结直肠侧向发育型肿瘤的内镜表现及病理特点研究

Endoscopic findings and pathological features of colorectal lateral spreading tumor

摘要:

摘要：目的 探讨结直肠侧向发育型肿瘤（LST）内镜形态、病理特点及治疗安全性的相关因素。方法 回顾性分析2014年1月－2017年6月经内镜黏膜下剥离术（ESD）治疗的105例LST患者的临床资料，分析完整、整块切除的病理特点（即非浸润性的低度异型性肿瘤、非浸润性的高度异型性肿瘤、管状腺瘤、绒毛状管状腺瘤、绒毛状腺瘤、锯齿状腺瘤、混合型腺瘤和浸润癌）与患者的年龄、病变部位、大小、内镜形态的相关性及内镜治疗安全性。结果 结直肠LST男女发病比例相当，差异无统计学意义（P >0.05）。60岁及以下发病率31.43%（33/105），60岁以上发病率68.57%（72/105），差异有统计学意义（P <0.05）；LST直肠好发，发病率为46.67%（49/105），其次升结肠，发病率为28.57%（30/105），直肠与降乙结肠、横结肠、升结肠发病率比较，差异均有统计学意义（P <0.05）；直肠与降乙结肠、横结肠、升结肠发生非浸润性的高度异型性肿瘤和浸润癌概率，差异均无统计学意义（P >0.05）；颗粒型侧向发育型肿瘤（LST-G）浸润癌发病率3.61%（3/83）；非颗粒型侧向发育型肿瘤（LST-NG）浸润癌发病率22.73%（5/22），差异有统计学意义（P <0.01）。病变最大直径>20 mm 浸润癌发病率5.66%（3/53），病变最大直径≤20mm浸润癌发病率9.62%（5/52），差异无统计学意义（P >0.05）。组织学类型中，低级别上皮内瘤变（LGIN）发病率39.05%（41/105），高级别上皮内瘤变（HGIN）及以上（HGIN、包含浸润癌），发病率60.95%（64/105），差异有统计学意义（P <0.01）。LST-G与LST-NG发生LGIN、HGIN、管状腺瘤、绒毛状管状腺瘤、绒毛状腺瘤、锯齿状腺瘤和混合型腺瘤概率相当，差异均无统计学意义（P >0.05）。内镜下ESD术后迟发性出血发生率2.86%（3/105）、迟发性穿孔发生率0.95%（1/105），经内镜下止血、荷包缝合穿孔部位痊愈，未中转外科手术治疗。非浸润性肿瘤ESD术后病理提示：2例水平切缘可见低级别管状腺瘤，1例水平切缘不肯定，6个月～1年复查内镜3例均复发。浸润癌8例，侵犯黏膜下层，水平切缘、基底切缘均干净5例，未追加外科手术；侵犯黏膜下层，脉管可见癌栓，水平切缘、基底切缘均干净2例，1例追加外科手术病理未见明确癌残留，脉管内未见癌栓，肠系膜淋巴结未见癌转移，1例放弃外科手术。结论 LST发病率与年龄和部位有关，浸润癌的发生与生长形态特征有关；60岁以上患者非浸润性的高度异型性肿瘤及浸润癌发病率高，尤其内镜表现为LST-NG的发生浸润癌概率高。内镜下治疗LST创伤小、安全、有效，术后病理能提供预后及进一步采取干预措施的可靠证据。

Abstract:

Abstract: Objective To explore the factors related to the endoscopic morphology, pathological features, and treatment safety of colorectal lateral spreading tumor (LST). Methods 105 patients with LST who had underwent endoscopic submucosal dissection (ESD) for complete or monolithic resection from January 2014 to June 2017 were included, and the relations between their pathological features (i.e., non-invasive mildly and highly atypical tumors, tubular adenomas, villous tubular adenomas, villous adenomas, serrated adenomas, mixed adenomas, and invasive carcinomas) and the patients’ age, lesion site and size, and endoscopic morphology, as well as the safety of endoscopic treatment, were retrospectively analyzed. Results The incidence of colorectal LST was similar in males and females with no statistically significant difference (P > 0.05). The incidence was 31.43% (33/105) among those of 60 years old and younger and 68.57% (72/105) among those older than 60 years old, with a statistically significant difference (P < 0.05). LST was usually found in the rectum, with an incidence of 46.67% (49/105), followed by the ascending colon, with an incidence of 28.57 (30/105), Comparison of incidence rates between rectum and descending colon, transverse colon and ascending colon, with a statistically significant difference (P < 0.05), there was no statistically significant difference in the incidence of non-invasive highly atypical tumors and invasive cancers (P > 0.05 ).The invasive incidence of the granular type lateral spreading tumor (LST-G) was 3.61% (3/83), while that of the non-granular type lateral spreading tumor (LST-NG) was 22.73% (5/22), with a statistically significant difference (P < 0.01). The incidence of the invasive carcinoma with a maximum diameter greater than 20 mm was 5.66% (3/53), while the incidence of that with a maximum diameter no greater than 20 mm was 9.62% (5/52), with no statistically significant difference (P > 0.05). Histologically, the incidence of the low group intraepithelial neoplasia (LGIN) was 39.05% (41/105), while the incidence of the high group intraepithelial neoplasia (HGIN) and above (HGIN including invasive carcinomas) was 60.95% (64/105), with a statistically significant difference (P < 0.01). LST-G and LST-NG had similar occurrences of LGIN, HGIN, tubular adenomas, villous tubular adenomas, villous adenomas, serrated adenomas, and mixed adenomas, respectively, with no statistically significant difference (P > 0.05). After ESD, the incidence of delayed bleeding was 2.86% (3/105), and that of delayed perforation was 0.95% (1/105). The perforated sites were healed through endoscopic hemostasis and purse-suturing, without referral for surgical treatment. After ESD of non-invasive tumor, pathological findings showed two cases with low-grade tubular adenomas at the horizontal margin and one case with uncertain horizontal margin. Endoscopic reviews from 6 months to one year after surgery suggested recurrence in all three cases. There were eight cases of invasive carcinomas. Among them, five cases showed invaded submucosa with the horizontal and basalt margins both clear, without additional surgery. Two cases showed invaded submucosa with tumor emboli found in the vessels and the horizontal and basalt margins both clear, and one case additional surgery was performed with pathological results suggesting no clear cancer residue, no tumor emboli within the vessels, and no metastasis in the mesenteric lymph nodes. One case gave up surgery. Conclusions The incidence of LST was related to age, and lesion site, and the occurrence of invasive carcinoma was related to the morphological features of development. Patients over 60 years old had high incidence of non-invasive highly atypical tumors and invasive carcinomas, especially in the endoscopic finding of invasive carcinoma occurring in LST-NG. Endoscopic treatment of LST is safe and effective with minimal surgical trauma, and the postoperative pathological results can provide reliable evidence for prognosis and further inventions.