子宫腺瘤样瘤临床病理分析

对12例子宫腺瘤样瘤进行临床病理及免疫组化观察，结果显示，12例子宫腺瘤样瘤占同期子宫切除标本的1．1％，肿瘤多位于子宫浆膜下及子宫角。临床表现无特征性，镜下见肿瘤由大小不等、形态不一的腺样及腔隙样结构组成，伴有间质平滑肌增生。AE1／AE2广谱细胞角蛋白（CK）、波形蛋白（Vimentln）、间皮细胞（MC）均阳性表达，而上皮膜抗原（EMA）、癌胚抗原（CEA）、FⅧ因子相关抗原均阴性。认为子宫腺瘤样瘤是一种良性病变，支持间皮起源，临床及病理检查均易误诊和漏诊，免疫组化检查可作为诊断和鉴别诊断的重要参考依据。     

大肠扁平腺瘤与息肉样腺瘤的对比研究

大肠扁平腺瘤指平坦或轻微隆起于大肠黏膜表面的腺瘤，其腺瘤成分的厚度不超过周围正常黏膜的两倍，1985年由Muto等最早报道。多项研究显示，大肠扁平腺瘤占所有大肠腺瘤患者的12％～42％，伴重度异型增生的比例超过12％，远高于息肉样腺瘤的4％，故认为扁平腺瘤是易癌变的特殊腺瘤类型。本研究通过结肠镜检查、病理检查和免疫组化染色研究大肠扁平腺瘤的特点。     

结直肠锯齿状腺瘤内镜和病理形态特征分析

目的 探讨锯齿状腺瘤（SA）内镜下形态和病理组织学特征.方法 回顾分析南方医院消化内镜中心2002年1月至2005年7月检出的大肠息肉病例,了解SA的检出率、内镜形态、腺管开口分型和病理组织学特征.结果 11894例肠镜检查共检出息肉病例1928例（2811枚）,检出率为16.21%,其中SA 61例（71枚）,检出率为0.51%,占息肉构成比为3.16%.SA直径＞1 cm者占39.44%,明显大于增生性息肉;内镜下表现为有蒂息肉所占的比例（26.76%）高于增生性息肉（13.25%）,但低于腺瘤性息肉（43.95%）.1815枚息肉进行腺管开口分型,SA多表现为Ⅲ型腺管开口（41.67%）,部分表现为Ⅳ型腺管开口（18.33%）,与腺瘤性息肉较接近.SA中度以上异型增生发生率介于管状腺瘤和绒毛状腺瘤之间,并有2.82%的癌变率.结论 SA内镜形态、腺管开口分型和病理学特点提示其本质上与增生性息肉不同,与肿瘤性息肉表现类似,具有恶变潜能.     

溃疡性结肠炎相关肿瘤3例诊疗报道并文献复习

目的探讨溃疡性结肠炎(ulcerative colitis, UC)相关肿瘤的临床特点、诊治、预后。方法对3例UC相关肿瘤患者的临床资料进行回顾性分析并复习相关文献。结果 3例UC相关肿瘤患者病程均超过10年;肠镜提示肿瘤性病变均为息肉样病变;2例为广泛结肠型结肠炎,1例为左半结肠型结肠炎;病理1例提示癌,2例活检组织提示中-度和重度异型增生;异型增生患者内镜下切除后经规范5-氨基水杨酸(5-aminosailcylic acid, 5-ASA)治疗及内镜下监测,病变处于黏膜愈合;1例癌变患者因未及时治疗,后期出现肿瘤多处转移。结论 UC相关肿瘤患者病程长,多见于广泛结肠受累的患者,以息肉样病变为主的肿瘤性病变可以内镜下切除,辅以规范治疗及监测,预后较好。     

炎症性肠病异型增生和癌变的病理学研究进展

溃疡性结肠炎（UC）和Crohns病（CD）,统称为炎症性肠病（IBD）,两者被公认与大肠癌关系密切。现有足够的证据支持大肠癌的发生经历了炎症-异型增生-癌的过程。最近的研究证实UC和CD的癌变风险相似,两者异型增生和癌变的病理学特征也相似。IBD的异型增生被定义为局限于基底膜内未侵犯固有层的确定性的瘤变上皮。本文就IBD异型增生和癌变的病理学研究进展作一综述。     

Syndecan-1在结直肠腺瘤和腺癌中的表达变化及其意义

Syndecan-1是一种由硫酸乙酰肝素链和硫酸软骨素链修饰的I型跨膜蛋白多糖，主要表达于上皮细胞表面，与肿瘤的多种生物学行为关系密切。目的：研究Syndecan-1在结直肠腺瘤和腺癌中的表达，探讨其与结直肠腺瘤和腺癌发生的关系。方法：分别采用逆转录聚合酶链反应（RT-PCR）和免疫组化染色检测56例结直肠腺瘤、42例腺癌和20例正常结肠组织中Syndecan．1mRNA和蛋白表达，并分析其与结直肠腺癌临床病理特征的关系。结果：RT-PCR和免疫组化染色结果显示Syndecan-1mRNA和蛋白在重度异型增生腺瘤和腺癌中的表达显著低于正常结肠组织和轻、中度异型增生腺瘤（P〈0．05），正常结肠组织与轻、中度异型增生腺瘤之间以及重度异型增生腺瘤与腺癌之间其表达无明显差异。Syndecan-1mRNA和蛋白表达与腺癌分化程度、浸润深度、淋巴结转移、远处转移以及TNM分期相关（P〈0．05），与性别、年龄以及是否合并结直肠腺瘤无关。结论：随着结直肠腺癌恶性程度的增加，Syndecan-1表达显著降低。Syndecan-1介导的细胞间黏附破坏在结直肠癌的致癌机制中可能起关键作用。     

大肠平坦型腺瘤与隆起型腺瘤的临床病理比较

目的 比较平坦型腺瘤和隆起型腺瘤的临床病理学特征,探讨两者生物学行为的差异.方法 选取2002年至2006年间行结肠镜检查并经病理证实的平坦型和隆起型腺瘤,比较两者的病理学特征差异.结果 平坦型和隆起型腺瘤重度异型增生的构成比分别为12.91％(4/31)和2.31％(12/519),在直径≤2.0 cm的腺瘤中,发生重度异型增生的比例分别为14.81％(4/27)和1.07％ (5/466),两组比较统计学差异均有显著性(P＜0.01,P＜0.01).结论 平坦型腺瘤发生重度异型增生的比例较隆起型腺瘤高,而且可能在体积更小时出现异型增生,提示平坦型腺瘤的生物学行为与隆起型腺瘤不同,平坦型腺瘤可能具有更高的恶变倾向.     

胰岛素样生长因子Ⅱ基因印迹丢失在结直肠腺瘤中的意义

背景：胰岛素样生长因子Ⅱ（IGF-Ⅱ）可促进多种细胞增殖,抑制细胞凋亡,其表达受基因印迹调控,IGF-Ⅱ基因印迹丢失（LOI）与多种肿瘤的发生相关。目前较少见IGF-Ⅱ与结直肠腺瘤关系的研究报道。目的：分析结直肠腺瘤中IGF-Ⅱ的表达及其基因印迹状态,初步探讨两者在结直肠腺瘤发生、发展中的作用。方法：以免疫组化方法检测14例正常结直肠黏膜、12例增生性息肉和53例结直肠腺瘤组织中IGF-Ⅱ的表达,以聚合酶链反应（PCR）-限制性片段长度多态性（RFLP）方法分析IGF-Ⅱ基因印迹状态。结果：IGF—Ⅱ的表达主要定位于细胞质,其表达在正常结直肠黏膜、增生性息肉和腺瘤组织中逐级递增（P＜0．05）。正常黏膜、增生性息肉和腺瘤组织的IGF—Ⅱ杂合子基因型比例分别为42．9％、41．7％和60．4％。杂合子标本中,腺瘤组织的IGF-ⅡLOI发生率显著高于正常黏膜和增生性息肉（68．8％对16．7％和20．0％,P＜0．05）。结论：IGF-Ⅱ LOI可能是导致IGF—Ⅱ蛋白表达增加,促进结直肠腺瘤发生以及向腺癌演变的重要机制。     

结直肠锯齿状腺瘤内镜表现和病理学特征分析

目的探讨锯齿状腺瘤（SA）内镜下表现和病理学特征。方法回顾分析滨州医学院附属医院2000年1月～2008年5月检出的大肠息肉病例,了解SA的检出率、内镜形态和病理学特征。结果8726例肠镜检查共检出大肠息肉1062例（1457枚）,检出率为12．17％,其中SA32例（60枚）,检出率为0．37％,占息肉构成比为3．01％。SA直径〉1cm者占21．63％,明显大于增生性息肉（8．57％）;SA表现为有蒂息肉所占的比例（8．33％）略高于增生性息肉（5．71％）,但都低于腺瘤性息肉（40．84％）。SA癌变率介于管状腺瘤和绒毛状腺瘤之间,接近于管状绒毛状腺瘤。结论SA内镜形态、病理学特点提示SA是兼有增生性息肉形态学特征和腺瘤性息肉组织学特点的息肉,具有恶变潜能.     

大肠小扁平腺瘤的形态及病理组织学特征研究

目的探讨大肠小扁平腺瘤的形态学特征及p53、p21、雌激素受体（estrogen receptor，ER）、孕激素受体（progesterone receptor，PR）表达的生物学意义。方法用Olympus CF240型电子结肠镜及OlympusBX41光学显微镜观察50例大肠小扁平腺瘤形态学特征。用免疫组化二步法检测50例小扁平腺瘤及其腺瘤旁组织、26例大肠癌及其癌旁组织、15例正常人大肠黏膜中p53、p21、ER、PR的表达情况。结果小扁平腺瘤发生于大肠任何部位，其发病率依次以横结肠、乙状结肠、直肠为多见；肠镜下见病灶呈圆形或椭圆形，扁平状，基底宽，体积≤1cm。光镜下小扁平腺瘤呈管状腺瘤样图像，上皮具有不同程度的异型增生。小扁平腺瘤中p53、p21、ER、PR的表达率分别为58％（29／50）、56％（28／50）、12％（6／50）、10％（5／50）。随着小扁平腺瘤异型增生程度的增高，p53、p21、ER、PR的表达率也逐渐升高（P〈0．05）。大肠癌中的表达最高（P〈0．05）。结论大肠小扁平腺瘤有其独特的形态学特征，p53、p21、ER、PR的表达与大肠小扁平腺瘤的发生发展有密切关系。     

Adenoma‐like and non‐adenoma‐like dysplasia‐associated lesion or mass in ulcerative colitis

Ulcerative colitis (UC) patients have an increased risk of colorectal cancer. UC has two general patterns of dysplasia, which are commonly classified as adenoma‐like dysplasia‐associated lesion or mass (DALM) and non‐adenoma‐like DALM. The latter has a high risk of concurrent malignancy and often requires a colectomy. Unfortunately, non‐adenoma‐like DALMs sometimes have endoscopic features similar to those of adenoma‐like DALMs. Therefore, new endoscopic techniques to distinguish between these two kinds of DALM have been proposed.     

Long-term follow-up after polypectomy treatment for adenoma-like dysplastic lesions in ulcerative colitis.

BACKGROUND & AIMS: A previously published study by our group suggested that adenoma-like dysplasia-associated lesions or masses (DALMs) in ulcerative colitis (UC) may be treated adequately by polypectomy and continued endoscopic surveillance. The length of follow-up evaluation in these patients averaged only 42 months. The purpose of this study was to evaluate the long-term outcome of our previously defined group of UC patients, all with adenoma-like DALMs, who were treated by polypectomy. METHODS: The clinical, endoscopic, and pathologic outcome of 34 UC patients, 24 with an adenoma-like DALM, and 10 with a coincidental sporadic adenoma, 28 of whom were treated by polypectomy and continued endoscopic surveillance, and 6 by colonic resection, were compared with the outcome of 49 non-UC patients who were treated similarly for a sporadic adenoma. The mean length of follow-up evaluation averaged 82.1 months and 71.8 months for the 2 UC subgroups, respectively, and 60.4 months for the non-UC controls. RESULTS: Overall, 20 of 34 UC patients (58.8%) developed at least one further adenoma-like DALM on follow-up evaluation. One patient had flat low-grade dysplasia present in the colon, which was resected within 6 months of the initial polypectomy, and another patient, with primary sclerosing cholangitis, developed adenocarcinoma 7.5 years after her initial polypectomy. There was no significant difference in the prevalence of polyp formation on follow-up evaluation between UC patients with an adenoma-like DALM (62.5%) and UC patients with a sporadic adenoma (50%), or between either of these 2 UC patient subgroups and the non-UC sporadic adenoma patient group (49%; P > 0.05). CONCLUSIONS: UC patients who develop an adenoma-like DALM may be treated adequately by polypectomy with complete excision and continued endoscopic surveillance.     

Polypoid lesions in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) may develop a variety of neoplastic and nonneoplastic polyps. This review covers the pathology, pathogenesis, natural history, and treatment of polyps in IBD with special emphasis on dysplastic lesions. Elevated or polypoid dysplastic lesions in IBD patients are referred to by the acronym DALM (dyspasia-associated lesion or mass). DALMs are further categorized as adenoma-like (endoscopically resectable polypoid dysplasia) or non–adenoma-like (non–endoscopically resectable polypoid dysplasia) based on their endoscopic appearance. Colectomy is recommended for patients with a non–adenoma-like DALM because of the high risk of synchronous or metachronous adenocarcinoma. In contrast, adenoma-like DALMs can be safely treated by polypectomy and continued surveillance provided that the lesion is removed in total, with negative margins, and no flat dysplasia is identified in the colon adjacent to and distant from the polyp.     

Variability in the diagnosis and management of adenoma-like and non-adenoma-like dysplasia-associated lesions or masses in inflammatory bowel disease: an Internet-based study

BACKGROUND: Dysplasia-associated lesions or masses (DALMs) in inflammatory bowel disease (IBD) are a heterogeneous group of tumors with different natural histories. OBJECTIVES: Our purpose was to determine the ability of gastroenterologists (GE) to distinguish adenoma-like (ALD) from non-adenoma-like DALMs (NALD) in patients with ulcerative colitis (UC) and to evaluate management practices with regard to these lesions. PARTICIPANTS: Randomly chosen academic and private practice members of the American Society for Gastrointestinal Endoscopy and a group of IBD experts. DESIGN: All GEs answered a series of questions related to UC-associated DALMs and were asked to classify 13 digitally transmitted endoscopic images (5 ALD, 5 NALD, and 3 inflammatory polyps [IP]). SETTING: Internet-based survey. PATIENTS: Not applicable. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASUREMENTS: Percentage of respondents who answered management questions and classified endoscopic images correctly. RESULTS: ALD, NALD, and IP were correctly diagnosed by 68%, 75%, and 82% of IBD experts; 58%, 56%, and 57% of academic gastroenterologists; and 60%, 73%, and 60% of private practice GEs, respectively. Overall, there were no significant differences in rates of correct diagnosis for the 3 types of polyps (P=.603). IBD experts showed a significantly higher correct diagnosis rate (P=.048) and interobserver agreement (P<.01) compared with the other two GE groups. Many GEs were not aware of the currently recommended management guidelines for patients with IBD with DALMs. LIMITATIONS: Only a single endoscopic image was used in this study. The response rate was 32%. CONCLUSION: These data suggest that academic GEs and private practice GEs have more difficulty than IBD experts do in distinguishing between and managing DALMs in patients with UC.     

High-grade dysplastic adenoma-like mass lesions are not an indication for colectomy in patients with ulcerative colitis

Objective. The management of high-grade dysplasia (HGD) in polypoid lesions in patients with ulcerative colitis (UC) is not well characterized. The purpose of this study was to characterize the clinical course of patients with HGD in adenoma-like dysplasia-associated lesion or masses (DALMs) in the absence of any synchronous flat dysplasia. We hypothesize that colectomy is not warranted in patients who undergo complete excision of adenoma-like DALMs with HGD in UC. Material and methods. Pathology and clinical databases were systematically searched for the presence of dysplastic lesions in inflammatory bowel disease from 1997 to 2004. Patients with UC who had adenoma-like DALMs were identified, and a subset with HGD lesions was defined as our study cohort. Results. A total of 102 patients with UC were identified. Thirty of them (29%) had adenoma-like DALMs without synchronous flat dysplasia; 9 of these patients (30%) had HGD in these lesions. Thirty-two surveillance colonoscopies were performed in this cohort (mean 3.6 colonoscopies/patient). The patients were followed for a mean of 76.5 months (52–99 months). Three out of 9 patients (33%) had colectomy. None of the patients in this cohort was detected to have carcinoma in surveillance biopsies and/or in the resection specimens. Conclusions. Our data suggest that the presence of HGD in DALMs does not warrant colectomy. Continued close observation is suggested in this patient cohort after complete excision of polyps. Further prospective evaluation of this patient population is merited.     

The present status and problems with diagnosis and management of dysplasia/colitic cancer in ulcerative colitis

Patients with long-standing UC (ulcerative colitis) have an increased risk of colorectal cancer. Colonoscopic surveillance for UC patients is generally accepted to reduce mortality due to colitic cancer. However, the diagnosis and management of dysplasia remain controversial. The literature about the present status of and problems with diagnosis and management of dysplasia/colitic cancer was reviewed. The problems that arise are: (1) the surveillance program is different in each guideline; (2) the biopsy number that the guidelines propose for surveillance is too large to observe, and there is no adequate evidence of benefit from this number; (3) direct evidence to prove the efficacy of the present surveillance methods is not shown; (4) significant variability is thought to exist between diagnosticians in the diagnosis of low-grade dysplasia (LGD) and indefinite dysplasia (IND); (5) a consensus has not been reached about the management of flat LGD; (6) there is disagreement about the definition of dysplasia-associated lesions (DALM), and there are cases where the differentiation of DALM, adenoma-like mass (ALM)/adenoma-like dysplasia (ALD), sporadic adenoma and even inflammatory polyps is difficult.     

Management of neoplastic polyps in inflammatory bowel disease

Dysplasia-associated lesions or masses (DALMs) are a heterogeneous population of lesions with different endoscopic and morphologic features. Non-adenoma-like DALMs should be removed via colectomy. Adenoma-like DALMs that occur outside areas of colitis can be treated like sporadic adenomas and removed by polypectomy. Recent data suggest that adenoma-like DALMs located within areas of colitis should be removed by polypectomy with complete excision and multiple biopsies of the site. As long as there is no flat dysplasia or adenocarcinoma elsewhere in the colon, a colectomy is not required. However, this group of patients requires increased colonoscopic surveillance.     

Narrow band imaging with magnification for dysplasia detection and pit pattern assessment in ulcerative colitis surveillance: a case with multiple dysplasia associated lesions or masses

A 62 year old man with longstanding ulcerative colitis and previous endoscopic excision of two dysplasia associated lesions or masses (DALMs) was admitted to our endoscopy unit for evaluation and resection of other possible DALMs. He had previously been offered and refused colectomy because of comorbidity from Parkinson's disease. He had multiple polypoid and sessile lesions which were assessed using a third generation prototype narrow band imaging (NBI) colonoscope with magnification. Selected lesions were either biopsied or resected with a combination of endoscopic submucosal dissection and endoscopic mucosal resection techniques. We correlated the pit pattern and vascular pattern intensity seen with magnification NBI with histology of both inflammatory and dysplastic lesions. Dysplastic areas showed Kudo pit patterns II, IIIL, and IV and high vascular pattern intensity. Non-dysplastic and dysplastic areas of recurrence immediately adjacent to the scar from a previous endoscopic mucosal resection site were also assessed. This is the first case report where NBI has been shown to help in DALM detection and to distinguish dysplastic from non-dysplastic mucosa in ulcerative colitis.     

Cancer risk in IBD: how to diagnose and how to manage DALM and ALM

The risk of developing neoplasia leading to colorectal cancer is significantly increased in ulcerative colitis （UC） and most likely in Crohn＇s disease. Several endoscopic surveillance strategies have been implemented to identify these lesions. The main issue is that colitisassociated neoplasms often occurs in flat mucosa, often being detected on taking random biopsies rather than by identification of these lesions via endoscopic imaging. The standard diagnostic procedure in long lasting UC is to take four biopsies every 10 cm. Image enhancement methods, such as chromoendoscopy and virtual histology using endomicroscopy, have greatly im- proved neoplasia detection rates and may contribute toreduced random biopsies by taking targeted ＂smart＂ biopsies. Chromoendoscopy may effectively be performed by experienced endoscopists for routine screening of UC patients. By contrast, endomicroscopy is often only available in selected specialized endoscopic centers. Importantly, advanced endoscopic imaging has the poten- tial to increase the detection rate of neoplasia whereas the interplay between endoscopic experience and interpretation of histological biopsy evaluation allows the physician to make a proper diagnosis and to find the appropriate therapeutic approach. Colitis-associated intraepithelial neoplasms may occur in flat mucosa of endoscopically normal appearance or may arise as dysplasia-associated lesion or mass （DALM）, which may be indistinguishable from sporadic adenomas in healthy or non-colitis mucosa [adenoma-like mass （ALM）]. The aim of this review was to summarize endoscopic and histological characteristics of DALM and ALM in the context of therapeutic procedures.     

Is p53 immunohistochemistry useful for optimal decision for treatment of polypoid lesions in ulcerative colitis?]

BACKGROUND: Usefulness of p53 staining for the differentiation between adenoma and DALM has been reported recently, so recognizable lesions stained positively can be diagnosed as DALMs. For the cases with DALMs, total colectomy has been thought to be necessary. METHODS: Immunohistochemical staining for p53 was performed in 4 adenocarcinomas and 4 adenomas in ulcerative colitis. RESULTS: Three carcinomas and 3 adenomas were positive. One carcinoma (protruded mucosal cancer) and 3 adenomas (1 flat elevated lesion and 2 laterally spreading tumors) stained positively for p53 were treated only by polypectomy or local excision. The patients have been under surveillance for periods ranging from 1 to 10 years, during which no metachronous dysplasia has developed. CONCLUSIONS: These findings suggest that some groups of the polypoid lesions can be resected locally even if stained positively by p53 immunohistochemistry.