蜕膜组织和合体滋养细胞以及细胞滋养细胞，最后一图似为中间滋养细胞，虽未见绒毛，仍可符合宫内妊娠，请询问病史。

Trophoblastic neoplasm is always challenge, especially online based on few photos without reviewing slides. It is also a clinicopathologic diagnosis, not sole pathologic diagnosis. Therefore, I would like to know more about this case before jumping on conclusion.

First of all, such a viable and proliferative trophoblastic cells retained in uterine after three months of delivery is abnormal. Since there is no villi, the top priority here is to rule out Choriocarcinoma. Since more than 75% of choriocarcinomas occur in women with history of either molar pregnancy or abortion, it is imperative to have those information from clinicians. It is also very helpful to know the HGC level clinically.

From histopathologic point of view, the differential dx includes (1) retained residual placental tissue. In this setting, pt should have bleeding continously after delivery, not suddenly bleeding after three month. Also, you should see somewhat degenerated areas since most part will undergo degeneration; (2) placental site trophoblastic tumor (PSTT), which is often more homogenous population with mainly intermediate trophoblastic cells, less syncythial or cytotrophoblasts. If there are fragments of underlying myometrial tissue in this currettings, you should see some muscular infiltration; (3) choriocarcinoma which should have bimorphic pattern, such as seen in this case. But it is important to evaluate those areas of blood to see if there is lot of hemorrhage, fibrinoid necrosis and so on. For now, I am suspicious of a choriocarcinoma, but need more information to confirm it. More lower power view of hemmorrhagic areas and interface between myometrial tissue and this lesion will be helpful.

Again, make a sound dx based on few focus of photos is very very challenge here. I hope my opinion is helpful only for you to analyze the case, instead of providing a "diagnosis" here.

“滋养细胞肿瘤的诊断总是很有挑战性的，特别是没看切片而在网上看几张图片。它应是一个临床病理诊断而不是一个单纯的病理诊断。因此，在得出结论前我希望了解更多的信息。

  首先，在产后3个月子宫内仍有这样增生的滋养细胞是不正常的。因为没有绒毛，首先要排除的是绒癌。75%以上的绒癌发生在水泡状胎块或流产后，很有必要了解这些临床情况，知道HCG水平也是很有帮助的。

  从图片看鉴别诊断包括：（1）胎盘组织的残留。在这种情况下患者应是产后持续性出血，而不是3个月后突然出血。同时应看看退变的区域，因为大部分会退变；（2）胎盘部位滋养细胞肿瘤（PSTT），应是一致的细胞，主要是中间滋养细胞，少有合体滋养细胞和细胞滋养细胞，如果有平滑肌片段的话，应能看到肌层浸润；（3）绒癌应有双向的形态，就像在这一例中看到的，但是重要的是要看看那些出血的区域，是否有大量出血，纤维素样坏死等。我怀疑是绒癌，但需要更多的信息。出血区域和病变与肌层交界处的低倍照片可能有帮助。

  以上意见仅供参考，而不是提供的诊断。”

 谢谢杨老师和各位老师的回复！

  从患者处了界到一些情况，是产后持续性出血，淋漓不尽，临床以产后宫内胎盘残留刮宫，宫腔内无包块，未检查HCG。

  送检组织不多，约1.5X2x0.3cm，无大量的出血。但我总觉得滋养细胞增生显著，怕漏掉滋养细胞肿瘤，特别是这种门诊病例！做病理真是如旅薄冰！

 明天再照几张照片请各位看（不好意思，总是照不好，盼哪位网友能教教我！！！先谢谢！）

 照片很清楚了，个别图片不清晰，可能是焦距问题或者抖动了，需要多练习。色彩不太自然，不知道是否做了图像处理。

我一般是这样拍照的：数码相机定为自动、近拍、关闪光灯。镜头对准目镜（稳定很重要，手指可搭在目镜架上增加稳定）。图像导入电脑后，用Photoshop处理，主要是调整图片大小（一般把图片宽度设为1024即可）和自动对比度。最后用ACDsee减肥。

 谢谢Abin!

这是电脑采集的图，没有处理过！数码相机照出来的更差！

 各位老师：

又照了些照片（更差了），请大家看这样的照片真不好意思！

不过病情到是清楚了，患者右肺发现包块！我们考虑是绒癌，非常感谢大家的回复！

 再次学习：双相性细胞（细胞滋养细胞和合体滋养细胞）伴有异型，未见明确的中间滋养细胞。绒癌不能排除！

电脑采集的图片主要有两个问题：

1、不清晰，这是焦距没有调节好；容易解决。

2、偏色。

（1）可能用了特殊的滤光片？实际观察效果也是这样？如果这样看片子，是无法忍受的。估计不是这个原因。

（2）图像采集系统的参数没有调节好。不同的软件可能有不同的参数，我估计主要是色彩平衡和亮度/对比度。请销售商来帮助调整，或者请电脑高手试试。

很典型的绒癌。