外科病例汇报

口腔癌皮瓣修复术后口腔颌面外科病例汇报2012级八年制魏迪洋1210303109病例一基本信息：刘伊寒，30岁，女；主诉：右舌鳞癌切除术后3年，舌背前部肿物半月余；现病史：半月前发现舌背前部肿物，无意中发现，发现时大小约1cm。自发现以来肿物未见明显变化，无明显疼痛，不影响咀嚼，不影响吞咽，不影响言语，不影响张口。自起病以来一般情况良好，体重无明显减轻。3年前因右侧舌腹鳞癌于我院行“右侧舌癌根治+右颈清扫+左前臂皮瓣修复术+左上臂取皮植皮术”。全身情况良好。专科检查

舌背前部大小约直径为1.5cm的肿物：质地中等，表面黏膜未见异常颜色变化，边界清楚，不活动。触觉稍迟钝。牙无松动，无下唇麻木，其它牙龈及口腔黏膜未见异常，口腔卫生状况好，未触及肿大颈部淋巴结。辅助检查颌面部增强CT我院（2017-03-16）显示：右舌术后表现，皮瓣修复，舌部未见确切复发性占位。右颈术后，右颈部未见确切肿大淋巴影像。下颌骨劈开术后，骨愈合良好。初步诊断：右舌腹鳞癌术后舌背肿物治疗计划：舌癌术后舌背肿物扩大切除术+邻位瓣修复术手术经过：1.患者仰卧位，全麻成功后，常规消毒铺巾后，口腔冲洗消毒。2.术中见肿物中心体表投影位于：右舌背。在肿物外约1cm处切开舌粘膜至肌层，完整切除肿物，下标本。3.术区未涉及口底组织。未显露舌神经。术区未及舌中线。4.大量生理盐水冲洗术野。检查无活跃出血点。清点器械敷料无误，可吸收线分层对位缝合伤口。5.送患者到复苏室观察。标本送病理科。病理标本肉眼所见：

肿物最大径约1cm，肿物剖面实性，表面欠光滑。我院病理科：

（舌背前部肿物）符合炎症性增生。病例二：基本信息：王维振，男，64岁；主诉：右下牙龈癌术后9月，软腭右侧肿物20日现病史：20日前发现软腭右侧肿物，发现时大小不明确。自发现以来肿物未见明显变化,无明显疼痛，不影响咀嚼，不影响吞咽,不影响言语，不影响张口。自起病以来一般情况无明显异常，体重无明显减轻。9月前于我科行“右下牙龈SCC扩大切除术+右颈淋巴结清扫术+下颌骨区段截骨术+左腓骨瓣修复术”。全身情况良好。专科检查软腭右侧近皮瓣处见肿物直径约2cm，周围黏膜色红，触痛（-）；右下唇及颏部麻木,其它牙龈及口腔黏膜未见,未触及肿大颈部淋巴结。辅助检查颌面部CT我院（2017-03-03）显示：术区未见确切异常软组织占位表现。右下颌肿物术后，请结合临床。

初步诊断：右软腭肿物

治疗计划：右软腭肿物扩大切除术+人工皮修复术手术经过：1.患者仰卧位，全麻下消毒铺巾，口腔冲洗、消毒。2.在肿物周围外观正常处扩大切开粘膜至骨面，顺骨面及软腭鼻腔侧粘膜下分离，完整切除肿物。电凝止血。3.创面后界位于软腭，腭部骨质未见明显改变，未穿通。软硬腭交界处未见穿通。创面未见牙根暴露

4.生理盐水冲洗创面，电凝止血；创面覆盖人工皮，表面放置碘纱布，反包扎固定。5.清点器械敷料无误。患者送复苏室观察，标本送病理。病理标本肉眼所见：肿物周围黏膜色红，质地中等。肿物最大径约1.0cm。我院病理科（2017-03-22）：

（右软腭）白斑，上皮中至重度异常增生，局部倾向于早期癌变。选择性边界未见肿瘤病例三：基本信息：卢嘉启，男，66岁；主诉：左颊癌术后17年，左前颊部肿物6年；现病史：6年前发现左前颊部肿物，发现时大小不明确，自发现以来肿物未见明显变化，一般情况无明显异常。

17年前于我院行“左颊SCC扩大切除术+前臂皮瓣修复术”，16年前于我院行左颊增生物切除术。全身情况良好。专科检查左前颊部可见皮瓣，皮瓣后缘有最大径约为4cm的增生物；牙无松动，无下唇麻木，其他牙龈及口腔黏膜未见。初步诊断：左颊肿物治疗计划：左颊肿物切除术手术经过：1.患者仰卧位，全麻下消毒铺巾，口腔冲洗、消毒。2.术中见病变为肿物，病变中心位于左侧上颊前部，原皮瓣前方，在病变部位边界外约0.5cm处切开粘膜至粘膜下，完整切除病变组织，下标本，腮腺导管未累及。3.生理盐水冲洗创面，电凝止血，检查无活跃出血点；手术创口对位缝合。拔管。4.清点器械敷料无误。患者送复苏室观察，标本送病理。一些疑问皮瓣移植到口腔环境中，究竟都经历了些什么？它还能保持自己最初的模样吗？皮瓣移植术后，就可以高枕无忧了吗？会不会变得更加危险？为什么？肉眼观retainednormalskintexturenormalcolor.【1monthaftersurgicalresection】Shibahara,T.,etal.,Morphologicchangesinforearmflapsoftheoralcavity.JOralMaxillofacSurg,2000.58(5):p.495-9.【16monthsaftersurgicalresection】AppearssmoothandresemblesmucosaShibahara,T.,etal.,Morphologicchangesinforearmflapsoftheoralcavity.JOralMaxillofacSurg,2000.58(5):p.495-9.【18monthaftersurgicalresection】Theskinlooksnormotrophic,lightlypale,andishairy.RubinoC,DessyLA,FaraceF,etal.Microscopicandimmunohistochemicalanalysisoftheskinchangesoffreeforearmflapsinintraoralreconstruction.[J].AnnPlastSurg.2002,49(4):362-368.【60monthaftersurgicalresection】healthyMax,R.C.,etal.,ExpressionofKi-67andp53incutaneousfreeflapsusedtoreconstructsofttissuedefectsfollowingresectionoforalsquamouscellcarcinoma.OralOncol,2007.43(3):p.263-71.组织学1月后Forearmflapsshowedhistologicfeaturessimilartothoseoftheforearmskin.orthokeratinizationmaintained（正角化）melaninpigment（黑色素）slightlysmallerquantityCapillary（毛细血管）countslowerCollagenfibers（胶原纤维）smallerquantityfibroblast（成纤维细胞）countshigher.thehairroots,follicles,sebaceousglands（皮肤附属器）shrinkShibahara,T.,etal.,Morphologicchangesinforearmflapsoftheoralcavity.JOralMaxillofacSurg,2000.58(5):p.495-9.10MONTHSAFTERGRAFTINGcontinuedkeratinizationcornifiedlayers（角化层）thickengranulosumandpricklecelllayers（颗粒层、棘层）thinMelaninpigmentationdecreasesubstantiallycollagenfibersslightlythickencapillaryandfibroblastlowerskinappendagestendedtoshrinkShibahara,T.,etal.,Morphologicchangesinforearmflapsoftheoralcavity.JOralMaxillofacSurg,2000.58(5):p.495-9.【after18month】SkinthicknessisreducedThedermal–epidermaljunctionisslightlyundulated[起伏的].RubinoC,DessyLA,FaraceF,etal.Microscopicandimmunohistochemicalanalysisoftheskinchangesoffreeforearmflapsinintraoralreconstruction.[J].AnnPlastSurg.2002,49(4):362-368.32MONTHSAFTERGRAFTINGParakeratosis（不全角化）thecornifiedlayer,granulosum,andpricklelayerallthinnomelaninpigmentationorepithelialpegs（上皮钉突）onlyafewcapillaries,fibroblasts,andcollagenfibersskinappendagesalldisappearedShibahara,T.,etal.,Morphologicchangesinforearmflapsoftheoralcavity.JOralMaxillofacSurg,2000.58(5):p.495-9.theskinbeginsmucosa-likechangeabout10monthsaftergraftingoftheforearmflap——“mucosalization”Shibahara,T.,etal.,Morphologicchangesinforearmflapsoftheoralcavity.JOralMaxillofacSurg,2000.58(5):p.495-9.Theskindiffersfromthemucosainvariousways：

keratosisversusparakeratosisactivityofthebasallayerandgranulosumthecompositionoftheconnectivetissue········

change

pathologicallyabnormalstateTheareaconnectingtheoralmucosaandthegraftedflapduringthewoundhealingprocessoftenshowsapathologicallyabnormalstate,suchas：Dysplasia、Inflammation、Acceleratedkeratinization.Shibahara,T.,etal.,Morphologicchangesinforearmflapsoftheoralcavity.JOralMaxillofacSurg,2000.58(5):p.495-9.Beahmfoundthatthetransferredskinischaracterisedbychronicinflammationinalltissuesandcandidainfectionin50%ofcases；Pathologicalchangesinskingraftssuchaspsoriasis[牛皮癣],focalacantholyticdyskeratosis[局灶性棘层松解性角化不良]andcarcinoma

havebeenreportedassinglecases；Max,R.C.,etal.,ExpressionofKi-67andp53incutaneousfreeflapsusedtoreconstructsofttissuedefectsfollowingresectionoforalsquamouscellcarcinoma.OralOncol,2007.43(3):p.263-71.一些分子学证据·······CKs(cytokeratins)细胞角蛋白：TheCKpatternisamaturationmarkeranddifferentiates[分化]epidermisfrommucosa.ChangeofCKdistributionhasbeenshownincasesofsquamouscellmetaplasiaandneoplastictransformationoftheepitheliumInvolucrin总苞蛋白：Ahighlyreactiveproteinpresentinkeratinocytes[角化]ofepidermisandotherstratifiedsquamousepithelia.RubinoC,DessyLA,FaraceF,etal.Microscopicandimmunohistochemicalanalysisoftheskinchangesoffreeforearmflapsinintraoralreconstruction.[J].AnnPlastSurg.2002,49(4):362-368.ShibaharaT,MohammedAF,KatakuraA,etal.Long-termresultsoffreeradialforearmflapusedfororalreconstruction:functionalandhistologicalevaluation.[J].JournalofOral&MaxillofacialSurgeryOfficialJournaloftheAmericanAssociationofOral&MaxillofacialSurgeons,2006,64(8):1255-1260.CKpattern：somechange——粘膜化过程的发生

didnotchangesubstantially——并不是化生为粘膜上皮mucosalizationisconsideredtobeaprocesssimilartometaplasia粘膜化不等于化生involucrin：reductioninthegranularlayer;disappearanceinthehornylayer；——角化程度下降Ki-67：——theproliferationmarker——hasrecentlybeenshowntobeasurrogate[替代]markerofLOH（beusedtopredictmalignantchangeinorallesions)inoralepithelialdysplasiaP53：——thetumoursuppressormolecule——highfrequencyofp53mutationsdetectablep53proteinprobablyrepresentsasomaticmutation[体细胞突变]Max,R.C.,etal.,ExpressionofKi-67andp53incutaneousfreeflapsusedtoreconstructsofttissuedefectsfollowingresectionoforalsquamouscellcarcinoma.OralOncol,2007.43(3):p.263-71.AllofthegraftswithdysplasiashowedstrongnuclearstainingwithbothKi-67andp53.ThedysplasticoralepitheliumadjacenttothegraftedareashowedasimilarpatternofKi-67andp53staining.DysplasticgroupMax,R.C.,etal.,ExpressionofKi-67andp53incutaneousfreeflapsusedtoreconstructsofttissuedefectsfollowingresectionoforalsquamouscellcarcinoma.OralOncol,2007.43(3):p.263-71.TheKi-67labellingindices(LI)significantlylowernop53staininginmostofthe‘non-dysplastic’lesions；intwograftsshowingcandidosis,therewasweaknuclearp53stainingthatwasrestrictedtothestratumbasale.Non-dysplasticgroupHalfofthelesionsexcised[离体的]showedseveredysplasiaatthemarginsofexcision···Inallthecasesexamined:——dysplasiaintheepidermiswascontiguous[连续的]withdysplasiaintheadjacentoralmucosa

——dysplasticchangeswereconsistentlyfoundextendingdownpilosebaceousfollicles[毛囊皮脂腺]andeccrinesecretoryducts[外分泌腺导管].Max,R.C.,etal.,ExpressionofKi-67andp53incutaneousfreeflapsusedtoreconstructsofttissuedefectsfollowingresectionoforalsquamouscellcarcinoma.OralOncol,2007.43(3):p.263-71.Alteredkeratinocyteswithagrowthadvantageexpandlaterally[邻近地]displacingadjacentnormalepithelium【fieldcancerization】BraakhuisBJ,LeemansCRBrakenhoffRH.Expandingfieldsofgeneticallyalteredcellsinheadandnecksquamouscarcinogenesis.[J].SeminarsinCancerBiology,2005,15(2):113-120.Alocalrecurrenttumortheresultofgrowthoftumortissueleftaftersurgeryoftheprimarytumoroccurringwithin3yearsafterthefirsttumoratadistancelessthan2cmawayfromthattumorAsecondprimarytumorThetimeintervalbetweentheoccurrenceoftheprimaryandsecondarycarcinomais3yearsAtleast2cmbetweenthetumorsandalocalrecurrence.Whattheoriginofasecondprimarytumor？a‘truesecondprimarytumor’(anindependentlyevolvedcarcinoma）a‘secondfieldtumor’(atumordevelopedfromafield)field【Field】anepithelialsheetofcellswithcancer-associatedgeneticalterationswithoutinvasivegrowth.

BraakhuisBJ,LeemansCRBrakenhoffRH.Expandingfieldsofgeneticallyalteredcellsinheadandnecksquamouscarcinogenesis.[J].SeminarsinCancerBiology,2005,15(2):113-120.So·······对field的监控很重要！Whenatriskforasecondfieldtumor,apatientmayverywellneedadifferentfollowupandmorefocusedscreening.Patientswithafieldareapotentiallyimportanttargetgroupforthestudyofcancerprevention.Whengeneticmarkerscanbeusedtopredictahighriskforcancer,chemopreventiontrials[化学预防实验]canbestartedinthesepatientgroups.EnvironmentalfactorsmoistureinducedbysalivaachangeinthebacterialfloralmechanicalandchemicalstimuliassociatedwithfoodingestionCandidainfection.Shibahara,T.,etal.,Morphologicchangesinforearmflapsoftheoralcavity.JOralMaxillofacSurg,2000.58(5):p.495-9.Continuedexposureoftheoralmucosatoriskfactors（suchastobaccoandalcohol）resultinthedevelopmentofgeneticallyalteredkeratinocytesprogressivelyreplacenormalepithelialcells;clonaldivergenceandselectionwithintheseareasleadstothedevelopmentofnewcarcinomasM