CAJ | 학술논문

目的分析早期胃癌内镜黏膜下剥离术(ESD)及手术后的病理特点,评价ESD治疗的有效性、可行性及应用指征.方法收集上海仁济医院2009年1月至2011年12月共324例早期胃癌患者的临床资料,按治疗方法分为外科组(297例)与ESD组(27例).应用卡方检验与Logistic回归进行统计学分析；依据ESD术前、术后病理评价ESD疗效并评估ESD相对外科手术推广的可行性与安全性.结果早期胃癌占所有胃癌的14.1％ (324/2306),淋巴结转移率为9.6％ (31/324),其中黏膜层癌为4.3％(7/164),黏膜下癌为15.0％ (24/160).经单因素及多因素分析显示,浸润深度是影响淋巴结转移的重要因素；而年龄、性别、肿瘤大小以及淋巴结转移则显著影响肿瘤的浸润深度.ESD组病灶的整块切除率为100％ (27/27),完全切除率为77.8％(21/27),治愈性切除率为74.1％(20/27).其中2例因侧缘有癌组织残留而再次行ESD治疗,所有ESD治疗病例在随访中均未复发.依据ESD治疗指南,外科组中37.0％(110/297)的患者符合ESD指征且无淋巴结转移,而符合指征但有淋巴结转移者仅占所有早期胃癌经外科手术患者的5.2％(6/297).结论目前经外科手术的早期胃癌中超过1/3可能经ESD获得治愈.重视胃镜活检、适当放宽术前病理诊断的标准有助于提高早期胃癌诊治比例.术前准确判断肿瘤浸润深度则有助于改善ESD组织学治愈率,选择适宜的治疗方法.
목적 분석조기위암내경점막하박리술(ESD)급수술후적병리특점,평개ESD치료적유효성、가행성급응용지정.방법 수집상해인제의원2009년1월지2011년12월공324례조기위암환자적림상자료,안치료방법분위외과조(297례)여ESD조(27례).응용잡방검험여Logistic회귀진행통계학분석；의거ESD술전、술후병리평개ESD료효병평고ESD상대외과수술추엄적가행성여안전성.결과 조기위암점소유위암적14.1％ (324/2306),림파결전이솔위9.6％ (31/324),기중점막층암위4.3％(7/164),점막하암위15.0％ (24/160).경단인소급다인소분석현시,침윤심도시영향림파결전이적중요인소；이년령、성별、종류대소이급림파결전이칙현저영향종류적침윤심도.ESD조병조적정괴절제솔위100％ (27/27),완전절제솔위77.8％(21/27),치유성절제솔위74.1％(20/27).기중2례인측연유암조직잔류이재차행ESD치료,소유ESD치료병례재수방중균미복발.의거ESD치료지남,외과조중37.0％(110/297)적환자부합ESD지정차무림파결전이,이부합지정단유림파결전이자부점소유조기위암경외과수술환자적5.2％(6/297).결론 목전경외과수술적조기위암중초과1/3가능경ESD획득치유.중시위경활검、괄당방관술전병리진단적표준유조우제고조기위암진치비례.술전준학판단종류침윤심도칙유조우개선ESD조직학치유솔,선택괄의적치료방법.
Objective To analyze the pathological features of early gastric cancer (EGC),and to evaluate the efficacy,feasibility and indications of ESD (endoscopic submucosal dissection).Methods A total of 324 patients with EGC,who received treatment during January 2009 and December 2011 in our hospital were followed up,including 27 cases treated by ESD and 297 cases treated by radical surgery.Feasibility and safety of ESD were analyzed with chi-square test and Logistic regression based on preoperative and postoperative pathological findings.Results The overall detection rate of EGC in all gastric cancers was 14.1％ (324/2306).The incidence of LNM (lymph node metastasis) was 9.6％ (31/324) for all EGCs,including4.3％ (7/164) mucosal cancers,and 15.0％ (24/160) submucosal cancers.Univariate and multivariate analyses showed LNM was associated with submucosal invasion (P ＜ 0.05) and DI (depth of in vasion) was closely related to age,sex,size of lesion and LNM (P ＜ 0.05,respectively).The rates of en bloc,complete and curative resection of ESD were 100％ (27/27),77.8％ (21/27) and 74.1％(20/27),respectively.There was no recurrence among the 27 patients treated by ESD,however,two cases underwent a second ESD due to cancer residue at horizontal margin.In accordance with guideline of ESD for EGC,37.0％ (110/297) surgical patients without LNM should have undergone ESD,while patients who showed indications for ESD but with LNM were only 5.2％ (6/297).Conclusion More than one-third of patients treated by surgery should have been cured by ESD.Effective gastroscopic biopsy,with reasonable expansion of pathological diagnostic criteria would increase the early diagnostic and curative rates of EGC.Moreover,accurate evaluation of DI helps to improve histological curative rate of EGC and to make a proper therapeutic choice between ESD and radical surgery.