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杭御戎
4 years ago
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1 Case Report Intern E 組蔡億霖李幸芸楊俊泓楊宗維楊念珊

2 General data Name : 盧 X X Sex : Female Age : 70 y/o Native : 高雄市 Martial status : 已婚 Attending V.S.: 陳中和醫師 First visit :95/09/13

3 Chief Complaint A swelling mass over right side of mouth floor for one year, with painful sensation for 1 month

4 Present illness A swelling mass over right side of mouth floor was found one year ago and didn t t make her uncomfortable. She didn t t go for help. One month ago, she felt painful sensation of the mass, went to 第一門診 and was referred her to our OPD.

5 Present illness Besides, she didn t t feel uncomfortable of right submandibular region during meal time. The patient had lost all teeth 28 years ago. The latest CD was fabricated at 苓雅門診 5 years ago. When the CD was delivered and adjusted, the patient didn t felt uncomfortable when wearing denture.

6 Past history Past Medical History Left breast cancer: operation at veterans hospital 802H 10 years ago without C/T and R/T. F/U for 3 years. Stroke 2 years ago: routine medication with Aspirin Denied any drug or food allergy Past Dental History OD, Endo, Extraction Wearing CD from 42 y/o

7 Personal history Risk factors related to malignancy Alcohol:(-) Betel quid:(-) Cigarette:(-) Other oral habits: avoid sour foods

OMF Examination A swelling mass over right side of mouth floor - 1.5 cm x 2.

8 OMF Examination A swelling mass over right side of mouth floor cm x 2.5 cm - Red - Mild depression of central portion - Tenderness(+) - Firm - fixed to underlying tissue Saliva secretion of Wharton s duct: clear No paresthesia of right side of tongue border

9 Image finding Panorex (95/09/13)

10 Panorex image finding This panorex shows edentulous alveolar ridge with general horizontal resorption,, especially in maxilla (only basal bone left) and the trabecular density of maxilla decrease. There is an elevated dome shape soft tissue image over r t mandible, extending from the posterior ½ of mandible body to the anterior region of ramus,, measuring approximately 2.8cm in diameter. Sinus: NP Condyle: : NP

11 Peripheral or Intrabony Origin Bony destruction (-)( Mucosal lesion (+) Peripheral Origin

12 Inflammation, Neoplasm or Cyst Fever or local heat (-)( Fluctuation (-)( Lymphadenopathy (-)) / (+) Induration (-) Long duration (1 year) Neoplasm

13 Benign or Malignant Pain (+) Tenderness (+) Induration (-) Lymphadenopathy (+)/(-) Well-defined margin Ulceration(+) Benign or low grade malignant

14 Differential Diagnoses Mescenchymal Metastasis Salivary gland Fibroma Rhabdomyoma Lipoma Breast cancer Mucoepidermoid ca. Mixed tumor Acinic cell adenocarcinoma Teachers comments: We suggest the differential diagnosis should only include malignance without considering whether it is of low-grade (this is a matter of histology). So, the malignancies of mesenchymal origin such as fibrosarcoma, rhabdomyosarcoma, etc should be considered. For salivary gland origin, PLGA, adenocystic carcinoma should be included

15 Working diagnosis Mucoepidermoid carcinoma Pleomorphic tumor Acinic cell adenocarcinoma Fibroma Rhabdomyoma

16 Mucoepidermoid carcinoma Our case Mucoepidermoid carcinoma age gender female female frequency Most common salivary gland malignancies site Growth rate L`t mouth floor Parotid gland, minor salivary gland 1 year 1 year 大小 1.5*2.5 < 3cm color mobility red fixed to underlying tissue Blue or red movable pain + + induration - - LAP - - P.S Lower lip, floor of mouth, tongue, retromolar pad 中最常見的 salivary tumor

17 Mixed tumor Our case Mixed tumor age gender female female frequency Most common site Growth rate consistency mobility L`t mouth floor Parotid gland, submandibular 1 year Slow, months to years firm fixed to underlying tissue firm Movable, 變大 less mobility pain + - induration - - LAP - -

18 Acinic cell adenocarcinoma Our case Acinic cell adenocarcinoma age gender female female frequency Much less site 速度 L`t mouth floor 一年 Parotid gland, Submandibular gland Slow, months to years 大小 1.5*2.5 < 3 cm mobility fixed to underlying tissue movable pain + +/ - tendernes s + +/ -

19 Fibroma Our case fibroma age gender site Growth rate female L`t mouth floor 一年 female Anywhere in mouth, Buccal mucosa slow 大小 1.5*2.5 < 1.5 cm surface Smooth smooth base sessile sessile color consistency mobility red firm fixed to underlying tissue pink firm fixed pain + +/ - tenderness + - induration - - LAP - -

20 Rhabdomyoma Our case rhabdomyoma age 70 Middle-aged and older p`t gender site consiste ncy female L`t mouth floor firm male Pharynx, oral cavity, laynx (Mouth floor, soft palate, base of tongue) pain + +

21 Biopsy 9/13 arrange to Oral Surgery for biopsy Incisional biopsy was performed over right mouth floor Before going into biopsy, a clinical impression should be provided, such as Clinical impression: Mucoepidermoid carcinoma, right posterior mouth floor

22 ㄧ般血液檢驗 (95/9/20) 項目結果值參考標準值單位 WBC *1000/ul RBC *10*6 次方 /ul Hgb g/dl Hct % MCV fl MCH Pg MCHC g/dl PLT *1000/ul NEUT % EOSIN % BASO % LYMPH % MONO % RDW-CV % RDW-SD fl

23 ㄧ般生化檢驗 (95/9/20) 項目結果值參考標準值單位 Protein gm/dl Bil(Total) mg/dl GOT(AST) IU/L GPT(ALT) IU/L ALP IU/L UN mg/dl Creatinine mg/dl NA mmol/l K mmol/l CL mmol/l GGT U/L Sugar mg/dl Albumin gm/dl A/G

24 Image finding CT of Oral Cavity (95/09/22) A focal oval homogeneous tumor (2.32cm x 1.92cm x 2.75cm) with mild ring enhancement is found in the right aspect of the mouth floor. No regional lymph node enlargement could be identified. The adjacent bony structure is essentially intact. The visible portion of brain parenchyma is unremarkable. Low attenuation soft tissue component is found within the sphenoid sinus.

25 Image CT of Oral Cavity (95/09/22) (with contrast) Axial Coronal

26 Image finding CT of Oral Cavity (95/09/22) Impression : 1. homogeneous tumor (2.32cm x 1.92cm x 2.75cm) in the right aspect of mouth floor, consistent with mixed tumor. 2. Sphenoid sinusitis.

27 Image finding Chest PA View (95/09/22) The heart size enlarged. Atherosclerotic plaque of aorta is visualized. Mild linear increased densities in upper lungs are present. bony density decreased. Peribronchial thickening at lower lungs are also present. Thoracolumbar spurs.

28 Image finding Chest PA View (95/09/22) Impression : 1. Cardiomegaly and atherosclerosis of aorta. 2. Suspect chronic bronchitis in lower lungs. 3. Mild postinflammatory fibrosis at upper lobes. 4. Thoracolumbar degenerative spondylosis.

29 Image finding Skull PA, Lat and Waters' Views (95/09/23) Mild mucosal thickening at bilateral maxillary sinuses is identified. Mild nasal septal deviation is also present. The nasal turbinates are prominent. The calvarium appears intact. There is teeth defect.

30 Image finding Skull PA, Lat and Waters' Views (95/09/23) Impression : 1. R/O chronic rhinitis and mild maxillary sinusitis. 2. Nasal septal deviation.

31 Biopsy 9/28 arrange to Oral Surgery for wide excision Wide excision was performed over right mouth floor

32 Thanks for your attention!

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投影片 1 指導老師 : 林立民陳玉昆王文岑陳靜怡醫師報告者 :Intern G 組張啟源鄧聖霖戴宇昀何盈興 General Data Name : 蔡昇峰 Gender : male Age : 23 Native : Taiwan Occupation : 勞工 Attending V.S. : 王文岑醫師 First visit :2007/02/14 Chief Complaint Pain