纳博科临细胞学家Francesco的细胞学总结—— 基础实用（豁然开朗）

小柿子 · 发表于 2018-5-28 11:22:41

本帖最后由小柿子于 2018-5-28 11:34 编辑

纳博科临驻英国细胞学家Francesco这次来中国做了四天讲座，很荣幸参与翻译了其中两次。最后一次东西部讲座之前也翻译了老师写的文档总结，因为还有ppt，一直不明白老师为什么还去写个word 文档，直到东西部大会上才知道，原来老师担心PPT打印出来，字很小，大家看不清，所以特意写了总结，这样方便大家听完课了再复习。不得不佩服老师的细心和耐心，确实ppt很多时候只适合用来讲课，而文档很适合拿来认真看。而且写了PPT，还愿意再写个word总结的老师，我想也不多吧。而Francesco老师写的细胞学总结非常棒，全面实用，尤其是之前我一直不知道肿瘤如何看如何分类，经老师一总结，真的豁然开朗。所以特意征求了老师的同意，将其分享出来。另老师有写一本关于细胞学的书，从临床病例的角度分析细胞学，也非常棒。最后，再次感谢纳博科临举办这么好的课程。

INTRODUCTION TO CYTOLOGY 细胞学简介
Francesco Cian, DVM, DipECVCP, FRCPath, MRCVS

Introduction 简介
Fine-needle aspiration (FNA) cytology is a useful tool in the diagnosis of skin disorders. It is a safe, quick, inexpensive, and relatively painless procedure, and can be easily performed by clinicians, usually without sedation or anaesthesia. However, the success of the procedure depends on several factors:
细针抽吸细胞学检查是诊断皮肤疾病一种非常有用的工具。它是一种安全、快速、便宜和相对无痛的过程，临床医生操作起来很容易，通常不需要镇静或麻醉。然而，整个过程的成功依赖于以下几个因素：
Selection of the adequate sampling technique and correct execution
选择一种可以采集到足够样本的方法，并且正确操作
Acquisition of a representative specimen
获得具有代表性的样本
Proper preparation of the smear and staining
采用合适的制片和染色方法
Correct examination of the smear
正确读片

Sampling collection technique 采样技术
The collection technique used depends mostly on the type of lesion being sampled. The choice of the correct procedure is crucial because, regardless of the experience of the operator examining the smears, poor sampling collection and preparation will most likely result in non-diagnostic samples because of low cellularity or poor preservation of the cell population harvested. Improving the quality of the cytological samples will maximize the likelihood of a definitive diagnosis from cytology. Moreover, even when a definitive cytological diagnosis cannot be made, cytological findings may be important in determining which additional laboratory tests to perform (e.g. histopathology) or directing further diagnostic procedures (e.g. radiography, ultrasound). Several methods of collecting samples for cytology exist. Below are listed the most common collection techniques:
具体采样方法主要根据需要采样的病变类型而定。选择正确的采样方法非常重要，因为不管读片人员的经验有多么丰富，如果采样制片技术不佳，很大可能会由于细胞含量低或采集细胞未保存好而无法获得诊断。提高细胞学样本质量可以最大化通过细胞学获得确切诊断的可能性。还有，即使细胞学无法做出确切诊断，细胞学发现对我们决定要再做哪些实验室检查（例如组织病理学）或是否需要其他诊断步骤（例如X光片、超声）有非常大的帮助。现有多种细胞学采样方法，下面列出了最常用的几种采样方法：
Fine-needle biopsy (with or without aspiration) 细针活检（抽吸法或不抽吸法）
Impression/scrapings 压片/刮片
Swabs 棉签

Sample processing 样本加工
Slide preparation is crucial in the process of obtaining a good cytological sample. The aim is to obtain a monolayer of well-preserved cells that can be described and identified by the pathologist. This can be achieved by several methods, including compression/squash preparation, blood smear technique, line smear technique and star-fish preparation.
制片对获得高质量的细胞学样本来说非常重要。目的是要制备单层完好保存的细胞，以便病理学家可以描述和鉴别。制片有多重方法，包括压片推片法、血涂片法、推线法和海星制片法。

Sample staining 样本染色
It is usually advisable to prepare multiple slides from each lesion and stain onsite at least one of them to ensure that the sample is adequately cellular. Further unstained slides can be sent to the referring laboratory, which might consider using a different stain.
通常建议每个病变制备多个玻片，并至少立即染色一个玻片，确保样本中含有足够多的细胞。其它未染色的玻片可以送检到转诊实验室，他们可能会考虑用另一种染液染色。
The majority of stains used in veterinary cytology are Romanowsky-type (eg. Diff Quik, Hema 3, Wright and Giemsa stains). These are inexpensive, readily available stains, easy to prepare and to use.
兽医细胞学中用到的绝大多数染液是罗曼诺斯基型（例如Diff Quik，Hema 3，瑞姬氏染液）。这些染液都不贵，很容易买到，并且制备和使用都非常简单。

Slide examination 读片
A systematic approach to slide examination is considered crucial in the correct interpretation of cytological samples. A too quick examination of the slide, the lack of recognition of important details and the tendency to start examining the slide at high power field, are only a few of the errors that can easily lead to a wrong diagnosis and sometimes also to incorrect clinical decisions. In the following a general approach to the slide examination has been described.
系统性的读片对获得正确的细胞学判读结果非常重要。看片太快，没有注意重要细节还有喜欢从高倍镜开始读片，这些还只是一小部分错误，这些错误很容易导致错误诊断甚至有时会导致错误的临床决定。下面会介绍一个完整的读片程序。

1. Evaluation of cellularity and cell preservation 评估细胞量和细胞完整性
Smears should be initially scanned with low power objective (4x-10x) to gain an appreciation of the overall cellularity and the preservation.
刚开始可以用低倍镜（4x-10x）浏览玻片，获得细胞量和完整性的整体印象。
Preservation is also essential for a correct cytological interpretation and usually requires observation at higher power fields (20x-50x). The presence of intact cells with clearly recognizable cytoplasmic borders and nucleus are synonymous of good preservation. When a smear is characterized by high numbers of disrupted cells with no clear and distinct cytoplasm (bare nuclei, naked nuclei) cytological interpretation is not possible.
完整性对正确的细胞学判读也非常重要，通常需要在高倍镜（20x-50x）下观察。保存良好指细胞完整并且胞浆边缘和细胞核清晰可辨。如果一个玻片上都是大量的破裂细胞，没有清楚明显的胞浆（裸核），也就无法进行细胞学判读。
If these two requirements are not fulfilled, there are high chances the aspirate will be either non-diagnostic or non evaluable, therefore re-aspiration may be considered.
如果这两个要求没有满足，那么很有可能这次抽吸没有诊断性或没有价值，因此要考虑再次抽吸。

2. Evaluation of cell types 评估细胞类型
Assuming the cellularity and the preservation of the sample are adequate, the next step is the evaluation of the main cell type present in the smears. The prevalence of inflammatory cells (e.g. neutrophils, eosinophils, lymphocytes, monocytes/macrophages) is supportive of an inflammatory process, the presence of a significant number of other cell types (e.g. epithelial, mesenchymal or round cells) is usually seen in hyperplastic/ dysplastic/ neoplastic conditions of different origins.
假设样本中细胞量和完整性都足够，下一步就是评估玻片中主要的细胞类型。如果存在炎性细胞（例如中性粒细胞、嗜酸性粒细胞、淋巴细胞、单核细胞/巨噬细胞）说明是炎症反应，如果存在明显大量其他类型的细胞（例如上皮细胞、间质细胞或圆形细胞），这通常见于增生/发育不良/不同来源的肿瘤。
Interestingly, coexistence of both inflammatory and neoplastic cells is not uncommon since rapidly growing tumours may easily cause tissue necrosis and therefore concurrent inflammation secondary to this. At the same time skin tumours (e.g. squamous cell carcinoma) may ulcerate leading to a concurrent inflammation, which sometimes may also be septic.
有趣的是，炎性细胞和肿瘤细胞同时存在也挺常见，因为快速生长的肿瘤可能很容易会引起组织坏死继而引起并发的炎症反应。同时，皮肤肿瘤（例如鳞状细胞癌）可能会溃疡，导致并发炎症，这有时也可能会发展成败血性感染。

3. Cytology of inflammation 炎症细胞学
Inflammation is classified according to the main cell type present (neutrophilic, eosinophilic, macrophagic, lymphocytic). In the absence of a prevalent cell type, the term mixed is used. Recognizing the type of inflammation may help in the identification of the causative agent of it. For example, eosinophilic inflammation is more commonly associated with hypersensitivity, parasitic or fungal diseases or it may represent a paraneoplastic syndrome (e.g. mast cell tumour, lymphoma. On the other hand, neutrophilic inflammation is frequently (but not always) associated with bacterial infections and bacterial culture is often recommended in those cases.
根据主要细胞类型将炎症分类（中性粒细胞性、嗜酸性粒细胞性、巨噬细胞性、淋巴细胞性）。如果不是以哪一种细胞为主，可以联合起来描述。识别炎症的类型可以帮助我们更好的找出病因。例如，嗜酸性粒细胞性炎症更常见于过敏、寄生虫性或真菌性疾病或者可能代表副肿瘤综合征（例如肥大细胞瘤、淋巴瘤）。另一方面，中性粒细胞性炎症经常（但不总是）于细菌感染有关，在这种情况下，常建议进行细菌培养。

Figure 1. (Left) Dog, skin lesion, eosinophilic inflammation, Wright Giemsa, 50x. 图1. （左）犬，皮肤病变，嗜酸性粒细胞性炎症，瑞姬氏染液，50x。

(Right) Dog, skin lesion, septic neutrophilic inflammation with intracellular cocci bacteria, Wright Giemsa, 100x.
（右）犬，皮肤病变，感染性中性粒细胞性炎症，可见胞内球菌，瑞姬氏染液。

4. Cytology of neoplasia 肿瘤细胞学
a) Identification of the cell origin. Neoplasia is usually characterized by the presence of a monomorphic population of cells which may be either epithelial, mesenchymal, or round cell in origin. Evaluation of the cellular morphology, architecture and distribution of cells on the slide are important for defining their origin.
a) 鉴别细胞来源。肿瘤常见的特征是存在大量单一形态的细胞，可能是来源于上皮细胞、间质细胞或圆形细胞。评估细胞形态、结构和在玻片上的分布对确定它们的来源非常重要。
- Epithelial cells have a variable shape, from cuboidal to polygonal and columnar. They have a high tendency to form cohesive clusters with different cytoarchitecture. The most typical cell arrangements are pavement, acinar, honeycomb, papillary, palisade and trabecular.
-上皮细胞有多种形状，从立方状到多边形和柱状都有。它们倾向于聚集成块形成不同的细胞结构。最典型的细胞排列结构是路面样、腺泡状、蜂窝样、乳头状、栅栏样和小梁状。
- Mesenchymal cells are usually elongated and fusiform and tend to be individually arranged in the slide. They may form small groups, but usually not cohesive. In poorly differentiated forms, mesenchymal tumour cells may become larger and rounded.
-间质细胞通常呈长条样梭形，在玻片中常单个存在。它们也可能成群出现，但通常不会相互粘连。在一些分化不良的形式中，间质肿瘤细胞可能会变得更大更圆。
- Round cells are round by definition and have a discrete appearance. They tend to be individually arranged in the slide and a defined architectural pattern is not present.
-圆形细胞根据定义是圆形的，离散型外观。它们通常在玻片中单个存在，不存在明确的结构模式。

Figure 2. (Left) Dog, skin mass, epithelial neoplasm (trichoblastoma), Wright Giemsa, 100x.
图2. （左）犬，皮肤肿块，上皮细胞瘤（毛母细胞瘤），瑞姬氏染液，100x。

(Centre) Dog, skin mass, mesenchymal neoplasm (sarcoma), Wright Giemsa, 20x.
（中间）犬，皮肤肿块，间质细胞瘤（肉瘤），瑞姬氏染液，20x。

(Right), dog, enlarged lymph node, round cell tumour (lymphoma), Wright Giemsa, 50x.
（右）犬，肿大的淋巴结，圆形细胞瘤（淋巴瘤），瑞姬氏染液，50x

b) Identification of criteria of malignancy. On cytology, the distinction into benign and malignant neoplasia is based mostly on morphologic characteristics. The lack of architectural information (available on histologic sections) does not allow evaluation of factors such as disruption or normal architecture and invasion into adjacent normal tissues or vessels, which are usually indicative of malignancy. Cytologic criteria are divided into general and nuclear criteria of malignancy. The absence of marked criteria of malignancy is generally supportive of a benign origin whereas the presence of three or more criteria of malignancy is most commonly associated with a malignant nature.
b)鉴别恶性标准。通过细胞学来区分良性和恶性肿瘤更多的依赖于形态学特征。缺乏结构信息（组织学切片上才有）便无法评估其它因素例如组织结构的破坏或正常和是否入侵附近正常组织或血管，这些因素通常代表恶性。细胞学恶性标准分为整体和细胞核标准。如果缺乏显著的恶性标准，一般认为是良性，然而如果存在3个或更多的恶性标准，很可能是恶性的。

Figure 3. Dog, skin mass, malignant neoplasm with marked cytological features of atypia including anisocytosis, anisokaryosis, binucleation and prominent nucleoli, Wright Giemsa, 50x.
图3. 犬，皮肤肿块。恶性肿瘤表现显著的细胞学异型性特征，包括细胞大小不等、细胞核大小不等、双核和明显核仁，瑞姬氏染液，50x。

Unfortunately, the absence of significant criteria of malignancy does not rule out completely the presence of a malignant tumour since well-differentiated neoplasms are not uncommon. Thyroid carcinoma, anal sac adenocarcinoma, hepatocellular carcinoma, fibrosarcoma are only a few of the neoplastic conditions which may do not show significant cytological criteria of malignancy at the smear examination but having an aggressive behaviour with rapid clinical progression and high tendency to metastasize.
不幸的是，没有显著的恶性特征并不代表一定不存在恶性肿瘤，因为有些分化良好的恶性肿瘤也很常见。甲状腺癌、肛门囊腺癌、肝细胞癌、纤维肉瘤只代表了一小部分肿瘤，这些肿瘤在细胞学检查时可能不会表现出显著的细胞学恶性特征，但是有很强的侵袭性行为，并且临床发展快速还有很高的转移倾向。

Further reading 更多阅读
Cian F, Freeman K (2017) (eds) Veterinary Cytology: Dog, Cat, Horse and Cow: Self-Assessment Color Review, 2nd edn. CRC press, New York.
Harvey JW (2012) Veterinary Haematology: A Diagnostic Guide and Color Atlas.
Raskin RE, Meyer DJ (2016) (eds) Atlas of Canine and Feline Cytology, 3rd edn. Saunders, Elsevier, St. Louis.
Valenciano AC, Cowell RL (2014) (eds) Cowell and Tyler’s Diagnostic Cytology and Hematology of the Dog and Cat, 4th edn. Mosby, Elsevier, St. Louis.
Villiers E, Ristic J (2016) (eds) BSAVA Manual of Canine and Feline Clinical Pathology, 3rd edn. British Small Animal Veterinary Association, Gloucester.