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1、生殖系统和乳腺疾病（一）Diseases of genital system andmammary gland,Department of Pathology Southern Medical University,子宫,子宫颈,Content,Chronic cervicitis;Cervical epithelial dysplasia;Cervical carcinoma;Leiomyoma of the uterus;Endomertrial adenocarcinoma,The yellow dashed line marks the outer boundary of the tr
2、ansformation zone.Outside the boundary the long-established and thick stratified squamous epithelium appears white or light pink following the dilute acid treatment.Inside the boundary,the transformation zone is characterized by areas of thin epithelium,which appear red or almost inflamed.,1.生育期妇女最常
3、见 2.多继发于分娩、流产等子宫颈损伤 3.临床:白带过多,一、慢性子宫颈炎,(Chronic cervicitis),常见感染:链球菌、肠球菌、大肠杆菌、葡萄球菌等 特殊感染:沙眼衣原体、淋球菌、病毒(单纯疱疹病毒、人乳头状瘤 病毒、巨细胞病毒等)、结核 菌、寄生虫及放线菌等,Etiology,肉眼：宫颈粘膜充血、肿胀，颗粒状或糜烂状,Pathological changes,子宫颈粘膜充血水肿 间质单核C、淋巴C、浆C浸润 子宫颈柱状上皮、腺上皮增生或鳞状化生 子宫颈息肉(cervical polyp)有时子宫颈囊肿(纳博特囊肿,Nabothian cyst),镜下：,This is no
4、rmal cervical non-keratinizing squamous epithelium.The squamous cells show maturation from basal layer to surface.,This is chronic cervicitis at the squamo-columnar junction of the cervix.Small round dark lymphocytes are seen in the submucosa,and there is also hemorrhage.,Squamous metaplasia of cerv
5、ix,Cervical polyp,Nabothian cyst,In the cervix,koilocytotic change with human papillomavirus(HPV)infection,with vacuolization of epithelial cells.,子宫颈糜烂 假性糜烂-柱状上皮代替鳞状上皮，多见 真性糜烂-鳞状上皮坏死脱落,Cervical erosion occurs when the surface of the cervix is replaced with inflamed tissue from the cervical canal.Th
6、e condition may be caused by trauma,infection or chemicals.,二、子宫颈上皮非典型增生和原位癌,子宫颈上皮非典型增生癌前病变异型细胞增生，从基底层向表层发展 原位癌上皮全层为异型细胞所替代，未突破基底膜 好发部位：子宫颈鳞-柱上皮交界带(移行带),(Cervical epithelial dysplasia and carcinoma in situ),异型细胞：类似正常基底细胞或体积较小，大小不等，细胞排列紊乱，可见核分裂。,级（轻度）异型细胞限于上皮下1/3（CIN）多数可消退级（中度）异型细胞累及上皮下2/3（CIN）级（重度）异
7、型细胞超过上皮2/3以上（CIN）原位癌 上皮全层细胞异型，极性消失，但基底膜完整（CIN）原位癌累及腺体（仍为原位癌）浸润癌突破基底膜，向上皮下浸润扩展,重度非典型增生和原位癌没有明显界限，原位癌的异型细胞多形性更显著，核分裂多见。,CIN：级非典型增生 CIN：级非典型增生 CIN：级非典型增生及原位癌,子宫颈上皮内瘤变(Cervical intraepithelial neoplasia,CIN),Cervical intraepithelial neoplasia(CIN-1 and-2),Cervical intraepithelial neoplasia(CIN-3),Cervic
8、al carcinoma in situ with glands,轻度非典型增生:多数可自然消退 20%CIN 浸润癌 10年内 非典型增生+16、18或33型HPV感染较高 恶变倾向 检查手段：碘液实验、脱落细胞学、组织病检,Prognosis,三、子宫颈癌,1.女性高发恶性肿瘤之一，开展普查晚期 癌，5年生存率和治愈率2.40-60岁高发3.临床:阴道不规则流血、接触性出血、白带,(Carcinoma of the cervix),*与早婚、多产、性生活紊乱、子宫颈裂 伤、包皮垢、感染等因素有关*通常继发于CIN*与人类乳头状瘤病毒(HPV)16、18型，其次31、33型的感染有关,Eti
9、ology,组织来源子宫颈阴道部或移行带：鳞状上皮子宫颈管粘膜柱状上皮柱状上皮下的储备细胞,大体分型：糜烂型外生菜花型内生浸润型溃疡型,Pathological changes,1.子宫颈鳞状细胞癌：占90%,早期浸润癌,（微小浸润型鳞状细胞癌）,浸润癌,少数肿瘤细胞突破基底膜浸润间质的深度不超过基底膜下5mm没有血管浸润也无淋巴结转移常无明显临床症状,癌组织突破基底膜明显浸润间质，深度超过基底膜下5mm伴有临床症状者,组织分型,高分化鳞癌(20%):癌巢、角化珠,核分裂不多,镜下:,中分化鳞癌(60%):无明显角化和癌珠形成，不规则和条型癌巢,核分裂和细胞异型性较明显,低分化磷癌(20%):
10、细胞呈小梭形，似基底细胞，异型性及核分裂都很明显，对放射线最敏感，但预后较差,2.子宫颈腺癌：占10-25%,A large protruding mass is seen in cervical canal extending to the fornix of vagina.,Adenocarcinoma in situ,Poorly differentiated adenocarcinoma,直接蔓延:膀胱、直肠、盆腔、阴道、宫体淋巴道转移:最常见，子宫旁闭孔、髂内、髂外、髂总、腹股沟、骶前Ln，晚期锁骨上Ln 血道转移:肺、胃、肝,Spreading and metastasis,Thi
11、s is a larger cervical squamous cell carcinoma which spread to the vagina.,This is another pelvic exenteration for cervical squamous cell carcinoma.The irregular grey-brown tumor extends toward bladder and up into the uterus.,Invasive squamous carcinoma of cervix in vascular channel.The presence of
12、tumor cells within the lumen of a capillary-like space is evidence for aggressive growth potential in squamous carcinoma of the cervix and has been correlated with increased risk for regional lymph node metastasis.,1.不规则阴道流血、接触性出血2.白带增多3.腰骶部疼痛4.子宫膀胱瘘/子宫直肠瘘5.定期脱落细胞检查早期发现,Clinical relations,临床分期：0期:原位
13、癌I期:局限于子宫颈内期:侵及盆腔和阴道期:侵及盆腔壁和阴道下1/3期:侵出骨盆,累及膀胱粘膜或直肠,四.子宫平滑肌瘤 Leiomyoma of the uterus,1.最常见2.30岁,70%3.多无症状，出血，尿频，不孕，自然流产，绝经后萎缩4.遗传倾向,Pathological changes,A large,solitary leiomyoma.,A submucosal leiomyoma,Multiple submucosal,intramural,and subserosal leiomyomas of the uterus.,Red degeneration,生长部位：子宫肌
14、层、子宫浆膜下或子宫内膜下单发或多发：多者达数十个大小悬殊：小者仅镜下可见，大者30cm形态：球形或不规则形，界清，无包膜切面观：灰白，质韧，编织状或旋涡状继发性改变：玻璃样变、粘液变、囊性变、钙化、出血及坏死等,大体：,与正常子宫平滑肌细胞相似瘤细胞-核排列较密集 束状或编织状排列 核长杆状，两端钝圆，染色质纤细,镜下:,Uterine leiomyoma is a benign connective tissue tumor of the smooth muscle cells of the myometrium.Tumor cells resemble normal cells(elon
15、gated,spindle-shaped,with a cigar-shaped nucleus)and form bundles with different directions(whirled).The tumor is well circumscribed,but not encapsulated.,良、恶性之间的区别取决于四个标准：坏死 分裂像 细胞异型性 浸润肿瘤核分裂像10个/10 HP，有细胞异型性及浸润者为恶性,子宫平滑肌肉瘤（Leiomyosarcoma）,This is a leiomyosarcoma protruding from myometrium into th
16、e endometrial cavity of this uterus.,Much more cellular and the cells have much more pleomorphism and hyperchromatism than the benign leiomyoma.An irregular mitosis is seen in the center.,子宫体癌(子宫内膜腺癌)（Endometrial adenocarcinoma）,1.发病率上升2.绝经期、绝经后妇女，50-59岁3 不规则阴道流血4.生长缓慢,转移较晚5.一般与雌激素长期作用有关,肉眼：局部型：多见，多
17、位于子宫底或子宫角，息肉状、乳头状弥漫型：内膜弥漫性增厚，灰白质脆，伴出血、坏死、溃疡,Pathological changes,镜下：高分化：多见，腺管排列拥挤、紊乱，轻度异型，似增生的内膜腺体中分化：腺体不规则，排列紊乱，乳头或筛状，异型明显，核分裂易见低分化：实体片状，无腺样结构，异型明显，核分裂多见,grade I,grade II,grade III,Adenocarcinoma,endometrium,uterus,well differentiated.The tall columnar epithelium and well-defined gland formation il
18、lustrate a well-differentiated adenocarcinoma.,This is endometrial adenocarcinoma which can be seen invading into the smooth muscle bundles of the myometrial wall of the uterus.,Well differentiated adenocarcinoma has invaded through the muscle bundles of the myometrium(red arrow).The adenocarcinoma
19、is indicated by the red arrows.,腺棘皮癌：分化较好的腺癌中有良性化生的鳞状上皮,腺鳞癌：腺癌组织中混杂鳞癌上皮,直接蔓延：上子宫角，输卵管、卵巢 下宫颈管和阴道 外浆膜、腹膜和大网膜淋巴道：宫底腹主动脉旁Ln 子宫角腹股沟Ln 宫颈宫旁、髂内外、髂总Ln血道：肺、肝、骨骼,Spreading and metastasis,临床分期：期:局限于宫体,5年生存率90%期:累及子宫体和子宫颈,30-50%期:侵入盆腔期:侵出盆腔,累及膀胱和直肠,张三，女，58岁，五年前绝经，近一月来出现阴道不规则流血，B超发现子宫底部见一菜花状肿物，病理活检见灰白色质脆组织，显微镜下腺体排列拥挤、紊乱，细胞异性，似增生的内膜腺体。病理诊断：?,Case discuss,子宫内膜腺癌,
