结直肠高级别上皮内瘤变的处理策略

[目的]研究结直肠高级别上皮内瘤变的临床及病理特征,探讨外科治疗原则和策略。[方法]45例结直肠肿瘤患者术前经内镜病理活检均诊断为高级别上皮内瘤变者,其中1例行腹腔镜探查,2例扩肛肿瘤局部切除,1例扩肛局部切除后补充行Miles术,2例行姑息性肿瘤手术,余39例行根治性结直肠癌手术,并将手术标本与术前病理作比较。[结果]术后病理活检示45例中有3例仍为高级别上皮内瘤变;42例证实为腺癌,其中1例伴有肝转移,24例有淋巴结转移,17例无淋巴结转移。[结论]术前病理活检确诊的结直肠高级别上皮内瘤变的肿瘤与术后病理活检结果一致性较差,对于这类患者应予积极的外科处理。     

非内镜下黏膜剥离术切除结直肠高级别上皮内瘤变和癌变息肉的临床特征分析

目的 非内镜下黏膜剥离术(ESD)切除结直肠息肉标本存在高级别上皮内瘤变(HGIN)和癌变可能,通过分析安徽省立医院非ESD切除结直肠已发生HGIN和癌变息肉的临床特征,为结直肠息肉选择最佳治疗方式提供临床证据。方法回顾性分析2019年1月1日至2022年4月30日于该院本部及南区所有行内镜下非ESD切除结直肠息肉的住院患者,分析术后病理已发生HGIN和癌变息肉的危险因素及内镜下特征。结果 结直肠息肉非ESD切除患者共计9446例,其中已发生HGIN159例(1.68%, 159/9446例);发生癌变83例(0.88%, 83/9446例),HGIN和癌变共计发生率2.6%(242/9446例)。小于45岁HGIN和癌变合计占总体发生率8.7%(21/242例)。切除息肉标本为HGIN和癌变无法确定其切除部位、息肉大小、息肉形态合计发生率分别16.1%(40/248枚)、19.8%(49/248枚)、14.1%(35/248枚)。年龄(≥60岁)、息肉部位(直肠、乙状结肠)、息肉大小(≥1 cm)是息肉癌变危险因素;亚蒂、长蒂息肉是结直肠息肉HGIN和癌变的危险因素(P<0.0...     

共聚焦激光内镜检查体内诊断上皮内瘤样变和结直肠癌

活检材料组织学分析仍是确诊结直肠病变的金标准.然而,这一检查和评估耗时较长,使内镜医师无法在结肠镜检查中立即确定是否须行切除术,导致需重复结肠镜检查.而且治疗过度(切除良性病变)或治疗不足(以活检代替肿瘤组织的切除)会给患者带来不必要的风险(如出血).近年开发的共聚焦激光显微内镜整合于传统电子结肠镜的远端头端.这一共聚焦激光显微镜可在结肠镜检查时进行活组织表面下成像,为体内组织学研究提供了快速、可靠的诊断工具.本研究旨在评价该新系统是否适用于结肠镜检查中上皮内瘤样变和结肠癌的诊断.     

结直肠高级别上皮内瘤变的临床分析38例

目的:研究结直肠高级别上皮内瘤变的临床病理特征,探讨临床合理治疗决策.方法:回顾性总结38例经内镜检查和病理初步诊断为结直肠高级别上皮内瘤变患者的,临床资料,分析其临床表现、内镜形态学、组织病理学特点、预后等,随访观察3-36 mo.结果:38例患者中,最终确诊17例为结直肠癌.21例仍为高级别上皮内瘤变.治疗前后诊断一致性较差(Kappa值为0.376).结直肠高级别上皮内瘤变合并癌的高危因素包括:肿瘤大小、内镜形态特点、症状严重、绒毛状腺瘤合并高级别上皮内瘤变、CEA或CA19-9增高等.结论:使用WHO新的诊断结直肠高级别上皮内瘤变需引起临床医生重视,特别是对于内镜下单纯活检病例.应当谨慎选择治疗方式和随访时间.     

共聚焦激光显微内镜对胃高级别上皮内瘤变的诊断价值

随着对胃癌癌前病变重要性的认识,上皮内瘤变(intraepithelial neoplasia,IEN)诊断体系[1]逐步得以推广和认识。胃镜活组织检查(活检)诊断为高级别上皮内瘤变(highgrade intraepithelial neoplasia,HGIEN)的病灶逐渐增多,经随访研究或手术及内镜下切除后病理学检查,其中部分确     

胃食管连接部低级别上皮内瘤变内镜黏膜下剥离术后与术前病理比较分析

目的 探讨胃食管连接部低级别上皮内瘤变（low-grade intraepithelial neoplasia,LGIEN）的治疗方案。方法 收集我院2013年1月至2017年6月经胃镜活检病理检查证实胃食管连接部LGIEN的61例患者,行内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）,进行术前与术后病理结果比较分析。结果ESD术后病理诊断炎症6例,LGIEN26例,HGIEN18例,早期胃食管连接部癌11例。术前诊断过度率9.84%（6/61）,术前术后病理一致率42.62%（26/61）,术前诊断不足率47.54%（29/61）,早期癌漏诊率18.03%（11/61）。病灶＜10mm者术前诊断不足率32.43%（12/37）,病灶≥10mm者术前诊断不足率70.83%（17/24）。结论 由于胃食管连接部位置特殊,病灶分布不均,易造成取检偏差,胃镜活检不能全面反映病灶真实情况。另外随着病灶面积增大其术前诊断不足率增加,早期癌漏诊率增加。胃食管连接部低级别上皮内瘤变应尽早ESD干预治疗,既能获得完整病理,完善检查,避免早癌漏诊,又能减轻患者心理负担。     

胃食管高级别上皮内瘤变内镜切除术前后病理结果对比研究

目的 比较胃、食管高级别上皮内瘤变病灶内镜活检与内镜切除标本病理诊断的异同.方法 选取近4年间147例内镜活检诊断为胃、食管黏膜高级别上皮内瘤变、经内镜下切除（EMR或ESD）患者的资料,对切除前后的病理结果进行对照分析.结果 147例患者活检病理均诊断胃、食管上皮内瘤变,其中胃41例,食管106例;内镜术后97例（66%）维持上皮内瘤变诊断,50例（34%）诊断为癌,且有11例已经侵犯到黏膜下层.病理分型腺癌34例,鳞癌16例,其中低-中分化癌22例（44%）.结论 内镜活检诊断胃、食管高级别上皮内瘤变的病例超过三分之一已经癌变,应该采取积极的治疗措施.     

内镜黏膜下剥离术在诊治胃上皮内瘤变中的价值

目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)在诊治胃上皮内瘤变(gastric intraepithelial neoplasia,GIN)中的价值。方法回顾性分析2012年1月-2013年8月南京医科大学附属苏州医院收治的32例行ESD治疗的GIN患者,并比较ESD治疗前后的病理差异,总结整块病灶切除率、切除病灶直径、手术操作时间、术中术后并发症、复发率。结果 (1)完整切除率100%(32/32);切除病灶直径1.1~5.2 cm,平均(2.3±1.2)cm;从黏膜下注射至完整剥离结束时间10~75 min,平均(35.0±16.5)min;术中无穿孔发生,术中出血率12.5%(4/32),予以止血等对症治疗后好转。无迟发性出血,32例患者均完成3~12个月随访,无病变残留或复发。(2)32例GIN患者行ESD治疗,术前低级别GIN 26例,高级别GIN 6例。行ESD后病理发现26例低级别GIN中有1例黏膜内癌,3例高级别GIN;6例高级别GIN中有2例黏膜内癌,癌变发现率为9.4%(3/32),总病理升级率为18.8%(6/32)。结论 ESD治疗GIN能及时发现胃早癌,且能安全、有效地根治。     

胰腺高级别上皮内瘤变及其miRNA的研究进展

胰腺上皮内瘤变（pancreatic intraepithelial neoplasia,PanIN）是指胰腺中小导管上皮细胞从不典型增生至原位癌这一系列病变的连续过程,根据其组织学异型性可分为3期,其中PanIN-1、2期为低级别,PanIN-3期为高级别[1-3].目前已经证实PanIN-3期是胰腺癌最直接的癌前病变[4].如果能在该期作出诊断,及时进行干预和治疗,是完全可以治愈胰腺癌的.因此寻找此期的特异性标志物是解决问题的关键.近年研究表明,miRNA不仅在肿瘤组织和细胞中的表达具有显著的肿瘤相关性、组织特异性和表达稳定性[5],而且在外周血中的表达同样具有肿瘤相关性和组织特异性,与RNA比较,其表达稳定性更为显著,因此认为外周血miRNA可能是一种理想的肿瘤分子标志物.同样,胰液中miRNAs检测也是早期诊断胰腺疾病的重要途径[6].因此,筛查和鉴定PanIN-3期组织和血或胰液中特异表达的miRNAs,探讨其作为胰腺癌早期诊断分子标志物的潜在可能性,对于提高胰腺癌的早期诊断率,改善其预后具有非常重要的意义.     

多环黏膜切除术治疗食管高级别上皮内瘤变围手术期处理

目的探讨多环黏膜切除术(MBM)治疗食管高级别上皮内瘤变的术前准备、术中操作注意事项及术后并发症的预防。方法回顾性分析2011年4月至2012年10月在河南宏力医院诊治的24例食管高级别上皮内瘤变患者的临床资料。24例患者均行MBM治疗,术前与患者及家属认真沟通,告知目前食管高级别上皮内瘤变的常见内镜处理方法及MBM的优缺点,获得患者及家属同意并签署知情同意书;准备套扎器、标记刀:针刀或dual刀、高频圈套器、两条单钳道胃镜或一条双钳道胃镜,调试内镜系统及高频电设备。手术过程依次为NBI内镜及碘染色确定病变范围,标记刀标记边界,套扎,高频电切除,后反复套扎、高频电切除,直至病变完全切除。术中及时止血。术后常规心电监护,防止迟发性出血,同时给予抑酸及对症支持治疗。术后1、3、6、12月分别复查胃镜随访远期并发症。结果 24例患者共26个病灶均顺利完成MBM治疗,其中2例行2次MBM治疗,平均操作时间为42 min。病灶长径为0.8~6.0 cm,平均3.1 cm,最宽3/4环周。单次使用套扎环1~6发,平均4发。术中4例患者出现明显出血,经热活检钳电灼后出血停止,未并发食管穿孔。术后病理检查结果提示重度不典型增生22例,原位癌2例。术后随访1~24个月,期间22例患者均愈合良好;1例患者(病变范围环3/4周径)术后1月出现食管瘢痕狭窄,行内镜下球囊扩张治疗症状缓解;1例患者(2处病变,分2次完成手术)术后3月复查,活组织检查考虑鳞状细胞癌,后行外科手术治疗。结论 MBM术前正确的病情评估,术中的精心操作,术后的恰当处理是治疗食管高级别上皮内瘤变成功的关键,同时表明MBM是内镜下切除食管高级别上皮内瘤变安全有效的治疗方法。     

Clinical role of endoscopic ultrasonography for the diagnosis of early colorectal cancer and selecting the treatment procedure

Background: Accurate evaluation of the depth of tumor invasion, including the degree of submucosal invasion, is a prerequisite to selecting the treatment procedure for early colorectal cancer (CRC). The purpose of the present study was to evaluate the significance of endoscopic ultrasonography (EUS) for diagnosing the depth of invasion of early CRC and selecting the treatment procedure. We concurrently estimated the usefulness of three‐dimensional EUS (3‐D‐EUS) compared with that of conventional EUS. Methods: We studied 413 consecutive early CRC for which the depth of invasion was examined by EUS. They consisted of 239 lesions of mucosal cancers and 174 lesions of submucosal cancers (sm cancers). We divided sm cancers into two groups, sm‐slight cancers (38 lesions) and sm‐massive cancers (136 lesions), according to the degree of infiltration in the vertical direction in the submucosa. The diagnostic accuracy of the depth of cancerous invasion by EUS and the characteristics of tumors that were difficult to image by EUS were examined. For 59 lesions, the depth of invasion was concurrently evaluated by 3‐D‐EUS to compare the clinical usefulness of this diagnostic tool with that of conventional EUS. Results: In 364 lesions (88%) of early CRC, we could diagnose the depth of invasion by EUS. Differentiation between mucosal or sm‐slight cancers, which were generally treated by endoscopic resection or local excision, and sm‐massive cancers, which were suitable for radical operation, was possible in 90%. A total of 49 lesions (12%) could not be imaged by EUS. Difficulty in imaging often occurred with lesions located proximally to the transverse colon and with protruded‐type lesions. The accuracy rate of 3‐D‐EUS for differentiating between mucosal or sm‐slight cancers and sm‐massive cancers, including difficult‐to‐image lesions, was 86%. This figure was slightly, but not significantly higher, than the accuracy rate of 73% for conventional EUS (P = 0.07). However, the concurrent application of 3‐D‐EUS was considered useful in 31 of the 59 lesions (53%) evaluated by both techniques. Conclusion: EUS is useful for evaluating the depth of tumor invasion and selecting the treatment procedure for early CRC. The concurrent use of 3‐D‐EUS may further improve diagnostic accuracy and decrease the number of difficult‐to‐image lesions.     

胃黏膜低级别上皮内瘤变中胃癌检漏的研究

目的探讨胃黏膜低级别上皮内瘤变(low grade intraepithelial neoplasia,LGIEN)中胃癌漏诊的情况。方法胃镜活检病理诊断为LGIEN的190例患者总结内镜下病灶部位和形态分类,并行内镜复查了解胃癌漏诊情况。结果 190例LGIEN患者病灶主要位于胃窦的137例(72.1%)。镜下病灶形态多样,其中糜烂及溃疡98例(51.6%)。190例患者平均随访时间11.7个月,经内镜病理或手术病理证实胃癌14例,HGIEN患者3例,较前加重者占8.95%;其中符合漏诊患者13例(76.5%),符合可能漏诊患者3例(17.6%)。结论胃镜活检病理检查为LGIEN的患者中部分同时存有癌灶,内镜短期、重复检查可减少胃癌漏诊率。     

Risk factors for pathological upgrading in perimenopausal women with cervical intraepithelial neoplasia grade 2/3 following conization

Postmenopausal women have a high risk for pathological upgrading in conization specimens due to pathological changes of the cervix. This study aimed to investigate the risk factors for pathological upgrading in conization specimens in Chinese women with cervical intraepithelial neoplasia grade 2/3 (Cervical intraepithelial neoplasia 2/3) ≥ 50 years of age. From January 2015 to December 2019, 443 CIN2/3 patients ≥ 50 years of age were retrospectively included and divided into the upgrade group (n = 47) and the non-upgrade group (n = 396) according to the presence or absence of pathological upgrading in the conization specimens. Multivariate logistic regression model was performed to analyze risk factors associated with pathological upgrading. The upgrade group was more likely to have gravidity < 2 times, postmenopausal period ≥ 5 years, higher incidences of endocervical glandular involvement (EGI) and human papillomavirus (HPV) 16/18 infection, as well as a lower incidence of cervical contactive bleeding and fewer cases undergoing endocervical curettage (all P < .05) than the non-upgrade group. Multivariate model showed that factors associated with pathological upgrading were postmenopausal period ≥ 5 years (OR = 2.55), EGI (OR = 17.71), endocervical curettage (OR = 0.33), and HPV type 16/18 (OR = 3.41) (all P < .05). The receiver operating characteristic analysis showed an area under curve of 0.782 (P < .001). Pathological upgrading in conization specimens is not uncommon in Chinese CIN2/3 patients ≥ 50 years of age. For those with high-risk factors of pathological upgrading (postmenopausal period ≥ 5 years, EGI, and HPV 16/18 infection), the follow-up interval can be appropriately shortened, and active intervention could be considered.     

高分级前列腺上皮内瘤和前列腺癌中Ezrin的表达及意义

目的探讨埃兹蛋白（Ezrin）在高分级前列腺上皮内瘤（HGPIN）及前列腺癌（CAP）中的表达及意义。方法采用免疫组化SP法检测44例CaP、12例HGPIN、20例前列腺增生（BPH）及10例正常前列腺（NP）组织中Ezrin的表达。结果31例（70．45％）CaP中Ezrin呈中等或强表达，12例HGPIN中Ezrin均呈弱或中等表达．20例BPH和10例NP中Ezrin没有或星弱表达。在CaP中。Gleason评分（GS）8～10分组的Ezrin表达明显高于7分组和5～6分组（P〈0．05），7分组Ezrin表达明显高于5～6分组（P〈0．05）。结论Ezrin的表达可能与CaP的发生有关，其对诊断HGPIN和判断CaP的转移及预后有重要意义。