病理学女性生殖系统和乳腺疾病课件.ppt

1、第第 十二十二 章章女性生殖系统和乳女性生殖系统和乳腺疾病腺疾病2022-10-82 2022-10-832022-10-84Here is a normal cervix with a smooth,glistening mucosal surface.There is a small rim of vaginal cuff from this hysterectomy specimen.The cervical os is small and round,typical for a nulliparous woman.The os will have a fish-mouth shape

2、after one or more pregnancies.2022-10-85The normal adult vaginal mucosa with a wrinkled appearance that is seen in women of reproductive years appears at the left.The cervix has been opened to reveal an endocervical canal leading to the lower uterine segment at the right that has an erythematous app

3、earance extending to the cervical os consistent with chronic inflammation.2022-10-862022-10-87 子宫颈疾病子宫颈疾病 子宫体疾病子宫体疾病2022-10-88一、慢性子宫颈炎一、慢性子宫颈炎二、子宫颈上皮非典型增生和原位癌二、子宫颈上皮非典型增生和原位癌 三、子宫颈癌三、子宫颈癌子宫颈疾病子宫颈疾病2022-10-89慢性子宫颈炎是育龄期妇女最常见慢性子宫颈炎是育龄期妇女最常见的疾病。多由于细菌、病毒感染或者继的疾病。多由于细菌、病毒感染或者继发于分娩、流产等所致子宫颈损伤。发于分娩、流产等所致子宫颈

4、损伤。临床主要表现是临床主要表现是白带过多白带过多。一、慢性子宫颈炎一、慢性子宫颈炎(chronic cervicitis)2022-10-810病理变化：病理变化：肉眼观肉眼观:子宫颈粘膜子宫颈粘膜 充血、肿胀，呈颗粒状或糜烂充血、肿胀，呈颗粒状或糜烂状。状。白带过多白带过多2022-10-811子宫颈粘膜充血水肿，间质有子宫颈粘膜充血水肿，间质有炎症细胞炎症细胞：单核细：单核细胞、淋巴细胞及浆细胞浸润；胞、淋巴细胞及浆细胞浸润；子宫颈柱状上皮和腺上皮伴不同程度增生或子宫颈柱状上皮和腺上皮伴不同程度增生或鳞状鳞状 上皮化生上皮化生。子宫颈子宫颈息肉息肉(cervical polyp)(cer

5、vical polyp)：良性瘤样病变，良性瘤样病变，恶变率很低。恶变率很低。有时子宫颈腺有时子宫颈腺囊肿囊肿(Nabothian cyst)(Nabothian cyst)。镜下镜下:2022-10-812慢性宫颈炎慢性宫颈炎This is normal cervical non-keratinizing squamous epithelium.The squamous cells show maturation from basal layer to surface.正常宫颈上皮正常宫颈上皮2022-10-813Endocervical polyp由子宫颈粘膜、腺体、间质纤维结缔组织局限性

6、增生而成由子宫颈粘膜、腺体、间质纤维结缔组织局限性增生而成2022-10-814假性糜烂假性糜烂 子宫颈阴道部子宫颈阴道部鳞状上皮鳞状上皮的真性糜烂被子宫颈管内的真性糜烂被子宫颈管内柱状柱状上皮上皮快速生长外移所取代。快速生长外移所取代。（由于所覆盖的单层柱状上（由于所覆盖的单层柱状上皮很薄，使上皮下血管容易暴露而呈红色，看上去皮很薄，使上皮下血管容易暴露而呈红色，看上去像糜烂，实际上所看到的是子宫颈内膜组织。像糜烂，实际上所看到的是子宫颈内膜组织。）Small round dark lymphocytes are seen in the submucosa,and there is also

7、 hemorrhage.2022-10-815二、子宫颈上皮非典型增生和原位癌二、子宫颈上皮非典型增生和原位癌 子宫颈上皮非典型增生：子宫颈上皮非典型增生：子宫颈上皮被不同程度异型性的细胞所取代，属子宫颈上皮被不同程度异型性的细胞所取代，属癌前病变。癌前病变。异型细胞增生从基底层开始，逐渐向表层发展。异型细胞增生从基底层开始，逐渐向表层发展。上皮上皮全层全层为异型细胞所替代，为异型细胞所替代，(Cervical epithelial dysplasia)好发部位：好发部位：子宫颈子宫颈 鳞鳞-柱柱 上皮交界带上皮交界带(移行带移行带)。2022-10-816非典型增生非典型增生 原位癌原位癌

8、分级分级：近年来将子宫颈上皮非典型增生至原位癌这一系列癌前病变的连续过程近年来将子宫颈上皮非典型增生至原位癌这一系列癌前病变的连续过程统称为统称为子宫颈上皮内瘤变子宫颈上皮内瘤变(Cervical intraepithelial neoplasia,CIN)。根据非典型增生的程度和范围，可将根据非典型增生的程度和范围，可将CIN分为：分为：(CIN)：轻度非典型增生轻度非典型增生 (CIN)：中度非典型增生中度非典型增生 (CIN)：重度非典型增生及原位癌重度非典型增生及原位癌2022-10-817 轻度非典型增生轻度非典型增生(CIN)(CIN)：异型细胞局限于上皮层的下异型细胞局限于上皮层

9、的下1/31/3区。区。中度非典型增生中度非典型增生(CIN)(CIN)：异型细胞占上皮层下异型细胞占上皮层下1/31/32/32/3；细胞异型明显，核质比例增加，极性稍乱。细胞异型明显，核质比例增加，极性稍乱。重度非典型增生及原位癌重度非典型增生及原位癌 (CIN)(CIN)：异型细胞显著增多，超过上皮层的下异型细胞显著增多，超过上皮层的下2/32/3，核异型性大，深染；核异型性大，深染；上皮细胞层次消失，仅表层尚见少量成熟扁平上皮细胞层次消失，仅表层尚见少量成熟扁平 细胞覆盖于表面。细胞覆盖于表面。原位癌：原位癌：异型细胞占据上皮厚度的全部，异型细胞占据上皮厚度的全部，未突破基底膜。未突破

10、基底膜。病理变化：病理变化：2022-10-818重度非典型增生和原位癌没有重度非典型增生和原位癌没有明显界限，明显界限，原位癌的异型细胞多原位癌的异型细胞多形性更显著，核分裂多见。形性更显著，核分裂多见。2022-10-819The marked maturation delay in this tissue can be identified by the presence of immature cells oriented perpendicular to the basement membrane(BM,blue dotted line)in the lower 2/3 of the

11、 epithelium(blue arrow).Mitotic figures can be seen at inappropriately high levels in the epithelium.Partial maturation is identified in the upper 1/3 by the cells that lie parallel to the BM(green arrow)and begin to acquire more cytoplasm.(The nuclei are widely spaced.)2022-10-820 类似正常基底细胞或体积较小，大小不

12、类似正常基底细胞或体积较小，大小不等，细胞核较大深染，细胞浆稀少，细胞排列紊乱，可见核等，细胞核较大深染，细胞浆稀少，细胞排列紊乱，可见核分裂。分裂。2022-10-821 预后：预后：（1 1）非典型增生级别与浸润癌的机会成正比。轻度非典型增生多数可自然消非典型增生级别与浸润癌的机会成正比。轻度非典型增生多数可自然消退，退，2%85%85%分：分：浸润性导管癌浸润性导管癌和和浸润性小叶癌浸润性小叶癌 约有约有10%10%浸润性导管癌与浸润性小叶癌并存浸润性导管癌与浸润性小叶癌并存 浸润性小叶癌的预后较差浸润性小叶癌的预后较差浸润性癌浸润性癌2022-10-881 导管内癌细胞导管内癌细胞 突

13、破管壁基底膜突破管壁基底膜向间向间质浸润。质浸润。乳腺癌中最常见的一种类型乳腺癌中最常见的一种类型（70%70%）1 1浸润性导管癌浸润性导管癌（Invasive ductal carcinoma）2022-10-882A normal duct cellsB ductal cancer cells breaking through the basement membraneC basement membrane2022-10-883 界限不清，灰白灰黄色、坚硬界限不清，灰白灰黄色、坚硬 切面有切面有硬粒感硬粒感 放射状小梁放射状小梁：从癌实质向四周脂肪伸展，呈明显星状：从癌实质向四周脂肪伸展

14、，呈明显星状 或蟹足状或蟹足状 乳头下癌肿累及大导管又伴纤维组织增生时，会由于纤维组织收缩，可使乳头下癌肿累及大导管又伴纤维组织增生时，会由于纤维组织收缩，可使乳头下陷乳头下陷 癌组织如在真皮淋巴管内扩散，可阻塞淋巴管，导致癌组织如在真皮淋巴管内扩散，可阻塞淋巴管，导致 皮肤水肿，毛囊汗腺处的皮肤因受皮肤附件牵引而相皮肤水肿，毛囊汗腺处的皮肤因受皮肤附件牵引而相 对下陷，造成对下陷，造成皮肤呈桔皮样外观皮肤呈桔皮样外观 晚期晚期侵犯深筋膜、胸膜和胸壁肌肉，使侵犯深筋膜、胸膜和胸壁肌肉，使肿块固定肿块固定病理特点：病理特点：肉眼：肉眼：2022-10-884The tumor occupies

15、the top portion of the specimen.Note the white streaks coursing through the lesion and contrast it with the normal adipose tissue of the breast.2022-10-885Here is a classic infiltrating ductal carcinoma 2022-10-886This mastectomy specimen demonstrates the gross findings of inflammatory carcinoma of

16、breast.This is not a specific histologic type of breast cancer,but rather it implies dermal lymphatic invasion by some type of underlying breast carcinoma.Such involvement of dermal lymphatics gives the grossly thickened,erythematous,and rough skin surface with the appearance of an orange peel2022-1

17、0-887 癌组织及癌细胞癌组织及癌细胞形态多样形态多样 致密的纤维组织间质中可见癌组织排致密的纤维组织间质中可见癌组织排 列成列成不规则巢状不规则巢状或或条索状浸润条索状浸润性生长性生长 腺管结构可有可无腺管结构可有可无 核分裂多见核分裂多见 常见灶性常见灶性坏死坏死或或钙化钙化 镜下：镜下：2022-10-888In the center is a duct lined by carcinoma cells.However,this ductal carcinoma is not confined to just the duct,but infiltrates outward into

18、the surrounding stroma as an infiltrating ductal carcinoma 2022-10-889At high magnification,the infiltrating ductal carcinoma of breast has pleomorphic cells infiltrating through the stroma.2022-10-890浸润性导管癌可分为：浸润性导管癌可分为：单纯癌：单纯癌：癌主质与间质大致相等癌主质与间质大致相等，癌细胞呈实性，癌细胞呈实性 条索，小梁或巢团块，可有少量腺样结构条索，小梁或巢团块，可有少量腺样结构

19、 硬癌：硬癌：癌实质少、间质成分多癌实质少、间质成分多而致密，质硬，而致密，质硬，很少形成腺样结构很少形成腺样结构 不典型髓样癌：不典型髓样癌：癌实质多，间质成分少癌实质多，间质成分少，癌呈片状，癌呈片状 或巢状，中央有坏死，间质或巢状，中央有坏死，间质无无淋巴细胞浸润淋巴细胞浸润 腺癌：腺癌：癌组织癌组织管样结构占半量管样结构占半量以上以上根据癌的根据癌的实质实质/纤维间质的比例纤维间质的比例、腺管形成腺管形成的不同的不同2022-10-891Scirrhous carcinoma of the breast2022-10-892This infiltrating ductal carcin

20、oma of breast at low magnification appears to radiate from a central area of desmoplasia.This collagenous component gives the neoplasm a hard scirrhous consistency that is palpable.Such an invasive carcinoma may be fixed to underlying chest wall,making it non-mobile.2022-10-893小叶原位癌小叶原位癌的的癌细胞突破了基底膜癌

21、细胞突破了基底膜向间质浸润向间质浸润性生长性生长多见于老年妇女多见于老年妇女占乳腺浸润性癌占乳腺浸润性癌5%5%10%10%，约约20%20%浸润性小叶癌浸润性小叶癌可累及双侧乳房可累及双侧乳房2 2浸润性小叶癌（浸润性小叶癌（Invasive lobular carcinomaInvasive lobular carcinoma）2022-10-894A normal cellsB lobular cancer cells breaking through the basement membraneC basement membrane2022-10-895 切面呈橡皮样，灰白色切面呈橡皮样

22、，灰白色 边界不清边界不清 质坚硬质坚硬肉眼：肉眼：2022-10-896 单行单行癌细胞呈癌细胞呈线状线状浸润于纤维间质中浸润于纤维间质中“列兵样列兵样”排列排列 癌细胞较小，大小一致，核大小也较癌细胞较小，大小一致，核大小也较一一 致，胞浆很少，核仁不明显致，胞浆很少，核仁不明显 核分裂少核分裂少镜下：镜下：2022-10-897This is a closer view of linear arrays of lobular carcinoma cells(blue arrows)infiltrating through dense fibrous stroma.The blue arr

23、ows identify the neoplastic cells.The cells are notable for eccentric nuclei set into mucin rich cytoplasm.The nuclei are hyperchromatic and round to oval.No pleomorphism or mitoses are seen.The stroma is very dense with accellular collagen.982022-10-899Single strands of malignant cells infiltrating

24、 the stroma(Indian filing).2022-10-8100 乳腺实质乳腺实质 乳头乳头 直接浸润直接浸润 皮肤皮肤 筋膜筋膜 胸肌及胸壁胸肌及胸壁 淋巴结转移淋巴结转移同侧腋窝淋巴结同侧腋窝淋巴结 内上、内下象限的癌内上、内下象限的癌 乳动脉的淋巴结乳动脉的淋巴结 血行转移：血行转移：2022-10-8101 雌激素受体（雌激素受体（ERER）和孕激素受体（）和孕激素受体（PRPR）与乳腺）与乳腺 癌发生的关系癌发生的关系 雌激素受体（雌激素受体（ERER）和孕激素受体（）和孕激素受体（PRPR）与乳腺）与乳腺 癌病人预后的关系。癌病人预后的关系。乳腺是女性激素的靶器官。正

25、常乳乳腺是女性激素的靶器官。正常乳腺上皮细胞存在腺上皮细胞存在雌激素受体（雌激素受体（ERER）和）和孕激素受体（孕激素受体（PRPR）。临床治疗与预后临床治疗与预后2022-10-8102The cells of this breast carcinoma are highly positive for estrogen receptor with this immunoperoxidase stain.Estrogen receptor positivity correlates with a better prognosis because such positive neoplasti

26、c cells are better differentiated and more amenable to hormonal manipulation.2022-10-8103This is progesterone receptor(PR)positivity in a breast carcinoma.The usefulness of this determination is not as well established as for estrogen receptors.Carcinomas that are PR positive,but not ER positive,may have a worse prognosis.2022-10-8104谢谢！谢谢！