1、 Jing Huan Dept of Pathology,Liaoning TCM Copyright 2004 井欢井欢 版权所有版权所有 NEOPLASIA2004.4.8Jinghuan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
2、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This 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
3、neoplastic in origin.Once a neoplasm has started,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 pigmen
4、t,giving it a green color.This is 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 i
5、s not as well circumscribed(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 th
6、e bronchi into the surrounding 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
7、多形性（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,nucleolilarge and irregular in shapeNo resemblance to colon epitheliaMitotic figures present,haphazard arrangementHere are three abnormal mitoses.Mitoses by themse
8、lves 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 malignancyMany mitotic figures,necrotic areasPleomorphic cells,pleomorphic nucleianaplasti
9、c tumor of the skeletal muscle(Rhabdomyosarcoma)Cellular and nuclear pleomorphism Tumor giant cells,hyperchromatic nucleiThis 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
10、 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
11、。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 often called a scirrhous appearance.There is also
12、 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 lymphocytesPink in S and MSAreas are cancerouscellsBoth lymphatic and hemat
13、ogenous spread of malignant neoplasms is possible to distant sites.Here,a breast carcinoma has spread to a lymphatic in the lung.Lymphatic vessel spreadRhabdomyosarcoma(anaplastictumor of the skeletal muscle)Cellular and nuclear pleomorphismTumor giant cells,hyperchromaticnucleiComparison between a
14、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
15、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）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（
16、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.
17、）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.The concept of differentiation is demonstrated by this small adenomatous polyp of the colon.Note the difference in staining q
18、uality 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 epithelium at the left contrasts with the atypical epithelium of the adenomatous polyp at the right.Nuclei are darker and more irregu
19、larly 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-differentiated.The two forms of cellular transformation that are potentially
20、 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 stimulus for it is taken away.Dysplasia:a disordered growth and maturation of an epithelium,which is still reversible if the factors drivin
21、g it are eliminated.The first step toward neoplasia is cellular transformation.Here,there is metaplasia of normal respiratory laryngeal epithelium on the 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
22、cervical squamous epithelium at the left,but dysplastic squamous epithelium at the right.Dysplasia is a disorderly growth of epithelium,but still confined to the epithelium.Dysplasia is still reversible.When the entire epithelium is dysplastic and no normal epithelial cells are left,then the process
23、 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 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
24、parenchyma.This renal cell carcinoma demonstrates distortion and displacement of the renal parenchyma by the tumor mass in the lower pole.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 diff
25、erentiated squamous cell carcinoma with pleomorphic cells and minimal pink keratinization.In general,mitoses are more likely to be seen in malignant neoplasms.At high magnification,this squamous cell carcinoma demonstrates enough differentiation to tell that the cells are of squamous origin.The cell
26、s are pink and polygonal in shape with intercellular bridges(seen as desmosomes or tight junctions by electron microscopy).However,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
27、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.This is the microscopic appearance of neoplasia,or uncontrolled new growth.Here,
28、the neoplasm is infiltrating into the underlying cervical stroma.Here is a moderately differentiated squamous cell 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 adenoc
29、arcinoma can be seen here.Normal gastric epithelium at the left merges into the carcinoma at the right,and irregular neoplastic glands infiltrate downward into the submucosa.The infiltrating glands of this colonic adenocarcinoma demonstrate less differentiation than the adenomatous polyp,although th
30、ey still resemble glands.In general,less differentiation means a greater likelihood of malignant behavior.At high magnification,the infiltrating ductal carcinoma of breast has pleomorphic cells infiltrating through the stroma.Microscopically,the infiltrating ductal carcinoma extends irregularly thro
31、ugh the tissue as cords and nests of neoplastic cells with intervening collagen.There is a purplish 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 sm
32、all and round,typical for a nulliparous woman.The os will have a fish-mouth shape after one 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 i
33、s 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.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 c
34、ourse,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 small intestine.It has the characteristics of a benign neoplasm:it is well circumscribed,slow growing,and resembles the tissue of orig
35、in(fat).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 cells such as striated muscle(rhabdomy
36、osarcoma),smooth muscle(leiomyosarcoma),fat(liposarcoma),blood 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 liposarc
37、oma.Common sites are the retroperitoneum and thigh,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 dem
38、onstrates a malignant melanoma,which is much 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 whic
39、h has a signet ring histologic pattern 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
40、seen here at the right(in left ovary-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 amoun
41、ts 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 teratomas with less differentiated tissue and are more aggressive.Rarely,there are frankly carcinomatous
42、 areas.Here are bilateral 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 t
43、he many papillations 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 demarc
44、ated from the 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 c
45、losely 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 right.At high magnification,large bizarre lipoblasts are seen in
46、this liposarcoma.Sarcomas are best treated surgically,because most respond poorly to chemotherapy or radiation.The osteosarcoma is composed of spindle cells.The pink osteoid formation seen here is consistent with differentiation that suggests osteosarcoma.This sarcoma is composed of very pleomorphic
47、 cells.This gastric adenocarcinoma is positive for cytokeratin by immunoperoxidase.This is a typical staining reaction for carcinomas and helps to distinguish carcinomas from sarcomas and lymphomas.Immunoperoxidase staining is helpful to determine the cell type of a neoplasm when the degree of diffe
48、rentiation,or morphology alone,does not allow an exact classification.This sarcoma 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.Some ep
49、ithelia are accessible enough,such as the cervix,that cancer screening can be done by sampling some of the cells and sending them to the laboratory.Here is a cervical Pap smear in which dysplastic cells are present that have much larger and darker nuclei than the normal squamous cells with small nuclei and large amounts of cytoplasm.1 掌握肿瘤的概念、形态特征，异型性，良、掌握肿瘤的概念、形态特征，异型性，良、恶性肿瘤的区别以及对机体的影响恶性肿瘤的区别以及对机体的影响2 掌握肿瘤的分类及命名原则。掌握肿瘤的分类及命名原则。3 了解并肿瘤的的病因和发生机制。了解并肿瘤的的病因和发生机制。4 了解恶性淋巴瘤、白血病、恶性组织增生了解恶性淋巴瘤、白血病、恶性组织增生症的病理特点、类型。症的病理特点、类型。目的要求目的要求
