外科病理学实践:诊断过程的初学者指南 | 第13章 肾
Circumscription and/or encapsulation
边界清楚和/或有包膜
Presence of stroma within the tumor
肿瘤内存在间质
Vascular or capillary pattern
血管或毛细血管模式
Architectural pattern (solid, acinar, trabecular, tubular, papillary, pseudopapillary, cystic)
结构模式(实性、腺泡、小梁、管状、乳头状、假乳头状、囊性)
Cellular pleomorphism (monotonous to bizarre)
细胞多形性(形态单一到奇异形)
Mitotic activity
核分裂活性
Cytoplasm (clear to granular pink to densely eosinophilic; perinuclear halos)
细胞质(透明至颗粒状粉红色至深嗜酸性;核周空晕)
Nuclear size and contour (note the shape and whether the membrane is smooth or wrinkled)
核大小和轮廓(注意核形状,核膜是否光滑或起皱)
Nucleoli
核仁
Tumor extending through the kidney capsule and into the perirenal fat
肿瘤穿透肾被膜延伸至肾周脂肪
Tumor invading adrenal gland (always note whether the adrenal is even present)
肿瘤侵犯肾上腺(始终注意肾上腺是否存在)
Gross tumor in the renal vein, both at the margin and in the renal pelvis (always open the renal vein)
肾静脉内肉眼可见肿瘤(始终打开肾静脉),以及切缘和肾盂肉眼可见肿瘤
Tumor growing through Gerota’s fascia (the very delicate membrane surrounding the peri-renal fat; this is actually fairly uncommon but indicates stage IV disease)
肿瘤生长穿透Gerota筋膜(即肾筋膜;围绕肾周脂肪的非常菲薄的膜;这实际上相当少见,但表明为IV期疾病)
Circumscription and presence of multiple lesions
范围和存在多个病灶
If cystic, multilocular versus unilocular, the presence of mural nodules, relationship to pelvis
如果是囊性,观察多房或单房,附壁结节,与肾盂的关系
If solid, the homogeneity and the color(s)—yellow gold, mahogany brown, areas of hemor-rhage, necrosis, fibrosis (gristle grey), or possible sarcomatoid foci (dense white)
如果是实性,观察均质性和颜色(金黄色、红褐色)、出血、坏死、纤维化(软骨灰色)或可能的肉瘤样病灶(致密白色)
Site of origin (cortex vs. medulla or pelvis), if you can tell
起源部位(皮质对比髓质或肾盂),如果你能辨别的话
Large, tangled, tortuous, thick-walled, hyalinized vessels
大的、缠结的、扭曲的、厚壁的、透明的血管
Smooth muscle cells (pink to clear and spindly) that seem to spin off of, or be continuous with, the vessel walls (Figure 13.4)
平滑肌细胞(粉红色至透明和梭形),似乎从血管壁上脱落或与血管壁相连(图13.4)
Mature fat cells without atypia or lipoblasts
成熟脂肪细胞,无异型性,无脂母细胞
Pushing borders but not encapsulated
推挤性边界,但无包膜
HMB-45 and Melan-A positive (this tumor is in the perivascular epithelioid cell tumor family, all of which stain for melanoma markers)
HMB-45和Melan-A阳性(该肿瘤属于血管周围上皮样细胞肿瘤家族,均表达黑色素瘤标记物)
A net-like array of delicate capillaries, dividing cells into packets (“acinar” pattern)
纤细的毛细血管呈网状排列,将细胞分成小团簇(“腺泡”型)
Clear cytoplasm, at least focally if not diffusely (Figure 13.6)
细胞质透明,如果不是弥漫的胞质透明,至少局部如此(图13.6)
Delicate, distinct cell membranes
纤细、清楚的细胞膜
Lack of desmoplasia (although sclerosis of burned-out tumor is common)
缺乏促结缔组织增生(尽管燃烬的肿瘤继发硬化很常见)
Grade I: nuclei resemble lymphocytes, no nucleoli (rarely used)
I级:核类似淋巴核,无核仁(很少使用)
Grade II: nuclei still small and without nucleoli, but with open chromatin
II级:核仍然很小,没有核仁,但染色质开放
Grade III: easily recognizable nucleoli, larger nuclei
III级:易于识别的核仁,较大的核
Grade IV: pleomorphic and hyperchromatic nuclei with big nucleoli
Ⅳ级:核多形性、深染,大核仁
Distinct cell membranes that give the tumor a three-dimensional texture, like alligator skin (Figure 13.8)
清楚的细胞膜,使肿瘤像三维结构,如鳄鱼皮(图13.8)
Cells of varying sizes and shapes
不同大小和形状的细胞
Pink, granular, wispy cytoplasm, often with a perinuclear clearing
粉红色,颗粒状,细腻的细胞质,常有核周透明
Nuclei that vary in size and shape and are crinkly, giving a koilocytic look (see Figure 13.8)
核大小和形状不同,呈皱褶状,看似挖空细胞的核(见图13.8)
Cytoplasm positive for Hale’s colloidal iron
Hale胶体铁染色呈阳性的细胞质
Can transform to sarcomatoid morphology
可转化为肉瘤样形态
Chromophobe (discussed above).
嫌色细胞癌(上文讨论)。
High-grade conventional renal cell carcinoma (discussed above).
高级别传统的肾细胞癌(如上所述)。
Oncocytoma: Oncocytoma is a benign tumor resembling oncocytes (or Hurthle cells) in other organs. Grossly, it is mahogany brown and well circumscribed but not encapsulated. There may be a stellate scar (a nonspecific sign of slow growth). The oncocytes are arranged in nests or cords of cells in a hypocellular stroma. The cells are round with dense pink cytoplasm and very regular, round nuclei (Figure 13.9). This regularity should strike you at low power, very different from a chromophobe. The oncocytoma is not graded. Features incompatible with this diagnosis include mitoses, papillary architecture, clear cells, and grossly identified vascular invasion.
嗜酸细胞瘤:一种良性肿瘤,类似于其他器官中的嗜酸细胞(或Hurthle细胞,许特来细胞。译注:正确拼写u上面有两个小点)。大体呈红褐色,边界清楚,但无包膜。可能有星芒状瘢痕(生长缓慢的非特异性迹象)。肿瘤细胞在细胞稀少的间质中排列成巢或条索。细胞呈圆形,胞质深染,呈粉红色,核规则,呈圆形(图13.9)。这种规律在低倍就会让你震撼,与嫌色细胞癌非常不同。嗜酸细胞瘤不分级。不符合本诊断的特征包括核分裂、乳头状结构、透明细胞和肉眼识别的血管浸润。
Papillary renal cell carcinoma: Papillary renal cell carcinoma is a cellular tumor of pink-to-blue cells (low-nuclear-grade tumors tend to be blue at low power, and high-nuclear-grade tumors tend to be pink; this seems backward) that may be arranged in papillary formations (helpful), solid sheets, or trabecular cords. The classic image is that of a fibrovascular core packed with foamy macrophages and lined by cuboidal cells with round nuclei (Figure 13.10). This image is so pathognomonic that if you find it, you are basically done. You may also see psammoma bodies, hemosiderin-laden cells, and focal clear cells.
乳头状肾细胞癌:由粉红色到蓝色的细胞组成的肿瘤(低核级别肿瘤在低倍镜下呈蓝色,而高核级别肿瘤呈粉红色;这似乎是反常的),可能排列成乳头状结构(有助于诊断)、实性片状或小梁状条索。经典图像为充满泡沫状巨噬细胞的纤维血管轴心,被覆圆核的立方细胞(图13.10)。这种图像如此具有病理诊断意义,如果你找到它,你基本上就确诊了。也可以看到砂粒体、含铁血黄素细胞和局灶性透明细胞。
Collecting duct carcinoma: A collecting duct carcinoma is a high-grade tumor that arises in the medulla. It looks and acts much like an adenocarcinoma. The cytology is clearly malignant, there is a desmoplastic response, and it may stain for mucin and carcinoembryonic antigen. However, it is rare. Rarer still is the variant of collecting duct carcinoma found in sickle cell trait patients, the medullary carcinoma.
集合管癌:发生在髓质的高级别肿瘤。形态学和生物学行为很像腺癌。细胞学明显恶性,有促结缔组织增生反应,黏液染色和CEA染色可能阳性。然而,此癌罕见。在镰状细胞特征的患者中发现的集合管癌变异型,即髓样癌,更为罕见。
Metanephric adenoma (blue, indigo blue, lymph node blue): Metanephric adenoma is usually a 1x diagnosis. It is a circumscribed but nonencapsulated tumor of monotonous, small, tightly packed, dense blue cells (Figure 13.11). It has little or no cytoplasm. The patterns range from tiny tubules to serpiginous gland-like structures. If this looks like a Wilms’ tumor to you, you are an astute observer. The metanephric adenoma may be essentially a differentiated (mature) form of a pure epithelial Wilms’ tumor.
后肾腺瘤(蓝色、靛蓝、淋巴结蓝色):后肾腺瘤通常为1x诊断(译注:1倍放大,即肉眼观察切片诊断)。它是一种边界清楚但无包膜的肿瘤,由形态单一、体积小、紧密堆积、致密分布的蓝色细胞构成(图13.11)。它几乎没有细胞质。结构模式从小管到蜿蜒的腺样结构不等。如果你觉得它像肾母细胞瘤,你的目光敏锐。后肾腺瘤实质上可能是一种分化(成熟)型纯上皮性肾母细胞瘤。
Wilms’ tumor: Wilms’ tumors are unusual in adults. See the following discussion of the pediatric population.
肾母细胞瘤:成人少见。参见以下关于儿科肾的讨论。
In the glomeruli: the percentage of globally sclerosed glomeruli, hypercellularity (mesangial vs. endocapillary), inflammatory cells, the thickness of mesangial matrix, segmental sclerosis, hyalinosis, crescents, thrombi, and changes in the basement membrane of the capillary loops (especially by PAS and silver stains)
肾小球:总体上硬化肾小球的百分比、细胞增多(系膜对比毛细血管内膜)、炎症细胞、系膜基质的厚度、节段性硬化、透明变性、新月体、血栓和毛细血管袢基底膜的改变(尤其是PAS和银染)
In the tubules: acute and chronic inflammation in the epithelium or lumen, injury (epithe-lial vacuolization, necrosis, or sloughing), cellular or hyaline casts, Tamm-Horsfall protein accumulation, atrophy (dropout)
肾小管:上皮或管腔的急性和慢性炎症、损伤(上皮空泡化、坏死或脱落)、细胞管型或透明管型、Tamm-Horsfall蛋白积累、萎缩(脱落)
In the interstitium: inflammation, fibrosis (especially by trichrome stain), edema
间质:炎症、纤维化(尤其是三色染色)、水肿
In the arteries and arterioles: intimal thickening, hyaline deposits, emboli, thrombotic micro-angiopathy (fibrin thrombi, red blood cell fragments in capillary walls, fibrinoid necrosis)
动脉和小动脉:内膜增厚、透明物质沉积、栓塞、血栓性微血管病(纤维素血栓、毛细血管壁中的红细胞碎片、纤维素样坏死)
In humoral rejection: glomerulitis, tubular injury, margination of neutrophils, and C4d staining in the peritubular capillaries
体液排斥反应:肾小球炎、肾小管损伤、中性粒细胞边集和管周毛细血管C4d染色
In acute cellular rejection: glomerulitis, interstitial inflammation, tubulitis, and intimal arteritis
急性细胞排斥反应:肾小球炎、间质炎症、小管炎和动脉内膜炎
In chronic rejection: glomerulopathy (double contours in basement membrane), mesangial matrix increase, tubular atrophy, interstitial fibrosis, intimal thickening of arteries, and hyaline thickening of arterioles
慢性排斥反应:肾小球疾病(基底膜双轮廓)、系膜基质增多、肾小管萎缩、间质纤维化、动脉内膜增厚和小动脉透明物质增厚
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