生殖系统和乳腺疾病子宫疾病

生殖系统和乳腺疾病（一） Diseases of genital system and mammary gland 子宫 子宫颈 Chronic cervicitis; Cervical epithelial dysplasia; Cervical carcinoma; Leiomyoma of the uterus; Endomertrial adenocarcinoma The yellow dashed line marks the outer boundary of the transformation zone. Outside the boundary the long-established and thick stratified squamous epithelium appears white or light pink following the dilute acid treatment. Inside the boundary, the transformation zone is characterized by areas of thin epithelium, which appear red or almost inflamed. 1.生育期妇女最常见 2.多继发于分娩、流产等子宫颈损伤 3.临床:白带过多 一、慢性子宫颈炎 (Chronic cervicitis)(Chronic cervicitis) n n 常见感染常见感染: : 链球菌、肠球菌、大肠杆菌、链球菌、肠球菌、大肠杆菌、 葡萄球菌等葡萄球菌等 n n 特殊感染特殊感染: : 沙眼衣原体、淋球菌、病毒沙眼衣原体、淋球菌、病毒 ( (单纯疱疹病毒、人乳头状瘤单纯疱疹病毒、人乳头状瘤 病毒、巨细胞病毒等病毒、巨细胞病毒等) )、结核、结核 菌、寄生虫及放线菌等菌、寄生虫及放线菌等 Etiology 肉眼：宫颈粘膜充血、肿胀， 颗粒状或糜烂状 Pathological changes 子宫颈粘膜充血水肿子宫颈粘膜充血水肿 间质间质单核C、淋巴C、浆C浸润浸润 子宫颈柱状上皮、腺上皮子宫颈柱状上皮、腺上皮增生或鳞状化生 子宫颈子宫颈息肉息肉(cervical polyp)(cervical polyp) 有时有时子宫颈囊肿 (纳博特囊肿,Nabothian cyst) cyst) 镜下： This is normal cervical non-This is normal cervical non- keratinizing squamous keratinizing squamous epithelium. The squamous epithelium. The squamous cells show maturation from cells show maturation from basal layer to surface.basal layer to surface. This is chronic cervicitis at the squamo-columnar junction of the cervix. Small round dark lymphocytes are seen in the submucosa, and there is also hemorrhage. Squamous metaplasia of cervix Cervical polypCervical polyp Nabothian cyst cyst In the cervix, koilocytotic change with human papillomavirus (HPV) infection, with vacuolization of epithelial cells. 子宫颈糜烂 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 Cervical erosion occurs when the surface of the cervix is replaced with inflamed tissue from the cervical canal. The condition may be caused by trauma, infection or chemicals. 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癌前病变癌前病变 异型细胞异型细胞增生，从基底层向表层发展增生，从基底层向表层发展 原位癌原位癌 上皮全层为异型细胞所替代，未未突破基底膜突破基底膜 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) ) (Cervical epithelial dysplasia and carcinoma in situ)(Cervical epithelial dysplasia and carcinoma in situ) 异型细胞：异型细胞：类似正常基底细胞或体积较小，大小不 等，细胞排列紊乱，可见核分裂。 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 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。 CIN CIN ：级非典型增生级非典型增生 CIN CIN ： 级非典型增生级非典型增生 CIN CIN ： 级非典型增生及原位癌级非典型增生及原位癌 子宫颈上皮内瘤变子宫颈上皮内瘤变 (Cervical intraepithelial neoplasia, CIN) Cervical intraepithelial neoplasia (CIN-1 and -2) Cervical intraepithelial neoplasia (CIN-3) Cervical carcinoma in situ with glands 轻度非典型增生轻度非典型增生: : 多数多数可自然消退可自然消退 20%20% CIN CIN 浸润癌浸润癌 1010年内年内 非典型增生非典型增生 + + 1616、1818或或3333型型HPVHPV感染感染较高较高 恶变倾向恶变倾向 检查手段：碘液实验、脱落细胞学、组织病检检查手段：碘液实验、脱落细胞学、组织病检 Prognosis 三、子宫颈癌 1.女性高发恶性肿瘤之一，开展普查晚期 癌，5年生存率和治愈率 2.40-60岁高发 3.3.临床临床: :阴道不规则流血、接触性出血、白带阴道不规则流血、接触性出血、白带 (Carcinoma of the cervix)(Carcinoma of the cervix) * * 与与早婚、多产、性生活紊乱、子宫颈裂早婚、多产、性生活紊乱、子宫颈裂 伤、包皮垢、感染等因素有关伤、包皮垢、感染等因素有关 * * 通常继发于通常继发于CINCIN * * 与人类乳头状瘤病毒与人类乳头状瘤病毒(HPV)16(HPV)16、1818型型，其，其 次次3131、3333型的感染有关型的感染有关 Etiology 组织来源 子宫颈阴道部或移行带：子宫颈阴道部或移行带： 鳞状上皮鳞状上皮 子宫颈管粘膜柱状上皮子宫颈管粘膜柱状上皮 柱状上皮下的储备细胞柱状上皮下的储备细胞 大体分型： 糜烂型 外生菜花型 内生浸润型 溃疡型 Pathological changes 1.子宫颈鳞状细胞癌：占90% 早期浸润癌早期浸润癌 （微小浸润型鳞 状细胞癌） 浸润癌浸润癌 少数肿瘤细胞突破基底膜少数肿瘤细胞突破基底膜 浸润间质的深度浸润间质的深度不超过基底膜下不超过基底膜下5mm5mm 没有血管浸润也无淋巴结转移没有血管浸润也无淋巴结转移 常常无明显临床症状无明显临床症状 癌组织突破基底膜癌组织突破基底膜 明显浸润间质，深度明显浸润间质，深度超过基底膜下超过基底膜下5mm5mm 伴伴有临床症状有临床症状者者 组织分型 高分化鳞癌 (20%) : : 癌巢、角化珠,核分裂不多核分裂不多 镜下: 中分化鳞癌 (60%): 无明显角化和癌珠形成，不 规则和条型癌巢,核分裂和细胞异型性较核分裂和细胞异型性较明显明显 低分化磷癌(20%): 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 2.子宫颈腺癌：占10-25% A large protruding mass is seen in cervical canal extending to the fornix of vagina. Adenocarcinoma in situ 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、胃、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. Invasive squamous carcinoma of cervix in Invasive squamous carcinoma of cervix in vascular channel. The presence of tumor vascular channel. The presence of tumor cells within the lumen of a capillary-like cells within the lumen of a capillary-like space is evidence for aggressive growth space is evidence for aggressive growth potential in squamous carcinoma of the potential in squamous carcinoma of the cervix and has been correlated with cervix and has been correlated with increased risk for regional lymph node increased risk for regional lymph node metastasis. metastasis. 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 临床分期： 0期:原位癌 I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 1.最常见 2.30岁,70% 3.多无症状，出血，尿频，不孕， 自然流产，绝经后萎缩 4.遗传倾向 Pathological changes A large, solitary leiomyoma.A large, solitary leiomyoma. A submucosal leiomyoma A submucosal leiomyoma Multiple submucosal, Multiple submucosal, intramural, and subserosal intramural, and subserosal leiomyomas of the uterus.leiomyomas of the uterus. Red degeneration 生长部位生长部位：子宫肌层、子宫浆膜下或子宫内膜下：子宫肌层、子宫浆膜下或子宫内膜下 单发或多发单发或多发：多者达数十个：多者达数十个 大小悬殊大小悬殊：小者仅镜下可见，大者：小者仅镜下可见，大者30cm30cm 形态形态：球形或不规则形，：球形或不规则形，界清，无包膜界清，无包膜 切面观切面观：灰白，质韧，编织状或旋涡状：灰白，质韧，编织状或旋涡状 继发性改变继发性改变：玻璃样变、粘液变、囊性变、钙化、：玻璃样变、粘液变、囊性变、钙化、 出血及坏死等出血及坏死等 大体： 与正常子宫平滑肌细胞与正常子宫平滑肌细胞相似相似 瘤细胞瘤细胞- - 核排列较密集 束状或编织状排列 核长杆状长杆状，两端钝圆，染色质纤细 镜下: 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良、恶性之间的区别取决于四个四个标准：标准： 坏死坏死 分裂像分裂像 细胞异型性细胞异型性 浸润浸润 肿瘤核分裂像肿瘤核分裂像1010个个/10 HP/10 HP，有，有细胞异型性细胞异型性及及浸润浸润 者者为恶性为恶性 子宫平滑肌肉瘤 （ LeiomyosarcomaLeiomyosarcoma） This is a leiomyosarcoma protruding from myometrium into This is a leiomyosarcoma protruding from myometrium into the endometrial cavity of this uterus.the endometrial cavity of this uterus. Much more cellular and the cells have much more Much more cellular and the cells have much more pleomorphism and hyperchromatism than the benign pleomorphism and hyperchromatism than the benign leiomyoma. An irregular mitosis is seen in the center. leiomyoma. An irregular mitosis is seen in the center. 1.发病率上升 2.绝经期、绝经后妇女，50-59岁 3 不规则阴道流血 4.生长缓慢,转移较晚 5.一般与雌激素长期作用有关 肉眼：肉眼： 局部型局部型：多见多见，多位于子，多位于子 宫底或子宫角，息肉状、宫底或子宫角，息肉状、 乳头状乳头状 弥漫型弥漫型：内膜弥漫性增厚：内膜弥漫性增厚 ，灰白质脆，伴出血、坏，灰白质脆，伴出血、坏 死、溃疡死、溃疡 Pathological changes 镜下： 高分化：多见，腺管排列拥挤、紊乱，轻度 异型，似增生的内膜腺体 中分化：腺体不规则，排列紊乱，乳头或筛 状，异型明显，核分裂易见 低分化：实体片状，无腺样结构，异型明 显，核分裂多见 grade I grade I grade II grade II grade III grade III Adenocarcinoma, endometrium, uterus, well differentiated. Adenocarcinoma, endometrium, uterus, well differentiated. The tall columnar epithelium and well-defined gland The tall columnar epithelium and well-defined gland f