1、论著411 例早期胃癌及癌前病变内镜黏膜下剥离术标本的病理学评估刘菊梅1，梁丽1，张继新1，戎龙2，张梓怡1，吴悠1，赵旭东2，李挺1(北京大学第一医院 1 病理科，2 内镜中心，北京100034)摘要目的:评估早期胃癌及癌前病变内镜黏膜下剥离术(endoscopic submucosal dissection，ESD)标本的病理学特征，为临床诊疗及病理学分析积累经验。方法:按日本早期胃癌 ESD 治疗指南和日本胃癌分类和处理指南，回顾性分析 2013 年9 月至2021 年12 月北京大学第一医院 ESD 治疗的411 例早期胃癌或癌前病变临床病理资料、病理诊断评估、术前胃镜活检(400 例
2、)与 ESD 术后组织病理学诊断符合情况，以及非治愈切除危险因素等。结果:411例中，96 例(23 4%)为腺瘤(WHO 低级别异型增生)，315 例(76 6%)为早期胃癌，后者包括 115 例(28 0%)非浸润性癌(WHO 高级别异型增生)和 200 例(48 7%)浸润性癌。术前活检与术后组织病理学诊断符合率为 66 0%(264/400)。ESD 前后诊断符合率与组织学类型及病变部位相关(P 0 01)。ESD 术后组织病理学诊断升级 119例(29 8%)、降级 17 例(4 2%)。315 例早期胃癌中，组织学分类的分化型癌 277 例(87 9%)，未分化型癌 38 例(12
3、 1%);绝对适应证 262 例(83 2%)，相对适应证 53 例(16 8%);整块切除率 98 1%，治愈性切除率 82 9%。非治愈性切除的独立危险因素包括病变最大径 20 mm(O=3 631，95%CI:1 170 11 270，P=0 026)、肿瘤浸润至黏膜下层(O=69 761，95%CI:21 033 231 376，P 0 001)，以及组织学分类为未分化型癌(O=16 950，95%CI:4 585 62 664，P 0 001)。结论:活检标本局限性、病变特点和分布、病理认识、内镜观察取材等主客观因素可导致术前活检与 ESD 术后组织病理学诊断存在差异，尤其术后升级诊
4、断更显著，应引起内镜中心与病理科医生的重视。ESD 手术早期胃癌治愈率高，非治愈性切除与病变最大径、肿瘤浸润深度及组织学类型相关。未分化型早期胃癌符合适应证标准也可实施 ESD。ESD 手术标本的全面及规范化病理学分析对 ESD 手术疗效及患者预后评估具有临床指导意义。关键词早期胃癌;异型增生;内镜黏膜下剥离术;病理学评估 中图分类号735 2 文献标志码A 文章编号1671-167X(2023)02-0299-09doi:10 19723/j issn 1671-167X 2023 02 014Pathological evaluation of endoscopic submucosal
5、dissection for early gastric cancerand precancerous lesion in 411 casesLIU Ju-mei1，LIANG Li1，ZHANG Ji-xin1，ONG Long2，ZHANG Zi-yi1，WU You1，ZHAO Xu-dong2，LI Ting1(1 Department of Pathology，2 Center of Endoscopy，Peking University First Hospital，Beijing 100034，China)基金项目:北京大学第一医院科研种子基金(2019SF13)Supporte
6、d by Scientific esearch Seed Fund of Peking University First Hospital(2019SF13)Corresponding author s e-mail，lixiaoting12 hotmail com网络出版时间:2023-3-311:32:52网络出版地址:http:/kns cnki net/kcms/detail/11 4691 202303021759022 htmlABSTACTObjective:To evaluate the pathological characteristics of endoscopic su
7、bmucosal dissection(ESD)specimens for early gastric cancer and precancerous lesions，accumulating experience for clinicalmanagement and pathological analysis Methods:A total of 411 cases of early gastric cancer or precan-cerous lesions underwent ESD According to the Japanese guidelines for ESD treatm
8、ent of early gastriccancer and classification of gastric carcinoma，the clinicopathological data，pathologic evaluation，con-cordance rate of pathological diagnosis between preoperative endoscopic forceps biopsies and their ESDspecimens(in 400 cases)，as well as the risk factors of non-curative resectio
9、n of early gastric cancer，were analyzed retrospectively esults:23 4%(96/411)of the 411 cases were adenoma/low-gradedysplasia and 76 6%(315/411)were early gastric cancer The latter included 28 0%(115/411)non-invasive carcinoma/high-grade dysplasia and 48 7%(200/411)invasive carcinoma The concordancer
10、ate of pathological diagnosis between endoscopic forceps biopsies and ESD specimens was 66 0%(264/400)，correlating with pathological diagnosis and lesion location(P 0 01)The rate of upgraded diag-nosis and downgraded diagnosis after ESD was 29 8%(119/400)and 4 2%(17/400)，respectivelyAmong the 315 ca
11、ses of early gastric cancer，there were 277 cases(87 9%)of differentiated type and38 cases(12 1%)of undifferentiated type In the study，262 cases(83 2%)met with absolute indica-tion，while 53 cases(16 8%)met relative indication En bloc and curative resection rates were 98 1%992北京大学学报(医学版)JOUNAL OF PEKI
12、NG UNIVESITY(HEALTH SCIENCES)Vol55No2Apr 2023and 82 9%，respectively isk factors for non-curative resection included a long diameter 20 mm(O=3 631，95%CI:1 170 11 270，P=0 026)，tumor infiltration into submucosa(O=69 761，95%CI:21 033 231 376，P 0 001)and undifferentiated tumor histology(O=16 950，95%CI:4
13、585 62 664，P 0 001)Conclusion:Several subjective and objective factors，such as the limita-tions of biopsy samples，the characteristics and distribution of the lesions，different pathological under-standing，and the endoscopic sampling and observation，can lead to the differences between the preopera-tiv
14、e and postoperative pathological diagnosis of ESD In particular，the pathological upgrade of postopera-tive diagnosis was more significant and should receive more attention by endoscopists and pathologistsThe curative resection rate of early gastric cancer in ESD was high Non-curative resection was r
15、elated tothe long diameter，the depth of tumor invasion and histological classification ESD can also be performedin undifferentiated early gastric cancer if meeting the indication criteriaThe comprehensive andstandardized pathological analysis of ESD specimens is clinically important to evaluate the
16、curative effectof ESD operation and patient outcomesKEY WODSEarly gastric cancer;Dysplasia;Endoscopic submucosal dissection;Pathological evalua-tion内镜黏膜下剥离术(endoscopic submucosal dis-section，ESD)已发展为消化道早期癌及癌前病变的有效治疗手段1 2，也是我国胃癌筛查、早诊早治的重要策略3 4。消化道早期癌及癌前病变的诊断与治疗包含内镜诊断、活检标本病理学诊断、ESD 实施、ESD 标本病理学诊断评估以及相关诊疗等系统性内容。针对 ESD 手术标本建立科学规范的病理诊断评估，对判定手术成功与否和患者预后非常重要。ESD 治疗前活检与术后标本组织病理学诊断可能存在一定差异5 7，术后组织学特征及切除治愈性的病理学评估，对于制定患者下一步治疗方案非常重要。目前国内大样本病例全面评估早期胃癌病理特点及治愈性分析的研究较少见。日本早期胃癌 ESD 治疗指南(第二版)重新定义了适应证及治愈性切除评估标准8。本