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- an easy case for you-Pap test (cqz 3)
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本帖最后由 于 2008-12-28 20:33:00 编辑
To 天山望月 and 月新 :
It does mean u answer is wrong. 这样的回答意谓着不合适、结果自然也就错了，It is true most serous carcinomas are from endometrium, but some can arise from endocervix. 虽然大部分浆液性癌起源于子宫内膜，但是也有部分起源于子宫颈，Just wonder you think you can tell the difference between cervical papillary serous carcinoma and endometrial papillary serous carcioma. 你肯定认为你可以鉴别宫颈或子宫内膜的乳头状浆液性癌，In fact it is very difficult. Endometrioid carcinoma, clear cell carcinoma can arise from endometrium and endocervix. 实事上，子宫内膜样癌，透明细胞癌都可以起源于子宫内膜，也可以起源于子宫颈，Often it is difficult to tell the origins even though you try to use IHC in the biopsy specimens.认清起源是非常困难的，就是用免疫组化也没有用。
感谢赵老师给我上了一课，一幅图，引出这么多的思维差距，虽然我可以感觉到这是一个恶性的腺上皮细胞团，但是如何进一步工作，如何发病理报告又是不同。看到了宫颈涂片中有上述的异形上皮细胞团，如果光说话让临床医生做这做那，自已不再做实际工作，不行，赵老师用剩余的TCT液体做成细胞块，一下子解决了大问题，把肿瘤的组织形态弄到手了，但是如何描述这样的形态，如何写报告又是一个思维落差。比如是乳突状浆液性腺癌，是子宫颈，还是子宫内膜，大包大揽，肯定说子宫内膜，当然子宫内膜多见，但是宫颈完全可以有。病理报告错一个字，意谓着不完整不科学，也就是完全错误。这一例给我的经验。应该象赵老师这样，做事有缜密性，自已应该做工作一定要做完，思维有多样性，考虑问题复杂，报告有原则性，不能说过头话，原则无论如何不能偏离。这次举一反三。大有收获。
| 以下是引用月新在2008-12-18 11:23:00的发言： It does mean u answer is wrong. 并非说你们的回答是错的，但是不完整。It is true most serous carcinomas are from endometrium, but some can arise from endocervix. 虽然大部分浆液性癌起源于子宫内膜，但是也有部分起源于子宫颈，Just wonder you think you can tell the difference between cervical papillary serous carcinoma and endometrial papillary serous carcioma. 你肯定认为你可以鉴别宫颈或子宫内膜的乳头状浆液性癌，In fact it is very difficult. Endometrioid carcinoma, clear cell carcinoma can arise from endometrium and endocervix. 实事上，子宫内膜样癌，透明细胞癌都可以起源于子宫内膜，也可以起源于子宫颈，Often it is difficult to tell the origins even though you try to use IHC in the biopsy specimens.认清起源是非常困难的，就是用免疫组化也没有用。
感谢赵老师给我上了一课，一幅图，引出这么多的思维差距，虽然我可以感觉到这是一个恶性的腺上皮细胞团，但是如何进一步工作，如何发病理报告又是不同。看到了宫颈涂片中有上述的异形上皮细胞团，如果光说话让临床医生做这做那，自已不再做实际工作，不行，赵老师用剩余的TCT液体做成细胞块，一下子解决了大问题，把肿瘤的组织形态弄到手了，但是如何描述这样的形态，如何写报告又是一个思维落差。比如是乳突状浆液性腺癌，是子宫颈，还是子宫内膜，大包大揽，肯定说子宫内膜，当然子宫内膜多见，但是宫颈完全可以有。病理报告错一个字，意谓着不完整不科学，也就是完全错误。这一例给我的经验。应该象赵老师这样，做事有缜密性，自已应该做工作一定要做完，思维有多样性，考虑问题复杂，报告有原则性，不能说过头话，原则无论如何不能偏离。这次举一反三。大有收获。 |
| 以下是引用小荷在2008-12-18 21:41:00的发言：
深深谢意！收获多多！ 请教一个问题：“无论什么年龄段出现了非典型的的子宫内膜腺上皮细胞都应该做活检，.如果刮宫标本正常还应该再做阴道镜，所以非典型的子宫内膜细胞是一定要报出来。” 如果是非典型腺细胞，不能明确是子宫内膜，还是宫颈管，需要活检吗？！ 如果能明确是非典型宫颈管腺细胞，需要活检吗？ |
You are right:
AGC, endometrial: endometrial and endocervical sampling. need to do colposcopy if no endometrial lesion noted.
All other AGC, (AGC, NOS; AGC, endocervical):
Colposcopy with endocervical sampling, high risk HPV testing. In additon, endometrial sampling is needed for patients are >35 year, or patients have risk for endometrial lesions ---family history, overweight et al.
So AGC is critical call. You have to be think over and try to not overcall or mis-call. A big challenge for all pathologists. I did AGC research for many years and reviewed more than 1000 AGC cases with follow up. I still feel struggle for most cases. Ha, ha. We all need learning from the practice.
It seems my online talk about AGC was not very effective for your guys. Sorry about this. In fact pathologists cannot learn pathology from few talks. Importance is that we learn from our practice and mistakes.
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Recommend one paper from a very good Chinese pathologist- Fan Lin
Cancer. 2007 Apr 25;111(2):74-82.
Immunohistochemical detection of p16INK4a in liquid-based cytology specimens on cell block sections.
Liu H, Shi J, Wilkerson M, Huang Y, Meschter S, Dupree W, Lin F.
Department of Pathology,
BACKGROUND: Colposcopy biopsy procedure is a standard recommendation for atypical squamous cell cannot exclude high-grade lesion (ASC-H) in abnormal Papanicolaou smears. p16 (p16INK4a), a cell cycle regulator, has been shown to be overexpressed in squamous dysplasia. To further improve the diagnostic accuracy of the ASC-H Papanicolaou smear and to reduce unnecessary procedures, the authors evaluated the utility of immunodetection of p16 in liquid-based cytology specimens on cell blocks. METHODS: Seventy-five liquid-based (SurePath; TriPath Imaging, Inc.
Lesson from above case: Cell block can be very useful for diagnosis sometime.
We cannot prepare the cell blocks for all Pap test, but we may have some unexpected findings in some cases. I ask cyto lab to prepare the cell block if the Pap smears show some high grade dysplastic cells (may be carcinoma), but I am not sure for the diagnosis. In this situation you can prepare a cell block to try your luck.
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本帖最后由 于 2008-12-19 11:08:00 编辑
| 以下是引用cqzhao在2008-12-19 10:49:00的发言：
Lesson from above case: Cell block can be very useful for diagnosis sometime.根据上述病例，证明细胞块在诊断中，有时是非常有用的。 We cannot prepare the cell blocks for all Pap test, but we may have some unexpected findings in some cases. 我们不能把所以有的宫颈涂片标本都做细胞块，在某些特殊的病例中做细胞块是会有意外之喜。I ask cyto lab to prepare the cell block if the Pap smears show some high grade dysplastic cells (may be carcinoma), but I am not sure for the diagnosis. 如果我看到细胞学出现了高度的异形性的细胞可能是癌，我就让试验室把剩余的液体做成细胞块，但是也不能确保做出病理诊断。In this situation you can prepare a cell block to try your luck.本例做的目的也是撞大运。没想到撞上了。 |
| 以下是引用月新在2008-12-19 11:05:00的发言：
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本帖最后由 于 2008-12-21 12:47:00 编辑
译上楼：这是老师给大家的周末的家庭作业。完成后咱们请赵老师点评：
Key for fig本例主要的病理图如下：
f1-2: uterus: tumor size 4x3x1.2 cm, myometrial invasion 75%. 图1-2子宫肿瘤，肿瘤大小4x3x1.2 cm, 浸及子宫肌的75%，
f3: R overy with focal tumor mass 4 mm, in the cortex, close to the ovary surface 图3：右卵巢和局部的肿瘤4 mm，肿瘤位于卵巢皮质，近靠卵巢表面。
f4: omentum图4为大网膜。
f5: pelvic washing.图5为盆腔冲洗液细胞涂片。
Lymph node is negative for malignant. No tumor is noted in the endocervix. Fallopian tubes and other ovary are normal. 淋巴结未见肿瘤转移，宫颈没有累及，输卵管和左侧卵巢未见肿瘤累及。
How would you sign out this case with pathologic staging.现在请大家当成自家的病例来签发病理报告，要有病理分级。 I hope to see a full report.我想看到一份完整的病理报告， I know a lot of people here are young pathologists.我知道大家多为年青的病理学家， You can ask your senior or professors if you are not sure.如果你没有信心，担心自己的病理报告不太正规不很完整的话，你也可以问你的上级医生或问教授。 Pathologists in the US need 5 or six years of resident or fellow training (after 4 years of coolege and 4 years of medical school)and pass the difficult pathology board examination before they can have the right to sign out the cases.在美国一个人如果想自己独立签发病理报告，需要先四年工科，然后四年医学，然后再5-6年专科职业培训，最后更是要通过非常艰难的病理职业医师考试，才能有权签发病理报告。 So it is ok to have some difficulties in pathology service 在美国想当病理医师发病理报告是相当困难的一件事情。if you are young and just complete medical school or jsut work few years.不知你们是否还非常年青，或者已经完成学业，甚至已经工作多年？
52楼图1：中间的2个管腔样结构，腔面锯齿状，看不到核，是结晶？还是上皮脱落坏死？感觉不像。还是其它病变？
Not epthelial cells. May be结晶 or other artifacts. Anyway it is not important.
图2：有乳头样结构，又有子宫内膜样癌，是混合型癌吗？可能是高级别的癌，IHC：P53,Ki67怎样？浆液性乳头状癌和子宫内膜样癌在HE上有哪些鉴别点？
It s a serous carcinoma with strong and diffuse positivity for P53. Ki67 is no use because all high grade ca can be strongly and diffusely pos. Serous ca with prominent glandular formation and without papillary features can be confused with endometrioid ca. Predominantly the nuclear features can help for the distinction. Glands in em-ca have a smooth luminal border and are lined by columinar cells with nucelar grade 1-2. EM-ca with grade 3 nuclei almost always show solid growth pattern with few glandular formation. In fact in this case you can appreciate some papillary structures even in the photo 2 of ECC specimen.
Key for fig
f1-2: uterus: tumor size 4x3x1.2 cm, myometrial invasion 75%.
f3: R overy with focal tumor mass 4 mm, in the cortex, close to the ovary surface
f4: omentum
f5: pelvic washing.
Lymph node is negative for malignant. No tumor is noted in the endocervix. Fallopian tubes and other ovary are normal.
How would you sign out this case with pathologic staging. I hope to see a full report. I know a lot of people here are young pathologists. You can ask your senior or professors if you are not sure. Pathologists in the US need 5 or six years of resident or fellow training (after 4 years of coolege and 4 years of medical school)and pass the difficult pathology board examination before they can have the right to sign out the cases. So it is ok to have some difficulties in pathology service if you are young and just complete medical school or jsut work few years.
