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1、女性生殖系统和乳腺疾病女性生殖系统和乳腺疾病女性生殖系统和乳腺疾病女性生殖系统和乳腺疾病 TheFemaleGenitalSystemandTheFemaleGenitalSystemandBreastBreast第十三章1;子宫颈疾病子宫颈疾病v慢性宫颈炎慢性宫颈炎 Chronic cervicitisv宫颈上皮内瘤变宫颈上皮内瘤变 Cervical intraepithelial Neoplasia (CIN) 宫颈上皮不典型增生宫颈上皮不典型增生 Cervical epithelial dysplasia 宫颈原位癌宫颈原位癌 Carcinoma in situv宫颈癌宫颈癌 Cervi
2、cal carcinoma 2;3;4;5;6;Normal cervix7;Normal cervix8;宫颈炎阴道（粘液）脓性分泌物感染性沙眼衣原体沙眼衣原体 (40% of cases)真菌类真菌类淋球菌淋球菌单纯疱疹单纯疱疹II型型人类乳头瘤状病毒人类乳头瘤状病毒 HPV非感染性9;10;Nabothian cyst at 5 oclock11;宫颈肿瘤宫颈肿瘤癌前病变癌前病变F CIN （组织学）（组织学）F SIL （脱落细胞学）（脱落细胞学）浸润型癌浸润型癌12;CIN I：Mild dysplasiaCIN II：Moderate dysplasiaCIN III:Severe
3、 dysplasia and CISCytologic smears SIL low-grade: CINI or flat condylomas SIL high-grade: CINII or CINIII，癌13;Cervical conization14;15;PAPsmear16;17;18;A normal Pap smear picture19;LSIL 20;HSIL21;Normal cervical squamous epithelium22;CIN I23;CIN I24;CIN II25;CIN III26;CIN III27;28;29;Carcinoma in si
4、tu (glands involved)30; 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 regress.31;CINI
5、 Regression 50-60%Persistence 30%Progression to CIN III 20%Progression to invasive cancer 1-5%CINIII Regression 33%Progression 6-74%32;流行病学CIN高峰年龄30y，癌高峰年龄50yRiskfactorsEarly age at first intercourseMultiple sexual partnersA male partner with multiple previous sexual partnersPersistent infection by
6、“High-risk” HPVOthers 33;The Death of Eva PeronEvaPeron(Evita),wifeofArgentinasleft-wingdictatorJuanPeron,diedinJanuary1952ofcervicalcancer.34;宫颈癌宫颈癌75-90%鳞癌腺癌和腺鳞癌小细胞癌5%20%糜烂型外生菜花型内生浸润型溃疡型Microinvasive carcinoma 35;36;37;38;39;40;Squamous cells carcinoma41;Squamous cells carcinoma42;Immunostaining f
7、or keratin 43;Spreading 44;45;临床表现Papsmear有助于早期诊断未能早期诊断者不规则阴道流血不规则阴道流血白带增多，伴有异味白带增多，伴有异味性交痛，排便困难性交痛，排便困难 扩散引起的症状扩散引起的症状晚期患者化疗有效46;宫颈癌分期宫颈癌分期 (FIGO,1985) 0 Preinvasive carcinoma Carcinoma strictly confined to the cervix Carcinoma that extends beyond the cervix, but does not extend into the pelvic wal
8、l Carcinoma that has extended into the pelvic sidewall Carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum 47;五年生存率五年生存率Stage 0 100%Stage I 90%Stage II 82%Stage III 35%Stage IV 10%48;滋养层细胞疾病滋养层细胞疾病Gestationaltrophoblasticdiseasev Hyda
9、tidiform molev Invasive molev Choriocarcinoma HCG49;50;Implantation of the Placenta 5 days after fertilization 51;6 days after fertilization52;12 days after fertilization53;a third-trimester placenta with baby54;55;葡萄胎葡萄胎 Hydatidiform mole56;葡萄胎葡萄胎 Hydatidiform mole57;Big uterus with mole58;葡萄胎Hydat
10、idiformMole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葡萄胎59;完全性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) 60;部分性葡萄胎部分性葡萄胎 Partial mole May have a non-viable baby Unevenly swollen villi 69XXX, 69XXY61;62;63;64;Partial mole65;临
11、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 benign10% complete mole become invasive2-3% give rise to choriocarcinoma66;侵袭性葡萄胎侵袭性葡萄胎 Invasive mole 不发生转移不发生转移 绒毛可栓塞至肺和脑绒毛可栓塞至肺和脑 67;绒毛膜癌ChoriocarcinomaAggressive起源于绒毛上皮细胞或全能干细胞1:2000Age40yHistory50% of case follow a complete mole25% arise aft
12、er an abortionRemainder after a normal pregnancy68;患者，女，患者，女，2424岁，农民，孕岁，农民，孕3 3产产1+21+2。主诉：流产主诉：流产1 1年多，阴道不规则流血，痰中带血年多，阴道不规则流血，痰中带血3 3月，月，头痛头痛1 1月，呕吐月，呕吐3 3天。天。现病史：现病史：1 1年前，因停经年前，因停经5 5月后自然流产，流出物似月后自然流产，流出物似“烂肉一堆烂肉一堆”，未见胎儿成份，当时未清宫，以后月经，未见胎儿成份，当时未清宫，以后月经正常。正常。3 3月前开始阴道不规则流血，时多时少，月前开始阴道不规则流血，时多时少，1
13、1月前月前阴道掉出鹅蛋大之腥臭阴道掉出鹅蛋大之腥臭“肉块肉块”，同时有咳嗽，痰中，同时有咳嗽，痰中带血，头昏头痛。近带血，头昏头痛。近3 3日来，头昏头痛加重，并出现日来，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。头痛、呕吐、昏迷，四肢小抽搐，急诊入院。病例讨论病例讨论69;体格检查体格检查: : 神志不清，脉搏神志不清，脉搏9090次次/min/min，呼吸，呼吸1616次次/min/min，血压，血压129/90mmHg129/90mmHg，心肺（），肝脾未扪清，心肺（），肝脾未扪
14、清，子宫底在耻骨联合上子宫底在耻骨联合上4 4指，外阴水肿，阴道前后壁指，外阴水肿，阴道前后壁有有4 4个紫红色结节，小者直径为个紫红色结节，小者直径为0.5cm0.5cm，最大者直径，最大者直径5cm5cm，掉出阴道之外。子宫，掉出阴道之外。子宫2 2月孕大，前位，活动，月孕大，前位，活动，双附件（），入院后双附件（），入院后1 1小时，呼吸骤停，抢救无小时，呼吸骤停，抢救无效死亡。效死亡。实验室检查实验室检查：入院前：入院前2020天，胸部天，胸部X X线照片见双肺有线照片见双肺有结节状影。查血：血红蛋白结节状影。查血：血红蛋白38g/L38g/L，白细胞，白细胞15.315.3109/L
15、109/L，嗜中性粒细胞，嗜中性粒细胞0.860.86，淋巴细胞，淋巴细胞0.130.13，大单核细胞，大单核细胞0.010.01，尿妊娠试验（，尿妊娠试验（+ +）。）。 70;尸检摘要尸检摘要: : 子宫长大如拳头，表面有黄豆大结子宫长大如拳头，表面有黄豆大结节数个，子宫底右侧有节数个，子宫底右侧有5cm5cm5cm5cm6cm6cm大包块，大包块，表面有坏死，溃烂，切面呈紫红色，边界不清，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，阴道前壁有已侵及肌层和浆膜，阴道前壁有4 4个大小不等的个大小不等的紫红色结节（同前），子宫旁有数个蚕豆大小紫红色结节（同前），子宫旁有数个蚕
16、豆大小的结节，双附件（）。双肺内可扪及多个黄的结节，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。脑死；双侧胸膜脏壁层有局灶性纤维性粘连。脑重重12301230克，左顶颞部硬膜下有血块约克，左顶颞部硬膜下有血块约10cm10cm6cm6cm0.6cm0.6cm，左侧脑室后角有核桃大小，左侧脑室后角有核桃大小紫红色结节，右额极也有紫红色结节，右额极也有3cm3cm2.5cm2.5cm之紫红色之紫红色结节。有明显小脑扁桃体疝形成。结节。有明显小脑扁桃体疝形成。 71;Choriocarcinoma
17、 72;73;74;Choriocarcinoma 75;Choriocarcinoma 76;Choriocarcinoma 77;Choriocarcinoma (metastasis to vagina ) 78;Choriocarcinoma (metastasis to lung ) 79;Choriocarcinoma (metastasis to lung ) 80;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，肾Chemotherapysavesalmostallcases81;乳腺癌Breastcarcinoma212,920new
18、case,40,940death(USA,2006)全球发病率增高发病机制Pathogenesis遗传遗传Geneticchange激素激素Hormonalinfluence环境环境Environmentalfactors82;83; Factors Relative riskWell-Established influencesGeographic factors VariesAge Increase after 30yFamily history First-degree relative with BC 1.2-3.0Menstrual history Age at menarche55
19、y 1.5-2.0Pregnancy First live birth 25-29yo 1.5 First live birth 30yo 1.9 First live birth 35yo 2.0-3.0 Nulliparous 3.0 84; Factors Relative riskWell-Established influencesBenign breast disease Proliferative disease 1.9 Proliferative disease with atypical hyperplasia 4.4 Lobular carcinoma in situ 6.
20、9-12.0Less Well-Established influences Exogenous estrogens Oral contraceptives Obesity High-fat diet Alcohol consumption Cigarette smoking85;86;乳腺癌类型 原位癌Non-invasiveDuctalcarcinomainsitu(DCIS)Lobularcarcinomainsitu(LCIS)浸润性癌Invasive(infiltrating)Invasive ductal carcinoma (硬癌硬癌)Invasivelobularcarcino
21、maMedullarycarcinomaColloidcarcinomaTubularcarcinomaOthertypes87;88;Normal resting breast89;Normal pregnant ladys breast90;导管内原位癌DCIS常伴坏死和钙化(乳腺摄片)97%longtermsurvival1/2low-gradeDCIS(leftalone)turnsinvasiveatthesamesite(Cancer 103: 2481, 2005). ArchitecturalpatternsofDCIS粉刺癌粉刺癌Comedo subtypeSolid,cri
22、briform,papillary91;Van Nuys grading-and-treatment scheme for non-infiltrating ductal carcinoma: (Lancet 345: 1154, 1995) 1: No necrosis (lumpectomy, skip the radiation)2: Necrosis but no ugly nuclei (lumpectomy, maybe radiation) 3: Ugly nuclei (lumpectomy-radiation or mastectomy) 92; 粉刺癌粉刺癌 93; 粉刺癌
23、粉刺癌 94; 粉刺癌粉刺癌 95; DCIS, cribriform type96; DCIS, cribriform type97; DCIS, cribriform type98; DCIS, cribriform type99;DCIS, papillary type100;DCIS, papillary type101;DCIS, solid type102;DCIS, solid type103;Paget disease of the nipple104;A distinctive proliferation of tame-looking cells filling the d
24、uctules of one or more lobulesSignet-ring cells are commonThe lobules are expanded but not distortedDoes not form massesUsually bilateral1/3 turns invasive小叶原位癌小叶原位癌 LCIS105;LCIS106;LCIS107;LCIS108;浸润型导管癌InvasiveductalcarcinomaAllcarcinimasthatcannotbesubclassifiedintooneofthespecializedtypesdescribedbelow.(NST)Someariseinthelobules70-80%浸润性乳腺癌为浸导大部分为硬癌109;
