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女,45岁,疑子宫肌瘤全切子宫

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楼主 发表于 2011-11-09 21:20|举报|关注(3)
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  • 女,45岁,疑子宫肌瘤全切子宫图1
    图1
  • 女,45岁,疑子宫肌瘤全切子宫图2
    图2
  • 女,45岁,疑子宫肌瘤全切子宫图3
    图3
  • 女,45岁,疑子宫肌瘤全切子宫图4
    图4
  • 女,45岁,疑子宫肌瘤全切子宫图5
    图5
  • 女,45岁,疑子宫肌瘤全切子宫图6
    图6
  • 女,45岁,疑子宫肌瘤全切子宫图7
    子宫体
  • 女,45岁,疑子宫肌瘤全切子宫图8
    子宫体
  • 女,45岁,疑子宫肌瘤全切子宫图9
    子宫体
  • 女,45岁,疑子宫肌瘤全切子宫图10
    子宫体

 

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1 楼    发表于2011-11-11 12:20:41举报|引用
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腺癌,转移不能除外。结合临床再查原发灶

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2 楼    发表于2011-11-11 15:21:14举报|引用
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从大体标本到镜下观察,该病例最大的可能性是子宫腺肌症癌变。

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3 楼    发表于2011-11-11 19:13:25举报|引用
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我认为腺癌。

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4 楼    发表于2011-11-11 19:49:53举报|引用
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低分化腺癌。

有可能是在肌腺症基础上,由其内膜异位的基础上发生的,那么,宫内膜样腺癌这一类型的可能性很大。

看看标记ER、PR等是不是阳性,看是不是I 型癌;

看看P53、P16是不是阳性,看看是不是II 型癌。

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5 楼    发表于2011-11-12 10:58:51举报|引用
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  • CK7
  • CK20
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    CK20
引用:1 楼 在 2011-11-11 12:20:41 的发言:

腺癌,转移不能除外。结合临床再查原发灶


最后诊断:转移性腺癌,建议检查胃肠道

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6 楼    发表于2011-11-12 11:00:40举报|引用
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此病例子宫体、宫颈、阴道及双侧韧带脉管腔内均充满癌栓,临床术中子宫与肠道粘连紧密,加上免疫组化,认为是转移性

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7 楼    发表于2011-11-12 11:40:26举报|引用
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非常有意思的病例。

学习了。

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8 楼    发表于2011-11-12 22:51:41举报|引用
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IHC标记的确像是肠、胆来源的转移性腺癌。

请问:下张图片显示的是子宫深肌层与浆膜面吗?

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9 楼    发表于2011-11-12 23:00:47举报|引用
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引用 8 楼 海上明月 在 2011-11-12 22:51:41 的发言:

IHC标记的确像是肠、胆来源的转移性腺癌。

请问:下张图片显示的是子宫深肌层与浆膜面吗?


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10 楼    发表于2011-11-12 23:02:30举报|引用
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回复海上明月:是子宫内膜面,几乎被癌细胞侵蚀完,只有散在几个子宫内膜腺体

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11 楼    发表于2011-11-12 23:09:32举报|引用
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我们再来看看是不是CK20 和CK7表达就一定是消化道来源的转移性腺癌?

请参阅下列文献。

1.     Am J Clin Pathol. 2009 Oct;132(4):531-8.

CDX-2 expression is a common event in primary intestinal-type endocervical adenocarcinoma.

Saad RS, Ismiil N, Dubé V, Nofech-Mozes S, Khalifa MA.

We studied the expression of cytokeratin (CK) 7, CK20, CDX-2, and p16 in 119 cervical adenocarcinomas (65 usual type [50 invasive; 15 in situ], 37 intestinal type [21 invasive; 16 in situ], 10 endometrioid, 5 adenosquamous, and 2 signet-ring carcinomas) in comparison with 55 cases of rectal adenocarcinomas. The percentage of cells staining was considered negative if 0% to 5% stained; more than 5% was considered positive. For p16, staining of more than 50% was considered positive. CK7 was expressed in all cervical cases and in 12 rectal adenocarcinomas (22%). CK20 was expressed in 17 cervical adenocarcinomas (14.3%) and in 48 rectal adenocarcinomas (87%). CK20 immunostaining was diffuse in the majority of rectal tumors but focal in most cervical tumors. CDX-2 was expressed in all cases of rectal adenocarcinoma and in 46 cervical adenocarcinomas (38.7%): usual type, 10 (15%); intestinal type, 31 (84%); endometrioid type, 5 (50%); adenosquamous and signet-ring types, 0 (0%). CDX-2 is a marker for intestinal differentiation irrespective of a rectal or cervical origin. Therefore, it should not be used as the sole basis to confirm the colorectum as the primary origin in metastatic cases.

2.    Appl Immunohistochem Mol Morphol. 2008 Oct;16(5):453-8.

Intestinal type and endocervical-like ovarian mucinous neoplasms are immunophenotypically distinct entities.

Lin X, Lindner JL, Silverman JF, Liu Y.

Ovarian mucinous neoplasm (OMN) is traditionally classified as either intestinal type or endocervical-like subtypes. The 2 subtypes represent different clinicopathologic characteristics. The immunophenotype of the 2 subtypes has not been adequately investigated. In this study, we investigated 14 intestinal type OMNs (borderline and adenocarcinoma) and 12 endocervical-like OMNs (borderline and adenocarcinoma) for their expression of PDX-1, CDX-2, CA-125, CK7, CK20, WT-1, D2-40, and TTF-1. We also included 15 colorectal adenocarcinomas metastatic in the ovary, as they may occasionally mimic OMN. The intestinal type OMNs were positive for PDX-1 (100%), CK7 (100%), CK20 (100%), CDX-2 (29%), whereas were negative for CA-125. The endocervical-like OMNs were positive for CA-125 (100%) and CK7 (100%), whereas were negative for CK20, PDX-1, and CDX-2. Metastatic colorectal adenocarcinomas were positive for CK20 (100%), CDX-2 (100%), and PDX-1 (33%), whereas were negative for CA-125 and CK7. All of the intestinal type and endocervical-like OMNs as well as metastatic colorectal adenocarcinomas were negative for WT-1, D2-40, and TTF-1. Our results demonstrated that the intestinal type and endocervical-like OMNs are immunophenotypically distinct entities. The 2 subtypes can be separated from metastatic colorectal adenocarcinoma by the different immunohistochemical profile of PDX-1, CA-125, CK7, CK20, and CDX-2. In the work-up of mucinous adenocarcinoma in the ovary or abdominal cavity, caution should be exercised in interpreting the possible primary site on the basis of the immunohistochemical profiles.

 

3.    Int J Gynecol Pathol. 2008 Jan;27(1):92-100.

Intestinal-type cervical adenocarcinoma in situ and adenocarcinoma exhibit a partial enteric immunophenotype with consistent expression of CDX2.

McCluggage WG, Shah R, Connolly LE, McBride HA.

Most cases of cervical adenocarcinoma in situ (AIS) and adenocarcinoma are of the usual or endocervical type. However, intestinal types of AIS and adenocarcinoma exist. With an intestinal-type adenocarcinoma in the cervix, the question may arise as to whether one is dealing with a primary cervical neoplasm or direct or secondary spread from an intestinal adenocarcinoma. In organs such as the ovary, urinary bladder, esophagus, and gallbladder, intestinal-type glandular epithelium often expresses enteric markers, but this has hardly been studied in the cervix. The purpose of this study was to investigate whether intestinal-type AIS and adenocarcinoma in the cervix express enteric markers and to ascertain whether these antibodies are of value in the distinction from a metastatic intestinal adenocarcinoma. We compared the immunophenotype of these lesions with that of usual-type AIS and adenocarcinomain the cervix. Cases included were AIS of usual type (n = 6), primary cervical adenocarcinoma of usual type (n = 6), AIS of intestinal type (n = 21), primary cervical adenocarcinoma of intestinal type (n = 3), primary cervical adenocarcinoma with signet ring cells (n = 2), and colorectal adenocarcinoma involving the cervix (n = 5). All cases were stained with cytokeratin (CK) 7, CK20, monoclonal carcinoembryonic antigen (CEA), p16, and CDX2. Staining was categorized as negative, focally positive (<50% cells), or diffusely positive (50% or more cells). Usual-type AIS was always diffusely CK7 positive, typically diffusely CEA and p16 positive, and always CK20 negative. CDX2 was positive in 1 case. All usual cervical adenocarcinomas were diffusely CK7 and p16 positive, and all were immunoreactive with CEA. Five and 2 cases were CK20 and CDX2 positive, respectively. Intestinal-type AIS was diffusely CK7 positive (all cases) and typically CK20 negative and diffusely CEA and p16 positive. All but 1 case exhibited diffuse nuclear positivity with CDX2. In addition, usual-type AIS adjacent to intestinal type was CDX2 positive in 13 of 21 cases. The 3 cases of primary cervical intestinal-type adenocarcinoma were diffusely CK7 positive, focally or diffusely positive with CK20 and CDX2, and focally positive with CEA. One case was diffusely p16 positive, 1 focal and 1 negative. The foci of signet ring cells in the 2 primary cervical adenocarcinomas were diffusely CK7 and p16 positive and negative with CK20 and CDX2. Colorectal adenocarcinomas involving the cervix were typically diffusely positive with CK20, CEA, and CDX2; negative with CK7; and negative or focally positive with p16. Intestinal types of cervical AIS and adenocarcinoma exhibit a partial enteric immunophenotype, usually with diffuse expression of CDX2 and, in some cases, staining with CK20. They maintain their CK7 immunoreactivity and are usually p16 positive. Although there is immunophenotypic overlap, focal staining with CK20 together with diffuse CK7 and sometimes p16 positivity helps to distinguish intestinal types of cervical adenocarcinoma from involvement by a colorectal adenocarcinoma; CEA and CDX2 are of no value in this regard. CDX2 positivity in usual-type AIS adjacent to intestinal type and in occasional cases of pure usual-type AIS may be a reflection of early intestinal differentiation before this is morphologically apparent. Using a set of cases of AIS diagnosed in a single institution over a 7-year period (77 usual type; 13 intestinal type), intestinal type was more likely to be associated with early invasive adenocarcinoma than usual type (31% vs 17%), suggesting that intestinal differentiation may be a risk factor for invasion in premalignant cervical glandular lesions.

 

4 .Am J Surg Pathol. 2006 Sep;30(9):1130-9.

Cytokeratins 7 and 20 in primary and secondary mucinous tumors of the ovary: analysis of coordinate immunohistochemical expression profiles and staining distribution in 179 cases.

Vang R, Gown AM, Barry TS, Wheeler DT, Yemelyanova A, Seidman JD, Ronnett BM.

Coordinate expression profiles for cytokeratins 7 and 20 (CK7 and CK20) are useful for distinguishing certain types of adenocarcinomas but use for distinction of primary and secondary mucinous tumors in the ovary is limited due to the existence of a number of tumor types exhibiting overlapping CK7/CK20 immunoprofiles; the use of staining distribution patterns in the distinction of tumors with shared profiles has not been evaluated in detail. We report analysis of both coordinate expression profiles and staining distribution in 179 rigorously classified mucinous tumors in the ovary, including 53 primary tumors [35 atypical proliferative (borderline) mucinous tumors of gastrointestinal type and 18 invasive mucinous carcinomas] and 126 secondary tumors [28 colorectal adenocarcinomas, 54 appendiceal tumors (23 adenocarcinomas, 31 low-grade adenomatous mucinous tumors associated with pseudomyxoma peritonei), 14 pancreatic adenocarcinomas, 8 endocervical adenocarcinomas, 5 gastric adenocarcinomas, 4 gallbladder/biliary tract adenocarcinomas, and 13 adenocarcinomas of unknown primary sites). A CK7+/CK20+ immunoprofile was the most common profile in primary ovarian tumors (74%), upper gastrointestinal tract tumors (78%), and endocervical tumors (88%) but was occasionally observed in lower intestinal tract tumors (colorectal: 11%; appendiceal: 13% of low-grade tumors, 35% of carcinomas). A CK7-/CK20+ immunoprofile was the most common profile in lower intestinal tract tumors (79%) and was uncommon in upper gastrointestinal tract tumors (9%), rarely seen in primary ovarian tumors (4%), and not seen in endocervical tumors. A CK7+/CK20- profile was observed in some primary ovarian (23%), upper gastrointestinal tract (13%), and endocervical tumors (13%) but not in lower intestinal tract tumors. For CK7+ tumors, staining distribution was very frequently diffuse (>50% of tumors cells positive) in primary ovarian, upper gastrointestinal tract, and endocervical tumors, whereas staining distribution was often focal (<50% of tumors cells positive) when present in colorectal and appendiceal carcinomas but not in low-grade appendiceal tumors. For CK20+ tumors, staining distribution was variable but often focal in primary ovarian tumors and nonlower intestinal tract tumors, whereas the pattern was almost always diffuse in lower intestinal tract tumors. Immunohistochemical staining distribution can supplement CK7/CK20 coordinate expression profiles to distinguish subsets of primary ovarian and metastatic lower intestinal tract mucinous tumors having overlapping immunoprofiles but neither coordinate expression profiles nor staining distribution distinguishes primary ovarian tumors from the nonlower intestinal tract metastases.

 

5. Zhonghua Bing Li Xue Za Zhi. 2001 Apr;30(2):114-7.

[Expression of cytokeratin 7 and 20 in ovarian metastatic carcinomas].

[Article in Chinese]

Dai L, Song Q, Li L, Zhong D, Hui Y.

OBJECTIVE: To study the distinctive clinicopathologic and immunohistochemical difference between ovarian metastatic carcinomas and primary ovarian carcinomas.METHODS: The clinical and pathological features of 27 cases of ovarian metastatic carcinomas (gastric carcinomas 12 cases, colon carcinomas 11 cases, others 4 cases) obtained from our department were reviewed. Immunostainings for CK (AE1/AE3), CK7, CK20, CEA, vimentin, nm23 were performed with SP staining methods.RESULTS: On gross examination, metastasis from gastric adenocarcinoma were usually bilateral, while solid (11/12) and metastases from colonic adenocarcinoma were more often unilateral and cystic (7/11). Microscopically, metastases from gastric adenocarcinoma revealed signet ring cells or poorly differentiated adenocarcinomas (12/12), whereas metastases from colonic adenocarcinomas showed similar morphology of endometrioid adenocarcinoma (8/11). The majority of ovarian metastases of gastric carcinoma (7/12) and colon carcinoma (8/11) were CK20 positive. In particular, CK20 was invariably expressed in colon cancer metastases. Most of the ovarian metastatic carcinomas from the gastrointestinal tract failed to react with immunostaining of CK7. A combined use of CEA, vimentin and nm23 had made a correct classification for 11/12 cases of the gastric carcinoma, 10/11 cases of the colonic cancer.CONCLUSIONS: CK7 and CK20 have been proved to be useful antibodies in distinguishing between metastatic carcinomas and primary carcinomas of the ovary. Combined use of a panel of antibodies can give more significant results

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12 楼    发表于2011-11-12 23:12:13举报|引用
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我们再来看看宫颈鳞状上皮和柱状上皮交界处移行带发生了什么问题?

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13 楼    发表于2011-11-12 23:14:05举报|引用
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我们再来查查大肠或卵巢有没有什么问题。

待有更多的证据除外子宫原发癌后,有明确的证据证明是转移癌。

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14 楼    发表于2011-11-12 23:20:43举报|引用
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非常好的病例,多谢了!

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15 楼    发表于2011-11-12 23:32:27举报|引用
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本例标记CK7+/CK20+,一般来说这样的阳性组套在大肠癌少见,因为大肠癌表达CK7阳性的比例很小。那么,请看从上述文献中摘录的部分内容:

CK7+/CK20+ immunoprofile was the most common profile in primary ovarian tumors (74%), upper gastrointestinal tract tumors (78%), and endocervical tumors (88%) but was occasionally observed in lower intestinal tract tumors (colorectal: 11%; appendiceal: 13% of low-grade tumors, 35% of carcinomas).

上文说:CK7+/CK20+的组套最常见于原发性卵巢癌(74%)、胃与上部肠道癌(78%)和宫颈内膜癌(88%);而下消化道(下部肠道:结直肠癌11%,阑尾低级别肿瘤复合表达CK7+/CK20+占13%,癌占35%)。

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16 楼    发表于2011-11-12 23:38:00举报|引用
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引用 9 楼 猪猪 在 2011-11-12 23:00:47 的发言:
引用 8 楼 海上明月 在 2011-11-12 22:51:41 的发言:

IHC标记的确像是肠、胆来源的转移性腺癌。

请问:下张图片显示的是子宫深肌层与浆膜面吗?

谢谢!

问题就在这里:宫内膜面的癌浸润为主,多数情况下要考虑子宫原发,尤其是宫颈管内膜原发;少数情况下是转移癌。

仅供参考。


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17 楼    发表于2011-11-13 20:04:54举报|引用
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谢谢“海上明月”的关注,并查了如此多资料。

正如文献所说“CK7 was expressed in all cervical cases”,但我们这例其实在癌细胞CK7完全阴性的,CK20阳性,正常的宫颈腺上皮CK7才阳性。至于你说的“我们再来看看宫颈鳞状上皮和柱状上皮交界处移行带发生了什么问题?”其实不是鳞柱交界(可能倍数太低,引起误解),两边都是鳞状上皮。

这个病例到现在我们相当迷惑,因为按肿瘤这种点状浸润方式和大量脉管内浸润,并连累到整个子宫体宫颈阴道和韧带,临床有子宫和直肠的严重粘连,再加上免疫组化,更象个转移来的,但腺体中清楚的正常和癌细胞的交界如何解释呢?

请教了两位专家,他们提出一个现代新的观点,就是癌细胞侵犯腺体,把正常腺细胞吃掉,而非腺体中正常和癌的移行关系。我们再看这例的腺体中CK7和CK20表达模式,确实象如此,CK7大部分没有,有的只是上面薄薄一层,癌细胞从下面长上来,甚至部分区域完全替代了正常细胞(CK7-)。鳞状上皮部分也是,癌细胞突然取代了正常上皮,突兀地出现

这个观点是我第一次听说,查了很久的资料,可能因为不得法,所以没查出个所以然,把这个病例放到这里和CPN,也是希望在大家帮助下,能查出这类文献,把这种模式搞明白

至于临床,我会继续跟进,临床上下周会做胃肠镜和腹部CT检查

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18 楼    发表于2011-11-13 20:07:13举报|引用
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引用 16 楼 海上明月 在 2011-11-12 23:38:00 的发言:
引用 9 楼 猪猪 在 2011-11-12 23:00:47 的发言:
引用 8 楼 海上明月 在 2011-11-12 22:51:41 的发言:

IHC标记的确像是肠、胆来源的转移性腺癌。

请问:下张图片显示的是子宫深肌层与浆膜面吗?

谢谢!

问题就在这里:宫内膜面的癌浸润为主,多数情况下要考虑子宫原发,尤其是宫颈管内膜原发;少数情况下是转移癌。

仅供参考。


整个癌浸润并不是以宫内膜为主,宫内膜已经相当薄,在肉眼上几乎看不到,镜下也不见非典型增生等现象,而是被吃掉的感觉,所以更象转移过来的

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19 楼    发表于2011-11-14 00:43:59举报|引用
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转移性腺癌的可能性较大。提出来进一步讨论是为了深化一些知识点,提醒鉴别诊断中需要考虑的问题。谢谢!

从大体标本看,子宫壁弥漫增厚,脉管内易见癌栓。所以,转移癌的可能性大一些。但是,需要找到原发癌,才谓之转移。

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20 楼    发表于2011-11-15 17:00:41举报|引用
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这个病例很有意思,等胃肠道检查

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