411例早期胃癌及癌前病变内镜黏膜下剥离术标本的病理学评估

Pathological evaluation of endoscopic submucosal dissection for early gastric cancer and precancerous lesion in 411 cases

目的:评估早期胃癌及癌前病变内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)标本的病理学特征,为临床诊疗及病理学分析积累经验。方法:按日本早期胃癌ESD治疗指南和日本胃癌分类和处理指南,回顾性分析2013年9月至2021年12月北京大学第一医院ESD治疗的411例早期胃癌或癌前病变临床病理资料、病理诊断评估、术前胃镜活检(400例)与ESD术后组织病理学诊断符合情况,以及非治愈切除危险因素等。结果:411例中,96例(23.4%)为腺瘤(WHO低级别异型增生),315例(76.6%)为早期胃癌,后者包括115例(28.0%)非浸润性癌(WHO高级别异型增生)和200例(48.7%)浸润性癌。术前活检与术后组织病理学诊断符合率为66.0%(264/400)。ESD前后诊断符合率与组织学类型及病变部位相关(P<0.01)。ESD术后组织病理学诊断升级119例(29.8%)、降级17例(4.2%)。315例早期胃癌中,组织学分类的分化型癌277例(87.9%),未分化型癌38例(12.1%);绝对适应证262例(83.2%),相对适应证53例(16.8%);整块切除率98.1%,治愈性切除率82.9%。非治愈性切除的独立危险因素包括病变最大径>20 mm(OR=3.631,95%CI:1.170~11.270,P=0.026)、肿瘤浸润至黏膜下层(OR=69.761,95%CI:21.033~231.376,P<0.001),以及组织学分类为未分化型癌(OR=16.950,95%CI:4.585~62.664,P<0.001)。结论:活检标本局限性、病变特点和分布、病理认识、内镜观察取材等主客观因素可导致术前活检与ESD术后组织病理学诊断存在差异,尤其术后升级诊断更显著,应引起内镜中心与病理科医生的重视。ESD手术早期胃癌治愈率高,非治愈性切除与病变最大径、肿瘤浸润深度及组织学类型相关。未分化型早期胃癌符合适应证标准也可实施ESD。ESD手术标本的全面及规范化病理学分析对ESD手术疗效及患者预后评估具有临床指导意义。

Objective:To evaluate the pathological characteristics of endoscopic submucosal dissection(ESD)specimens for early gastric cancer and precancerous lesions,accumulating experience for clinical management and pathological analysis.Methods:A total of 411 cases of early gastric cancer or precancerous lesions underwent ESD.According to the Japanese guidelines for ESD treatment of early gastric cancer and classification of gastric carcinoma,the clinicopathological data,pathologic evaluation,concordance rate of pathological diagnosis between preoperative endoscopic forceps biopsies and their ESD specimens(in 400 cases),as well as the risk factors of non-curative resection of early gastric cancer,were analyzed retrospectively.Results:23.4%(96/411)of the 411 cases were adenoma/low-grade dysplasia and 76.6%(315/411)were early gastric cancer.The latter included 28.0%(115/411)non-invasive carcinoma/high-grade dysplasia and 48.7%(200/411)invasive carcinoma.The concordance rate of pathological diagnosis between endoscopic forceps biopsies and ESD specimens was 66.0%(264/400),correlating with pathological diagnosis and lesion location(P<0.01).The rate of upgraded diagnosis and downgraded diagnosis after ESD was 29.8%(119/400)and 4.2%(17/400),respectively.Among the 315 cases of early gastric cancer,there were 277 cases(87.9%)of differentiated type and 38 cases(12.1%)of undifferentiated type.In the study,262 cases(83.2%)met with absolute indication,while 53 cases(16.8%)met relative indication.En bloc and curative resection rates were 98.1%and 82.9%,respectively.Risk factors for non-curative resection included a long diameter>20 mm(OR=3.631,95%CI:1.170-11.270,P=0.026),tumor infiltration into submucosa(OR=69.761,95%CI:21.033-231.376,P<0.001)and undifferentiated tumor histology(OR=16.950,95%CI:4.585-62.664,P<0.001).Conclusion:Several subjective and objective factors,such as the limitations of biopsy samples,the characteristics and distribution of the lesions,different pathological understanding,and the endoscopic sampling and observation,can lead to the differences between the preoperative and postoperative pathological diagnosis of ESD.In particular,the pathological upgrade of postoperative diagnosis was more significant and should receive more attention by endoscopists and pathologists.The curative resection rate of early gastric cancer in ESD was high.Non-curative resection was related to the long diameter,the depth of tumor invasion and histological classification.ESD can also be performed in undifferentiated early gastric cancer if meeting the indication criteria.The comprehensive and standardized pathological analysis of ESD specimens is clinically important to evaluate the curative effect of ESD operation and patient outcomes.