口腔紅色病變 口腔診斷學 Oral Red Lesions 陳玉昆副教授: 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw

學 習 目 標 明白病歷書寫的方式 瞭解病歷書寫的原理 知道其中的應用

參考資料 References: Kaohsiung Medical University, Oral Pathology Department 自購網路資源：super_toolcool

Extraoral Examination 臨床檢查及病歷書寫應包括 General Data Chief Complaint Present Illness Extraoral Examination

Intraoral Examination 臨床檢查及病歷書寫應包括 Intraoral Examination Past Medical History Past Dental History Personal Habits

Radiographic & imaging examinations 視個別病例可能還包括 Radiographic & imaging examinations Laboratory tests Biopsy

General Data 年齡 籍貫 性別 職業 姓名 病人的基本資料 病歷號碼 首次就診日期

Chief Complaint 病人自己所描述的主訴 可以是以完整的句子寫下來 也可以是以鑰詞的方式記錄 e.g. a reddish ulceration over the right soft palate e.g. a reddish ulceration Chief complaint可視為 一篇敘述文的題目 Ref. 1

Present Illness 全部有關病人主訴的病史 按照發生的順序詳細紀載 否則會文不對題 Intraoral examination Extraoral examination Ref. 2

Past Medical History Past Dental History 所有有關病人過去的醫療病史 如 DM, HT, AIDS, Hepatitis… etc. Past Dental History 有關病人過去的牙科醫療病史 如 OD, Endo, extraction… etc.

Personal Habits 有關病人的不良習慣 如 抽煙, 咀嚼檳榔, 喝酒…… etc. How many bottles per day? Refs. 1, 2 How many grains per day? How many packages per day?

Radiographic & imaging examinations 有關病人的影像攝影 如 Pano, CT, MRI, US, PET,.. etc. Positron emission tomography Ref. 1

Laboratory tests Biopsy 有關病人的實驗室檢查 如 blood routine, AKP, Ca2+ … etc. 有關病人的組織學檢查 如 incisional/excisional/cytology … etc.

General Data Name: 蔡xx Chart no.: xxxxxxxx Sex: 女 Age: 38 y/o Native: 台灣屏東 Occupation: 家管 First visit: 92.7.29 Ref. 1

Chief Complaint Delayed healing of extraction wound of tooth 37 for about 3 weeks Ref. 1

Present Illness (1) The 38 y/o female suffered from 37 toothache since the end of June, 2003 The LDC dentist diagnosed her symptoms as periodontitis and no other abnormal mucosal lesion was noted Subsequently, prosthetic crown of 37 was removed to perform endodontic tx. Unfortunately the symptoms/signs were still persisted

Present Illness (2) 92.7.10, tooth 37 was extracted at another LDC due to severe pain Till 92.7.28, the post extraction wound remained unhealed Her dentist referred her to visit our OPD for further examination

Extraoral Examination A firm swelling mass over L’t face about 4x4 cm in diameter Numbness of left lower lip A palpable fixed, firm lymph node in L’t submandibular region No fever or local hyperemia is noted Ref. 1

Intraoral Examination (1) Tooth 37 extraction wound Ulcerative unhealed extraction wound with red & white appearance, sessile, firm, fixed and painful The adjacent mucosa seemed to be normal. Dimension : 1 cm x 1cm Induration (－) Ref. 1

Intraoral Examination (2) Dental findings: Missing teeth : 28、36、37、38、46、48 C&B : 11、12、21、22、23 45x47 33

Past Medical History Denied OP/hospitalization history Denied any allergies Denied any systemic diseases

Past Dental History OD Extraction RCT Prosthesis

Personal Habits Alcohol drinking (－) Betel-quid chewing (－) Cigarette smoking (－) Denied other specific oral habits

Radiographic Examinations (1) Rationale for X-ray taking 臨床檢查顯然存在一個underlying intrabony lesion Panorex Occlusal view (mesial-disal dimension) (buccal-lingual dimension)

Panoramic Film (1) Panorex showed an ill-defined radiolucency with ragged, irregular border, approximately 3.0x2.5cm in diameter over the left mandible body area Ref. 1

Panoramic Film (2) Extending from L’t superior alveolar ridge down to the inferior border of mandible, & from edentulous 37 area posterior to ramus & angle The loss of cortical outline of ID canal is noted Ref. 1

Occlusal Film It showed destruction of lingual and buccal cortical plates without bony expansion Ref. 1

Radiographic Examinations (2) Necessary for CT taking 臨床檢查除了存在一個underlying intrabony lesion, 還有submandibular area的soft tissue involvement

Axial CT Scan (1) CT scan showed destruction of lingual & buccal cortical plates Ref. 1

Axial CT Scan (2) An enlarged lymph node is noted in the L’t submandibular area Ref. 1

Differential Diagnosis 思考方向 臨床檢查發現 病人過去病史 影像檢查發現 Ref. 2

Inflammation or Neoplasm? Fever or local heat (－) No purulent drainage was presented Destruction of lingual and buccal cortical plates without expansion Neoplasm

Malignant Benign or Malignant? Pain (＋) Tenderness (＋) Lymphadenopathy (＋) Numbness of left lower lip Ill-defined radiolucency with ragged, irregular border Destruction of lingual and buccal cortical plates without expansion Malignant

Peripheral or Intrabony origin? Adjacent mucosa seems normal appearance Induration (－) Intrabony ,,,,, Ref. 1

Working Diagnosis Intrabony malignant tumor Epithelial originCentral SCC Fibrous originFibrosarcoma Bone originOsteosarcoma Lymphatic origin Central lymphoma Metastatic tumors in jawbone 由最有可能開始 由最不可能開始

Central SCC Higher compatible ~ Md/30~80 y/o /molars region Surface epithelium appeared normal in appearance (before tooth extraction) Most often irregular ill-defined radiolucency Border shows osseous destruction and varying degree of extension Less compatible ~ Male

Fibrosarcoma Higher compatible ~ Male : Female = 1:1 Mean age 4th decade MandiblePremolar and molars area Painful enlarging mass Overlying mucosa : normal

Fibrosarcoma Higher compatible ~ Less compatible ~ Ragged, noncorticated, ill-defined, entirely radiolucency, with little internal structure Destruction of inferior border of the jaw and cortices of the neurovascular canal are lost Paresthesia Periosteal reaction is uncommon Less compatible ~ Usually entirely radiolucency

Osteosarcoma Higher compatible ~ Less compatible ~ Typically occur in 4th decade Mandible, tooth-bearing area Swelling, pain, tenderness, ulceration Ill-defined radiolucency with little internal structure Destruction of the neurovascular canal and inferior border of the mandible Less compatible ~ Male :Female  2:1 Lymph node involvement is rare

Central lymphoma Higher compatible ~ Less compatible ~ Occur in all age groups but is rare in the 1st decade Md (posterior area) Pain, lymphadenopathy, sensorineural deficits Radiolucency with ill-defined border Destruction of cortex of the neurovascular canal Less compatible ~ The lesion occurring outside lymph node in head & neck are present in as much as 1/5

Metastatic tumor in jaw Higher compatible ~ Usually situated deep in the bone 70% in mandible--Premolar and molars area Slight predilection for female (3:1) Solitary, poorly defined radiolucency Usually erodes rather than expands the adjacent cortical plates Less compatible ~ There was no systemic symptom to suggest a primary tumor elsewhere (although there could been occult primary tumor)

Clinical Impression Intrabony malignant tumor over left mandible body, ramus and angle areas

Biopsy 92 / 7 / 29 ＊Refer to O.S. Dept. for incisional biopsy ＊Submitted superficial & deep specimens for H-P exam 92 / 8 / 5 ＊Recall for H-P report

H-P Report 低倍 高倍 Ref. 1

Final Diagnosis Congratulations, you are correct Central Squamous Cell Carcinoma, Left mandible Congratulations, you are correct

Treatment Plan Refer to oncology dept. for chemotherapy ( I.A.) then come back for OP If lesion enlarged OP immediately

Treatment Course (1) 92 / 08 / 12 ~ Admission 92 / 08 / 14 ~ Arterial system with port implantation 92 / 08 / 15 ~ Started one course chemotherapy with MTX

Treatment Course (2) 92 / 08 / 23 ~ Discharge with stable condition ~ Continue chemotherapy at home with MTX 92 / 09 / 19 ~ Lab. data WBC：6.9 × 103 / L Hb：12.1 g / dl PLT：2.68 × 105 / ul

Discussion

Central SCC Definition Arising from intraosseous remnants of odontogenic epithelium Ariji et al. ,1994  malignant transformation of the epithelial component of an existing odontogenic tumor  the epithelial lining of an odontogenic cyst  residues of epithelium after tooth development

Central SCC WHO classified into two groups:  those arising in the intrabony cysts  primary carcinoma, presumably started from the residues of the dental organ Clinical criteria of central carcinoma  the tumor is not metastatic in origin and is covered with normal mucosa

Central SCC Clinical features These neoplasa are rare. Commonly occurred in men, mandible, and age from 30-80y/o Pain, pathologic fracture, sensory nerve abnormalibilities, lymphadenopathy

Central SCC Radiographic features Molar region, tooth-bearing area Radiolucency with no evidence of bone production, irregular in shape, with ill-defined border. Destruction of buccal or lingual plate and cortical outline of the mandibular neurovascular canal

Central SCC Differential diagnosis Not aggressive  Periapical cyst or granuloma Extensive bone destruction metastatic lesion, multiple myeloma, fibrosarcoma

Central SCC Management En bloc resection Adjunctive therapies of radiation and chemotherapy

Summaries 以紅色口腔病變為例，說明病歷書寫的方式，瞭解病歷書寫的原理，並且知道其中的應用。