拟诊胃肠间质瘤的上消化道黏膜下病变的超声内镜征象及其与病变进展和病理危险度分级的关系

Endoscopic ultrasonographic features of submucosal lesions of upper digestive tract suspected gastrointestinal stromal tumors and their correlation with progression and pathological risk grade of the lesions

目的探讨拟诊胃肠道间质瘤(GIST)的上消化道黏膜下病变的超声内镜(EUS)表现及其与病变进展和病理危险度的关系。方法回顾性队列研究。收集2013年1月至2021年4月在北京大学人民医院消化内镜中心经EUS检查拟诊为GIST患者的EUS表现、随诊复查、手术治疗及病理资料。根据病变情况与患者治疗意愿将患者分为随访观察组与手术治疗组。根据复查的EUS中肿瘤是否增大,将随访观察组分为肿瘤未增大组与肿瘤增大组,采用配对t检验比较随诊前、后病变大小,采用logistic回归模型分析肿瘤增大的危险因素。根据治疗方式,将手术治疗组再分为内镜治疗组和外科治疗组,根据病理结果和危险度分级进一步分为低危及以下组和中危及以上组,采用logistic回归模型分析病变病理恶性风险的危险因素,受试者工作特征(ROC)曲线预测病理中度及以上风险患者的肿瘤直径。探讨GIST的EUS表现及其与病变进展和病理危险度的关系。结果随访观察组共纳入73例患者,男23例,女50例,年龄58(30~88)岁;随访前病变直径为(1.21±0.49)cm,中位随访间隔为33.8个月,随访后病变直径(1.18±0.49)cm,随访前、后病变直径差异无统计学意义(均P>0.05);肿瘤增大组(18例,24.7%)和未增大组(55例,75.3%)各指标间的差异均无统计学意义(均P>0.05)。手术治疗组共纳入138例患者,男52例,女86例,年龄60(19~84)岁;术前EUS提示病变直径为(2.55±1.35)cm,术后病理提示病变直径为(3.43±2.42)cm。术后病理提示95例(68.8%)确诊为GIST,其他类型肿瘤43例(37例良性肿瘤与6例恶性肿瘤),多因素logistic回归模型分析提示仅有肿瘤直径增大[OR(95%CI):1.800(1.172~2.766),P=0.007]为中危及以上组的危险因素。ROC曲线分析预测中危及以上组的肿瘤直径为2.75 cm,灵敏度为71.4%,特异度为79.0%,约登指数为0.5,ROC曲线下面积为0.807(95%CI:0.703~0.909)。结论EUS对于评估拟诊GIST的上消化道黏膜下病变的进展和病理风险具有重要意义,对于直径较小的病变,可适当延长随诊间隔,放宽治疗指征。

Objective To investigate the endoscopic ultrasonographic(EUS)characteristics of submucosal lesions of upper digestive tract suspected gastrointestinal stromal tumors(GIST)and their correlation with biological behaviors and pathological risk grade of the tumors.Methods Retrospective cohort study.The EUS findings,follow-up review,surgical treatment and pathological data of patients with suspected GIST at the Gastrointestinal Endoscopy Center of Peking University People′s Hospital from January 2013 to April 2021 were collected.All samples were divided into follow-up group and treatment group based on the pathological condition and the patient′s treatment intention.According to whether or not the tumor was enlarged in EUS,the follow-up group was divided into non-enlarged group and enlarged group.Paired T-test was used to compare the lesion size before and after follow-up,and logistic regression was used to analyze the risk factors of tumor enlargement.According to the treatment methods,the treatment group was further divided into endoscopic treatment group and surgical treatment group.According to the pathological results and risk grade,the treatment group was further divided into the low-risk group and the medium-risk group.The risk factors of pathological malignant risk were analyzed by logistic regression,and the tumor diameter of patients with moderate or above pathological risk was predicted by receiver operation characteristic(ROC)curve.The relationship between the findings of EUS and the progression and pathological risk of GIST were also explored.Results Seventy-three cases including 23 males and 50 females,with an age of 58(30-88)years,were included in the follow-up group,with a mean lesion diameter of(1.21±0.49)cm before follow-up,median follow-up interval of 33.8 months,and a lesion diameter of(1.18±0.49)cm after follow-up.There was no significant difference(all P>0.05)in lesion diameter between before and after follow-up.There was no significant difference(all P>0.05)between tumor enlargement group(18 cases,24.7%)and non-enlargement group(55 cases,75.3%).One hundred and thirty-eight cases,including 52 males and 86 females,with an age of 60(19-84)years,were enrolled in the treatment group,with a mean EUS estimated diameter of(2.55±1.35)cm and pathological diameters of(3.43±2.42)cm.Ninety-five(68.8%)of these cases were pathologically confirmed as GIST while 43 cases were diagnosed as other tumor types,including 37 benign tumors and 6 malignant tumors.In multifactorial logistic regression analysis,only the increase of tumor diameter[OR(95%CI):1.800(1.172-2.766),P=0.007]was a risk factor for pathological intermediate or higher risk.The optimal tumor diameter for predicting pathological intermediate or higher risk using ROC curve analysis was 2.75 cm,with a sensitivity 71.4%,specificity 79.0%,Youden index 0.5 and area under ROC curve 0.807(95%CI:0.703-0.909).Conclusions EUS is essential for assessing the risk of progression and malignancy of submucosal lesions of upper digestive tract suspected GIST.For lesions of small diameter,the interval of follow-up shall be relatively extended while the indication of treatment could be partially waived.