宫颈疾病于.ppt

,Click to edit Master Title Style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Mucosal surface,：,smooth and glistening,The cervical os,：,small and round(a mulliparous woman),fish-mouth shape(after pregnancy),Normal cervix,Content,Chronic cervicitis;,Cervical epithelial dysplasia,;,Cervical carcinoma,;,Leiomyoma of the uterus;,Endometrial adenocarcinoma,1,、,生育期妇女,常见病,2,、继发于分娩、流产等所致子宫颈损伤,3,、临床表现：,白带过多,Chronic Cervicitis,Etiology,常见感染,:,链球菌、葡萄球菌、肠球菌等,特殊感染：病毒,(,型单纯疱疹病毒、,人乳头状瘤病毒、巨细胞病毒等,),、,沙眼衣原体、淋球菌、,寄生虫及放线菌等,Pathological Changes,大体：,宫颈粘膜充血、肿胀，呈颗粒状或糜烂状。,镜下：,子宫颈非特异性炎症,间质有淋巴细胞、浆细胞及单核细胞浸润；,宫颈腺上皮伴不同程度,增生或鳞状上皮化生,。,子宫颈息肉,(cervical polyp),良性病变,子宫颈腺体囊肿,(,Nabothian,cyst),子宫颈糜烂,（,cervical erosion,）,Pathological Changes,Chronic cervicitis,squamous-columnar junction of the cervix.,Submucosa:Small round dark lymphocytes;hemorrhage.,Normal,Squamous metaplasia of cervix,In the cervix,koilocytotic change with human papillomavirus(,HPV,)infection,with vacuolization of epithelial cells.,Cervical polyp,Nabothian,cyst,子宫颈糜烂,(,Cervical erosion),假性糜烂,-,柱状上皮代替鳞状上皮，,多见,真性糜烂,-,鳞状上皮坏死脱落,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,异型细胞增生从基底层开始，逐渐向表层发展。子宫颈上皮部分被,不同程度异型性的细胞,所取代，属,癌前病变,。,原位癌,(Carcinoma in situ),上皮,全层为异型细胞,所替代，,未突破基底膜,。,好发部位：子宫颈,鳞,-,柱,上皮交界带,(,移行带,),。,(,Cervical epithelial dysplasia,),异型细胞：,类似正常基底细胞或体积较小，大小不等，核大深染，可见核分裂，细胞排列紊乱。,异型细胞：,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，可见核分裂。,损伤和炎症,柱状细胞,下,腺上皮,储备细胞,增生,鳞状上皮,化生,非典型增生,移行带,Pathogenesis,指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,。,根据非典型增生的程度和范围，可将,CIN,分为：,CIN,：,轻度非典型增生,CIN,：,中度非典型增生,CIN,：,重度非典型增生及原位癌,子宫颈上皮内瘤变,(Cervical intraepithelial neoplasia,CIN),异型细胞局限于上皮层的下,1/3,区,CIN,级（轻度非典型增生）,CIN,级,(,中度非典型增生,),异型细胞占上皮层的下,1/32/3,，异型性较,级明显,CIN,级,（重度非典型增生及原位癌）,异型细胞超过上皮层的,2/3,者为重度非典型增生；达全层者为原位癌；,异型性较,级明显，核分裂像增多，原位癌可出现病理性核分裂像（,但胞浆成熟,）,级,（轻度）异型细胞限于上皮,下,1/3,（,CIN,）,多数可消退,级,（中度）异型细胞累及上皮,下,2/3,（,CIN,）,级,（重度）异型细胞超过上皮,2/3,以上,（,CIN,）,原位癌,上皮,全层,细胞异型，极性消失，但,基底膜完整,（,CIN,）,原位癌累及腺体（仍为原位癌）,浸润癌,突破基底膜,，向上皮下浸润扩展,Cervical intraepithelial neoplasia(CIN-1 and-2),Cervical intraepithelial neoplasia(CIN-3),Cervical intraepithelial neoplasia(CIN-3),Cervical carcinoma in situ with glands,Prognosis,轻度非典型增生,:,多数可自然消退，,2%,发展为浸润癌。,非典型增生级别与浸润癌的机会成正比。,CIN,至少有,20%,在,10,年内发展为浸润癌。,非典型增生 原位癌平均时间：,约,10,年,。,非典型增生,+,16,、,18,或,33,型高危型人乳头状瘤病毒,(HPV),合并感染,较高恶变倾向,。,(Carcinoma of the cervix),三、子宫颈癌,子宫颈癌是女性生殖系统常见的恶性肿瘤之一。,发病年龄以,40,60,岁为多，发病最高峰年龄为,54,岁。,临床表现多变：,阴道不规则流血,阴道排泄物带血,接触性出血等,Etiology,1.,早婚、多产、性生活紊乱、子宫颈裂伤、包皮垢、感染等因素有关。,2.,通常继发于,CIN,。,3.,与人类乳头状瘤病毒（,HPV,）,16,、,18,型，,31,、,33,、,35,型的感染有关。,子宫颈阴道部或移行带：,鳞状上皮,子宫颈管粘膜,柱状上皮,柱状上皮下的,储备细胞,组织来源,大体分型,：,糜烂型,外生菜花型,内生浸润型,溃疡型,Pathological changes,鳞状细胞癌 约,80%,95%,腺 癌,其他类型癌 很少,早期浸润癌,浸润癌,Histopathology,(Squamous cell carcinoma of the cervix),早期浸润癌,（微小浸润性鳞状细胞癌）,浸润癌,少数肿瘤细胞突破基底膜,浸润间质的深度,不超过基底膜下,5mm,没有血管浸润也无淋巴结转移,常无明显临床症状,癌组织突破基底膜,明显浸润间质，深度,超过基底膜下,5mm,伴有临床症状者,1,）子宫颈鳞状细胞癌,镜下：,角化型（高分化）鳞癌,（,20%,）,癌细胞主要为多角形，似鳞状上皮的棘细胞；,有,癌巢,、,角化,和,癌珠,形成；,核分裂不多。,Nests of squamous cell carcinoma have invaded underlying stroma at the center and left.,非角化型大细胞鳞癌（中分化,),:,无,明显角化珠，,有不规则和条型癌巢形成,，,核分裂,和细胞,异型性,较明显,中分化鳞癌,（,60%,）,多为,大细胞型,，癌细胞为椭圆形或大梭形；,无明显角化和癌珠形成，,有单个细胞角化和细胞间桥,;,；,核分裂和细胞异型性较明显。,非角化型小细胞鳞癌（,低分化鳞癌,):,细胞呈,小梭形,，似基底细胞，,异型性,及,核分裂,都很明显，对放射线最敏感，但,预后较差,占,10%,25%,。,2,）子宫颈腺癌,(cervical adenocarcinoma),A large protruding mass is seen in cervical canal extending to the fornix of vagina.,肉眼：,与鳞癌基本相同。,镜下：,子宫颈管内膜腺癌,（,70%,）,多数为高分化或中分化,腺体结构,低分化腺癌与鳞癌不易鉴别,腺鳞癌：,有些腺癌中混杂有鳞癌成分,Pathological Changes,Well differentiated adenocarcinoma,poorly differentiated adenocarcinoma,直接蔓延,:,膀胱、,直肠、盆腔、阴道、宫体,淋巴道转移,:,最常见,，子宫旁,闭孔、髂内、,髂外、髂总、腹股沟、,骶前,LN,，,晚期锁骨上,LN,血道转移,:,肺、骨、肝,Spreading and metastasis,This is a larger cervical squamous cell carcinoma which spread to the,vagina,.,This is another pelvic exenteration for cervical squamous cell carcinoma.The irregular grey-brown tumor extends toward,bladder and up into the uterus,.,1.,不规则阴道流血、接触性出血,2.,白带增多,3.,腰骶部疼痛,4.,子宫膀胱瘘,/,子宫直肠瘘,5.,定期,脱落细胞检查,早期发现,Clinical relations,0,期,:,原位癌（,CIN,）,期,:,局限于子宫颈内,期,:,侵及盆腔和阴道,期,:,侵及盆腔壁和阴道下,1/3,期,:,侵出骨盆,累及膀胱粘膜或直肠,子宫颈癌临床分期,Leiomyoma and Leiomyosarcoma of the uterus,Endomertrial adenocarcinoma,四、子宫肿瘤,女性生殖器官中最常见的一种,良性肿瘤,多见于,30,50,岁妇女,50%,平滑肌瘤有症状：,出血，尿频，不孕，自然流产，绝经后萎缩,遗传倾向，雌激素,子宫平滑肌瘤,(leiomyoma),部位：,子宫任何部位。,数量：,单发或多发。,大小：,悬殊。,形态：,球形或不规则形，质较硬，界清，无包膜,切面：,灰白，质韧，编织状或漩涡状,继发性改变,：玻璃样变、粘液变、囊性变、,水肿、出血及坏死等。,肉眼：,Pathological Changes,A large,solitary leiomyoma,Red,degeneration,镜下：,瘤细胞与正常子宫平滑肌细胞相似,瘤细胞的,特点：排列较密集，不规则束状或编织状排列；,核长杆状，两端钝圆，染色质纤细,Uterine leiomyoma is a,benign connective tissue tumor,of the smooth muscle cells,of the myometrium.Tumor cells resemble normal cells(,elongated,spindle-shaped,with a cigar-shaped nucleus,)and form bundles with different directions(whirled).The tumor is well circumscribed,but,not encapsulated,.,良、恶性之间的区别取决于三个标准：,分裂像,细胞异型性,浸润,肿瘤核分裂像在最活跃区大于,15,个,/10 HPF,，有,细胞异型性、坏死,及,浸润者,为恶性。,子宫平滑肌肉瘤,（,Leiomyosarcoma,）,This is a leiomyosarcoma protruding from myometrium into the endometrial cavity of this uterus.,The irregular nature of this mass suggests that is not just an ordinary leiomyoma.,Much more cellular and the cells have much more pleomorphism and hyperchromatism than the benign leiomyoma.An irregular mitosis is seen in the center.,Often have very,large bizarre giant cells,along with the spindle cells.A couple of mitotic figures appear at the left and lower left.,Leiomyosarcoma of uterus,poorly differentiated,with,multinucleated histiocytes,high power.This illustrates the extreme pleomorphism that can occur in high grade leiomyosarcoma.,子宫内膜癌是女性生殖道常见的肿瘤之一,多发生在,55,65,岁,主要症状：,白带增多和不规则阴道流血。,病因未明，可能与雌激素长期刺激有关。,（二）子宫内膜癌,（,Endometrial carcinoma,）,肉眼：,局部型,：,多见,，多位于子宫底或子宫角，息肉状、乳头状,弥漫型,：内膜弥漫性增厚，灰白质脆，伴出血、坏死、溃疡,Pathological changes,1,、,子宫内膜样腺癌（常见）,Pathological Changes,（,1,）,高分化腺癌（,级,）：,结构类似子宫内膜腺体,腺管排列拥挤、紊乱，腺体间极少有间质相隔,细胞轻度异型,Adenocarcinoma,endometrium,uterus,well differentiated,high power.The tall columnar epithelium and well-defined gland formation illustrate a well-differentiated adenocarcinoma.Note the sparsity of stroma in between the glands.,（,2,）,中分化腺癌（,级,）：,腺体不规则，有较多腺体或微腺体结构，排列紊乱,细胞不规则、复层，核异型，可见核分裂；,Pathological Changes,The endometrial adenocarcinoma in the polyp at the left is,moderately differentiated,as a glandular structure can still be discerned.Note the hyperchromatism and pleomorphism of the cells,compared to the underlying endometrium with cystic atrophy at the right.,（,3,）,低分化腺癌（,级,）：,大部分区域为实心片状或条索状，腺体结构很少。,细胞异型性大，分裂像多。,Pathological Changes,2,、腺棘皮癌：,分化较好的腺癌中有化生的良性鳞状细胞团存在。,3,、腺鳞癌：,腺癌组织中混杂有恶性鳞状上皮。,直接蔓延,：,上子宫角，输卵管、卵巢,下宫颈管和阴道,外浆膜、腹膜和大网膜,淋巴道,：,宫底腹主动脉旁,LN,子宫角腹股沟,LN,宫颈宫旁、髂内外、髂总,LN,血 道,：,肺、肝、骨骼,Spreading and metastasis,This is endometrial adenocarcinoma which can be seen invading into the smooth muscle bundles of the myometrial wall of the uterus.,临床分期,根据子宫内膜癌侵犯的范围，临床上分,1,4,期：,期，癌局限于子宫体；,5,年生存率,90%,；,期，癌侵犯子宫体及子宫颈；,期，癌扩散至子宫以外，但未超过真骨盆；,IV,期，癌超出真骨盆或明显侵犯膀胱或直肠粘膜。,张三，女，,58,岁，五年前,绝经,，近一月来出现,阴道不规则流血,，,B,超发现,子宫底部,见一菜花状肿物，病理活检见灰白色质脆组织，显微镜下腺体排列拥挤、紊乱，细胞有明显异型性。,病理诊断：,?,Case discuss,子宫内膜腺癌,思考题,子宫颈癌的病理变化和临床病理联系。,子宫内膜腺癌的病理变化和临床病理联系。,名词解释：子宫颈上皮非典型增生、原位癌、子宫颈上皮内瘤变、红色变性,Thanks for,your attention!,