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.

腺癌，可以通过做免疫组化区分子宫内膜还是宫颈原发。

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。

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期待中。

宫颈管内膜来源腺癌

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 Now given negativity of p16 and a mass at lower uterine segment/uterine isthmus region, she likely has an endometrial adenocarcinoma linked with Lynch syndrome. As matter of fact, a tumor located in lower uterine segment in a younger woman is one of the criteria for screening of an endometrial adenocarcinoma associated with microsatelite instability. Now she needs to be screened either with IHC of PMS2 and MSH6 or PCR-based molecular testing of MSI with at least 5 markers. If you cannot perform these tests, I can help you out if you can provide me several unstained slides from both tumor and non-tumor endometrium. 

Now you may want to check her family history of colorectal cancer, gynecological cancers especially endometrium and ovary, and skin lesions such as sebacous hyperplasia/adenoma/carcinoma. If confirmed she is linked with MSI, then her siblings should be consutled with medical geneticist for education and screening of colorectal and gynecologic cancers linked with Lynch syndrome. 

下面几项免疫组化鉴别原发宫颈还是宫腔有帮助：P16、Wimtin、CEA、PR、ER

子宫内膜癌

宫颈管内膜复杂性增生伴不典型增生