结直肠上皮内瘤变的诊断意义与处理原则

Diagnostic significance and management principles of colorectal intraepithelial neoplasia

目的探讨结直肠上皮内瘤变病理诊断的临床意义和外科治疗的原则。方法于2004年1月至2008年6月共收治术前经内镜活检、病理诊断为“上皮内瘤变”的病例共158例（共162个肿瘤），其中诊断为低级别上皮内瘤变73例，高级别上皮内瘤变89例。行腺瘤切除术5例，根治性结肠切除手术49例，直肠低位前切除术74例，经肛门局部切除术16例，Hartmann直肠经腹切除结肠造口术2例，腹会阴切除术4例，Parks结肠肛管吻合术7例，乙结肠造口术1例。经手术切除的标本常规作病理学检查，并与该患者的术前活检作比较，进行回顾性分析。结果术后109例（67．3％）病理证实为浸润性腺癌，在89例术前诊断为高级别上皮内瘤变的腺瘤中，80例（89．9％）术后病理确定是腺癌；在低级别上皮内瘤变中亦有29例（39．7％）术后确定为浸润性腺癌。在109例腺癌中2例伴有肝转移（M1），18例则有邻近组织浸润（T4）。术后病理证实有局部淋巴结转移或见癌结节者26例（23．9％）。结论应重视结直肠上皮内瘤变的病理诊断，高度警惕高级别上皮内瘤变。在临床和内镜中疑为恶性的病变，若不涉及保肛问题，宜首选作病变肠段切除，如术中可确诊为浸润性癌，则应作根治性切除。

Objective To discuss the significance of pathological diagnosis of colorectal intraepithelial neoplasia and its treatment principles. Methods One hundred and fifty-eight cases with coloreetal tumors were treated between January 2004 and June 2008, among them 73 cases of tumors were diagnosed as low grade intraepithelial neoplasia and 89 tumors as high grade intraepithelial neoplasia on biopsy. Five patients with adenoma were treated with endoscopic polypectomy, 49 patients with radical eolectomy, 74 patients with low anterior resection （LAR）, 16 patients with local excision, 2 patients with Hartmann operation, 4 patients with abdominal perineal resection, 7 patients with Parks coloanal anastomosis and 1 patient with sigmoid colostomy. The postoperative pathological examination result was compared with preoperative biopsy examination. Results With postoperative pathological examination, 109 cases （67. 3% ） were identified as infiltrative adenoearcinoma, among them 80 cases （89. 9% ） had been diagnosed as high grade intraepithelial neoplasia and the other 29 cases （39.7%） had been diagnosed as low grade intraepithelial neoplasia before the operation. In patients with infiltrative adenocarcinomas, 2 cases developed hepatic metastasis, 18 were classified as phase T4, and 26 cases （23.9%） were found with lymph nodes metastasis after the operation. Conclusions We should pay more attention to tumors with a diagnosis of intraepithelial neoplasia due to its high potential of malignancy. When the lesion was highly suspected to be malignant, and the resection of the tumor would save the anal sphincter, the tumor should be treated with segmental resection. If the tumor could be confirmed as a infiltrating one then a curative resection is the first choice.