病理学——女性生殖系统与乳腺疾病

1、女性生殖系统和乳腺疾病 The Female Genital System and Breast,第十三章,子宫颈疾病,慢性宫颈炎 Chronic cervicitis 宫颈上皮内瘤变 Cervical intraepithelial Neoplasia (CIN) 宫颈上皮不典型增生 Cervical epithelial dysplasia 宫颈原位癌 Carcinoma in situ 宫颈癌 Cervical carcinoma,Normal cervix,Normal cervix,宫颈炎,阴道（粘液）脓性分泌物 感染性 沙眼衣原体 (40% of cases) 真菌类 淋球菌 单纯疱疹II型 人类乳头瘤状病毒 HPV 非感染性,Nabothian cyst at 5 oclock,宫颈肿瘤,癌前病变 CIN （组织学） SIL （脱落细胞学） 浸润型癌,CIN I ：Mild dysplasia CIN II：Moderate dysplasia CIN III: Severe dysplasia and CIS,Cytologic smears SIL low-grade

2、: CINI or flat condylomas SIL high-grade: CINII or CINIII，癌,Cervical conization,PAP smear,A normal Pap smear picture,LSIL,HSIL,Normal cervical squamous epithelium,CIN I,CIN I,CIN II,CIN III,CIN III,Carcinoma in situ (glands involved),It is important to emphasize that most (perhaps all) invasive cervical squamous cell carcinoma arise from precursor epithilial changes referred to as CIN. However, not all cases of CIN progress to invasive cancer, and indeed many persist without change or even regre

3、ss.,CINI Regression 50-60% Persistence 30% Progression to CIN III 20% Progression to invasive cancer 1-5%,CINIII Regression 33% Progression 6-74%,流行病学,CIN高峰年龄 30y，癌高峰年龄50y Risk factors Early age at first intercourse Multiple sexual partners A male partner with multiple previous sexual partners Persistent infection by “High-risk” HPV Others,The Death of Eva Peron Eva Peron (“Evita“), wife of Argentinas left-wing dictator Juan Peron, died in January 1952 of cervical cancer.,宫颈癌,75-90%,鳞癌 腺癌和腺鳞癌 小细

4、胞癌,5%,20%,糜烂型 外生菜花型 内生浸润型 溃疡型,“Microinvasive carcinoma“,Squamous cells carcinoma,Squamous cells carcinoma,Immunostaining for keratin,Spreading,临床表现,Pap smear 有助于早期诊断 未能早期诊断者 不规则阴道流血 白带增多，伴有异味 性交痛，排便困难 扩散引起的症状 晚期患者化疗有效,宫颈癌分期 (FIGO,1985) 0 Preinvasive carcinoma Carcinoma strictly confined to the cervix Carcinoma that extends beyond the cervix, but does not extend into the pelvic wall Carcinoma that has extended into the pelvic sidewall Carcinoma that has extended beyond the true pelvis or has clin

5、ically involved the mucosa of the bladder and/or rectum,五年生存率,Stage 0 100% Stage I 90% Stage II 82% Stage III 35% Stage IV 10%,滋养层细胞疾病 Gestational trophoblastic disease,Hydatidiform mole,Invasive mole,Choriocarcinoma,HCG,Implantation of the Placenta 5 days after fertilization,6 days after fertilization,12 days after fertilization,a third-trimester placenta with baby,葡萄胎 Hydatidiform mole,葡萄胎 Hydatidiform mole,Big uterus with mole,葡萄胎 Hydatidiform Mole,一堆水肿甚至囊性扩张的绒毛 美国1/1000次妊娠，中国发病率更高 分为完全性和不完全性

6、葡萄胎,完全性葡萄胎 complete mole No associated baby The villi are uniformly swollen All the chromosomes from father (46XX,46XY),部分性葡萄胎 Partial mole May have a non-viable baby Unevenly swollen villi 69XXX, 69XXY,Partial mole,临床表现,12-14周发现子宫过大就诊，超声可早期诊断 5个月出血流产 hCG升高 清宫后 80-90% remains benign 10% complete mole become invasive 2-3% give rise to choriocarcinoma,侵袭性葡萄胎 Invasive mole,不发生转移 绒毛可栓塞至肺和脑,绒毛膜癌 Choriocarcinoma,Aggressive 起源于绒毛上皮细胞或全能干细胞 1:2000 Age 40y History 50% of case follow a complete mole 25% a

7、rise after an abortion Remainder after a normal pregnancy,患者，女，24岁，农民，孕3产1+2。 主诉：流产1年多，阴道不规则流血，痰中带血3月，头痛1月，呕吐3天。 现病史：1年前，因停经5月后自然流产，流出物似“烂肉一堆”，未见胎儿成份，当时未清宫，以后月经正常。3月前开始阴道不规则流血，时多时少，1月前阴道掉出鹅蛋大之腥臭“肉块”，同时有咳嗽，痰中带血，头昏头痛。近3日来，头昏头痛加重，并出现剧烈呕吐。去某院妇科门诊求治，在检查中病人突然头痛、呕吐、昏迷，四肢小抽搐，急诊入院。,病例讨论,体格检查: 神志不清，脉搏90次/min，呼吸16次/min，血压129/90mmHg，心肺（），肝脾未扪清，子宫底在耻骨联合上4指，外阴水肿，阴道前后壁有4个紫红色结节，小者直径为0.5cm，最大者直径5cm，掉出阴道之外。子宫2月孕大，前位，活动，双附件（），入院后1小时，呼吸骤停，抢救无效死亡。 实验室检查：入院前20天，胸部X线照片见双肺有结节状影。查血：血红蛋白38g/L，白细胞15.3109/L，嗜中性粒细胞0.86，淋巴细胞

8、0.13，大单核细胞0.01，尿妊娠试验（+）。,尸检摘要: 子宫长大如拳头，表面有黄豆大结节数个，子宫底右侧有5cm5cm6cm大包块，表面有坏死，溃烂，切面呈紫红色，边界不清，已侵及肌层和浆膜，阴道前壁有4个大小不等的紫红色结节（同前），子宫旁有数个蚕豆大小的结节，双附件（）。双肺内可扪及多个黄豆大小的硬结节，切面为深紫红色，中心有坏死；双侧胸膜脏壁层有局灶性纤维性粘连。脑重1230克，左顶颞部硬膜下有血块约10cm6cm0.6cm，左侧脑室后角有核桃大小紫红色结节，右额极也有3cm2.5cm之紫红色结节。有明显小脑扁桃体疝形成。,Choriocarcinoma,Choriocarcinoma,Choriocarcinoma,Choriocarcinoma,Choriocarcinoma (metastasis to vagina ),Choriocarcinoma (metastasis to lung ),Choriocarcinoma (metastasis to lung ),临床表现,阴道流血伴hCG显著升高 早期血道转移至肺 (50%)， 阴道(30-40%)， 脑，肝

9、，肾 Chemotherapy saves almost all cases,乳腺癌 Breast carcinoma,212,920 new case, 40,940 death (USA, 2006) 全球发病率增高 发病机制 Pathogenesis 遗传 Genetic change 激素 Hormonal influence 环境 Environmental factors,Factors Relative risk Well-Established influences Geographic factors Varies Age Increase after 30y Family history First-degree relative with BC 1.2-3.0 Menstrual history Age at menarche55y 1.5-2.0 Pregnancy First live birth 25-29yo 1.5 First live birth 30yo 1.9 First live birth 35yo 2.0-3.0 Nulliparous 3.0,Factors Relative risk Well-Established influences Benign breast disease Proliferative disease 1.9 Proliferative disease with atypical hyperplasia 4.4 Lobular carcinoma in situ 6.9-12.0 Less Well-Es

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