Our fellow showed a case last week. I think it is interesting. Send here as a chinese new year gift for some ones interested.

about 50 y women with headach, CSF cytology exam. paitent has no previous malignant history.

 For the case I mentioned above:

Cytopathologists asked clinician to get second time of CSF. It is a malignant melanoma based on IHC result and cytologic features (very calssic for both). Patient had no melanoma history, so it may be a primary melanoma of meninges.

 This is a rare and interesting case. Occasionally I came here to  check and notice no people who are truely interested to this case. I am not interested to continue to complete this case until Dr.  海上明月 asked me about this case.

In this section, I saw a lot of cases to show some atypical cells in pleural or peritoneal fluid. Questions are these cells are reactive mesothelial cells or malignant cells. In many situation we cannot answer the questions. We must do some basic stains, such as calretinin and BerEP4. This is the principle all residents should know. If we know they are malignant cells (most common adenocarcinoma), we should try to know the origins of the adenocarcinoma and provide more information to clinicians. This is our duty.

Do not use the terms too often, suggestive; may be; suspicious et al.

 Base on cytology, I think D may be correct answer. Of cause answer C is fine. E should not be right because you cannot make sure it is glandular lesion based on cytology.

多选题，选其一。

本例脑脊液检查所见的最佳表述是：

A.阴性,考虑为反应性单(个)核细胞

B.可见非典型性细胞

C.疑恶性肿瘤细胞

D.见恶性肿瘤细胞,需鉴别上皮性与非上皮性来源

E.见恶性肿瘤细胞,考虑为腺癌

 细胞形态不规则，高核/浆比，大核仁（1-2个/每个细胞），胞浆内偶见颗粒状物（色素颗粒？）。

结合免疫细胞化学标记和讨论中Dr.Zhao的有关病史陈述，考虑为脑膜来源黑色素细胞病变：（1）黑色素细胞增生症恶性变？（2）黑色素细胞瘤（melanocytoma）进展？（3）恶性黑色素瘤？（4）中间型或混合性黑色素细胞肿瘤？

 D. Positive for malignant cells, epithelial vs. non-epithelial malignancy

见恶性肿瘤细胞, 需鉴别上皮性与非上皮性来源.

 IHC stains

f1 s-100

f2 HMB45

f3 Tyrosinase

名称：图1
描述：图1

名称：图2
描述：图2

名称：图3
描述：图3

 Quickly review above interpretation, suggestion, common.

We are pathologists. It is good for us to make some suggestion. However it is important for us to provide more information or more specific diagnosis for clinic.

For example we make the diagnosis, suspicous malignancy, ? metastatic adenocarcinoma et al. What do yo want to clinicians to do based on our cytology diagnosis.

Can we do some stains for this case?

 考虑为转移性腺癌，建议：查消化道: negative

有没有可能是造血系统疾病呢: No

不会是腔性弥漫大B细胞淋巴瘤: No

  考虑转移性腺癌: How do you know it is adenocarcinoma?

看到再次送检的CSF涂片，仍然考虑为恶性。

原发、继发？

癌、非癌？

图中可见到个别细胞核明显偏位、胞质中见到不光滑的空泡，核分裂活跃，细胞核大小不一，核仁明显，似乎还能见到少许细胞邻接和排列趋势。

考虑为转移性腺癌，建议：查消化道；尚不全排除原发可能，如果永远也发现不了原发灶的话。

但是，有没有可能是造血系统疾病呢？很多细胞的那张图（含两个分裂像的）猛一看象是白血病。会不会是腔性弥漫大B细胞淋巴瘤？纯属猜测，能用流式细胞仪多做几项标记看看就好了。