结直肠高级别上皮内瘤变的临床意义及外科治疗(附83例报告)

Clinical and pathological characteristics of high-grade colorectal intraepithelial neoplastic changes and its surgical treatment (with a report on 83 cases)

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 :本院腹外科 2 0 0 2年 1月～ 2 0 0 4年 7月收治的结直肠肿瘤患者中 ,术前经内镜病理活检诊断为高级别上皮内瘤变者 83例 ,术前提示癌变者 2 8例 (33.7% )。 83例中男性 4 5例 ,女性 38例 ;年龄 33～ 88岁 ,中位年龄 6 0岁 ;肿瘤位于盲肠 1例 ,升结肠 7例 ,结肠肝曲 2例 ,横结肠 3例 ,结肠脾曲 1例 ,降结肠 5例 ,乙结肠 15例 ,直肠 4 6例 ,多原发 3例肿瘤分别位于盲肠 /直肠、升结肠 /乙结肠、降结肠 /乙结肠。 83例患者中 1例单纯探查 ,4例单纯扩肛肿瘤局切术 ,2例扩肛局切术后补充行Miles术 ,8例行姑息性肿瘤切除手术 ,余 6 8例行根治性结直肠癌手术。手术标本与术前病理作比较。结果 :术后病理 4例 (4 .8% )仍为高级别上皮内瘤变 ,肿瘤最大径 1～ 2cm ,平均 1.5cm ;余 79例 (95 .2 % )均证实为腺癌 ,肿瘤最大径 1～ 8cm ,平均 3.76cm ,两组大小有显著性差异 (P <0 .0 1)。术前后病理结果比较 ,Kappa一致值为 0 .0 4 4 ,一致性较差。多元相关分析显示肿瘤癌变与大小及浸润深度相关。证实为腺癌的 79例中已有 7例伴有肝转移 ,4例伴有盆腔转移 ;34例 (4 3.0 4 % )有局部淋巴结转移。 4 7例直肠肿瘤 (包括 1例多原发 )

Purpose:To study the clinical and pathological characteristics of high-grade colorectal intraepithelial neoplastic changes and to discuss the principles and strategy of its surgical treatment.Methods:Of the cases of colorectal tumors accepted for treatment at the Cancer Hospital from January 2002 to July 2004,83 cases underwent pre-operative endoscopic biopsy and were diagnosed as tumors with high-grade colorectal intraepithelial neoplastic changes.Of these cases,28 were found to be cancerous before operation(33.7%).Sex ratio:male 45,female 38.Age range:33～88,median age 60.Location:cecum 1,ascending colon 7,right flexure of colon 2,transverse colon 3,left flexure of colon 1,descending colon 5,sigmoid colon 15,rectum 46.The remaining 3 cases had multiple primary tumors at different sites.Of the 83 cases,1 had exploratory surgery,4 had transanal local excisions,2 had Miles operation after previous transanal excisions,8 cases had palliative surgery.The remaining 68 cases had radical colorectal surgery.The surgical specimens were all examined pathologically and compared with the pre-operative diagnosis of the case in question.Results:4 cases (4.8%) were pathologically diagnosed as high-grade intraepithelial neoplasia,their average diameter was 1.5cm.The other 79(95.2%) cases were diagnosed as adenocarcinoma,with an average diameter of 3.76cm.The difference in tumor size was statistically significant (P<0.01).Comparison of pre-and post-operative specimens showed poor consistency,the Kappa value was 0.044.Multivariate analysis showed a correlation between cancerous change to tumor size and depth of invasion.In the 79 cases confirmed as adenocarcinoma,liver metastasis occurred in 7 cases,pelvic metastasis in 4 cases,and regional lymph nodes metastasis in 34 cases (43.04%).Of the 47cases with rectal tumors,44(93.62%) were pathologically diagnosed as adenocarcinomas after operation.26 of these cases had their tumors located in the rectum<6 cm from the anal verge,with a median diameter of 3 cm, and the anus preservation rate was 38.46%.Of the factors involved in preservation and non-preservation of the anus,only the distance from anal verge was found to be significant(P<0.05).Conclusions:We have found that of the cases first diagnosed as high-grade intraepithelial neoplasia,approximately 95% already have cancerous changes,thus active surgical measures should be taken.For cases with tumors larger than 3 cm,radical surgery is recommended,but for tumors located at the lower rectum,the final decision should be made only after repeated endoscopic or transanal biopsy.[