報告日期: 103.02.25

(1)

指導醫師：陳玉昆醫師暨口腔病理科全體醫師

報告者: Intern G組陳俊男、詹淨、王雅羽、李姿瑩 報告日期: 103.02.25

(2)

• Name : OOO

• Sex : Female

• Age : 16 y/o

• Native : 高雄市

• Marital status : 未婚

• Attending V.S. : OOO 醫師

• First visit : 102/11/20

2

(3)

 Ask for treatment of a swelling mass over the L’t hard palate since 102/9 , which was noted by LDC , who suggested her to our OPD

3

(4)

This 16 y/o female had a swelling mass over the L’t palate since 102/09, which was noted by a LDC dentist, who referred her to KMUH for

further examination. In 102/11/20, she first went to KMUH OS. Dept. for examination and she

said she had pathology examination in OOH.

Therefore, she made an appointment in

102/11/27, and the pathology result showed benign salivary gland. In 103/1/8, GA routine was arranged, and OP arranged on 103/01/23.

4

(5)



Size: 2 x 2 cm



Color: Pinkish



Surface: Smooth



Shape: Dome shaped



Consistency: Firm



Pain (-)



Tenderness (-)



Induration (-)



Ulceration (-)



MMO: > 40 mm

₅

(6)

 Past Medical History



Underlying disease: (-)



Hospitalization: (+), fever when 2 y/o



Surgery under GA: (-)



Allergy: (-)

 Past Dental History



General routine dental treatment

 Attitude to dental treatment: co-operative

6

(7)

 Risk factors related to malignancy



Alcohol: (-)



Betel quid: (-)



Cigarette: (-)



Special oral habits: Denied

 Irritation: Denied

7

(8)

 No obviously bony lesion was noted.

102/11/20

8

102/11/20

(9)

 No obviously bony lesion was noted.

102/11/20

9

(10)

Salivary gland origin lesions 10

(11)



Age & gender: 16 y/o, female



Pain: (-)



Tenderness: (-)



Mobility: Fixed



Consistency: Firm



Ulceration: (-)



Swelling: (+)



Destruction of bone structures: (-)



Development: Slow-growing

(12)

→ Cyst or neoplasm

This case Inflammation Cyst Neoplasm

Color Pinkish Red Yellow or

white Variable

Fever or local heat - + - -

Consistency Firm Firm/rubbery Rubbery Variable Duration Months days to months years Months to

years Mobility Fixed (in

palate) Fixed (in palate) Fixed (in

palate) Fixed (in palate)

Pain - + -/+ -/+

Ulceration - - -/+ -

(13)

→ Benign tumor or low-grade malignancy

This case Benign Malignance

Progressive Unknown Slow Variable

Swelling with intact epithelium

+ + -

Pain - +/- +/-

Induration - - +

Mobility Fixed Fixed Fixed

Lymphadenopathy No data - +

(14)

Minor salivary gland origin lesions 14

(15)

1) Pleomorphic adenoma

2) Mucoepidermoid carcinoma, low grade

3) Adenoid cystic carcinoma

4) Polymorphous low-grade adenocarcinoma

5) Malignant mixed tumor

(16)

Pleomorphic adenoma Our case Age & gender all ages, but common in

30~60 y/o; F:M=2:1 16 y/o Site Parotid gland (most common);

minor gland (especially palate)

✔

Pain Painless ✔

Consistency Variable Firm

Progressive & duration Slow; many years Unknown Other feature Firm single nodular

Rate: 45~75%

(17)

 Pleomorphic adenoma ^ Our case

(18)

Mucoepidermoid carcinoma Our case Age & gender 10~60 y/o; slight male ✔

Site Parotid gland > minor gland (especially palate)

✔

Pain Painless in early stage ✔

Consistency Firm or hard ✔

Progressive & duration Slow; 1 year or less Unknown Other feature Fluctuation: low-grade(+),

high-grade(-) Rate: 22.9%

(19)

 Mucoepidermoid carcinoma ^ Our case

(20)

Adenoid cystic carcinoma Our case Age & gender Middle-aged; equal in gender 16 y/o Site minor gland (especially palate) ✔

Pain Painless, but sometimes

painful or tenderness painless

Consistency Firm ✔

Progressive & duration Slow Unknown Other feature Bone destruction

Rate: 6.4%

(21)

 Adenoid cystic carcinoma ^ Our case

(22)

PLGA Our case Age & gender Middle-aged; equal in gender 16 y/o Site minor gland (especially palate) ✔

Pain Painless ✔

Consistency Variable Firm

Progressive & duration Slow Unknown Other feature Ulceration: + / -

Infiltrate the underlying bone Rate: 5.1%

(23)

 Polymorphous low-grade

adenocarcinoma ^ Our case

(24)

Malignant mixed tumor Our case Age & gender average age 60 years, but

also children, teenagers;

female

16 y/o

Site 68% in Parotid gland, 18% in minor salivary gland

✔

Pain Painful or facial paralysis painless

Consistency Firm ✔

Progressive & duration Variable Unknown Other feature Associated with pleomorphic

adenomas: 2% risk of

malignant transformation if present < 5 years, 10% risk if 15 years

Rate: 0.4%

(25)

 Pleomorphic adenoma, left hard palate

25

(26)

26

(27)

 102/11/20



First went to OS. dept. for mass over L’t palate



Wait for pathology report done by OOO Hospital

27

(28)

 102/11/27



Came for explanation of pathology report



Pathology report showed benign salivary gland tumor

 103/1/8



Arranged GA routine



Operation of WE scheduled on 103/01/08

28

(29)

 103/01/08

 Impression：

 No imaging evidence of active cardiopulmonary disease.

29

(30)

 103/01/08

 Impression:

 Sinus Arrhythmia

 RAD

30

(31)

 103/01/23

 OP under GA with NETT

 Wide excision + terudermis + palatal stent

103/1/23 ³¹

(32)

 103/01/29

 H-P report: pleomorphic adenoma, L’t hard palate

 Remove stitches and local debridement

 103/02/05

 Check wound and medical certificate x 3 張

(33)

Discussion

(34)

Salivary gland tumor (WTO)

1. Adenoma

2. Carcinoma

3. Non-epithelial tumor

4. Malignant lymphomas

5. Secondary tumor

6. Unclassified tumor

7. Tumor-like lesions

(35)

Salivary gland tumor

2/3 to 3/4 of all salivary gland tumors(SGTs) occur in the parotid gland.

2/3 to 3/4 of all parotid gland tumors are benign.

 9 ％-23％ occur in minor salivary gland

(36)

Minor salivary gland

Benign 及 malignant 發生率約各佔一半

The most common benign tumor in minor SG is pleomorphic adenoma (about 40%)

(37)

Minor salivary gland

The most common tumor location in minor SG is palate (50%),lateral post hard or soft palate

The most common palatal SGT is pleomorphic adenoma (40-50%)

(38)

Pleomorphic adenoma (benign mixed tumor)

1. Entirely of epithelial origin, has a prominent mesenchyme-appearing “stromal” component

2. Mixture of ductal and myoepithelial elements

3. A painless, slowly growing, firm mass

4. Any age, most common in young and middle- aged adults (30 – 60y/o), a little female

predilection

5. In parotid: most in the superficial lobe overlying the ramus in front of the ear

6. Movable initially

(39)

In minor salivary gland:

palate (50%),

upper lip (27 %),

buccal mucosa (17 %)

Pleomorphic adenoma over lateral post hard palate

Pleomorphic adenoma

over pterygomandibular area

(40)

Histopathologic features

Well-circumscribed, round to ovoid massed with smooth surfaces, encapsulated tumor

Incomplete encapsulation is more common in minor SG tumors.

Glandular and myoepithelial cells within a mesenchyme-like background

Pleomorphic adenoma

Well-circumscribed, encapsulated tumor

Duct-like structure and myxomatous background

(41)

Chondroid material

Myoepithelial cells and duct like structure

hyalinization

Plasmacytoid Myoepithelial cells: plasmacytoid, angular, spindled



Stromal changes:

•Myxomatous

•Chondroid (vacuolar degeneration)

•Myxomatous

•Hyalinization

(42)

 Tumors composed entirely or almost exclusively of myoepithelial cells with no ductal element, call myoepithelioma, having a similar biologic behavior to mixed tumor.

Treatment and prognosis

 Surgical excision

 Conservative enucleation often results in recurrence

 5% malignant transformation (carcinoma ex pleomorphic adenoma)

(43)

(44)

INTRODUCTION

 Pleomorphic adenoma (PA) is the most common tumor (60%) of major and minor salivary glands

 Nearly 70% of the tumors of minor salivary glands are Pas

 Most common intraoral site is the palate, followed by upper lip and buccal mucosa

 More likely to be malignant when associated with minor salivary glands (50%)

(45)

CASE REPORT

 A 45-year-old female presented with a slow growing swelling, of approximately 20 years duration involving her hard and soft

palate junction on the left side, which was peanut sized when she first observed. The lesion always had been asymptomatic, with no associated pain or paresthesia.

(46)

Medical history

 Patient's medical history was noncontributory.

 No known allergies and had not undergone any surgeries of head and neck.

 General physical examination revealed a well oriented and

moderately built individual with no signs of any systemic illness.

(47)

clinical examination

 A nonulcerated, dome-shaped, palatal swelling on her hard and soft palate junction, crossing the midline.

 Patient presented a typical ‘hot potato in mouth’ speech.

 No complaints of pharyngeal or

airway obstruction.

(48)

Image Finding-MRI

 A well-defined, multilobulated mass measuring 3.2 × 5.5 × 6.3 cm (AP × TR × CC) with

multiple well-defined areas.

 The mass had well-enhanced soft tissue density without any invasion to adjacent tissues, displacing posterior third of the tongue downward

(49)

Operation

(50)

(51)

Post-OP MRI

(52)

DISCUSSION

 PA of minor salivary gland is most common in palate (10%), followed by lip (4%).

 Unusual sites are sinuses, larynx epiglottis, and trachea, also reported in tongue, soft palate, uvula, and even external auditory canal

 malignant transformation is documented to be 1.9-23.3%.

 The primary goal of excision should be complete removal of mass without risking recurrence.

(53)

(54)

•

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

→ patientcentered model

(55)

 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。

 誠信原則(Veractity)：

– 醫師對其病人有「以誠信相對待」的義務。

 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。

 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。

 保密原則(Confidentiality):

– 醫師對病人的病情負有保密的責任。

 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。

(56)

1. 病人發現病灶=> 地方診所就診 => 轉診至阮綜合 => 轉診至高醫

是否因為轉診而造成診斷延遲

轉診是否可以讓病人獲得較好的治療

2. 初診日期為102.11.20，而至103.01.08 才排定在 103.01.23 OP 處理病人的問題

是否因為間隔時間較長而拖延到治療時間

(57)

1. 病人就診過程之中有轉診至數間醫院

是否因為耗費較多時間在各個醫院轉診過程之中，而造成病灶較慢被診斷？

 病人的病灶已經持續一段時間，若沒有突然急遽的變化應該對診斷影響不大

病人由門診轉至地區醫院再轉至教學醫院，是否可以因此獲得較精確的診斷與較好的治療？

 病人應該可以藉由轉診獲得專科醫師較專業的建議與比較完整的治療評估

(58)

2. 初診日期和實際手術時間相差2個月

間隔時間較長，是否可能影響到病人的治療及預後？

 病人在初診之前一個星期的檢驗報告為良性，雖然良性mix tumor是有5%的機會轉成惡性，只要沒有突然加速加劇的變化，基本上變差的機率較低，不過建議還是要盡快的處理為佳

(59)

 在本案例中病人尚未成年，在手術同意書簽署方面遇到不同狀況時我們應該怎麼做？不同的作法又和醫學倫理以及法律層面有何相關？

(60)

病人本身害怕手術，不願意進行手術，但父母親同意進行並且簽署同意書，那是否要進行手術呢？

(61)

以病人本身的意見為主，若病人感到害怕且不願意進行手術，即使家屬已簽署手術同意書，亦不進行手術。



遵照自主原則(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。



遵照不傷害原則(Nonmaleficence)



醫師要盡其所能避免病人承受不必要的身心傷

害。



違反行善原則(Beneficence)



醫師要盡其所能延長病人之生命且減輕病人之痛

苦。

(62)

家屬支持進行手術並且簽署同意書後，即使病人本身不願意，仍進行手術治療



遵照行善原則(Beneficence)



醫師要盡其所能延長病人之生命且減輕病人之

痛苦。



違反自主原則(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。



違反不傷害原則(Nonmaleficence)

