同时性多发早期胃癌和（或）高级别上皮内瘤变临床病理特点和病灶之间关联性分析

Clinicopathologlc characteristics and relevance of main and minor lesions of synchronous multiple early gastric cancer and gastric high grade intraepithelial neoplasia

目的探讨同时性多发早期胃癌（EGC）和（或）高级别上皮内瘤变（HGIN）患者的临床病理特点及主副病灶之间的关联性。方法收集2012年7月至2016年9月在南京鼓楼医院诊断并接受ESD治疗的32例同时性多发EGC和（或）HGIN病例，总结患者临床病理特点，并将多发病灶定义为主病灶和副病灶，探索分析主副病灶在大小、部位、内镜分型、组织学类型、浸润深度和脉管侵犯等方面的关联程度。结果研究纳入的32例多发性EGC和（或）HGIN患者平均年龄（66．19±7．46）岁，男性多见（90．62％，29／32），17例（53．13％）有胃癌家族史，有吸烟和饮酒史的分别有25例（78．13％）和22例（68．75％），病灶周围黏膜合并萎缩和肠上皮化生的分别有30例（93．75％）和31例（96．88％）。主病灶和副病灶的直径存在正相关（r=0．4167，P=0．018）。主、副病灶的内镜形态不具有一致性（P=0．314），但病理类型和侵犯深度均具有较高的一致性（P〈0．05）和匹配度。主、副病灶在空间分布方面没有相关性，但主病灶在高位胃体（胃上1／3）与副病灶在低位胃体（胃下1／3）具有较强关联性（列联相关系数=0．463，P=0．003），并且，当主肿瘤在高位胃体后壁时，副肿瘤在低位胃体小弯侧的可能性较大，两者之间的列联相关系数为0．417（P=0．009）。结论长期吸烟、饮酒、有胃癌家族史，合并黏膜萎缩、肠上皮化生的老年男性为同时性多发早期胃癌及癌前病变的高危人群，在发现一个病灶时，需警惕多病灶存在可能，并注重主、副病灶之间的关联性，避免漏诊。

Objective To investigate the clinicopathologic characteristics and relevance of main and minor lesions of synchronous multiple early gastric cancers （SMEGC） and gastric high grade intraepithelial neoplasia （GHGIN）. Methods Thirty-two patients with SMEGC or/and GHGIN who were diagnosed and treated with endoscopic submucosal dissection in Nanjing Drum Tower Hospital from July 2012 to September 2016 were enrolled in this study. Their clinicopathologic characteristics were summed up, and the correlation between main and minor lesions on the size, location, endoscopic classification, pathologic type, invasion depth and vascular invasion were analyzed. Results Among the 32 patients, with mean age of 66. 19＋7.46 years, 90. 62% （29/32） were male, 17 cases （ 53.3% ） had family history of gastric cancer, 25 （ 78.13% ） had smoking history, and 22 （68.75%） were alcohol users. There were 30 cases （93.75%） and 31 cases （96. 88%） with mucosal atrophy and intestinal metaplasia, respectively. The size of main and minor lesions showed a positive correlation （r = 0. 4167, P = 0. 018）. The endoscopic classification of major and minor lesions had no statistical significant consistency （P= 0. 314）, but the pathologic type and invasion depth between major and minor lesions demonstrated a moderate significant positive correlation （P〈0. 05 ）. The comparison of location between the main and minor lesions did not show correlation. However, it showed a significant correlation between major lesion which on the upper 1/3 of stomach and minor lesion on the lower 1/3 of stomach （ r = 0. 463, P = 0. 003 ）. Further more, when the main lesion was at posterior gastric wall, the minor lesions on lesser curvature were increased, which showed a positive correlation（ r= 0. 417 ,P= 0. 009）. Conclusion Old-age male with long-term smoking and alcohol history whose lesions combined with surrounding mucosa merger atrophy and intestinal metaplasia are considered as a high risk group in patients with SMEGC or/and GHGIN. Therefore, clinicians must keep high vigilant and make carefully observations on this group of patients during endoscopic examination, and consider the correlation between main and minor lesions to avoid misdiagnosis.