内镜黏膜下剥离术治疗浅表结直肠肿瘤的疗效及恶性病理相关危险因素

Endoscopic submucosal dissection for superficial colorectal neoplasms: efficacyand risk factors for malignancy

目的探讨内镜黏膜下剥离术(ESD)治疗浅表性结直肠肿瘤的疗效、安全性、适应证,并分析浅表性结直肠肿瘤恶性病理的预测因素。方法回顾性分析2014年7月至2016年6月在北京大学肿瘤医院ESD治疗的111例患者(152处高危结直肠黏膜病变)的临床疗效,记录治疗相关的不良事件。根据最终病理良恶性分组后,采用单因素及多因素Logistic分析恶性相关危险因素。结果所纳入病例中病理结果为腺癌的病变有78处,腺瘤74处。全部病例的完整切除率为95.4%,其中恶性病理病变为91.0%。发现或高度怀疑的不良事件(穿孔或出血)7处(4.6%)。其中病理活检结果与术后病理一致99处(65.1%)。在恶性病变中共有67.9%活检病理诊断为腺瘤。不同病变类型的患者中,年龄、病变最大径、形态及位置构成比例不同,差异有统计学意义(腺癌组和腺瘤组患者平均年龄分别为64.4岁和59.8岁,P<0.001;平均最大径分别为2.13、1.45 cm,P=0.009;直肠、左半结肠、右半结肠病变中恶性病变的比例分别为67.5%、49.0%、42.4%,P=0.045;侧向发育型肿物中恶性病变占63.2%,隆起型病变中仅41.6%为恶性,P=0.008)。结论 ESD治疗浅表结直肠上皮性肿瘤安全有效。肿瘤的良恶性判定不能简单地依靠活检,应当结合年龄、病变最大径、位置及病变形态综合判断,进而选择合适的处理方法,以达到整块完整切除的目的。

Objective To analyze the short-term outcomes of patients undergoing endoscopic submucosal dissection(ESD)for superficial colorectal neoplasms,and to identify predictors of malignant pathology of these lesions.Methods ESD was performed in111patients with152high-risk colorectal tumors[≥10mm in diameter or laterally spreading tumor(LST)morphology]at the Peking University Cancer Hospital.We retrospectively reviewed the patient records,therapeutic outcomes,and procedure-related adverse events.We used univariate and multivariate analyses to identify the risk factors for malignancy.Results There were78adenocarcinomas and74adenomas.The complete resection rates were95.4%and91.0%for all and malignant cases,respectively.Adverse events were confirmedor highly suspected in seven(4.6%)cases.As to the biopsy pathology,thefindings were consistent with the postoperative pathology in99(65.1%)lesions.The majority of malignancies(67.9%)were diagnosed as adenomas before resection.Older patients were more susceptible to developing malignant lesions(mean age,64.4vs59.8years in the carcinoma and adenoma group,respectively,P<0.001),and the tumor size was significantly larger in the malignant group(2.13cm vs1.45cm,P=0.009).The proportions of malignant tumors were67.5%,49.0%,and42.4%for rectal,left colon,and right colon lesions,respectively(P=0.045).Moreover,a significant difference was found according to morphology,with63.2%of LSTs diagnosed as malignancies,compared to only41.6%of protruding tumors(P=0.008).Conclusion ESD is a generally safe and effective procedure for treating colorectal neoplasms when performed by experienced endoscopists.Biopsy is not always reliable for the diagnosis.Several factors such as old age,large size,rectal location,and LST morphology are related to malignant pathology.For tumors with these high-risk factors,treatment with ESD instead of endoscopic mucosal resection should be considered to achieve enbloc resection.