病理學(xué)-女性生殖系統(tǒng)和乳腺疾病

女性生殖系統(tǒng)和乳腺疾病TheFemaleGenitalSystemandBreast第十三章整理ppt子宮頸疾病慢性宮頸炎Chroniccervicitis宮頸上皮內(nèi)瘤變CervicalintraepithelialNeoplasia(CIN)宮頸上皮不典型增生Cervicalepithelialdysplasia

宮頸原位癌Carcinomainsitu宮頸癌Cervicalcarcinoma

整理ppt整理ppt整理ppt整理ppt整理pptNormalcervix整理pptNormalcervix整理ppt宮頸炎陰道〔粘液〕膿性分泌物感染性沙眼衣原體(40%ofcases)真菌類淋球菌單純皰疹I(lǐng)I型人類乳頭瘤狀病毒HPV非感染性整理ppt整理pptNabothiancystat5o'clock整理ppt宮頸腫瘤癌前病變CIN〔組織學(xué)〕SIL〔脫落細(xì)胞學(xué)〕浸潤型癌整理pptCINI

：MilddysplasiaCINII：ModeratedysplasiaCINIII:SeveredysplasiaandCISCytologicsmearsSIL

low-grade:CINIorflatcondylomasSIL

high-grade:CINIIorCINIII，癌整理pptCervicalconization整理ppt整理pptPAPsmear整理ppt整理ppt整理ppt

AnormalPapsmearpicture整理pptLSIL整理pptHSIL整理pptNormalcervicalsquamousepithelium整理pptCINI整理pptCINI整理pptCINII整理pptCINIII整理pptCINIII整理ppt整理ppt整理pptCarcinomainsitu(glandsinvolved)整理ppt

Itisimportanttoemphasizethatmost(perhapsall)invasivecervicalsquamouscellcarcinomaarisefromprecursorepithilialchangesreferredtoasCIN.However,notallcasesofCINprogresstoinvasivecancer,andindeedmanypersistwithoutchangeorevenregress.整理pptCINI

Regression50-60%Persistence30%ProgressiontoCINIII20%Progressiontoinvasivecancer1-5%CINIII

Regression33%Progression6-74%整理ppt流行病學(xué)CIN頂峰年齡30y，癌頂峰年齡50yRiskfactorsEarlyageatfirstintercourseMultiplesexualpartnersAmalepartnerwithmultipleprevioussexualpartnersPersistentinfectionby“High-risk〞HPVOthers整理pptTheDeathofEvaPeron

EvaPeron("Evita"),wifeofArgentina'sleft-wingdictatorJuanPeron,diedinJanuary1952ofcervicalcancer.整理ppt宮頸癌75-90%鱗癌腺癌和腺鱗癌小細(xì)胞癌<5%20%糜爛型外生菜花型內(nèi)生浸潤型潰瘍型"Microinvasivecarcinoma"整理ppt整理ppt整理ppt整理ppt整理ppt整理pptSquamouscellscarcinoma整理pptSquamouscellscarcinoma整理pptImmunostainingforkeratin整理pptSpreading整理ppt整理ppt臨床表現(xiàn)Papsmear有助于早期診斷未能早期診斷者不規(guī)那么陰道流血白帶增多，伴有異味性交痛，排便困難擴(kuò)散引起的病癥晚期患者化療有效整理ppt宮頸癌分期(FIGO,1985)

0PreinvasivecarcinomaⅠCarcinomastrictlyconfinedtothecervixⅡCarcinomathatextendsbeyondthecervix,butdoesnotextendintothepelvicwallⅢCarcinomathathasextendedintothepelvicsidewallⅣCarcinomathathasextendedbeyondthetruepelvisorhasclinicallyinvolvedthemucosaofthebladderand/orrectum

整理ppt五年生存率Stage0100%StageI90%StageII82%StageIII35%StageIV10%整理ppt滋養(yǎng)層細(xì)胞疾病Gestationaltrophoblasticdisease

Hydatidiformmole

Invasivemole

ChoriocarcinomaHCG↑整理ppt整理pptImplantationofthePlacenta

5daysafterfertilization

整理ppt6daysafterfertilization整理ppt12daysafterfertilization整理pptathird-trimesterplacentawithbaby整理ppt整理ppt葡萄胎Hydatidiformmole整理ppt葡萄胎Hydatidiformmole整理pptBiguteruswithmole整理ppt葡萄胎HydatidiformMole一堆水腫甚至囊性擴(kuò)張的絨毛美國1/1000次妊娠，中國發(fā)病率更高分為完全性和不完全性葡萄胎整理ppt完全性葡萄胎completemoleNoassociatedbabyThevilliareuniformlyswollenAllthechromosomesfromfather(46XX,46XY)

整理ppt局部性葡萄胎PartialmoleMayhaveanon-viablebabyUnevenlyswollenvilli69XXX,69XXY整理ppt整理ppt整理ppt整理pptPartialmole整理ppt臨床表現(xiàn)12-14周發(fā)現(xiàn)子宮過大就診，超聲可早期診斷5個月出血流產(chǎn)hCG升高清宮后80-90%remainsbenign10%completemolebecomeinvasive2-3%giverisetochoriocarcinoma整理ppt侵襲性葡萄胎

Invasivemole

不發(fā)生轉(zhuǎn)移

絨毛可栓塞至肺和腦

整理ppt絨毛膜癌ChoriocarcinomaAggressive起源于絨毛上皮細(xì)胞或全能干細(xì)胞1:2000Age<20yor>40yHistory50%ofcasefollowacompletemole25%ariseafteranabortionRemainderafteranormalpregnancy整理ppt患者，女，24歲，農(nóng)民，孕3產(chǎn)1+2。主訴：流產(chǎn)1年多，陰道不規(guī)那么流血，痰中帶血3月，頭痛1月，嘔吐3天?，F(xiàn)病史：1年前，因停經(jīng)5月后自然流產(chǎn)，流出物似“爛肉一堆〞，未見胎兒成份，當(dāng)時未清宮，以后月經(jīng)正常。3月前開始陰道不規(guī)那么流血，時多時少，1月前陰道掉出鵝蛋大之腥臭“肉塊〞，同時有咳嗽，痰中帶血，頭昏頭痛。近3日來，頭昏頭痛加重，并出現(xiàn)劇烈嘔吐。去某院婦科門診求治，在檢查中病人突然頭痛、嘔吐、昏迷，四肢小抽搐，急診入院。病例討論整理ppt體格檢查:神志不清，脈搏90次/min，呼吸16次/min，血壓129/90mmHg，心肺〔－〕，肝脾未捫清，子宮底在恥骨聯(lián)合上4指，外陰水腫，陰道前后壁有4個紫紅色結(jié)節(jié)，小者直徑為0.5cm，最大者直徑5cm，掉出陰道之外。子宮2月孕大，前位，活動，雙附件〔－〕，入院后1小時，呼吸驟停，搶救無效死亡。實驗室檢查：入院前20天，胸部X線照片見雙肺有結(jié)節(jié)狀影。查血：血紅蛋白38g/L，白細(xì)胞15.3×109/L，嗜中性粒細(xì)胞0.86，淋巴細(xì)胞0.13，大單核細(xì)胞0.01，尿妊娠試驗〔+〕。

整理ppt尸檢摘要:子宮長大如拳頭，外表有黃豆大結(jié)節(jié)數(shù)個，子宮底右側(cè)有5cm×5cm×6cm大包塊，外表有壞死，潰爛，切面呈紫紅色，邊界不清，已侵及肌層和漿膜，陰道前壁有4個大小不等的紫紅色結(jié)節(jié)〔同前〕，子宮旁有數(shù)個蠶豆大小的結(jié)節(jié)，雙附件〔－〕。雙肺內(nèi)可捫及多個黃豆大小的硬結(jié)節(jié)，切面為深紫紅色，中心有壞死；雙側(cè)胸膜臟壁層有局灶性纖維性粘連。腦重1230克，左頂顳部硬膜下有血塊約10cm×6cm×0.6cm，左側(cè)腦室后角有核桃大小紫紅色結(jié)節(jié)，右額極也有3cm×2.5cm之紫紅色結(jié)節(jié)。有明顯小腦扁桃體疝形成。整理pptChoriocarcinoma整理ppt整理ppt整理pptChoriocarcinoma整理pptChoriocarcinoma整理pptChoriocarcinoma整理pptChoriocarcinoma(metastasistovagina)整理pptChoriocarcinoma(metastasistolung)整理pptChoriocarcinoma(metastasistolung)整理ppt臨床表現(xiàn)陰道流血伴hCG顯著升高早期血道轉(zhuǎn)移至肺(50%)，陰道(30-40%)，腦，肝，腎Chemotherapysavesalmostallcases整理ppt乳腺癌Breastcarcinoma212,920newcase,40,940death(USA,2006)全球發(fā)病率增高發(fā)病機(jī)制Pathogenesis

遺傳Geneticchange激素Hormonalinfluence環(huán)境Environmentalfactors整理ppt整理ppt

FactorsRelativeriskWell-EstablishedinfluencesGeographicfactorsVariesAgeIncreaseafter30yFamilyhistory

First-degreerelativewithBC1.2-3.0Menstrualhistory

Ageatmenarche<12y1.3Ageatmenopause>55y1.5-2.0PregnancyFirstlivebirth25-29yo1.5Firstlivebirth>30yo1.9Firstlivebirth>35yo2.0-3.0Nulliparous3.0整理ppt

FactorsRelativeriskWell-EstablishedinfluencesBenignbreastdiseaseProliferativedisease1.9Proliferativediseasewithatypicalhyperplasia4.4Lobularcarcinomainsitu6.9-12.0LessWell-Establishedinfluences

ExogenousestrogensOralcontraceptivesObesityHigh-fatdietAlcoholconsumptionCigarettesmoking整理ppt整理ppt乳腺癌類型原位癌Non-invasiveDuctalcarcinomainsitu(DCIS)Lobularcarcinomainsitu(LCIS)浸潤性癌Invasive(infiltrating)Invasiveductalcarcinoma(硬癌)InvasivelobularcarcinomaMedullarycarcinomaColloidcarcinomaTubularcarcinomaOthertypes整理ppt整理pptNormalrestingbreast整理pptNormalpregnantlady’sbreast整理ppt導(dǎo)管內(nèi)原位癌DCIS常伴壞死和鈣化(乳腺攝片)97%longtermsurvival1/2low-gradeDCIS(leftalone)turnsinvasiveatthesamesite(Cancer103:2481,2005).ArchitecturalpatternsofDCIS粉刺癌ComedosubtypeSolid,cribriform,papillary整理pptVanNuysgrading-and-treatmentschemefornon-infiltratingductalcarcinoma:(Lancet345:1154,1995)1:Nonecrosis(lumpectomy,skiptheradiation)2:Necrosisbutnouglynuclei(lumpectomy,mayberadiation)3:Uglynuclei(lumpectomy-radi