消化道早癌的診斷3

1、消化道早癌的內(nèi)鏡診斷譚慶華譚慶華 四川大學(xué)華西醫(yī)院四川大學(xué)華西醫(yī)院概 述診 斷治 療發(fā)現(xiàn)早癌的內(nèi)鏡診斷技術(shù)白光內(nèi)鏡檢查。染色內(nèi)鏡檢查。白光放大（ME）。染色+放大。ME+NBI (magnified endoscopy)?；顧z超聲內(nèi)鏡。共聚焦顯微內(nèi)鏡。自體熒光內(nèi)鏡光學(xué)相干斷層成像術(shù)細(xì)胞內(nèi)鏡藍激光成像白光內(nèi)鏡發(fā)現(xiàn)早癌的前提理想的消化內(nèi)鏡術(shù)前檢查的準(zhǔn)備：清理視野，抵制蠕動。嚴(yán)格的質(zhì)量控制。時刻準(zhǔn)備發(fā)現(xiàn)早癌的警覺性。特殊、小病變，可借助特殊內(nèi)鏡診斷方法?；顧z。一、染色內(nèi)鏡最常用的染料：最常用的染料：碘染色：碘染色：食管黏膜染色。0.1-0.4%0.1-0.4%靛胭脂：靛胭脂：對比性染料，常用于腺瘤。

2、0.1-0.2%0.1-0.2%美美藍藍( (亞甲藍亞甲藍) )：吸收性，常用于腺瘤。0.05%0.05%結(jié)晶紫（龍膽紫）結(jié)晶紫（龍膽紫）：吸收性，常用于侵襲性病變?nèi)旧?。在病變表面滴?shù)滳，然后再用溫水沖洗。最好用鏈霉蛋白酶。表表1 1 消化內(nèi)鏡下常用消化內(nèi)鏡下常用染料染料染料類型染料類型被染對象染色原理陽性顏色臨 床 應(yīng) 用LugolsLugols碘碘液液( (碘碘+ +碘化鉀碘化鉀) )磷狀上皮內(nèi)的糖原非角化上皮結(jié)合碘深棕色a)正常食管磷狀上皮著色。b)食管磷狀細(xì)胞癌黏膜、Barrett食管黏膜、柱狀上皮和食管炎黏膜均不著色。亞甲藍亞甲藍腸道上皮細(xì)胞，腸化上皮細(xì)胞吸收入上皮細(xì)胞內(nèi)藍色a)食管

3、和胃的腸化上皮、早期胃癌上皮和正常腸道上皮著色。b)十二指腸內(nèi)化生的胃上皮不著色。甲苯胺藍甲苯胺藍胃或腸內(nèi)的柱狀上皮細(xì)胞胞核差色自由擴散入細(xì)胞藍色食管磷狀細(xì)胞癌上皮和Barrets食管中的化生上皮著色剛果紅剛果紅胃內(nèi)泌酸細(xì)胞當(dāng)pH3.0時變色變?yōu)樯钏{或黑色a)泌酸的胃上皮變色，包括異位胃黏膜上皮。b)胃癌上皮細(xì)胞不變色。酚紅酚紅感染HP的胃上皮細(xì)胞由于HP周邊有“氨云”，局部呈堿性而便酚紅變色由黃變紅診斷胃內(nèi)HP的感染及其分布情況。靛胭脂靛胭脂細(xì)胞不著色沉積于上皮表面的低凹處，勾勒出病變形態(tài)。藍色全消化道黏膜均可使用。Conventional white light imagingIndigo

4、 carmine chromoendoscopyIndigo carmineIndigo carmine結(jié)晶紫：結(jié)構(gòu)消失，侵及黏膜下層。 白光內(nèi)鏡：7mm扁平息肉樣隆起靛胭脂：中央凹陷二、特殊光譜及放大內(nèi)鏡C-WLI: 20-40倍ME: 80-170倍Magnifying endoscopy Magnifying endoscopy (ME)(ME)Narrow band imagingEP, epithelium; LPM, lamina propria mucosae; MM, muscularis mucosae; SM, submucosa; PM, proper muscle; M

5、1, cancer is limited epithelium; M2, cancer invades LPM but does not reach MM; M3, cancer invasion reaches MM; SM, submucosally invasive cancerNBI imaging of a lesion of IPCL type III. NBI imaging of a lesion of IPCL type IV regional atrophic mucosa or low grade intraepithelial neoplasia high-grade

6、intraepithelial neoplasia：Tis This pattern is called IPCL-V1. IPCL-V1 includes four major characteristic morphological changes of IPCL: dilation, meandering, irregular caliber, and figure variation. T1a.This is typical image of intrapapillary capillary loop (IPCL)-V3. Cancer invasion depth was M3 (m

7、uscularis mucosae: T1a).Large white arrows point to large tumor vessel (IPCL-VN). The striking morphological feature is its extra-large diameter. Note the difference of vessel caliber between IPCL-V3 (small white arrow) and VN (large white arrow: T1b or deeper). V: microvascular pattern Subepithelia

8、l capillary (SEC) Collecting venule (CV) Pathological microvessels (MV)S: microsurface pattern Marginal crypt epithelium (MCE) Crypt opening (CO) Intervening part (IP) between cryptsMNBI, magnifying endoscopy with narrow-band imaging; LBC, lightblue crestSECN, subepithelial capillary network; RAC, r

9、egular arrangement of collecting venules; CO, crypt-opening; MCE, marginal crypt epithelium;CV, collecting volumeYao K. Ann Gastroenterol. 2013;26(1):11-22.(A, B) Normal gastric body mucosa. (C) Helicobacter pylori-associated gastritis. (D)Atrophic gastritis. ABCD(A) C-WLI :erosion(B) M-NBI: a regul

10、ar microvascular pattern and a regular microsur-face pattern with light blue crest. (C) chronic gastritis with intestinal metaplasia(A) C-WLI: 輕微凹陷。(B) M-NBI：irregular MV and MS with a clear demarcation line.(C) Histopathological findings: a well-differentiated adenocarcinoma confined to the mucosaP

11、it pattern classification (1)Kudo分型(pit pattern).分為5型（Type I to type V）：Type I and II ：良性，非腫瘤性。type III to V：腫瘤性，其準(zhǔn)確率達90%。Type III：III-S and III-L血管袢(CP，sano)分型(佐野分型)CP分型分為I, II, III型，其中III型又分為A和B兩亞型。NBI加放大能有效識別低級別上皮內(nèi)瘤變和高級別上皮內(nèi)瘤變或浸潤性癌。能有效預(yù)測病變的組織學(xué)類型。Modified 3-step strategy of NBI colonoscopy.(a) 普通光下

12、觀察，乙狀結(jié)腸息肉，0.4cm，表面無明顯平坦變化(b) NBI：NBI放大下見明顯凹陷，pit pattern為IIIB（佐野分型）提示有黏膜下侵犯，肉眼觀呈“0-I s + II c”,這種病變易出現(xiàn)黏膜下侵犯。(c)結(jié)晶紫染色：呈VN pits，為浸潤性改變，強烈提示深度黏膜下層侵犯。外科手術(shù)。(d)病理發(fā)現(xiàn)：中分化腺癌. 兩個小的、非侵襲性結(jié)直腸癌(5mm). (a)普通白光：降結(jié)腸0.5cm的小息肉，無明顯凹陷。(b) NBI：NBI+ME見病變中央凹陷，pit pattern為Sano分型的B型說明可能為浸潤性癌，需進一步行結(jié)晶紫染色。(c)結(jié)晶紫染色：腺管開口呈浸潤癌特征，但因中

13、央凹陷太小，不肯定，內(nèi)鏡下切除，為高分化腺癌，再行外科手術(shù).圖 1. 現(xiàn)有結(jié)直腸息肉的 NICE 分類Typical endoscopic findings of NICE classificationFigures to illustrate the NBI International Colorectal Endoscopic (NICE) classification.三、其它內(nèi)鏡檢查EUS：共聚焦內(nèi)鏡EUS：20MHzEUSEUSTis High-grade dysplasiaT1 Tumor invades the lamina propria, muscularis mucosae

14、 (T1a) or submucosa (T1b), but does not breach the submucosaT2 Tumor invades the muscularis propria, but does not breach the muscularis propriaT3 Tumor invades the adventitiaT4 Tumor invades adjacent structures; T4a: resectable tumor invading the pleura, pericardium, or diaphragm, T4b: unresectable

15、tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc.Confocal Endomicroscopy in normal colonic epitheliumConfocal Endomicroscopy in a colonic dyspalsia五、內(nèi)鏡下活檢我科胃癌的早期篩查流程 六六、胃蛋白酶原與胃癌胃蛋白酶原與胃癌Riecken B. Prev Med,2002胃蛋白酶原（胃蛋白酶原（pepsinogen，PG）PG：由胃底腺的主細(xì)胞和頸粘液細(xì)胞分泌PG：除了胃底腺，

16、胃竇幽門腺和近端十二指腸Brunner腺也能分泌PGR： PG / PGPG法用于胃癌篩查，已被多部共識意見推薦缺點：陽性預(yù)測值較低PG IPGRFock KM. J Gastroenterol Hepatol 2008; 中華消化內(nèi)鏡雜志中華消化內(nèi)鏡雜志 2014高胃泌素血癥、PGR低值是非賁門胃癌的高危因素（腸型胃癌）。Vnnen. Eur J Gastroenterol Hepatol 2003 A 組組B 組組C 組組G-17-+-+PG-+血清血清PG聯(lián)合聯(lián)合G-17lG-17(+)G-17(+)：G-17 G-17 1pmol/L 1pmol/L或或G-17 G-17 15pmol/L15pmol/LlPGPG（+ +）：）：PGPG 70ng/ml 70ng/ml 且且PGR 7.0PGR 7.0胃癌風(fēng)險遞增胃癌風(fēng)險遞增體檢人群檢測血清PGI、PGII、PGR