40-45 y/f with hx of cervical ca with radiation, chemotherapy, ovarian mass 11 cm. I did frozen. Gynecologist came to frozen room to sit with me to read frozen slide.

What can you tell your surgen about the case if your were the pathologist?

What is your differential dx?

I ordered IHC in frozen block and will know basic result tomorrow.

abin译：

20分钟前的卵巢肿瘤冰冻切片。我们能告诉妇科医生什么？

40-45岁女性，有宫颈癌病史和化疗、放疗史。卵巢肿块11cm。我做冰冻切片，妇科医生跑到冰冻室，和我坐在一起看冰冻切片。本例，如果你是病理医生，你能告诉手术医生什么？

你的鉴别诊断是什么？

我用冰冻切片做了免疫组化，明天会知道基本结果。

对于这一例，大体下有淡黄色的切面，这让我首先想到了性索－间质的肿瘤。镜下我看到的列兵样排列，我个人认为是性索样的分化的感觉，如果去掉广泛的纤维胶原区，那么性索样的分化更为明显，类似于颗粒细胞瘤的缎带，波纹型。颗粒细胞瘤是低度恶性的，即使是幼年型的颗粒细胞瘤也有10%是低度恶性的，当然这一例显然不是幼年型的颗粒细胞瘤，而硬化性间质瘤与卵泡膜瘤是良性的，所以如何发报告，对病理医生是一个较大的挑战。只能依赖于免疫组化，问题是性索间质之内的3个肿瘤可以靠免疫来区分吗？呵呵。对于术中快速，只能与临床有良好的沟通，以帮助临床做出手术选择，又不必给自己带来过大的压力。这些是个人的浅见，请各位老师批评指正。还是看不懂，呵呵

 呵呵，我觉得"defer译为" 延迟发报告"较合适。

Dr.Zhao的意思是：

我们做冰冻切片时，必须选择一下三种之一作为冰冻切片报告：1）良性，2）延迟，3）恶性。

延迟报告，也就是“确诊待常规石蜡切片”，用于冰冻切片不能明确诊断的情形。"Defer"（延迟）意味着病理医生不能作出明确诊断（良性或恶性）。换言之，病理医生不确信病变的性质。病变可能是良性，但也可能是恶性。

 谢谢赵老师的回复

从您的分类benign,malignant和defer来看，将defer直接翻译为延迟发报告是不合适的。

在国内这样的情况大多写作：良恶性，不能确定，请待常规切片。但是有时候会经过与临床手术医生沟通后，征求手术医生的意见及临床情况后，口头上给临床医生一个“倾向于……”这样的意见。

 Thank Dr. wq_9603  for your excellent translation.

When we do frozen we must choose one of the three to write in our frozen report---1) benign, 2) defer, 3) malignant. "Defer" means that pathologist can not make definite diagnosis (benign or malignant). In other words pathologists are not sure of the nature of the lesions. The lesions can be benign, but also can be malignant.

I do not know how to translate the "defer". Is " 延迟发报告" good words?

 cqzhao老师回复：

谢谢张老师对此例的关注，使我又想起了这个病例。我本来以为我已经将我们的诊断及解释贴出来了，实际上是我忘记了，还好我在27楼回帖中贴出了免疫组化结果。
结合组织学特点和免疫组化结果，该例是个卵巢的性索间质肿瘤，鉴别诊断包括粒层细胞瘤和卵泡膜/纤维瘤组肿瘤。如果能阅读玻片的话，那么很容易就可以看出是个卵泡膜/纤维瘤组的种类，而不是粒层细胞瘤。免疫组化也支持该诊断。我曾将此例在我们的部门的阅片会上讨论过，大家都赞成此诊断。问题是我们该将其划分到哪个亚型呢？如同前面我们讨论的，该例尚具有硬化性间质瘤的特征。既不是一个典型的硬化性间质瘤，也不是一个典型的卵泡膜/纤维瘤。最后我的报告是这样发的：卵巢间质肿瘤，兼有硬化性间质瘤和卵泡膜瘤的特征，又加上了长长的补充意见。该例的重点是这是个良性卵巢间质瘤。在我们每周的妇科肿瘤专业讨论中我也提交了此例。妇科专家对此例的诊断还是满意的，对于该患者会进行密切随访。
一个住院医师进行了文献检索，发现至今为止有115例硬化性间质瘤的报道。患者平均年龄27或28岁。所有报道的病例临床行为都是良性的。所有报导的病例都没有小叶癌的细胞形态。她还在继续努力，准备就此例发一个病例报道。我将我们的工作说出来并非是告诉大家最后的诊断或者明确的正确诊断，你还可以有自己的意见和见解。
非常感谢各位的参与和阅读此例。
我注意到开始的时候在冰冻切片我报了恶性。当时我和妇科医生进行了好长时间的讨论。他说即使我延迟发报告，他也需要对此例做出疾病分期。我当时以文件的方式进行了记录。这样以来，即使我做出了错误诊断，对患者也不会造成伤害，这样我就没责任了。实际上我将此例提交我们部门会诊的时候，每个人都认为这是一个粒层细胞瘤或者一个转移性肿瘤。因此我们要认识到我们的局限性，我们还可以做点什么？或许我们冰冻切片时候可以更多的延迟一些？但是外科医生就不高兴了啊。或许我们冰冻时候可以多取材？可能可以……
专门对张老师的回复：谢谢您的讨论。很高兴在网站上与您交流。我想您应该是来自山东，姓张。我毕业于青岛医学院。如果你也是毕业于山东，或许我们是校友，至少我们是山东老乡。

 To Dr. Zhang,

Thank you for your great discussion for some cases. It is great to have some communication with you in the web.

I guess Zhang is your last name and you are from Shandong. I was from Qingdao Medical School. If you graduated from the medical school in shandong we may be schoolmate, or at least we are Shandongness.

 As I mentioned in the begining I reported my frozen as malignant for this case. However I had a long discussion with gynecologist during the frozen. He mentioned that he would do staging for this women even I defered the case. I documented this exactly. Even though I made wrong interpretation it did not cause harm to the patient. So I am ok. In fact I showed the frozen section in our dept conference. Every one though it was a granulosa tumor or metastatic tumor. Anyway we know our limitation. What can we do?  Maybe we should have more defered cases for frozen. Surgeons will not be happy. Maybe we should take more sections for frozen.

Ok, this is.

Thank Dr. Zhang for your reminding this case.   Sorry I thought I have put here our interpretaion. In fact i did not.  However I listed all IHC results in the floor 27.

Based on the morphologic features and IHC results this is an ovarian sex-cord stromal tumor. The differential dx includes granulosa cell tumor and fibroma/thecoma tumor. If you read the true glass slides it is easy to tell it is a fibroma/thecoma tumor, but not granulosa cell tumor. IHC results also support the dx of fibroma/thecoma. I showed the case in our department slide showing  conference. All pathologists agree with the interpretaion. Now the question is that this tumor should classified into ?subgroup of fibroma/thecoma group. As what I and other people discribed before the tumor had some features of sclerosing stromal tumor and also some features of thecoma. However, it is not a typical sclerosing stroma tumor, nor typical fibro-thecoma. Finally I released the case as ovarian stromal tumor with features of sclerosing stromal tumor and thecoma with a long comment. The key for this case is that it is a benign ovarian stromal tumor. The case was also discussed in our weekly gynecologic tumor board. gynecoogists felt satisfacted for the dx. The patient will get close follow-up.

A resident did the literature search and noticed that  115 cases of sclerosing stromal tumor (SST) was reported since the initial report. The mean age for SST is 27 or 28 year. All SSTs have been clinically benign in reported cases. None of these cases reported had the lobular ca-like cytomorphology. She is working on and trying to write a case report for this case.

 I just told you our interpretation for this case. It does not mean that it is a correct or final diagnosis for your guys. You can have your own interpretation.

Thank all of you for attending the discussion and reading this case.

cz

 大家讨论的都非常充分了，主题也标出[已确诊]，可是我还是有些不明白，

最后结论是什么？

CK7？CK20？

“可能wolffian起源的肿瘤”可能吗？

 Cqzhao老师提供的病例很难!

如果在考场,我早就填了"乳腺浸润性小叶癌卵巢转移"交卷了,当然这样的病例我只能跟着感觉瞎懵.

可现在回到病理网,看了这么多高手精彩的分析,我更加迷惑了,大家现在的焦点似乎集中在硬化性间质瘤,但形态学上也不太支持.我也来猜一个:卵泡膜细胞瘤.

期待cqzhao老师公布谜底,再做一个详细的讲解.

感谢各位老师的精彩分析，学习了

 经过各位老师的分析，回头好好看看硬化性间质瘤应该是最好的选择。

以前也碰到过一例，42岁，因为似有似无的小管结构、透亮的胞质和长形的核，总是觉得像sertoli细胞瘤。

但是冰冻的问题还是没有解决，良恶性的问题，对于育龄期妇女还是大问题。

我经常担心在冰冻时印戒细胞间质瘤会与转移性消化道肿瘤混淆，毕竟冰冻时没有见过印戒细胞间质瘤。

精彩！期待！放化疗会影响肿瘤的免疫表型吗？

 硬化性间质瘤多发生于年轻妇女，80%发生于20-30岁女性。Young和Scully的43例和文献中21例的平均年龄为27岁。（from张建民·卵巢病理学；WHO2003蓝皮书）

不过我见过一例为50岁。