未分化型早期胃癌超内镜下切除扩大适应证的危险因素分析

Risk factors for endoscopic resection beyond expanded indication of undifferentiated early gastric cancer

目的探讨未分化型早期胃癌(undifferentiated early gastric cancer,UD-EGC)超内镜下切除扩大适应证的相关危险因素,为临床上精确筛选符合扩大适应证的UD-EGC病例提供诊断依据。方法回顾性分析2011年-2018年间中国医学科学院肿瘤医院内镜中心行内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)的UD-EGC患者。根据第4版日本胃癌协会指南,将其分为符合扩大适应证组和超扩大适应证组,对比评估两组病变内镜下表现及临床病理特征的差异。结果共计158例术后病理证实为UD-EGC,其中57例(36.1%)符合扩大适应证,101例(63.9%)超扩大适应证。多因素分析显示,内镜下萎缩分型、浅表隆起/凹陷分型、病变显著发红与超扩大适应证显著相关。基于多因素Logistic二元回归β系数对各危险因素进行赋值:开放型萎缩,2分;闭合型萎缩,1分;浅表隆起/凹陷分型,1分;病变显著发红,1分。该风险评分模型经内部验证显示出良好的差异性(曲线下面积:0.796,95%置信区间:0.726~0.866)。结论 UD-EGC如合并萎缩、浅表隆起/凹陷、显著发红的内镜下表现,其超ESD扩大适应证的比例很高。由此得出的预测模型简单、实用,可以为内镜医师临床上选择符合ESD扩大适应证的UD-EGC的病例提供有价值的信息。

Objective To explore the risk factors associated with endoscopic resection beyond expanded indication of undifferentiated early gastric cancer(UD-EGC)patients so as to provide diagnostic evidence for precisely selecting UD-EGC cases in clinical work.Methods Clinical data of patients who underwent endoscopic submucosal dissection(ESD)at Cancer Hospital,Chinese Academy of Medical Sciences,from 2011 to 2018 were reviewed.Patients were divided into expanded indication group and beyond expanded indication group,according to the 4 th edition guideline of Japanese Gastric Cancer Association.The endoscopic findings and clinicopathologic characteristics were compared between the groups to identify the risk factors for ESD beyond expanded indication of UD-EGC.Results A total of 158 patients were pahologially confirmed as UD ECC postoperatively,ineluding 57 patients(36.1%)of expanded indication and 101 patients(63.9%)beyond expanded indication.Multivariate analysis showed endoscopic atrophy type,superficial elevation/depression type,surface redness were significantly associated with beyond expanded indication of UD-EGC.Points of risk scores were assigned for these variables based on the β coefficient as fllows:0-type atrophy,2 points;C-type atrophy,1 point;superficial elevation/depression type,1 point;surface redness,1 point.The risk scoring model showed good discriminatory performance on internal validation(area under the curve:0.796,95%CI:0.726-0.866).Conclusion UD-EGC combined with endoscopic findings such as atrophy,superficial elevation/depression or surface redness shows high possibility of ESD beyond expanded indication.This simple and practical prediction model can provide useful information for endoscopists in selecting UD-EGC patients within ESD expanded indication.