做病理的会说是好，关键是要会看，先不要说诊断是什么，先要概括看到了什么，然后哪几种疾病鉴别，要有一个正确的简洁的临床病理思维。

看看表面乳头状异型增生的结构，看看图1、3、4、6的肌束被异型腺体离断（不同于炎症时Aschoff-Rokitansky窦腺体的向下延伸），再看看图5中腺旁单个细胞浸润。

这个病例如果不诊断癌变，当断不断，若干年后见后患。

请随访看看。

 本例肯定是有问题的，只是目前还没有充分的证据说是浸润性癌，但疑癌。多取材。

说其有问题，是因为：

多量乳头状结构，部分区域乳头结构稍复杂；

腺腔的不规则性；

不规则腺体与平滑肌垂直生长，并呈横截状，是最怀疑为癌的区域，图6所示。

腺体周围促纤维反应（但非肿瘤性胆囊也可出现）；

腺上皮极性紊乱，细胞核不是一致的位于基底部，而是上上下下不一致；

细胞假复层；

细胞还是具有一定异型性。

如果重取还是这样，至少要发到高度上皮内瘤变。

Well differentiated adenocarcinoma of gallbladder is always a very difficult diagnosis to make. Equally difficult is a well differentiated pancreatic adenocarcinoma or cholangiocarcinoma with direct extension to gallbladder wall. I have seen rare cases of both diagnoses that showed very subtle changes. Stromal desmoplasia is always a worrisome sign, but many cases of chronic cholecystitis have Aschoff-Rokitansky sinuses extending from mucosa to muscle wall. Some normal gallbladder contain ducts of Luschka on the adventitia and subserosal soft tissue that are surrounded by desmoplastic stroma. All of these makes detection of primary gallbladder adenocarcinoma very difficult. I have always looked for epithelial dysplasia in the overlying mucosa to support the possibility of a rare incidental case of gallbladder adenocarcinoma. In the photos uploaded from this case, I do not see definite epithelial dysplasia. Certainly an isolated cell budding off the nearby gland and embedded in the stroma is very suspicious, but I would like to see deeper levels of this focus to better appreciate its three-dimensional extent before making a final judgement. I believe more extensive histologic sampling of the remaining specimen would definitely help. An interesting and challenging case this is!