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- Pap test with cervical bx result
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Last week I had a cervical bx case. I found the patient's recent Pap smear. I feel it is interesting case. Just take some photos and share with you here.
67 y women, Pap was negative in 2006, endometrial bx with endometrial polyp in 2007.The followings are the Pap last month. (上周有了这个病例的活检，并复习了这个病人最近的巴氏涂片。感觉这个病例很有意思，在这里贴些图片跟大家分享。病史：67岁女性，2006年涂片阴性，2007年子宫内膜活检为内膜息肉。这是上个月的巴氏随访涂片。)
Fig 1-4 400x
Fig 5 600x
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本帖最后由 于 2009-12-02 09:46:00 编辑
×参考诊断
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本帖最后由 于 2009-12-23 10:41:00 编辑
I hope people know that Pap test is most difficult area for cytopathologists even though a lot of people think it is very easy to read Pap (like several hundred Pap/day, need only a few days or few weeks of training for reading Pap). We all need to gradually 积累our experience in practice. We always need to think patient's clinical presentaion and previous Pap test and related history.（即使很多人认为阅巴氏涂片很容易<像每天阅几百张巴氏涂片，阅巴氏片只需要几天或几周的培训>，我仍然希望大家知道巴氏涂片对细胞病理医生来说是最困难的领域。我们需要逐步的从实践中积累经验。我们需要考虑病人临床表现、过往的巴氏涂片和相关的病史）
We need to know what clinicans will do based on our Pap interpretation.".（我们要知道基于我们的巴氏结果，临床医生会做什么处理。）
In fact I spent several hours on this topic and hope our pathologists or technicians to know only one thing "Pap test is a screening test（我花几个小时在这个主题是希望我们病理医生或技术员明白一件事情“巴氏试验是一个筛查试验”。）
Ok, I think I finish my duty for this case. Thank 掌心0164 ,青青 and all others who attended discussion, translation and read this topic.（好了。我认为我已经完成了这个病例。感谢掌心0164 ,青青子矜和所有参与讨论、翻译和阅读这个主题的网友。）
cz
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本帖最后由 于 2009-12-23 10:29:00 编辑
When I had biopsy I reviewed the Pap. Also I showed them to the pathologist who signed out the Pap. She still thought there are some glandular feature in biopsy. Please check the last histologic photo above. There are some nuclear palisading, feathering in the edges.（当我看活检片子的时候复阅了巴氏涂片。我也让签发巴氏报告的病理医生看了活检的片子。她仍然认为活检是腺的病变。请回顾前面的组织学照片。有一些核呈栅栏状、羽状边缘。）
For this reason I did squamous marker stains（因为这我做了鳞状标记）
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本帖最后由 于 2009-12-23 10:21:00 编辑
In our hospital (most hospitals in the US, cytotechnicians read Pap firstly, called primary screen, all abnormal Pap including reactive change et al will give pathologists to review and sign out. Cytotechnician input their interpretation in computer system, pathologists can make the final decision for the diagnosis. I can change whatever I like for final diagnosis. However, the primary interpretation of cytotechnicians can still be found in computer system. （在我们医院<美国的大多数医院>，细胞技术员先读巴氏涂片，也叫初筛；所有异常的涂片包括反应性改变都要给病理医生复核和签发报告。细胞技术员把他们自己的结果输入电脑系统中，病理医生做出最后诊断。我无论什么时候都可以更改最后诊断，但是技术员最初的结果仍然会在我们的系统中。）
For this case, the interpretaion of cytotech was invasive carcinoma and the case was singed out by our pathologist as AGC-FN. This pathologist called gynecologist to discuss the risk of cancer. Often cytotechnicians have more accurate diagosis. It is a pressure for pathologists to change cytotechnicans' interpretation. Of cause cytotech often over call. It is not a problem for cytotech to over call, but it is problem for them to low call or miss call.(这个病例，技术员的结果是浸润性癌但是我们病理医生最后签发的是AGC-FN。病理医生跟妇科医生讨论了叫癌的风险。通常细胞技术员会诊断得更准确，病理医生更改技术员的结果时面临很大的压力。当然技术员经常过诊，对技术员来说过诊没有关系，但是低诊或漏诊是大问题。）
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本帖最后由 于 2010-01-07 22:44:00 编辑
Share several points （分享几点：）
1. Clinical hx is important: old women with vaginal bleeding（临床病史很重要：老年女性伴有阴道流血）
2. positive HR-HPV testing（高危HPV检测阳性）
2. Several clusters of hyperchromatic crowded groups (HCGs) of cells impliy the presence of a high-grade lesion（一些深染拥挤细胞团表明可能出现在高度病变中）
3. Very few normal squamous cells are not normal pap（非常少的正常鳞状上皮细胞是不正常的涂片）
4. Something-like tumor diathesis background （背景中的肿瘤样素质）
5. Cell, nuclear shape: more spindles than columnar（细胞、核形：比柱状上皮更多的呈纺锤形）
6. It is easy to appreciate nucleoli.（核仁明显）
7. It is true the case shows some features of glandular and squamous lesion. If you observed carefully, cytologic features of the case favor more squamous lesion then glandular lesion（实际病例中有一些鳞状病变和腺病变的特征。如果你自己观察，这例的细胞特征更倾向于鳞状病变而不是腺病变。）
8. If it is squmous lesion, it should be HSIL or invasive ca. Clearly it is not like a classic HSIL case. Tumor diathesis and nucleoli are two important features to distinguish invasion from HSIL or in situ ca.（如果是鳞状病变，应该是HSIL或浸润癌。显然这不是一个典型的HSIL病例。肿瘤素质和核仁是鉴别HSIL和浸润癌的两个重要特征。）
9. It is a difficult case for cytologic disgnosis. I think it is acceptable if we call this case as ASC-H, AGC, AGC-FN. Bottomline is that you need to contact with clinician to make sure the women had tissue biopsy. It is a bad call if you call asc-us or negative for this case. It is better to study more before you sign out Pap case independly（这是一个细胞学诊断疑难病例。如果我们叫这个病例为ASC-H、AGC或AGC-FN是可接受的。底线是你必须跟临床沟通让这个病例有组织学活检。如果叫ASCUS或阴性是比较糟糕了。在你独立签发巴士涂片报告之前需要更多的学习。）
10. Pap is a screening test. In your clinical practice, until you are 100% sure it is squamous carcinoma or adenocarcinoma, please do not use the term.（巴氏涂片是一个筛查。在您的临床实践中，除非您能100%肯定是鳞癌或腺癌，否则请不要用那么肯定的术语。）
11. It is not unusual that we meet the cases in clinic that patients with invasive squamous ca had true negative Pap within few years. It means that some invasive cases can develop very quickly, but not like the usual way, step by step: HPV-CIN1-CIN2/3-invasion.(我们在临床工作中遇到几年前巴氏确实是阴性而几年后是浸润性鳞癌的病例并不少见。这表明一些浸润病例可以进展很快，但是不像普通的进展模式，逐步进展：HPV-CIN1-CIN2/3-浸润。)
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本帖最后由 于 2009-12-23 09:20:00 编辑
| 以下是引用掌心0164在2009-12-20 13:10:00的发言： 盼星星盼月亮终于盼来了赵老师最终的结果。回过头来总结我还是那句话：细胞学是组织学的片段。对我来说，有时需要解释病例的时候是痛苦的；因为没有组织学基础；单纯从细胞学看细胞学会时不时感觉到力不从心。现在我想请赵老师您从细胞学和组织学结合起来整个思路的分析给我们讲述一下。谢谢赵老师完整而精彩的病案。 |
Knew that Dr. 巴山夜雨涨秋池 and 法师 are excellent cytopathologist s and noticed that you had excellent interpretaion for many cases in the web.
I am interested to know you interpretation for my case. 请.
Of cause, welcome all of you to share your impression.
I will take some photos from histological sample in the sollowing days and paste here in the weekend.
Thanks
cz
| 以下是引用海浪信使在2009-12-9 10:57:00的发言： 这个病例是挺有意思的！先说一下俺的观点：高级别鳞状上皮内病变，对应的组织学为CINⅢ级（或伴有累腺，只在第三次图片中有提示）。再说一下俺的问题：对于病史我比较感兴趣，07年子宫内膜活检的原因是什么？相对应的临床症状是什么？有没有相对应的细胞学检查结果？此次来就诊相对应的临床症状又是什么？ |
They are good questions. I gave all information I had above. Patient saw doctor this time due to vaginal bleeding.
It is right whenever we sign out Paps we should try to know patients' hx especially for some difficult cases.
All patients's previous pathologic reports can be found in our database if they were reported in UPMC system (about 20 hospitals).
Can you check previous pathologic reports in computer in China?
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本帖最后由 于 2009-12-09 19:00:00 编辑
My dear pathology or cytology friends:（我亲爱的病理学或细胞学朋友们：）
I noticed that very few of you share your oppinion. I do not know why. Maybe I should not tell you I had histologic results in the begining. Seems that more people enjoy discussing the cytology cases (including body fluid, FNA) without final conclusion. Ha, ha. （仍然很少人来分享你们的观点。我不知道为什么，我应该在开始的时候不告诉你们已经有了组织学结果。看来更多的人喜欢讨论那些没有最后结论的细胞学病例（包括体液、FNA），哈哈。）掌心0164翻译
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本帖最后由 于 2009-12-09 18:56:00 编辑
掌心0164 : 我们不知道做没有做HR-HPV和B超等等相关的检查。Good question. I will give clearly pathology history I knew in our system.（很好的问题。我给出所有我知道的病理学病史。）
1. December 2006, Pap negative. I reviewed the smear. At most we can call ascus. Before this date, no more histology in our data base.（2006年12月，巴氏涂片阴性。我复阅了该片，最多叫ASCUS。在这之前，数据库里没有任何该病人的病史资料）
2. Feb 2007 enmotrial polypectomy, dx of hyperplastic endometrial polyp, benign.（2007年2月，宫内膜息肉切除术；诊断宫内膜增生性息肉，良性。）
3. November 6, 2009. Vaginal bleeding. Pap test and small biopsy "called endometrial biopsy". I took photos from this Pap. In the same time HR HPV was positive. HPV testing regardless of Pap result.（200911月6日，阴道流血。做了巴氏涂片和小活检“叫内膜活检”。我已经贴了这次的巴氏的图片。不管巴氏结果如何同时进行了高危HPV检测呈阳性。）
4. November 23, 2009. Cervical biopsy. I signed out this case.（2009年11月23日，宫颈活检，我签发这个病例。）
This is all I knew about the history of the patient.（这是我知道关于这个病人所有的病史）
| 以下是引用青青子矜在2009-12-6 17:33:00的发言：
哈哈，真有意思！ 谢谢赵老师不辞劳苦继续传图，也谢谢掌心的辛苦翻译工作。 的确，看了第三次图片，我又改变思路啦。 看第一幅图片，背景出血坏死，有些散在细胞，细胞虽然很小，但核浆比高、染色质非常深染似墨水点，这应该是高度病变细胞； 第三幅放大图片，团块松散，似乎有两种细胞，而且有明确水平排列细胞（这是鳞的特点而非腺），但同时也有飞起来的腺的特点。所以现在我考虑： 1、HSIL，累及腺体； 2、腺鳞癌。 以上是考试的答案，发报告的话退一步好了，保证后续临床处理一样就可以 不知道妇科检查宫颈肉眼所见如何？有糜烂或新生物吗？ |
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本帖最后由 于 2009-12-06 15:39:00 编辑
1. I am 砌楼 to see 掌心0164 's interpretation.（我砌楼想看看掌心的解释）
2. 青青子矜 : you can change your interpretion if you want to when you see more photos. The bottomline is that I did not say your current interpretation is not reasonable-no comment.（青青子矜：你看到更多图片之后可以更改你自己的解释。底线是我没有对你目前的诊断给出评价。）
3. Of cause i hope more people share your oppinion. （当然我希望更多的人来分享你们的观点）
4. I noticed that many Pap cases in this section were interpretated with different ways, normal-atypical-malignant. However, there are often no histologic correlation. So finally what do you learn from these equivical cases? Pap is a screening test, histology is gold standard. Of cause the lesions can be missed in histologic follow up.（我注意到在这个专栏很多巴氏病例用不同的方式来解释，正常——非典型——恶性。但是，同时没有组织学对照。最后你们从这些模棱两可的病例学到什么呢？巴氏涂片是一个筛查，组织学是金标准。当然这些病变可能在组织学随访中被漏掉。）
5. I had to do my today's work-55 Pap sign out now. By the way I noticed a talk in this section pathologists can read several hundreds of Pap for one day without the primary screen of cytotechnicians. I think it is crazy. （我得开始今天的工作——55张巴氏异常片等着发报告。顺便说一句，我看到一个讨论中提到在没有细胞技术员初筛的情况下一天看几百张巴氏涂片，我认为那太疯狂了。）
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本帖最后由 于 2009-12-06 15:26:00 编辑
| 以下是引用青青子矜在2009-12-4 11:04:00的发言：
总之这个病例很棘手，赵老师也“no more clue”提示，最主要没有周围其它视野散在细胞的对照。 |
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本帖最后由 于 2009-12-06 17:12:00 编辑
come here to check. Interesting. Still very few heroes here gave the interpretation. When American people know 50% of the questions they will think they know 90%. When our chinese people know 90%, we will say we know only 50%. We Chinese people consider our "reputation" too much. In fact it does not mean you are wrong if your Pap interpretation does not match the final histologic dx. （来这里逛逛，有趣的是，仍然很少人愿意当“英雄”给出自己的解释。美国人，只有半桶水他们认为自己接近满桶水；而我们中国人，接近满桶水却说自己只有半桶水。我们中国人太注重“面子”。实际上，即使你的巴氏涂片的跟组织学结果不一致也不意味着你是错的。）掌心0164翻译
