临床检验基础

临床检验基础脱落细胞学检查,上海第二医科大学附属瑞金医院袁勤,脱落细胞检查基本知识,脱落细胞学（exfoliative cytology) :人体各部位，特别是管腔系统表面的脱落细胞或病变器官及肿物通过细针吸取的方法获得的细胞，经染色后，在显微镜下观察这些细胞的形态，从而作出诊断的一门临床检验学科，又称临床细胞学（clinical cytology) ，细胞病理学（cytopathology),脱落细胞检查基本知识,1928年，Papaniculaou 阴道涂片诊断宫颈癌, 创建了巴氏染色法.50年代，我国推广应用70年代，针吸细胞学的开展和发展近年来，免疫细胞化学、DNA分析、PCR技术、超微结构分析等,脱落细胞检查的标本来源,自然排出物（痰液、尿液、乳头溢液等）体腔抽出液（胸水、腹水、心包液、脑脊液）细针穿刺吸取液（软组织肿块、乳腺、淋巴结、甲状腺等）,第一节 正常脱落细胞形态,一、复层鳞状上皮被覆于全身皮肤、口腔、喉部、鼻咽的一部分，食管、阴道的全部以及子宫颈基底层 (Basal Cells, Parabasal Cells)中层 (Intermediate Cells)表层 (Superficial Cells),鳞状上皮细胞Squamous epithelium cells,第一节 正常脱落细胞形态,二、柱状上皮被覆于鼻腔、鼻咽、支气管、子宫颈管、子宫内膜等分成纤毛柱状上皮和黏液柱状上皮,纤毛柱状上皮细胞Ciliated columnar epithelium cell,纤毛柱状上皮细胞Ciliated columnar epithelium cell,Ciliated columnar epithelium cell with terminal bars and cilia.,粘液柱状上皮细胞Mucus columnar epithelium cell,Mucus columnar epithelium cellNote that the nuclei are uniform, basal, and do not stratify,第一节 正常脱落细胞形态,三、脱落上皮细胞的退化变性肿胀性退变固缩性退变,第一节 正常脱落细胞形态,四、正常脱落的非上皮细胞包括红细胞、中性粒细胞、嗜酸中性粒细胞、淋巴细胞、组织细胞、多核巨细胞等坏死物、黏液及异物,第二节 核异质和角化不良细胞形态,核异质(dyskaryosis) :是指细胞核的异常，表现为核形态、大小及染色质分布异常，核边增厚，核边界不整齐等，胞质的质和量的分化正常。核异质细胞介于良性和恶性细胞之间，又称为不典型细胞或增生不良细胞。角化不良：又称异常角化、不成熟角化，是指鳞状上皮非角化层细胞出现个别散在的胞浆内角化。,鳞状上皮细胞,第三节 恶性肿瘤细胞形态,恶性肿瘤细胞一般形态特征细胞核的异型性：核增大，核大小不一，核染色质深染，粗糙，核畸形，核浆比失常，核仁增大，增多，核分裂相增多，出现瘤巨细胞，裸核；细胞质的异型性：高分化恶性肿瘤细胞胞质丰富；低分化则胞质少；细胞的分布：失去极性，排列混乱。,鳞状细胞癌Squamous cell carcinoma,癌细胞单个散在，癌细胞体积大，多形性明显，可以呈圆形、蝌蚪形、梭形及不规则形；核大而畸形，核染色质丰富深染，粗颗粒状或团块状。核仁常不明显。胞浆丰富红染，有角化倾向。,鳞状细胞癌Squamous cell carcinoma,腺癌 Adenocarcinoma,常见成团脱落, 呈腺腔样、乳头状，管状等等。成团癌细胞排列极性混乱; 细胞核大小不一, 多为圆形、卵圆形，胞浆丰富，常见粘液空泡, 染色质丰富深染，呈粗颗粒状，可见明显核仁。,腺癌 Adenocarcinoma,未分化癌 Undifferentiated Carcinoma,未分化癌是各种上皮组织发生的分化极差的的癌,在形态上很难确定其组织来源。癌细胞可单个散在, 常成团脱落，细胞核相互挤压呈镶嵌状结构。细胞胞体小，比淋巴细胞稍大，常为不规则的圆形或卵圆形，胞浆少，呈裸核样.,未分化小细胞癌 Small cell carcinoma,阴道脱落细胞学检查Gynecologic Cytology,阴道细胞学检查应用于宫颈癌的防癌普查，是早期诊断宫颈癌的重要手段。,阴道脱落细胞学检查 (Gynecology Cytology),（一）鳞状上皮细胞底层细胞中层细胞表层细胞：角化前和角化细胞（二）柱状上皮细胞子宫颈内膜细胞分泌型柱状上皮细胞纤毛柱状上皮细胞子宫内膜细胞,第一节 正常脱落细胞形态,一、复层鳞状上皮被覆于全身皮肤、口腔、喉部、鼻咽的一部分，食管、阴道的全部以及子宫颈基底层 (Basal Cells, Parabasal Cells)中层 (Intermediate Cells)表层 (Superficial Cells),阴道脱落细胞-鳞状上皮细胞,阴道脱落细胞-鳞状上皮细胞,阴道脱落细胞-鳞状上皮细胞,阴道脱落细胞学检查 (Gynecology Cytology),柱状上皮细胞:被覆于子宫颈内膜和子宫内膜子宫颈内膜细胞分泌型柱状上皮细胞纤毛柱状上皮细胞子宫内膜细胞,子宫颈内膜细胞 (Endocervical cells),Endocervical cells. Note uniformity of cells: Prominent cell borders-a benign feature of endocervical cells-results in characteristic honeycomb appearance.Nuclei are round to oval with smooth outlines. This is the classic cytologic appearance of benign glandular epithelium from virtually any site.,子宫颈内膜细胞 (Endocervical cells),Endocervical cells Note that the nuclei are uniform, basal, and do not stratify,子宫颈内膜细胞 (Endocervical cells),Ciliated endocervical cells with terminal bars and cilia.,子宫内膜细胞 (Endometrial cells),In contrast with usually flat lying, well-preserved endocervical cells, endometrial cells tend to be packed together and degenerated. Note that the normal endometrial cell nucleus is approximately the size of the intermediate squamous cell nucleus.,子宫内膜细胞 (Endometrial cells),Classic double contour arrangement (stroma in center surrounded by epithelium) is associated with exodus (days 6 to 10).,阴道正常脱落细胞,Cervix (tissue)Transformation zone, from simple columnar epithelium of endocervix into squamous metaplasia.This area is of particular interest because it is where most neoplastic lesions of the cervix arise.,阴道正常脱落细胞,The presence of endocervical cells is one measure of the adequacy of a Pap smear, indicating that the transformation zone has been sampled.,阴道炎症脱落细胞,滴虫性阴道炎 淋球菌感染阴道炎 萎縮性阴道炎 病毒感染有關的細胞學改變 (單純疱疹病毒，人乳头状瘤病毒）,滴虫性阴道炎Trichomonas vaginalis,萎縮性阴道炎Atrophic Vaginitis,單純疱疹病毒相關的細胞學改變 Cellular changes associated with Herpes Simplex Virus,人乳头状瘤病毒相關的細胞學改變 Cellular changes associated with Human Papiloma Virus,HPV infection (tissue)Note well-defined cytoplasmic vacuoles and nuclear atypia of the koilocytes.,人乳头状瘤病毒相關的細胞學改變 Cellular changes associated with Human Papiloma Virus,人乳头状瘤病毒相關的細胞學改變 Cellular changes associated with Human Papiloma Virus,Koilocytes: HPV infection, low-grade squamous intraepithelial lesion.To be a diagnostic koilocyte, the cytoplasmic vacuole must be clear and extremely well defined, with condensation of the peripheral cytoplasm. In addition, the nucleus must appear abnormal Binucleation is common.,低度鳞状上皮内病变 (LSIL),Low-grade Squamous Intraepithelial Lesion (LSIL) Note resemblance to normal intermediate cells, although the cytoplasm is slightly thick and dense. The nuclei are big and dark .,高度鳞状上皮内病变 (HSIL),High-grade Squamous Intraepithelial Lesion (HSIL)This is represented by small cells with high nuclear/cytoplasmic ratios and irregular nuclei. Note thin rim of dense cytoplasm,阴道脱落细胞学检查 (Gynecology Cytology),女性生殖系统的恶性肿瘤以宫颈癌为最多见，宫颈癌中以鳞状细胞癌为多见（）；其次腺癌；未分化癌极少见。,宫颈鳞状细胞癌Squamous cell carcinoma,癌细胞单个散在，癌细胞体积大，多形性明显，可以呈圆形、蝌蚪形、梭形及不规则形；核大而畸形，核染色质丰富深染，粗颗粒状或团块状。核仁常不明显。胞浆丰富红染，有角化倾向。,宫颈鳞状细胞癌Squamous cell carcinoma,Keratinizing squamous cell carcinoma Markedly pleomorphic or bizarre shaped, heavily keratinized tumor cells, and marked hyperchromasia are characteristic. Cells tend to occur singly.,宫颈鳞状细胞癌Squamous cell carcinoma,宫颈鳞状细胞癌Squamous cell carcinoma,Keratinizing squamous cell carcinoma (tissue). Note squamous pearl (aka squamous eddy): pearls are pathognomonic of keratinization.,宫颈鳞状细胞癌Squamous cell carcinoma,Nonkeratinized squamous cell carcinoma. Compared with keratinizing SCC, the cells of nonkeratinizing SCC are more uniform and more often occur in aggregates. Nuclear abnormalities are usually easier to appreciate in nonkeratinizing SCC.,阴道脱落细胞学检查 Gynecology Cytology,宫颈腺癌：仅占阳性涂片总数左右，可能来源于子宫颈、子宫内膜或输卵管。腺癌细胞中等大小，多为圆形、卵圆形，胞浆丰富，染色质丰富深染，呈粗颗粒状，常见巨大核仁。癌细胞可散在，也可成团，呈腺腔样、乳头状，管状等等。成团癌细胞极性混乱，核大小不一，畸形明显。,宫颈腺癌 (Endocervical Adenocarcinoma),Endocervical adenocarcinoma is represented by a rosette-like arrangement of malignant endocervical cells. Note prominent nucleoli.,宫颈腺癌 (Endocervical Adenocarcinoma),Endocervical adenocarcinoma in situ. Crowded rosette, Benign endocervical cells rarely form rosettes.,宫颈腺癌 (Endocervical Adenocarcinoma),阴道脱落细胞学检查 Gynecology Cytology,宫颈未分化癌： 极少见，少于阳性涂片总数，细胞分化程度极低恶性程度高。胞体小，大小不等，常为圆形或不规则形。核小，染色质较细致。核仁不明显。浆极少或呈裸核样。,宫颈小细胞未分化癌 (Small cell neuroendocrine carcinoma),A rare cause of HCGs, small cell neuroendocrine carcinoma is cytologically similar to the far more common small oat cell carcinoma that occurs in the lung. Note high nuclear /cytoplasmic ratios, fine, dark chromatin, and inconspicuous nucleoli. There is an attempt at rosette formation by the cells in this field.,其他恶性肿瘤,Malignant mixed mesodermal (mllerian) tumor or carcinosarcoma.Often, only the malignant epithelial component is seen in the Pap smear. The adenocarcinoma can range from well differentiated to poorly differentiated.,阴道脱落细胞学检查 Gyne