肠镜活检诊断的结直肠高级别上皮内瘤变治疗对策

Management of colorectal high-grade intraepithelial neoplasia based on colonoscopic biopsy

目的探讨肠镜活检诊断为结直肠高级别上皮内瘤变（HGIN）病例的处理原则。方法对第二军医大学附属长海医院2002年1月至2009年12月间收治的203例肠镜活检诊断为HGIN病例的临床诊治资料进行回顾性分析。直接接受根治术156例，全瘤切除活检47例，分别将术后诊断与肠镜活检诊断进行对比．并对两组问的临床病理学差异进行统计学分析。结果肿瘤位于结肠（P=0．02）、肿瘤无蒂（P=0．00）以及体积大（P=0．00）是导致选择直接行根治术的影响因素。术后共有163例（80．3％）诊断为浸润性癌，而仅有40例（19．7％）证实为HGIN。156例根治性切除患者中，有140例手术标本确诊为浸润性癌，16例仍为HGIN。47例行全瘤切除活检的患者中,24例术后确诊为HGIN,23例被诊断为浸润性癌,其中15例后续行根治术。结论基于肠镜活检诊断的HGIN应积极行全瘤切除活检明确诊断：在不具备全瘤切除的条件下,对于不涉及保留肛门的高度疑癌病例也可直接行根治术以防延误治疗。

Objective To investigate the principle of management of colorectal high-grade intraepithelial neoplasia （HGIN） based on colonoscopic biopsy. Methods Patients diagnosed as colorectal HGIN based on colonoscopic biopsy in the Changhai Hospital from January 2002 to December 2009 were enrolled in the study. The clinical data of all the patients were collected and analyzed. According to the subsequent operation, cases were divided into local complete resection group and radical operation group. The discrepancy between the biopsy diagnosis and postoperative diagnosis was investigated. Results Of the 203 biopsy-based colorectal HGIN lesions, 156 underwent radical resection, while 47 received local complete resection. Univariate analyses indicated that tumors located in colon （P=0.02）, tumors with sessile growth （P=0.00） and large tumors （P=0.O0） were more likely to be treated with radical resection. Postoperative diagnosis revealed that 163 cases （80.3%）were invasive cancers, while the other 40 cases （19.7%） were HGIN lesions. Of the 156 cases resected radically, 140 cases were invasive cancers, 16 cases were diagnosed as HGIN. Of the 47 cases who underwent local complete resection, 24 cases were confirmed as HGIN but the other 23 cases were invasive cancers, in which 15 cases received subsequent radical operation. Conclusions A large proportion of biopsy-proven colorectal HGIN lesions are invasive cancers. Therefore, local resection should be performed to confirm diagnosis. For highly suspected malignant tumors which can not be removed completely by local resection, if anus can be reserved, a radical transabdominal surgery is recommended even without biopsy-proven malignancy in order to avoid treatment delay.