早期胃癌ESD扩大适应症淋巴结转移风险分析 PPT课件.ppt

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1、ESD扩大适应症与胃癌转移风险 早期胃癌ESD扩大适应证：（1）直径2 cm，分化型，pT1a，UL（-）；（2）直径2 cm，分化型，pT1a，UL（+）；（3）直径2 cm，未分化型，pT1a，UL（-）；概念本次讲述指南以日本指南为准关于早期胃癌转移淋巴管及血管浸润、肿瘤大小、组织学类型、浸润深度常用来作为衡量黏膜下早期胃癌是否适合ESD治疗的因素。在这些因素中，肿瘤大小和组织学类型可以通过活组织检查而在内镜治疗前明确。但事实上，由于标本极小且缺乏黏膜下组织，活组织检查很难发现黏膜下浸润或淋巴管、血管浸润的证据，考虑到这些限制，对于需行ESD治疗的早期胃癌，建议使用二步法来管理：第一步是

2、根据影像学检查（确认浸润深度）、内镜发现（肿瘤大小）和组织病理学发现（组织学特点）来选择适合 和（或）治疗的患者；然后在行 和（或）治疗后通过全面评估切除的标本（包括肿瘤大小、组织学类型、浸润深度及是否存在淋巴管及血管浸润）来确定是否需要追加手术。早期胃癌ESD 淋巴结转移率 当无脉管转移时，文献报道淋巴结转移率的情况如下：（1）直径3 cm，分化型为主，pT1a，UL（+）的病灶约为3.0%；（2）直径3 cm，分化型为主，pT1b（SM1）的病灶约为 2.6%；（3）直径2cm，未分化型为主，pT1a，UL（-）的病灶约为2.8%；（4）未分化型为主，pT1a，UL（+）的病灶约为5.1%

3、。（5）未分化型为主，pT1b（SM1）的病灶约为10.6%。日本2015早期胃癌内镜黏膜切除术和黏膜下剥离术治疗指南The prognostic factors for EGC include depth of tumor invasion,LN metastasis,grade of histologic differentiation,and curative surgery,and many studies have reported that LN metastasis is the most important risk factor for MGC recurrence。In p

4、articular,the LN metastasispositive group had younger age(P=0.019),deeper invasion depth(muscularis mucosa invasion,P0.001),larger tumor size(P=0.002),more frequent ulceration on preoperative endoscopy(P=0.01),more diffuse type as per Lauren classification(P=0.005),and more undifferentiated type(P=0

5、.001)。Univariate and multivariate analyses of risk factors for LN metastasis in MGC age 50 years(P=0.045),tumor invasion to the muscularis mucosa(P 2 cm(P=0.014),presence of ulceration(P=0.01),diffuse type as per Lauren classification(P=0.005),and undifferentiatedtype histology were associated with

6、LN metastasis in MGC；tumor invasion to the muscularis mucosa(P=0.001;OR,4.909),presence of ulceration(P=0.036;OR,1.982),and undifferentiatedtype histology(P=0.025;OR,4.233)were independent risk factors for LN metastasis in MGC Among the cases of MGC invading the lamina propria,5 of 444(1.1%)exhibite

7、d LN metastasis,whereas only 1 of 186(0.5%)had extended indications for ESD(Fig.3,Table 3).Furthermore,among the cases of MGC invading the muscularis mucosae without penetration,37 of 747(5.0%)exhibited LN metastasis。Review of LN metastasispositive cases with indications for ESD MATERIALS AND METHOD

8、S Patients：with EGC who underwent surgery with lymphnode dissection(dissection,dissection ofat least the group 1 lymph nodes)at Jichi Medical University Hospital from 1972 to December 2005.We examined the relations of lymphnode metastasis to clinicopathological factors such as age,sex,tumor location

9、,size,macroscopic appearance,histological type and the presence or absence of lymphatic involvement,vascular involvement and ulcerated lesions.The terminology and definitions used in this study are in accordance with the Japanese Classification of Gastric Carcinoma Histologically,welldifferentiated

10、tubular adenocarcinomas,moderately differentiated tubular adenocarcinomas and papillary adenocarcinomas were grouped together as the differentiated type.Poorly differentiated adenocarcinomas and signetring cell carcinomas were histologically classified as an undifferentiated type.Submucosal carcinom

11、as were divided into two subgroups according to their depth of invasion:sm1 cancers(penetration of submucosal layer less than 500 m from the muscularis mucosa)and sm2 cancers(penetration of 500 m or more).Lesions with ulceration or scarring from previous ulceration(converging folds or deformity of t

12、he muscularis propria,or fibrosis in the submucosa or deeper layers)were regarded as ulcerated lesions.RESULTSOf the 718 patients with intramucosal carcinomas,14(1.9%)had lymphnode metastasis.All cases of lymphnode metastasis were associated with ulceration.No lymphnode metastasis was found in patie

13、nts with intramucosal carcinomas without ulceration,irrespective of tumor size and histological type.Lymphnode metastasis was present in 14(4.7%)of the 296 patients who had cancer with a submucosal invasion depth of less than 500 m(sm1).Significantly increased rates of lymphnode metastasis were asso

14、ciated with undifferentiated types,ulcerated lesions and lymphatic invasion.No lymphnode metastasis was found in patients with differentiated sm1 carcinomas 30 mm or less in diameter without ulceration.Lymphnode metastasis occurred in 29%of the patients who had cancer with a submucosal invasion dept

15、h of 500 m or more(sm2)CONCLUSION This large series of patients with EGC provides further evidence supporting the expansion of indications for endoscopic treatment,as well as warns against potential risks.分化型癌转移风险：1.大小等报道直径 的胃癌，不论其组织学类型如何，均更早发生深层黏膜浸润，且淋巴结转移率明显上升。Early gastric cancer:lymph node metas

16、tasis starts with deep mucosal infiltration.Ann Surg.2009 Nov;250(5):791-7.doi:10.1097/SLA.0b013e3181bdd3e4转移风险：未分化癌Predictive Factors for Lymph Node Metastasis in Undifferentiated Early Gastric Cancer:a Systematic Review and Meta-analysisJ Gastrointest Surg DOI 10.1007/s11605-017-3364-71.Sex:In tot

17、al,16 studies with 11,289 patients(6162 males and 5127 females)were included for the meta-analysisof sex.The results of this analysis showed that male patients had a lower risk of LNM than do female patients(P=0.36,I2=8%;pooled OR=0.84,95%CI=0.750.94,P=0.003),as shown in Fig.2.2.AgeData regarding ag

18、e(60 or 60 years)were described in four papers,which included 1711 patients(997 patients 60 years and 714 patients 60 years).After analysis,the rate of LNM in younger patients(60 years)was reduced compared with that in older patients(60 years;P=0.29,I2=21%;pooled R=0.61,95%CI=0.440.86,P=0.004),as sh

19、own in Fig.3.3.Size Eleven studies including 8974 patients(3447 patients 20 mm and 5527 patients 20 mm)met the criteria for the meta-analysis of tumor size.Patients with larger tumors(20 mm)were at increased risk of LNM compared to patients with smaller tumors(20 mm;P=0.06,I2=43%;pooled OR=2.64,95%C

20、I=2.093.33,P 0.00001),as shown in Fig.4.4.Depth of invasionDepth of invasion:Twenty studies with 12,048 patients(mucosa,6591;submucosa,5457)were included in the meta-analysis for depth of invasion.The results demonstrated that mucosal lesions had a lower risk of LNM than do submucosal lesions(P=0.01

21、,I2=47%;pooled OR=0.18,95%CI=0.140.22,P0.00001),as shown in Fig.5.5.Lymphovascular involvementLymphovascular involvement:Eligible reports of LVI were provided in 11 articles,including 9246 patients(LVI presence,1112;LVI absence,8134).The pooled result of meta-analysis indicated that the presence o L

22、VI was significantly correlated with LNM(P=0.0007,I2=67%;pooled OR=12.24,95%CI=8.6917.25,P 0.00001),as shown in Fig.6 6.Ulcer findings In total,15 studies,including 11,002 patients(ulcer,4457;no ulcer,6545)reported relationship between ulcer findings and LNM.The pooled result of the meta-analysis re

23、vealed that ulcers were significantly related to LNM(P0.0001,I2=68%;pooled OR=1.7,95%CI=1.282.27,P=0.0003),as shown in Fig.7.7.Histology typeFourteen studies,including 6807 patients(SRC,3475;other types,3332),reported a correlation between histology type and LNM.The pooled result of the meta-analysi

24、s demonstrated that SRC had a lower risk of LNM than do other carcinoma types(P=0.36,I2=9%;pooled OR=0.42,95%CI=0.360.49,P 0.00001),as shown in Fig.8.8.Tumor locationTumor location data were reported in 15 studies,which included a total of 10,982 patients(middle,5584;others,5528).Meta-analysis showe

25、d that carcinomas in the middle part of the stomach exhibited a reduced risk of LNMcomparedwith carcinomas in other parts of the stomach(P=0.53,I2=0%;pooled OR=0.84,95%CI=0.740.95,P=0.007),as shown in Fig.9.9.Macroscopic typeFour articles with a total of 1646 patients(depressed,1290;non-depressed,356)were included for the meta-analysis of macroscopic type.The pooled result showed that patients with depressed carcinomas did not exhibit an increased risk of LNM(P=0.13,I2=47%;pooled OR=0.71,95%CI=0.511.01,P=0.06).This difference was not statistically significant,as shown in Fig.10.