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1、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 (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、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。,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
3、, 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
4、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
5、. 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 IPC
6、L-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, magni
7、fying 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 mucos
8、a. (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 demarcatio
9、n 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
10、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IIIB（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VN 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(5 mm).,(a)
11、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) classifica
12、tion.,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 T
13、umor 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 d
14、yspalsia,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,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,谢 谢,
