共聚焦显微内镜对消化道黏膜病变诊断偏差的原因分析

A clinical analysis of biased diagnosis of confocal laser endomicroscopy on gastrointestinal mucosal lesions

目的分析共聚焦显微内镜(confocal laser endomicroscopy,CLE)诊断胃肠道黏膜病变出现偏差的原因。方法统计2009年6月至2018年9月在上海交通大学医学院附属瑞金医院消化内科接受CLE检查的患者。检查过程中静脉注射质量浓度为100 g/L的荧光素钠作为荧光剂。采用四级诊断标准(炎症/化生性病变、低级别上皮内瘤变、高级别上皮内瘤变、癌)对CLE图像进行实时诊断,根据手术病理或随访结果作为最终诊断,并将最终诊断与CLE实时诊断作对比。回顾患者的内镜和共聚焦影像资料,分析诊断偏差的原因。结果总计540例患者纳入研究,扫描病灶总数613处。与最终病理结果相比,CLE诊断准确率为87. 9%(539/613)。在诊断偏差的74处病变中,CLE诊断偏轻40处,诊断偏重34处。CLE诊断偏差的原因主要包括以下情形:病变程度解读误差(45/74,60. 8%);白光内镜可见确切病变但CLE未见典型阳性表现(16/74,21. 6%);难以鉴别炎症与淋巴瘤(3/74,4. 0%);检查过程中白光内镜未见病灶(1/74,1. 4%);操作者观察欠仔细或诊断经验不足(9/74,12. 2%)。活动期炎症、重度糜烂、坏死组织、荧光素钠明显外渗、图像解读误差是造成CLE诊断程度偏差的常见原因,探头贴合不良、异型细胞散在浸润常导致CLE诊断偏轻,而腺体异型性重于腺上皮细胞、异型腺体浅表、活检未能取材于最典型部位常导致CLE诊断偏重。结论 CLE诊断偏差的原因涵盖多个方面。通过增进内镜医师的操作技能、诊断能力,控制荧光素钠剂量,增进与病理医师之间的交流互动,可改善CLE的临床诊断效能。

Objective To investigate the cause of biased diagnosis of confocal laser endomicroscopy(CLE)on gastrointestinal mucosal lesions.Methods Patients receiving CLE in Shanghai Ruijin Hospital from Jun.2009 to Sep.2018 were collected.Intravenous injection of 100 g/L fluorescin was given during the procedure.A four-tier diagnostic system(inflammation/metaplasia,low-grade intraepithelial neoplasia,high-grade intraepithelial neoplasia and malignancy)was applied.Targeted biopsy,resection or follow-up was performed where necessrary.The diagnosis of CLE and final pathology were reviewed and the cause of biased diagnosis was analyzed.Results A total of 540 patients were included in the study with 613 lesions.Compared with final pathological diagnosis,the accuracy of CLE was 87.9%(539/613).As for the 74 lesions with biased diagnosis,40 lesions were under-diagnosed and 34 lesions over-diagnosed by CLE.The situations leading to a biased diagnosis were improper judgment of severity(45/74,60.8%),failure to display corresponding features on CLE while a suspected lesion was shown under white light endoscopy(16/74,21.6%),difficulty in differentiating between inflammation and lymphoma(3/74,4.0%),missed lesion during endoscopy(1/74,1.4%),inexperienced endoscopist(9/74,12.2%).Active inflammation,marked erosion,significant exudation of fluorescin,improper interpretation of confocal images were the most common reasons leading to a biased diagnosis.Bad probe contact to the mucosa,scarce infiltration of tumor cells in the mucosa propria frequently caused under-diagnosis of CLE,while atypia more apparent in glands than in epithelial cells,superficial atypical glands and inadequate biopsy sampling could yield in an over-diagnosis.Conclusion Various reasons could lead to a biased diagnosis by CLE.The clinical diagnositic efficacy could be further enhanced by improving endoscopic maneuvering skill and experience,better dosage control of fluorescin and deeper cooperation with pathologists.