女  75岁

病史：绝经30年，阴道少量出血3天。乳腺癌术后2年余，口服他莫昔芬1年，现已停药1年余。

手术所见：宫腔深9厘米，宫内不平感，较硬。

彩超：宫腔内多个小结节，大的6*5毫米，无回声。

巨检：灰褐色碎组织一堆，共直径0.8厘米。

 Difficult case.

Basically I agree with Abin's oppinion. The morphology does not like typical metastatic breast ca. You can review the breast ca case and compare the morphologic features.

H@E shows focal glandular proliferation with hobnail pattern and clear cytoplasm. Is this serous carcinoma or serous endometrial intraepithelial ca? It does not look like. Do IHC for p53 and WT1. Serous tumor should be strongly and diffusely positive for them, especially for P53. Of cause Clear cell ca can be positive also.

My feeling is that the lesion is a clear cell lesion. Clearly they are clear cells, hobnail growths. Nuclei are large in high power even though they are not so urgly.

Now the queation is that it is reactive change to hormon or neoplastic lesion. I have difficulty to make the judgment based on the photos. It is true it is not a classic picture of clear cell carcinoma, but i cannot completely exclude.

You can call atypical glandular proliferation with clear cell feature and suggest to get more tissue for definite diagnosis.

Just suggestion.

cz

Difficult case.本例为疑难病例，Basically I agree with Abin's oppinion.我基本上同意ABIN的分析， The morphology does not like typical metastatic breast ca.形态上不象典型的转移性乳腺癌， You can review the breast ca case and compare the morphologic features.你可以复习她过去的乳腺癌的切片，与现在的形态做一比较分析，H@E shows focal glandular proliferation with hobnail pattern and clear cytoplasm. HE切片上出现局部腺体增生伴有鞋钉样细胞和透明的胞浆，Is this serous carcinoma or serous endometrial intraepithelial ca? 这是浆液性癌或浆液性子宫内膜上皮内的癌吗？It does not look like.看上去不象， Do IHC for p53 and WT1.做免疫组化p53和 WT1。 Serous tumor should be strongly and diffusely positive for them, especially for P53. 浆液性肿瘤就该是弥漫性强阳性，特别是P53。Of cause Clear cell ca can be positive also.当然透明细胞癌也可以阳性。My feeling is that the lesion is a clear cell lesion.我自己感觉这是一例透明细胞病变。 Clearly they are clear cells, hobnail growths.很明显这是透明细胞，鞋钉样细胞生长。 Nuclei are large in high power even though they are not so urgly. 高倍镜下看，核大，尽管看上去并不恶。Now the queation is that it is reactive change to hormon or neoplastic lesion. 现在问题是它是一个对激素反应性的改变还是肿瘤性病变。I have difficulty to make the judgment based on the photos. 根据这些形态我难以做出判断。It is true it is not a classic picture of clear cell carcinoma, but i cannot completely exclude. 确实，这不是典型透明细胞癌的图像，但我也不能完全排除。You can call atypical glandular proliferation with clear cell feature and suggest to get more tissue for definite diagnosis.你可以称为伴有透明细胞特征的非典型腺体增生，建议再次活检获得更多组织以明确诊断。Just suggestion.cz仅供参考。赵大夫/

 Thinking the case and check the phtos again.

Agree with Dr. Yu.

1. Endometrial polyp.

2. Habnail pattern, may be habnail metaplasia.

3. The clear cell change may be Arias-Stella-like change related to the tamoxifen treatment. Arias-Stella-like change can be mimic of adenocarcinoma, especially clear cell carcinoma.

So I will choose endometrial polyp with Arias-Stella change if it is a question.

But in the true case I may still call polyp with atypical gland proliferation. Then write the comment with differential dx, and favoring dx

Anyway, p53 and ki67 may be helpful.

 这个不像乳腺癌转移。

他莫昔芬治疗已经停药1年余，很难将它与本病变联系起来。他莫昔芬引起的癌多为子宫内膜样癌，本例也不像。

本病变的基本改变是：息肉中的腺体改变。本例重要的是区分：良性化生？异型增生？癌（透明细胞癌和浆液性癌）？p53和Ki67可能有助于鉴别。

Crum CP所著的妇产科诊断病理学中，提到一种“钉头样化生”，可能伴发透明细胞癌或浆液性癌。也许正是本病变？

如果不能判断病变性质，可以密切随访，必要时再次诊刮。

由于对本病变认识不足，期待有经验的老师进一步讲解。谢谢！

不觉得是她服用激素之后的病变吗？我不觉得是癌。只有非典而已，这个病例请妇幼医院的老师指导指导啊。期待！！

 好像看不出转移的迹象，更不像乳腺癌转移。

内膜腺体部，分无异常，部分如图所示，细胞钉突样，有的核大异形，未见分裂相。现在甚至不能肯定病变为恶性。请大家再仔细看看。