浅表食管癌及癌前病变内镜黏膜下剥离术后水平切缘阳性高危因素分析及随访研究

Risk factor analysis and follow-up study of positive lateral margin after endoscopic submucosal dissection for superficial esophageal cancer and precancerous lesions

目的探讨浅表食管癌及癌前病变内镜黏膜下剥离术(ESD)后标本水平切缘阳性的高危因素及其残留复发情况。方法选取2012年1月-2017年12月该院消化内镜中心行ESD的浅表食管癌及癌前病变患者,收集相关临床、内镜及病理资料,分析食管ESD标本水平切缘阳性的高危因素,并通过术后随访,比较水平切缘阳性与阴性患者的ESD术后病灶残留复发情况。结果最终纳入患者186例病灶194处,水平切缘阳性组37处,水平切缘阴性组157处。水平切缘阳性组中,水平切缘为低级别上皮内瘤变(LGIN)累及病灶25处、水平切缘为高级别上皮内瘤变(HGIN)累及病灶10处、水平切缘为癌累及病灶2处,水平切缘阴性组157处病灶。单因素及多因素Logistic回归分析表明:食管ESD术后病理标本水平切缘阳性与ESD术中标记前是否碘染、术后标本面积具有相关性(P<0.05)。186例患者随访过程中,最终156例患者164处病灶纳入水平切缘阳性组与阴性组的残留复发率随访分析。其中,水平切缘阳性组内镜随访30处,残留复发4处(残留复发率13.3%),水平切缘阴性组内镜随访134处,7处残留复发(残留复发率5.2%),两者比较,差异无统计学意义(P>0.05)。结论食管ESD术中病灶标记前无碘染及大面积病灶的病理标本,水平切缘阳性发生率增加。对于食管ESD术后单纯水平切缘阳性、切缘阳性性质为癌前病变者,可先内镜下密切随访,暂不追加二次治疗。

Objective To explore the risk factors of positive lateral margins after endoscopic submucosal dissection(ESD)for superficial esophageal cancer and precancerous lesions and to follow up with local recurrence.Methods Clinical data of patients who underwent ESD of esophagus,from January 2012 to December 2017,were collected.All these lesions were divided into positive lateral margin group or negative lateral margin group according to histopathology of lateral margin after ESD.Clinicopathological features of the lesions and the risk factors related to positive lateral margin were analyzed.The incidence of residual or local recurrence was followed up postoperatively and compared between the two groups.Results 194 lesions from 186 patients were included,and 37 and 157 lesions were divided into positive lateral margin group and negative lateral margin group,respectively.In the positive lateral margin group,there were 25 lesions of lateral margin diagnosed LGIN,10 lesions of lateral margin diagnosed HGIN,2 lesions of lateral margin diagnosed carcinoma.In the negative lateral margin group,there were 157 lesions.Univariate and multivariate analysis show significant association between iodine staining before marking the boundaries in esophageal ESD or not and area of sample.Late follow-up results showed that the rate of residual or local recurrence was 13.3%(4/30)in the positive lateral margin group,which was higher than 5.2%(7/134)in the negative lateral margin group,but it was not statistically significant.Conclusion No iodine staining before marking the boundaries in esophageal ESD and larger area of sample were associated with increasing incidence of positive lateral margins.In the case of positive lateral margins after ESD,especially when the histopathology of lateral margin indicated precancerous lesions,the patients could be followed up closely with endoscopy and further treatment was not required immediately.