平滑肌脂肪瘤

 梭形细胞癌也要考虑，看看免疫组化结果吧。

 Large atypical cell with area of cell necrosis strongly suggestive of malignant neoplasm.  At least focally, the neoplastic cells appear to form nest, therefor, I would first consider renal cell caricnoma or urothelial carcinoma with sarcomatoid changes.  Looking forward to hearing the final anwser.  Thanks.

 谢谢大家关注,因为我考虑是肉瘤样肾细胞癌,因为科室只有我一个人,没得商量,不敢出,已经让病人拿出去会诊了,有结果再说

 会诊结果,血管平滑肌脂肪瘤,免疫组化HMB45(+)

 做随访。时间是检验真理的唯一标准。

 Thanks for the follow-up with immunstain result.  I have seen quite a few angiomyolipoma (AML) including some atypica ones, such as myoid rich, epithelioid, pigmented, cystic etc.  Some can have significant cytologic atypia.  But combinations of cytologic atypia + hypercelluarity + necrosis are rare.  I still worry about sarcomatoid carcinoma.  Immunostain with other markers including pan-cytokeratin, AE1/3, SMA are also necessary to confirm the diagnosis of a atypical angiomyolipoma.  Also a symptomatic 3.0 cm AML will be pretty rare.  Opinions from 曲直 ﹢指环王 ﹢pathdoc will certainly help.  Thanks.

 形态学首选肉瘤样癌，与Stevenshen有同感。

 其它的免疫表型如何？

 The staining of HMB45 is a special mark for AML, which is never positive  in RCCs. I think the case could be a variant of AML- epithelioid AML, which is a seprated entity in WHO book and potential for malignancy. 

肉瘤样癌