第五章肿瘤PPT课件

-,1,罗京，因病于2009年6月5日与世长辞。,淋巴瘤,-,2,罗京,沈殿霞,阿桑,陈晓旭,梅艳芳,李钰,-,3,傅彪,叶凡,帕瓦罗蒂,赫本,李媛媛,罗文,-,4,第五章肿瘤,P76,-,5,-,6,-,7,世界上最动听的话不是“我爱你”,而是“你的肿瘤是良性的”！,两度获得奥斯卡最佳导演奖的美国著名导演伍迪-艾伦(WoodyAllen),-,8,本章内容,肿瘤的概念肿瘤的形态和结构肿瘤的分化与异型性肿瘤的命名与分类良恶性肿瘤的区别癌前病变、非典型增生和原位癌肿瘤的病因及病机,-,9,第一节概述,一、肿瘤的概念,-,10,肿瘤性增生,-,11,注意：,1、肿瘤性增生与非肿瘤性增生的区别（三性）,-,13,2、肿瘤与肿块的关系,-,14,二、肿瘤的一般形态和结构,-,15,数目大小形状颜色质地,受多种因素的影响(与组织来源，生长方式，发生部位等有关)，多种多样，在一定程度上反映了肿瘤的良恶性。,（一）肿瘤的大体形态,-,16,1、数目,多数为一个，可多个；,-,17,单发,多发,-,18,Thisirregularreddish,ulceratedexophyticmid-esophagealmassasseenonthemucosalsurfaceisasquamouscellcarcinoma.Endoscopicviewsofanulceratedmid-esophagealsquamouscellcarcinomacausinglumenalstenosisareseenbelow.RiskfactorsforesophagealsquamouscarcinomaincludemainlysmokingandalcoholismintheU.S.Inotherpartsoftheworlddietaryfactorsmayplayarole,-,19,Thisisaleiomyosarcomaofthesmallbowel.Aswithsarcomasingeneral,thisoneisbigandbad.Sarcomasareuncommonatthissite,butmustbedistinguishedfromothertypesofneoplasms,-,20,Benignneoplasmscanbemultiple,asisshowninthisuteruswithleiomyomasofvaryingsize,butallbenignandwell-circumscribedfirmwhitemasses.Rememberthatthemostcommonneoplasmisabenignnevus(pigmentedmole)oftheskin,andmostpeoplehaveseveral.Asageneralrule,benignneoplasmsdonotgiverisetomalignantneoplasms,-,21,Hereisanotherexampleofpolyposiswithnumeroussmallpolypscoveringthecolonicmucosa.Inthisparticularcase,therewereosteomasoftheskull,aperiampullaryadenocarcinoma,andepidermalinclusioncysts.Thus,thisisacaseofGardnerssyndrome.Aswithfamilialadenomatouspolyposis,theinheritancepatternisautosomaldominant,-,22,-,23,2、大小,大小不一（大小与肿瘤发展阶段、发生部位和肿瘤的性质等有关）,-,24,-,25,-,26,Thecircumscribedmasslesionpresenthereinthesellaturcicaisapituitaryadenoma.,-,27,3、形状,多种多样（发生部位、组织来源、生长方式和肿瘤的性质等有关）,-,28,形状千姿百态,-,29,-,30,-,31,Thisisanadenocarcinomaarisinginavillousadenoma.Thesurfaceoftheneoplasmispolypoidandreddishpink.Hemorrhagefromthesurfaceofthetumorcreatesaguaiacpositivestool.Thisneoplasmwaslocatedinthesigmoidcolon,justoutofreachofdigitalexamination,buteasilyvisualizedwithsigmoidoscopy,-,32,Thegrossappearanceofavillousadenomaisshownabovethesurfaceattheleft,andincrosssectionattheright.Notethatthistypeofadenomaissessile,ratherthanpedunculated,andlargerthanatubularadenoma(adenomatouspolyp).Avillousadenomaaveragesseveralcentimetersindiameter,andmaybeupto10cm.Oncolonoscopy,asessilepolypisseenbelow,-,33,Hereisaresectedmeningioma.Thesearerelativelyeasyfortheneurosurgeontoremove,-,34,Hereisanovarianstromaltumorthatishardandwhiteandisafibroma,-,35,Benignepithelialtumorsoftheovarycanreachmassiveproportions.Theserouscystadenomaseenherefillsasurgicalpananddwarfsthe4cmruler,-,36,Thisisatumorofovariansurfaceepithelium.Thesearethemostcommonovarianneoplasms.Suchneoplasmsmaybelinedbyepitheliumthatisserousormucinous.Picturedhereisaserouscystadenoma.Itwasfilledwithpaleyellowserousfluidinonlyasinglecavity.Mucinoustumorsarefilledwithstickymucinandtendtobemultiloculated.Benignepithelialovariantumorsarebilateralinabout20%ofcases.,-,37,Thecysticnatureofamatureteratomaofovaryisseenhere.Themostcommontissueelementoftheseteratomasisskin,solargeamountsofhairandsebumareproduced,leadingtoachallengingcleanupprobleminsurgicalpathologyfollowingdissectionofthesetumors.Ifthesetumorsaremostlysolid,thentheyareoftenimmatureteratomaswithlessdifferentiatedtissueandaremoreaggressive.Rarely,therearefranklycarcinomatousareas,-,38,Hereisabenignserouscystadenomathatdemonstratesmultiloculation.Notethattheinnersurfaceis,forthemostpart,smooth,withonlyasolitarypapillationattheupperright,-,39,Hereisanothercervicalsquamouscellcarcinoma.NotetheIUDstringprotrudingfromthecervix.ThisimpliesthatsomeonecouldhavedoneaPapsmearwhenitwasinserted.Thereisanaturalhistoryofprogressionofdysplasiatocarcinoma,sodontleavedysplasiasalone,-,40,Thisisalargercervicalsquamouscellcarcinomawhichspreadtothevagina.Atotalabdominalhysterectomywithbilateralsalpingo-oopherectomy(TAH-BSO)wasperformed,-,41,Thismastectomyspecimendemonstratesthegrossfindingsofinflammatorycarcinomaofbreast.Thisisnotaspecifichistologictypeofbreastcancer,butratheritimpliesdermallymphaticinvasionbysometypeofunderlyingbreastcarcinoma.Suchinvolvementofdermallymphaticsgivesthegrosslythickened,erythematous,androughskinsurfacewiththeappearanceofanorangepeel(peaudorangeforyoufrancophiles).,-,42,4、颜色,一般为灰白色或灰红色，可为其它颜色。,-,43,Thisinfiltratingductalcarcinomaofthebreastisdefinitelyinfiltratingthesurroundingbreast.Thecentralwhiteareaisveryhardandgritty,becausetheneoplasmisproducingadesmoplasticreactionwithlotsofcollagen.Thisisoftencalledascirrhousappearance.Thereisalsofocaldystrophiccalcificationleadingtothegrittyareas,-,44,Thecutsurfaceofaschwannomaissimilartothatofmanymesenchymalneoplasms,withafishfleshsofttanappearance.,-,45,Hereisanotherfollicularneoplasm(afollicularadenomahistologically)thatissurroundedbyathinwhitecapsule.Itissometimesdifficulttotellawell-differentiatedfollicularcarcinomafromafollicularadenoma.Thus,patientswithfollicularneoplasmsaretreatedwithsubtotalthyroidectomyjusttobeonthesafeside,-,46,Thisexcisionofskindemonstratesamalignantmelanoma,whichismuchlargerandmoreirregularthanabenignnevus,-,47,Hereisaverylargeleiomyomaoftheuterusthathasundergonedegenerativechangeandisred(so-calledreddegeneration).Suchanappearancemightmakeyouthinkthatitcouldbemalignant.Rememberthatmalignanttumorsdonotgenerallyarisefrombenigntumors,whichisagoodthing,becauseleiomyomasaresocommon(20%ofwomenwillhaveatleastone).Postmenopausally,leiomyomastendtoregressinsizeandbecomefibrotic,Thislargefleshymassaroseintheretroperitoneumandisanexampleofasarcoma.Sarcomasarisefrommesenchymaltissues.Thisonehappenedtobeamalignantfibroushistiocytomawhichisawastebaskettermforsarcomasthatdonotresemblemesenchymalcellssuchasstriatedmuscle(rhabdomyosarcoma),smoothmuscle(leiomyosarcoma),fat(liposarcoma),bloodvessels(angiosarcoma),bone(osteosarcoma),orcartilage(chondrosarcoma).Sarcomasarebigandbad,Thisisasquamouscellcarcinomaofthelungthatisarisingcentrallyinthelung(asmostsquamouscellcarcinomasdo).Itisobstructingtherightmainbronchus.Theneoplasmisveryfirmandhasapalewhitetotancutsurface,Thisrenalcellcarcinomademonstratesdistortionanddisplacementoftherenalparenchymabythetumormassinthelowerpole.Thismalignantneoplasmisvariegatedoncutsurface,withyellowtowhitetoredtobrownareas,Ofcourse,neoplasmscanbebenignaswellasmalignant,thoughitisnotalwayseasytotellhowaneoplasmwillact.Hereisabenignlipomaontheserosalsurfaceofthesmallintestine.Ithasthecharacteristicsofabenignneoplasm:itiswellcircumscribed,slowgrowing,andresemblesthetissueoforigin(fat).,-,52,5、质地(硬度),软硬不一,-,53,Hereisanosteosarcomaofbone.Thelarge,bulkymassarisesinthecortexoftheboneandextendsoutward,-,54,(二)肿瘤的组织结构,1、肿瘤的实质：肿瘤细胞决定肿瘤的一切性质肿瘤的分化程度、方向肿瘤的组织学分类,肿瘤的组织实质与间质,-,55,Notethesmallnestsandinfiltratingstrandsofneoplasticcellswithprominentbandsofcollagenbetweentheminthisductalcarcinomaofthebreast.Itisthismarkedincreaseinthedensefibroustissuestromathatproducesthecharacteristichardscirrhousappearanceofthetypicalinfiltratingductalcarcinoma.Notethenervesurroundedbytheneoplasmatthelowerleft,实质,间质,-,56,实质,间质,-,57,营养支架（支持）,2、间质：含脉管的纤维结缔组织，无特异性,作用：,还可见淋巴细胞等浸润，与机体对肿瘤细胞的免疫反应有关,-,58,-,59,第二节肿瘤的异型性(atypia),-,60,异型性（atypia）：肿瘤细胞形态组织结构与其来源的正常组织不同程度的差异。异型性大小反映肿瘤组织的成熟程度（分化程度）。,-,61,肿瘤的分化（differentiation）：分化：胚胎学中指幼稚细胞发育成为成熟细胞的过程；,肿瘤的分化指肿瘤组织在形态和功能上与某种正常组织的相似之处即成熟程度（分化程度）；,肿瘤缺乏与正常组织的相似之处称未分化/间变（异型性显著，恶性程度高）。,-,62,肿瘤分化程度越高，异型性越小，恶性程度越低即越良，反之，分化程度越低，异型性越大，肿瘤恶性程度越高即越恶。,异型性、分化程度与肿瘤良恶性的关系,异型性大小在病理学上是诊断和鉴别良、恶性肿瘤的重要形态学依据。,-,63,一、肿瘤细胞的异型性,1、细胞的多形性（大小、形态）2、核的多形性(核浆比、大小、形状、染色、数目、核裂等),-,64,Thisneoplasmissopoorlydifferentiatedthatitisdifficulttotellwhatthecelloforiginis.Itisprobablyacarcinomabecauseofthepolygonalnatureofthecells.Notethatnucleoliarenumerousandlargeinthisneoplasm.Neoplasmswithnodifferentiationaresaidtobeanaplastic,-,65,Sarcomas,includingleiomyosarcomas,oftenhaveverylargebizarregiantcellsalongwiththespindlecells.Acoupleofmitoticfiguresappearattheleftandlowerleft.,-,66,图13,-,67,-,68,3、细胞浆的改变：嗜碱性染色增强与来源相关的瘤细胞产物,-,69,Thisisasignetringcellpatternofadenocarcinomainwhichthecellsarefilledwithmucinvacuolesthatpushthenucleustooneside,asshownatthearrow,图(恶黑、粘液腺癌儿镜下各一幅）,-,70,肿瘤细胞的异型性可归纳为：,大（细胞大，核大，核仁大）多（核多，核仁多，染色质多，产物多）怪（瘤细胞和细胞核奇形怪状）裂（核分裂及病理性核分裂）,-,71,二、肿瘤组织结构的异型性,细胞的极向排列方式细胞层次腺体大小形态密度等发生紊乱和变化,-,72,图镜下：（皮肤乳头状瘤与皮肤鳞癌）,-,73,Theinfiltratingglandsofthiscolonicadenocarcinomademonstratelessdifferentiationthantheadenomatouspolyp,althoughtheystillresembleglands.Ingeneral,lessdifferentiationmeansagreaterlikelihoodofmalignantbehavior,（大肠腺瘤性息肉）与大肠癌）,-,74,Theconceptofdifferentiationisdemonstratedbythissmalladenomatouspolypofthecolon.Notethedifferenceinstainingqualitybetweentheepithelialcellsoftheadenomaatthetopandthenormalglandularepitheliumofthecolonicmucosabelow,（大肠腺瘤性息肉）与大肠癌）,-,75,Athighmagnification,thenormalcolonicepitheliumattheleftcontrastswiththeatypicalepitheliumoftheadenomatouspolypattheright.Nucleiaredarkerandmoreirregularlysizedandclosertogetherintheadenomatouspolypthaninthenormalmucosa.However,theoveralldifferencebetweenthemisnotgreat,sothisbenignneoplasmmimicsthenormaltissuequitewellandthis,therefore,well-differentiated,（大肠腺瘤性息肉）与大肠癌）,-,76,-,77,恶性肿瘤：细胞异型性和组织结构异型性都明显（如鳞癌、腺癌）,良性肿瘤：细胞异型性较小，有不同程度的组织结构异型性（如平滑肌瘤、腺瘤）,总结：,第四节肿瘤的命名与分类p85,1、良性肿瘤来源组织+瘤,一、肿瘤的命名,（一）一般命名原则：根据肿瘤的组织/细胞来源和生物学行为来命名。,2、恶性肿瘤命名所有恶性瘤总称为癌症(cancer)。,（1）癌(carcinoma)定义：指来源于上皮组织的恶性肿瘤,-,80,Transitionalcellcarcinomaofthebladder,-,81,（2）肉瘤(sarcoma),定义：指来源于间叶组织的恶性肿,-,82,骨肉瘤,-,83,（3）癌肉瘤:癌+肉瘤,（二）结合形态命名,-,84,1、母细胞瘤（良性：骨母、软骨母恶性：肾母、髓母、神母）2、冠以“恶性”命名：恶性神经鞘瘤3、以“病”“瘤”命名：白血病、精原细胞瘤4、人名命名：尤文瘤(Ewing)、霍奇金(Hodgkin)淋巴瘤5、肿瘤的多发-瘤病6、畸胎瘤,（三）其他特殊命名,-,85,（四）转移瘤的命名：转移部位+“转移性”+原发瘤的名称或原发瘤的名称+转移部位+“转移”如肺转移性肝癌或肝癌肺转移（图）,-,86,-,87,二、肿瘤的分类,原则：以肿瘤的组织或细胞类型（组织来源）+肿瘤生物学行为（良、恶性）为依据。,-,88,第三节肿瘤的生长和扩散p79,克隆性增生恶性肿瘤的增生呈现出阶段性：,肿瘤生长的生物学：,细胞恶性转化细胞克隆性增生局部浸润远处转移,-,90,1、膨胀性生长多为良性包膜,（一）生长方式：三种,一、肿瘤生长的生物学,-,91,平滑肌瘤leiomyoma,-,92,-,93,Hereisasmallhepaticadenoma,anuncommonbenignneoplasm,butonethatshowshowwell-demarcatedanbenignneoplasmis.Italsoillustrateshowfunctionofthenormaltissueismaintained,becausetheadenomaismakingbilepigment,givingitagreencolor,-,94,2、浸润性生长多为恶性,Malignantneoplasmsarealsocharacterizedbythetendencytoinvadesurroundingtissues.Here,alungcancerisseentobespreadingalongthebronchiintothesurroundinglung.,-,96,Thisgliomaisarisinginthecerebralhemisphere.Asinmostgliomas,itisdifficulttotellwherethemarginis,-,97,Thisisasquamouscellcarcinomaofthelung.Itisabulkymassthatextendsintosurroundinglungparenchyma.,Arisingcentrallyinthislungandspreadingextensivelyisasmallcellanaplastic(oatcell)carcinoma.Thecutsurfaceofthistumorhasasoft,lobulated,whitetotanappearance.Thetumorseenherehascausedobstructionofthemainbronchustoleftlungsothatthedistallungiscollapsed.Oatcellcarcinomasareveryaggressiveandoftenmetastasizewidelybeforetheprimarytumormassinthelungreachesalargesize,-,99,Thenormalsquamousepitheliumattheleftmergesintothesquamouscellcarcinomaattheright,whichisinfiltratingdownward.Theneoplasticsquamouscellsarestillsimilartothenormalsquamouscells,butarelessorderly.Thisisawell-differentiatedsquamouscellcarcinoma,-,100,Thissarcomaisstainedforvimentinbyimmunoperoxidase.Thepositiveneoplasticcellsareinvadingintonormalmusclefibers(whicharenotstainingforvimentin)attheleft.Thisisatypicalstainingreactionforsarcomas,-,101,广义狭义,复发,-,102,3、外生性生长良、恶均可,-,103,Hereisanotherexampleofanadenocarcinomaofcolon.Thiscancerismoreexophyticinitsgrowthpattern.Thus,oneofthecomplicationsofacarcinomaisobstruction(usuallypartial).Colonoscopicviewsofanotherulceratingmass,arectaladenocarcinoma,areseenbelow,-,104,Thisisalargercervicalsquamouscellcarcinomawhichspreadtothevagina.Atotalabdominalhysterectomywithbilateralsalpingo-oopherectomy(TAH-BSO)wasperformed,-,105,Thisadenomatouspolyphasahemorrhagicsurface(whichiswhytheymayfirstbedetectedwithstooloccultbloodscreening)andalongnarrowstalk.Thesizeofthispolyp-above2cm-makesthepossibilityofmalignancymorelikely,butthispolypprovedtobebenign,-,106,(二)生长动力学,生长速度,良性肿瘤缓慢恶性肿瘤快,-,107,倍增时间,影响生长速度因素：,生长分数：恶性肿瘤细胞的生长分数先高后低。生长分数高的肿瘤对化学治疗敏感（主要干扰细胞增殖）。,生成与死亡的比例,-,108,肿瘤细胞与炎细胞能产生系列血管生成因子，能诱导肿瘤内血管的生成,(三)肿瘤血管形成肿瘤生长与扩散的前提,VEGF（血管内皮细胞生长因子）P53基因的表达可抑制肿瘤血管的生成,-,109,单克隆：单一转化细胞增殖演进：恶性肿瘤在生长过程中侵袭性增加的现象。异质性：恶性转化细胞单克隆性增殖子代细胞生长速度、侵袭能力、对生长信号的反应、对抗癌药物的敏感性等不同亚克隆(P83),(四)肿瘤的克隆性及演进与异质性,-,110,二、肿瘤的扩散,途径：组织间隙、神经束衣连续生长结果：破坏，瘤体长大,（一）直接蔓延,-,111,图（宫颈癌的局部蔓延大体）,Thisisanotherpelvicexenterationforcervicalsquamouscellcarcinoma.Theirregulargrey-browntumorextendstowardbladderandupintotheuterus.,-,112,1、淋巴道转移（癌的主要转移途径）,（二）转移,概念,局部淋巴结远处淋巴结受累淋巴结常肿大，变硬，切面呈灰白色。,-,113,图5-6图5-7图（鼻咽癌，乳腺癌转移大体）,-,114,Microscopically,metastaticadenocarcinomaisseeninalymphnodehere.Itiscommonforcarcinomastometastasizetolymphnodes.Thefirstnodesinvolvedarethosedrainingthesiteoftheprimary.,-,115,Bothlymphaticandhematogenousspreadofmalignantneoplasmsispossibletodistantsites.Here,abreastcarcinomahasspreadtoalymphaticinthelung.,2、血道转移（为肉瘤的主要转移途径）,途径：体循环、门脉系,瘤细胞血管（V）瘤栓其他部位转移瘤,-,117,全身各器官组织的瘤细胞（如骨肉瘤）体静脉肺,-,118,腹腔脏器肿瘤的瘤细胞门静脉肝（如胃肠道癌）,肝转移性癌,-,119,Herearelivermetastasesfromanadenocarcinomaprimaryinthecolon,oneofthemostcommonprimarysitesformetastaticadenocarcinomatotheliver,-,120,脾转移性癌,-,121,肺内瘤细胞肺静脉全身各器官（如肺癌全身转移）,肾转移性癌,-,122,瘤细胞胸、腰、骨盆静脉脊椎V丛脊椎和脑（如前列腺癌）,脑转移性癌,-,123,最常见累及的器官是肺，其次是肝,最常见转移部位：,-,124,瘤细胞入血是否必定发生转移？单个瘤细胞大多数被NKcell消灭，进入血管的癌细胞形成瘤栓才易形成新的转移灶。,-,125,某些肿瘤的转移具有明显的器官亲合性。这些器官的血管内皮细胞上有与癌细胞表面的粘附分子相结合的配体存在这些器官释放吸引某些癌细胞的趋化物质某些组织、器官不适合转移瘤的生长,受原发肿瘤部位和血液循环途径的影响,-,126,多个，散在分布，边界清楚，多靠近器官表面癌脐,血道转移瘤的形态特点,-,127,3、种植性转移,体腔内器官的肿瘤,-,128,Krukenberg瘤种植性转移常伴血性积液,-,129,Neoplasmscanspreadbyseedingalongbodycavities,andthispatternismoretypicalforcarcinomasthanotherneoplasms.Notethemultitudeofsmalltantumornodulesseenovertheperitonealsurfaceofthemesenteryshownhere,-,130,大网膜种植性转移,-,131,胃癌种植于卵巢形成krukenberg瘤,-,132,Metastatictumorstoovaryareuncommon,butthereisonesituationinwhichametastaticadenocarcinomatoovaryappearsasalargemassandresemblesaprimarytumor:aso-calledKrukenbergtumorofovarywhichhasasignetringhistologicpatternandusuallyismetastaticfromaprimaryingastrointestinaltract.Seenhereextendingoutofthepelvisatautopsyisalargerightovarianmass.Metastasesarealsopresentinthelowerrightportionofliver.,-,133,种植性转移腹水形成,-,134,脱落细胞学检查,-,135,（三）恶性肿瘤的浸润和转移机制（了解）,肿瘤的异质性和血管形成都对肿瘤的浸润和转移起重要作用。,过程：,-,136,细胞间粘附力下降与基底膜的粘着增加细胞外基质的降解细胞的迁移,-,137,2、肿瘤转移的分子遗传学,转移基因与转移抑制基因：,CD44过表达与血行播散有关nm23的高表达，低转移性；缺或低表达，高转移性,上皮钙粘素、组织金属蛋白酶抑制物,-,138,第五节肿瘤的分级和分期p87,一、分级（三级划分）,国际：TNM分期系统国内：常分为早期，中晚期,（恶性瘤）,二、分期病理结合临床,高分化中分化低分化,-,139,取决于肿瘤的性质，跟部位、大小、继发改变等有关。,第六节肿瘤对机体的影响,-,140,1、局部压迫、阻塞症状（主要）2、内分泌腺良性肿瘤,相应激素过多的症状,一、良性肿瘤,对机体影响相对较小,-,141,二、恶性肿瘤,-,142,恶性瘤影响严重，除局部压迫和阻塞症状外，还有下列影响：,肺癌,-,143,继发性改变,-,144,浸润并破坏组织器官的结构和功能，出血、穿孔、病理性骨折和感染；发热（肿瘤产物或感染引起）；疼痛（如肝癌等）（下图）,-,145,Branchesofperipheralnerveareinvadedbynestsofmalignantcells.Thisisoftenwhypainassociatedwithcancersisunrelenting,-,146,2、恶病质（cachexia）指机体严重消瘦、无力、贫血和全身衰竭的状态。,-,147,3、副肿瘤综合征和异位内分泌综合征,-,148,副肿瘤综合征肿瘤的产物或异常免疫反应等引起全身多系统病变及临床表现。,-,149,异位内分泌综合征：一些非内分泌腺的肿瘤产生和分泌激素或激素类物质，如促肾上腺皮质激素、生长激素、甲状旁腺素等，引起内分泌紊乱的临床症状。,-,150,第七节良、恶性肿瘤的区别,区别的重要性主要依据（三性）:分化程度和异型性；有无浸润转移；对机体的影响（表）,（表5-2）P89良性肿瘤与恶性肿瘤的区别,-,152,注意事项：相对性、交界性、转化性,有些良性肿瘤或恶性肿瘤并不完全具有上述特征，如毛细血管瘤、基底细胞癌交界性肿瘤：有些肿瘤的组织形态和/或生物学行为介于良、恶性肿瘤之间。有些良性肿瘤也可发展为恶性恶变,-,153,表53癌与肉瘤的比较P98,癌肉瘤组织分化上皮组织间叶组织发病情况较高，约为肉瘤的9倍。较低、有些类型主要发生多见于40岁以上之成人在年轻人或儿童；有些类型主要见于中老年肉眼特点色灰白，质较硬、较干燥色灰红、质软、湿润，鱼肉状组织学特点多形成癌巢，实质与瘤细胞多弥漫分布，间质分界清楚，纤维实质与间质分界不清，组织常有增生间质内血管丰富，纤维组织少网状纤维见于癌巢周围，癌细肉瘤细胞间多有网状纤维胞间多无网状纤维免疫组化表达上皮标记如CK、EMA间叶组织标记如vimentin转移多经淋巴道转移，多经血道转移,第八节癌前病变、非典型增生和原位癌,一、癌前病变,概念：指某些具有癌变潜能的良性病变，如长期存在有可能转变为癌。常见的癌前病变有：,-,155,1、大肠腺瘤：多发者癌变率高,家族性腺瘤性息肉病,-,156,绒毛状腺瘤,-,157,Multipleadenomatouspolypsofthececumareseenhereinacaseoffamilialpolyposis,-,158,2、乳腺增生性纤维囊性变,-,159,3、宫颈糜烂伴上皮非典型增生,-,160,4、慢性萎缩性胃炎及胃溃疡,-,161,5、溃疡性结肠炎,-,162,6、粘膜白斑：口腔、外阴,-,163,7、皮肤慢性溃疡,-,164,8、肝硬化,-,165,二、非典型性增生（dysplasia）,轻度（）中度（）重度（）,指增生的上皮细胞在形态上呈现一定的异型性，但还不足以诊断为癌。根据非典型增生的程度和范围分为三度/级：,-,166,异型细胞局限于上皮层的下1/3区,轻度（）：,-,167,中度（）：,异型细胞占上皮层1/32/3,-,168,重度（）：,异型细胞超过上皮层的2/3，不及全层,-,169,三、原位癌（carcinomainsitu）,概念：指癌局限于上皮内即重度不典型增生累及上皮全层，但未突破基底膜向下浸润生长者。（图）,-,170,-,171,-,172,-,173,I级：轻度不典型增生II级：中度不典型增生III级：重度不典型增生及原位癌。,四、上皮内瘤变（CIN）：,-,174,图1CIN级图2CIN级图3CIN级,图1,图2,图3,第十节肿瘤的病因学和发病学,一、肿瘤发生的分子生物学基础,正常细胞的增生和分化受某些信号分子的调控，如细胞内的