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- A pap case yesterday-the patient will have biopsy soon
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本帖最后由 于 2009-09-29 05:10:00 编辑
Hope some ones can answer the following questions.
1. Tumor cells are positive for p16, cea, negative for vimentin and ER. They are very typical pattern for ( ? ) adenocarcinoma.
2. Based on the H&E, IHC, clinical prsentation, what is the full dx for this case?
3. Do you think women should have hysterectomy?
Thank all of you reading or participating discussion for this topic. Basically I finish my duty for this topic. cz
尝试翻译：（海浪信使）
希望（有兴趣的）一些网友可以回答下列问题。
1、肿瘤细胞中p16阳性，CEA、Vimentin和ER为阴性。他们是非常典型的（？）腺癌模式。
2、based on HE、免疫组化、临床资料, what is your final diagnosis?
1、肿瘤细胞中p16阳性，CEA、Vimentin和ER为阴性。他们是非常典型的（？）腺癌模式。
2、based on HE、免疫组化、临床资料, what is your final diagnosis?
3、你认为患者应该做子宫切除术吗？
4. What is staging (at least) for this case?
谢谢各位阅读或参与这一病例的讨论。基本上我完成了这个病例我所做的工作。
谢谢各位阅读或参与这一病例的讨论。基本上我完成了这个病例我所做的工作。
Thank 海浪信使. cz
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本帖最后由 于 2009-09-28 11:40:00 编辑
recently I noticed Pap section is very hot due to the effort of benzhu, assistants, and all of you. It is great. Cervical cancer screening is a very important work in China. We still have a long way to 达到world advanced level. It needs all people 共同effort including our pathologists.
Suggestion: When you have histologic follow up result for the Pap smears you pasted in the web, please paste the photos of histologic results if you can. This is a good way for us to learn. Thanks, cz
尝试翻译（海浪信使）：
最近我留意到宫颈细胞学版块在版主、助理和大家的共同努力下变的很火！这是非常好的。宫颈癌筛查在中国是一个非常重要的工作，仍然需要漫长的道路才能达到世界先进水平。它需要包括我们的病理学家在内的所有人的共同努力。
建议：当你在宫颈抹片的帖子中跟进报告组织病理学检查结果的时候，请附上组织病理学结果的照片，如果你能够做到的话。这是一种很好的学习方法。谢谢！
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本帖最后由 于 2009-10-11 21:41:00 编辑
十分感谢赵老师的病例，也感谢掌心和青青还有海浪的翻译，使我看完了整个帖子。我在看第二张片子就感觉是癌，第三张就肯定是了腺癌了，这也许是源自我多年组织学的经验吧。但是我对掌心的那句”在中国细胞医生是被组织医生看不起"那句话有很大的意见的。细胞只是后起之秀。我觉得细胞很重要。现在不管是三级医院还是二级医院都在逐步完善细胞医生的培训。我再给我的下级医生讲TCT时，就要求他们把看见的细胞放在宫颈鳞状上皮的层次中去看，觉得在哪一层是最贴切的。我们现在在细胞学上，越来越多的为临床提供可靠的依据。正如赵老师那样，在发现有疑问时我们都会往下做，再涂片--做HE--做组织块--做免疫组化。同时培养优秀的技术员。我想在为自己事业作出方向时，就要为更多的病人减轻痛苦。我们的细胞学应用得到被越来越多临床医生们认可。
每次赵老师的帖子都很有意思，很有思想，不但在叫我们怎样看片，指导诊断思路，还引伸我们如何指导临床的下一步措施，还有号召网友们做事有始有终。我敬仰您！！
| 以下是引用cqzhao在2009-9-28 4:14:00的发言：
Hope some ones can answer the following questions. 1. Tumor cells are positive for p16, cea, negative for vimentin and ER. They are very typical pattern for ( ? ) adenocarcinoma. 2. Based on the H&E, IHC, clinical prsentation, what is the full dx for this case? 3. Do you think women should have hysterectomy? Thank all of you reading or participating discussion for this topic. Basically I finish my duty for this topic. cz 尝试翻译：（海浪信使） 希望（有兴趣的）一些网友可以回答下列问题。
1、肿瘤细胞中p16阳性，CEA、Vimentin和ER为阴性。他们是非常典型的（？）腺癌模式。 2、based on HE、免疫组化、临床资料, what is your final diagnosis? 3、你认为患者应该做子宫切除术吗？
4. What is staging (at least) for this case?
谢谢各位阅读或参与这一病例的讨论。基本上我完成了这个病例我所做的工作。 Thank 海浪信使. cz
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seems our pathologists are not interested to these clinical questions.
Clearly this is invasive adenosquamous carcinoma.
You can find answers from the web about staging and standard treatment for this patient.
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp
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本帖最后由 于 2009-10-15 18:31:00 编辑
| 以下是引用cqzhao在2009-9-28 4:07:00的发言：
Above IHC is ki67. The other IHC results in bladder wall biopsy specimen are also the same as that in cervical biopsy specimen. |
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本帖最后由 于 2009-10-15 18:44:00 编辑
| 以下是引用cqzhao在2009-9-28 4:14:00的发言：
Hope some ones can answer the following questions. 1. Tumor cells are positive for p16, cea, negative for vimentin and ER. They are very typical pattern for ( ? ) adenocarcinoma. 2. Based on the H&E, IHC, clinical prsentation, what is the full dx for this case? 3. Do you think women should have hysterectomy? Thank all of you reading or participating discussion for this topic. Basically I finish my duty for this topic. cz 尝试翻译：（海浪信使） 希望（有兴趣的）一些网友可以回答下列问题。
1、肿瘤细胞中p16阳性，CEA、Vimentin和ER为阴性。他们是非常典型的（？）腺癌模式。 2、based on HE、免疫组化、临床资料, what is your final diagnosis? 3、你认为患者应该做子宫切除术吗？
4. What is staging (at least) for this case?
谢谢各位阅读或参与这一病例的讨论。基本上我完成了这个病例我所做的工作。 Thank 海浪信使. cz
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懒了很多天，今天终于得空重新看完了全帖，现在来回答这些问题。
1、宫颈腺癌。“肿瘤细胞中p16阳性，CEA、Vimentin和ER为阴性"但一般宫颈腺癌的CEA也常常是阳性，呵呵；
2、宫颈腺鳞癌(有明确腺癌成分，另实性巢团部分CK5/6和P63都为阳性，这是鳞的标记)，转移或浸润到膀胱壁；
3、不需要了。放化疗时首选；
4、膀胱壁有转移，至少是临床III期以上（盆腔内），四期是有远处转移。而宫颈癌IIb以上就不再是外科手术切除的指征，鳞癌对放疗敏感，但此例的预后就很难说了。
期待赵老师指正。感谢海浪的不辞劳苦。
| 以下是引用cqzhao在2009-10-13 18:48:00的发言：
seems our pathologists are not interested to these clinical questions. Clearly this is invasive adenosquamous carcinoma. You can find answers from the web about staging and standard treatment for this patient. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp |
赵老师您有误会，不是我们病理医生对临床问题不关心，而实在是我们版细胞病理医生大部分都不做组织，临床知识不是太好，呵呵。您要常来指导，我们就进步得快了。
我们做的是临床病理，不仅临床病史对我们的诊断有很大帮助，而且作为一个合格的病理医生，临床知识尤其是诊断的临床处理是一定要熟悉的，这对我们诊断度的把握非常重要，这样进退才能自如，这样才能谈得上对临床医生的治疗进行指导。。。
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本帖最后由 于 2009-10-15 20:52:00 编辑
因为是细胞专栏，所以我想再啰嗦一下前面细胞的诊断。
重新再回过头来看，当时我是“一叶障目，不见森林”。只看到了典型腺的病变（图2、4）而忽视了:成团细胞的鳞病变的可能（图1）。为此我专门学习了一下，以下供大家参考。
HSIL:深染的拥挤细胞群
HSIL可以呈现为单个细胞、片状、未成熟细胞构成的厚的三维立体簇，这些细胞簇有时表现为深染的拥挤细胞群(A)。有几种病变可以类似于这种深染拥挤群，如：（1）萎缩背景中的萎缩性基底样细胞簇，但这些细胞拥有低N:C比、胞核无变化、无核分裂(B)；（2）腺上皮病变常表现为拥挤群，良性宫颈内膜细胞的胞核位于基底部、胞质内粘液、胞核大小和外形几乎无变化；（3）输卵管化生细胞群也可能相当拥挤，伴随有N:C比的增加，但常有顶部纤毛、胞核大小和形状变化小；（4）良性剥脱性子宫内膜细胞，常含有胞质内空泡和规则的小胞核；（5）子宫下段（LUS）片段，胞核很象剥脱的子宫内膜细胞，常排列为管状，或与间质细胞相关联；（6）宫颈AIS细胞同样可类似于HSIL，核膜不规则、不同程度的核增生及易见的核分裂，然而AIS群的外围细胞常排成柱状。
深染细胞群：良性到HSIL
HSIL细胞常常表现为深染的拥挤群，常排列为三维结构、厚的发育不良的鳞状细胞簇，这些细胞群代表的是表面上皮的全层碎片或远离宫颈腺隐窝的粘附性群团。它们在现代的取样器条件下更易出现，因其细胞厚度和深染带来了诊断的困难和挑战。在HSIL，还有核膜的不规则，这个特点在细胞簇的边缘更明显；核分裂和凋亡小体常见。另外，正如前面提到的单个未成熟鳞状细胞从NILM到 HSIL都可见，这种谱系变化在深染的拥挤细胞群同样存在，从良性化生细胞群、到ASC-H、一直到HSIL，在这个变化过程中：深染和N:C比增加、核膜不规则变得更明显、胞核大小多型性也增加。
| 以下是引用青青子矜在2009-10-15 18:13:00的发言：
懒了很多天，今天终于得空重新看完了全帖，现在来回答这些问题。 1、宫颈腺癌。“肿瘤细胞中p16阳性，CEA、Vimentin和ER为阴性"但一般宫颈腺癌的CEA也常常是阳性，呵呵； 2、宫颈腺鳞癌(有明确腺癌成分，另实性巢团部分CK5/6和P63都为阳性，这是鳞的标记)，转移或浸润到膀胱壁； 3、不需要了。放化疗时首选； 4、膀胱壁有转移，至少是临床III期以上（盆腔内），四期是有远处转移。而宫颈癌IIb以上就不再是外科手术切除的指征，鳞癌对放疗敏感，但此例的预后就很难说了。 期待赵老师指正。感谢海浪的不辞劳苦。 |
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本帖最后由 于 2009-10-18 09:18:00 编辑
adenocarcinoma component of this case is positive for p16, CEA, negative for vimentin and ER. So it is very calssic pattern for endocervical adenocarcinoma.
Tis is a very classic invasive adenosquamous carcinoma of cervix.
本例的腺癌成分是p16、 CEA阳性，vimentin 、ER阴性，所以这是个经典的宫颈腺癌表达模式。
这是例典型的宫颈浸润性腺鳞癌。（青青子矜译）
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本帖最后由 于 2009-10-18 09:53:00 编辑
- Stage IA: Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm.
- Stage IA1: Stage IA1: Measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm diameter.
- Stage IA2: Stage IA2: Measured invasion of stroma greater than 3 mm but no greater than 5 mm in depth and no wider than 7 mm in diameter.
- Stage IB: Stage IB: Clinical lesions confined to the cervix or preclinical lesions greater than Stage IA. All gross lesions even with superficial invasion are Stage IB cancers.
- Stage IB1: Stage IB1: Clinical lesions no greater than 4 cm in size.
- Stage IB2: Stage IB2: Clinical lesions greater than 4 cm in size.
- Stage IIA: No obvious parametrial involvement. Involvement of up to the upper two-thirds of the vagina.
- Stage IIB: Obvious parametrial involvement, but not into the pelvic sidewall.
- Stage IIIA: No extension into the pelvic sidewall but involvement of the lower third of the vagina.
- Stage IIIB: Extension into the pelvic sidewall or hydronephrosis or non-functioning kidney.
- Stage IVA: Spread of the tumour into adjacent pelvic organs.
- Stage IVB: Spread to distant organs.
FIGO stage: Tomor is metastatic to the wall of bladder. It should be at least stage IIB. If tumor metastatic to the mucosa of bladder and recturm or beyond true pelvis it is stage IV. We do not know if the tumor speads to the low third of vagina or pelvic wall. Bladder wall is a parametrial organs. This is why I think the tumor is at least stage IIB. Correct me if i am wrong.
FIGO分期：肿瘤转移到膀胱壁，应该是至少临床IIB以上。如果肿瘤转移到膀胱粘膜层和rectum（这里好像有笔误，我的理解是rectum--直肠--((I am wrong, you are right）或真骨盆，应该是临床IV期。我们不知道如果肿瘤超出了阴道的下1/3或骨盆壁，其分期又是怎样？膀胱壁是子宫旁器官，这是我认为该肿瘤的临床分期至少在IIB以上的原因。如果我错了，请纠正。
呵呵，赵老师谦虚。（青青子矜）
具体FIGO分期不再翻译，请感兴趣的网友自己参考中文译本
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FIGO STAGING OF CERVICAL CARCINOMAS | ||
| Stage I | ||
| Stage I is carcinoma strictly confined to the cervix; extension to the uterine corpus should be disregarded. The diagnosis of both Stages IA1 and IA2 should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion. |
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| Stage II | ||
| Stage II is carcinoma that extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third. |
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| Stage III | ||
| Stage III is carcinoma that has extended into the pelvic sidewall. On rectal examination, there is no cancer-free space between the tumour and the pelvic sidewall. The tumour involves the lower third of the vagina. All cases with hydronephrosis or a non-functioning kidney are Stage III cancers. |
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| Stage IV | ||
| Stage IV is carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum. |
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本帖最后由 于 2009-10-18 10:00:00 编辑
Pts with stage II should get radiation and chemotherapy. This is why we may not see the hysterectomy specimen for this patient.
you can check detailed information for staging and treatment for cancer from NCCN guideline -the version of translation, provided by Dr. Lotus from another topic.
临床II期以上的病人应该是放化疗，这是为何我们看不到这个病人的子宫切除标本的原因。
你们可以参照NCCN指引（website provided by Dr. Lotus ）来核对肿瘤临床分期和治疗的详细资料。详见下列网址：
另外：我记得应该是具体到IIb以上的病人才失去手术机会，只做放化疗。（青青子矜）
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本帖最后由 于 2009-10-18 09:46:00 编辑
| 以下是引用cqzhao在2009-9-28 4:14:00的发言： Hope some ones can answer the following questions. 1. Tumor cells are positive for p16, cea, negative for vimentin and ER. They are very typical pattern for ( ? ) adenocarcinoma |
谢谢赵老师，我只看了海浪的翻译，没仔细看您的原文，抱歉抱歉！我还说怎么有点不一致呢，真不好意思！不过我又回头看了一下标记表达，cea只能算作弱阳？？
关于宫颈癌的临床分期，我只是凭着印象来说，没仔细核对，在赵老师如此仔细认真的治学态度面前，真是羞愧难当 
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