第五章肿瘤1学习教案

1、会计学1第五章肿瘤第五章肿瘤(zhngli)1第一页，共206页。罗京沈殿霞阿桑陈晓旭梅艳芳李钰第1页/共206页第二页，共206页。傅彪叶凡帕瓦罗蒂赫本(h bn)李媛媛罗文(lu wn)第2页/共206页第三页，共206页。第3页/共206页第四页，共206页。第4页/共206页第五页，共206页。第5页/共206页第六页，共206页。两度获得奥斯卡最佳导演奖的美国著名(zhmng)导演伍迪-艾伦 ( Woody Allen ) 第6页/共206页第七页，共206页。癌前病变、非典型增生和癌前病变、非典型增生和原位癌原位癌肿瘤肿瘤(zhngli)的病因及的病因及病机病机第7页/共206页第

2、八页，共206页。第8页/共206页第九页，共206页。致瘤因素致瘤因素生长调控紊乱生长调控紊乱克隆性异常增生克隆性异常增生新生物（肿块）新生物（肿块）细胞基因水平的异常，并细胞基因水平的异常，并可以传递给子代细胞。可以传递给子代细胞。肿瘤性增生肿瘤性增生(zngshng)第9页/共206页第十页，共206页。第10页/共206页第十一页，共206页。的区别的区别肿瘤增生肿瘤增生非肿瘤增生非肿瘤增生 质质失分化性失分化性（瘤细胞具有瘤细胞具有异常的形态、代谢和异常的形态、代谢和功能，功能，失失去分化成熟的能力；）去分化成熟的能力；）分化成熟分化成熟, ,一定程一定程度恢复原有结构功度恢复原有结

3、构功能能 量量持续性持续性（肿瘤细胞生长肿瘤细胞生长旺盛，失去控制，具旺盛，失去控制，具有相对自主性，与机有相对自主性，与机体不协调）体不协调）自限性自限性 影响影响对机体有害无益对机体有害无益大多有利大多有利第11页/共206页第十二页，共206页。第12页/共206页第十三页，共206页。第13页/共206页第十四页，共206页。受多种因素受多种因素(yn s)的的影响影响(与组织来源，生与组织来源，生长方式，发生部位等有长方式，发生部位等有关关)，多种多样，在一，多种多样，在一定程度上反映了肿瘤的定程度上反映了肿瘤的良恶性。良恶性。（一）肿瘤的大体（一）肿瘤的大体(dt)(dt)形态形态

4、 第14页/共206页第十五页，共206页。第15页/共206页第十六页，共206页。单发单发(dn f)多发多发(du f)第16页/共206页第十七页，共206页。This irregular reddish, ulcerated exophytic mid-esophageal mass as seen on the mucosal surface is a squamous cell carcinoma. Endoscopic views of an ulcerated mid-esophageal squamous cell carcinoma causing lumenal ste

5、nosis are seen below. Risk factors for esophageal squamous carcinoma include mainly smoking and alcoholism in the U.S. In other parts of the world dietary factors may play a role第17页/共206页第十八页，共206页。This is a leiomyosarcoma of the small bowel. As with sarcomas in general, this one is big and bad. Sa

6、rcomas are uncommon at this site, but must be distinguished from other types of neoplasms第18页/共206页第十九页，共206页。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

7、is a benign nevus (pigmented mole) of the skin, and most people have several. As a general rule, benign neoplasms do not give rise to malignant neoplasms第19页/共206页第二十页，共206页。Here is another example of polyposis with numerous small polyps covering the colonic mucosa. In this particular case, there we

8、re osteomas of the skull, a periampullary adenocarcinoma, and epidermal inclusion cysts. Thus, this is a case of Gardners syndrome. As with familial adenomatous polyposis, the inheritance pattern is autosomal dominant第20页/共206页第二十一页，共206页。第21页/共206页第二十二页，共206页。第22页/共206页第二十三页，共206页。第23页/共206页第二十四页，共

9、206页。第24页/共206页第二十五页，共206页。The circumscribed mass lesion present here in the sella turcica is a pituitary adenoma. 第25页/共206页第二十六页，共206页。第26页/共206页第二十七页，共206页。第27页/共206页第二十八页，共206页。第28页/共206页第二十九页，共206页。第29页/共206页第三十页，共206页。This is an adenocarcinoma arising in a villous adenoma. The surface of the n

10、eoplasm is polypoid and reddish pink. Hemorrhage from the surface of the tumor creates a guaiac positive stool. This neoplasm was located in the sigmoid colon, just out of reach of digital examination, but easily visualized with sigmoidoscopy第30页/共206页第三十一页，共206页。The gross appearance of a villous ad

11、enoma is shown above the surface at the left, and in cross section at the right. Note that this type of adenoma is sessile, rather than pedunculated, and larger than a tubular adenoma (adenomatous polyp). A villous adenoma averages several centimeters in diameter, and may be up to 10 cm. On colonosc

12、opy, a sessile polyp is seen below第31页/共206页第三十二页，共206页。Here is a resected meningioma. These are relatively easy for the neurosurgeon to remove第32页/共206页第三十三页，共206页。Here is an ovarian stromal tumor that is hard and white and is a fibroma第33页/共206页第三十四页，共206页。Benign epithelial tumors of the ovary can

13、 reach massive proportions. The serous cystadenoma seen here fills a surgical pan and dwarfs the 4 cm ruler第34页/共206页第三十五页，共206页。This is a tumor of ovarian surface epithelium. These are the most common ovarian neoplasms. Such neoplasms may be lined by epithelium that is serous or mucinous. Pictured

14、here is a serous cystadenoma. It was filled with pale yellow serous fluid in only a single cavity. Mucinous tumors are filled with sticky mucin and tend to be multiloculated. Benign epithelial ovarian tumors are bilateral in about 20% of cases.第35页/共206页第三十六页，共206页。The cystic nature of a mature tera

15、toma of ovary is seen here. The most common tissue element of these teratomas is skin, so large amounts of hair and sebum are produced, 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

16、teratomas with less differentiated tissue and are more aggressive. Rarely, there are frankly carcinomatous areas第36页/共206页第三十七页，共206页。Here is a benign serous cystadenoma that demonstrates multiloculation. Note that the inner surface is, for the most part, smooth, with only a solitary papillation at

17、the upper right第37页/共206页第三十八页，共206页。Here is another cervical squamous cell carcinoma. Note the IUD string protruding from the cervix. This implies that someone could have done a Pap smear when it was inserted. There is a natural history of progression of dysplasia to carcinoma, so dont leave dyspla

18、sias alone第38页/共206页第三十九页，共206页。This is a larger cervical squamous cell carcinoma which spread to the vagina. A total abdominal hysterectomy with bilateral salpingo-oopherectomy (TAH-BSO) was performed第39页/共206页第四十页，共206页。This mastectomy specimen demonstrates the gross findings of inflammatory carci

19、noma of breast. This is not a specific histologic type of breast cancer, but rather it implies dermal lymphatic invasion by some type of underlying breast carcinoma. Such involvement of dermal lymphatics gives the grossly thickened, erythematous, and rough skin surface with the appearance of an oran

20、ge peel (peau dorange for you francophiles).第40页/共206页第四十一页，共206页。第41页/共206页第四十二页，共206页。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 l

21、ots of collagen. This is often called a scirrhous appearance. There is also focal dystrophic calcification leading to the gritty areas第42页/共206页第四十三页，共206页。The cut surface of a schwannoma is similar to that of many mesenchymal neoplasms, with a fish flesh soft tan appearance.第43页/共206页第四十四页，共206页。He

22、re is another follicular neoplasm (a follicular adenoma histologically) that is surrounded by a thin white capsule. It is sometimes difficult to tell a well-differentiated follicular carcinoma from a follicular adenoma. Thus, patients with follicular neoplasms are treated with subtotal thyroidectomy

23、 just to be on the safe side第44页/共206页第四十五页，共206页。This excision of skin demonstrates a malignant melanoma, which is much larger and more irregular than a benign nevus第45页/共206页第四十六页，共206页。Here is a very large leiomyoma of the uterus that has undergone degenerative change and is red (so-called red de

24、generation). Such an appearance might make you think that it could be malignant. Remember that malignant tumors do not generally arise from benign tumors, which is a good thing, because leiomyomas are so common (20% of women will have at least one). Postmenopausally, leiomyomas tend to regress in si

25、ze and become fibrotic第46页/共206页第四十七页，共206页。This large fleshy mass arose in the retroperitoneum and is an example 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

26、cells such as striated muscle (rhabdomyosarcoma), smooth muscle (leiomyosarcoma), fat (liposarcoma), blood vessels (angiosarcoma), bone (osteosarcoma), or cartilage (chondrosarcoma). Sarcomas are big and bad第47页/共206页第四十八页，共206页。This is a squamous cell carcinoma of the lung that is arising centrally

27、 in the lung (as most squamous cell carcinomas do). It is obstructing the right main bronchus. The neoplasm is very firm and has a pale white to tan cut surface第48页/共206页第四十九页，共206页。This renal cell carcinoma demonstrates distortion and displacement of the renal parenchyma by the tumor mass in the lo

28、wer pole. This malignant neoplasm is variegated on cut surface, with yellow to white to red to brown areas第49页/共206页第五十页，共206页。Of course, neoplasms can be benign as well as malignant, though it is not always easy to tell how a neoplasm will act. Here is a benign lipoma on the serosal surface of the

29、small intestine. It has the characteristics of a benign neoplasm: it is well circumscribed, slow growing, and resembles the tissue of origin (fat).第50页/共206页第五十一页，共206页。第51页/共206页第五十二页，共206页。Here is an osteosarcoma of bone. The large, bulky mass arises in the cortex of the bone and extends outward第5

30、2页/共206页第五十三页，共206页。第53页/共206页第五十四页，共206页。Note the small nests and infiltrating strands of neoplastic cells with prominent bands of collagen between them in this ductal carcinoma of the breast. It is this marked increase in the dense fibrous tissue stroma that produces the characteristic hard scirrh

31、ous appearance of the typical infiltrating ductal carcinoma. Note the nerve surrounded by the neoplasm at the lower left实质实质(shzh)间质间质第54页/共206页第五十五页，共206页。实实质质(shzh)间质间质第55页/共206页第五十六页，共206页。第56页/共206页第五十七页，共206页。第57页/共206页第五十八页，共206页。第58页/共206页第五十九页，共206页。第59页/共206页第六十页，共206页。第60页/共206页第六十一页，共206页

32、。第61页/共206页第六十二页，共206页。第62页/共206页第六十三页，共206页。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 nature of the cells. Note that nucleoli are numerous and large in this neoplasm. Neoplasms with no diffe

33、rentiation are said to be anaplastic第63页/共206页第六十四页，共206页。Sarcomas, including leiomyosarcomas, often have very large bizarre giant cells along with the spindle cells. A couple of mitotic figures appear at the left and lower left.第64页/共206页第六十五页，共206页。第65页/共206页第六十六页，共206页。第66页/共206页第六十七页，共206页。第67页/

34、共206页第六十八页，共206页。This is a signet ring cell pattern of adenocarcinoma in which the cells are filled with mucin vacuoles that push the nucleus to one side, as shown at the arrow第68页/共206页第六十九页，共206页。第69页/共206页第七十页，共206页。第70页/共206页第七十一页，共206页。第71页/共206页第七十二页，共206页。The infiltrating glands of this colon

35、ic adenocarcinoma demonstrate less differentiation than the adenomatous polyp, although they still resemble glands. In general, less differentiation means a greater likelihood of malignant behavior第72页/共206页第七十三页，共206页。The concept of differentiation is demonstrated by this small adenomatous polyp of

36、 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第73页/共206页第七十四页，共206页。At high magnification, the normal colonic epithelium at the left contrasts with the atypical epithelium of t

37、he 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 mimics the normal tissue quite well and this, therefore, well-dif

38、ferentiated第74页/共206页第七十五页，共206页。第75页/共206页第七十六页，共206页。总结总结(zngji)：第76页/共206页第七十七页，共206页。第77页/共206页第七十八页，共206页。第78页/共206页第七十九页，共206页。Transitional cell carcinoma of the bladder第79页/共206页第八十页，共206页。第80页/共206页第八十一页，共206页。第81页/共206页第八十二页，共206页。第82页/共206页第八十三页，共206页。第83页/共206页第八十四页，共206页。第84页/共206页第八十五页，

39、共206页。第85页/共206页第八十六页，共206页。原则：以肿瘤的组织或细胞类型原则：以肿瘤的组织或细胞类型（组织来源）（组织来源） + 肿瘤生物学行为（良、肿瘤生物学行为（良、恶性恶性( xng)）为依据。）为依据。第86页/共206页第八十七页，共206页。第87页/共206页第八十八页，共206页。第88页/共206页第八十九页，共206页。第89页/共206页第九十页，共206页。平滑肌瘤平滑肌瘤leiomyoma第90页/共206页第九十一页，共206页。第91页/共206页第九十二页，共206页。Here is a small hepatic adenoma, an uncom

40、mon 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第92页/共206页第九十三页，共206页。第93页/共206页第九十四页，共206页。Malignant neoplasms are also characte

41、rized by the tendency to invade surrounding tissues. Here, a lung cancer is seen to be spreading along the bronchi into the surrounding lung.第94页/共206页第九十五页，共206页。This glioma is arising in the cerebral hemisphere. As in most gliomas, it is difficult to tell where the margin is第95页/共206页第九十六页，共206页。T

42、his is a squamous cell carcinoma of the lung. It is a bulky mass that extends into surrounding lung parenchyma.第96页/共206页第九十七页，共206页。Arising centrally in this lung and spreading extensively is a small cell anaplastic (oat cell) carcinoma. The cut surface of this tumor has a soft, lobulated, white to

43、 tan appearance. The tumor seen here has caused obstruction of the main bronchus to left lung so that the distal lung is collapsed. Oat cell carcinomas are very aggressive and often metastasize widely before the primary tumor mass in the lung reaches a large size第97页/共206页第九十八页，共206页。The normal squa

44、mous 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 normal squamous cells, but are less orderly. This is a well-differentiated squamous cell carcinoma第98页/共206页第九十九页，共206页。This sarcom

45、a is stained for vimentin by immunoperoxidase. The positive neoplastic cells are invading into normal muscle fibers (which are not staining for vimentin) at the left. This is a typical staining reaction for sarcomas第99页/共206页第一百页，共206页。第100页/共206页第一百零一页，共206页。第101页/共206页第一百零二页，共206页。Here is another

46、example of an adenocarcinoma of colon. This cancer is more exophytic in its growth pattern. Thus, one of the complications of a carcinoma is obstruction (usually partial). Colonoscopic views of another ulcerating mass, a rectal adenocarcinoma, are seen below第102页/共206页第一百零三页，共206页。This is a larger c

47、ervical squamous cell carcinoma which spread to the vagina. A total abdominal hysterectomy with bilateral salpingo-oopherectomy (TAH-BSO) was performed第103页/共206页第一百零四页，共206页。This adenomatous polyp has a hemorrhagic surface (which is why they may first be detected with stool occult blood screening)

48、and a long narrow stalk. The size of this polyp-above 2 cm-makes the possibility of malignancy more likely, but this polyp proved to be benign第104页/共206页第一百零五页，共206页。第105页/共206页第一百零六页，共206页。第106页/共206页第一百零七页，共206页。第107页/共206页第一百零八页，共206页。第108页/共206页第一百零九页，共206页。第109页/共206页第一百一十页，共206页。This is anothe

49、r pelvic exenteration for cervical squamous cell carcinoma. The irregular grey-brown tumor extends toward bladder and up into the uterus.第110页/共206页第一百一十一页，共206页。第111页/共206页第一百一十二页，共206页。第112页/共206页第一百一十三页，共206页。Microscopically, metastatic adenocarcinoma is seen in a lymph node here. It is common fo

50、r carcinomas to metastasize to lymph nodes. The first nodes involved are those draining the site of the primary.第113页/共206页第一百一十四页，共206页。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.第114页/共2

51、06页第一百一十五页，共206页。第115页/共206页第一百一十六页，共206页。第116页/共206页第一百一十七页，共206页。第117页/共206页第一百一十八页，共206页。Here are liver metastases from an adenocarcinoma primary in the colon, one of the most common primary sites for metastatic adenocarcinoma to the liver第118页/共206页第一百一十九页，共206页。第119页/共206页第一百二十页，共206页。第120页/共20

52、6页第一百二十一页，共206页。第121页/共206页第一百二十二页，共206页。第122页/共206页第一百二十三页，共206页。第123页/共206页第一百二十四页，共206页。第124页/共206页第一百二十五页，共206页。o 多个，散在分布，边界(binji)清楚，多靠近器官表面癌脐血道转移(zhuny)瘤的形态特点第125页/共206页第一百二十六页，共206页。第126页/共206页第一百二十七页，共206页。第127页/共206页第一百二十八页，共206页。Neoplasms can spread by seeding along body cavities, and this

53、 pattern is more typical for carcinomas than other neoplasms. Note the multitude of small tan tumor nodules seen over the peritoneal surface of the mesentery shown here第128页/共206页第一百二十九页，共206页。大网膜大网膜(wngm)种种植性转移植性转移第129页/共206页第一百三十页，共206页。胃癌胃癌(wi i)种植于卵巢形种植于卵巢形成成krukenberg瘤瘤第130页/共206页第一百三十一页，共206页。

54、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 and usually is metastatic from a primary in gastro

55、intestinal 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.第131页/共206页第一百三十二页，共206页。种植种植(zhngzh)性转移性转移腹水腹水形成形成第132页/共206页第一百三十三页，共206页。脱落脱落(tulu)细细胞学检查胞学检查第133页/共206页第一百三十四页，共206页。第134页/共206页第一百三十五

56、页，共206页。第135页/共206页第一百三十六页，共206页。第136页/共206页第一百三十七页，共206页。高分化高分化中分化中分化低分化低分化第137页/共206页第一百三十八页，共206页。第138页/共206页第一百三十九页，共206页。第139页/共206页第一百四十页，共206页。第140页/共206页第一百四十一页，共206页。第141页/共206页第一百四十二页，共206页。第142页/共206页第一百四十三页，共206页。第143页/共206页第一百四十四页，共206页。Branches of peripheral nerve are invaded by nests

57、of malignant cells. This is often why pain associated with cancers is unrelenting第144页/共206页第一百四十五页，共206页。第145页/共206页第一百四十六页，共206页。第146页/共206页第一百四十七页，共206页。第147页/共206页第一百四十八页，共206页。第148页/共206页第一百四十九页，共206页。第149页/共206页第一百五十页，共206页。良性肿瘤良性肿瘤恶性肿瘤恶性肿瘤组织分化程度组织分化程度异型性异型性分化好，异型性小，与原有组织分化好，异型性小，与原有组织的形态相似的形态

58、相似分化不好，异型性大，与原有组织分化不好，异型性大，与原有组织的形态差别大的形态差别大核分裂像核分裂像无或稀少，不见病理核分裂像无或稀少，不见病理核分裂像多见，并可见病理性核分裂像多见，并可见病理性核分裂像生长速度生长速度缓慢缓慢较快较快生长方式生长方式膨胀性或外生性生长，前者常有膨胀性或外生性生长，前者常有包膜形成，与周围组织一般分界包膜形成，与周围组织一般分界清楚，故通常可推动清楚，故通常可推动 浸润性或外生性生长，前者无包膜，一浸润性或外生性生长，前者无包膜，一般与周围组织分界不清楚，通常般与周围组织分界不清楚，通常不能推动；后者常伴有浸润性生长不能推动；后者常伴有浸润性生长继发改变继发改变很少发生坏死、出血很少发生坏死、出血常发生出血、坏死、溃疡形成等常发生出血、坏死、溃疡形成等复发复发手术切除后很少复发手术切除后很少复发手术切除等治疗后较多复发手术切除等治疗后较多复发转移转移不转移不转移常有转移常有转移对机体影响对机体影响较小，主要为局部压迫或阻塞。较小，主要为局部压迫或阻塞。如发生在重要器官也可引起严重如发生在重要器官也可引起严重后果后果 较大，除压迫、阻塞外，还可以破坏原较大，除压迫、阻塞外，还可以破坏原发处和转移处的组织，引起坏死、出血、发处和转移处的组织，引起坏死、出血、合并感