放大內(nèi)鏡結合窄帶成像對早期上消化道腫瘤診斷的臨床相關研究
發(fā)布時間：2018-08-12 16:41
【摘要】：背景和目的上消化道惡性腫瘤主要指食管癌和胃癌,是新近發(fā)病率增長較快的惡性腫瘤,其發(fā)病率、死亡率居高不下均位于全球惡性腫瘤的前10名。上消化道腫瘤的預后與診斷的時機密切相關,早期診斷和早期治療是其根治性治療的關鍵,能夠有效提高患者生存率及預后。放大內(nèi)鏡結合窄帶成像(magnifying endoscopy with narrow-band imaging,ME-NBI)能夠清楚顯示消化道黏膜形態(tài)以及黏膜內(nèi)血管結構,發(fā)現(xiàn)上消化道早期腫瘤出現(xiàn)的細微結構改變,有利于及時發(fā)現(xiàn)高級別上皮內(nèi)瘤變等早期上消化道腫瘤性病變。本文主要探討ME-NBI及其鏡下分型對早期上消化道腫瘤及癌前病變的診斷價值和臨床意義。資料和方法回顧性分析2015年1月至2017年1月于鄭州大學第二附屬醫(yī)院消化內(nèi)科病區(qū)住院且符合納入標準的上消化道腫瘤及癌前病變患者共139例。早期食管癌及癌前病變患者79例,其中男性患者48例(60.76%),女性患者31例(39.24%),平均年齡61.92±9.64歲,共計病灶86處。早期胃癌(early gastric cancer,EGC)及癌前病變患者60例,男性患者46例(76.67%),女性患者14例(22.33%),平均年齡61.03±9.87歲,共計病灶63處。所有患者均行黏膜切除術(endoscopic mucosal resection,EMR)或黏膜下剝離術(endoscopic submucosal dissection,ESD),有完整的臨床和病理資料,入選患者均自愿簽署知情同意書。本文主要觀察符合納入標準的患者的年齡、性別、病變部位、內(nèi)鏡下巴黎分型、普通放大內(nèi)鏡(magnifying endoscopy,ME)及ME-NBI鏡下的微結構形態(tài)和微血管形態(tài)、內(nèi)鏡下診斷結果和病理診斷結果。統(tǒng)計學分析早期上消化道腫瘤性疾病的病變部位、鏡下形態(tài),對比普通白光內(nèi)鏡(white light imaging,WLI)和ME-NBI觀察病變部位、微結構和微血管形態(tài)的清晰度,比較內(nèi)鏡診斷結果和病理診斷結果的一致性,分析ME-NBI分型對上消化道腫瘤診斷的敏感性和特異性及比較微血管及表面結構分型(vessel plus surface classification,VS)和改良微血管及表面結構分型(Reform vessel-plus-surface classification,RVS)分型對EGC診斷的價值。結果早期食管癌及癌前病變患者內(nèi)鏡下最常見的形態(tài)為Type0-Ⅱ共計81處(94.19%),其中Type0-Ⅱb有58處(67.44%)。病理診斷早期食管腫瘤性病變共有64處(74.42%),內(nèi)鏡下最常見的形態(tài)為Type0-Ⅱ共計60處(93.75%),其中Type0-Ⅱb有39處(60.94%)。病變最常見的部位為胸中段有56處(65.12%)�；颊叩男詣e與食管病變部位間無統(tǒng)計學相關性(P0.05,P=0.32),而發(fā)病年齡與食管病變部位間有顯著的相關性,中下段食管病變的發(fā)病年齡較上段提早約10年(P0.05,P=0.02)。NBI觀察食管病變部位清晰度均顯著高于WLI,差異具有統(tǒng)計學意(P0.001)。ME-NBI觀察食管病變部位IPCL形態(tài)清晰度均顯著高于ME,差異具有統(tǒng)計學意義(P0.001)。病理組織學證實的食管腫瘤性病變共有64處,內(nèi)鏡下診斷Ⅳ、Ⅴ1、Ⅴ2、Ⅴ3、ⅤN的共有67處,診斷早期食管腫瘤性疾病的敏感度、特異度、陽性預測值、陰性預測值分別為:89.06%、54.55%、85.07%、63.15%。運用KAPPA一致性檢驗判斷內(nèi)鏡下診斷與術后病理診斷關系,KAPPA系數(shù)為0.47提示內(nèi)鏡下診斷與術后病理結果有較好的一致性,說明食管黏膜IPCL井上分型對早期食管腫瘤性病變具有良好的診斷價值。EGC及癌前病變患者內(nèi)鏡下最常見的形態(tài)是Type0-Ⅱ共計48處(76.19%),其中Type0-Ⅱc有20處(31.75%)。病理診斷胃部腫瘤性病變共計44處(69.84%),內(nèi)鏡下最常見的形態(tài)是Type0-Ⅱ共計33處(75%),其中Type0-Ⅱc有15處(34.09%)。病變最常見的部位為賁門和胃竇,分別有23處(36.51%)、22處(34.92%)�；颊叩男詣e和年齡與病變部位均無統(tǒng)計學相關性(P0.05)。NBI內(nèi)鏡觀察胃病變部位清晰度均顯著高于WLI,差異具有統(tǒng)計學意義(P0.05)。ME-NBI觀察胃病變部位腺管開口形態(tài)和毛細血管結構形態(tài)清晰度均顯著高于ME,差異具有統(tǒng)計學意義(P0.001)。RVS分型診斷EGC的敏感度和特異度分別為:“分界線”為100%、88.1%、“不規(guī)則的黏膜微血管”為85.71%、42.86%�！安灰�(guī)則的表面腺管”為80.95%、23.81%�！跋俟苊芏仍黾印睘�71.43%、50%�！梆つの⒀苊芏仍黾印睘�57.14%、66.67%。KAPPA一致性檢驗判斷內(nèi)鏡下診斷與術后病理診斷關系,KAPPA系數(shù)為0.86提示內(nèi)鏡下診斷與術后病理結果幾乎完全一致,提示RVS分型對EGC有非常高的診斷價值。VS分型的AUC為0.92,RVS分型的AUC為0.91,均對EGC有很高的診斷價值。結論1.早期上消化道腫瘤及癌前病變內(nèi)鏡下最常見的形態(tài)為平坦型(Type0-Ⅱ),其中食管淺表平坦型(Type0-Ⅱb)常見,胃部淺表凹陷型(Type0-Ⅱc)多見。2.ME-NBI在對食管和胃部病變部位、微結構及微血管形態(tài)的觀察比WLI和ME內(nèi)鏡更有優(yōu)勢。3.井上分型對早期食管腫瘤性疾病有良好的診斷預測價值,其內(nèi)鏡下診斷與術后病理結果有較好的一致性。4.RVS分型5項指標有助于胃腫瘤性病變與非腫瘤性病變的鑒別,RVS分型對EGC有很高的診斷價值。
[Abstract]:BACKGROUND AND OBJECTIVE Malignant tumors of the upper gastrointestinal tract mainly refer to esophageal cancer and gastric cancer, which are the fastest-growing malignant tumors in recent years. The incidence and mortality of these malignant tumors are among the top 10 in the world. Enlarged endoscopy combined with narrow-band imaging (ME-NBI) can clearly show the morphology of gastrointestinal mucosa and the vascular structure in the mucosa. Fine structural changes of early upper gastrointestinal tumors can be found, which is conducive to the timely detection of high-grade intraepithelial neoplasms. This article mainly discusses the diagnostic value and clinical significance of ME-NBI and its microscopic classification for early upper gastrointestinal neoplasms and precancerous lesions.Data and methods A retrospective analysis was made on the patients hospitalized in the Department of Gastroenterology, Second Affiliated Hospital of Zhengzhou University from January 2015 to January 2017 and the patients met the inclusion criteria. There were 139 patients with metastatic tumors and precancerous lesions. Among the 79 patients with early esophageal cancer and precancerous lesions, 48 (60.76%) were male, 31 (39.24%) were female, with an average age of 61.92 [9.64] years. There were 86 lesions. 60 patients with early gastric cancer (EGC) and precancerous lesions, 46 (76.67%) were male and 14 (22.67%) were female. All patients underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). All patients had complete clinical and pathological data and signed informed consent voluntarily. Age, sex, lesion location, endoscopic classification of Paris, microscopic and microvascular morphology under magnifying endoscopy (ME) and ME-NBI, endoscopic diagnosis and pathological diagnosis were performed. The lesion location and microscopic morphology of early upper gastrointestinal neoplasms were statistically analyzed and compared with those under general white light endoscopy (whit). E-light imaging, WLI and ME-NBI were used to observe the location, microstructure and microvascular morphology of lesions, to compare the consistency of endoscopic diagnosis and pathological diagnosis, to analyze the sensitivity and specificity of ME-NBI typing in the diagnosis of upper gastrointestinal tumors, and to compare vessel plus surface classification (VS) and its modification. Results 81 (94.19%) of the patients with early esophageal cancer and precancerous lesions had the most common endoscopic morphology of Type 0-II, 58 (67.44%) of which had Type 0-II B. 64 (74.42%) had early pathological diagnosis of esophageal neoplasms. The most common endoscopic appearance was Type 0-II in 60 lesions (93.75%), including Type 0-II in 39 lesions (60.94%). The most common lesion was in the middle thoracic segment in 56 lesions (65.12%). The onset age of esophageal lesions was 10 years earlier than that of upper esophageal lesions (P 0.05, P = 0.02). The intelligibility of esophageal lesions by NBI was significantly higher than that by WLI (P 0.001). The morphological intelligibility of IPCL by ME-NBI was significantly higher than that by ME (P 0.001). The sensitivity, specificity, positive predictive value and negative predictive value were 89.06%, 54.55%, 85.07% and 63.15% respectively. KAPPA consistency test was used to determine the relationship between endoscopic diagnosis and postoperative pathological diagnosis. The KAPPA coefficient was 0.47, indicating endoscopic diagnosis. The most common endoscopic morphology of EGC and precancerous lesions was Type 0-II in 48 (76.19%) patients, of which 20 (31.75%) were Type 0-II C. Pathological diagnosis of gastric neoplastic lesions was 44 (41.75%). 69.84%. The most common endoscopic morphology was Type 0-II in 33 (75%) sites, of which 15 (34.09%) were Type 0-II C. The most common lesions were cardia and antrum, 23 (36.51%) and 22 (34.92%) respectively. There was no significant correlation between gender and age and lesion site (P 0.05). In WLI, the difference was statistically significant (P 0.05). The difference was statistically significant (P 0.001). The sensitivity and specificity of RVS typing in diagnosis of EGC were 100%, 88.1% and 85.71% respectively. "Irregular surface glandular duct" was 80.95%, 23.81%. "Increase of glandular duct density" was 71.43%, 50%. "Increase of mucosal microvessel density" was 57.14%, 66.67%. KAPPA consistency test judged the relationship between endoscopic diagnosis and postoperative pathological diagnosis. KAPPA coefficient was 0.86, suggesting that endoscopic diagnosis and postoperative pathological results were almost identical, suggesting that R. VS typing has very high diagnostic value for EGC. AUC of VS typing is 0.92, and AUC of RVS typing is 0.91. Conclusion 1. The most common endoscopic appearance of early upper gastrointestinal neoplasms and precancerous lesions is flat type (Type 0-II). Esophageal superficial flat type (Type 0-II b) is common, and gastric superficial depression type (Type 0-II) is common. ME-NBI is more advantageous than WLI and ME in the observation of pathological location, microstructure and microvascular morphology of esophagus and stomach. 3. Well classification has a good diagnostic and predictive value for early esophageal neoplasms, and its endoscopic diagnosis and postoperative pathological results have a good consistency. 4. RVS classification of five indicators contribute to gastric neoplasms. RVS typing is of high diagnostic value for EGC.
【學位授予單位】：鄭州大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R735
本文編號：2179649
[Abstract]:BACKGROUND AND OBJECTIVE Malignant tumors of the upper gastrointestinal tract mainly refer to esophageal cancer and gastric cancer, which are the fastest-growing malignant tumors in recent years. The incidence and mortality of these malignant tumors are among the top 10 in the world. Enlarged endoscopy combined with narrow-band imaging (ME-NBI) can clearly show the morphology of gastrointestinal mucosa and the vascular structure in the mucosa. Fine structural changes of early upper gastrointestinal tumors can be found, which is conducive to the timely detection of high-grade intraepithelial neoplasms. This article mainly discusses the diagnostic value and clinical significance of ME-NBI and its microscopic classification for early upper gastrointestinal neoplasms and precancerous lesions.Data and methods A retrospective analysis was made on the patients hospitalized in the Department of Gastroenterology, Second Affiliated Hospital of Zhengzhou University from January 2015 to January 2017 and the patients met the inclusion criteria. There were 139 patients with metastatic tumors and precancerous lesions. Among the 79 patients with early esophageal cancer and precancerous lesions, 48 (60.76%) were male, 31 (39.24%) were female, with an average age of 61.92 [9.64] years. There were 86 lesions. 60 patients with early gastric cancer (EGC) and precancerous lesions, 46 (76.67%) were male and 14 (22.67%) were female. All patients underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). All patients had complete clinical and pathological data and signed informed consent voluntarily. Age, sex, lesion location, endoscopic classification of Paris, microscopic and microvascular morphology under magnifying endoscopy (ME) and ME-NBI, endoscopic diagnosis and pathological diagnosis were performed. The lesion location and microscopic morphology of early upper gastrointestinal neoplasms were statistically analyzed and compared with those under general white light endoscopy (whit). E-light imaging, WLI and ME-NBI were used to observe the location, microstructure and microvascular morphology of lesions, to compare the consistency of endoscopic diagnosis and pathological diagnosis, to analyze the sensitivity and specificity of ME-NBI typing in the diagnosis of upper gastrointestinal tumors, and to compare vessel plus surface classification (VS) and its modification. Results 81 (94.19%) of the patients with early esophageal cancer and precancerous lesions had the most common endoscopic morphology of Type 0-II, 58 (67.44%) of which had Type 0-II B. 64 (74.42%) had early pathological diagnosis of esophageal neoplasms. The most common endoscopic appearance was Type 0-II in 60 lesions (93.75%), including Type 0-II in 39 lesions (60.94%). The most common lesion was in the middle thoracic segment in 56 lesions (65.12%). The onset age of esophageal lesions was 10 years earlier than that of upper esophageal lesions (P 0.05, P = 0.02). The intelligibility of esophageal lesions by NBI was significantly higher than that by WLI (P 0.001). The morphological intelligibility of IPCL by ME-NBI was significantly higher than that by ME (P 0.001). The sensitivity, specificity, positive predictive value and negative predictive value were 89.06%, 54.55%, 85.07% and 63.15% respectively. KAPPA consistency test was used to determine the relationship between endoscopic diagnosis and postoperative pathological diagnosis. The KAPPA coefficient was 0.47, indicating endoscopic diagnosis. The most common endoscopic morphology of EGC and precancerous lesions was Type 0-II in 48 (76.19%) patients, of which 20 (31.75%) were Type 0-II C. Pathological diagnosis of gastric neoplastic lesions was 44 (41.75%). 69.84%. The most common endoscopic morphology was Type 0-II in 33 (75%) sites, of which 15 (34.09%) were Type 0-II C. The most common lesions were cardia and antrum, 23 (36.51%) and 22 (34.92%) respectively. There was no significant correlation between gender and age and lesion site (P 0.05). In WLI, the difference was statistically significant (P 0.05). The difference was statistically significant (P 0.001). The sensitivity and specificity of RVS typing in diagnosis of EGC were 100%, 88.1% and 85.71% respectively. "Irregular surface glandular duct" was 80.95%, 23.81%. "Increase of glandular duct density" was 71.43%, 50%. "Increase of mucosal microvessel density" was 57.14%, 66.67%. KAPPA consistency test judged the relationship between endoscopic diagnosis and postoperative pathological diagnosis. KAPPA coefficient was 0.86, suggesting that endoscopic diagnosis and postoperative pathological results were almost identical, suggesting that R. VS typing has very high diagnostic value for EGC. AUC of VS typing is 0.92, and AUC of RVS typing is 0.91. Conclusion 1. The most common endoscopic appearance of early upper gastrointestinal neoplasms and precancerous lesions is flat type (Type 0-II). Esophageal superficial flat type (Type 0-II b) is common, and gastric superficial depression type (Type 0-II) is common. ME-NBI is more advantageous than WLI and ME in the observation of pathological location, microstructure and microvascular morphology of esophagus and stomach. 3. Well classification has a good diagnostic and predictive value for early esophageal neoplasms, and its endoscopic diagnosis and postoperative pathological results have a good consistency. 4. RVS classification of five indicators contribute to gastric neoplasms. RVS typing is of high diagnostic value for EGC.
【學位授予單位】：鄭州大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R735
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