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- 同时发生卵巢肿物，子宫内膜肿物，宫颈原位癌。
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| 姓 名： | ××× | 性别： | 女 | 年龄： | 72岁 |
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| 简要病史： | |||||
| 肉眼检查： | 一侧附件切除标本，卵巢为一卵圆形结节状肿物所替代，大小7×4．5×3．5厘米，表面光滑，切面灰黄色，分叶状，质中。一侧附输卵管，长5．5厘米，直径0．5厘米，伞端开放，表面可见多个小囊肿，灰白色，壁薄，直径0．2－0．4厘米。 2、子宫及一侧附件切除标本，子宫大小9×7．5×4．5厘米，宫颈长3．5厘米，外口直径3厘米，可见一息肉，直径0．8厘米，外口粗糙，充血，子宫肌壁厚2．6厘米，未见肌瘤，内膜厚0．2厘米，子宫腔体、底部内膜可见广基底息肉状肿物，4×3×0．8厘米，切面灰白色，质中，未累及肌层。输卵管长6厘米，直径0．5厘米，表面颗粒状，伞端开放，卵巢大小3×1．5×0．8厘米，表面光滑，切面灰白色，质硬，宫颈一侧见一囊肿，直径0．7厘米，内壁光滑。 | ||||
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本帖最后由 于 2010-01-16 15:40:00 编辑
×参考诊断
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本帖最后由 于 2010-01-20 03:10:00 编辑
（1） 卵巢：纤维瘤/卵泡膜瘤 fibrothecoma, 细胞的密度比较大，可以叫 cellular fibrothecoma。如果分裂相＞＝４个核分裂/10个HPF－－＞就叫ｍｉｔｏｔｉｃａｌｌｙ ａｃｔｉｖｅ cellular ｆｉｂｒｏｔｈｅｃｏｍa。
Am J Surg Pathol. 2006 Aug;30(8):929-38.
Cellular fibromas of the ovary: a study of 75 cases including 40 mitotically active tumors emphasizing their distinction from fibrosarcoma.
Irving JA, Alkushi A, Young RH, Clement PB.
Department of Pathology, Vancouver General Hospital and the University of British Columbia, Vancouver, BC, Canada. Julie.Irving@vch.ca
Cellular fibroblastic tumors of the ovary are currently classified as either cellular fibroma (CF) or fibrosarcoma. The former are characterized by bland nuclei, 3 or fewer mitotic figures per 10 high-power fields (MFs/10 HPFs), and a low malignant potential, whereas fibrosarcomas usually have severe nuclear atypia, > or = 4 MFs/10 HPFs, and an aggressive clinical course. The prognosis of cellular fibromatous tumors with > or = 4 MFs/10 HPFs and low-grade cytology is not established and it is the purpose of this study to investigate that aspect. It has been our anecdotal experience that otherwise typical CFs with > or = 4 MFs/10 HPFs usually have a benign clinical course, suggesting that such tumors should be regarded as "mitotically active cellular fibroma" (MACF) rather than fibrosarcoma. Seventy-five cellular fibromatous neoplasms were analyzed to determine their clinicopathologic features and the appropriateness of "MACF" as a designation for otherwise typical CFs with > or = 4 MFs/10 HPFs. The mean age of patients with CF (n = 35, 0 to 3 MFs/10 HPFs) and MACF (n = 40, > or = 4 MFs/10 HPFs) was 51 and 41 years, respectively. Patients most commonly presented with symptoms related to a pelvic mass. All tumors were unilateral. The mean tumor size of CFs was 8.0 cm and 9.4 cm for MACFs. The majority of the tumors were solid; approximately one-third of them had a cystic component. Ovarian surface adhesions, involvement of the ovarian surface, or both, was present in 6% of CFs and 10% of MACFs. Eleven percent of CFs and 13% of MACFs were associated with extraovarian involvement. All tumors consisted of cellular, intersecting bundles of spindle cells with bland nuclear features. The mean highest mitotic count for MACFs was 6.7 MFs/10 HPFs (range 4 to 19 MFs/10 HPFs). Follow-up of 3 months to 12 years (mean 4.75 y) was available in 18 of the 40 patients with MACFs and was uneventful in all cases. We conclude that cellular fibromatous neoplasms with bland cytology and elevated mitotic counts are associated with favorable patient outcome and should be diagnosed as MACF rather than fibrosarcoma, which usually have moderate to severe atypia and elevated mitotic rates. As prior observations have shown that even typical CFs can occasionally recur locally, particularly if they are associated with rupture or adherence, long-term follow-up for patients with CFs and MACFs is appropriate.
（2） 子宫： 看起来是浆液性癌（endometrial intraepithelial carcinoma EIC 或者uterine serous carcinoma，需要看肿瘤大小和是否有浸润), 做个ｐ５３和ｐ１６，Ｋｉ６７。EIC好发于老年人的子宫息肉。
| 以下是引用dujun0522在2010-1-17 11:57:00的发言：
If there is still doubt, alpha-inhibin and calretinin can settle the dispute once and for all. 卵泡膜细胞瘤和颗粒细胞瘤是不是都会表达alpha-inhibin and calretinin ？ |
Yes.
Some 卵泡膜细胞瘤 can be focally positive for alpha-inhibin and calretinin. But 颗粒细胞瘤geneally are diffusely positive.
The ovarian tumor is a cellular fibroma or fibroma/thecoma. I do not see vacuolated cytoplasm to suggest luteinization. There is no hemorrhage, necrosis, cytologic atypia or diffuse brisk mitotic activity to suggest fibrosarcoma. WHO classification of ovarian fibroma has a criterion emphasizing the importance of mitotic count; <4 mitoses/10 high-power fields is seen in benign fibroma, and >3 mitoses/10 high-power fields is seen in fibrosarcoma. It is important to note that this criterion is outdated now. In 2006 an authoritative article published in American Journal of Surgical Pathology by Young and Clement has clearly shown a category of "mitotically active cellular fibroma" among cellular fibromas that contains >3 mitoses/10 high-power fields (mostly in focal areas only and not diffuse) and remains benign in biological behavior, even in the presence of hemorrhage and necrosis. Therefore, do not diagnose ovarian fibrosarcoma unless there is atypia and the high mitotic rate is observed diffusely in a large ovarian spindle cell tumor.
The endometrial growth appears to be hyperplastic polyp with proliferative glands. Figures 48, 50, 52 and 54 display some smaller endometrial glands lined by crowded epithelia with high nucleocytoplasmic ratios that suggest focal atypia (I am not sure it is based on the photos, more would help). There is no features of invasive endometrioid adenocarcinoma or endometrial intraepithelial carcinoma of the serous type.
聞道有先後,術業有專攻
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One differential diagnosis brought up by the case presenter is sarcomatoid granulosa cell tumor, which is why so many photos of reticulin silver stain were uploaded. Reticulin silver stain has been used to differentiate between the two - with inter- and pericellular reticulin fibrils found in fibroma/thecoma and not in granuloca cell tumor. The uploaded photos of reticulin of this case show the presence of intercellular reticulin fibrils in mant areas except for when cellularity is high and intercellular reticulin and collagen is cery scant. I believe they support the diagnosis of fibroma/thecoma and not granulosa cell tumor. Even in sarcomatois granulosa cell tumor one should be able to find traces or areas with classic features of granulosa cell tumor - oval clefted nuclei, organoid pattern, cystic change, even Call-Exner bodies. If there is still doubt, alpha-inhibin and calretinin can settle the dispute once and for all.
聞道有先後,術業有專攻
