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1、ChapterVITumor(Neoplasm) Tumor(neoplasm)isacommondisease,amongstthemostharmfulofitbeingmalignanttumor恶性肿瘤恶性肿瘤.CanceristhesecondleadingcauseofdeathfromvariousdiseaseintheEuropeanandUnitedStates.But,itisthefirstleadingcauseinourcountry.Inourcountry,themortalityrate死亡率死亡率are139.28/10million.(males:166.
2、92/10million,females:109.99/10million) Tumorincidenceishighindevelopedcountries.Sotospeak,tumorisakindofenvironmentaldisease.Tenhighestrankingtumorsarelistedinorderofincidenceormortalityinourcountry:LungStomachLiverEsophagusLargeintestineCervixBreastNasopharynxLeukemiaLymphoma Aboutone-thirdofcancer
3、smaybecured,andaboutone-thirdofcancersmaybeprotected.Thereare3defensivelinesofcancer:First:Prevention预防预防Second:Diagnoseandtreatmentintheearlystage早期诊断、早期治疗早期诊断、早期治疗Third:Activesyntheticaltherapy积极综合治疗积极综合治疗SectionI.TheConceptionandGeneralMorphologicalCharacteristicsofTumor I.TheConceptionofTumorTum
4、orisaneoplasmformedbyabnormalhyperplasiaofcellsresultfromgeneticalterations.致瘤因素致瘤因素基因水平基因水平异常增生异常增生新生物新生物 内外因素癌基因质的改变局部肿块内外因素癌基因质的改变局部肿块 抑癌基因无限制抑癌基因无限制 肿瘤肿瘤 （Tumor，Neoplasm）Thisabnormalhyperplasiaofcellsareinclude2aspect:i.alterationofquality分化异常分化异常:(includesthechangesinstructure,function,metaboli
5、sm,growingcapability,behavior,etc.)ii.autonomy自律性、无限制自律性、无限制:Losttheresponsetonormalgrowthcontrols. Cancer癌症癌症isawordusedmoreinthepublicarenathaninmedicine;ithasemotiveconnotationsandgenerallyreferstoamalignanttumororneoplasm. 泛指恶性肿瘤泛指恶性肿瘤II.NeoplasiaComparingwithResponsiveHyperplasia:Responsivehype
6、rplasia反应性增生反应性增生:i.Responsetoorganism(coordination)ii.Polyclonalproliferationiii.Containtheirnormalstructure,function,andmetabolism,etc. iv.Containtheirnormalgrowthcontrols Neoplasia肿瘤性增生肿瘤性增生:i.Notresponsetoorganism(un-coordination)ii.Monoclonalproliferationiii.Losedifferentiativeabilityandchanges
7、intheirstructure,function,andmetabolism,etc.iv.autonomyIII.TheMorphologyandStructureofTumors (I).TheGrossofTumor1.Thenumberandsizeoftumor(1).Number:Singleinmosttumorsmonoclonalorigin(arisefromasinglecell) Multipletumors多发性肿瘤多发性肿瘤(sometimeitisambiguous)Thereare2implicationsofit:i.Therearemorethenonet
8、umororiginatedfromdifferenttissuesimultaneously.ii.Therearemanytumorwithsamecharacteristicandinsametissue,simultaneouslyornot.e.g.multipleneurofibroma多发性神经纤维瘤病多发性神经纤维瘤病 (2).Size:Itisrelatedtothenature(benignancyormalignancy),duration,siteoftumorandthereeffectsonhost.Small:e.g.occultcarcinomaofthyroi
9、d,隐匿性甲状腺癌隐匿性甲状腺癌carcinomainsitu原位癌原位癌,“carcinomaatpoint一点癌一点癌”Large:e.g.ovarianserouscystadenoma卵巢浆液性囊腺瘤卵巢浆液性囊腺瘤Benigntumors:Maybebigger. 2.TheshapeoftumorsTheshapeoftumorsdependonthesite,histogenesis,modeofgrowth,andnature(benignancyormalignancy)i.exophyticgrowth外生性生长外生性生长:papillary,cauliflower,vil
10、liform,fungation,polypusii.expansivegrowth膨胀性生长膨胀性生长:nodular,lobulated,cysticiii.infiltratinggrowth浸润性生长浸润性生长:infiltratingmass,(rootsorcrablikeoncutsurface),diffusethickening,ulcerated epidermis-papillarymucosa-polypous,villiform,cauliflower,Benignandfungatingtumorhypodermaorsolidorgan-nodular,lobul
11、ated ovary,thyroid-cystic theappearancedescribedaboveMalignanttumorinfiltratingmass,(rootsorcrablikeon cutsurface),diffusethickening,ulcerated3.Thecolorandconsistencyoftumor(1).Color:General:Gray-white,gray-red(richwithblood)Especial:Redordarkred:-angioma血管瘤血管瘤Yellow:-lipoma脂肪瘤脂肪瘤Black:-melanoma黑色素瘤
12、黑色素瘤Green:-chloroma绿色瘤绿色瘤(2).Consistency:Carcinoma-dryandsolidoncutsurfaceSarcoma-fishfleshlikeoncutsurface 4.ThehardnessoftumorRelationtoosteoma-hardkindoftissuelipoma-softmoreparenchymaandRelationtolessmesenchyma-softmesenchymae.g.medullarycarcinoma髓样癌髓样癌moremesenchymaandlessparenchyma-harde.g.sci
13、rrhouscarcinoma硬癌硬癌Relationtocalcification-hard secondarychangenecrosis-soft 5.TheenvelopeoftumorIngeneral,thebenigntumorspossesstheenvelope.Themalignanttumordontpossesstheenvelopeandadhesiontoaroundtissue. Sometime,ithasapseudoenvelope. (II).ThestructureoftumorunderLM1.parenchymaoftumor肿瘤实质肿瘤实质:Mai
14、npartoftumor,determiningthespecialproperty,showingtheoriginoftissue.Theparenchymacellsinthetumorarecalledtumorcells.2.mesenchymaoftumor肿瘤间质肿瘤间质: Consistofconnectivetissueandvessels. Thesupportingstroma间质间质,providingbloodandnutrition,relatingtothequalityoftumors(scirrhouscarcinoma硬癌硬癌ormedullarycarci
15、noma髓样癌髓样癌)Thestromaoftencontainsalymphocyticinfiltrationofvariabledensity;thismayreflectahostimmunereactiontothetumor(denselyinfiltratedbylymphocytestendtohaveabetterprognosis(预后预后). Stromalmyofibroblasts肌成纤维细胞肌成纤维细胞areoftenabundant,particularlyincarcinomasofthebreast. Section II. The Atypia of Tum
16、or Atypia异型性异型性Alterationincellularshapeandtissularstructureofsameoriginalnormaltissues.Theatypiaoftumorsmayreflectdifferentiation分化分化oftumor.Mildatypia-highdifferentiationSevereatypia-poordifferentiationItismajorsignofdiagnosisofbenigntumorandmalignanttumor.诊断良恶性肿瘤的组织学依据诊断良恶性肿瘤的组织学依据 Anaplasia间变间变D
17、edifferentiationorlossofstructuralandfunctionaldifferentiationofnormalcells.Generalspeak,anaplasiacellsmayshowsignsofatypia. I. The Atypia of Structure of Tumor Tissue 极性消失极性消失 Disorder of arrange 排列紊乱 Benigntumorcellsarenotsodifferentfromnormalcellsofcounterpart;butitsstructuremayshowatypiaoftumort
18、issue. 良性肿瘤在细胞层面无异型性，而在良性肿瘤在细胞层面无异型性，而在组织结构层面有轻度异型性组织结构层面有轻度异型性II.TheAtypiaofTumorCells (I).ThepleomorphismoftumorcellBiggerinsize,markedpleomorphism(markedvariationinsizeandshape) Bizarretumorgiantcell瘤巨细胞瘤巨细胞Somekindofpoorerdifferentiativetumor,itscellsaresmallerinsize(e.g.smallcellcarcinomaoflung
19、)肺小细胞癌肺小细胞癌 (II).Thepleomorphismofnucleii.Thesizeofnuclei:Extremelylarge,Nuclei-cytoplasmratiomayapproach1:1(normalis1:4-6)ii.Theshapeofnuclei:multiple,irregularbizarre,iii.Thechromatinofnuclei:CoarseandclumpedappearanceofhyperchromatinConcentrationofchromatininclumpsalongnuclearmembraneiv.Mastnucle
20、oli:distinctandnumerous(3-5). v.Pathologicalmitoticfigures病理性核分裂相病理性核分裂相:numerousandatypical.Itisaimportantsignofdiagnosisofmalignanttumor.vi.Karyotypic倍体类型倍体类型changes:Fromnormaldiploidtomultiploidandaneuploid v. Pathological mitotic figures: numerous and atypical. (III).ThechangeofcytoplasmBasophil
21、iaincytoplasm(increaseofribosome)(IV).ThechangeofultrastructureoftumorcellNospecialqualitativechangeofultrastructure Varywithinthenumber(increaseofendoplasm,mitochondriaandribosomeetc.) EMishelpfultoestablishthediagnosisoftheundifferentiatedtumor未分化肿瘤未分化肿瘤.Forexample:Epithelialorigin-desmosome桥粒桥粒,t
22、onofilament张力细丝张力细丝Hepaticcellorigin-bilecanaliculi毛细胆管毛细胆管Myocyteormyoepitheliumorigin-myofibril肌丝肌丝Smoothmuscleorigin-myofilament平滑肌肌丝平滑肌肌丝,densebodies致密体致密体 Neuroendocrineorigin-neuroendocrinegranules神经内分泌颗粒神经内分泌颗粒SectionIII.TheGrowthandSpreadofTumor I.BiologyofTumorGrowthGrowthfractionTumor生长分数生
23、长分数Survivalandperishgrowthand生成和丢失生成和丢失TumorangiogenesisprogressionHost演进演进Immuneresponse (I).DynamicsoftumorsgrowthGeneralspeaking,thematureandwelldifferentiatedbenigntumorsgrowslowly.Sudden increase in growth of benigntumorsuggestsmalignantchange.Thespeedoftumorsgrowthisrelationto3aspectsby:1.Doub
24、lingtime2.Growthfraction:3.Tumorcellssurviveandperish1.Doublingtime:2.Growthfraction:Sphase+G2phaseaGF=Totaltumorcellsa+b+cTheGFisonlyabout20%eventhetumorgrowingfast. 3.TumorcellssurviveandperishSurvivalLoseTumorgrowingThe speed of tumor growth is according togrowthfraction,survivalandloseoftumorcel
25、ls,nodoublingtime.Theconceptionofdynamicsoftumorgrowthhaveimportantsignificanceonchemicaltreatment化疗化疗oftumor. 4.Tumorstemcell(tumorinitiatingcells) (II).TumorangiogenesistumorcellsangiogenesisvascularendothelialGFmacrophagefactorsbasicfibroblasticGF (III).TheProgressionandHeterogeneityofTumorProgre
26、ssion演进演进Themailgnanttumorschangetheirinvensionabilitymoreandmoreinthegrowthprogress.Heterogeneity异质性异质性Amonocloneorigintumorcelloccursdifferentsubclone亚克隆亚克隆cell(onaspectsofinvasionability,speedofgrowth,responsetohormoneandsensibilityofanti-tumordrug)inthegrowthprogress.(Attachgenemutation附加突变附加突变)
27、II.TheGrowthPatternandSpreadofTumors (I).TheGrowthPatternofTumors1.Expansivegrowth膨胀性生长膨胀性生长Itsagrowthpatternofalargenumbersofbenigntumors.Compressingsurroundingtissue,demarcatedandencapsulated,freelymobilewhensuperficiallylocated. 2.Exophyticgrowth外生性生长外生性生长Thetumorssiteofepidermis,surfaceofcavitya
28、ndmucosapossessthisgrowthpatterncommonlyandformingpapillary,polypous,villiform,fungation,cauliflower,etc.Thisgrowthpatterntakesonnotonlybenigntumorsbutalsomalignanttumors. 3.Infiltratinggrowth浸润性生长浸润性生长Alargenumbersofmalignanttumorsaremainlyinfiltrativegrowthpattern,immobilewhensuperficiallylocated.
29、Completeremovalofthetumorshouldincludecertainsurroundingtissue. (II).TheSpreadofTumorsInfiltrationandmetastasis,especiallymetastasisarethespecialeventsofmalignanttumors.Directspread直接播散直接播散Metastasis转移转移1.DirectspreadFollowingtumorgrow,tumorcellsinvasiveanddestroytheadjacentorgansortissuesalongtheti
30、ssuespaces,lymphatic,bloodvesselsandotherchannelscontinuously连续连续不断不断andgoingongrowth. 2.Metastasis:Tumormetastasismeanstheprocessthatthetumorcellsdetachfromtheprimarysite,passthroughthechannels(lymphatic,bloodvessels)andnaturalcavitiesandenterindiscontinuousparts带到他处带到他处toproliferatecontinuouslyand
31、formsecondarytumors继发瘤与原发瘤一致继发瘤与原发瘤一致. Metastesisinclued3pattern(1).LymphaticmetastasisItismorecommoninvariouscarcinomas.Theinvolvedregionallymphnodesareenlargedfromwhichthetumorwillspreadmorewidely.切面呈瓷白色切面呈瓷白色skipmetastasis跳跃式转移跳跃式转移(e.g.Virchowslymphnodes)Theknowledgeoflymphaticmetastasiswillbehe
32、lpfultodisplaytheprimarycarcinomaandtodetermindthedeviceoftreatment(radicalsurgery外科根治手术外科根治手术). (2).HematogeneousmstastasisItismorecommoninsarcoma肉瘤肉瘤aswellasinundifferentiatedcarcinomas未分化癌未分化癌.Majorofthewaysareinvasionofvein.Venoussystemrightheartlung(e.g.osteosarcomalung)PortalsystemLiver(e.g.ga
33、striccarcinomaliver)Lungandliverarecommoninvolved. Secondarytumorsinlungpulmonaryveinsleftheartarterialsystembrain,bone,kidney,andadrenalglandetc.（由肺再转移到全身（由肺再转移到全身） Thecharacteristicsofsecondarytumorsinliverorlungi.Multipleii.Globaldemarcated nave-likeofcarcinoma(癌脐癌脐) A、肝转移性胃癌、肝转移性胃癌B、胃转移性肝癌、胃转移性肝
34、癌 (3).Transcoelomicmetastasis(Seedingmetastasis)Seedinginbodycavityandsurface.It is caused by detached tumor cellsenteringinorinvadingthenaturalcavities(pleural,peritoneal).Krukenbergstumor克鲁根勃氏瘤克鲁根勃氏瘤:Mucoidcarcinoma粘液癌粘液癌ofgastrointestinemetastasizetoovary.(III).Themechanismofinfiltrationandmetast
35、asisofmalignanttumors1.Localinfiltrationi.firststep:Thedetachmentoftumorcells(bycelladhesionmolecules,CAMs)arediminished.ii.secondstep:Attachmentoftumorcellsandbasilarmembrane.integrin整合素整合素thereceptorofcelladhesionmolecules iii.thirdstep:Degradationofextracellularmatrix(ECM)TypeVIcollagenase胶原酶胶原酶C
36、athepsinD组织酶组织酶D（基质金属酶）（基质金属酶）iv.fourthstep:MigrationoftumorcellsTumorcellspenetratedeficientmembranebyamoebiodmotion.autocrinemotilityfactor自分泌移动因子自分泌移动因子2.HematogeneousspreadSingletumorcelliskilledbyNKcellseasily.Tumorcellsbeaggregatebyplateletformingtumorembolus和血小板形成肿瘤栓子和血小板形成肿瘤栓子arenoteasybekil
37、led.Thetumorcellsoftumorembolusadheartoendothelial与血管内皮粘附与血管内皮粘附. CD44isakindofcelladhesionmoleculesandmayrelationtohematogenousspread(mutationofCD44ofcoloncarcinoma).Somekindsoftumormetastasispossessofespecialhisto-affinity亲组织性亲组织性.Forexample:CarcinomaoflungAdrenalgland,Brain,Thyroidcarcinoma,renal
38、carcinoma,andcarcinomaoftheprostateBoneCarcinomaofthebreastLung,Liver,Bone,Ovary, AndAdrenalglandGastricmucoidcarcinomaOvary Itmayisinfluencedbysuchfactors:i.especialcombinationofcellsadhesionmolecules细胞粘附因子细胞粘附因子ii.chemotacticmaterial(e.g.insulinoidGFI,II胰岛素样生长因子胰岛素样生长因子)iii.localgrowthenvironmente
39、.g.splen(immuneorgan),skeletalmuscle(motion) 3.Themoleculargeneticsoftumormetastasistumorsuppressorgene肿瘤抑癌基因肿瘤抑癌基因nm23(non-metastasis)4.StromalmicroenviromentandcarcinogenesisIII.TheGradinandStagingofTumor 1.Gradin:Itisbasedondifferentiationoftumorcellsandnumberofmitoticfigureswithinthetumor.Broder
40、sclassification:Poorlydifferentiatedcells75%IVgrade Threegradesclassification:Igrade:well-differentiationIIgrade:middle-differentiationIIIgrade:poorlydifferentiatedandundifferentiation 2.Staging:Itisbasedonthesizeofprimarytumoranditsspread(metastasis).IUAC(InternationalUnionAgainstCancer)TNMsystem:T
41、:PrimarytumorT1-T4N:LymphaticmetastasisN0,N1N3M:HematogenousmetastasisM0,M1orM2 AJCS(AmericanJointCommitteeonCancerStaging)O:-insiteI:-inorganII:-outoforganIII:-invadetoadjacentorgansIV:-distantspread(metastasis)The gradin and staging of tumorrelatetotreatmentandprognosis.SectionIVTheEffectsofTumoro
42、nHost I.BenignTumors:Thebenigntumorsmayhaveamildinfluenceonhost.Majorofappearancesarecompression,obstruction压迫和阻塞压迫和阻塞.Othereffectsofhormones激素激素whensecretedonhost.Forexample:Gigantism巨人症巨人症andacromegaly肢端肢端肥大症肥大症duetoacidophilicadenoma（脑垂体（脑垂体前叶的）嗜酸性细胞腺瘤前叶的）嗜酸性细胞腺瘤I.MalignantTumors:Severeeffectsonh
43、ostbecauseofhighspeedofgrowth,wideinfiltrationandmetastasis. Besidesthecomplicationsmentionedinbenigntumors,therearehemorrhage,infection,pain,fever,anemia,weightloss,cachexia,etc. constitutionalsymptoms体质性症状体质性症状includefever,weightloss,andnightsweat. cachexia恶病质恶病质Aprofoundandmarkedstateofconstituti
44、onaldisorderreferstoprogressiveweakness,weightloss,anemiawasting,usuallyoccurredinthepatientsatlatestageofneoplasiaorotherchronicdiseases.ectopicendocrinetumor异位内分泌肿瘤异位内分泌肿瘤ectopicendocrinesyndromee.g.parvicellularcarcinomaoflungACTHlikeCushingssyndromeThecomplexsymptomscausedbyectopichormonesynthes
45、isappearinginabout15%patientsofmalignanttumors.APUDomas(AminePrecursorUptakeandDecarboxylation胺前体摄取脱羧胺前体摄取脱羧)arethegroupoftumorsinwhichthetumorcellssynthesizeamine,polypeptide-secretoryproducts,orboth,andtakeupdecarboxylateandstorearomatic-amineprecursorsinducingmanysymptomsandsigns.e.g.Carcinoid类癌类
46、癌,Pheochromocytoma嗜铬细胞瘤嗜铬细胞瘤,etc.5-HTparaneoplasticsyndrome副肿瘤综合征副肿瘤综合征SectionVDifferenceBetweenBenignTumor andMalignantTumor I.Importancee.g.thecarcinomaofthebreast,rectalcancerII.TheRuleofDifferenceBetweenBenignTumorandMalignantTumorTable5-1DifferenceBetweenBenignTumorandMalignantTumor BenignTumor
47、s MalignantTumors Differentiation Well,Similartonormaltissue Poor,Anaplasia Mitoticfigures Less,NormaltypeMore,Abnormaltype Speedofgrowth Slowly Quickly Modeofgrowth ExpansilegrowthEncapsulated MainlyinfiltrationNocapsule Secondarychange RarenecrosisandhemorrhageWithnecrosisandhemorrhageMetastasis N
48、o YesRecurrence No MayoccurafterradicalsurgeryEffectsonhost LocalcompressionLeadingtoobstruction SeveresequelaCachexia,incurable III.TheRelativityofDifferenceBetweenBenignTumorandMalignantTumorThedifferencebetweenbenignandmalignanttumorsisnotabsolute.Forexample:Hemagioma:Nocapsule,undemarcated,recur
49、renceBenigntumorsincranialcavity:Leadtocompressionofbrainand/orobstructionofCSFpassageearly.Severesequelamayoccur. Basalcellcarcinomaofskin:Moremitoticfiguresandnecrosis,butgrowingslowlyandraremetastasis.Malignantchangeofbenigntumors:e.g.polyposisofcolonwillbechangedintocarcinoma.Borderlinetumors:Bi
50、ologicalcharacteristicsoftumorsareintermediarybetweenbenignandmalignanttumorse.g.Papillomasoriginatedfromepitheliaofbladder,colon,thyroidandbreasthavebenignappearanceinmorphologybutareinfiltratedwidelyandeasytorecur,eventometastasize.Malignanttumormaystopsgrowthandregressesinindividualpatient.(e.g.m
51、elanoma,neuroblastoma) SectionVIClassificationandNomenclatureofTumors I.Nomenclature:(I).GeneralnomenclatureBenigntumors:originaltissue+-omae.g.fibroma,adenoma,fibroadenomaSometime,nomenclaturecouplewithmorphologicalfeatures.Cyst-Papillarye.g.papillarycystadenoma 粘液性囊腺瘤粘液性囊腺瘤总菜单Malignanttumors:origi
52、naltissue+carcinoma癌癌or+sarcoma肉瘤肉瘤Carcinoma:malignanttumororiginatedfrom epithelialtissuee.g.squamouscellcarcinoma,adenocarcinomaSarcoma:malignanttumororiginatedfrommesenchymaltissuee.g.fibrosarcoma Carcinosarcoma癌肉瘤癌肉瘤:Containingbothelementsofcarcinomaandsarcoma.Cancer（癌症）癌症）:Itisgenerallyrefersto
53、amalignant(II).Specialnames:-blastoma:malignanttumorsoriginatedfromembryonictissuee.g.neuroblastoma,nephroblastoma,retinoblastoma,etc.Malignanttumors:Tumorswithuncertainorigine.g.malignantteratoma,malignantschwannomamalignantmeningioma,etc.(malignant)melanoma(malignant)lymphomaEponymouslynamed:e.g.E
54、wingssarcoma,HodgkinslymphomaMorphologyoftumorcells:e.g.clearcellsarcoma,oatcellcarcinomaTraditionalterms:e.g.leukomia,seminoma-omatosis(瘤病瘤病):multipliedbenigntumorse.g.neurofibromatosis,lipomatosisangiomatosis,etc.II.ClassificationoftumorsTumorsmaybeclassifiedasmaintypesbasisoftheirhistogenesis,fur
55、ther,itmaybedivideintotwogroups,benignandmalignant.P139Table6-21.Epithelium2.Mesenchymaltissue3.Lymphohematopoietictissue4.Nervoustissue5.Othertumors SectionVIIBriefIntroductionofCommonTumors I.Epithelialoriginaltumors(I).BenignepithelialtumorsCoverepitheliumpapillomaGlandularepitheliumadenoma 1.Pap
56、illoma:乳头状瘤乳头状瘤Growthpattern:exophyticgrowthMorphology:Histogenesis:Seuamousskin,oralcavity,eartractvocalcords,vulvaColumngastro-intestinaltractTransitionalepitheliarenalpelvis,bladderHighmalignancyofsiteoneartract,penisandbladder. 2.AdenomaUsuallyoccurinbreast,thyroid,ovary,salivarygland,andintesti
57、naltract,etc.Shapeandgrowthpattern:Mucosalglands-polyp（细蒂）（细蒂）,(exophyticgrowth)Glandualorgans-nodularwithenvelope(expansivegrowth) Adenomamaybeclassified4typesas:(1).Cystadenoma:Usuallyoccursinovary,andalsooccursinthyroidandpancreasrarely.e.g.cystadenomaofovarycanbedividedinto:serouspapillarycystad
58、enomamucouscystadenoma(2).Fibroadenoma:UsuallyasingletumoroccursinfemalebreastGlandularpolifillation+fibroustissueproliffilation(3).Pleomorphicadenoma多形性腺瘤多形性腺瘤:(mixedtumor混合瘤混合瘤) Containingelementsofglandular,mucoidandcartilagoidtissue.Usuallyoccursinsalivarygland,especiallyparotidgland.Histogenesi
59、s:myoepithelium,epithelium Slowgrowth,buthighrateofrecurrenceaftersurgery. (4).Polypousadenoma:Site:mucosa,usuallyoccursinrectumandcolonShape:polypusEasilymalignancyofpapillary,villiformappearanceofsurfaceMultipleadenomasofcolon,namedpolyosisofcolonisahereditarydiseaseandhasatendencyofmalignantchang
60、e.家族性多发性肠息肉病家族性多发性肠息肉病（黑斑综合征）（黑斑综合征）(II).MalignantepithelialtumorsCoverepitheliumGlandularepithelium TheyaregenerallyreferedtocarcinomaGeneralappearance:Gross:Gray-white,dryandsolidoncutsurfaceLM:Formtumornests癌巢癌巢(cleardemarcatetumorcellsandmesenchymalcells)Shapeandgrowthpattern:(nodular-fungating)
61、Skin,mucosa:polypus(largepedicel)Up-exophyticCauliflower,Down-infiltrationFungatingSurface:UlcertedInorgans:Infiltratingmass-infiltratiedgrowth(rootsorcrablike) Commontypesofcarcinoma:1.Squamouscellcarcinoma:Frequentlyseenincervix,nasopharynx,skin,esophagus,tongue,penis,vagina,aswellasinbronchus,gal
62、lbladder,renalpelvis. Therearedesmosome桥粒桥粒,Intercellularbridge细胞间桥细胞间桥,Tonofilaments张力细丝张力细丝andkeratin角蛋白角蛋白inwelldifferentiatedsquamouscellcarcinoma. 2.Basalcellcarcinoma:Usuallyoccursintheskinoffaceaccompaniedbyulcerationwithmanymitoticfiguresbutslowgrowth,raremetastasisandhighsensitivitytoradiat
63、ion. 3.Transitionalcellcarcinoma:Usuallyoccursinbladderorrenalpelvis.Gross and growthpattern:LM:(branchofpapillary,Arrangeoflayer)4.Adenocarcinoma:Columnarepithelium:-coverongastrointestinal,Site:respiratorytractmucosa,etc.Glandulousorgan:-liver,breast,pancreas,etc. Types:Itcanbedividedinto3typessuc
64、has:(1).Tubularadenocarcinoma:Usuallyoccursinthegastrointestinaltract,thyroid,gallbladder,etc.LM:FormadenoidstructurePapillaryadenocarcinomaCysticadenocarcinoma (2).Solidcarcinoma实体癌实体癌(orcarcinomasimplex单纯癌单纯癌)Itisbelongtopoordifferentiationaltumorswithhighmalignance.Usuallyoccursinbreast,andrarely
65、occursinstomachandthyroid.LM:tumornestsissolid(noadenoidstructure)scirrhouscarcinomamedullarycarcinoma(3).Mucoidcarcinoma(orcolloidcarcinoma胶样癌胶样癌)mucouscellularcarcinoma(signet-ringcell印戒细胞癌印戒细胞癌)mucoidadenocarcinoma(III).Precancerouscondition,Precancerouslesion,dyeplasia,andcarcinomainsitu1.Precan
66、cerouscondition(lesion):癌前癌前疾病（癌前状态）疾病（癌前状态）、癌前、癌前病变病变Thenon-cancerousconditiom(lesion)whichtendstobecomemalignanttumorisabasisofthegenesisofmalignanttumor.Itisimportantinknowledgeofcarcinogenesisaswellastumorprophylaxis.Itmaybeclaasifiled2typesasgeneticandacquired. Commonprecancerousconditionare:(1
67、).Leukoplakia:Itisduetoproliferationandkeratinizationoflocalepitheliaofmucosa.Usuallyoccursintheoralcavity,vulva,etc.Carcinomawilldevelopin30%casesofleukoplakiaoforalcavityand50%casesofvulva.(2).Chroniccervicitisandcervicalerosion:Theincidenceofchroniccervitisincarcinomaofcervixisabout7timeshigherof
68、normalseries. Itisrelationtoinfectionofhumanpapillomavirus,(HPV) (3).Proliferativefibrocysticchangeofthebreast:Usuallyoccursin30-40yearsoldfemalsduetothestimulationofestrogen.Proliferationofmammaryglandsandfibroustissues.(4).Polypusadenomaofrectumandcolon:MultiplepolyposisofcolonAheritarydisease.Ade
69、nocarcinomamaydevelopfrom50-60%ofsuchcases (5).Chronicatrophicgastritisandgastriculcer:PrecancerousconditionPrecanceriuslesion(gastricdysplasia)Lessthen1%casesofchronicatrophicgastritiswouldbechangedingastriccarcinoma.About1%casesofgastriculcerwouldbealsochangedingastriccarcinoma. (6).Chroniculcerat
70、ivecolitis:(7).Chronicskinulcer:(8).CirrhosisoftheliverMorethen7085%hepatocellularcarcinomaareaccompaniedbynodularcirrhosis,5-50%nodularcirrhosiswithhepatocellularcarcinoma. 2.Displasia,atypicalhyperplasiaAlterationinsize,shape,andorganizationofadultcellsMideIgradeMiddleIIgradeSevereIIIgrade3.Carcin
71、omainsitu;Aneoplasticentitywhereinthetumorcellsstillliewithintheoriginalepitheliumormucosawithoutpenetrationorinvasionofthebasementmembrane.Itisusuallyfoundincervix,skin,bronchus,andbreast,etc.Compairingtoinfiltrativecarcinoma,ithasgoodprognosis（预后）预后）aftersurgery. Intraepithelialneoplasia 上皮内瘤变上皮内瘤
72、变Displasia+CarcinomainsituII.MesenchymalOriginalTumors(I).MesenchymaloriginalbenigntumorsWelldifferentiated,expansivegrowthwithenvelope,slowgrowthCommontypessuchas:1.Fibroma纤维瘤纤维瘤Usually occurs in subcutaneoustissueoflimbsandtrunk.Composingoflargeamountofmaturefibrocytesandcollagenfibers. 2.Lipoma:脂
73、肪瘤脂肪瘤Verycommon,usuallysubcutaneouslocationMultiplelobularappearance 3.Vesseltumors脉管瘤脉管瘤:Hemangioma:capillaryTypes:cavernousmixedUsuallyoccursinskinofheadandneck,liverandspleen.Lymphangioma:Resultinginhydroma,hydrocyst.Usuallyoccursinneckofchildren. 4.Leiomyoma平滑肌瘤平滑肌瘤:Usuallyoccursinuterusandintes
74、tine5.Osteoma骨瘤骨瘤:Usuallyoccursinboneofhead 6.Chondroma软骨瘤软骨瘤:Chondromainshortbones(boneoffinger,toe)willbeofgoodprognosis.Chondromainlongorflatbonesareinfiltrativeandeasytorecuraftersurgery. (II).MesenchymaloriginalmalignanttumorsItiscalledassarcomagenerally.Gray-red (rich with blood), Fishfleshlik
75、eoncutsurfaceComparison of carcinoma andsarcomaisimportantTab5-3Thedifferencebetweencarcinomaandsarcoma Carcinoma Sarcoma OriginEpitheliumMesenchymaIncidenceCommonly, 9 times ofsarcomaNotcomonlyAge40yearsoldYoungerGrossfeaturesGray-white,solidanddryGray-red,softandwet,fishfleshlikeHistologicalfeatur
76、ei. Forming tumor nests,cleardemarcatetumorcellsandmesenchymal.ii. Prolifration of fibroustissuei.Diffusionoftumorcells,not-cleardemarcatetumorcellsandmesenchymal.ii. Rich with blood vessel ,rarewithfibroustissueReticularfiberBundlearoundthetumornestsAroundtumorcellsIm.His.Che.keratinDesmin,vimentin
77、etcmetastasisMainlylymphaticMainlyhematogenousCommontypesofsarcoma:1.Fibrosarcoma纤维肉瘤纤维肉瘤:Itsoriginisfibroustissue.Itoccursinsitesimilartofibroma.Highrateofrecurrenceaftersurgery. 2.Liposarcoma脂肪肉瘤脂肪肉瘤:ItisquitecommonofsaecomaUsuallyoccursinthigh,poplitealfossa,arm,andpost-peritoneumofmorethen40adul
78、twithapleomorphicpattern.Itisnotmalignantchangefromlipoma. 3.Rhabdomyosarcoma横纹肌肉瘤横纹肌肉瘤:Morecommonofmalignanttumorofchildren(10y).Highmalignancy,earlyhemogenousmetastasis.4.Leiomyosarcoma平滑肌肉瘤：平滑肌肉瘤：Usuallyoccursinuterus,gastri-intestineofoldman. 5.Hemangiosarcoma血管肉瘤血管肉瘤:Itsoriginatedfromangioendoe
79、pithelium.6.Kaposisarcoma:Itmaybeoriginatedfromangioendoepitheliumorgerminalmesenchymaltissue.ItisrelationtoHIVinfection(Acquiredimmunodeficiencysyndrome,AIDS).Usuallyoccursinskinoflowerlimbandfoot7.Osteosarcoma骨肉瘤骨肉瘤:Itismostcommonofmalignanttumorofbone.Usuallyoccursinlowerpartoffemur,upperpartsoft
80、ibiaandhumerusinadolescents.Gross:Siteonmetaphsisoflongbone“X”-ray:Codman-trigone Sunradiatio-likeshadowForming tumor bone is the most important evidence ofhistologicaldiagnosis.LargeamountofAKPintumorcells.Highmalignancy,earlyhematogenousmatastasis. III.Neuroectodermaloriginaltumor神经外胚源性肿瘤神经外胚源性肿瘤(
81、I).Retinoblastoma视网膜母细胞瘤视网膜母细胞瘤:Alargenumbersofitoccursinlessthen3yearsoldbaby.Itisakindofgeneticaldisease. (II).Pigmentednevusandmelanoma1.Pigmentednevus色素痣色素痣:Itisbelongtoacongenitalmalformation.Intradermalnevus皮内痣皮内痣(Itisquitecommon)Types:Junctionalnevus交界痣交界痣(locatedatdermoepidermaljunction) Mix
82、ednevus混合痣混合痣2.Melanoma黑色素瘤黑色素瘤:Usually occurs in foot, vulva,peripheryofanus,andhead,etc.High malignancy, rapid growth,earlymetastasis.About50%melanomadevelopedfrompigmentednevus,especiallyjunctionalnevus. IV.Miscellaneousoriginaltumors多种组织构成的肿瘤多种组织构成的肿瘤(I).Teratoma畸胎瘤畸胎瘤Consisting of various kind
83、of tissue frommultiplegerminallayers.Usuallyoccursinovary,testis,(rareoccursincranicalbase,anteriormediastinum,retroperitoneum,sacro-caudaalongmiddlelineofthebody).Benignteratoma-cyst(dermoidcyst)Malignantteratoma-solid (II).Embryonictumorofkidney肾胚胎瘤肾胚胎瘤ItisalsocalledasnephroblastomaorWilmstumor.It
84、isoriginatedfromrudimentaryblastematissueinkidney.Usuallyoccursinlessthen5yearsoldchildrenwitharenalmass.(III).Carcinosarcoma Containingbothelementsofcarcinomaandsarcoma.Itwouldbedifferentiatedfromsarcomatoidcarcinoma.SectionVIII.EtiologyandPathogenesisoftumors The cause of tumor being verycomplicat
85、edincludethefactorsinenvironmentandpotentialfactorsinhost.内因内因:抗肿瘤能力下降抗肿瘤能力下降外因外因:环境致瘤因素环境致瘤因素I.Molecularbiologicaloftumorpathogenesis(I).Oncogene癌基因癌基因Oncogeneisdiscoveredfromretrovirusatfirst.Itpresentinthenormalcellswithnon-activity,soitwouldbecalledproto-oncogene.ActivityformOncogeneNon-activity
86、form(proto-oncogene)Productiveproteinsofproto-oncogeneare:i.growthfactorsii.growthfactorsreceptorsiii.signaltransducingproteins(e.g.ras)iv.nuclearregulatoryproteins(e.g.myc)(Theyareimportantmechanismsofnormalgrowthcontrols). (II).Tumorsuppressorgene抑癌基因抑癌基因p53andRbgenearebothmostknownrecently.II.Env
87、ironmentalcarcinogensandcarcinogenesismechanism80-90% of human cancers areenvironmentalinorigin.(I).ChemicalcarcinogensTherearemorethan1000chemicalcarcinogensfoundinexperimentaltumorsandmorethan30relatedtohumancancerssofar Thestudiesofchemicalcarcinogensindicate:i.Alargenumbersofitareindirectlyreact
88、ingchemicals间接致癌物间接致癌物(orprecarcinogens).Itconvertedintoultimatecarcinogensthroughmetabolism体内（肝）代谢体内（肝）代谢.Asmallnumbersofaredirectlyreactingchemicals直接致癌物直接致癌物. 如烷化剂ii.Allchemicalcarcinogensarehighreactiveelectrophiles亲电子基团亲电子基团(e.g.epoxide)whichreactwithnucleophillicresiduesinDNA,RNAandcellularpro
89、teins(especiallyN-7,C-8inguanine)bycovalencecombinationinterferethenormalmatchesofbasepairsandinduceamutation.So,alargenumbersofchemicalcarcinogensaremutagens突变剂突变剂iii.Chemicalcarcinogensmaybeclassifiedascompletecarcinogens完全致癌物完全致癌物(itpossessbothofinitiation激发激发andpromotion促发促发)andincomplete不完全致癌物不
90、完全致癌物carcinogens(itpossessonlyofinitiationnopromotion;tumordevelopeddependingonprotomotor).Majorofchemicalcarcinogensmaybegroupedas:1.Indirectlyreactingchemicals(1).Polycyclichydrocarbons多环芳烃多环芳烃:3,4-benzpyrane芘芘苯丙苯丙,1,2,5,6-dibenzanthracene双奈苯蒽，双奈苯蒽，3-methycholanthrene甲基胆蒽甲基胆蒽,9,10-dimethy二甲基萘蒽二甲基萘
91、蒽incoaltar,carexhaustfume,tobaccotar,etc.Theymayinducecarcinomasoflungorstomach.(2).Aromaticamines芳香胺芳香胺andazodyes氨基偶氮染料氨基偶氮染料:Theformermaygivesrisetocarcinomaofbladder,thelatter,butteryellow奶油黄奶油黄(e.g.dimethylaminoazobenzene二甲基氨基二甲基氨基偶氮苯偶氮苯)andscarletred猩红猩红,mayinducescarcinomaofliverinrats. (3).Ni
92、trosamines亚硝胺类亚硝胺类:Synthesizedbynitrites亚硝酸盐亚硝酸盐andamine.Causingvariouskindsoftumorsinanimals,Andmayinducesgastrointestinalcarcinomaofhuman. (4).Aflatoxins黄曲霉素黄曲霉素:especiallyaflatoxinB1Itmaygivesrisetocarcinomaoftheliver2.DirectlyreactingchemicalsThiskindsofchemicalsaremildcarcinogengenerally.(1).Al
93、kylate烷化剂烷化剂andacylate酰化剂酰化剂(2).Others:Metalelements:,chromium铬铬,nickel镍镍,etc.Overdoseofarsenic砷砷mayinducecarcinomaofskin.benzene苯苯toleukemia白血病白血病.Vinylchloride乙烯乙烯氯化物氯化物tohemangiosarcomainliver肝血管瘤肝血管瘤. (II).Physicalfactors:Radiation(X-ray,isotopes同位素同位素),sunlight光照光照,ultraviolet紫外线紫外线,chronicirri
94、tation慢性刺激慢性刺激,foreignbodies异物异物(asbestos,plasticfilms)Somearerelatedtotheincidenceofoccupationaltumors.(III).Biologicalcarcinogens:Oncogenicviruses:therearemore600oncogenicvirusesinanimals,inwhich150cantransformthecellsinvitro.1.DNAoncogenicviruses:(1/3)(1).Humanpapillomavirus,HPV人类乳头状病毒人类乳头状病毒Thep
95、ossiblerelationshipbetweencarcinomaofcervixandHPV.(2).Epstein-Barr(EBV)Itmaygivesrisetonasopharyngealcarcinomaandburkittslymphoma.(3).HepatitisvirusB,HBV乙肝病毒乙肝病毒:primaryhepatocellularcarcinomaandHBVhavebeensuggested. 2.RNAoncogenicviruses(oncornaviruses,retroviruses):(2/3)Acutetransformationviruses急
96、性转化病毒急性转化病毒(Containoncogenes)Chronictransformationviruses慢性转化病毒慢性转化病毒(Nooncogenes)HTLV-1(humanT-cellleukemia/lymphomavirus1)inhuman.Leukemia,sarcoma,lymphomavirusesinchickens,birds,mice,rats,cats,cattle,etc.Mammarytumorvirusesinmice. 3.Helicobacterpylori幽门螺旋杆菌幽门螺旋杆菌:Itmayberelatedtolowmalignantlymph
97、oma.4.Parasites:SchistosomaJaponica日本血吸虫日本血吸虫tocarcinomaofthecolon结肠癌结肠癌.Clonorchiasissinensis华支睾吸虫华支睾吸虫isrelatedtoadenomatoidproliferationofepithelialcellsofintrahepaticbileductandthentobiliarycarcinoma胆管细胞癌胆管细胞癌. III.PotentialFactorsinHost(I).Heredity;1、呈常染色体显性遗传的肿瘤：呈常染色体显性遗传的肿瘤：Polyposisofcolon,结
98、肠多发性腺瘤性息结肠多发性腺瘤性息肉病肉病，retinoblastoma视网膜母细胞瘤视网膜母细胞瘤,nephroblastoma肾母细胞瘤肾母细胞瘤,neurofibromatosis神经纤维瘤病神经纤维瘤病,etc.2、呈常染色体隐性遗传的遗传综合征：呈常染色体隐性遗传的遗传综合征：易患白血病等其它肿瘤，如：易患白血病等其它肿瘤，如：Bloom综合征综合征累及累及DNA修复基因修复基因Li-Fraumeni综合征综合征累及累及p53基因基因3、遗传、遗传易感性易感性与环境因素协同作用与环境因素协同作用（多基因）（多基因）Itmaybesensitivityratherthenheredit
99、ypredisposingorcontributingfactors. 绝大多数肿瘤，尤其是环境因素造成的绝大多数肿瘤，尤其是环境因素造成的肿瘤不直接遗传肿瘤不直接遗传家庭群聚现象家庭群聚现象(II).Tumorimmunity1.TumorantigenTumorespecialantigen肿瘤特异抗原肿瘤特异抗原(presentofonlytumorcells)Tumorassociatedantigen肿瘤相关抗原肿瘤相关抗原(presentofnormalandtumorcells) Tumorembryonicantigens肿瘤胚胎抗原肿瘤胚胎抗原(presentofembryo
100、nicandtumortissue)Forexample:ATP甲胎蛋白甲胎蛋白(AlphaFetoprotein)inhepatocellularcarcinomaandsometumorsofoveryandtestis.CEA癌胚抗原癌胚抗原(Carcino-embryonicantigen)inomeintestinalcarcinomas.Tumordifferentiativeantigens 肿瘤分化抗原肿瘤分化抗原Tumordifferentiativeantigens(presentofmaturenormalandtumortissue)Forexample:EspecialantigenofprostateThyroglobulin,andKeratin,etc. 2.Immunereactivemechanismofanti-tumorTumorimmunereactionaremajorofcellularimmunity,andadjuncttohumoralimmunity.CTL,NK,andmacrophage3.Immunesurveillance免疫监视免疫监视
