消化道早癌的診斷培訓(xùn)課件

1、概 述診 斷治 療概 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)細胞內(nèi)鏡藍激光成像發(fā)現(xiàn)早癌的內(nèi)鏡診斷技術(shù)白光內(nèi)鏡檢查。超聲內(nèi)鏡。白光內(nèi)鏡發(fā)現(xiàn)早癌的前提理想的消化內(nèi)鏡術(shù)前檢查的準備：清理視野，抵制蠕動。嚴格的質(zhì)量控制。時刻準備發(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。白光內(nèi)鏡發(fā)現(xiàn)早癌的前提理想的消化內(nèi)鏡術(shù)前檢查的準備：清理視野一、染色內(nèi)鏡最常用的染料：碘染色：食管黏膜染色。0.1-0.4%靛胭脂：對比性染料，

2、常用于腺瘤。0.1-0.2%美藍(亞甲藍)：吸收性，常用于腺瘤。0.05%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。一、染色內(nèi)鏡最常用的染料：表1 消化內(nèi)鏡下常用染料染料類型被染對象染色原理陽性顏色臨 床 應(yīng) 用Lugols碘液(碘+碘化鉀)磷狀上皮內(nèi)的糖原非角化上皮結(jié)合碘深棕色正常食管磷狀上皮著色。食管磷狀細胞癌黏膜、Barrett食管黏膜、柱狀上皮和食管炎黏膜均不著色。亞甲藍腸道上皮細胞，腸化上皮細胞吸收入上皮細胞內(nèi)藍色食管和胃的腸化上皮、早期胃癌上皮和正常腸道上皮著色。十二指腸內(nèi)化生的胃上皮不著色。甲苯胺藍胃或腸內(nèi)的柱狀上皮細胞

3、胞核差色自由擴散入細胞藍色食管磷狀細胞癌上皮和Barrets食管中的化生上皮著色剛果紅胃內(nèi)泌酸細胞當pH3.0時變色變?yōu)樯钏{或黑色泌酸的胃上皮變色，包括異位胃黏膜上皮。胃癌上皮細胞不變色。酚紅感染HP的胃上皮細胞由于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。靛胭脂細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。表1 消化內(nèi)鏡下常用染料染料類型被染對象染色原理陽Conventional white light imagingIndigo carmine chromoendoscopyConventional white ligh

4、t imagiIndigo carmineIndigo 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Indigo carmine結(jié)晶紫：結(jié)構(gòu)消失，侵及黏膜下層。二、特殊光譜及放大內(nèi)鏡C-WLI: 20-40倍ME: 80-170倍Magnifying endoscopy (ME)Narrow band imaging二、特殊光譜及放大內(nèi)鏡C-WLI: 20-40倍Magnif消化道早癌的診斷培訓(xùn)課件消化道早癌的診斷培訓(xùn)課件消化道早癌的診斷培訓(xùn)課件EP, epithelium; LPM, lamina propria

5、mucosae; MM, muscularis mucosae; SM, submucosa; PM, proper muscle; M1, cancer is limited epithelium; M2, cancer invades LPM but does not reach MM; M3, cancer invasion reaches MM; SM, submucosally invasive cancerEP, epithelium; LPM, lamina pr消化道早癌的診斷培訓(xùn)課件消化道早癌的診斷培訓(xùn)課件NBI imaging of a lesion of IPCL typ

6、e III. NBI imaging of a lesion of IPCL type IV regional atrophic mucosa or low grade intraepithelial neoplasia high-grade intraepithelial neoplasia：Tis NBI imaging of a lesion of IPCThis pattern is called IPCL-V1. IPCL-V1 includes four major characteristic morphological changes of IPCL: dilation, me

7、andering, irregular caliber, and figure variation. T1a.This pattern is called IPCL-V1This is typical image of intrapapillary capillary loop (IPCL)-V3. Cancer invasion depth was M3 (muscularis mucosae: T1a).This is typical image of intraLarge white arrows point to large tumor vessel (IPCL-VN). The st

8、riking 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). Large white arrows point to laV: microvascular pattern Subepithelial capillary (SEC) Collecting venule (CV) Pathological micr

9、ovessels (MV)S: microsurface pattern Marginal crypt epithelium (MCE) Crypt opening (CO) Intervening part (IP) between cryptsV: microvascular patternS: micMNBI, magnifying endoscopy with narrow-band imaging; LBC, lightblue crestSECN, subepithelial capillary network; RAC, regular arrangement of collec

10、ting 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. ABCDMNBI, magnifying endoscopy witC-WLI :erosionM-NBI: a regular mic

11、rovascular pattern and a regular microsur-face pattern with light blue crest. chronic gastritis with intestinal metaplasiaC-WLI :erosionC-WLI: 輕微凹陷。M-NBI：irregular MV and MS with a clear demarcation line.Histopathological findings: a well-differentiated adenocarcinoma confined to the mucosaC-WLI: 輕微

12、凹陷。Pit 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，其準確率達90%。Type III：III-S and III-LPit pattern classification (1)消化道早癌的診斷培訓(xùn)課件血管袢(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。血管袢(CP

13、，sano)分型(佐野分型)CP分型分為I, IModified 3-step strategy of NBI colonoscopy.Modified 3-step strategy of NB(a) 普通光下觀察，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VNpits，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) 普通光下觀

14、察，乙狀結(jié)腸息肉，0.4cm，表面無明顯平(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).(a)普通白光：降結(jié)腸0.5cm的小息肉，無明顯凹陷。圖 1. 現(xiàn)有結(jié)直腸息肉的 NICE 分類圖 1. 現(xiàn)有結(jié)直腸息肉的 NICE 分類Typical endoscopic findings of NICE classificationFigures to illus

15、trate the NBI International Colorectal Endoscopic (NICE) classification.Typical endoscopic findings of消化道早癌的診斷培訓(xùn)課件三、其它內(nèi)鏡檢查EUS：共聚焦內(nèi)鏡三、其它內(nèi)鏡檢查EUS：EUS：20MHzEUSTis High-grade dysplasiaT1 Tumor invades the lamina propria, muscularis mucosae (T1a) or submucosa (T1b), but does not breach the submucosaT2 Tum

16、or 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 tumor invading other adjacent structures, such as aorta, vertebral

17、 body, trachea, etc.EUS：20MHzEUSTis High-grade dysConfocal Endomicroscopy in normal colonic epitheliumConfocal Endomicroscopy in a colonic dyspalsiaConfocal Endomicroscopy in nor五、內(nèi)鏡下活檢五、內(nèi)鏡下活檢我科胃癌的早期篩查流程我科胃癌的早期篩查流程 六、胃蛋白酶原與胃癌Riecken B. Prev Med,2002胃蛋白酶原（pepsinogen，PG）PG：由胃底腺的主細胞和頸粘液細胞分泌PG：除了胃底腺，胃竇幽

18、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)測值較低反映胃體萎縮PG IPGRFock KM. J Gastroenterol Hepatol 2008; 中華消化內(nèi)鏡雜志 2014 六、胃蛋白酶原與胃癌Riecken B. Prev Me高胃泌素血癥、PGR低值是非賁門胃癌的高危因素（腸型胃癌）。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B 組C 組G-17-+-+PG-+血清PG聯(lián)合G-17G-17(+)：G-17 1pmol/L或G-17 15pmol/LPG（+）：PG 70ng/ml 且PGR 7.0胃癌