直肠神经内分泌瘤内镜治疗后垂直切缘阳性的危险因素分析

Analysis on risk factors of positive vertical resection margin after endoscopic treatment of rectal neuroendocrine tumors

目的分析影响直肠神经内分泌瘤(NET)患者经内镜治疗术后标本垂直切缘阳性的相关因素。方法采用病例对照研究方法,回顾性收集2015年1月至2018年6月在北京清华长庚医院消化中心接受内镜治疗的直肠NET(G1级)患者资料。病例纳入标准为内镜切除[包括内镜下黏膜切除术(EMR)和内镜黏膜下剥离术(ESD)]黏膜标本病理证实为NET的病例,且内镜治疗前均进行核素显像检查确认NET局限于直肠,排除临床资料或随访资料不完整的病例。切除标本垂直切缘阳性的判断方法为内镜下切除标本固定后,每隔2mm垂直切片,若垂直切缘有肿瘤细胞浸润则判定为垂直切缘阳性。分析患者的性别、年龄、肿瘤切除方式、病变直径、病变形态(包括结节样病变、活检或治疗后瘢痕样改变)、核分裂像以及Ki-67阳性指数等对切除标本垂直切缘阳性的影响。单因素分析采用二元logistic检验;多因素分析采用logistic回归分析。结果133例直肠NET患者入组,其中男性93例,女性40例,年龄为(50.0±10.7)岁。64例行EMR治疗,术后有3例(4.7%)垂直切缘阳性;69例行ESD治疗,术后有13例(18.8%)垂直切缘阳性;内镜下治疗后垂直切缘阳性共计16例(12.0%),其中男性11例,女性5例,年龄为(52.4±10.4)岁,患者病变直径为(9.0±4.7)mm。单因素分析结果显示,病变直径≥10 mm(χ^2=5.575,P=0.018)和瘢痕样改变(χ^2=3.894,P=0.048)与本组直肠NET患者内镜下治疗后标本垂直切缘阳性有关。多因素分析结果显示,病变直径≥10 mm是本组直肠NET患者内镜下治疗后标本垂直切缘阳性的独立危险因素(OR=10.136,95%CI:2.114~48.591,P=0.004)。结论直肠NET直径≥10 mm提示内镜治疗后标本垂直切缘阳性高风险。

Objective To analyze the risk factors of positive vertical resection margin of the postoperative specimens after endoscopic treatment of rectal neuroendocrine tumors (NET). Methods A case-control study was performed. Clinical data of patients with rectal NET (G1) undergoing endoscopic treatment between January 2015 and June 2018 at the Department of Gastroenterology,Beijing Tsinghua Changgung Hospital were retrospectively collected. Inclusion criteria: cases underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD),whose mucosal specimens were pathologically confirmed as NET,and NET was confined to the rectum by nuclide imaging examination before endoscopic treatment. Those with incomplete clinical data or follow-up data were excluded. Resected specimen was fixed and sliced every 2 mm,and when tumor cells were found to infiltrate the vertical cutting edge,the positive vertical margin was defined. Associations of gender,age,resection method,tumor diameter,lesion morphology (nodular lesions,biopsy or post-treatment scar-like changes),mitotic figure,Ki-67 index,etc. and positive vertical margin were analyzed. Univariate analysis was performed using binary logistic analysis and multivariate analysis was performed using logistic regression model. Results A total of 133 patients with rectal NET were enrolled,including 93 males and 40 females,with an average age of (50.0±10.7) years. Sixty-four patients received EMR treatment and 3 patients (4.7%) had positive vertical margins. While 69 patients received ESD treatment and 13 (18.8%) had positive vertical margins. After endoscopic treatment,16 cases (12.0%) were vertical positive margin,including 11 males and 5 females with an average age of (52.4±10.4) years. The lesion diameter was (9.0±4.7) mm. Univariate analysis showed that lesion diameter ≥10 mm (χ^2=5.575,P=0.018) and scar-like changes (χ^2=3.894,P=0.048) were significantly associated with positive vertical margin. Multivariate analysis showed that the lesion diameter ≥10 mm (OR=10.136,95%CI: 2.114 to 48.591,P=0.004) was an independent risk factor for positive vertical margin of the specimen after endoscopic treatment of rectal NET. Conclusion The diameter of rectal NET ≥10 mm indicates a high risk for positive vertical margin after endoscopic treatment.