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1、临床检验基础脱落细胞学检查,上海第二医科大学附属瑞金医院袁勤,痰液脱落细胞学检查,肺脱落细胞学检查是早期诊断肺癌的重要手段之一。肺癌的早期诊断可根据临床症状、X线检查、痰液涂片检查和纤维支气管等多方面配合进行。痰液标本采集：痰液必须新鲜；痰液必须是肺部咳出。,痰液脱落细胞学检查,正常的痰涂片中可见来自口腔的鳞状上皮细胞、纤毛柱状上皮细胞和肺泡吞噬细胞（后两者为确定痰液来自肺及支气管深部的标志）以及中性白细胞、淋巴细胞、浆细胞、嗜酸性白细胞等。,痰液纤毛柱状上皮细胞 Ciliated columnar cells,纤毛柱状上皮细胞 Ciliated columnar cells,Note the
2、 moderately coarse and hyperchromatic chromatin Also note the little tails where the cells were attached to the basement membrane and,of course,the presence of terminal bars and cilia(Oil),Goblet cells,Goblet cell hyperplasia Normally,the ciliated cells far outnumber the secretory cells(by at least
3、5 to 1).However,in asthma,for example,the goblet cells may actually outnumber the ciliated cells.,痰液肺泡吞噬细胞 Alveolar macrophages in sputum,Alveolar macrophages are key cells to look for in a sputum specimen.The presence of alveolar macrophages indicates that the deep lung has been sampled.dust cells,
4、痰液肺泡吞噬细胞 Alveolar macrophages in sputum,Giant Cell Histiocytes,Giant cell histiocytes can be seen in a wide variety of pulmonary disorders,They can also be seen in apparently healthy people,and therefore do not necessarily indicate the presence of disease.,痰液良性病变脱落细胞,炎症病变脱落细胞：支气管炎、肺炎和肺结核等急、慢性呼吸道炎症引起
5、上皮细胞发生细胞核轻度固缩退变或细胞轻度肿大。巴氏细胞（Papaniculaou cell):因炎症刺激造成，细胞体积较小，圆形或卵圆形，胞质深红色，核小而圆形，致密深染，有轻度核异形,可能是鳞状化生细胞。,痰液良性病变脱落细胞巴氏细胞,Squamous metaplasia can be seen in sputm smear,ie,rounded cells with dense,cyanophilic cytoplasm.,肺癌脱落细胞,痰液涂片检查主要用于检查癌细胞，肺癌患者痰内癌细胞检出率可达90%。根据细胞学形态，肺癌主要分为鳞癌，腺癌，未分化癌，混合型癌及类型未明癌。,痰液脱落细
6、胞学检查,肺鳞状细胞癌：最常见，男性远多于女性，主要发生于大支气管，多数为中央型。细胞形态和大小异常：癌细胞单个散在，多形性明显，可以呈圆形、蝌蚪形、梭形及不规则形；核的异型：癌细胞大而畸形，核染色质丰富深染，成团块状或墨水滴样。核仁常不明显；胞质的异常：癌细胞胞浆丰富红染，有角化倾向；癌细胞吞噬现象,痰液鳞状细胞癌Keratinizing squamous cell carcinoma(tissue),Note the presence of squamous eddies,or pearls,which are pathognomonic of keratinization.,痰液鳞状细胞
7、癌Keratinizing squamous cell carcinoma,Pearls are characteristic of keratinizing lesions.,角化鳞状细胞癌Keratinizing squamous cell carcinoma,Bizarre keratinizing cells,often single,are a characteristic feature.Such cells are particularly associated with sputum specimens,痰液鳞状细胞癌,痰液鳞状细胞癌,非角化鳞状细胞癌Non-keratiniz
8、ing squamous cell carcinoma,The groups of malignant cells tend to be more cohesive and the cells more uniform Pearls,extensive keratinization,and bizarre-shaped cells are not present.,痰液脱落细胞学检查,肺腺癌：常发生于小支气管，以周围型肺癌多见，易发生血道转移和侵犯胸膜引起的癌性胸水。分化好的腺癌以成群脱落为主，细胞群大，且细胞相互重叠呈立体结构，单个癌细胞一般为圆形或卵圆形，胞质常有许多小空泡，偶见较大空泡。
9、核圆形或卵圆形，核膜染色质呈颗粒状，有明显的核仁。,肺腺癌 Adenocarcinoma,AdenocarcinomaThree-dimensional cell balls or papillary clusters of malignant cells are characteristic architectural features of adenocarcinoma.,肺腺癌 Adenocarcinoma,Microacinar or rosette-like structures indicate glandular differentiation.Microacinar compl
10、exes are a cytologic equivalent of the gland-in-gland histologic growth pattern of adenocarcinoma.,肺腺癌 Adenocarcinoma,肺腺癌 Adenocarcinoma,Note that intracytoplasmic secretory vacuole containing mucin(arrow).,痰液脱落细胞学检查,未分化小细胞癌：恶性度较高，多为中央型，较早发生转移。癌细胞单个或成团脱落，胞体小，比淋巴细胞稍大，常为不规则的圆形或卵圆形，胞浆少，呈裸核样；细胞核相互挤压呈镶嵌状
11、结构。,未分化小细胞癌 Small cell carcinoma,Small cell carcinoma(brushing specimen)The tumor cells have very little cytoplasm,relatively fine but very hyperchromatic chromatin,and inconspicuous nucleoliNote the similarity of bronchial cell nuclear chromatin to that of the tumor cells.,未分化小细胞癌 Small cell carcin
12、oma,Small cell carcinoma(brushing specimen)The cells obtained by direct brushing appear fresher.well-preserved material,未分化小细胞癌 Small cell carcinoma,浆膜腔积液脱落细胞学检查,浆膜腔，又称体腔，包括胸膜腔、腹膜腔和心包膜腔。在正常生理情况下，体腔脏层和壁层间有少量液体，起润滑作用。在炎症刺激、肿瘤转移或循环障碍等情况下，可形成胸水、腹水和心包积液。浆膜腔积液脱落细胞学检查主要用于判断积液中有无癌细胞。,浆膜腔积液脱落细胞学检查,良性病变脱落细胞：脱
13、落间皮细胞：圆形或椭圆形，胞浆厚实，胞核居中，胞核亦为圆形或椭圆形，核染色质细颗粒状，分布均匀。退化变性的间皮细胞：肿胀性退变表现为细胞增大，胞浆出现大小不等的液化空泡，胞核肿胀，偏位。,间皮细胞(Mesothelial Cells),Mesothelial cells in an effusion always show reactive changes of various degrees.Note nuclear enlargement and a prominent nucleolus but fine chromatin and a smooth nuclear membrane.,
14、间皮细胞(Mesothelial Cells),Gland-like cluster of benign mesothelial cells mimicking adenocarcinoma.Note that the component cells are identical to the other reactive mesothelial cells,and do not constitute a foreign population.,组织细胞(Histiocyte),Hemosiderin-laden histiocyte.Hemosiderin is a refractile go
15、lden brown pigment.The presence of hemosiderin indicates old bleeding.,良性病变脱落细胞结核性病变(Tuberculous effusion),Abundance of lymphocytes and virtual absence of mesothelial cells are characteristic of tuberculous pleural effusions.,浆膜腔积液退化变性的间皮细胞,浆膜腔积液脱落细胞学检查,恶性病变脱落细胞：浆膜腔积液中肿瘤细胞的来源：积液中以上的癌细胞是转移性的，原发性的恶性间皮
16、瘤较少见。肿瘤性的胸水和心包水常见于肺癌、乳腺癌等，肿瘤性的腹水常见于卵巢癌、胃癌、肠癌、肝癌、胰腺癌等。原发性的恶性间皮瘤，恶性淋巴瘤较少见。,浆膜腔积液脱落细胞学检查,腺癌：占积液中转移癌的80%以上，腺癌细胞形态多样，排列构成腺腔样、乳头状，洋葱皮和桑葚形状等等，腺癌细胞形态多样，细胞大小相差数倍，癌细胞呈圆或椭圆形，核偏位，核边不规则，核仁明显增大或多个核仁，胞浆中常含空泡，常见异常分裂象。,腺癌 Adenocarcinoma,Adenocarcinoma is the most common cause of a malignant effusion.Among the most u
17、seful features in the diagnosis of adenocarcinoma are increased N/C ratio,irregular nuclear membranes,large nucleoli,secretory vacuoles,and three-dimensional aggregates,腺癌 Adenocarcinoma,腺癌 Adenocarcinoma,The general patterns of adenocarcinomas in fluids include cell balls(morulas),papillary or acin
18、ar groups,signet ring cells,腺癌 Adenocarcinoma,Papillary groups are elongated,three-dimensional aggregates.Psammoma bodies may be present.Adenocarcinomas of the lung(illustrated here),breast,and female genital tract are common sources,腺癌 Adenocarcinoma,Signet ring cells are cells with large cytoplasm
19、ic vacuoles that compress the nucleus to the periphery of the cell Large signet ring cells are characteristic of carcinoma of the stomach.(Oil),腺癌 Adenocarcinoma,Indian files,Chains of tumor cells,particularly when long,suggest breast cancer.However,other possibilities,such as pancreas or lung cance
20、rs as well as mesothelioma,must also be considered.,浆膜腔积液脱落细胞学检查,鳞状细胞癌：在积液中少见，仅占2%-3%。高分化鳞癌，细胞奇形怪状，胞浆有角化倾向。癌细胞单个散在，细胞为圆形，胞核居中，核质深染，胞浆厚实并界限清晰，癌细胞易成堆或成团，背景中伴有或不伴有坏死物。,鳞状细胞癌 Squamous Cell Carcinoma,Irregularly shaped cells Irregularly shaped cells are abnormal and suggest malignancy,such as keratinizin
21、g squamous cell carcinoma,浆膜腔积液脱落细胞学检查,小细胞型未分化癌：在积液中也很少见，为3%-5%，癌细胞呈葡萄堆状排列，细胞重叠，胞浆极少或裸核样，核形不规则，典型者为瓜子状或燕麦状，亦有圆或椭圆形，核染色质粗颗粒或呈块状。,小细胞型未分化癌 Small Cell Carcinoma,Small cell(neuroendocrine)carcinoma,is characterized by small to medium-sized cells with scant cytoplasm,inconspicuous nucleoli,and prominent
22、molding and indian file arrangements.,浆膜腔积液脱落细胞学检查,间皮瘤（mesothelioma)原发于浆膜，良性间皮瘤生长局限，包膜完整，很少引起积液；恶性间皮瘤可见到大量增生活跃的间皮细胞，间皮细胞的恶性特征与转移性腺癌类似，细胞呈团或相嵌，单凭光镜不能明确诊断，应辅以电镜和免疫细胞化学技术，临床表现及影象学的诊断进行鉴别。,间皮瘤（mesothelioma),Mesothelioma.A clue to the diagnosis is more and bigger cells,in more and bigger clusters.The gro
23、ups often have very irregular outlines.,恶性淋巴瘤(Non-Hodgkins Lymphoma),Non-Hodgkins lymphoma,large cell type.The most characteristic feature of lymphoma is that all of the cells are single,without formation of true tissue aggregates.,泌尿系统脱落细胞检查,尿液正常脱落细胞泌尿系统良性病变脱落细胞泌尿系统恶性肿瘤脱落细胞,尿液正常脱落细胞,移行上皮细胞鳞状上皮细胞柱状上
24、皮细胞非上皮细胞成分,尿液正常脱落细胞,移行上皮细胞尿沉渣涂片中的上皮细胞主要来源于肾盏、肾盂、输尿管、膀胱和尿道的移行上皮，正常情况下脱屑细胞不多，无肿瘤细胞。,尿液正常脱落细胞,移行上皮细胞涂片内表层细胞体积大，大小相当于鳞状上皮表层细胞，又称盖细胞呈扁圆行或多边形；双核或多核；核圆形或卵圆形，染色质细颗粒状，分布均匀，核仁不明显，底层细胞是圆形或多边形，中层细胞梭形或多边形因尿液渗透压变化，脱落的移行上皮细胞常会有不同程度的变性,泌尿系统脱落细胞检查,Bladder(tissue)The mucosa is usually no more than six or seven cells
25、thick.Note eosinophilic umbrella cells covering the surface.,泌尿系统脱落细胞检查,Transitional cellsPleomorphic,but benign,transitional cells are normal findings in bladder washing specimens Single,mononuclear,parabasal-sized transitional cells usually predominate in voided urine specimens.Basaloid transition
26、al cells are seen near bottom of field.,泌尿系统脱落细胞检查,Transitional cellsSuperficial transitional cells are large and may have multiple nuclei.Note scalloping of the cytoplasm:the underlying cells fit into the concavities.,尿液正常脱落细胞,鳞状上皮细胞：正常尿液中少见，妇女尿液中有时可见，形态同阴道涂片柱状上皮细胞：正常尿液中极少见，形态同阴道涂片非上皮细胞成分：可见少量中性粒细胞
27、，淋巴细胞，浆细胞，组织细胞和红细胞,泌尿系统良性病变脱落细胞,炎症性疾病病毒感染结石 放化疗影响移植后改变,泌尿系统良性病变脱落细胞,炎症性疾病：炎症时，涂片内细胞数目明显增多，包括上皮细胞及炎症细胞，细胞常变形，体积增大，胞质内可有液化空泡或核固缩细胞,泌尿系统良性病变脱落细胞,病毒感染巨细胞包涵体病人多瘤病毒人乳头状瘤病毒,泌尿系统良性病变脱落细胞,尿结石症 涂片内见上皮细胞呈轻度核异质改变，可见大量的表层细胞，含多个核,Stone Atypia,Urolithiasis can cause significant cytologic atypia sometimes comparabl
28、e to high-grade malignancy,including nuclear enlargement and pleomorphism,high N/C ratios,coarse,hyperchromatic chromatin,and prominent nucleoli.Be cautious when diagnosing malignancy in patients with stones,particularly if the chromatin appears degenerated or smudgy.,Stone Atypia,Note high N/C rati
29、os,irregular nuclear membranes,dark chromatin,and prominent nucleoli,all features that could easily be mistaken for malignancy.Note cytoplasmic vacuolization,a feature seen in reactive cells and high-grade malignancy but usually not present in low-grade tumors.,泌尿系统良性病变脱落细胞,放射及化学治疗对膀胱上皮细胞的影响盆腔区放射治疗对
30、膀胱影响主要为膀胱壁水肿，上皮细胞胞质和胞核都出现空泡，核固缩或核碎裂，细胞有时有异形性，易误认为癌细胞,泌尿系统良性病变脱落细胞,放射及化学治疗对膀胱上皮细胞的影响化学治疗影响：尿沉渣中上皮细胞增大，空泡变性，核增大，染色质增粗呈粗颗粒状，核固缩，碎裂，可有明显核仁膀胱上皮可明显增多，细胞退行性改变，与放射治疗反应类似,泌尿系统良性病变脱落细胞,Radiation.As in other body sites,the classic cytologic change is macrocytosis.However,radiation can also cause reactive or de
31、generative changes in the cells.Radiation can cause radiation cystitis and cellular atypia,which may be mistaken for malignancy.,泌尿系统良性病变脱落细胞,Chemotherapy.Agents such as cyclophosphamide and busulfan can cause cellular atypia mimicking malignancy.Although both the cell and nucleus enlarge,the nucleu
32、s enlarges more,and an increase in the N/C ratio may occur.Cells with bizarre shapes may be seen.,泌尿系统良性病变脱落细胞,BCG therapyHistiocytic aggregates and giant cell histiocytes(arrow)associated with the granulomatous inflammation induced by this therapy are characteristic.,泌尿系统良性病变脱落细胞,移植后尿液细胞学改变肾移植的排斥反应
33、有项细胞学改变：肾小管细胞，淋巴细胞，管型，背景坏死物，核退变，红细胞，混合细胞团,泌尿系统良性病变脱落细胞,Renal transplant rejection.Increased in number of renal tubular cells with degenerative changes Increased lymphocytesMixed cell clustersCasts RBCs Dirty background and macrophages.,泌尿系统良性病变脱落细胞,Renal transplant rejectionIncreased in number of re
34、nal tubular cells with degenerative changes,泌尿系统恶性病变脱落细胞,当泌尿系统有肿瘤时，尿沉渣中可发现肿瘤细胞,连续3次送检,肿瘤细胞检出率达70%。尿液中的恶性细胞以移行细胞癌最常见，发生于肾盏、肾盂、输尿管、膀胱.鳞状细胞癌和腺癌少见。,移行细胞癌形态特点,癌细胞形态异常,大小不等,核大并高度畸形,核边不规则,有小周边突起.染色质增多，增粗，核浆比明显增大,可见核仁.癌细胞可单个,也可成团块状.涂片背景为大量炎性细胞和坏死细胞碎片等。,移行细胞癌 Transitional Cell Carcinoma,Low-grade transitiona
35、l cell carcinoma(TCC)This is also known as papillary transitional cell carcinoma grade II(WHO).Note disorganized groups,variation in cell/nuclear size and shape,increased N/C ratio,irregular nuclear membranes,and granular chromatin.,移行细胞癌 Transitional Cell Carcinoma,Low-grade TCCNote irregular nucle
36、ar membranes,granular chromatin,and occasional micronucleolus.,移行细胞癌 Transitional Cell Carcinoma,High-grade TCCThis is also known as TCC grade III(WHO).Numerous cells are shed in loose aggregates and singly.Malignant cytologic atypia is obvious.,思考题,试述浆膜腔积液腺癌的形态特点 试述肺未分化小细胞癌的形态特点试述尿液肿瘤细胞的形态特点痰液标本中巴氏细胞的形态特点,
