32例大肠锯齿状腺瘤临床、结肠镜及病理特点分析

目的探讨大肠锯齿状腺瘤患者的临床、结肠镜及病理特点。方法回顾性分析我院2008年4月-2009年12月消化内镜中心及病理科检出的32例大肠锯齿状腺瘤患者的临床、结肠镜及病理特点。结果32例大肠锯齿状腺瘤患者以腹痛就诊者20例（62．5％）,腹泻7例（21．7％）,便血2例（6．2％）,CEA升高体检2例（6．2％）,结肠癌术后复查1例（3．1％）;结肠镜检查病变位于直肠者18例（56．2％）,位于乙状结肠者3例（9．3％）,位于直乙交界处者5例（15．5％）,位于降结肠者2例（6．2％）,位于横结肠者3例（9．3％）,位于升结肠者1例（3．1％）;多发4例（12．5％）,单发28例（87．5％）;腺瘤直径多在1～6mm,最大直径20mm,平均直径9．5mm,32例大肠锯齿状腺瘤中广基息肉（Is）25例（77．3％）,亚蒂息肉（Isp）6例（19．6％）,有蒂息肉（Ip）1例（3．1％）。组织病理学检查为单纯锯齿状腺瘤8例（25．8％）,活检结果为锯齿状腺瘤,低级别上皮内瘤变22例（68．2％）,锯齿状腺瘤,局部高级别上皮内瘤变1例（3．1％）,锯齿状腺瘤,局部恶变1例（3．1％）,手术后病理证实为中分化腺癌。结论大肠锯齿状腺瘤作为一种独立的腺瘤形态与直结肠肿瘤密切相关,应引起重视。     

结直肠锯齿状病变的临床研究进展

结直肠锯齿状病变是一类具有典型"锯齿状"形态特征的病变,因其具有恶变潜能,近年来学者们对它的关注度越来越高。虽然目前国内外对该病变的基础研究较多,但临床研究不多,此文就结直肠锯齿状病变的流行病学特征、癌变机制、内镜特征及处理策略等方面进行归纳总结,旨在提高对此类病变的认知及临床处理能力。     

结直肠锯齿状病变特性的研究进展

多数临床和科研工作者认为,结直肠腺瘤是结直肠癌的癌前病变.但是,传统意义上认为惟有腺瘤是腺癌的癌前病变的观念已经受到来自多方面的挑战.     

锯齿状腺瘤的研究进展

传统上将良性结直肠息肉分为两大类：增生性息肉（ｈｙ－ｐｅｒｐｌａｓｔｉｃｐｏｌｙｐｓ,ＨＰ）和腺瘤性息肉（ａｄｅｎｏｍａｔｏｕｓｐｏｌｙｐｓ,ＡＰ）,这两类息肉有不同的结构及歧异的上皮生长和分化模式。通常认为ＨＰ无恶变倾向,而ＡＰ被认为是结肠腺癌的前...     

结直肠锯齿状病变的研究进展

结直肠锯齿状病变是一组隐窝上皮以“锯齿状”外观为特征的病变,以前认为这些病变没有恶变的风险,近年来发现它可以通过锯齿状通路进展为结直肠癌,故受到胃肠病学家的广泛关注。本综述介绍了结直肠锯齿状病变流行病学特征、内镜组织学特征、癌变分子机制、病变处理及与微生物群关联等方面,旨在提高对于该病变的认识及临床诊治能力。     

结直肠锯齿状病变：从组织学形态到分子机制的研究进展

结直肠锯齿状病变是一组上皮呈锯齿状结构的息肉/腺瘤,包括增生性息肉、无蒂锯齿状病变、无蒂锯齿状病变伴异型增生、传统锯齿状腺瘤和未分类的锯齿状腺瘤。无蒂锯齿状病变和传统锯齿状腺瘤是锯齿状病变发展为结直肠癌的前驱病变。锯齿状病变的特征是遗传（BRAF或KRAS基因突变）和表观遗传（CpG岛甲基化表型）的改变,协同驱动结直肠黏膜发生息肉、腺瘤,并恶性转化为结直肠癌。锯齿状病变的复杂性使其诊断困难,易漏诊且恶变率高。本文从内镜特征、病理特征、分子学进展等方面对结直肠锯齿状病变的研究进展作一综述。     

结直肠浅表锯齿状腺瘤的研究现状

浅表锯齿状腺瘤是2018年提出的一种新型锯齿状病变,具有独特临床病理和分子特征,表现出典型的混合性腺瘤和锯齿状特征。分子机制上,浅表锯齿状腺瘤病变表现为β‑连环蛋白的核积累和MYC过表达,提示WNT信号通路激活,同时浅表锯齿状腺瘤显示出与相关传统锯齿状腺瘤一致的KRAS突变和RSPO融合或过表达,提示浅表锯齿状腺瘤可能是KRAS突变的传统锯齿状腺瘤重要前体。本文重点讲述浅表锯齿状腺瘤的特点以引起内镜医师对该病变的重视。     

结直肠锯齿状病变的微卫星状态研究

目的 比较结直肠锯齿状病变与传统腺瘤、腺癌的微卫星状态的差异,以期间接验证传统型锯齿状成瘤通路的存在.方法 收集北京军区总医院病理科保存的75例大肠息肉及肿瘤组织蜡块标本,其中锯齿状腺癌(Sca)15例,非锯齿状腺癌(N-Sca)20例,传统型锯齿状腺瘤(TSA)20例,普通腺瘤20例.抽提基因组DNA,采用荧光标记引物扩增BAT25、BAT26两个位点,随后使用DNA自动测序仪检测其微卫星状态,并对实验结果进行统计学分析.结果部分标本扩增失败,对于成功扩增的68例标本:18例TSA中6例为高度微卫星不稳定型(MSI-H),12例为低度微卫星不稳定型(MSI-L)/微卫星稳定型(MSS);18例普通腺瘤均为MSS;13例Sca中3例为MSI-H,10例为MSI-L/MSS;19例N-Sca中仅1例为MSI-H,18例为MSI-L/MSS.统计学分析表明,普通腺瘤组、N-Sca组MSI-H发生率明显低于TSA组和Sca组(P<0.05),而后两组间差异无统计学意义(P>0.05).结论 与普通腺瘤、N-Sca相比,MSI-H更多见于TSA、Sca,由此推断存在一条有别于传统"腺瘤-癌"发生模式的传统型锯齿状成瘤通路,但尚需大规模前瞻性研究确认.     

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.     

结直肠锯齿状病变一癌前病变新通路

近年来人们注意到结直肠内存在一系列锯齿状结构病变,统称为锯齿状病变,其与部分散发性大肠癌的发生密切相关。这些病变包括畸形隐窝灶（ACF）、锯齿状息肉（SP）和锯齿状腺癌。本文将重点介绍畸形隐窝灶及锯齿状息肉的形态学、分子生物学研究的现状及进展。     

大肠锯齿状病变的分子改变

大肠癌是世界范围内死亡率居第三位的恶性肿瘤，大肠息肉一直被认为是其主要的癌前疾病。传统观点将大肠息肉分为腺瘤、增生性息肉、错构瘤性息肉以及炎性息肉，并认为近80％散发性大肠癌是由腺瘤引起的，而增生性息肉，一直以来认为其不会引起恶变。     

结直肠锯齿状病变的癌变机制及内镜诊断研究进展

结直肠锯齿状病变以往被认为是一种良性病变,近10年的研究表明其具有恶性潜能,锯齿状途径被认为是除腺瘤—癌、炎症—异型增生—癌变、de novo癌途径外新的结直肠癌癌变途径。据最新的世界卫生组织分类标准,锯齿状病变分为增生性息肉、无蒂锯齿状病变和传统锯齿状腺瘤3种类型。由于锯齿状病变具有相对特异的癌变途径及内镜下特点,本...     

Clinical features of upper gastrointestinal serrated lesions: An endoscopy database analysis of 98746 patients

AIM To analyse the clinical features of patients with the serrated lesions in the upper gastrointestinal tract(UPGI) tract.METHODS Patients who underwent routine esophagogastroduodenoscopy(EGD) at the Digestive Endoscopy Centre of General Hospital, Tianjin Medical University between january 2011 and December 2015 were consecutively recruited. Patients with UPGI serrated lesions were consecutively identified. The patients' demographics and histopathology were recorded. The colorectal findings for patients who underwent colonoscopy simultaneously or within six months were also extracted from the colonoscopy database. In addition, we analyseddifferences in colorectal neoplasia detection between the study patients and randomly selected patients matched for age and gender who did not exhibit serrated lesions and who also underwent colonoscopy in the same period.RESULTS A total of 21 patients out of 98746 patients(0.02%) who underwent EGD were confirmed to have serrated lesions with predominantly crenated, sawtooth-like configurations. The mean age of the 21 patients was(55.3 ± 17.2) years, and 11 patients were male(52.4%). In terms of the locations of the serrated lesions, 17 were found in the stomach(including 3 in the cardia, 9 in the corpus and 5 in the antrum), 3 were found in the duodenum, and 1 was found in the esophagus. Serrated lesions were found in different mucosal lesions, with 14 lesions were detected in polyps(8 hyperplastic polyps and 6 serrated adenomas with low grade dysplasia), 3 detected in Ménétrier gastropathy, 3 detected in an area of inflammation or ulcer, and 1 detected in the intramucosal carcinoma of the duodenum. In addition, colonoscopy data were available for 18 patients, and a significantly higher colorectal adenoma detection rate was observed in the UPGI serrated lesions group than in the randomly selected age- and gender-matched group without serrated lesions who also underwent colonoscopy in the same period(38.9% vs 11.1%, OR = 5.091, 95%CI: 1.534-16.890, P = 0.010). The detection rate of advanced adenoma was also higher in the UPGI serrated lesions group(22.2% vs 4.2%, OR = 6.571, 95%CI: 1.322-32.660, P = 0.028).CONCLUSION Serrated lesions in the UPGI were detected in various mucosal lesions with different pathological morphologies. Moreover colonoscopy is recommended for the detection of concurrent colorectal adenoma for these patients.     

近端锯齿状息肉检出的单中心回顾性研究

目的 探讨近端锯齿状息肉的检出情况并筛选其危险因素。方法 纳入2016年9月至2017年9月香港大学深圳医院内镜中心22位医师完成的9 010例结肠镜检查,计算腺瘤检出率（ADR）和近端锯齿状息肉检出率（PSDR）,并使用Pearson相关系数评估两者的相关性,利用logistic回归分析对比不同医师的PSDR。结果22位医师的全部受检者平均ADR为30.07%（20.00%~40.78%）,PSDR为4.70%（1.52%~9.28%）,男性PSDR为女性的1.38倍（OR=1.38,95%CI：1.13~1.69,P＜0.01）。≥50岁受检者3 560例（39.51%）,平均ADR为45.01%（28.99%~57.78%）,PSDR为6.08%（2.07%~10.56%）。在≥50岁受检者中,ADR与PSDR存在中等相关性（r=0.48,P=0.02）,男性PSDR为女性的1.36倍（OR=1.36,95%CI：1.04~1.80,P=0.03）。内镜医师是近端锯齿状息肉检出的显著危险因素（P＜0.01）,与检出率最高的医师相比,其他医师PSDR的OR值范围为0.16（95%CI：0.06~0.40;P＜0.01）到0.83（95%CI：0.53~1.32;P=0.44）。结论 近端锯齿状息肉在男性以及50岁以上人群中更为多见,检出率与内镜医师显著相关,不同医师的检出率差异巨大,结肠镜检查存在漏诊锯齿状息肉的风险。     

Sessile serrated adenomas in the proximal colon are likely to be flat,large and occur in smokers

AIM:To examine the epidemiology and the morphology of the proximal sessile serrated adenomas(SSAs).METHODS:We conducted a retrospective study to identify patients with SSAs using a university-based hospital pathology database query from January 2007to April 2011.Data collected included:age,gender,ethnicity,body mass index,diabetes,smoking,family history of colorectal cancer,aspirin,and statin use.We collected data on morphology of SSAs including site(proximal or distal),size,and endoscopic appearance(flat or protuberant).We also compared proximal SSAs to proximal tubular adenomas detected during same time period.RESULTS:One hundred and twenty patients with SSAs were identified:61%were distal and 39%were proximal SSAs.Proximal SSAs were more likely to be flat than distal(100%vs 78%respectively;P=0.0001).Proximal SSAs were more likely to occur in smokers(OR=2.63;95%CI:1.17-5.90;P=0.02)and in patients with family history of colorectal cancer(OR=4.72;95%CI:1.43-15.55;P=0.01)compared to distal.Proximal SSAs were statistically more likely to be≥6 mm in size(OR=2.94;P=0.008),and also more likely to be large(≥1 cm)(OR=4.55;P=0.0005)compared to the distal lesions.Smokers were more likely to have proximal(P=0.02),flat(P=0.01)and large(P=0.007)SSAs compared to non-smokers.Compared to proximal tubular adenomas,proximal SSAs were more likely to be large and occur in smokers.CONCLUSION:Proximal SSAs which accounted for two-fifths of all SSAs were more likely to present as flat lesions,larger SSAs,and were more likely to occur in smokers and in patients with family history of colorectal cancer.Our data has implications for colorectal cancer screening.     

Interendoscopist variability in proximal colon polyp detection is twice higher for serrated polyps than adenomas

AIMTo assess the interendoscopist variability in the detection of colorectal polyps according to their location and histological type.METHODSThis study was a retrospective analysis of prospectively collected data from a regional colorectal cancer (CRC) screening program; 2979 complete colonoscopies from 18 endoscopists were included. Variability in performance between endoscopists for detection of at least one adenoma (A), one proximal adenoma (PA), one distal adenoma (DA), and one proximal serrated polyp (PSP) was assessed by using multilevel logistic regression models.RESULTSThe observed detection rates among the 18 endoscopists ranged from 24.6% to 47.6% (mean = 35.7%) for A, from 19.1% to 39.0% (mean = 29.4%) for DA, from 6.0% to 22.9% (mean = 12.4%) for PA, and from 1.3% to 19.3% (mean = 6.9%) for PSP. After adjusting for patient-level variables (sex, age), the interendoscopist detection rates variability achieved a significant level for A, PA, and PSP but not for DA (P = 0.03, P = 0.02, P = 0.02 and P = 0.08, respectively). This heterogeneity, as measured by the variance partition coefficient, was approximately threefold higher for PA (6.6%) compared with A (2.1%), and twofold higher for PSP (12.3%) compared with PA.CONCLUSIONThese results demonstrate significant interendoscopist variability for proximal polyp particularly for serrated polyps, but not for distal adenoma detection. These findings contribute to explain the decreased effectiveness of complete colonoscopies at preventing proximal CRCs and the need to carefully assess the proximal colon during scope procedure.     

Correlations of morphology and molecular alterations in traditional serrated adenoma

Traditional serrated adenoma was first reported by Longacre and Fenoglio-Presier in 1990. Their initial study described main features of this lesion, but the consensus diagnostic criteria were not widely adopted until recently. Traditional serrated adenoma presents with grossly protuberant configuration and pinecone-like appearance upon endoscopy. Histologically, it is characterized by ectopic crypt formation, slit-like serration, eosinophilic cytoplasm and pencillate nuclei. Although much is now known about the morphology and molecular changes, the mechanisms underlying the morphological alterations are still not fully understood. Furthermore, the origin of traditional serrated adenoma is not completely known. We review recent studies of the traditional serrated adenoma and provide an overview on current understanding of this rare entity.     

Endoscopic and histologic characteristics of serrated lesions

In recent years , a second pathway for colonic carcinogenesis , distinct from the adenomatous pathway, has been explored. This is referred to as serrated pathway and includes three types of polyp,characterised by a serrated appearance of the crypts:hyperplastic polyps(HP),sessile serrated adenomas(SSA)or lesions,and traditional serrated adenomas.Each lesion has its own genetic,as well as macroscopic and microscopic morphological features.Because of their flat aspect,their detection is easier with chromoendoscopy(carmin indigo or narrow-band imaging).However,as we show in this review,the distinction between SSA and HP is quite difficult.It is now recommended to resect in one piece as it is possible the serrated polyps with a control in a delay depending on the presence or not of dysplasia.These different types of lesion are described in detail in the present review in general population,in polyposis and in inflammatory bowel diseases patients.This review highlights the need to improve characterization and understanding of this way of colorectal cancerogenesis.