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临床检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•肺脱落细胞学检查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线检查、痰液涂片检查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Ciliatedcolumnarcells•Notethemoderatelycoarseandhyperchromaticchromatin•Alsonotethelittletailswherethecellswereattachedtothebasementmembraneand,ofcourse,thepresenceofterminalbarsandcilia(Oil)Gobletcells•Gobletcellhyperplasia•Normally,theciliatedcellsfaroutnumberthesecretorycells(byatleast5to1).•However,inasthma,forexample,thegobletcellsmayactuallyoutnumbertheciliatedcells.痰液肺泡吞噬细胞Alveolarmacrophagesinsputum•Alveolarmacrophagesarekeycellstolookforinasputumspecimen.•Thepresenceofalveolarmacrophagesindicatesthatthedeeplunghasbeensampled.•dustcells痰液肺泡吞噬细胞AlveolarmacrophagesinsputumGiantCellHistiocytes•Giantcellhistiocytescanbeseeninawidevarietyofpulmonarydisorders,•Theycanalsobeseeninapparentlyhealthypeople,andthereforedonotnecessarilyindicatethepresenceofdisease.痰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。痰液良性病变脱落细胞－巴氏细胞•Squamousmetaplasiacanbeseeninsputmsmear,ie,roundedcellswithdense,cyanophiliccytoplasm.肺癌脱落细胞•痰液涂片检查主要用于检查癌细胞，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。痰液脱落细胞学检查肺鳞状细胞癌：•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．痰液鳞状细胞癌Keratinizingsquamouscellcarcinoma(tissue)•Notethepresenceofsquamouseddies,orpearls,whicharepathognomonicofkeratinization.痰液鳞状细胞癌Keratinizingsquamouscellcarcinoma•Pearlsarecharacteristicofkeratinizinglesions.角化鳞状细胞癌Keratinizingsquamouscellcarcinoma•Bizarrekeratinizingcells,oftensingle,areacharacteristicfeature.Suchcellsareparticularlyassociatedwithsputumspecimens痰液鳞状细胞癌痰液鳞状细胞癌非角化鳞状细胞癌Non-keratinizingsquamouscellcarcinoma•Thegroupsofmalignantcellstendtobemorecohesiveandthecellsmoreuniform•Pearls,extensivekeratinization,andbizarre-shapedcellsarenotpresent.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Adenocarcinoma•Adenocarcinoma•Three-dimensionalcellballsorpapillaryclustersofmalignantcellsarecharacteristicarchitecturalfeaturesofadenocarcinoma.肺腺癌Adenocarcinoma•Microacinarorrosette-likestructuresindicateglandulardifferentiation.•Microacinarcomplexesareacytologicequivalentofthegland-in-glandhistologicgrowthpatternofadenocarcinoma.肺腺癌Adenocarcinoma肺腺癌Adenocarcinoma•Notethatintracytoplasmicsecretoryvacuolecontainingmucin(arrow).痰液脱落细胞学检查未分化小细胞癌：•恶性度较高，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。未分化小细胞癌Smallcellcarcinoma•Smallcellcarcinoma(brushingspecimen)•Thetumorcellshaveverylittlecytoplasm,relativelyfinebutveryhyperchromaticchromatin,andinconspicuousnucleoli•Notethesimilarityofbronchialcellnuclearchromatintothatofthetumorcells.未分化小细胞癌Smallcellcarcinoma•Smallcellcarcinoma(brushingspecimen)•Thecellsobtainedbydirectbrushingappearfresher.well-preservedmaterial未分化小细胞癌Smallcellcarcinoma浆膜腔积液脱落细胞学检查•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查主要用于判断积液中有无癌细胞。浆膜腔积液脱落细胞学检查良性病变脱落细胞：•脱落间皮细胞：圆形或椭圆形，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(MesothelialCells)•Mesothelialcellsinaneffusionalwaysshowreactivechangesofvariousdegrees.•Notenuclearenlargementandaprominentnucleolusbutfinechromatinandasmoothnuclearmembrane.间皮细胞(MesothelialCells)•Gland-likeclusterofbenignmesothelialcellsmimickingadenocarcinoma.•Notethatthecomponentcellsareidenticaltotheotherreactivemesothelialcells,anddonotconstituteaforeignpopulation.组织细胞(Histiocyte)•Hemosiderin-ladenhistiocyte.Hemosiderinisarefractilegoldenbrownpigment.•Thepresenceofhemosiderinindicatesoldbleeding.良性病变脱落细胞结核性病变(Tuberculouseffusion)•Abundanceoflymphocytesandvirtualabsenceofmesothelialcellsarecharacteristicoftuberculouspleuraleffusions.浆膜腔积液脱落细胞学检查恶性病变脱落细胞：•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。浆膜腔积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，癌细胞呈圆或椭圆形，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•Adenocarcinomaisthemostcommoncauseofamalignanteffusion.•AmongthemostusefulfeaturesinthediagnosisofadenocarcinomaareincreasedN/Cratio,irregularnuclearmembranes,largenucleoli,secretoryvacuoles,andthree-dimensionalaggregates腺癌Adenocarcinoma腺癌Adenocarcinoma•Thegeneralpatternsofadenocarcinomasinfluidsincludecellballs(morulas),papillaryoracinargroups,signetringcells腺癌Adenocarcinoma•Papillarygroupsareelongated,three-dimensionalaggregates.•Psammomabodiesmaybepresent.•Adenocarcinomasofthelung(illustratedhere),breast,andfemalegenitaltractarecommonsources腺癌Adenocarcinoma•Signetringcellsarecellswithlargecytoplasmicvacuolesthatcompressthenucleustotheperipheryofthecell•Large