消化道早癌的诊断课件.ppt

消化道早癌的内镜诊断,谭庆华四川大学华西医院,概述,诊断,治疗,发现早癌的内镜诊断技术,白光内镜检查。染色内镜检查。白光放大（ME）。染色+放大。ME+NBI(magnifiedendoscopy)。活检,超声内镜。共聚焦显微内镜。自体荧光内镜光学相干断层成像术细胞内镜蓝激光成像,白光内镜发现早癌的前提,理想的消化内镜术前检查的准备：清理视野，抵制蠕动。严格的质量控制。时刻准备发现早癌的警觉性。特殊、小病变，可借助特殊内镜诊断方法。活检。,一、染色内镜,最常用的染料：碘染色：食管黏膜染色。0.1-0.4%靛胭脂：对比性染料，常用于腺瘤。0.1-0.2%美蓝(亚甲蓝)：吸收性，常用于腺瘤。0.05%结晶紫（龙胆紫）：吸收性，常用于侵袭性病变染色。在病变表面滴数滳，然后再用温水冲洗。最好用链霉蛋白酶。,Conventionalwhitelightimaging,Indigocarminechromoendoscopy,Indigocarmine,Indigocarmine,结晶紫：结构消失，侵及黏膜下层。,白光内镜：7mm扁平息肉样隆起,靛胭脂：中央凹陷,二、特殊光谱及放大内镜,C-WLI:20-40倍ME:80-170倍,Magnifyingendoscopy(ME),Narrowbandimaging,EP,epithelium;LPM,laminapropriamucosae;MM,muscularismucosae;SM,submucosa;PM,propermuscle;M1,cancerislimitedepithelium;M2,cancerinvadesLPMbutdoesnotreachMM;M3,cancerinvasionreachesMM;SM,submucosallyinvasivecancer,NBIimagingofalesionofIPCLtypeIII.,NBIimagingofalesionofIPCLtypeIV,regionalatrophicmucosaorlowgradeintraepithelialneoplasia,high-gradeintraepithelialneoplasia：Tis,ThispatterniscalledIPCL-V1.IPCL-V1includesfourmajorcharacteristicmorphologicalchangesofIPCL:dilation,meandering,irregularcaliber,andfigurevariation.T1a.,Thisistypicalimageofintrapapillarycapillaryloop(IPCL)-V3.CancerinvasiondepthwasM3(muscularismucosae:T1a).,Largewhitearrowspointtolargetumorvessel(IPCL-VN).Thestrikingmorphologicalfeatureisitsextra-largediameter.NotethedifferenceofvesselcaliberbetweenIPCL-V3(smallwhitearrow)andVN(largewhitearrow:T1bordeeper).,V:microvascularpatternSubepithelialcapillary(SEC)Collectingvenule(CV)Pathologicalmicrovessels(MV),S:microsurfacepatternMarginalcryptepithelium(MCE)Cryptopening(CO)Interveningpart(IP)betweencrypts,MNBI,magnifyingendoscopywithnarrow-bandimaging;LBC,lightbluecrest,SECN,subepithelialcapillarynetwork;RAC,regulararrangementofcollectingvenules;CO,crypt-opening;MCE,marginalcryptepithelium;CV,collectingvolume,YaoK.AnnGastroenterol.2013;26(1):11-22.,(A,B)Normalgastricbodymucosa.(C)Helicobacterpylori-associatedgastritis.(D)Atrophicgastritis.,A,B,C,D,C-WLI:erosionM-NBI:aregularmicrovascularpatternandaregularmicrosur-facepatternwithlightbluecrest.chronicgastritiswithintestinalmetaplasia,C-WLI:轻微凹陷。M-NBI：irregularMVandMSwithacleardemarcationline.Histopathologicalfindings:awell-differentiatedadenocarcinomaconfinedtothemucosa,Pitpatternclassification(1),Kudo分型(pitpattern).分为5型（TypeItotypeV）：TypeIandII：良性，非肿瘤性。typeIIItoV：肿瘤性，其准确率达90%。TypeIII：III-SandIII-L,血管袢(CP，sano)分型(佐野分型),CP分型分为I,II,III型，其中III型又分为A和B两亚型。NBI加放大能有效识别低级别上皮内瘤变和高级别上皮内瘤变或浸润性癌。能有效预测病变的组织学类型。,Modified3-stepstrategyofNBIcolonoscopy.,(a)普通光下观察，乙状结肠息肉，0.4cm，表面无明显平坦变化(b)NBI：NBI放大下见明显凹陷，pitpattern为IIIB（佐野分型）提示有黏膜下侵犯，肉眼观呈“0-Is+IIc”,这种病变易出现黏膜下侵犯。(c)结晶紫染色：呈VNpits，为浸润性改变，强烈提示深度黏膜下层侵犯。外科手术。(d)病理发现：中分化腺癌.,两个小的、非侵袭性结直肠癌(5mm).,(a)普通白光：降结肠0.5cm的小息肉，无明显凹陷。(b)NBI：NBI+ME见病变中央凹陷，pitpattern为Sano分型的B型说明可能为浸润性癌，需进一步行结晶紫染色。(c)结晶紫染色：腺管开口呈浸润癌特征，但因中央凹陷太小，不肯定，内镜下切除，为高分化腺癌，再行外科手术.,图1.现有结直肠息肉的NICE分类,TypicalendoscopicfindingsofNICEclassification,FigurestoillustratetheNBIInternationalColorectalEndoscopic(NICE)classification.,三、其它内镜检查,EUS：共聚焦内镜,EUS：20MHz,EUS,TisHigh-gradedysplasiaT1Tumorinvadesthelaminapropria,muscularismucosae(T1a)orsubmucosa(T1b),butdoesnotbreachthesubmucosaT2Tumorinvadesthemuscularispropria,butdoesnotbreachthemuscularispropriaT3TumorinvadestheadventitiaT4Tumorinvadesadjacentstructures;T4a:resectabletumorinvadingthepleura,pericardium,ordiaphragm,T4b:unresectabletumorinvadingotheradjacentstructures,suchasaorta,vertebralbody,trachea,etc.,ConfocalEndomicroscopyinnormalcolonicepithelium,ConfocalEndomicroscopyinacolonicdyspalsia,五、内镜下活检,我科胃癌的早期筛查流程,六、胃蛋白酶原与胃癌,RieckenB.PrevMed,2002,胃蛋白酶原（pepsinogen，PG）,PG：由胃底腺的主细胞和颈粘液细胞分泌PG：除了胃底腺，胃窦幽门腺和近端十二指肠Brunner腺也能分泌PGR：PG/PGPG法用于胃癌筛查，已被多部共识意见推荐缺点：阳性预测值较低,反映胃体萎缩,PG