Share a case of this week.

Old lady with atrophic endometrium showing tumor mass in the surface of cystic atrophic endometrium (first figure)

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F6 and 7 showing focal glandular lesion mixed with other solid lesion.

Your dx or differential dx

 good case

 This is my colleague's case. I reviewed the case for diagosis. When we got the above IHC results we thought it is high grade, undifferentiated or poorly differentiated carcinoma with neuroendocrine features plus with well differentiated adenocarcinoma (glanular componnet). I think it is interesting case. Morphology likes a MMMT, but it is a carcinoma finely. So I sent the case for sharing.

More IHC were ordered for this case.

See Photos

abin译：

这是同事的病例，我复片诊断。我们得到免疫组化结果时，认为它是高级别、未分化或低分化癌伴神经内分泌特征，并有高分化腺癌成分（腺样成分）。我觉得这例很有趣。形态学像MMMT，但它是纯粹的癌，因此上传分享。

这例还有更多免疫组化，见图。

 看来我以前考虑得太简单了。它不是一个普通的低分化/未分化癌。

再看看第1楼的图，低倍：蓝色的海洋！

尽管极罕见，还是会想起小蓝细胞肿瘤的鉴别诊断，特别是PNET！

Pan CK呈核旁点状阳性，是否有特殊意义 . I think yes. Bur cam 5.2 is true positive.

You will suprise more later.

 Pan CK, Cam 5.2, chromogranin, synaptophysin都是阳性, vimentin阴性

低分化子宫内膜癌伴神经内分泌分化？真没想到啊，组织学图像似乎也不像……

Pan CK呈核旁点状阳性，是否有特殊意义？

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Pan CK, Cam 5.2, chromogranin, synaptophysin, vimentin

Now what do you think the case?

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 Sharp eyes. I will send some IHC photos in the weekend.

The main differential dx: MMMT (癌肉瘤) vs carcinoma. I may need to learn how to type Chinese. Who would like to be my teacher? In fact my Chinese Pin Yin is very good. Ha, ha

abin译：

目光锐利。周末我会上传一些免疫组化图片。

主要鉴别诊断：恶性苗勒氏混合瘤（癌肉瘤）VS癌。

我可能需要学习中文打字了。谁愿意做我的老师？事实上我的中文拼音非常好，哈哈。

（如果赵老师想学中文打字，abin愿意效劳。我精通五笔盲打，各种拼音输入法也很熟练。）

 很有趣的病例！Dr.cqzhao的宝贝真多，学不完哈！

图像显示老年女性萎缩子宫内膜背景上出现的恶性形态成分。最后二图可以辨认腺样分化，并且与实性成分移行过渡。因此考虑：低分化or未分化or去分化腺癌，是否存在肉瘤成分可能需要免疫组化帮助，仅用CK和Vimentin也许足够了。我感觉没有肉瘤成分。

它不是EIC。在郑文新教授的启发下，我也做一些UPSC及其前驱病变的研究工作。

 took two previous endometrial biopsy photos

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All the cases posted by Dr. Zhao are pretty interesting. This case is no exception. Basically, we all agree that it is a high-grade malignancy and it mostly likely involve an endometrial polyp (fist figure).  There are mainly several possibilities: 1) a high nuclear grade carcinoma (such as serous carcinoma or undifferentiated carcinoma); 2) Carcinosarcoma (癌肉瘤); 3) Adenosracoma (腺肉瘤) with sarcomatous overgrowth. I don't think that this case fits well with adenosarcoma, since I favor there is at least some adenocarcinomatous components. I did not realize that even expert GYN pathologists cannot always agree on the diagnosis of Cracinosarcoma until I came to Cleveland Clinic and learned GYN path from Dr. Bill Hart (one of the top GYN pathologists in the USA). He has a very strigent criteria for Carcinosarcoma, which should have a perfect bi-phasic pattern of malignant glands and stroma. I doubt that he will call this thing carcinosarcoma.

 For all practical purpose, we would NOT do a lot immunostains in  biopsy cases in our practice, since the clinical management does not matter, if you call high-grade carcinoma vs. carcinosarcoma or even adenosarcoma with sarcomatous overgrowth, it will be total hystrectomy with lymph node staging. So, we usually further classify a tumor on the bigger resection specimen. Not uncommon, you thought it was high-grade carcinoma on the biopsy, but when the whole uterus came out, it clearly showed carcinosarcoma. Is this a biopsy (curretings) or hysterectomy? Thanks!

abin译：

Dr. Zhao提供的病例都非常有趣，这一例也不例外。我们基本上都一致认为它是高级别恶性肿瘤，并且它可能累犯子宫内膜息肉（第1图）。有几种可能性：1）高核级别的癌（如浆液性癌或未分化癌）；2）癌肉瘤；3）腺肉瘤伴肉瘤样过度生长。我认为不太像腺癌，我倾向于至少有部分腺癌样成分。在我来到Cleveland Clinic并向Dr. Bill Hart（美国顶级妇科病理专家之一）学习妇科病理之前，不知道即使妇科病理专家对癌肉瘤的诊断也不一致。他对癌肉瘤有非常严格的诊断标准，即：恶性腺体和间质必须形成非常完美的双相性形态。

从实用角度看，我们不会对活检标本做许多免疫染色，因为临床处理差别不大，如果称为高级别癌vs癌肉瘤vs腺癌伴肉瘤样过度生长，都是全子宫切除加淋巴结分期。因此，我们通常在较大标本上作进一步分类。不少情况下，活检认为是高级别癌，而全子宫标本变成明显的癌肉瘤。这是活检（诊刮）还是子宫切除标本？谢谢！