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?

 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.

Liu H, Shi J, Wilkerson M, Huang Y, Meschter S, Dupree W, Lin F.

Department of Pathology, Lehigh Valley Hospital, Allentown, Pennsylvania, USA.

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. Burlington, NC) cytology specimens were prepared for cell blocks. Three groups (G1, G2, and G3) of cases were included: G1 comprised 44 cases of ASC-H; G2, 14 cases of high-grade dysplasia; and G3, 17 negative/reactive cases. All cases in G1 were confirmed by cervical biopsy or Digene Hybrid Capture 2 (Digene, Gaithersburg, Md) human papilloma virus (HPV) testing. Immunodetection for p16 was performed on cell blocks. RESULTS: In G1, 26 of 44 (59%) cases showed squamous dysplasia, with 14 high-grade squamous intraepithelial lesion (HSIL) cases. Twenty-two of 28 (79%) p16-positive cases were confirmed by surgical biopsy or HPV testing, with a diagnostic sensitivity of 85%, specificity of 67%, positive predictive value (PPV) of 79%, and negative predictive value (NPV) of 75%. Four cases with false-negative staining for p16 were identified. All 28 cases of HSIL (14 from G1 and 14 from G2) were positive for p16. CONCLUSIONS: 1) p16 is a sensitive marker to confirm the diagnosis of ASC-H on a cell block; 2) Multiple unstained slides with adequate cellularity can be obtained from each cell block; and 3) Additional markers can be used to further increase diagnostic sensitivity and specificity. (c) 2007 American Cancer Society.

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.

 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？

 感谢赵老师给我们上了精彩的一课！十分钦佩赵老师工作学习的缜密和严谨，学业的精益求精，思维的开阔长远！

感谢月新老师道出了大家的心声！

像这样的讨论方式，如果多些老师和朋友的加入，将会更好！如果论坛的每个病例，都如此，不久，会出现更多的病理专家！

在病理诊断中如果不是100%的确定，报告时要给自己留些余地，不但保护了自己，同时避免遗漏病情，错过进一步检查的时机。

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。

 To  天山望月 and 月新 :

It does mean u answer is wrong. It is true most serous carcinomas are from endometrium, but some can arise from endocervix. Just wonder you think you can tell the difference between cervical papillary serous carcinoma and endometrial papillary serous carcioma. In fact it is very difficult. Endometrioid carcinoma, clear cell carcinoma can arise from endometrium and endocervix. Often it is difficult to tell the origins even though you try to use IHC in the biopsy specimens.

Yes,i know that is from some residual fluid left in the lab .

So important!  hehe

C. Endometrial Papillary Serous Adenocarcinoma

What are the likely diagnosis?

A. Endometrial Endometroid adenocarcinoma

B. Malignant Mixed Mullerian Tumor

C. Endometrial Papillary Serous Adenocarcinoma

D. Reactive Mesothelial Cells

E. Malignant Mesothelioma

回复赵老师：

细胞图片，我觉得可以先电话告诉临床有非典型病变，待细胞块再定，如果还不能确定，建议分段诊刮。

不足之处，敬请赵老师补充,谢谢！