1、臨床檢驗(yàn)基礎(chǔ)臨床檢驗(yàn)基礎(chǔ)脫落細(xì)胞學(xué)檢查脫落細(xì)胞學(xué)檢查上海第二醫(yī)科大學(xué)附屬瑞金醫(yī)院上海第二醫(yī)科大學(xué)附屬瑞金醫(yī)院袁勤袁勤脫落細(xì)胞檢查基本知識脫落細(xì)胞檢查基本知識 脫落細(xì)胞學(xué)脫落細(xì)胞學(xué)（exfoliativeexfoliative cytology) : cytology) :人體各部位，特別是管腔系統(tǒng)表面人體各部位，特別是管腔系統(tǒng)表面的脫落細(xì)胞或病變器官及腫物通過細(xì)針吸取的脫落細(xì)胞或病變器官及腫物通過細(xì)針吸取的方法獲得的細(xì)胞，經(jīng)染色后，在顯微鏡下的方法獲得的細(xì)胞，經(jīng)染色后，在顯微鏡下觀察這些細(xì)胞的形態(tài)，從而作出診斷的一門觀察這些細(xì)胞的形態(tài)，從而作出診斷的一門臨床檢驗(yàn)學(xué)科，又稱臨床細(xì)胞學(xué)（臨床檢驗(yàn)學(xué)

2、科，又稱臨床細(xì)胞學(xué)（clinical clinical cytology) cytology) ，細(xì)胞病理學(xué)（，細(xì)胞病理學(xué)（cytopathologycytopathology) ) 脫落細(xì)胞檢查基本知識脫落細(xì)胞檢查基本知識 1928年，年，Papaniculaou 陰陰道涂片診斷宮道涂片診斷宮頸癌頸癌, 創(chuàng)建了巴氏染色法創(chuàng)建了巴氏染色法. 50年代，我國推廣應(yīng)用年代，我國推廣應(yīng)用 70年代，針吸細(xì)胞學(xué)的開展和發(fā)展年代，針吸細(xì)胞學(xué)的開展和發(fā)展 近年來，免疫細(xì)胞化學(xué)、近年來，免疫細(xì)胞化學(xué)、DNA分析、分析、PCR技術(shù)、超微結(jié)構(gòu)分析等技術(shù)、超微結(jié)構(gòu)分析等脫落細(xì)胞檢查的標(biāo)本來源脫落細(xì)胞檢查的標(biāo)本來源

3、1. 自然排出物（痰液、尿液、乳頭溢液等）自然排出物（痰液、尿液、乳頭溢液等）2. 體腔抽出液（胸水、腹水、心包液、腦體腔抽出液（胸水、腹水、心包液、腦脊液）脊液）3. 細(xì)針穿刺吸取液（軟組織腫塊、乳腺、細(xì)針穿刺吸取液（軟組織腫塊、乳腺、淋巴結(jié)、甲狀腺等）淋巴結(jié)、甲狀腺等）第一節(jié)第一節(jié) 正常脫落細(xì)胞形態(tài)正常脫落細(xì)胞形態(tài) 一、復(fù)層鱗狀上皮復(fù)層鱗狀上皮 被覆于全身皮膚、口腔、喉部、鼻咽的被覆于全身皮膚、口腔、喉部、鼻咽的一部分，食管、陰道的全部以及子宮一部分，食管、陰道的全部以及子宮頸頸 基底層基底層 (Basal Cells, Parabasal Cells) 中層中層 (Intermediat

4、e Cells) 表層表層 (Superficial Cells)鱗狀上皮細(xì)胞鱗狀上皮細(xì)胞Squamous epithelium cells第一節(jié)第一節(jié) 正常脫落細(xì)胞形態(tài)正常脫落細(xì)胞形態(tài) 二、柱狀上皮柱狀上皮 被覆于鼻腔、鼻咽、支氣管、子宮頸管、被覆于鼻腔、鼻咽、支氣管、子宮頸管、子宮內(nèi)膜等子宮內(nèi)膜等 分成纖毛柱狀上皮和黏液柱狀上皮分成纖毛柱狀上皮和黏液柱狀上皮纖毛柱狀上皮細(xì)胞纖毛柱狀上皮細(xì)胞Ciliated columnar epithelium cell纖毛柱狀上皮細(xì)胞纖毛柱狀上皮細(xì)胞Ciliated columnar epithelium cell Ciliated columnar e

5、pithelium cell with terminal bars and cilia. 粘液柱狀上皮細(xì)胞粘液柱狀上皮細(xì)胞Mucus columnar epithelium cell Mucus columnar epithelium cell Note that the nuclei are uniform, basal, and do not stratify第一節(jié)第一節(jié) 正常脫落細(xì)胞形態(tài)正常脫落細(xì)胞形態(tài) 三、脫落上皮細(xì)胞的退化變性脫落上皮細(xì)胞的退化變性腫脹性退變腫脹性退變固縮性退變固縮性退變第一節(jié)第一節(jié) 正常脫落細(xì)胞形態(tài)正常脫落細(xì)胞形態(tài) 四、正常脫落的非上皮細(xì)胞四、正常脫落的非上皮細(xì)胞

6、包括紅細(xì)胞、中性粒細(xì)胞、嗜酸中性粒包括紅細(xì)胞、中性粒細(xì)胞、嗜酸中性粒細(xì)胞、淋巴細(xì)胞、組織細(xì)胞、多核巨細(xì)細(xì)胞、淋巴細(xì)胞、組織細(xì)胞、多核巨細(xì)胞等胞等 壞死物、黏液及異物壞死物、黏液及異物第二節(jié) 核異質(zhì)和角化不良細(xì)胞形態(tài)核異質(zhì)核異質(zhì)(dyskaryosis) :是指細(xì)胞核的異常，表是指細(xì)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，現(xiàn)為核形態(tài)、大小及染色質(zhì)分布異常，核邊增厚，核邊界不整齊等，胞質(zhì)的質(zhì)和量的分化正常。核異核邊界不整齊等，胞質(zhì)的質(zhì)和量的分化正常。核異質(zhì)細(xì)胞介于良性和惡性細(xì)胞之間，又稱為不典型細(xì)質(zhì)細(xì)胞介于良性和惡性細(xì)胞之間，又稱為不典型細(xì)胞或增生不良細(xì)胞。胞或增生不良細(xì)胞。角化

7、不良角化不良：又稱異常角化、不成熟角化，是又稱異常角化、不成熟角化，是指鱗狀上皮非角化層細(xì)胞出現(xiàn)個(gè)別散在的胞漿內(nèi)角指鱗狀上皮非角化層細(xì)胞出現(xiàn)個(gè)別散在的胞漿內(nèi)角化。化。鱗狀上皮細(xì)胞鱗狀上皮細(xì)胞第三節(jié) 惡性腫瘤細(xì)胞形態(tài)惡性腫瘤細(xì)胞一般形態(tài)特征惡性腫瘤細(xì)胞一般形態(tài)特征1.細(xì)胞核的異型性：核增大，核大小不一，核細(xì)胞核的異型性：核增大，核大小不一，核染色質(zhì)深染，粗糙，核畸形，核漿比失常，染色質(zhì)深染，粗糙，核畸形，核漿比失常，核仁增大，增多，核分裂相增多，出現(xiàn)瘤巨核仁增大，增多，核分裂相增多，出現(xiàn)瘤巨細(xì)胞，裸核；細(xì)胞，裸核；2.細(xì)胞質(zhì)的異型性：高分化惡性腫瘤細(xì)胞胞質(zhì)細(xì)胞質(zhì)的異型性：高分化惡性腫瘤細(xì)胞胞質(zhì)豐

8、富；低分化則胞質(zhì)少；豐富；低分化則胞質(zhì)少；3.細(xì)胞的分布：失去極性，排列混亂。細(xì)胞的分布：失去極性，排列混亂。鱗狀細(xì)胞癌鱗狀細(xì)胞癌Squamous cell carcinoma 癌細(xì)胞單個(gè)散在，癌細(xì)胞體積大，多形癌細(xì)胞單個(gè)散在，癌細(xì)胞體積大，多形性明顯，可以呈圓形、蝌蚪形、梭形及性明顯，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(tuán)塊狀。核仁常不明深染，粗顆粒狀或團(tuán)塊狀。核仁常不明顯。胞漿豐富紅染，有角化傾向。顯。胞漿豐富紅染，有角化傾向。鱗狀細(xì)胞癌鱗狀細(xì)胞癌Squamous cell carcinoma腺癌腺癌 Adenoca

9、rcinoma 常見成團(tuán)脫落常見成團(tuán)脫落, 呈腺腔樣、乳頭狀，管狀呈腺腔樣、乳頭狀，管狀等等。成團(tuán)癌細(xì)胞排列極性混亂等等。成團(tuán)癌細(xì)胞排列極性混亂; 細(xì)胞核細(xì)胞核大小不一大小不一, 多為圓形、卵圓形，胞漿豐富，多為圓形、卵圓形，胞漿豐富，常見粘液空泡常見粘液空泡, 染色質(zhì)豐富深染，呈粗顆染色質(zhì)豐富深染，呈粗顆粒狀，可見明顯核仁。粒狀，可見明顯核仁。腺癌腺癌 Adenocarcinoma未分化癌未分化癌 Undifferentiated Carcinoma 未分化癌是各種上皮組織發(fā)生的分化極差的未分化癌是各種上皮組織發(fā)生的分化極差的的癌的癌, ,在形態(tài)上很難確定其組織來源。在形態(tài)上很難確定其組織來

10、源。 癌細(xì)胞可單個(gè)散在癌細(xì)胞可單個(gè)散在, 常成團(tuán)脫落，常成團(tuán)脫落，細(xì)胞核相細(xì)胞核相互擠壓呈鑲嵌狀結(jié)構(gòu)。細(xì)胞胞體小，比淋巴互擠壓呈鑲嵌狀結(jié)構(gòu)。細(xì)胞胞體小，比淋巴細(xì)胞稍大，常為不規(guī)則的圓形或卵圓形，胞細(xì)胞稍大，常為不規(guī)則的圓形或卵圓形，胞漿少，呈裸核樣漿少，呈裸核樣. .未分化小細(xì)胞癌未分化小細(xì)胞癌 Small cell carcinoma陰道脫落細(xì)胞學(xué)檢查陰道脫落細(xì)胞學(xué)檢查Gynecologic Cytology 陰道細(xì)胞學(xué)檢查應(yīng)用于宮頸癌的防癌陰道細(xì)胞學(xué)檢查應(yīng)用于宮頸癌的防癌普查，是早期診斷宮頸癌的重要手段。普查，是早期診斷宮頸癌的重要手段。陰道脫落細(xì)胞學(xué)檢查陰道脫落細(xì)胞學(xué)檢查 (Gyneco

11、logy Cytology) （一）鱗狀上皮細(xì)胞（一）鱗狀上皮細(xì)胞 底層細(xì)胞底層細(xì)胞 中層細(xì)胞中層細(xì)胞 表層細(xì)胞：角化前和角化細(xì)胞表層細(xì)胞：角化前和角化細(xì)胞 （二）柱狀上皮細(xì)胞（二）柱狀上皮細(xì)胞 子宮頸內(nèi)膜細(xì)胞子宮頸內(nèi)膜細(xì)胞 分泌型柱狀上皮細(xì)胞分泌型柱狀上皮細(xì)胞 纖毛柱狀上皮細(xì)胞纖毛柱狀上皮細(xì)胞 子宮內(nèi)膜細(xì)胞子宮內(nèi)膜細(xì)胞第一節(jié)第一節(jié) 正常脫落細(xì)胞形態(tài)正常脫落細(xì)胞形態(tài) 一、復(fù)層鱗狀上皮復(fù)層鱗狀上皮 被覆于全身皮膚、口腔、喉部、鼻咽的被覆于全身皮膚、口腔、喉部、鼻咽的一部分，食管、陰道的全部以及子宮一部分，食管、陰道的全部以及子宮頸頸 基底層基底層 (Basal Cells, Parabasal

12、Cells) 中層中層 (Intermediate Cells) 表層表層 (Superficial Cells)陰道脫落細(xì)胞陰道脫落細(xì)胞-鱗狀上皮細(xì)胞鱗狀上皮細(xì)胞陰道脫落細(xì)胞陰道脫落細(xì)胞-鱗狀上皮細(xì)胞鱗狀上皮細(xì)胞陰道脫落細(xì)胞陰道脫落細(xì)胞-鱗狀上皮細(xì)胞鱗狀上皮細(xì)胞陰道脫落細(xì)胞學(xué)檢查陰道脫落細(xì)胞學(xué)檢查 (Gynecology Cytology) 柱狀上皮細(xì)胞柱狀上皮細(xì)胞: 被覆于子宮頸內(nèi)膜和子宮內(nèi)膜被覆于子宮頸內(nèi)膜和子宮內(nèi)膜子宮頸內(nèi)膜細(xì)胞子宮頸內(nèi)膜細(xì)胞 分泌型柱狀上皮細(xì)胞分泌型柱狀上皮細(xì)胞 纖毛柱狀上皮細(xì)胞纖毛柱狀上皮細(xì)胞子宮內(nèi)膜細(xì)胞子宮內(nèi)膜細(xì)胞子宮頸內(nèi)膜細(xì)胞 (Endocervical cel

13、ls) Endocervical 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 si

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

15、dometrial cells 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(xì)胞 (Endometrial cells) Classic double contour arrangement (stroma in center surrounded by epithelium) is associated with

16、exodus (days 6 to 10). 陰道正常脫落細(xì)胞陰道正常脫落細(xì)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(xì)胞陰道正常脫落細(xì)胞 The presence of endocervical cell

17、s is one measure of the adequacy of a Pap smear, indicating that the transformation zone has been sampled. 陰道炎癥脫落細(xì)胞陰道炎癥脫落細(xì)胞 滴蟲性陰道炎滴蟲性陰道炎 淋球菌感染淋球菌感染陰道炎陰道炎 萎縮性陰道炎萎縮性陰道炎 病毒病毒感染感染有關(guān)的細(xì)胞學(xué)改變有關(guān)的細(xì)胞學(xué)改變 ( (單純皰單純皰疹疹病毒病毒，人乳頭狀瘤病毒）人乳頭狀瘤病毒）滴蟲性陰道炎滴蟲性陰道炎Trichomonas vaginalis 萎縮性陰道炎萎縮性陰道炎Atrophic Vaginitis 單純皰疹病毒單純皰疹病

18、毒相相關(guān)的細(xì)胞學(xué)改變關(guān)的細(xì)胞學(xué)改變 Cellular changes associated with Herpes Simplex Virus 人乳頭狀瘤病毒相人乳頭狀瘤病毒相關(guān)的細(xì)胞學(xué)改變關(guān)的細(xì)胞學(xué)改變 Cellular changes associated with Human Papiloma Virus HPV infection (tissue) Note well-defined cytoplasmic vacuoles and nuclear atypia of the koilocytes. 人乳頭狀瘤病毒相人乳頭狀瘤病毒相關(guān)的細(xì)胞學(xué)改變關(guān)的細(xì)胞學(xué)改變 Cellular cha

19、nges associated with Human Papiloma Virus人乳頭狀瘤病毒相人乳頭狀瘤病毒相關(guān)的細(xì)胞學(xué)改變關(guān)的細(xì)胞學(xué)改變 Cellular changes associated with Human Papiloma Virus Koilocytes: HPV infection, low-grade squamous intraepithelial lesion. To be a diagnostic koilocyte, the cytoplasmic vacuole must be clear and extremely well defined, with con

20、densation of the peripheral cytoplasm. In addition, the nucleus must appear abnormal Binucleation is common.低度鱗狀上皮內(nèi)病變低度鱗狀上皮內(nèi)病變 (LSIL)(LSIL) Low-grade Squamous Intraepithelial Lesion (LSIL) Note resemblance to normal intermediate cells, although the cytoplasm is slightly thick and dense. The nuclei a

21、re big and dark .高度鱗狀上皮內(nèi)病變高度鱗狀上皮內(nèi)病變 (HSIL)(HSIL) High-grade Squamous Intraepithelial Lesion (HSIL) This is represented by small cells with high nuclear/cytoplasmic ratios and irregular nuclei. Note thin rim of dense cytoplasm 陰道脫落細(xì)胞學(xué)檢查陰道脫落細(xì)胞學(xué)檢查 (Gynecology Cytology) 女性生殖系統(tǒng)的惡性腫瘤以宮頸癌為女性生殖系統(tǒng)的惡性腫瘤以宮頸癌為最

22、多見，宮頸癌中以鱗狀細(xì)胞癌為多最多見，宮頸癌中以鱗狀細(xì)胞癌為多見（）；其次腺癌；未分化癌見（）；其次腺癌；未分化癌極少見。極少見。宮頸鱗狀細(xì)胞癌宮頸鱗狀細(xì)胞癌Squamous cell carcinoma 癌細(xì)胞單個(gè)散在，癌細(xì)胞體積大，多形癌細(xì)胞單個(gè)散在，癌細(xì)胞體積大，多形性明顯，可以呈圓形、蝌蚪形、梭形及性明顯，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(tuán)塊狀。核仁常不明深染，粗顆粒狀或團(tuán)塊狀。核仁常不明顯。胞漿豐富紅染，有角化傾向。顯。胞漿豐富紅染，有角化傾向。宮頸鱗狀細(xì)胞癌宮頸鱗狀細(xì)胞癌Squamous cell car

23、cinoma Keratinizing squamous cell carcinoma Markedly pleomorphic or bizarre shaped, heavily keratinized tumor cells, and marked hyperchromasia are characteristic. Cells tend to occur singly. 宮頸鱗狀細(xì)胞癌宮頸鱗狀細(xì)胞癌Squamous cell carcinoma宮頸鱗狀細(xì)胞癌宮頸鱗狀細(xì)胞癌Squamous cell carcinoma Keratinizing squamous cell carcino

24、ma (tissue). Note squamous pearl (aka squamous eddy): pearls are pathognomonic of keratinization. 宮頸鱗狀細(xì)胞癌宮頸鱗狀細(xì)胞癌Squamous cell carcinoma Nonkeratinized squamous cell carcinoma. Compared with keratinizing SCC, the cells of nonkeratinizing SCC are more uniform and more often occur in aggregates. Nuclea

25、r abnormalities are usually easier to appreciate in nonkeratinizing SCC. 陰道脫落細(xì)胞學(xué)檢查陰道脫落細(xì)胞學(xué)檢查 Gynecology Cytology 宮頸腺癌：宮頸腺癌：僅占陽性涂片總數(shù)左右，可僅占陽性涂片總數(shù)左右，可能來源于子宮頸、子宮內(nèi)膜或輸卵管。腺癌細(xì)胞能來源于子宮頸、子宮內(nèi)膜或輸卵管。腺癌細(xì)胞中等大小，多為圓形、卵圓形，胞漿豐富，染色中等大小，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(xì)質(zhì)豐富深染，呈粗顆粒狀，常見巨大核仁。癌細(xì)胞可散在，也可成團(tuán)，呈腺腔樣、乳頭狀，管狀胞可散在，也可

26、成團(tuán)，呈腺腔樣、乳頭狀，管狀等等。成團(tuán)癌細(xì)胞極性混亂，核大小不一，畸形等等。成團(tuán)癌細(xì)胞極性混亂，核大小不一，畸形明顯。明顯。宮頸腺癌宮頸腺癌 (Endocervical Adenocarcinoma) Endocervical adenocarcinoma is represented by a rosette-like arrangement of malignant endocervical cells. Note prominent nucleoli. 宮頸腺癌宮頸腺癌 (Endocervical Adenocarcinoma) Endocervical adenocarcinoma i

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

28、樣。呈裸核樣。宮頸小細(xì)胞未分化癌宮頸小細(xì)胞未分化癌 (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 n

29、ucleoli. There is an attempt at rosette formation by the cells in this field. 其他惡性腫瘤其他惡性腫瘤 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 different

30、iated. 陰道脫落細(xì)胞學(xué)檢查陰道脫落細(xì)胞學(xué)檢查 Gynecology Cytology 巴氏五級分類法：巴氏五級分類法： I 級級 未見異常細(xì)胞未見異常細(xì)胞-基本正常基本正常; 級級 見有異常細(xì)胞，但均為良性見有異常細(xì)胞，但均為良性; 級級 見可疑惡性細(xì)胞見可疑惡性細(xì)胞; 級級 有高度可疑的惡性細(xì)胞，細(xì)胞有惡性特征，有高度可疑的惡性細(xì)胞，細(xì)胞有惡性特征，但不夠典型或數(shù)目少，需要核實(shí)但不夠典型或數(shù)目少，需要核實(shí); 級級 有癌細(xì)胞，細(xì)胞明顯惡性特征有癌細(xì)胞，細(xì)胞明顯惡性特征.陰道脫落細(xì)胞學(xué)檢查陰道脫落細(xì)胞學(xué)檢查 Gynecology Cytology TBSTBS診斷方式：近年來，世界衛(wèi)生組織和診斷方式：近年來，世界衛(wèi)生組織和美國細(xì)胞病理學(xué)家倡導(dǎo)美國細(xì)胞病理學(xué)家倡導(dǎo)TBSTBS描述性診斷方描述性診斷方式。它