Pap smears are too difficult, especially for photos in computer. Give you an easy one for fun.

A women aged over 50

How will you sign out the case?

 Ok, basically I complete the case. Hope you can get somethings when you spend your time to read the topic. Thank every one who read and joined the discussion for this case.

Merry Christamas and happy New Year to you and all your family.

cz

Cytomorphology of Papillary Serous Adenocarcinoma

n      Differential diagnosis:

1. Endometrioid carcinoma: difficult in Pap test

2. Reactive benign endocervical cells: this is the money for pathologists

3 Reactive mesothelial cells (in pelvic washing)

n      clusters, flat sheets or single cells

n      Cytoplasm is dense & distinct

n      Multinucleation

n      Nuclei chromatin vary from bland to hyperchromatic

n      Nucleoli-small to prominent

Cytomorphology of Papillary Serous Adenocarcinoma (Pap)

n      Malignant cells are isolated or arranged in clusters.

n      Nuclei are enlarged and demonstrate variation in size.

n      There is nuclear hyperchromasia with coarsely textured chromatin and prominent nucleoli.

n      Cytoplasm may be scant but is often abundantly vacuolated.

n      Psammoma bodies may be present.

Disease Fact Sheet about uterine serous carcinoma

1. Aggressive high grade endometrial adenocarcinoma first described in 1982.

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5. 2/3 have malignant pap smears since buds and tufts break off.

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Cytomorphology of the case

1. Clusters of  large malignant cells with scant cytoplasm,  marked variation in nuclei size, nuclear hyperchromasia with coarse chromatin, irregular nuclear membranes and prominent nucleoli.

2. Some of the clusters demonstrate a papillary morphology with an irregular outline.

3. The cell block preparation  demonstrates fibrovascular cores lined by stratified  malignant cells with scant cytoplasm, enlarged hyperchromatic nuclei, prominent nucleoli with scattered mitotic figures on hematoxylin and eosin staining.

Thank you for your good words.

You must learn Chairman Mao's words very well. You are a person with self-criticism. Kiding.

Everyone makes some mistakes, even the world-famous professors.

In the US many people always feel they are the best in the world. In fact they should learn from Chinese.

但是这个名称“子宫内膜中分化浆液性乳头状腺癌”不太合理。

Uterine serous and clear cell carcinoma are type 2 tumor.子宫浆液性了透明细胞性癌都是II型癌。 Both are high grade carcinoma. 两个都是高级别肿瘤。So we do not need to mention high grade serous or clear cell carcinoma. 因此我们不需要分级（即：浆液性癌或透明细胞癌都是高级别癌）。Of cause we will not say well or moderately differentiated serous or clear cellcarcinoma. 当然就不能说高分化或中分化浆液或透明细胞癌。Thank you two for working on this case.谢谢二位。

 Both of your reports are very good.

Only  this term 子宫内膜中分化浆液性乳头状腺癌:

Uterine serous and clear cell carcinoma are type 2 tumor. Both are high grade carcinoma. So we do not need to mention high grade serous or clear cell carcinoma. Of cause we will not say well or moderately differentiated serous or clear cell carcinoma.

Thank you two for working on this case.

按照我们单位的习惯写一下病理报告，请赵老师指正：

1、  子宫内膜中分化浆液性乳头状腺癌，肿瘤大小4x3x1.2 cm，浸及子宫肌的75%.宫颈未见癌生长，

2、  右卵巢查见转移性肿瘤，大小为4 mm，肿瘤位于卵巢皮质，近卵巢表面，

3、  大网膜查见一个转移性腺癌结节，

4、  （盆腔冲洗液细胞涂片）查见腺癌细胞团，

5、  左卵巢及双侧卵管，子宫颈未见肿瘤生长，

6、  送检标本中淋巴结未见癌转移（几分之0）。

 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.

 Ok I send you more follow-up data.

3 months later, the womren had hystectomy, BSO and staging

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 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？

 谢谢赵老师！非常漂亮的图片！

有几个问题，请赵老师赐教：

1、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？

2、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？

谢谢！

Surprised to see your dx for the pap and em-bx after many people'discussion.

 One week later after Pap report, the women had endometrial curettage and ECC. Endometrial biopsy showed in the photos.

Now every one should know the diagnosis.

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