoneal space
Cysts in liver and left kidney
Hypodense cystic lesions are noted in the liver and left kidney.
Spondylosis deformans of cervical spine, thoracic spine and lumbar spine
Spur is noted on the cervical spine, thoracic spine and lumbar spine
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
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
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 - -
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 - +
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 - -
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 - -
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
Metastases to jaw bones
Breast carcinoma
Prostate carcinoma
Lung carcinoma
Kidney carcinoma
Thyroid carcinoma
Clinical features
Older patient
80% in mandible
Symptoms:pain,swelling,tooth mobility,mass,pareesthesia
Numb chin
Radiographic features
Most Radiolucent
Well crcumscribed,ill-defined(moth eaten)
PDL widening
RO,mix RO-RL(breast/prostate)
Histopathologic features
Poorly differentiated
Immunohistochemical reaction is needed
Treatment and prognosis
Poor prognosis
Tx: excision and RT
Metastases to oral soft tissue
Route:Batson’s plexus
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
Histopathologic features
Resemble the tumor of origin
Treatment and prognosis
Poor prognosis
Palliative treatment
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
55
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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