肿瘤病理学PPT医学课件.ppt

1 welcome 2 个人简介 黄益玲 武汉大学肿瘤学博士 副教授 三峡大学151学术骨干 自2004年工作至今 主要从事本科生及留学生病理学教学及科研工作 公开发表论文三十余篇 其中SCI引用5篇 22篇为第一作者 主持湖北省教育厅及宜昌市科技局科研项目各一项 参与国家级 省厅级科研项目9项 2010年赴美国kansas大学医学中心访学一年 科研方向 肿瘤的发病机制研究及抗肿药物开发E mail lotus0717 处世格言 淡泊明志宁静致远 3 肿瘤病理学 4 课程安排肿瘤病理学总论 基本概念 肿瘤分子病理学等各论 常见肿瘤如呼吸系统 消化系统 女性生殖系统等肿瘤 5 病例分析 女 21岁主诉 近半年左下肢膝关节附近疼痛 活动后加重 一个月前发现左股骨下端局部隆起 逐渐长大 疼痛难忍 来诊 查体 左股骨下端局部肿物 压痛 处置 1 左股骨下端X线正侧位像2 胸部X线正侧位像3 左股骨下端肿物穿刺活检 6 检查结果 1 左股骨下端X线正侧位像 左股骨下端占位性病变 骨皮质破坏并有骨膜反应 2 胸部X线正侧位像 未见明显异常 7 临床诊断 恶性骨肿瘤 活检病理诊断 骨肉瘤 8 治疗原则 1 手术切除2 化疗3 放疗4 支持疗法 9 肿块 都是肿瘤吗 肿瘤一定形成 肿块 吗 是良性肿瘤还是恶性肿瘤 良性肿瘤患者对机体的影响 恶性肿瘤的预后 肿瘤是如何发生发展的 如何防治 10 TumorNeoplasmCancer Carcinomasarcoma 11 Aneoplasmisanabnormalmassoftissue thegrowthofwhichexceedsandisuncoordinatedwiththatofthenormaltissuesandpersistsinthesameexcessivemanneraftercessationofthestimuliwhichevokedthechange ThesegeneticchangesallowexcessiveandUnregulatedproliferationthatbecomesautonomous independentofphysiologicgrowthstimuli althoughtumorsgenerallyremaindependentonthehostfortheirnutritionandbloodsupply 12 Neoplasialiterallymeanstheprocessof newgrowth andanewgrowthiscalledaneoplasm Oncology Greekoncos tumor isthestudyoftumorsorneoplasms 13 14 Benigntumor Itwillremainlocalized itcannotspreadtoothersites anditisgenerallyamenabletolocalsurgicalremoval thepatientgenerallysurvives 15 Malignanttumor Itcaninvadeanddestroyadjacentstructuresandspreadtodistantsites metastasize tocausedeath Malignanttumorsarecollectivelyreferredtoascancers 16 Thetermsneoplasiaandcancerareoftenincorrectlyusedinterchangeably Neoplasiareferstobothbenignandmalignantgrowths while cancer refersspecificallytomalignantneoplasia Notallcancerswillcausedeath Somearediscoveredearlyandaretreatedsuccessfully Definitions 17 Nomenclature Alltumors benignandmalignant havetwobasiccomponents 1 theparenchyma madeupoftransformedorneoplasticcells and 2 thesupporting host derived non neoplasticstroma madeupofconnectivetissueandbloodvessels 18 Theparenchymaoftheneoplasmdeterminesitsbiologicalbehavior anditisthiscomponentfromwhichthetumorderivesitsname Thestromacarriesthebloodsupplyandprovidessupportforthegrowthofparenchymalcellsandiscrucialtothegrowthoftheneoplasm 19 鳞癌 20 parenchyma stroma 21 parenchyma stroma 22 腺癌 23 Classificationoftumor 24 benigntumorsaredesignatedbyattachingthesuffix omatothecelloforigin Tumorsofmesenchymalcellsgenerallyfollowthisrulefibroma chondroma osteomanomenclatureofbenignepithelialtumorsismorecomplex Theyarevariouslyclassified somebasedontheircellsoforigin microscopicarchitecture theirmacroscopicpatterns 25 Adenomaisthetermappliedtoabenignepithelialneoplasmthatformsglandularpatternsaswellastotumorsderivedfromglandsbutnotnecessarilyreproducingglandularpatterns Benignepithelialneoplasmsproducingmicroscopicallyormacroscopicallyvisiblefinger likeorwartyprojectionsfromepithelialsurfacesarereferredtoaspapillomasformlargecysticmasses asintheovary arereferredtoascystadenomas producepapillarypatternsthatprotrudeintocysticspacesandarecalledpapillarycystadenomas 26 Malignantepithelialneoplasmsarecalledcarcinomas adenocarcinomasifderivedfromglandularepithelia squamouscellcarcinomaandtransitionalcellcarcinomaiforiginatinginthosekindsofepithelia 27 Malignantmesenchymalneoplasmsarenamedafterthecelloforigin towhichisaddedthesuffix sarcoma eg fibrosarcoma liposarcoma chondrosarcoma 28 Figure SummaryofNomenclatureofneoplasmsarisingfromdifferentiated adult type cells 29 blastoma neuroblastoma nephroblastomaosteoblastomaOmatosis neurofibromatosislipomatosis angiomatosis 30 Nomenclature ExceptionstoTheseRulesNeoplasmsthatsoundbenignbutarereallymalignant eg lymphoma lymphocyte plasmacytoma plasmacell melanoma melanocyte Leukemias Neoplasmsofblood formingorgansarecalledleukemias MixedTumors Neoplasmscomposedofmorethanoneneoplasticcelltypearecalledmixedtumors salivaryglandplemorphicadenoma 31 TeratomasbelongtoaclassoftumorsknownasNonseminomatousgermcelltumor N S G C T Alltumorsofthisclassaretheresultofabnormaldevelopmentofpluriponentcells germcellsandembryonalcells Teratomasofembryonicoriginarecongenial occuronthesubject smidline inthebrain elsewhereintheskull inthenose inthetongue underthetongue intheneck mediastinum retroperitoneumandattachedtothecoccyx teratomasofgermcelloriginmayormaynotbecongenital occurinthetestesinmenandovariesinwomen 32 畸胎瘤的发生部位 33 骶尾部畸胎瘤 34 Nomenclature Hamartomasandchoristomasaretumor likegrowthsthoughttobetheresultofdevelopmentalanomalies Theyarenottrueneoplasms ie theydonotshowcontinuousexcessivegrowth Thetumorsareabnormal disorganized proliferatingmassesofseveraldifferentadultcelltypes 35 Ahamartomaisanon neoplastic disorganized tumor likeovergrowthofcelltypesthatareregularlyfoundwithintheaffectedorgan Ahamartomaofthelungconsistsofadisorganizedmassofbronchialepitheliumandcartilage Itsgrowthiscoordinatedwiththatofthelungitself Achoristomaisasmallnon neoplasticareaofnormaltissuemisplacedwithinanotherorgan suchaspancreatictissuewithinthewallofthestomach Nomenclature 36 37 Characteristicsoftumors 38 morphologychanges 1 gross 1 size 2 number 3 shape 4 color 5 texture 6 capsule 2 histology parenchymastroma 39 形状千姿百态 40 41 Multiplespiroma 42 lipoma 43 cutaneouspapilloma 44 Mucuscystadenomaofovary 45 Solitaryleiomyomaoftheuterus 46 ulcerativegastriccancercarcinoma 47 Polyiformcoloncarcinoma 48 Carcinomaofthelung 49 Renalcellcarcinoma 50 DifferentiationandAnaplasiaDifferentiationreferstotheextenttowhichneoplasticcellsresemblecomparablenormalcells bothmorphologicallyandfunctionally lackofdifferentiationiscalledanaplasia 51 Differetiationextendofgland well moderate poor anaplasia 52 AdiposetissueLipomaLiposarcoma 53 SmoothmuscleLeiomyomaLeiomyosarcoma 54 Squamouscellcarcinoma 55 1 histologicatypiaLossofpolarity cellsbecomederangementcrowdeddifferenceinSpatialarrangement atypia 56 LossofpolarityTheorientationofanaplasticcellsismarkedlydisturbed i e theylosenormalpolarity Sheetsorlargemassesoftumorcellsgrowinananarchic disorganizedfashion Characteristicsofbenignandmalignantneoplasms 57 Benigntumor fibroustissue fibroma 58 Normalsquamousepithelium Squamouscellcarcinoma 59 60 61 2 cellularatypia1 Pleomorphismofcell shape size2 Pleomorphismofnuclear shape sizeAbnormalmitoses3 thechangesofthecytoplasm 62 PleomorphismBoththecellsandthenucleicharacteristicallydisplaypleomorphism variationinsizeandshape Forexample cellsmaybefoundthataremanytimeslargerthantheirneighbors andothercellsmaybeextremelysmallandprimitiveappearing 63 AbnormalnuclearmorphologyCharacteristicallythenucleicontainanabundanceofDNAandareextremelydarkstaining hyperchromatic Thenucleiaredisproportionatelylargeforthecell andthenucleus to cytoplasmratiomarkedlyincreases Thenuclearshapeisveryvariable andthechromatinisoftencoarselyclumpedanddistributedalongthenuclearmembrane Largenucleoliareusuallypresentinthesenuclei 64 AbnormalmitosesUndifferentiatedtumorsusuallypossesslargenumbersofmitoses reflectingthehigherproliferativeactivityoftheparenchymalcells Moreimportantasamorphologicfeatureofmalignantneoplasiaareatypical bizarremitoticfigures sometimesproducingtripolar quadripolar ormultipolarspindles Characteristicsofbenignandmalignantneoplasms 65 Characteristicsofbenignandmalignantneoplasms OtherchangesInmanyanaplastictumors largecentralareasundergoischemicnecrosis 66 Nucler cytoplasmicratio 67 Abnormalmitoses 68 Leiomyosarcoma 69 Pleomorphismoftumorcells 70 Squamouscellcarcinoma 71 72 73 Mitoticfigure 74 Mitoticfigure 75 76 Dysplasiaatermusedtodescribedisorderlybutnon neoplasticproliferation Itisareversiblechange oftenprecedesmalignancy Dysplasiaisencountedprincipallyintheepithelia ItisalossintheuniformityoftheindividualcellsandalossintheirarchitecturalorientationDysplasticcellsalsoexhibitconsiderablepleomorphismandoftencontainhyperchromaticnucleithatareabnormallylargeforthesizeofthecell Mitoticfiguresaremoreabundantthanusual 77 Dysplasticcolumnarepithelium 78 Cervicalintraepithelialneoplasia 79 正常 CIN 1 CIN 3 CIN 2 80 CIN 1 CIN 1 81 CIN 2 CIN 2 82 CIN 3 83 Carcinomainsitu CIS Whendysplasticchangesaremarkedandinvolvetheentirethicknessoftheepithelium butthelesionremainsconfinedtothenormaltissue itisconsideredapreinvasiveneoplasmandisreferredtoascarcinomainsitu 84 Carcinomainsitu 85 Figure Carcinomainsitu Thislow powerviewshowsthattheentirethicknessoftheepitheliumisreplacedbyatypicaldysplasticcells Thereisnoorderlydifferentiationofsquamouscells Thebasementmembraneisintactandthereisnotumorinthesubepithelialstroma B Ahigh powerviewofanotherregionshowsfailureofnormaldifferentiation markednuclearandcellularpleomorphism andnumerousmitoticfiguresextendingtowardthesurface Thebasementmembrane below isnotseeninthissection 86 子宫颈原位癌 Figure 19 20 87 88 89 90 91 Thenaturalhistoryofmostmalignanttumorscanbedividedintofourphases 1 malignantchangeinthetargetcell referredtoastransformation 2 growthofthetransformedcells 3 localinvasion 4 distantmetastases 92 93 Characteristicsofbenignandmalignantneoplasms RateofgrowthMalignantneoplasmsgenerallygrowmorerapidlythanbenignones butthereisnocriticalratethatdistinguishesmalignantfrombenign Rapidlygrowingmalignanttumorsoftencontaincentralareasofischemicnecrosisbecausethetumorbloodsupply derivedfromthehost failstokeeppacewiththeoxygenneedsoftheexpandingmassofcells 94 Therateofgrowthofatumorisdeterminedbythreemainfactors thedoublingtimeoftumorcells thefractionoftumorcellsthatareinthereplicativepool therateatwhichcellsareshedandlostinthegrowinglesion 95 96 Fast growingtumorsmayhaveahighcellturnover implyingthatratesofbothproliferationandapoptosisarehigh forthetumortogrow therateofproliferationshouldexceedthatofapoptosis Thegrowthfractionoftumorcellshasaprofoundeffectontheirsusceptibilitytocancerchemotherapy 97 98 99 LocalinvasionThegrowthofcancersisaccompaniedbyprogressiveinfiltration invasion anddestructionofthesurroundingtissueAbenignneoplasmremainslocalizedatitssiteoforiginanddonothavethecapacitytoinfiltrate invade ormetastasizetodistantsites Characteristicsofbenignandmalignantneoplasms Nexttothedevelopmentofmetastases localinvasivenessisthemostreliablefeaturethatdistinguishesmalignantfrombenigntumors 100 Multipleleiomyomasoftheuterus 101 Breastcarcinoma 102 Breastcarcinoma 103 Characteristicsofbenignandmalignantneoplasms MetastasesMetastasesaretumorimplantsdiscontinuouswiththeprimarytumor Metastasisunequivocallymarksatumorasmalignantbecausebenignneoplasmsdonotmetastasize Malignantneoplasmsdisseminatebyoneofthreepathways 1 seedingwithinbodycavities 2 lymphaticspread or 3 hematogenousspread 104 LymphaticspreadTransportthroughlymphaticsisthemostcommonpathwayfortheinitialdisseminationofcarcinomas Thepatternoflymphnodeinvolvementfollowsthenaturalroutesoflymphaticdrainage Forexample carcinomasofthebreastusuallyariseintheupperouterquadrants theygenerallydisseminatefirsttotheaxillarylymphnodes Carcinomasofthelungarisinginthemajorrespiratorypassagesmetastasizefirsttotheperihilartracheobronchialandmediastinalnodes 105 106 NPC颈部淋巴结转移 107 108 109 110 Lymphaticspread 111 Lymphaticspread 112 Tumoremboliinthelymphaticchannel 113 HematogenousSpreadHematogenousspreadisthefavoredpathwayforsarcomasbutcarcinomauseitaswell Arteries withtheirthickerwalls arelessreadilypenetratedthanareveins Withvenousinvasion theblood bornecellsfollowthevenousflowdrainingthesiteoftheneoplasm Theliverandlungsarethemostfrequentlyinvolvedsecondarysitesinsuchhematogenousdissemination Allportalareadrainageflowstotheliver andallcavalbloodflowstothelungs 114 肺转移性癌 Metastaticadenocarcinoma 115 癌栓 116 Alungwithmetastaticcancer 117 肝转移 118 肝转移癌 119 肝转移癌 120 胃癌骨转移 Metastaticcarcinomaofbone 121 SeedingofbodycavitiesandsurfacesItoccurswhenamalignantneoplasmsinvadeanaturalbodycavity Mostofteninvolvedistheperitonealcavity butanyothercavity pleural pericardial subarachnoid andjointspace maybeaffected 122 卵巢Krukenberg瘤 123 种植性转移 ascites 124 脱落细胞学检查 125 126 Themolecularbasisofcancer TumorprogressionandheterogeneityItiswellestablishedthatoveraperiodoftime manytumorsbecomemoreaggressiveandacquiregreatermalignantpotential Thisphenomenonisreferredtoastumorprogression Despitethefactthatmostmalignanttumorsaremonoclonalinorigin bythetimetheybecomeclinicallyevident theirconstituentcellsareextremelyheterogeneous 127 128 129 ClinicalfeaturesofneoplasiaUltimatelytheimportanceofneoplasmsliesintheireffectsonpeople Thefollowingdiscussionconsiders EffectsoftumoronhostGradingandstagingofcancerLaboratorydiagnosisofcancer 130 Effectsoftumoronhostlocationandimpingementonadjacentstructuresfunctionalactivitysuchashormonesynthesisbleedingandsecondaryinfectionswhentheyulceratethroughadjacentnaturalsurfacesinitiationofacutesymptomscausedbyeitherruptureorinfarctioncachexia wasting paraneoplasticsyndromes Clinicalfeaturesofneoplasia 131 Clinicalfeaturesofneoplasia CancercachexiaPatientswithcancercommonlysufferprogressivelossofbodyfatandleanbodymassaccompaniedbyprofoundweakness anorexia andanemia Thiswastingsyndromeisreferredtoascachexia 132 Cancercachexia 133 Clinicalfeaturesofneoplasia ParaneoplasticsyndromesSymptomcomplexesincancer bearingpatientsthatcannotreadilybeexplained eitherbythelocalordistantspreadofthetumororbytheelaborationofhormonesindigenoustothetissuefromwhichthetumorarose areknownasparaneoplasticsyndromes 134 ParaneoplasticsyndromesCushingsyndromeisusuallyrelatedtoectopicproductionbythecancer e g smallcellcarcinomaoflung pancreaticcarcinoma ofACTHorACTH likepolypeptides EarlystagesofCushingsyndromemaypresentwithhypertensionandweightgain Withtime themorecharacteristiccentralpatternofadiposetissuedepositionbecomesapparent withresultanttruncalobesity moonfacies andaccumulationoffatintheposteriorneckandback buffalohump 135 136 137 Clinicalfeaturesofneoplasia GradingandstagingofcancerGradingofacancerisbasedonthedegreeofdifferentiationofthetumorcellsandthenumberofmitoseswithinthetumoraspresumedcorrelatesoftheneoplasm saggressiveness Thus cancersareclassifiedasgradesItoIVwithincreasinganaplasia 138 Gradingofadenocarcinoma 139 Gradingofsquamouscarcinoma 140 高分化鳞癌 级 角化珠 141 中分化鳞癌 级 142 低分化鳞癌 级 143 Thestagingofcancersisbasedonthesizeoftheprimarylesion itsextentofspreadtoregionallymphnodes andthepresenceorabsenceofblood bornemetastases 144 Clinicalfeaturesofneoplasia StagingofcancersTwomethodsofstagingarecurrentlyinuse theTNMsystem T primarytumor N regionallymphnodeinvolvement M metastases theAJCsystem dividesallcancersintostages0toIV incorporatingwithineachofthesestagesthesizeoftheprimarylesionsaswellasthepresenceofnodalspreadanddistantmetastases 145 146 147 Figure Pathologicstagingofcolorectalcancer Stagingisbasedonthedepthoftumorinvasion 148 LaboratorydiagnosisofcancerMorphologicmethodsSeveralsamplingapproachesareavailable needleaspiration 2 excisionorbiopsy 3 cytologicsmears Immunocytochemistryandflowcytometry offerpowerfuladjunctstoroutinehistology Biochemicalassays e g PSA CEAMoleculardiagnosis e g BCR ABLtranscripts HER 2amplificationMolecularprofilingoftumors Clinicalfeaturesofneoplasia 149 Papillaryadenocarcinoma 150 Signet ringcarcinoma 151 Humanpapillomavirus associatedchanges 152 Invasivesquamouscellcarcinoma 153 Immunohistochemicalstainingofestrogenreceptor 154 155 156 EpidemiologyBecausecancerisadisorderofcellgrowthandbehavior itsultimatecausehastobedefinedatthecellularandsubcellularlevels Studyofcancerpatternsinpopulations cancerepidemiology cancontributesubstantiallytoknowledgeabouttheoriginsofcancer 157 CancerEpidemiology CancerIncidenceGeographicandenvironmentalfactorsAgeHeredityAcquiredpreneoplasticdisorders Epidemiology 158 CancerIncidenceThoroughknowledgeoftheincidenceandpatternofcancerinthelocalpopulationisimportantfortheclinicianevaluatingthepossibilityofcancerinagivenpatient Boththeincidenceandthedeathrateofcancermustbeconsidered Thelatterreflectsboththeincidenceandthesuccessofdiagnosisandtherapy Epidemiology 159 1 2 160 1 2 161 162 163 男性 女性 Age adjustedca