医学消化道早癌的诊断课件.pptx

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2016/9/22,#,消化道早癌的诊断,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,(magnified endoscopy),。,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。,表,1,消化内镜下常用,染料,染料类型,被染对象,染色原理,阳性颜色,临,床,应,用,Lugols,碘液,(,碘,+,碘化钾,),磷状上皮内的糖原,非角化上皮结合碘,深棕色,正常食管磷状上皮着色。,食管磷状细胞癌黏膜、,Barrett,食管黏膜、柱状上皮和食管炎黏膜均不着色。,亚甲蓝,肠道上皮细胞，肠化上皮细胞,吸收入上皮细胞内,蓝色,食管和胃的肠化上皮、早期胃癌上皮和正常肠道上皮着色。,十二指肠内化生的胃上皮不着色。,甲苯胺蓝,胃或肠内的柱状上皮细胞胞核差色,自由扩散入细胞,蓝色,食管磷状细胞癌上皮和,Barrets,食管中的化生上皮着色,刚果红,胃内泌酸细胞,当,pH3.0,时变色,变为深蓝或黑色,泌酸的胃上皮变色，包括异位胃黏膜上皮。,胃癌上皮细胞不变色。,酚红,感染,HP,的胃上皮细胞,由于,HP,周边有,“,氨云,”,，局部呈碱性而便酚红变色,由黄变红,诊断胃内,HP,的感染及其分布情况。,靛胭脂,细胞不着色,沉积于上皮表面的低凹处，勾勒出病变形态。,蓝色,全消化道黏膜均可使用。,Conventional white light imaging,Indigo carmine chromoendoscopy,Indigo carmine,Indigo carmine,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,Magnifying endoscopy(ME),Narrow band imaging,EP,epithelium;LPM,lamina propria 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 cancer,NBI imaging of a lesion of IPCL type III.,NBI imaging of a lesion of IPCL type IV,regional atrophic mucosa or low grade intraepithelial neoplasia,high-grade intraepithelial,neoplasia,：,Tis,This pattern is called IPCL-V1.IPCL-V1 includes four major characteristic morphological changes of IPCL:dilation,meandering,irregular caliber,and figure variation,.T1a.,This is typical image of intrapapillary capillary loop(IPCL)-V3.Cancer invasion depth was M3(muscularis,mucosae:T1a).,Large white arrows point to large tumor vessel(IPCL-VN).The striking 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).,V:microvascular pattern,Subepithelial capillary(SEC),Collecting venule(CV),Pathological microvessels(MV,),S,:microsurface pattern,Marginal crypt epithelium(MCE),Crypt opening(CO),Intervening part(IP)between crypts,MNBI,magnifying endoscopy with narrow-band imaging;LBC,light,blue crest,SECN,subepithelial capillary network;,RAC,regular,arrangement of collecting venules;,CO,crypt-opening,;,MCE,marginal,crypt epithelium;,CV,collecting volume,Yao K,.Ann,Gastroenterol.2013;26(1):11-22,.,(A,B)Normal gastric body mucosa.,(C),Helicobacter pylori,-associated gastritis.,(D)Atrophic gastritis.,A,B,C,D,C-WLI:erosion,M-NBI:a regular microvascular,pattern and a regular,microsur-face pattern with light blue crest.,chronic,gastritis with intestinal metaplasia,C-WLI:,轻微凹陷。,M-NBI,：,irregular MV and MS with,a clear demarcation line,.,Histopathological findings:a,well-differentiated adenocarcinoma confined to the mucosa,Pit pattern classification(1),Kudo,分型,(pit pattern).,分为,5,型（,Type I to type,V,）：,Type,I and II,：,良性，非肿瘤性。,type,III to,V,：肿瘤性，其准确率达,90%,。,Type,III,：,III-S and III-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,。,Modified 3-step strategy of NBI colonoscopy.,(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，,pit pattern,为,III,B,（佐野分型）提示有黏膜下侵犯,，肉眼,观呈,“0-I s+II c”,这种病变易出现黏膜下侵犯。,(c),结晶紫染色：呈,V,N,pits,，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，,pit pattern,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,Typical endoscopic findings of NICE classification,Figures to illustrate the NBI International Colorectal Endoscopic(NICE)classification,.,三、其它内镜检查,EUS,：,共聚焦内镜,EUS,：,20MHz,EUS,Tis High-grade dysplasia,T1 Tumor invades the lamina propria,muscularis mucosae(T1a)or submucosa(T1b),but does not breach the submucosa,T2 Tumor invades the muscularis propria,but does not breach the muscularis propria,T3 Tumor invades the adventitia,T4 Tumor invades adjacent structures;,T4a:resectable tumor invading the pleura,pericardium,or diaphragm,T4b:unresectable tumor invading other adjacent structures,such as aorta,vertebral body,trachea,etc.,Confocal Endomicroscopy in normal,colonic,epithelium,Confocal Endomicroscopy in,a,colonic,dyspalsia,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,Riecken B.Prev Med,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/PG,PG,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 I,PGR,Fock KM.J Gastroenterol Hepatol 2008;,中华消化内镜杂志,2014,高胃泌素血症、,PGR,低值是非贲门胃癌的高危,因素（肠型胃癌）。,Vnnen.Eur J Gastroenterol Hepatol 2003,A,组,B,组,C,组,G-17,-,+,-,+,PG,-,-,+,+,血清,PG,联合,G-17,G-17(+),：,G-17,1pmol/L,或,G-17,15pmol/L,PG,（,+,）：,PG 70ng/ml,且,PGR 7.0,胃癌风险递增,体检人群,检测血清,PGI,、,PGII,、,PGR,、,G-17,B,组：,“,G-17(+),且,PG(-),”,或,“,G-17(-),且,PG(+),”,C,组：,“,G-17(+),且,PG(+),”,A,组：,“,G-17(-),且,PG(-),”,存在较低胃癌风险,胃癌高风险,进展期胃癌,胃癌风险低,不建议胃镜检查,可,根据临床需要，行胃镜检查,胃镜精查,早期胃癌，或高级别瘤变,非胃癌,其他,重度萎缩、肠化和低级别瘤变,定期复查,PG,、,G-17,ESD,等,微创治疗,外科手术,每年行,胃镜检查,每年复查,PG,、,G-17,每年行,胃镜检查,谢 谢,