臨床檢驗基礎(chǔ)-課件

1、臨床檢驗基礎(chǔ)脫落細胞學(xué)檢查上海第二醫(yī)科大學(xué)附屬瑞金醫(yī)院袁勤脫落細胞檢查基本知識脫落細胞學(xué)（exfoliative cytology) :人體各部位，特別是管腔系統(tǒng)表面的脫落細胞或病變器官及腫物通過細針吸取的方法獲得的細胞，經(jīng)染色后，在顯微鏡下觀察這些細胞的形態(tài)，從而作出診斷的一門臨床檢驗學(xué)科，又稱臨床細胞學(xué)（clinical cytology) ，細胞病理學(xué)（cytopathology) 脫落細胞檢查基本知識1928年，Papaniculaou 陰道涂片診斷宮頸癌, 創(chuàng)建了巴氏染色法.50年代，我國推廣應(yīng)用70年代，針吸細胞學(xué)的開展和發(fā)展近年來，免疫細胞化學(xué)、DNA分析、PCR技術(shù)、超微結(jié)構(gòu)分

2、析等脫落細胞檢查的標(biāo)本來源自然排出物（痰液、尿液、乳頭溢液等）體腔抽出液（胸水、腹水、心包液、腦脊液）細針穿刺吸取液（軟組織腫塊、乳腺、淋巴結(jié)、甲狀腺等）第一節(jié) 正常脫落細胞形態(tài)一、復(fù)層鱗狀上皮被覆于全身皮膚、口腔、喉部、鼻咽的一部分，食管、陰道的全部以及子宮頸基底層 (Basal Cells, Parabasal Cells)中層 (Intermediate Cells)表層 (Superficial Cells)第一節(jié) 正常脫落細胞形態(tài)二、柱狀上皮被覆于鼻腔、鼻咽、支氣管、子宮頸管、子宮內(nèi)膜等分成纖毛柱狀上皮和黏液柱狀上皮纖毛柱狀上皮細胞Ciliated columnar epitheli

3、um cellCiliated columnar epithelium cell with terminal bars and cilia. 粘液柱狀上皮細胞Mucus columnar epithelium cellMucus columnar epithelium cellNote that the nuclei are uniform, basal, and do not stratify第一節(jié) 正常脫落細胞形態(tài)三、脫落上皮細胞的退化變性腫脹性退變固縮性退變第二節(jié) 核異質(zhì)和角化不良細胞形態(tài)核異質(zhì)(dyskaryosis) :是指細胞核的異常，表現(xiàn)為核形態(tài)、大小及染色質(zhì)分布異常，核邊增厚，

4、核邊界不整齊等，胞質(zhì)的質(zhì)和量的分化正常。核異質(zhì)細胞介于良性和惡性細胞之間，又稱為不典型細胞或增生不良細胞。角化不良：又稱異常角化、不成熟角化，是指鱗狀上皮非角化層細胞出現(xiàn)個別散在的胞漿內(nèi)角化。鱗狀上皮細胞鱗狀細胞癌Squamous cell carcinoma 癌細胞單個散在，癌細胞體積大，多形性明顯，可以呈圓形、蝌蚪形、梭形及不規(guī)則形；核大而畸形，核染色質(zhì)豐富深染，粗顆粒狀或團塊狀。核仁常不明顯。胞漿豐富紅染，有角化傾向。鱗狀細胞癌Squamous cell carcinoma腺癌 Adenocarcinoma常見成團脫落, 呈腺腔樣、乳頭狀，管狀等等。成團癌細胞排列極性混亂; 細胞核大小不

5、一, 多為圓形、卵圓形，胞漿豐富，常見粘液空泡, 染色質(zhì)豐富深染，呈粗顆粒狀，可見明顯核仁。腺癌 Adenocarcinoma未分化癌 Undifferentiated Carcinoma未分化癌是各種上皮組織發(fā)生的分化極差的的癌,在形態(tài)上很難確定其組織來源。癌細胞可單個散在, 常成團脫落，細胞核相互擠壓呈鑲嵌狀結(jié)構(gòu)。細胞胞體小，比淋巴細胞稍大，常為不規(guī)則的圓形或卵圓形，胞漿少，呈裸核樣.未分化小細胞癌 Small cell carcinoma陰道脫落細胞學(xué)檢查 (Gynecology Cytology)（一）鱗狀上皮細胞底層細胞中層細胞表層細胞：角化前和角化細胞（二）柱狀上皮細胞子宮頸內(nèi)膜細

6、胞分泌型柱狀上皮細胞纖毛柱狀上皮細胞子宮內(nèi)膜細胞第一節(jié) 正常脫落細胞形態(tài)一、復(fù)層鱗狀上皮被覆于全身皮膚、口腔、喉部、鼻咽的一部分，食管、陰道的全部以及子宮頸基底層 (Basal Cells, Parabasal Cells)中層 (Intermediate Cells)表層 (Superficial Cells)陰道脫落細胞-鱗狀上皮細胞陰道脫落細胞-鱗狀上皮細胞陰道脫落細胞學(xué)檢查 (Gynecology Cytology)柱狀上皮細胞:被覆于子宮頸內(nèi)膜和子宮內(nèi)膜子宮頸內(nèi)膜細胞分泌型柱狀上皮細胞纖毛柱狀上皮細胞子宮內(nèi)膜細胞子宮頸內(nèi)膜細胞 (Endocervical cells)Endocerv

7、ical cells. Note uniformity of cells: Prominent cell borders-a benign feature of endocervical cells-results in characteristic honeycomb appearance.Nuclei are round to oval with smooth outlines. This is the classic cytologic appearance of benign glandular epithelium from virtually any site. 子宮頸內(nèi)膜細胞 (

8、Endocervical cells)Endocervical cells Note that the nuclei are uniform, basal, and do not stratify子宮頸內(nèi)膜細胞 (Endocervical cells)Ciliated endocervical cells with terminal bars and cilia. 子宮內(nèi)膜細胞 (Endometrial cells)In contrast with usually flat lying, well-preserved endocervical cells, endometrial cells

9、tend to be packed together and degenerated. Note that the normal endometrial cell nucleus is approximately the size of the intermediate squamous cell nucleus. 子宮內(nèi)膜細胞 (Endometrial cells)Classic double contour arrangement (stroma in center surrounded by epithelium) is associated with exodus (days 6 to

10、 10). 陰道正常脫落細胞Cervix (tissue)Transformation zone, from simple columnar epithelium of endocervix into squamous metaplasia.This area is of particular interest because it is where most neoplastic lesions of the cervix arise. 陰道正常脫落細胞 The presence of endocervical cells is one measure of the adequacy of

11、a Pap smear, indicating that the transformation zone has been sampled. 陰道炎癥脫落細胞滴蟲性陰道炎 淋球菌感染陰道炎 萎縮性陰道炎 病毒感染有關(guān)的細胞學(xué)改變 (單純皰疹病毒，人乳頭狀瘤病毒）滴蟲性陰道炎Trichomonas vaginalis 萎縮性陰道炎Atrophic Vaginitis 單純皰疹病毒相關(guān)的細胞學(xué)改變 Cellular changes associated with Herpes Simplex Virus 人乳頭狀瘤病毒相關(guān)的細胞學(xué)改變 Cellular changes associated wit

12、h Human Papiloma VirusHPV infection (tissue)Note well-defined cytoplasmic vacuoles and nuclear atypia of the koilocytes. 人乳頭狀瘤病毒相關(guān)的細胞學(xué)改變 Cellular changes associated with Human Papiloma Virus人乳頭狀瘤病毒相關(guān)的細胞學(xué)改變 Cellular changes associated with Human Papiloma VirusKoilocytes: HPV infection, low-grade squa

13、mous intraepithelial lesion.To be a diagnostic koilocyte, the cytoplasmic vacuole must be clear and extremely well defined, with condensation of the peripheral cytoplasm. In addition, the nucleus must appear abnormal Binucleation is common.低度鱗狀上皮內(nèi)病變 (LSIL)Low-grade Squamous Intraepithelial Lesion (L

14、SIL) Note resemblance to normal intermediate cells, although the cytoplasm is slightly thick and dense. The nuclei are big and dark .高度鱗狀上皮內(nèi)病變 (HSIL)High-grade Squamous Intraepithelial Lesion (HSIL)This is represented by small cells with high nuclear/cytoplasmic ratios and irregular nuclei. Note thi

15、n rim of dense cytoplasm 陰道脫落細胞學(xué)檢查 (Gynecology Cytology)女性生殖系統(tǒng)的惡性腫瘤以宮頸癌為最多見，宮頸癌中以鱗狀細胞癌為多見（）；其次腺癌；未分化癌極少見。宮頸鱗狀細胞癌Squamous cell carcinoma 癌細胞單個散在，癌細胞體積大，多形性明顯，可以呈圓形、蝌蚪形、梭形及不規(guī)則形；核大而畸形，核染色質(zhì)豐富深染，粗顆粒狀或團塊狀。核仁常不明顯。胞漿豐富紅染，有角化傾向。宮頸鱗狀細胞癌Squamous cell carcinomaKeratinizing squamous cell carcinoma Markedly pleom

16、orphic or bizarre shaped, heavily keratinized tumor cells, and marked hyperchromasia are characteristic. Cells tend to occur singly. 宮頸鱗狀細胞癌Squamous cell carcinoma宮頸鱗狀細胞癌Squamous cell carcinomaKeratinizing squamous cell carcinoma (tissue). Note squamous pearl (aka squamous eddy): pearls are pathogno

17、monic of keratinization. 宮頸鱗狀細胞癌Squamous cell carcinomaNonkeratinized squamous cell carcinoma. Compared with keratinizing SCC, the cells of nonkeratinizing SCC are more uniform and more often occur in aggregates. Nuclear abnormalities are usually easier to appreciate in nonkeratinizing SCC. 陰道脫落細胞學(xué)檢

18、查 Gynecology Cytology宮頸腺癌：僅占陽性涂片總數(shù)左右，可能來源于子宮頸、子宮內(nèi)膜或輸卵管。腺癌細胞中等大小，多為圓形、卵圓形，胞漿豐富，染色質(zhì)豐富深染，呈粗顆粒狀，常見巨大核仁。癌細胞可散在，也可成團，呈腺腔樣、乳頭狀，管狀等等。成團癌細胞極性混亂，核大小不一，畸形明顯。宮頸腺癌 (Endocervical Adenocarcinoma)Endocervical adenocarcinoma is represented by a rosette-like arrangement of malignant endocervical cells. Note prominent

19、 nucleoli. 宮頸腺癌 (Endocervical Adenocarcinoma)Endocervical adenocarcinoma in situ. Crowded rosette, Benign endocervical cells rarely form rosettes. 宮頸腺癌 (Endocervical Adenocarcinoma)陰道脫落細胞學(xué)檢查 Gynecology Cytology宮頸未分化癌： 極少見，少于陽性涂片總數(shù)，細胞分化程度極低惡性程度高。胞體小，大小不等，常為圓形或不規(guī)則形。核小，染色質(zhì)較細致。核仁不明顯。漿極少或呈裸核樣。宮頸小細胞未分化癌 (

20、Small cell neuroendocrine carcinoma)A rare cause of HCGs, small cell neuroendocrine carcinoma is cytologically similar to the far more common small oat cell carcinoma that occurs in the lung. Note high nuclear /cytoplasmic ratios, fine, dark chromatin, and inconspicuous nucleoli. There is an attempt

21、 at rosette formation by the cells in this field. 其他惡性腫瘤Malignant mixed mesodermal (mllerian) tumor or carcinosarcoma.Often, only the malignant epithelial component is seen in the Pap smear. The adenocarcinoma can range from well differentiated to poorly differentiated. 陰道脫落細胞學(xué)檢查 Gynecology Cytology巴氏五級分類法： I 級 未見異