继续关注：

1）尿路上皮癌伴鳞化；

2）鳞癌；

3）腺鳞癌；

4）尿路上皮癌+鳞癌

从图片上看，有尿路上皮癌成分，在低倍下见乳头状生长。局灶见鳞癌成分。

请教：在上述诊断中的2（鳞癌）如何与1和4鉴别？

同意这个观点。组织学观察是否存在尿路上皮癌成分以及与鳞癌成分是否有移行很重要。如果有尿路上皮原位癌的存在，拟诊断为尿路上皮癌伴鳞状分化。

如果没有尿路上皮肿瘤成分，可考虑直接诊断鳞癌？输尿管鳞癌的发生多与尿路结石有关，该患者之前没有结石的临床表现（似乎没有结石病史）。此外，原来是否有慢性肾盂肾炎（慢性间质性肾炎）病史？需要了解肾盂或肾髓质有无有无和输尿管同样的肿瘤（尿路上皮癌或鳞癌）。一般讲，上泌尿道单纯发生鳞癌还是很少见的。

如果在输尿管有两个独立病灶，或者是组织学上尿路上皮癌与鳞状细胞癌分隔的区域，是不是可以诊断尿路上皮癌+鳞癌？值得商榷。

P63和P53标记不能区分尿路上皮癌和鳞癌，但CK20标记可能有帮助，一般来说尿路上皮癌可表达CK20。

需要查阅文献，看看还有什么办法加以鉴别诊断。

学习之中的随记，仅供参考。不妥之处请指正。

支持尿路上皮癌伴鳞状分化，同意上面海上明月的分析。P63尿路上皮癌和鳞癌都表达，关键是能否找到尿路上皮癌的成分。

IHC 标记结果：

图1-2 34BE12

图3 Cam5.2

图4 CD34

图5 CK7

图6-7 CK20

图8 EGFR

图9 ki-67

图10-11 P53

图12-14 P63

请看目前主要外科病理诊断参考书中对“尿路上皮鳞状细胞癌”的定义。

1、[WHO 2004] Squamous cell carcinoma is defined as a malignant neoplasm derived from the urothelium that shows a pure squamous cell phenotype. When urothelial elements (including urothelial carcinoma in situ) are present the tumor should be classified as urothelial carcinoma with squamous differentiation.

2、[Morden Surgical Pathology 2^nd edition，2010]. Pathology Squamous cell carcinomas should be distinguished from typical urothelial carcinomas with squamous differentiation, which can be seen in a substantial proportion of urothelial carcinomas. When areas of squamous differentiation are seen, the urothelial carcinoma is considered high grade. If an identifiable urothelial element is seen, in particular urothelial CIS, or if a history of CIS in the upper or lower urinary tracts is obtained, the tumor should be classified as a urothelial carcinoma with squamous differentiation. The finding of squamous metaplasia and dysplasia in a patient with a history of bladder irritation favors a diagnosis of squamous cell carcinoma .

3、[AFIP新版-299页 ] Squamous cell carcinomas are a group of bladder neoplasms with histologic pattern and cytologic features reminiscent of similar neoplasms of the epidermis.…….

The distinction between urothelial carcinoma with squamous differentiation and squamous carcinoma is somewhat arbitrary, with most authorities requiring that a squamous cell carcinoma be composed of at least 80% squamous element.

4、[SDSP 第5版2010 -1850页] Squamous cell carcinoma should be reserved for those tumors that are predominantly keratin-forming.

诊断尿路上皮鳞状细胞癌主要有二种观点：

1）肿瘤中只要存在尿路上皮癌成分, 无论其多少、无论原位还是浸润，（包括以前有尿路上皮癌病史或尿路上游部位有尿路上皮癌），一概诊断为“尿路上皮癌伴鳞状分化”；

2）肿瘤中鳞状细胞癌成分达80% ，就可诊断为鳞状细胞癌。

对WHO2004的定义您有什么评论？

如果诊断为：尿路上皮癌伴鳞状分化（鳞状细胞癌95%， 尿路上皮原位癌5%）。 您认为是否非常合理？