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1、结直肠锯齿状息肉最新报道结直肠锯齿状息肉最新报道 Update on sUpdate on serratederrated polyps of the colorectum polyps of the colorectum2012014 4-03-03-1 19 91简要介绍锯齿状病变专家共识推荐规 范 增生性息肉(MVHP)与SSA/P的新认知 传统型锯齿状腺瘤(TSA)伴异型增生2简要介绍锯齿状病变专家共识推荐规范 2010年在Cleveland举行，由美国胃肠病学 会(ACG)支持、美国国立卫生研究院(NIH)赞助 专家组成员：endoscopy, surgery, pathology,
2、 epidemiology, and/or molecular aspects of serrated lesions and/or serrated polyposis.3经与会专家组讨论15年MEDLIAN文献，形成共识报告，目的是总结锯齿状息肉病理 、分子病理和内镜特征，提高这种疾病威 胁的意识，描述内镜特征，强调该疾病精 确探查和完全切除的重要性，提供有关该 病切除后处理的推荐规范。4Key conclusions and recommendations of the consensus group Pathology 1 Serrated lesions of the colorec
3、tum should be classified histologically as hyperplastic polyp (HP), sessile serrated adenoma/polyp(SSA/P) with or without cytologic dysplasia, or traditional serrated adenoma (TSA). Exceptions and subcategories are discussed in the text. Clinicians and pathologists within institutions should work co
4、llaboratively to achieve a common usage and understanding of terminology of serrated lesions. 2 SSA/P and TSA are pre-cancerous lesions. SSA/P is the principal precursor of hypermethylated colorectal cancers (cancers with the CpG Island Methylator Phenotype CIMP). This pathway occurs primarily in th
5、e proximal colon.53 SSA/P is distinguished from HP pathologically by findings of crypt distortion, particularly in the crypt base, in SSA/P. We recommend that a single unequivocal architecturally distorted, dilated, and/or horizontally branched crypt, particularly if it is associated with inverted m
6、aturation, is sufficient for a diagnosis of SSA/P. Most large serrated lesions in the proximal colon are SSA/Ps. 4 SSA/P with cytological dysplasia is a more advanced lesion in the progression to cancer compared to SSA/P without cytological dysplasia.6Endoscopy 5 SSA/P and hyperplastic polyps in the
7、 proximal colon have a distinct endoscopic appearance, which includes a “mucus cap”, color usually similar to normal mucosa, and indistinct edges. All colonoscopists should be able to recognize serrated lesions. 6 Detection of proximal colon serrated lesions by individual endoscopists is highly corr
8、elated with adenoma detection. Pending development of specific detection targets for proximal colon serrated lesions, endoscopists should measure their adenoma detection rates as a check on adequate detection of serrated lesions. 7 All serrated lesions proximal to the sigmoid colon should be fully r
9、esected during colonoscopy. All serrated lesions in the rectosigmoid colon 5 mm in size should be fully resected. 7Surveillance 8 Serrated polyposis is defined by the World Health Organization (see text for details). Patients with serrated polyposis require close endoscopic follow- up with control o
10、f polyp burden by endoscopy or by surgical resection if the number, size or location of serrated polyps precludes endoscopic resection or if a cancer is diagnosed. 9 First degree relatives of patients with SPS should undergo colonoscopy at age 40 or 10 years before the age at diagnosis of SPS. Colon
11、oscopy should be at 5 year intervals or more often if polyps are found. 10 There are few longitudinal observational studies after removal of serrated lesions on which recommendations for postpolypectomy surveillance can be based. Recommendations are mostly based on features of serrated lesions for w
12、hich there is evidence of an association with increased risk of cancer or advanced neoplasms, including: proximal colon location, large size, increasing number, and histologic features including SSA/P histology . Am J Gastroenterol, 2012 ,107(9): 13151330.8序言(introduction)锯齿状病变(serrated lesions)的真正发
13、病率，尤其是结肠近段，可能高于先前的报道；相当数量的 内镜医师漏掉了半数以上的锯齿状病变。 流行病学 尸解研究显示25-50%的白种成人有一个及以上锯齿状病变。内镜检出率很低。锯齿状 病变最常见于乙状结肠和直肠，其分布依据组织 学类型变化，70-95%的锯齿状病变为HPs，左半 结肠为主；SSA/Ps占5-25%，右半结肠为主，TSA 少于SSA/Ps，左半结肠常见。9 结直肠锯齿状病变是结直肠锯齿状病变是1/31/3结直肠癌的前驱病结直肠癌的前驱病变（癌前病变）。变（癌前病变）。 源于锯齿状病变的癌常发生于近端结肠。源于锯齿状病变的癌常发生于近端结肠。 结直肠锯齿状病变根据结直肠锯齿状病变根
14、据WHOWHO标准病理学分标准病理学分 三大类，即增生性息肉三大类，即增生性息肉(HP(HPs s) )、广基型锯齿、广基型锯齿 状腺瘤状腺瘤/ /息肉息肉(SSA/P)(SSA/P)伴或不伴细胞异型增生伴或不伴细胞异型增生 及传统型锯齿状腺瘤及传统型锯齿状腺瘤(TSA)(TSA)。1011对SSA/P的认识时间相对较短，其诊断对低年资病理医生常有困难； SSA/P诊断频率文献报道也是变化甚大。 MVHP与SSA/P交界性病变依然是一个诊断问题。 近年来对SSA/P的诊断阈值趋向降低，认为 在MVHP背景中即使是有1个确定的结构扭 曲、扩张和/或水平分支的SSA/P样隐窝，也 可以诊断SSA/
15、P(Am J Gastroenterol.2012, 107(9): 13151330)。12 SSA/PSSA/P和和TSATSA是恶性前病变，而是恶性前病变，而SSA/PSSA/P是结是结直肠癌主要的锯齿状前驱病变。直肠癌主要的锯齿状前驱病变。 结直肠锯齿状病变的内镜表现独特，一般结直肠锯齿状病变的内镜表现独特，一般 不如经典腺瘤性息肉易发现。不如经典腺瘤性息肉易发现。 近端至乙状结肠病变或所有直乙状结肠病近端至乙状结肠病变或所有直乙状结肠病 变变5mm5mm，应完全切除。，应完全切除。 锯齿状息肉切除后随访监测，减少间隔性锯齿状息肉切除后随访监测，减少间隔性 结直肠癌。结直肠癌。13pp
16、SSA/PSSA/P诊断标准有不同的意见：诊断标准有不同的意见： pp增生性息肉增生性息肉(MVHP)(MVHP)与与SSA/PSSA/P的区分以及诊的区分以及诊 断断SSA/PSSA/P需要特征性隐窝的分布范围和数量需要特征性隐窝的分布范围和数量 标准是困难的问题标准是困难的问题 pp 美国胃肠病协会指南建议假若美国胃肠病协会指南建议假若1 1个隐窝具有个隐窝具有 SSA/PSSA/P的特征，就可诊断的特征，就可诊断SSA/PSSA/P；而；而 WHO(2010)WHO(2010)的标准是至少的标准是至少3 3个或相邻个或相邻2 2个特个特 征性隐窝，可诊断征性隐窝，可诊断SSA/PSSA/P。 ppSSA/PSSA/P在息肉状病变中的比例实际并不低在息肉状病变中的比例实际并不低 ，14.7%14.7%。 pp 锯齿状息肉漏诊率依然很高。锯齿状息肉漏诊率依然很高。14 锯齿状息肉
