早期胃癌ESD扩大适应症淋巴结转移风险分析.ppt

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%。 （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 particular, 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 = 0.001)。,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 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%) exhibited 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 metastasis-positive cases with indications for ESD,MATERIALS AND METHODS,Patients：with EGC who underwent surgery with lymph-node dissection (dissection, dissection of at least the group 1 lymph nodes) at Jichi Medical University Hospital from 1972 to December 2005. We examined the relations of lymph-node metastasis to clinicopathological factors such as age, sex, tumor location, 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 tubular adenocarcinomas, moderately differentiated tubular adenocarcinomas and papillary adenocarcinomas were grouped together as the differentiated type. Poorly differentiated adenocarcinomas and signet-ring cell carcinomas were histologically classified as an undifferentiated type. Submucosal carcinomas 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 the muscularis propria, or fibrosis in the submucosa or deeper layers) were regarded as ulcerated lesions.,RESULTS,Of the 718 patients with intramucosal carcinomas, 14 (1.9%) had lymph-node metastasis.All cases of lymph-node metastasis were associated with ulceration. No lymph-node metastasis was found in patients with intramucosal carcinomas without ulceration, irrespective of tumor size and histological type. Lymph-node 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 lymph-node metastasis were associated with undifferentiated types, ulcerated lesions and lymphatic invasion. No lymph-node 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 depth 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 metastasis 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-analysis J Gastrointest Surg DOI 10.1007/s11605-017-3364-7,1. Sex:,In total, 16 studies with 11,289 patients (6162 males and 5127 females) were included for the meta-analysis of 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.Age,Data regarding age (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 shown 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% CI=2.093.33, P 0.00001), as shown in Fig. 4.,4.Depth of invasion,Depth 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, I2=47%;pooled OR=0.18, 95% CI=0.140.22, P0.00001), as shown in Fig. 5.,5.Lymphovascular involvement,Lymphovascular 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 LVI 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 revealed 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 type,Fourteen studies, including 6807 patients (SRC, 3475; other types, 3332), reported a correlation between histology type and LNM. The pooled result of the meta-analysis 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.