胃鏡活檢診斷食管高級別上皮內瘤變的可靠性分析

南京醫科大學第一附屬醫院消化內科，江蘇 南京 210029

【Abstract】ObjectiveTo investigate the histopathology of endoscopic submucosal dissection (ESD) specimens of esophageal high-grade intraepithelial neoplasia (HGIN) diagnosed by endoscopic forceps biopsy and correlate with endoscopic characteristics to predict the risks of cancer.MethodsThe information from 92 patients who underwent ESD for HGIN in the First Affiliated Hospital of Nanjing Medical University was retrospectively reviewed from Dec. 2012 to Apr. 2015. The clinical manifestation, endoscopic appearance and histopathological information were collected. All the enrolled patients were divided into concordant group (80 cases) and upgraded group (12 cases) according to the pathological results before and after ESD. The endoscopic characteristics before and after ESD were compared and the risk factors for discrepancy before and after ESD of esophageal HGIN were analyzed.ResultsAmong the enrolled 92 patients, histology of ESD specimens led to a change in diagnosis in 13.0% of the focal lesions and a relevant change in treatment policy in 6.5%. There were no significant differences in demographics, endoscopic and histopathologic features between concordant group and upgrade group, including gender, tumor location, erythema, nodularity, whitish fur, the number of biopsy and Lugol staining (P>0.05). The data of the cases including age ≤60 years old, the lesion size >2 cm, with erosion and macroscopic pattern were significant more frequently in the upgraded group than those in the concordant group (P<0.05). Further multivariate regression analysis demonstrated that the lesion size >2 cm, macroscopic patternl including 0-Ⅰ and 0-Ⅱc of focus as independent risk factors for upgraded pathology.Conclusion

For the lesions of pre-ESD histological diagnosis as HGIN, the lesion size >2 cm, 0-Ⅰ and 0-Ⅱc patterns to be the independent risk factors for histological changes, and we need to be vigilant against the possibility of missing cancer.

【Keywords】 Esophageal high-grade intraepithelial neoplasia; Endoscopic submucosal dissection; Endoscopic forceps biopsy; Follow-up

最新流行病學調查顯示，食管癌是中國第四大常見癌癥，也是癌癥相關死亡的第三大常見原因。其預后與診治時機密切相關，進展期食管癌的5年生存率不足25%。一項隨訪13.5年的研究發現，74%的食管高級別上皮內瘤變(high-grade intraepithelial neoplasia, HGIN)患者隨訪期間發生食管癌。因此，提高食管HGIN的診治率是決定食管癌患者預后的關鍵。食管HGIN被認為是內鏡黏膜下剝離術(endoscopic submucosal dissection, ESD)的絕對適應證，而進展期食管癌不適于內鏡治療。內鏡治療以其安全、高效、并發癥少、住院費用低、生活影響小等優勢目前成為治療食管HGIN的重要手段。國外文獻[4-5]報道，食管黏膜病灶活檢病理為HGIN病理升級率為25%～59%。本研究旨在分析影響食管HGIN病理升級內鏡下特點的因素，進而指導臨床決策。

1 資料與方法

1.1一般資料分析2012年12月至2015年4月在南京醫科大學第一附屬醫院內鏡中心診斷為HGIN并行ESD治療患者的臨床病理資料。納入標準：(1)ESD前后病理由兩位或兩位以上有經驗的病理科醫師報告；(2)術前病理提示食管HGIN；(3)完成術前檢查如超聲內鏡、CT等；(4)臨床資料完整。排除標準：(1)食管手術病史；(2)任何部位惡性腫瘤病史；(3)臨床資料不完整；(4)影像學資料(超聲食管鏡、電子計算機斷層掃描或核磁共振)顯示病變浸潤生長。最終篩選出92例患者為研究對象，男68例，女24例，年齡(64.78±7.67)歲。

1.2研究方法總結92例患者一般資料、術前內鏡下表現、術前病理、影像學檢查結果、術中情況及術后病理資料。其中內鏡下表現包括病變部位、大小、大體形態、盧戈氏染色、有無結節形成等；超聲胃……