28岁，未生育，既往外院内膜诊刮为复杂性增生，外院TCT检查无病变，我院发现宫颈病变，阴道镜下宫颈局部呈菜花状（8-11日补充的病史），遂行阴道镜下活检。

第一次检查：下图为宫颈活检标本：

可能看的不是很清楚，再上几张大一点的图片（8-11 9:24添加）：

第二次检查：（8-15添加）

诊断性刮宫，下面的图片是刮宫标本，患者没做分段诊刮，因为宫颈已经是菜花样的了。

第三次检查：

全子宫切除标本：宫颈宫体交界处偏向宫颈外口一侧局部粘膜表面粗糙呈菜花样，从宫颈外口可见。宫内膜较薄，子宫底部内膜稍增厚稍粗糙，重点取材宫颈病变处及底部子宫内膜（图片后面传）。

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 This is an invasive adenocarcinoma. She is very young for any type of cancer. As we all know, based on common sense, the chance for her age to have endocervical cancer is much more likely than having endometrial adenocarcinoma. Also it is important to try our best to provide the site of cancer for treatment concern. If this is an adenocarcinoma, clinically they may try radiation treatment plus chemotherapy before considering for radical hysterectomy; If this is endometrial adenocarcinoma, patient also can undergo a period of hormone therapy before hysterectomy. Given her age and her strong desire to save uterus, it is reasonable for clinician to consider a conservative approach before a backup hysterectomy. We have encountered several cases this year to help clinicians decide cancer from endocervical or endometrial origin. As pathologists, here is how I approach the case like this. 

1. We need to first rule out endocervical adenocarcinoma. You can run IHC of p16 on this case. It should be very informative. However, you make sure to run a positive control with your p16 because I am not very impressed with your p16 immunostaining on another case you posted. 

2. If possible, get HPV tested on this case, either by HC-II, PCR or In situ hybridization method on either cytology or histologic tissue block. This is kind of case you want to reach out for some help on HPV testing. In her age, it is vanishingly rare that an adenocarcinoma of cervix orgin is not HPV-positive, unless we entertain this adenocarcinoma is DES-related cancer or minimal deviated adenocarcinoma. But morphology is supportive neither DES-exposed adenocarcinoma nor minimal deviation adenocarcinoma. As matter of fact, it is not even compatible with typical endocervical adenocarcnoma I usually seen. Be honest with you, It is rather very endometrioid looking to me. 

3. Given both of your endometrial biopsy and endocervical biopsy showing the same tumor, we have to entertain an adenocarcinoma of the endometrial origin based on two reasons: 1) your picture 9 shows a typical endometrioid adenocarcinoma with squamous metaplasia or squamous morules in a background of endometrial stroma. 2) endometrial adenocarcinoma is more commonly seen to go down to invade endocervix; while endocervical adenocarcinoma is rarely seen to go up to invade endometrium. 

4. After we rule out endocervical origin by p16 and HPV testing, then we are forcing to do something to make sure this is endometrial origin. In her young age, two situations often linked with endometrial adenocarcinoma in younger women. 1) She has polycystic ovarian syndrome; 2) She has germline mutation of microsatelite stability. For latter, you may want to add IHC staining of PSM2 and MSH6 which will detect >95% of MSI. We are routinely run these two immunostaining in our patients <50 year old with endometrial adenocarcinoma. 

5. Most importantly, you may want to pick up phone and talk to your clinician about this case. I will specifically ask him if he palpate a cervical mass and what endometrial ultrasound look like. If she has a think endometrium (usually >11 mm in thickness by ultrasound) and also a palpatable mass in endocerx, I will not so cavalierly render a diagnosis of endocervical origin. 

6. Lastly, although it is small chance, we need rule out metastasis, such as from GI and other sources. You may want to add CK7 and CK20 in your IHC panel to have a peace of mind in rule out metastasis from GI. I had a case last year with a 40+ woman showing both endocervical and endometrial biopsy of "endometrioid" adenocarcinoma. IHC of p16 is negative. I was ready to make a diagnosis of endometrial adenocarcinoma. But When I talked to clinician, he told me this person had confirmed history of colorectal cancer. That saves me for rendering a wrong diagnosis.

Anyway, this is a very challenge case, I do not have a clear answer, but just share my thought process and my way to approach this case. I hope I do not confuse everybody here.

ER\PR\VIM\CEA\P16等鉴别宫颈管或宫内膜源性

大体切除标本显示：癌位于宫颈宫体交界处，偏向宫颈一侧，表面粗糙呈菜花样，宫颈外口可见。宫内膜较薄，宫底部内膜稍增厚粗糙，图片后面传。

后面的图说明是癌，无疑。

如楼上说，需做相关标记鉴别来源，因为宫颈癌与子宫内膜癌的手术方式是不完全相同的。

考虑内膜癌

该例患者最终做了癌根治术，具体情况后面会附上。

期待中。

讨论有益，谢谢各位老师的意见和建议，后面会上传分段诊刮的图片，我会依然在主题中继续添加图片，此病例涉及到想保留生育能力，所以非常谨慎，在我们作出浸润性腺癌的诊断后，又作了分段诊刮，以了解是否为内膜癌，若是宫颈原发腺癌则是否有内膜累及。

赵老师，我们想的和您的一样，子宫应该是不可以保留了，不管是宫颈还是内膜来源。但是一位非常大胆而高明的手术医生他可以替患者做保留子宫的手术（如果是宫颈原发的），所以必须要病理明确是宫颈原发还是来自内膜。

后面传的图像子宫内膜样腺癌

增加了图片，大家继续讨论，感谢以上各位老师的发言。

此例的为难在于患者结婚不久未生育，诊断宫颈癌手术，患者希望能保留子宫，此例是否可以保留子宫，就在于确立是否为宫颈癌，是否有子宫内膜累及。

老总 能否把细胞学也上来看看啊

既然是腺的问题干嘛不分段诊刮啊

依据目前的这些来看不是很支持宫腔内膜来源的肿瘤

建议 分段诊刮病理检查 必要时免疫组化或其它进一步诊断标记

颈管内膜可能性大。

宫颈管内膜复杂性增生伴不典型增生