病理学课件：6.肿瘤

1、NEOPLASIA 2004.4.8 Jinghuan 一一肿瘤的概念肿瘤的概念 二二. 肿瘤的大体形态和组织结构肿瘤的大体形态和组织结构 （一）（一）肿瘤的大体形态肿瘤的大体形态 （二二）肿瘤的组织结构肿瘤的组织结构 第一节、肿瘤的概念和一般形态 结构 P172 肿瘤（tumor)是机体在各种致 瘤因素作用下，局部组织的细 胞在基因水平上失去对其生长 的正常调控，导致克隆性异常 增生而形成的新生物。 二、二、肿瘤的大体形态和组织结构肿瘤的大体形态和组织结构 （一）肿瘤（一）肿瘤大体形态大体形态 1、数目和大小、数目和大小 2、形状、形状 3、颜色、颜色 4、硬度、硬度 5、包膜、包膜 Thi

2、s is a neoplasm. Neoplasia is uncontrolled new growth. Note the mass of abnormal tissue on the surface of the cervix. The term tumor is often used synonymously with neoplasm, but a tumor can mean any mass effect, whether it is inflammatory, hemodynamic, or neoplastic in origin. Once a neoplasm has s

3、tarted, it is not reversible. Here is a small hepatic adenoma, an uncommon benign neoplasm, but one that shows how well-demarcated an benign neoplasm is. It also illustrates how function of the normal tissue is maintained, because the adenoma is making bile pigment, giving it a green color. This is

4、an example of metastases to the liver. Note that the tan- white masses are multiple and irregularly sized. A primary neoplasm is more likely to be a solitary mass. Metastasis is the best indication that a neoplasm is malignant. In contrast, this hepatocellular carcinoma is not as well circumscribed

5、(note the infiltration of tumor off to the lower right) nor as uniform in consistency. It is also arising in a cirrhotic (nodular) liver. Malignant neoplasms are also characterized by the tendency to invade surrounding tissues. Here, a lung cancer is seen to be spreading along the bronchi into the s

6、urrounding lung. （二）肿瘤的组织结构（二）肿瘤的组织结构 1、肿瘤实质肿瘤实质 2、肿瘤间质肿瘤间质 一一肿瘤组织的异形性肿瘤组织的异形性 概念概念 二二. 肿瘤细胞的肿瘤细胞的异形性异形性 三三.肿瘤细胞的代谢特点肿瘤细胞的代谢特点 1.核酸代谢核酸代谢 2.蛋白质代谢蛋白质代谢 3.酶系统酶系统 4.糖代谢糖代谢 第二节、肿瘤的异形性 P174 肿瘤的异型性肿瘤的异型性 肿瘤组织在组织结构以致细胞 形态上， 与其发源的正常组织有分化成熟的差异， 这种差异称为异型性异型性。 恶性肿瘤细胞缺乏分化，异型性显 著的现象称为间变间变。 （一）肿瘤细胞的多形性（一）肿瘤细胞的多形性

7、 （二）肿瘤细胞核的多形性（二）肿瘤细胞核的多形性 （三）肿瘤细胞胞浆的改变（三）肿瘤细胞胞浆的改变 肿瘤细胞的异型性肿瘤细胞的异型性 Nuclei irregular in shape and arrange- ment, no mucin, nuclei stratified, nucleoli large and irregular in shape No resemblance to colon epithelia Mitotic figures present, haphazard arrangement Here are three abnormal mitoses. Mitose

8、s by themselves are not indicators of malignancy. However, abnormal mitoses are highly indicative of malignancy. The marked pleomorphism and hyper chromatism of surrounding cells also favors malignancy. Cytologic features of malignancy Many mitotic figures, necrotic areas Pleomorphic cells, pleomorp

9、hic nuclei anaplastic tumor of the skeletal muscle ( Rhabdomyosarcoma ) Cellular and nuclear pleomorphism Tumor giant cells, hyperchromatic nuclei This neoplasm is so poorly differentiated that it is difficult to tell what the cell of origin is. It is probably a carcinoma because of the polygonal na

10、ture of the cells. Note that nucleoli are numerous and large in this neoplasm. Neoplasms with no differentiation are said to be anaplastic. 一一肿瘤的生长肿瘤的生长 （一）（一）肿瘤的生长速度肿瘤的生长速度 （二）（二）肿瘤的生长方式肿瘤的生长方式 二二. 肿瘤的肿瘤的扩散扩散 （一）（一）直接蔓延直接蔓延 （二）（二）转移转移 第三节、肿瘤的生长和扩散 P176 肿瘤的肿瘤的生长速度生长速度 肿瘤的肿瘤的生长速度生长速度决定于肿瘤决定于肿瘤 细胞的生成和

11、丢失之比。细胞的生成和丢失之比。 肿瘤细胞的生成大于丢失。肿瘤细胞的生成大于丢失。 浸润性生长 外生性生长 膨胀性生长 This infiltrating ductal carcinoma of the breast is definitely infiltrating the surrounding breast. The central white area is very hard and gritty, because the neoplasm is producing a desmoplastic reaction with lots of collagen. This is oft

12、en called a scirrhous appearance. There is also focal dystrophic calcification leading to the gritty areas. 肿瘤转移途径肿瘤转移途径 淋巴道 血道 种植 Branches of peripheral nerve are invaded by nests of malignant cells. This is often why pain associated with cancers is unrelenting. Dark spots are lymphocytes Pink in S

13、 and MS Areas are cancerous cells Both lymphatic and hematogenous spread of malignant neoplasms is possible to distant sites. Here, a breast carcinoma has spread to a lymphatic in the lung. Lymphatic vessel spread Rhabdomyosarcoma (anaplastic tumor of the skeletal muscle) Cellular and nuclear pleomo

14、rphism Tumor giant cells, hyperchromatic nuclei Comparison between a begin tumor of the leiomyoma and a malignant of tumor of similar origin(leiomyosarcoma) 一一良性肿瘤对机体的影响良性肿瘤对机体的影响 （一）局部压迫和阻塞（一）局部压迫和阻塞 （二）并发症（二）并发症 （三）内分泌腺良性肿瘤的激素分泌过多（三）内分泌腺良性肿瘤的激素分泌过多 二二.恶性肿瘤对机体的影响恶性肿瘤对机体的影响 （一）破坏器官的结构和功能（一）破坏器官的结构和功

15、能 （二）并发症（二）并发症 （三）相关症状（三）相关症状 （四）（四）异位内分泌综合征异位内分泌综合征 （五）（五）副肿瘤综合征副肿瘤综合征 （六）（六）恶病质恶病质 第四节、肿瘤对机体的影响 P176 一一 第五节、良性肿瘤与恶性肿瘤 的区别 P176 一一肿瘤的命名肿瘤的命名 二二. 肿瘤的分类肿瘤的分类 第六节、肿瘤的命名和分类 P182 一一分子生物学基础分子生物学基础 二二.外界致癌因素外界致癌因素 第七节、肿瘤的病因学和发病学 P184 一一上皮组织良性肿瘤上皮组织良性肿瘤 （一）乳头状瘤（一）乳头状瘤 （二）腺瘤（二）腺瘤 二二.上皮组织恶性肿瘤上皮组织恶性肿瘤 （一）概述（一

16、）概述 （二）常见类型（二）常见类型 第八节、各类常见肿瘤 P176 三三.间叶组织良性肿瘤间叶组织良性肿瘤 （一）纤维瘤（一）纤维瘤 （二）脂肪瘤（二）脂肪瘤 （三）血管瘤（三）血管瘤 （四）平滑肌瘤（四）平滑肌瘤 四四.间叶组织恶性肿瘤间叶组织恶性肿瘤 （一）概述（一）概述 （二）常见肉瘤（二）常见肉瘤 五五. 淋巴造血组织肿瘤淋巴造血组织肿瘤 （一）恶性淋巴瘤（一）恶性淋巴瘤 （二）白血病（二）白血病 一一上皮组织良性肿瘤上皮组织良性肿瘤 （一）乳头状瘤（一）乳头状瘤 （二）腺瘤（二）腺瘤 1.1.单纯性腺瘤单纯性腺瘤 2.2.纤维腺瘤纤维腺瘤 3.3.囊腺瘤囊腺瘤 4. 4. 多形性腺

17、瘤多形性腺瘤 二二.上皮组织恶性肿瘤上皮组织恶性肿瘤 （一）概述（一）概述 （二）常见类型（二）常见类型 1.鳞状细胞癌鳞状细胞癌 2.基底细胞癌基底细胞癌 3.移形细胞癌移形细胞癌 4.腺上皮癌腺上皮癌 1）腺癌）腺癌2）黏液癌）黏液癌3.）实性癌）实性癌 Here is a small fibroadenoma of the breast. The blue dye was injected during a radiographic procedure to mark the location of the neoplasm so the surgeon could find it. T

18、he concept of differentiation is demonstrated by this small adenomatous polyp of the colon. Note the difference in staining quality between the epithelial cells of the adenoma at the top and the normal glandular epithelium of the colonic mucosa below. At high magnification, the normal colonic epithe

19、lium at the left contrasts with the atypical epithelium of the adenomatous polyp at the right. Nuclei are darker and more irregularly sized and closer together in the adenomatous polyp than in the normal mucosa. However, the overall difference between them is not great, so this benign neoplasm mimic

20、s the normal tissue quite well and this, therefore, well- differentiated. The two forms of cellular transformation that are potentially reversible, but may be steps toward a neoplasm, are: Metaplasia: the exchange of normal epithelium for another type of epithelium. Metaplasia is reversible when the

21、 stimulus for it is taken away. Dysplasia: a disordered growth and maturation of an epithelium, which is still reversible if the factors driving it are eliminated. The first step toward neoplasia is cellular transformation. Here, there is metaplasia of normal respiratory laryngeal epithelium on the

22、right to squamous epithelium on the left in response to chronic irritation of smoking. This is the next step toward neoplasia. Here, there is normal cervical squamous epithelium at the left, but dysplastic squamous epithelium at the right. Dysplasia is a disorderly growth of epithelium, but still co

23、nfined to the epithelium. Dysplasia is still reversible. When the entire epithelium is dysplastic and no normal epithelial cells are left, then the process is beyond dysplasia and is now neoplasia. If the basement membrane is still intact, as shown here, then the process is called carcinoma in situ

24、because the carcinoma is still confined to the epithelium. This is a squamous cell carcinoma of the lung. It is a bulky mass that extends into surrounding lung parenchyma. This renal cell carcinoma demonstrates distortion and displacement of the renal parenchyma by the tumor mass in the lower pole.

25、This malignant neoplasm is variegated on cut surface, with yellow to white to red to brown areas. A mitotic figure is seen in the center, surrounded by a poorly differentiated squamous cell carcinoma with pleomorphic cells and minimal pink keratinization. In general, mitoses are more likely to be se

26、en in malignant neoplasms. At high magnification, this squamous cell carcinoma demonstrates enough differentiation to tell that the cells are of squamous origin. The cells are pink and polygonal in shape with intercellular bridges (seen as desmosomes or tight junctions by electron microscopy). Howev

27、er, the neoplastic cells show pleomorphism, with hyperchromatic nuclei. A mitotic figure is present near the center. The normal squamous epithelium at the left merges into the squamous cell carcinoma at the right, which is infiltrating downward. The neoplastic squamous cells are still similar to the

28、 normal squamous cells, but are less orderly. This is a well-differentiated squamous cell carcinoma. This is the microscopic appearance of neoplasia, or uncontrolled new growth. Here, the neoplasm is infiltrating into the underlying cervical stroma. Here is a moderately differentiated squamous cell

29、carcinoma in which some, but not all, of the neoplastic cells in nests have pink keratin. In general, neoplasms with less differentiation are more aggressive. Microscopically, invading adenocarcinoma can be seen here. Normal gastric epithelium at the left merges into the carcinoma at the right, and

30、irregular neoplastic glands infiltrate downward into the submucosa. The infiltrating glands of this colonic adenocarcinoma demonstrate less differentiation than the adenomatous polyp, although they still resemble glands. In general, less differentiation means a greater likelihood of malignant behavi

31、or. At high magnification, the infiltrating ductal carcinoma of breast has pleomorphic cells infiltrating through the stroma. Microscopically, the infiltrating ductal carcinoma extends irregularly through the tissue as cords and nests of neoplastic cells with intervening collagen. There is a purplis

32、h microcalcification at the lower center right. Here is a normal cervix with a smooth, glistening mucosal surface. There is a small rim of vaginal cuff from this hysterectomy specimen. The cervical os is small and round, typical for a nulliparous woman. The os will have a fish-mouth shape after one

33、or more pregnancies. Benign neoplasms can be multiple, as is shown in this uterus with leiomyomas of varying size, but all benign and well-circumscribed firm white masses. Remember that the most common neoplasm is a benign nevus (pigmented mole) of the skin, and most people have several. As a genera

34、l rule, benign neoplasms do not give rise to malignant neoplasms. Benign epithelial tumors of the ovary can reach massive proportions. The serous cystadenoma seen here fills a surgical pan and dwarfs the 4 cm ruler. Of course, neoplasms can be benign as well as malignant, though it is not always eas

35、y to tell how a neoplasm will act. Here is a benign lipoma on the serosal surface of the small intestine. It has the characteristics of a benign neoplasm: it is well circumscribed, slow growing, and resembles the tissue of origin (fat). This large fleshy mass arose in the retroperitoneum and is an e

36、xample of a sarcoma. Sarcomas arise from mesenchymal tissues. This one happened to be a malignant fibrous histiocytoma which is a wastebasket term for sarcomas that do not resemble mesenchymal cells such as striated muscle (rhabdomyosarcoma), smooth muscle (leiomyosarcoma), fat (liposarcoma), blood

37、vessels (angiosarcoma), bone (osteosarcoma), or cartilage (chondrosarcoma). Sarcomas are big and bad. Here is an osteosarcoma of bone. The large, bulky mass arises in the cortex of the bone and extends outward. This large mass lesion is a liposarcoma. Common sites are the retroperitoneum and thigh,

38、and they occur in middle aged to older adults. This one is yellowish, like adipose tissue, and is well-differentiated. Though indolent, it continues growing to reach a large size, and following excision, it has a tendency to recur. This excision of skin demonstrates a malignant melanoma, which is mu

39、ch larger and more irregular than a benign nevus. Metastatic tumors to ovary are uncommon, but there is one situation in which a metastatic adenocarcinoma to ovary appears as a large mass and resembles a primary tumor: a so-called Krukenberg tumor of ovary which has a signet ring histologic pattern

40、and usually is metastatic from a primary in gastrointestinal tract. Seen here extending out of the pelvis at autopsy is a large right ovarian mass. Metastases are also present in the lower right portion of liver. There is a large unilateral mature cystic teratoma seen here at the right (in left ovar

41、y-the uterus is opened anteriorly). The uterus has an intramural and a subserosal leiomyoma. The other ovary is replaced by a fibroma. The cystic nature of a mature teratoma of ovary is seen here. The most common tissue element of these teratomas is skin, so large amounts of hair and sebum are produ

42、ced, leading to a challenging cleanup problem in surgical pathology following dissection of these tumors. If these tumors are mostly solid, then they are often immature teratomas with less differentiated tissue and are more aggressive. Rarely, there are frankly carcinomatous areas. Here are bilatera

43、l mature cystic teratomas of the ovaries. These are a form of ovarian germ cell tumor. Histologically, a variety of mature tissue elements may be found. These tumors are often called dermoid cysts because they are mostly cystic. This is a papillary serous cystadenocarcinoma. Note the many papillatio

44、ns on the inner surface. Between benign cystadenomas and malignant cystadenocarcinomas lies the grey zone of borderline lesions that are not clearly malignant, but are treated as though they could be. At low power magnification, a lipoma of the small intestine is seen to be well demarcated from the

45、mucosa at the lower center-right. This neoplasm is so well-differentiated that, except for its appearance as a localized mass, it is impossible to tell from normal adipose tissue. The microscopic appearance of a leiomyoma indicates that the cells do not vary greatly in size and shape and closely resemble normal smooth muscle cells. Sarcomas tend to have a spindle cell pattern. Note that some of the cells are much larger and very pleomorphic. This sarcoma has many mitoses. A very large abnormal mitotic figure is seen at the