Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8728, Los Angeles, CA 90048, USA.
Arch Pathol Lab Med. 2010 Feb;134(2):194-206. doi: 10.5858/134.2.194.
The diagnosis of the site of origin of metastatic neoplasms often poses a challenge to practicing pathologists. A variety of immunohistochemical and molecular tests have been proposed for the identification of tumor site of origin, but these methods are no substitute for careful attention to the pathologic features of tumors and their correlation with imaging findings and other clinical data. The current trend in anatomic pathology is to overly rely on immunohistochemical and molecular tests to identify the site of origin of metastatic neoplasms, but this "shotgun approach" is often costly and can result in contradictory and even erroneous conclusions about the site of origin of a metastatic neoplasm.
To describe the use of a systematic approach to the evaluation of metastatic neoplasms.
Literature review and personal experience.
A systematic approach can frequently help to narrow down differential diagnoses for a patient to a few likely tumor sites of origin that can be confirmed or excluded with the use of selected immunohistochemistry and/or molecular tests. This approach involves the qualitative evaluation of the "pretest and posttest probabilities" of various diagnoses before the immunohistochemical and molecular tests are ordered. Pretest probabilities are qualitatively estimated for each individual by taking into consideration the patient's age, sex, clinical history, imaging findings, and location of the metastases. This estimate is further narrowed by qualitatively evaluating, through careful observation of a variety of gross pathology and histopathologic features, the posttest probabilities of the most likely tumor sites of origin. Multiple examples of the use of this systematic approach for the evaluation of metastatic lesions are discussed.
转移性肿瘤起源部位的诊断常常给临床病理医生带来挑战。为了确定肿瘤的起源部位，已经提出了各种免疫组化和分子检测方法，但这些方法不能替代对肿瘤病理特征的仔细关注，也不能替代肿瘤与影像学表现和其他临床数据的相关性。目前，解剖病理学的趋势是过度依赖免疫组化和分子检测来确定转移性肿瘤的起源部位，但这种“ shotgun 方法”通常成本高昂，并且可能导致对转移性肿瘤起源部位的结论相互矛盾，甚至错误。
描述一种用于评估转移性肿瘤的系统方法。
文献复习和个人经验。
系统方法通常有助于缩小患者的鉴别诊断范围，将可能的肿瘤起源部位缩小到少数几个，然后使用选定的免疫组化和/或分子检测来确认或排除这些部位。这种方法涉及在进行免疫组化和分子检测之前，对各种诊断的“术前和术后概率”进行定性评估。通过考虑患者的年龄、性别、临床病史、影像学表现和转移部位，对每个个体的术前概率进行定性估计。通过仔细观察各种大体病理和组织病理特征，对最可能的肿瘤起源部位的术后概率进行定性评估，进一步缩小术前概率的范围。讨论了多个使用这种系统方法评估转移性病变的例子。
