胃镜病理活检诊断高级别上皮内瘤变的临床探讨

目的 评价胃高级别上皮内瘤变（HIN）这一概念在临床应用中的价值和不足.方法 回顾性分析经胃镜活检病理诊断为HIN的45例患者的临床和病理资料,并与术后病理诊断结果进行对比研究.结果 本组患者33例接受远端胃大部切除术,3例行近端胃大部分切除术,7例行全胃切除术,2例行内镜黏膜切除术.术后病理结果显示,15例（33.3%）维持HIN的诊断：14例（31.1%）为早期胃癌,16例（35.6%）为进展期胃癌,其中40.0%（12/30）伴有局部淋巴结转移.术前胃镜活检显示直径大于或等于3 cm、伴有溃疡或具有低分化癌特点的HIN病灶.术后多提示为癌（P〈0.05）.对于胃癌患者,具有上述特征者多为进展期胃癌,易发生淋巴结转移（P〈0.05）.结论 术前采用胃镜病理活检对HIN作出诊断应慎重;当HIN病灶直径大于或等于3 cm、伴有溃疡或具有低分化癌特点时,建议选择积极的根治性手术治疗.

Clinical discussion on the pathological diagnosis of high-grade intraepithelial neoplasia in gastric biopsy

Objective To evaluate the value and inadequacy in clinical practice of the concept of gastric high-grade intraepithelial neoplasia (HIN). Methods Forty-five cases with gastric HIN diagnosed by the esophagogastroduodenoscopy (EGD) biopsy were treated from 2003 to 2009.The clinical and histopathological data were analyzed retrospectively. Results Radical surgeries were successfully performed on all the patients,among whom 33 underwent distal subtotal gastrectomy,3 proximal partial gastrectomy,7 total gastrectomy,and 2 endoscopic mucosal resection.In postoperative pathological examination,only 15 cases(33.3%) were HIN,while 14 cases(31.1%)were found to be early gastric cancers,and 16(35.6%)were advanced cancers.Twelve(40.0%)out of 30 cancers had regional lymph nodes metastasis.When the maximum diameter of the HIN lesion was greater than 3.0 cm,or when ulcer or the features of poorly-differentiated carcinoma or signet-ring cell carcinoma were present in preoperative biopsy,the likelihood of cancer in postoperative pathological examination was higher(P<0.05),and when malignancy was confirmed,the presence of the features above was associated with lymph nodes metastasis and advanced cancer. Conclusions Carcinoma is identified in a large proportion of patients with gastric HIN by the EGD biopsy.Lymph nodes metastasis or advanced cancer may be detected in these cases.Cautions must be taken when the new concept of HIN is widely used for diagnosing gastric lesion.Radical resection should be considered when the maximum diameter of the HIN lesion is greater than 3.0 cm,or when ulcer,or the feature of poorly-differentiated carcinoma or signet-ring cell carcinoma are present in the EGD biopsy.