-
食管癌是临床常见的一种消化系统恶性肿瘤,具有预后不良、复发率及病死率高等特点,其在所有恶性肿瘤中的发病率居于第5位,死亡率居于第4位[1-2]。因食管癌早期并无明显临床症状表现,多数病人就诊时已处于肿瘤中晚期,使得其预后较差,5年生存率低于10%[3],对病人生命安全造成极大的威胁。作为切除早期肿瘤的微创技术之一,内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)具有疗效确切、手术创伤小、安全性高等诸多临床优势,是治疗消化系统黏膜下肿瘤、癌前病变及早期食管癌等疾病的重要方法[4]。活体组织检查(简称“活检”)是目前评估ESD术前病变性质的重要手段,通过活检病理检查可初步评估病变黏膜性质,但在临床诊断中其评估准确性受多种因素的影响。基于此,本研究通过回顾性分析的方式,探讨ESD术前病理提示食管低级别上皮内瘤变(low-grade intraepithelial neoplasia,LGIN)病人术后出现病理升级的相关因素。
-
83例ESD术前病理提示食管LGIN病人中,病变整块切除74例(89.16%),ESD术后病理提示侧切缘阳性9例,未发现垂直切缘阳性。ESD术后出现病理升级44例(53.01%),其中升级至早期食管鳞癌8例(黏膜肌层浸润4例,黏膜内固有层浸润4例),高级别上皮内瘤变(high-grade intraepithelial neoplasia,HGIN)36例;术后病理仍提示食管LGIN者35例(42.17%),提示食管慢性炎症4例(4.82%)。其中,ESD术前行窄带成像放大内镜诊断35例,准确判断浸润深度者30例,准确率为85.71%(30/35)。
-
根据ESD术后是否出现病理升级对病人进行分组,其中病理升级组44例,无病理升级组39例。伴有结节样改变、黏膜表面发红的病人ESD术后病理升级的发生率升高(P < 0.01和P < 0.05);而不同性别、年龄、内镜分型、病变范围、病变部位及病变形态的病人ESD术后病理升级发生率差异均无统计学意义(P>0.05)(见表 1)。
因素 无病理升级组
(n=39)病理升级组
(n=44)χ2 P 性别 男
女26(66.67)
13(33.33)32(72.73)
12(27.27)0.36 >0.05 年龄/岁 < 65
≥6529(74.36)
10(25.64)24(54.55)
20(45.45)3.52 >0.05 内镜分型 Ⅱa型 17(43.59) 12(27.27) 2.90 >0.05 Ⅱb型 20(51.28) 27(61.36) Ⅱc型 2(5.13) 5(11.36) 病变范围 < 1/2食管管周 23(58.97) 16(36.36) 4.85 >0.05 1/2~3/4食管管周 15(38.46) 24(54.55) >3/4食管管周 1(2.56) 4(9.09) 病变部位 食管上段 3(7.69) 6(13.64) 1.58 >0.05 食管中段 28(71.79) 26(59.09) 食管下段 8(20.51) 12(27.27) 病变形态 形态规则 3(7.69) 0 6.32 >0.05 形态不一
花斑样改变21(53.85)
2(5.13)30(68.18)
5(11.36)地图样改变 13(33.33) 9(20.45) 结节样改变 是
否2(5.13)
37(94.87)12(27.27)
32(72.73)7.23 < 0.01 黏膜表面发红 是
否6(15.38)
33(84.62)18(40.91)
26(59.09)6.55 < 0.05 表 1 影响ESD术后出现病理升级的单因素分析[n; 百分率(%)]
-
以是否以病理升级为因变量,单因素分析差异有统计学意义的变量为自变量进行logistic回归分析,结果显示,结节样改变、黏膜表面发红是食管LGIN病人ESD术后出现病理升级的影响因素(P < 0.01)(见表 2)。
变量 B SE Waldχ2 P OR 95%CI 结节样改变 1.35 0.44 9.41 < 0.01 3.86 1.63~9.14 黏膜表面发红 1.08 0.31 12.14 < 0.01 2.95 1.60~5.41 表 2 影响ESD术后出现病理升级的多因素logistic回归分析
ESD术前病理提示食管LGIN病人术后出现病理升级的相关因素分析
Related factors analysis of the pathological escalation in patients with esophageal LGIN after ESD
-
摘要:
目的分析内镜黏膜下剥离术(ESD)术前病理提示食管低级别上皮内瘤变(LGIN)病人术后出现病理升级的相关因素。 方法回顾性分析2013年3月至2018年3月83例ESD术前病理提示食管LGIN病人的临床资料,通过单因素及多因素logistic回归分析病人ESD术后出现病理升级的相关影响因素。 结果83例ESD术前病理提示食管LGIN病人中,ESD术后出现病理升级44例(53.01%),其中升级至早期食管鳞癌8例,高级别上皮内瘤变(HGIN)36例;术后病理仍提示食管LGIN者35例(42.17%),提示食管慢性炎症4例(4.82%)。其中,ESD术前行窄带成像放大内镜诊断35例,准确判断浸润深度者30例,准确率为85.71%(30/35)。经单因素分析结果发现,伴有结节样改变、黏膜表面发红的病人ESD术后病理升级的发生率较无结节样改变、无黏膜表面发红者升高(P < 0.01和P < 0.05);而不同性别、年龄、内镜分型、病变范围、病变部位及病变形态的病人ESD术后病理升级发生率的比较差异无统计学意义(P>0.05)。经多因素logistic回归分析结果发现,结节样改变(OR=3.86,95%CI:1.63~9.14)、黏膜表面发红(OR=2.95,95%CI:1.60~5.41)是食管LGIN病人ESD术后出现病理升级的影响因素(P < 0.01)。 结论ESD术前病理提示食管LGIN病人术后出现病理升级的情况并不少见,且结节样改变、黏膜表面发红是ESD术后出现病理升级的危险因素,临床中对此类病人应提高警惕,行窄带成像放大内镜诊断辅助病理检查对提高ESD术前病理评估的准确性具有重要临床意义。 -
关键词:
- 食管肿瘤 /
- 内镜黏膜下剥离术 /
- 食管低级别上皮内瘤变
Abstract:ObjectiveTo analyze the related factors of pathological escalation after endoscopic submucosal dissection(ESD) in patients with low-grade intraepithelial neoplasia(LGIN) of esophagus. MethodsThe clinical data of 83 patients with esophageal LGIN diagnosed by pathology before ESD from March 2013 to March 2018 were retrospectively analyzed.The univariate and multivariate logistic regression analysis were used to analyze the related factors of pathological escalation after ESD. ResultsAmong 83 cases with esophageal LGIN, there were 44 cases(53.01%) with pathological escalation after ESD, which included 8 cases of early esophageal squamous cell carcinoma and 36 cases of high-grade intraepithelial neoplasia(HGIN).The results of postoperative pathology showed that 35 cases(42.17%) were esophageal LGIN, and 4 cases(4.82%) were chronic esophageal inflammation.Thirty-five cases were diagnosed using narrow-band imaging magnifying endoscopy before ESD, the depth of invasion in 30 cases were accurately judged, and the accuracy rate of which was 85.71% (30/35).The results of univariate analysis showed that the incidence rate of the pathological escalation in patients with nodular changes and reddening of mucosal surface was significantly higher than that in patients without nodular changes and redness of mucosal surface(P < 0.01 and P < 0.05), but there was no statistical significance in the incidence rate of pathological escalation in patients with different gender, ages, endoscopic classification, lesion ranges, lesion location and lesion morphology(P>0.05).The results of multivariate logistic regression analysis showed that nodular changes(OR=3.86, 95%CI:1.63-9.14) and mucosal surface rednes(OR=2.95, 95%CI:1.60-5.41) were the influencing factors of pathological escalation in patients with esophageal LGIN after ESD(P < 0.01). ConclusionsThe postoperative pathological escalation of esophageal LGIN is common, and the nodular changes and redness of mucosal surface are the risk factors of pathological escalation.In clinical practice, we should pay more attention to this kind of patients.It is of great clinical significance to improve the accuracy of preoperative pathological evaluation using narrow-band imaging magnifying endoscopy diagnosis and auxiliary pathological examination. -
表 1 影响ESD术后出现病理升级的单因素分析[n; 百分率(%)]
因素 无病理升级组
(n=39)病理升级组
(n=44)χ2 P 性别 男
女26(66.67)
13(33.33)32(72.73)
12(27.27)0.36 >0.05 年龄/岁 < 65
≥6529(74.36)
10(25.64)24(54.55)
20(45.45)3.52 >0.05 内镜分型 Ⅱa型 17(43.59) 12(27.27) 2.90 >0.05 Ⅱb型 20(51.28) 27(61.36) Ⅱc型 2(5.13) 5(11.36) 病变范围 < 1/2食管管周 23(58.97) 16(36.36) 4.85 >0.05 1/2~3/4食管管周 15(38.46) 24(54.55) >3/4食管管周 1(2.56) 4(9.09) 病变部位 食管上段 3(7.69) 6(13.64) 1.58 >0.05 食管中段 28(71.79) 26(59.09) 食管下段 8(20.51) 12(27.27) 病变形态 形态规则 3(7.69) 0 6.32 >0.05 形态不一
花斑样改变21(53.85)
2(5.13)30(68.18)
5(11.36)地图样改变 13(33.33) 9(20.45) 结节样改变 是
否2(5.13)
37(94.87)12(27.27)
32(72.73)7.23 < 0.01 黏膜表面发红 是
否6(15.38)
33(84.62)18(40.91)
26(59.09)6.55 < 0.05 表 2 影响ESD术后出现病理升级的多因素logistic回归分析
变量 B SE Waldχ2 P OR 95%CI 结节样改变 1.35 0.44 9.41 < 0.01 3.86 1.63~9.14 黏膜表面发红 1.08 0.31 12.14 < 0.01 2.95 1.60~5.41 -
[1] CHEN W, HE Y, ZHENG R, et al.Esophageal cancer incidence and mortality in China, 2009[J].J Thorac Dis, 2013, 5(1):19. [2] 兰青, 贺璐璐, 韦娜, 等.M2型巨噬细胞对食管癌移植瘤脉管生成的影响[J].郑州大学学报(医学版), 2017, 52(6):677. [3] 朱相展, 张彦婷, 韩康, 等.β-胡萝卜素对食管癌细胞凋亡与Cav-1表达的影响[J].郑州大学学报(医学版), 2016, 51(6):695. [4] 周震萍.内镜黏膜下剥离术在消化道黏膜下肿瘤治疗中的疗效研究[J].河北医学, 2016, 22(12):2047. doi: 10.3969/j.issn.1006-6233.2016.12.046 [5] SCHLEMPER RJ, RIDDELL RH, KATO Y, et al.The Vienna classification of gastrointestinal epithelial neoplasia[J].Gut, 2000, 47(2):251. doi: 10.1136/gut.47.2.251 [6] KUWANO H, NISHIMURA Y, OYAMA T, et al.Guidelines for diagnosis and treatment of carcinoma of the esophagus April 2012 edited by the Japan Esophageal Society[J].Esophagus, 2015, 12(1):1. doi: 10.1007/s10388-014-0465-1 [7] 陈欣然, 曲艺, 郝青, 等.可溶性协同刺激分子B7-H4在食管癌前病变病人血清的表达[J].河北医学, 2018, 24(8):1242. doi: 10.3969/j.issn.1006-6233.2018.08.003 [8] BORGGREVE AS, MOOK S, VERHEIJ M, et al.Preoperative image-guided identification of response to neoadjuvant chemoradiotherapy in esophageal cancer (PRIDE):a multicenter observational study[J].BMC Cancer, 2018, 18(1):1006. doi: 10.1186/s12885-018-4892-6 [9] 中华医学会消化内镜学分会, 中国抗癌协会肿瘤内镜专业委员会.中国早期食管癌筛查及内镜诊治专家共识意见精简版(2014年, 北京)[J].中华消化杂志, 2015, 35(5):294. doi: 10.3760/cma.j.issn.0254-1432.2015.05.003 [10] LIU S, GUO L, CHEN Q, et al.The improved cure fraction for esophageal cancer in Linzhou city[J].BMC Cancer, 2018, 18(1):949. doi: 10.1186/s12885-018-4867-7 [11] CHUA T, FUKAMI N.Upfront endoscopic submucosal dissection for superficial squamous cell carcinoma is superior to upfront surgical therapy[J].Gastrointest Endosc, 2018, 88(4):634. doi: 10.1016/j.gie.2018.07.021 [12] NAKAJO K, YODA Y, HORI K, et al.Technical feasibility of endoscopic submucosal dissection for local failure after chemoradiotherapy or radiotherapy for esophageal squamous cell carcinoma[J].Gastrointest Endosc, 2018, 88(4):637. doi: 10.1016/j.gie.2018.06.033 [13] 朱顺其, 卢忠生, 梁浩, 等.胃镜活检在食管黏膜病变治疗中的价值[J].解放军医学院学报, 2014, 35(5):427. doi: 10.3969/j.issn.2095-5227.2014.05.008 [14] LIU L, WEI H, FU J.Autologous esophageal mucosa transplantation to prevent esophageal stricture after endoscopic submucosal dissection:promising, but too early to draw a conclusion[J].Gastrointest Endosc, 2018, 88(4):784. [15] 丁炎波, 陈炳芳, 王莉, 等.三种方法预测食管早癌及高级别上皮内瘤变浸润深度的对比观察[J].中华消化内镜杂志, 2014, 31(11):665. doi: 10.3760/cma.j.issn.1007-5232.2014.11.015 [16] 王芳军, 汪娟, 赵可, 等.放大结合窄带成像在上消化道内镜检查中指导靶向活检的价值[J].中华消化内镜杂志, 2014, 31(7):393. doi: 10.3760/cma.j.issn.1007-5232.2014.07.007