脱落细胞检查基本知识

敝验基础脱落细胞学检查上海第二医科大学附属瑞金医院袁勤痰液脱落细胞学检查•肺脱落细胞学检査是早期诊断肺癌的重要手段之一。肺癌的早期诊断可根据临床症状、X线检査、痰液涂片检査和纤维支气管等多方面配合进行。•痰液标本采集：①痰液必须新鲜；②痰液必须是肺部咳出。痰液脱落细胞学检查正常的痰涂片中可见来自口腔的鳞状上皮细胞、纤毛柱状上皮细胞和肺泡吞噬细胞（后两者为确定痰液来自肺及支气管深部的标志）以及中性白细胞、淋巴细胞、浆细胞、嗜酸性白细胞等。痰液纤毛柱状上皮细胞Ciliatedcolumnarcells纤毛柱状上皮细胞NotethemoderatelycoarseandhyperchromaticchromatinAlsonotethelittletailswherethecellswereattachedtothebasementmembraneand，ofcourse^thepresenceofterminalbarsandcilia(Oil)GobletcellsThepresenceofalveolarmacrophagesindicatesthatthe"deeplung’’hasbeensampled."dustcells"Alveolarmacrophagesinsputum痰液肺海吞吸细胞AlveolarmacrophagesinsputumGiantCeHistiocytes•Giantcellhistiocytescanbeseeninawidevarietyofpulmonarydisorders,•Theycanalsobeseeninapparentlyhealthypeople,andthereforedonotnecessarilyindicatethepresenceofdisease.炙液良性病变脱落细胞•炎症病变脱落细胞：支气管炎、肺炎和肺结核等急、慢性呼吸道炎症引起上皮细胞发生细胞核轻度固缩退变或细胞轻度肿大。•巴氏细胞(Papaniculaoucell):因炎症刺激造成，细胞体积较小，圆形或卵圆形，胞质深红色，核小而圆形，致密深染，有轻度核异形，可能是鳞状化生细胞。细胞-巴氏细胞•Squamousmetaplasiacanbeseeninsputmsmear,ie,roundedcellswithdense,cyanophiliccytoplasm*肺癌脱落细胞•痰液涂片检査主要用于检査癌细胞，肺癌患者痰内癌细胞检出率可达90%。根据细胞学形态，肺癌主要分为鳞癌，腺癌，未分化癌，混合型癌及类型未明癌。政液脱落细胞学检查肺鱗状细胞癌：•最常见，男性远多于女性，主要发生于大支气管，多数为中央型。•细胞形态和大小异常：癌细胞单个散在，多形性明显，可以呈圆形、蝌蚪形、梭形及不规则形；•核的异型：癌细胞大而畸形，核染色质丰富深染，成团块状或墨水滴样。核仁常不明显；•胞质的异常：癌细胞胞浆丰富红染，有角化倾向；•癌细胞吞噬现象.疚液鱗状细胞癌Keratinizingsquamouscellcarcinoma(tissue)Notethepresenceofsquamouseddies，orpearls^whicharepathognomonicofkeratinization.荻液鱗状细胞癌Keratinizingsquamouscellcarcinoma•*Pearlsarecharacteristic角化鱗状细胞癌KeratinizingsquamouscellcarcinomaBizarrekeratinizingcells,oftensingle,areacharacteristicfeature.Suchcellsareparticularlyassociatedwithsputumspecimens痰液鱗状细胞癌痰液鱗状细胞癌非角化鱗状细胞癌Non-keratinizingsquamouscellcarcinomaunitormPearls,extensivekeratinization，andbizarreshapedcellsarenotpresent痰液脱落细胞学检查肺腺癌：•常发生于小支气管，以周围型肺癌多见，易发生血道转移和侵犯胸膜引起的癌性胸水。•分化好的腺癌以成群脱落为主，细胞群大，且细胞相互重叠呈立体结构，单个癌细胞一般为圆形或卵圆形，胞质常有许多小空泡，偶见较大空泡。核圆形或卵圆形，核膜染色质呈颗粒状，有明显的核仁。肺腺癌AdenocarcinomaAdenocarcinomaThree-dimensionalcel直ballsorpapillaryclustersofmalignantcellsarecharacteristicarchitecturalfeaturesofadenocarcinoma.肺腺癌AdenocarcinomaMicroacinarorrosette-likestructuresindicateglandulardifferentiation.Microacinarcomplexesareacytologicequivalentofthe”gland-in-gland”histologicgrowthpatternofadenocarcinoma.肺腺癌Adenocarcinoma肺腺癌AdenocarcinomaNotethatintracytoplasmicsecretoryvacuolecontainingmucin(arrow).痰液脱落细胞学检查朱分化小细胞癌:•恶性度较髙，多为中央型，较早发生转移。•癌细胞单个或成团脱落，胞体小，比淋巴细胞稍大，常为不规则的圆形或卵圆形，胞浆少，呈裸核样；细胞核相互挤压呈镶嵌状结构。LSmallcellcarcinoma(brushingspecimen)Thetumorcellshaveverylittlecytoplasm,relativelyfinebutveryhyperchromaticchromatinandinconspicuousnucleoliNotethesimilarityofbronchialcellnuclearchromatintothatofthetumorcells.未分化小细胞痛Smallcellcarcinoma•Smallcellcarcinoma(brushingspecimen)•Thecellsobtainedbydirectbrushingappear”fresher.”well-preservedmaterial未分化小细胞痛Smallcellcarcinoma浆膜腔积液脱落细胞查•浆膜腔，又称体腔，包括胸膜腔、腹膜腔和心包膜腔。在正常生理情况下，体腔脏层和壁层间有少量液体，起润滑作用。在炎症刺激、肿瘤转移或循环障碍等情况下，可形成胸水、腹水和心包积液。•浆膜腔积液脱落细胞学检査主要用于判断积液中有无癌细胞。浆膜腔租液脱落细胞学检查良性病变脱落细胞：•脱落间皮细胞：圆形或楠圆形，胞浆厚实，胞核居中，胞核亦为圆形或椭圆形，核染色质细颗粒状，分布均匀。•退化变性的间皮细胞：肿胀性退变表现为细胞增大，胞浆出现大小不等的液化空泡，胞核肿胀，偏位。间皮细胞esotlielialCells)•Mesothelialcellsinaneffusionalwaysshowreactivechangesofvariousdegrees.•Notenuclearenlargementandaprominentnucleolusbutfinechromatinandasmoothnuclearmembrane.间皮细胞esotlielialCells)•Gland-likeclusterofbenignmesothelialcellsmimickingadenocarcinoma.•Notethatthecomponentcellsareidenticaltotheotherreactivemesothelialcells,anddonotconstituteaforeignpopulation.组织细胞（Histiocyte:Hemosiderin-ladenhistiocyte.HemosiderinisarefractilegoldenbrownpigmentThepresenceofhemosiderinindicatesoldbleeding.良性病变脱落细胞绝核性病变(Tuberculouseffusion)Abundanceoflymphocytesandvirtualabsenceofmesothelialcellsarecharacteristicoftuberculouspleuraleffusions.浆膜腔积液脱落细胞学检查您性病变脱落细胞:•浆膜腔积液中肿瘤细胞的来源：积液中98%以上的癌细胞是转移性的，原发性的恶性间皮瘤较少见。•肿瘤性的胸水和心包水常见于肺癌、乳腺癌等，肿瘤性的腹水常见于卵巢癌、胃癌、肠癌、肝癌、胰腺癌等。原发性的恶性间皮瘤，恶性淋巴瘤较少见。浆膜腔租液脱落细胞学检查腺癌：占积液中转移癌的80%以上，腺癌细胞形态多样，排列构成腺腔样、乳头状，洋葱皮和桑葚形状等等，腺癌细胞形态多样，细胞大小相差数倍，癌细胞呈圆或楠圆形，核偏位，核边不规则，核仁明显增大或多个核仁，胞浆中常含空泡，常见异常分裂象。腺癌Adenocarcinoma«wunc^mi^鍾m!Adenocarcinomaisthemostcommoncauseofamalignanteffusion.AmongthemostusefulfeaturesinthediagnosisofadenocarcinomaareincreasedN/Cratio,irregularnuclearmembranes,largenucleoli,secretoryvacuoles,andthree-dimensionalaggregates腺癌Adenocarcinoma腺癌AdenocarcinomaThegeneralpatternsofadenocarcinomasinfluidsincludecellballs(morulas),papillaryoracinargroups,signetringcells腺癌AdenocarcinomaPapillarygroupsareelongated,threedimensionalaggregates*Psammomabodiesmaybepresent.Adenocarcinomasofthelung(illustratedhere),breast,andfemalegenitaltractarecommonsources腺癌AdenocarcinomaSignetringcellsarecellswithlargecytoplasmicvacuolesthatcompressthenucleustotheperipheryofthecellLargesignetringcellsarecharacteristicofcarcinomaofthestomach.(Oil)腺癌AdenocarcinomaIndianfiles，Chainsoftumorcells，particularlywhenlong,suggestbreastcancer.However,otherpossibilities,suchaspancreasorlungcancersaswellasmesothelioma,mustalsobeconsidered.浆膜腔租液脱落细胞学检查麟状细胞癌：在积液中少见，仅占2%-3%。高分化鳞癌，细胞奇形怪状，胞浆有角化倾向。癌细胞单个散在，细胞为圆形，胞核居中，核质深染，胞浆厚实并界限清晰，癌细胞易成堆或成团，背景中伴有或不伴有坏死物。鱗状细胞癌SquamousCellCarcinoma•Irregularlyshapedcells•Irregularlyshapedcellsareabnormalandsuggestmalignancy,suchaskeratinizingsquamouscellcarcinoma浆膜腔租液脱落细胞学检查小细胞型未分化癌：在积液中也很少见，为3%-5%，癌细胞呈葡萄堆状排列，细胞重叠，胞浆极少或裸核样，核形不规则，典型者为瓜子状或燕麦状，亦有圆或椭圆形，核染色质粗颗粒或呈块状。小细胞型未分化癌SmallCellCarcinomaSmallcell(neuroendocrine)carcinoma，ischaracterizedbysmalltomedium-sizedcellswithscantcytoplasm,inconspicuousnucleoli,andprominentmoldingandindianfilearrangements.浆膜腔租液脱落细胞学检查J旬皮瘤(mesothelioma)原发于浆膜，良性间皮瘤生长局限，包膜完整，很少引起积液；恶性间皮瘤可见到大量增生活跃的间皮细胞，间皮细胞的恶性特征与转移性腺癌类似，细胞呈团或相嵌，单凭光镜不能明确诊断，应辅以电镜和免疫细胞化学技术，临床表现及影象学的诊断进行鉴别。间皮烟(mesothelioma)MesotheliomaAdiagnosisandbiggermoreandbiggerclusters/Thegroupsoftenhaveveryirregularoutlines.uetotheis"morecells,ir思性淋巴瘤(Non-Hodgkin’sLymphoma)Non-Hodgkin’slymphoma，largecelltype.Themostcharacteristicfeatureoflymphomaisthatallofthecellsaresingle,withoutformationoftruetissueaggregates.•尿液正常脱落细胞•泌尿系统良性病变脱落细胞•泌尿系统恶性肿瘤脱落细胞•移行上皮细胞•鳞状上皮细胞•柱状上皮细胞•非上皮细胞成分移行上皮细胞•尿沉渣涂片中的上皮细胞主要来源于肾盏、肾盂、输尿管、膀胱和尿道的移行上皮，正常情况下脱屑细胞不多，无肿瘤细胞。尿液正常脱落细胞移行上皮细胞•涂片内表层细胞体积大，大小相当于鳞状上皮表层细胞，又称盖细胞.呈扁圆行或多边形；双核或多核；核圆形或卵圆形，染色质细颗粒状，分布均匀，核仁不明显，底层细胞是圆形或多边形，中层细胞梭形或多边形.因尿液渗透压变化，脱落的移行上皮细胞常会有不同程度的变性.•Bladder(tissue)•Themucosaisusuallynomorethansixorsevencellsthick.•Noteeosinophilic"umbrella'cellscoveringthesurface.TransitionalcellsPleomorphic,butbenign,transitionalcellsarenormalfindingsinbladderwashingspecimensSingle,mononuclear,parabasal-sizedtransitionalcellsusuallypredominateinvoidedurinespecimens,•Basaloidtransitionalcellsareseennearbottomoffield.I查arehaveei.NoteTransitionalcellsSuperficialtransitionalcellslargeandmaymultiplenucscallopingofthecytoplasm:theunderlyingcellsfitintotheconcavities尿液正常脱落细胞•鳞状上皮细胞：正常尿液中少见，妇女尿液中有时可见，形态同阴道涂片.•柱状上皮细胞：正常尿液中极少见，形态同阴道涂片.•昨上皮细胞成分：可见少量中性粒细胞，淋巴细胞，浆细胞，组织细胞和红细胞，•炎症性疾病•病毒感染•结石•放化疗影响•移植后改变•炎症性疾病：•炎症时，涂片内细胞数目明显增多，包括上皮细胞及炎症细胞，细胞常变形，体积增大，胞质内可有液化空泡或核固缩细胞.洗尿系统良性病变脱落细胞•病毒感染-巨细胞包涵体病-人多瘤病毒-人乳头状瘤病毒•尿结7J症涂片内见上皮细胞呈轻度核异质改变，可见大量的表层细胞，含多个核.eoignancyinlignancynuclearStoneAtypia•Urolithiasiscancausesignificantcytologicatypiasometimescomparabletohigh¬grademaincludingenlargementandpleomorphJW^tlos>^oa,hyperchroichromatin,iJMFprominent・BecautiouswhendiagnosingmapatientswithstonesparticularlyiftheStoneAtypiaNotehighN/Cratios,irregularnuclearmembranes,darkchromatin,andprominentnucleoli,allfeaturesthatcouldeasilybemistakenformalignancy*Notecytoplasmicvacuolization,afeatureseeninreactivecellsandhigh-grademalignancybutusuallynotpresentinlow-gradetumors.进尿系统良性病变脱落细胞•放射及化学治疗对膀胱上皮细胞的影响-盆腔区放射治疗对膀胱影响主要为膀胱壁水肿，上皮细胞胞质和胞核都出现空泡，核固缩或核碎裂，细胞有时有异形性，易误认为癌细胞.进尿系统良性病变脱落细胞•放射及化学治疗对膀胱上皮细胞的影响-化学治疗影响：尿沉渣中上皮细胞增大，空泡变性，核增大，染色质増粗呈粗颗粒状，核固缩，碎裂，可有明显核仁.膀胱上皮可明显增多，细胞退行性改变，与放射治疗反应类似.洗尿系统良病变脱落细胞•Radiation.Asinotherbodysites,theclassiccytologicchangeismacrocytosis.However,radiationcanalsocausereactiveordegenerativechangesinthecells.•Radiationcancauseradiationcystitisandcellularatypia,whichmaybemistakenformalignancy.Chemotherapy.Agentssuchascyclophosphamideandbusulfancancausecellularatypiamimickingmalignancy.Althoughboththecellandnucleusenlarge,thenucleusenlargesmore,andanincreaseintheN/Cratiomayoccur.Cellswithbizarreshapesmaybeseen.洗尿系统良病变脱落细胞•BCGtherapy•Histiocyticaggregatesandgiantcellhistiocytes(arrow)associatedwiththegranulomatousinflammationinducedbythistherapyarecharactenstic.•移植后尿液细胞学改变-肾移植的排斥反应有7项细胞学改变：肾小管细胞，淋巴细胞，管型，背景坏死物，核退变，红细胞，混合细胞团.病变脱落细胞•Renaltransplantrejection.•Increasedinnumberofrenaltubularcellswithdegenerativechanges•Increasedlymphocytes•Mixedcellclusters•Casts•RBCs•Dirtyback