食管鳞状上皮内瘤变内镜黏膜下剥离术后病理升级的危险因素分析

饶星宇; 蒲柯; 崔逵; 莫琳; 蹇顺海; 杨国栋

doi:10.12354/j.issn.1000-8179.2023.20230785

食管鳞状上皮内瘤变内镜黏膜下剥离术后病理升级的危险因素分析

doi: 10.12354/j.issn.1000-8179.2023.20230785

饶星宇^1,,
蒲柯¹,
崔逵¹,
莫琳²,
蹇顺海²,
杨国栋^1, ,

1.
川北医学院附属医院消化内科（四川省南充市637000）
2.
病理科

基金项目: 本文课题受国家自然科学基金项目（编号：81960430）和四川省胰腺疾病重点实验平台项目（编号：18SXHZ0371）资助

详细信息

作者简介:
饶星宇：专业方向为消化道肿瘤的早诊早治研究

通讯作者:
杨国栋　ygd_ld2003@163.com

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- 被引次数: 0
出版历程
- 收稿日期: 2023-08-14
- 录用日期: 2023-10-24
- 修回日期: 2023-10-16

Analysis of risk factors for histopathological upgrade after endoscopic submucosal dissection for esophageal squamous intraepithelial neoplasia

Xingyu Rao^1
,,
Ke Pu¹,
Kui Cui¹,
Lin Mo²,
Shunhai Jian²,
Guodong Yang^{1
, ,}

1.
Department of Gastroenterology
2.
Department of Pathology, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China

Funds: This work was supported by the National Natural Science Foundation of China（No. 81960430） and the Construction of Key Experimental Platform for Pancreatic Diseases in Sichuan Province (No. 18SXHZ0371)

More Information

Corresponding author: Guodong Yang; E-mail: ygd_ld2003@163.com

摘要

摘要: 目的分析内镜钳夹活检术（endoscopic forceps biopsy，EFB）提示食管鳞状上皮内瘤变的患者，行内镜黏膜下剥离术（endoscopic submucosal dissection，ESD）后组织病理升级的危险因素。方法回顾性分析2019年11月至2023年5月于川北医学院附属医院就诊的术前EFB提示食管鳞状上皮内瘤变并接受ESD手术的255例患者共255处病灶，按术前EFB与ESD术后病理差异分为升级组（n=123）与未升级组（n=132），采用单因素和多因素Logistic回归分析危险因素。结果低级别上皮内瘤变（low-grade intraepithelial neoplasia，LGIN）组术前EFB与ESD术后病理一致率为42.9%（18/42），病理升级率为57.1%（24/42）；高级别上皮内瘤变（high-grade intraepithelial neoplasia，HGIN）组术前EFB与ESD术后病理一致率为44.1%（94/213），病理升级率为46.0%（98/213），9.9%（21/213）病理降级为LGIN。单因素分析结果提示饮酒史、乳头内毛细血管袢（intrapapillary capillary loop，IPCL）分型、糜烂、溃疡或出血、病变纵向直径≥2 cm、病变累及管腔范围≥1/2差异均具有统计学意义（均P<0.05）；多因素分析结果提示B2/B3型IPCL（P=0.001）、病变纵向直径≥2 cm（P=0.014）、病变累及管腔范围≥1/2（P<0.001）是ESD术后病理升级的独立危险因素。结论对于内镜下提示B2/B3型IPCL、病变纵向直径≥2 cm、病变累及管腔范围≥1/2的病灶，临床医生应高度警惕病灶病变程度被低估的可能性。
- 上皮内瘤变 /
- 组织病理学升级 /
- 内镜黏膜下剥离术
Abstract: Objective To analyze the risk factors for histopathological upgrade after endoscopic submucosal dissection (ESD) of esophageal squamous intraepithelial neoplasia suggested by endoscopic forceps biopsy (EFB). Methods We retrospectively analyzed 255 lesions from 255 patients with esophageal squamous intraepithelial neoplasia suggested by EFB who had undergone ESD in the Affiliated Hospital of North Sichuan Medical College between November 2019 and May 2023. Based on the pathological differences between EFB and ESD, they were assigned into upgraded (n=123) and non-upgraded (n=132) groups. Univariate and multivariate Logistic regression analyses were used to analyze the risk factors. Results The preoperative endoscopic forceps biopsy (EFB) and post-endoscopic submucosal dissection (ESD) pathological concordance rate for low-grade intraepithelial neoplasia (LGIN) group is 42.9% (18/42), with a pathological upgrade rate of 57.1% (24/42). For high-grade intraepithelial neoplasia (HGIN) group, the preoperative EFB and post-ESD pathological concordance rate is 44.1% (94/213), with a pathological upgrade rate of 46.0% (98/213) and 9.9% (21/213) of cases being downgraded to LGIN. The results of the univariate analysis indicate that there is a statistically significant difference in the following factors: alcohol history, intrapapillary capillary loop (IPCL) classification, erosion, ulceration or bleeding, longitudinal diameter of the lesion ≥2 cm, and involvement of more than 1/2 of the lumen (P<0.05). Multivariate analysis showed that B2/B3 IPCL (P=0.001), lesion longitudinal diameter ≥2cm (P=0.014), and lumen involvement ≥1/2 (P<0.001) were independent risk factors for pathological upgrade after ESD. Conclusions Clinicians should be extremely cautious regarding the possibility of underestimating the severity of lesions with endoscopic findings of B2/B3 IPCL, lesion longitudinal diameter ≥2cm, and lesion involvement of the lumen ≥1/2.
- intraepithelial neoplasia /
- histopathological upgrade /
- endoscopic submucosal dissection (ESD)

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图 1 1例典型病例显示术前EFB和ESD术后标本之间的组织病理学差异

A：白光镜下可见黏膜粗糙发红病变；B：ME-NBI：B1型IPCL；C：ESD术后组织标本；D：术前EFB示HGIN（H&E×100）；E：ESD术后病检示食管鳞状细胞癌，浸润至黏膜固有层（H&E×100）；F：ESD术后病检示食管鳞状细胞癌，浸润至黏膜固有层（H&E×200）

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表 1 术前EFB与ESD术后的病理结果比较处

术前活检	ESD术后病理
术前活检	LGIN	HGIN	ESCC	合计
LGIN	18	19^*	5^*	42
HGIN	21⁺	94	98^*	213
合计	39	113	103	255
*：病理升级；⁺：病理降级

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表 2 术前EFB示食管鳞状上皮内瘤变ESD术后病理升级的单因素分析处 (%）

变量	未升级组（n=132）	升级组（n=123）	χ²	P
性别
女	56（42.4）	45（36.6）	0.907	0.341
男	76（57.6）	78（63.4）
年龄（岁）
<60	32（24.2）	26（21.1）	0.349	0.555
≥60	100（75.8）	97（78.9）
吸烟史
无	91（68.9）	73（59.3）	2.551	0.110
有	41（31.1）	50（40.7）
饮酒史
无	107（81.1）	82（66.7）	6.877	0.009
有	25（18.9）	41（33.3）
IPCL分型
B1	113（85.6）	81（65.9）	13.65	<0.001
B2/B3	19（14.4）	42（34.1）
白苔
无	87（65.9）	71（57.7）	1.810	0.179
有	45（34.1）	52（42.3）
黏膜色泽改变
正常	38（28.8）	27（22.0）	2.505	0.286
发白	7（5.3）	4（3.3）
发红	87（65.9）	92（74.8）
病变部位
颈段	2（1.5）	2（1.6）	1.770	0.624^a
胸上段	23（17.4）	17（13.8）
胸中段	67（50.8）	58（47.2）
胸下段	40（30.3）	46（37.4）
粉色征
阴性	36（27.3）	26（21.1）	1.302	0.254
阳性	96（72.7）	97（78.9）
糜烂、溃疡或出血
无	112（84.8）	92（74.8）	4.021	0.045
有	20（15.2）	31（25.2）
病变纵向直径（cm）
<2	49（37.1）	19（15.4）	15.295	<0.001
≥2	83（62.9）	104（84.6）
累及管腔范围
<1/4	1（0.8）	0	27.524	<0.001^a
1/4～1/2	55（41.6）	17（13.8）
1/2～3/4	56（42.4）	70（56.9）
≥3/4	20（15.2）	36（29.3）
大体分型
隆起	7（5.3）	15（12.2）	4.492	0.106
平坦	116（87.9）	97（78.9）
凹陷	9（6.8）	11（8.9）
活检（块）
1	82（62.1）	75（61.0）	1.247	0.558^a
2～3	47（35.6）	42（34.1）
≥4	3（2.3）	6（4.9）
（）内单位为%；^a：采用Fisher概率确切法

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表 3 术前EFB显示食管鳞状上皮内瘤变ESD术后病理升级的多因素分析

变量	β	OR	95%CI	P
IPCL分型
B1	参考变量
B2/B3	1.163	3.198	1.646～6.213	0.001
病变纵向直径(cm)
<2	参考变量
≥2	0.831	2.295	1.186～4.440	0.014
累及管腔范围
<1/2	参考变量
≥1/2	1.282	3.603	1.864～6.965	<0.001

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