大肠类癌45例内镜诊治分析

Endoscopic Diagnosis and Treatment of Colorectal Carcinoids:An Analysis of 45 Cases

目的：分析大肠类癌内镜下的表现特点，探讨内镜对大肠类癌的诊断及治疗价值。方法回顾性分析2003年1月-2013年3月广东省人民医院伟伦内镜室接受结肠镜检查并经病理证实的大肠类癌患者45例，总结其内镜下表现特点及治疗情况。结果45例患者均完成全大肠镜检查，按病灶部位不同分为：直肠类癌42例（93.4%）、乙状结肠类癌1例（2.2%）、升结肠类癌1例（2.2%）、盲肠类癌1例（2.2%）。直肠类癌多位于距肛缘〈11 cm，其中34例（75.6%）距肛缘〈8 cm。内镜下病灶直径0.3-3.0 cm，其中0.3-1.0 cm者41例（91.2%），1.1-2.0 cm者2例（4.4%），2.1-3.0 cm者2例（4.4%）。内镜下病灶主要表现为广基半球形或扁平隆起，多为黄白色，表面光滑，黏膜完整，边界清楚，用活检钳触之质地偏硬、活动度尚好。直径2.1-3.0 cm的病灶镜下表现为溃疡浸润型肿物。11例直肠类癌行超声内镜检查，超声扫描表现为病变来源于黏膜肌层和/或黏膜下层，呈低回声或混合回声改变，病灶内部回声均匀或欠均匀。除2例表现为浸润型肿物者行手术治疗以及1例直肠类癌镜下钳除外，42例大肠类癌患者均行内镜黏膜切除术（ EMR）、内镜黏膜吸引切除术（ EMRC）或内镜黏膜下剥离术（ ESD）并全瘤送检。显微镜下见瘤细胞呈圆形、卵圆形或柱状，体积较小，大小一致，瘤细胞排列呈梁状、缎带样、巢状及腺样，可见菊形团结构；细胞质丰富，嗜酸性，细胞核多呈圆形空泡状，核分裂象无或少见；瘤细胞多数位于黏膜下层，少数位于黏膜层；切缘均未见类癌细胞。免疫组织化学检测显示，神经内分泌肿瘤标记物：突触素阳性率为88.4%（38/43）， CD56阳性率为81.4%（35/43），CAM5.2阳性率为72.1%（31/43）。45例患者中成功随访38例（84.4%），随访时间为3个月-3年；随访期间无死亡，所有患者无复发及转移。结论掌握大肠类癌的内镜下特点，经超声内镜检查判断内镜治疗的可行性，EMR及ESD全瘤切除病灶送检是内镜下诊断及治疗大肠类癌的关键。

Objective To analyze the features of colorectal carcinoids under colonoscopy and endoscopic ultrasonogra-phy（ EUS）to investigate the clinical values of endoscopic diagnosis and treatment for colorectal carcinoids. Methods Data of 45 patients with colorectal carcinoids confirmed by colonoscopy and pathology in Guangdong General Hospital from January 2003 to March 2013 were analysed retrospectively. Morphologic characteristics,trans-endoscopic treatment and prognosis were summa-rized. ResUlts All patients completed full colonoscopy and were divided,according to lesion site,into groups rectal carcinoid （n=42,93. 4%）,sigmoid colon carcinoid（n =1,2. 2%）,ascending colon carcinoid（n =1,2. 2%）,cecal carcinoid （ n=1,2. 2%）. Most of rectal carcinoid located within 11 cm from anal margin,34 located within 8 cm. The lesion diameters were 0. 3-3. 0 cm under endoscopy. Forty-one patients had 0. 3-1. 0 cm（91. 2%）,2 had 1. 1-2. 0 cm（4. 4%）,2 had 2. 1-3. 0 cm（4. 4%）. The lesions presented mainly with broad-based semisphere or flat bulg,most were yellow -white, with smooth surface,integrated mucose,clear boundary,good activity range. The 2. 1-3. 0 lesions presentd with ulcer infiltra-ting tumors. Eleven of group rectal carcinoid group had EUS,showing that the lesions rooted in muscularis mucosa and（ or）sub-mucosa,with changes of hypoechoic or mixed echo,echo within lesion being well- or poorly-distributed. The 2 patients with＆amp;nbsp;infiltrating tumors had surgical treatment,1 with rectal carcinoid had endoscopic removal,42 colorectal carcinoid patients had endoscpic mucosal resection（ EMR ）, EMR with cap（ EMRC ） or endoscopic submucosal dissection（ ESD ）. Under micro-scope,tumor cells were round,oval or cylindrical,small,the same in size,arranging in shapes of beam-like,ribbon-like, nested and adenoid,and rosettes structure seen;cytoplasms were abundant,acidophilia;cell nucleus were round vacuoles, without or with few mitoses;tumor cells located mostly at submucosa;no carcinoids were seen at cutting edge. Immunohisto-chemistry showed that synaptophysin positive rate was 88. 4%（38/43）,that of CD56 was 81. 4%（35/43）,that of CAM5. 2 was 72. 1%（31/43）. Thirty-eight patients were followed up successfully（84. 4%）,the follow -ups lasted 3 months -3 years. No death,recurrence or metastasis occurred during follow-up. ConclUsion After grasping the endoscopic features of colorectal carcinoids and ultrasonography to determine the feasibility of endoscopic therapy,EMR and whole tumor resection of le-sions for inspection is the key of endoscopical diagnosis and treatment of colorectal carcinoids.