资源简介

(共78张PPT)
Section 5 Lung tumors
大多数原发肺癌源于支气管上皮
(Lancet 355: 479, 2000)
肿瘤死亡原因之首
发病随年龄和吸烟史上升
性别 Gender (male-to-female ratio is 2:1)
早发现预后好 Early detection (operable)— Good prognosis
第七章 呼吸系统疾病
病 理 学 第五章 肿 瘤
Etiology
① Cigarette smoking
烟雾中有害物质：包括一氧化碳、尼古丁、砷、镍等。
其他多种生物学作用， 对呼吸道、心血管、胃肠、神经系统和肝、肾等器官都有不同程度的损害。 吸烟与肺癌有因果关系：３，４－苯并芘、煤焦油
　目前我国有３亿“烟民”，青少年吸烟有增加的趋势。 ５亿20岁以下的青年人中可能有２亿人经常吸烟，其中成百万人将由于吸烟而至残，约５千万人将因吸烟而死于肺癌、心脏病或其他肺部疾患。
京、津、沪等大城市男性成年人吸烟率近５０％，女性近５％
临床确诊的肺癌病例中，纸烟２０支/日以上，历时３０年以上，约占８０％以上。
吸烟之害，触目惊心!
吸烟者痰内检出 鳞化和非典型增生细胞的机会明显高于非吸烟者。
② 职业因素
放射元素
Industrial hazard：砷、镍、石棉等工人
③ Environmental factors
Atmospheric pollution ( city / kitchen )
工业发达国家肺癌的发病率高
城市比农村高
厂矿区比居住区高
大气污染与吸纸烟对肺癌的发病率可能互相促进，起协同作用
主要原因是由于工业和交通发达地区，石油，煤和内燃机等燃烧后和沥青公路尘埃产生的含有苯并芘致癌烃等有害物质污染大气有关。
④ 肺部慢性疾病
肺结核、矽肺、尘肺等可与肺癌并存。这些病例癌肿的发病率高于正常人。
⑤ 机体内在因素
家族遗传，免疫机能降低，内分泌功能失调等可能对肺癌的发病起一定的促进作用。
① 中央型 （ 肺门型 ）
起源于主支气管、肺叶支气管的肺癌
最常见，60-70%
易于发现（咳嗽、咯血、内镜、痰细胞）
Metastasis locally to hilar lymph nodes
病理改变
This chest radiograph demonstrates a large squamous cell carcinoma of the right upper lobe.
② 周围型
30-40%
起源于段以下支气管或肺泡
肺组织近胸膜处（胸水）
球形或分叶状肿块 2-8 cm
界清 ，无包膜
不易发现
Peripheral adenocarcinoma of the lung
③ 弥漫型
肿瘤沿肺泡管、肺泡弥漫浸润生长，累及大叶或全肺叶
粟粒性结节
细支气管肺泡癌多见
鉴别： 肺转移癌
小叶性肺炎
2-5%
早期肺癌：直径 < 2cm、局限于支气管内或浸润管壁。
隐性肺癌：临床及X-ray（-），痰细胞学（+），手术切除标本证实为原位癌或早期浸润癌无淋巴结转移。
组织学分类 Classification
小细胞肺癌Small cell lung carcinoma
(SCLC, 20-25% of cases)
非小细胞肺癌 Non-small cell lung carcinoma
(NSCLC, 70-80% of cases)
鳞癌 Squamous cell carcinoma
腺癌 Adenocarcinoma
大细胞癌 Large cell carcinoma
SCLC
侵袭性强,早转移
对放化疗显示短期反应
手术机会少
NSCLC
对化疗反应不明显
治疗不依赖组织学
吸烟相关 Smoking related
中央型 Centrally located
气道阻塞 Airway obstruction
低血钠(ectopic secretion)
SCLC
Hilar lymph nodes with metastatic carcinoma
SCLC
The carcinoma is spreading along the bronchi.
燕麦细胞癌Oat cell carcinoma
细胞小，胞浆少
分裂相多
坏死明显
癌细胞密集成群（巢）
少量结缔组织分隔
燕麦细胞癌
( oat cell carcinoma )
It is aggressive and highly malignant , metastasis very early , 1- 2% 5-year survival
Oat cell carcinoma
small cell lung carcinoma ( 30% )
中青年男性 M ：F ≈ 20 ：1；吸烟史；中央型多见
生长快、转移早、预后差；放化疗敏感
It appear to be derived from Kulchitsky ( 库尔契茨基 ) cells
which present in bronchial mucosa .
[ 2/3 为 中央型 ]
电镜见胞浆中含嗜银性电子致密颗粒 （ 嗜银细胞 ）
神经内分泌颗粒 （APUD 细胞）
该肿瘤有异源性内分泌功能
副肿瘤综合征
鳞癌 Squamous cell carcinoma
男性Men
烟民Somker
中央型 Central located
阻塞气道 Obstructing
Extends into the lumen
Firm and pale white
NSCLC
Clinical Summary
Male,55-yo, had a long history of emphysema and a 60-70 pack-year smoking history. He was in his usual state of health until about one month before admission, at which time he developed increasing dyspnea on exertion. At the same time, his sputum increased from two tablespoons to half a cup of yellow blood-streaked sputum a day.
Chest x-ray showed a right hilar mass. Sputum cytology revealed abnormal cells that were "positive for malignancy." He later developed pneumonia and fever. The patient expired soon thereafter.
Squamous cell carcinoma
NSCLC
阻塞支气管
淋巴结受累
a section of the right lung, obtained surgically from a heavy smoker,
A large carcinoma ("cancer") arising from the main bronchus, approximately 6 cm in diameter, obstructing the bronchi supplying the lower and middle lobes, as well as infiltrating into local lymph nodes
Squamous cell carcinoma
NSCLC
The carcinoma extends from hilum to pleura.
Squamous cell carcinoma
Cavitation
NSCLC
Squamous cell carcinoma
NSCLC
Squamous cell carcinoma
NSCLC
Squamous cell carcinoma
squamous pearls (left), less differentiated (right)
NSCLC
坏死区域 an area of necrosis
角化珠more differentiated area with keratin pearl formation
an area of central necrosis
Adenocarcinoma
非吸烟 Non-smoker and women
生长慢 Grow slowly
周围型Peripherally located
Pleural effusions
NSCLC
Adenocarcinoma
>>glands ; mucin
NSCLC
>>scars
Adenocarcinoma
NSCLC
细支气管肺泡癌 Bronchioloalveolar carcinoma (BAC)
腺癌亚型
源于终末细支，向肺泡间隔延伸
结构损伤小
非侵袭
Bronchioloalveolar carcinoma (BAC)
Bronchial goblet cells, type II pneumocytes, Clara cells
Malignant cells grow along the alveolar septal framework
Bronchioloalveolar carcinoma
Consolidation (chest radiograph), mucin+
Bronchioloalveolar carcinoma
分化差
非柱状细胞
不含粘液
不发生鳞化
不发生神经内分泌
可发生于任何部位
吸烟相关
Large cell carcinoma
NSCLC
( 5 % )
Large cell carcinoma
胞浆丰富 abundant cytoplasm
核大 prominent nucleoli
NSCLC
Summary of clinical characteristics of NSCLC by histologic subtype
腺癌 Adenocarcinoma
最常见类型
周围型
支气管粘液腺
可以以瘢痕癌出现
不吸烟
Summary of clinical characteristics of NSCLC by histologic subtype
鳞癌 Squamous cell carcinoma
空洞
角化珠
痰细胞学检查
高钙相关
大细胞癌 Large cell carcinoma
周围肿块
男子乳房发育
支气管肺癌的临床表现
原发瘤症状
中央型 Central tumors
咳嗽, 气短, 支扩, 阻塞后肺炎, 哮喘，喀血
周围型 Peripheral tumors
咳嗽，气短
胸痛
局部扩散症状
上腔静脉阻塞
声嘶、膈肌麻痹
臂丛受压
吞咽困难
胸膜
转移症状
脑 骨 肾上腺
副肿瘤综合症
Cushing's syndrome (ACTH-producing)
Hyponatremia (hADH-producing)
Hypercalcemia
盲、痴呆
肌无力
其他
Horner ’s syndrome
肺尖部肺癌 : 压迫颈交感神经，引起患侧眼睑下垂、瞳孔缩小、额部少汗等
副癌综合症（肺外表现）：
主要以骨关节病变和内分泌紊乱引起的症状最为常见。
主要有：关节肿胀疼痛，杵状指、趾，高血压，浮肿，肌力减弱，尿糖增多，多尿，烦渴，心动过速、心律紊乱，高血钙，低血磷和精神错乱等；还有的表现重症肌无力，小脑运动失调，多发性神经炎等。
杵状指
眼球内陷 a sunken eyeball (enophthalmia)
瞳孔对光反射消失
上睑下垂
前额、眼、脸、颈无汗
Horner's Syndrome
Normal
Abnormal
Clubbing of digits
Metastatic carcinoma
dilated lymphatic channel
CPC (clinical pathological conference)
Clinical summary :
A 66-year-old, emaciated man was admitted (6/19) for 2 days of increasing confusion. He had been under continuous medical care for 2 months when he was admitted for a complaint of "feeling bad." There was a history of intravenous drug use (heroin), smoking crack cocaine, and hepatitis C, but he was HIV negative.
Clinical summary (con’d)
He was afebrile. The white blood cell count was 8.3 k/ l. End-stage renal disease (membranoproliferative glomerulonephritis thought to be secondary to hepatitis C) requiring hemodialysis, R knee and L wrist septic arthritis (S aureus and S pneumoniae： 葡萄球菌staphylococci；链球菌 streptococcus).
Clinical summary (con’d)
On admission, he had T 37.1°C, HR 80/min, RR 26/min, BP 144/83 mmHg , and O2 saturation of 96% on room air. Lungs were clear. No cardiac murmurs were heard. The R knee and L wrist were again swollen. Laboratory values were: WBC 18 k/ l and plt 187 k/ l. A blood culture yielded 新青霉素 methicillin-resistant S aureus. Vancomycin was begun.
Clinical summary (con’d)
Bacteremia persisted, thrombocytopenia developed, and he remained confused. He was found dead on 6/30. An autopsy was performed.
Transesophageal Echocardiogram
6/22, 8 days before death, …showed thickening of the leaflets of the PV and one of two pedunculated（带蒂的） vegetations, There was no valvar insufficiency.
Radiographic Findings
6/26, 4 days before death, a frontal film showing the right lung demonstrated multiple areas of mass-like consolidation, at least two of which showed central cavitation. There was a small right effusion. The left lung appeared normal.
Autopsy Findings
Pulmonic valve
Normal pulmonic valve
The right lung weighed 1000 g and the left, 900 g (normal about 250 g apiece).
The right had a fibrinous pleuritis.
After distension with formalin and fixation, one slice from the left lung showed two yellowish lesions.
A slice of the right lower lobe showed two lesions.
Pulmonic vegetation
Thrombus in one of the segmental arteries
the same artery-- transmural inflammation of the arterial wall (between 2 arrows）
Another vessel（ (platelet-fibrin columns (arrow)), transmural arterial inflammation, and adjacent pneumonia ）
4/xx-6/19 in another hospital, “feeling bad”
6/19…“2 days of increasing confusion”
6/30… die
Hepatitis C
End-stage renal disease
R knee and L wrist septic arthritis
intravenous drug use
R knee and L wrist septic arthritis 脓毒性关节炎
Bacteremia
No cardiac murmur
Lungs are clear
6/22 PV vegetations
6/26 lung masses,cavitated
pleural effusion
Questions
What are the possible conditions of the multiple masses in the lung
Questions
Diagnosis
Cause of death
Differential diagnosis
Diagnoses
Infective endocarditis (methicillin resistant S. aureus)
Infected emboli
Infective pulmonary arteritis
Infected, cavitated infarcts, lung.
Summary
COPD
Pneumonia
Interstitial diseases
PHD
Lung tumors

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