已经连续上了10天班，极度疲惫

今天在和同事讨论肺的粘液表皮样癌的时候，针对她认为的一例肺的粘液表皮样癌我提出不同意见，认为是腺鳞癌，就此大家开始了痛苦的求索过程，现在我想就这个问题和大家讨论一下，如何鉴别高级别的粘液表皮样癌与腺鳞癌？

What an excellent question. I copied a paragraph from AFIP Series III Fascicle 13 p. 281 -

According to Yousem and Hochholzer, a high-grade mucoepidermoid carcinoma is an exophytic tumor in the proximal bronchial tree that lacks carcinoma in situ in the surface epithelium; is composed of a random mixture of sheet-like and glandular cells lacking individual cell keratinization and squamous pearl formation; and shows areas of low-grade mucoepidermoid carcinoma. Most adenosquamous carcinomas are peripheral, and all produce keratin or have intercellular bridges. In mucoepidermoid carcinomas, glandular differentiation usually manifests as scattered goblet cells rather than as tubular, acinar, or papillary growth patterns.

 不好意思，一直很忙，很长时间没有能够把讨论的结果向大家汇报，现在就汇报一下

在WHO中，也有类似于 mjma 老师引用的地方，具体如下

诊断高级别粘液表皮样癌典型的标准包括

1、外生性支气管内生长（因此大多数粘液表皮样癌是中心性的，如果是外生性，腺鳞癌或者转移性癌的可能性更大一些，因为一般认为该肿瘤是由气管支气管粘液腺内的原始细胞分化而来，但是也有一些高级别粘液表皮样癌具有向外周侵袭，而不仅仅局限于中心）

2、表面上皮缺乏原位癌改变

3、缺乏单个细胞角化和鳞状角化珠形成（这一点不知道如何理解）

4、有向低级别粘液表皮样癌的移行区

查阅了一下他所引用的文献

1  Yousem SA, Hochholzer L. Mucoepidermoid tumors of the lung. Cancer, 1987, 60:1346-1352.

A major problem in diagnosis posed by these lesions is the distinction of high-grade mucoepidermoid tumors and adenosquamous (adenoepidermoid) carcinm a . Ambiguities in histologic identification have resulted in differences in opinions, focusing primarily on the presence of keratinization, squamous pearl formation, and parenchymal involvement. Because of these conflicts the following criteria for highgrade mucoepidermoid tumors was adapted from Klacsmann et al: (1) tumor was located in the proximal bronchial tree and had an exophytic endobronchial component; (2) the surface epithelium lacked changes of in situ carcinoma; (3) the tumor contained a random admixture of solid sheetlike and glandular areas, along with heterogeneous cellular constituents (described in text), but lacked abundant individual cell keratinization and squamous pearl formation; and (4) the tumor had transitional areas to low-grade mucoepidermoid tumor. Any tumor which did not satisfy all of these criteria was excluded from this study.

Klacsmann的那篇文章没有继续查找

Klacsmann PG, Olson JL, Eggleston JC. Mucoepidermoid carcinoma  of   the bronchus. Cancer 1979; 43: 1720-1733.