高清电视图像和窄带成像在鉴别大肠小息肉上的临床应用研究
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摘要
在西方国家,大肠癌是最常见的肿瘤且其是引起癌症相关死亡的主要的原因。在中国,大肠癌的发生率也在逐年增加。大肠息肉,尤其是腺瘤性息肉,被认为是大肠癌的癌前病变。有学者根据与大肠癌相关与否将大肠息肉分为肿瘤性息肉和非肿瘤性息肉。大肠肿瘤性息肉是指腺瘤性息肉、不典型增生及早期癌。所以发现并切除大肠肿瘤性息肉可以降低大肠癌的发生率和死亡率。目前,临床上对于大肠息肉的处理大部分学者认为应该先进行活组织检查后再决定进一步的治疗方案,因为非肿瘤性息肉并不需要内镜下切除,这个诊疗过程既费时费力且增加了诊疗的费用。因此,在体内准确的鉴别肿瘤性息肉与非肿瘤性息肉尤为重要。因为这样可以即时的决定是否需要进行息肉切除术,这会使得结肠镜检查更为有效。
自从大肠“高危”肿瘤的概念提出之后,更多的学者关注大于10mm的大肠息肉。有研究显示在结肠镜检查中有90%是大肠小息肉(<10mm),在组织学类型上,最初的数据显示80-90%的大肠小息肉(<10mm)是增生性息肉,但是最近的研究显示40%-50%的大肠小息肉是肿瘤性息肉。所以明确大肠小息肉的发生率及其病理特点显得尤为重要。体内即时的诊断大肠小息肉的病理类型(肿瘤性还是非肿瘤性息肉)也会使得结肠镜诊疗更加有效。
本实验将大肠小息肉分为<5mm和6-10mm息肉组,旨在对大肠小息肉的内镜、病理特点及肿瘤性小息肉中的“高危”肿瘤进行对比分析以明确大肠小息肉的临床意义并评估高清电视图像结合窄带成像在大肠小息肉组织学诊断上的可行性。
Background: Colorectal cancer (CRC) is one of the most common cancers diagnosed in Western countries and is major cause of cancer-associated morbidity and mortality. In China, the incidence of CRC is increaing rapidly. Colorectal polyps,especialy adenomatous polyps, is precancerous lesions of CRC. So the detection and subsequent removal of neoplastic colorecal lesions, including adenomatous polyps and aerly cancers can reduce CRC morbidity and mortality. Since the concept of“advanced”lesions was proposed, more scholars concerned polyps larger than 10 mm. Although initial data suggest that 80%-90% of small colorectal polyps(<10mm) are histologically heperplastic, more recent date indicate that 40%-60% of such polyps are neoplastic. The ability to accurately differentiate the neoplastic and non-neoplastic polyps is useful because it obviates the need for biopsiea during colonoscopy and for removal of small polyps. Accurate optical diagnosis of small (<10 mm) colorectal polyps in vivo, without formal histopathology could make colonoscopy more efficient and cost effective. The aim of this study was to assess whether optical diagnosis of small polyps with HDE with NBI is feasible and safe in routine clinical practice. Methods Consecutive patients with a positive small coloractal polyps(<10mm) in routine colonoscopy at The First Hospital of Jilin University(Changchun, China), from January 1, 2008, to October 1, 2009, were included in this prospective study.Patient with inflammatory bowel disease (IBD), Hereditary non-polyposis colorecal cancer (HNPCC), familial adenomatous polyposis (FAP) and polyps larger than 10 mm were excluded from this study.Experimented colonoscopist predicted polyp histology using optical diagnosis with High Definition Endoscopy (HDE), followed by narrow-band imaging without chromoendoscopy, as required. The primary outcome was accuracy of polyp characterisation using optical diagnosis compared with histopathology, the current gold standard. Findings 501 polyps smaller than 10 mm were detected. By histology, 358 of these polyps were neoplastic lesions(71.5%) and 143 were non-neoplastic lesions (of which 122 were hyperplastic). In group of 6-10mm polyps, 61 of 64 polyps were neoplastic lesions (95.3%). In group of polyps small than 5mm,297 of 437 polyps were neoplastic lesions(67.9%). Optical diagnosis accurately diagnosed 325 of 358 neoplasic lesions (sensitivity 0·91) and 111 of 143 hyperplastic polyps (specificity 0·77), with an overall accuracy of 435 of 501(0·87) for polyp characterisation. Outcomes: In our study, for polyps less than 10 mm in size, the neoplastic polyps has larger proportion (>65%), especially 6-10mm polyps (95.3%). So we suggeated polypectomy was conduced once a 6-10mm polyps was found. For polyps less than 10 mm in size, in-vivo optical diagnosis seems to be an acceptable strategy to assess polyp histopathology. Dispensing with formal histopathology for most small polyps found at colonoscopy could improve the efficiency of the procedure and lead to substantial savings in time and cost.
自从大肠“高危”肿瘤的概念提出之后,更多的学者关注大于10mm的大肠息肉。有研究显示在结肠镜检查中有90%是大肠小息肉(<10mm),在组织学类型上,最初的数据显示80-90%的大肠小息肉(<10mm)是增生性息肉,但是最近的研究显示40%-50%的大肠小息肉是肿瘤性息肉。所以明确大肠小息肉的发生率及其病理特点显得尤为重要。体内即时的诊断大肠小息肉的病理类型(肿瘤性还是非肿瘤性息肉)也会使得结肠镜诊疗更加有效。
本实验将大肠小息肉分为<5mm和6-10mm息肉组,旨在对大肠小息肉的内镜、病理特点及肿瘤性小息肉中的“高危”肿瘤进行对比分析以明确大肠小息肉的临床意义并评估高清电视图像结合窄带成像在大肠小息肉组织学诊断上的可行性。
Background: Colorectal cancer (CRC) is one of the most common cancers diagnosed in Western countries and is major cause of cancer-associated morbidity and mortality. In China, the incidence of CRC is increaing rapidly. Colorectal polyps,especialy adenomatous polyps, is precancerous lesions of CRC. So the detection and subsequent removal of neoplastic colorecal lesions, including adenomatous polyps and aerly cancers can reduce CRC morbidity and mortality. Since the concept of“advanced”lesions was proposed, more scholars concerned polyps larger than 10 mm. Although initial data suggest that 80%-90% of small colorectal polyps(<10mm) are histologically heperplastic, more recent date indicate that 40%-60% of such polyps are neoplastic. The ability to accurately differentiate the neoplastic and non-neoplastic polyps is useful because it obviates the need for biopsiea during colonoscopy and for removal of small polyps. Accurate optical diagnosis of small (<10 mm) colorectal polyps in vivo, without formal histopathology could make colonoscopy more efficient and cost effective. The aim of this study was to assess whether optical diagnosis of small polyps with HDE with NBI is feasible and safe in routine clinical practice. Methods Consecutive patients with a positive small coloractal polyps(<10mm) in routine colonoscopy at The First Hospital of Jilin University(Changchun, China), from January 1, 2008, to October 1, 2009, were included in this prospective study.Patient with inflammatory bowel disease (IBD), Hereditary non-polyposis colorecal cancer (HNPCC), familial adenomatous polyposis (FAP) and polyps larger than 10 mm were excluded from this study.Experimented colonoscopist predicted polyp histology using optical diagnosis with High Definition Endoscopy (HDE), followed by narrow-band imaging without chromoendoscopy, as required. The primary outcome was accuracy of polyp characterisation using optical diagnosis compared with histopathology, the current gold standard. Findings 501 polyps smaller than 10 mm were detected. By histology, 358 of these polyps were neoplastic lesions(71.5%) and 143 were non-neoplastic lesions (of which 122 were hyperplastic). In group of 6-10mm polyps, 61 of 64 polyps were neoplastic lesions (95.3%). In group of polyps small than 5mm,297 of 437 polyps were neoplastic lesions(67.9%). Optical diagnosis accurately diagnosed 325 of 358 neoplasic lesions (sensitivity 0·91) and 111 of 143 hyperplastic polyps (specificity 0·77), with an overall accuracy of 435 of 501(0·87) for polyp characterisation. Outcomes: In our study, for polyps less than 10 mm in size, the neoplastic polyps has larger proportion (>65%), especially 6-10mm polyps (95.3%). So we suggeated polypectomy was conduced once a 6-10mm polyps was found. For polyps less than 10 mm in size, in-vivo optical diagnosis seems to be an acceptable strategy to assess polyp histopathology. Dispensing with formal histopathology for most small polyps found at colonoscopy could improve the efficiency of the procedure and lead to substantial savings in time and cost.
引文
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[10] Apel D, Jakobs R, Schilling D, et al. Accuracy of high resolution of chromoendoscopy in prediction of histologic finding in diminutive lesions of the rectosigmoid. Gastrointeest Endosc 2006;63:824-28
[11] Tischedorf JJ, Wasmuth HE, Koch A, et al. Value of magnifying chromoendoscopy and narrow band imaging in classifying colorectal polyps:a prospective controlled study.Endoscopy 2007;39:1092-96.
[12] East JE, Suzuki N, Saunders BP. Comparision of magnifield pit patter interpretation with narrow band imaging versus chromoendoscopy for diminutive colonic polyps:a pilot study. Gastrointest Endosc 2007;66:310-16.
[13] Xu Shaoming, Melton LJ. The epidenmiology of primary hyporparathyroidism in North American. Journal of Bone & Mineral Reseach 2002(12):12-172.
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[32] Tribonias G, Theodoropoulou A, Konstantinidis K, et al. Comparisonof standard versus high-definition, wide-angle colonoscopy for polyp detection: A Randomized Controlled Trial. Colorectal Dis. 2009 Nov 23. [Epub ahead of print].
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[35] Vatan MH, Stalsbert H. The prevalence of polyps of large intestine in Oslo:an autopsy study. Cancer 1982;40:819-25.
[36] Fu KI, Sano Y, Kato S, et al. Chromeendoscopy using indigo carmine dye spraying with magnifying observation is the most reliable method for differential diagnosis between non-neoplastic and neoplastic colorectal lesions: a prospective study.Endoscopy 2004;36(12):1089-93
[37] Sano Y, Saito Y, Fu KI, et al. Efficacy of magnifying chromoendoscopy for the differential diagnosis of cororectal lesions. Dig Endosc 2005;17(2)105-116
[38] Sano Y, Kobayashi M, Hamamoto Y, et al. New diagnostic method based on color imaging using narrow band imaging system for gastrointestinal tract. Gastrointest Enodsc 2001;53:AB125.
[39] Gono K, Obi T, Yamaguchi M, et al. Appearance of enhanced tissurefeatures in narrow-band endoscopic imaging.J Biomed Opt 2004;9(3):568-77.
[40] Sano Y, Muto M, Tajiri H, et al. Optical\digital chromoendoscopy during coloscopy using narrow band imaging system. Dig Endosc 2005;17:S60-65
[41] Machida H, Sano Y, Hamamoto Y, et al. Narrow band imaging for differential diagnosis colorectal mocosal lesions:a pilot study. Endoscopy 2004;36:1094-98
[42] Sano Y, Horimatsu T, Fu KI, et al. Magnified observation of microvascular architecture using narrow band imaging for diffrential diagnosis betweem non-neoplastic and neoplastic colorectal lesion:a prospective study.Gastrointest Endosc 2006;64(40:604-613
[43] Tanaka S, Kaltenbach T, Chayama K, et al. High-magnification coloscopy. Gastrointest Endosc 2006;64(4):604-13.
[44] MJ Carter, AJ Lobo, SPL Travis. Guidlines for the management of inflammatory bowel disease in adults. Gut 2004;53:v1-16.
[45] van Rijn JC, Reitsma JB, Stoker J, et al. Polyp miss rate determined by randem coloscopy:a systematic review. Am J Gastroenterol 2006;101:343-50.
[46] Inoue T, Murano M, Murano N, et al. Comparative study of conventional colonoscopy nad pan-colonoscopy narrow-band imaging system in the detection of neoplastic colonic polyps:a randomized controlled trial. J Gastroenterol 2008;43:45-50.
[47] Sikka S, Ringold DA, Jonnalagadda S, et al. Comparision of whitelight and narrow band high definition images in predicting colon polyp histology, using standard colonoscopes without optical magnification. Endoscopy 2008;40:818-22.
[48] Rogart JN, Jain D, Siddiqiu DU, et al. Narrow-band imaging without high magnidication to differentiate polyps during real-time colonscopy: improvement when experience. Gastrointest Endosc 2008;68:1136-45
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[2] Winawer SJ, Ho M, O’Brien MJ, et al. Prevention of colorectal cancer by colonscopic polypectomy: The national Polyp Study Workgroup.N Engl J Med 1993;329:1977-81.
[3] C. A.Rubio, E. Jaramillo, A. Lindblom, et al. Classification of Colorectal Polyps:Guidelines for the Endoscopist.Endoscopy 2002;34(3):326-36.
[4] Atkin WS, Morson BC, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas.N Eng J Med 1992;326:658-62.
[5] Lieberman D, Moravec M, Holub J, Michaels L, Eisen G.Polyp size and advanced histology in patients undergoing colonscopy screening:implications for CT colonography.Gastroenterology 2008;135:1100-05.
[6] Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007;102:856-61
[7] Butterly LF, Chase MP, Pohl H, Fiarman GS. Prevenlence of clinically important histology in small adnomas.Clin Gastroenterol Hepatol 2006;4:343-48
[8] Cairns S, Scholefeild JH. Guidlines for colorectal cancer screening in high risk groups.Gut 2002;51(suppl 5):1-2.
[9] Machinda H, Sano Y, Hammamoto Y, et al. Narrow-band imaging in the diagnosis of colorectal mucosal lesions:a poit study.Endoscooy 2004;36:1094-98
[10] Apel D, Jakobs R, Schilling D, et al. Accuracy of high resolution of chromoendoscopy in prediction of histologic finding in diminutive lesions of the rectosigmoid. Gastrointeest Endosc 2006;63:824-28
[11] Tischedorf JJ, Wasmuth HE, Koch A, et al. Value of magnifying chromoendoscopy and narrow band imaging in classifying colorectal polyps:a prospective controlled study.Endoscopy 2007;39:1092-96.
[12] East JE, Suzuki N, Saunders BP. Comparision of magnifield pit patter interpretation with narrow band imaging versus chromoendoscopy for diminutive colonic polyps:a pilot study. Gastrointest Endosc 2007;66:310-16.
[13] Xu Shaoming, Melton LJ. The epidenmiology of primary hyporparathyroidism in North American. Journal of Bone & Mineral Reseach 2002(12):12-172.
[14] Yang L, Parkin DM, Li LD, et al. Estimation and projection of the national profile of cancer mortality in China:1995 to 2005.Br J Cancer 2004;90:2157-66.
[15] Sung JJ, Lau JY, Young GP, et al. Asia Pacific consensus recommendations for colorectal cancer screening. Gut 2008;57:1166-76.
[16] Fearon ER, Vogelstein B.A genetic model for colorectal tumorigenesis.Cell 1990;61:759-67.
[17] Wen Peng, Shan-RoNG Cai, Lun Zhou, et al. Performance valure of high risk factors in colorectal cancer screening in China.World J Gastroenterol 2009;15(48):6111-6116.
[18] Smith RA, Von Eschenbach AC, Wender R, et al. American cancer society guidelines for the early detection of cancer: update of early detection guidelines for prostate,colorectal,and endometrial cancers.CA Cancer J Clin 2001;51:38-75.
[19] Lowenfels AB. Fecal occult blood testing as a screening procedure for colorectal cancer .Ann Oncol 2002;13:40-43.
[20] Gluecker T, Dorta G, Keller W, et al. Performance of multidetector computed tomography colonography compared with conventional colonoscopy. Gut 2002;51:207-211.
[21]崔西玉,黄燕霞,罗笑雁. 2706例大肠息肉内镜治疗与随访.中华消化内镜杂志, 2005;22(2):123-124.
[22]王志永,徐红,孙岩,等.吉林地区1911枚大肠小息肉内镜及病例特点.吉林医学2010;31(4) 512-514.
[23]卫金岐,乔林帮. 239例大肠小息肉内镜下及病理特点.中华消化内镜杂志, 1997;14(3):188.
[24] James M. Church, M.B.Ch.B.Clinical significance of small colorectal polyps.Dis Colon Rectum 2004;47:481-85.
[25] Chiu HM, Wang HS, Lee YC, et al. Aprepective study of the frequency and topographic distribution of colon neoplasia in asymptomatic average-risk Chinese adults as determined by coloscopic screening. Gastrointest Endosc 2005;62:547-53.
[26] Church JM, Fazio VW, Jones IT. Small colorectal polyps:are they worth treating?Dis Colon Rectum 1988;31:50-3.
[27] Loeve F, Brown ML, Boer R, et al. Endoscopic colorectal cancer screening: a cost-saving analysis. J Natl Cancer Inst 2000;92:557-563.
[28] Nusko G, Mansmann U, Altendorf-Hofmann A, et al. Risk of invasive canrcinoma in colorectal adenomas assessed by size ane site. Int J Colorect Dis 1997;12:267-71.
[29] Chantereau MJ, Faivre J, Boutron MC, et al. Epidemiology, management and prognosis of malignant large bowel polyps whiin a defined population. Gut 1992;33:259-63
[30] Fujii T, Sano Y, Lishi H, et al. Colerectal cancer screening in Japan: results of the multicenter retrospective cohort study. Gastroenterology 2002;122:A481.
[31] E East J, Stavrindis M, Thomas-Gibson S,et al. A comparative study of standard versus high definition colonoscopy for adenoma and hyperplastic polyp detection with optimized withdrawal technique. Aliment Pharmacol Ther. 2008 Jul 1.
[32] Tribonias G, Theodoropoulou A, Konstantinidis K, et al. Comparisonof standard versus high-definition, wide-angle colonoscopy for polyp detection: A Randomized Controlled Trial. Colorectal Dis. 2009 Nov 23. [Epub ahead of print].
[33] PelliséM, Fernández-Esparrach G, Cárdenas A, et al. Impact of wide-angle, high-definition endoscopy in the diagnosis of colorectal neoplasia: a randomized controlled trial. Gastroenterology. 2008 Oct; 135(4):1062-8.
[34] ASGE Technology Committee, Song LM, Adler DG, et al. Narrow band imaging and multiband imaging[J]. Gastrointestinal Endoscopy, 2008;67(4)581-589.
[35] Vatan MH, Stalsbert H. The prevalence of polyps of large intestine in Oslo:an autopsy study. Cancer 1982;40:819-25.
[36] Fu KI, Sano Y, Kato S, et al. Chromeendoscopy using indigo carmine dye spraying with magnifying observation is the most reliable method for differential diagnosis between non-neoplastic and neoplastic colorectal lesions: a prospective study.Endoscopy 2004;36(12):1089-93
[37] Sano Y, Saito Y, Fu KI, et al. Efficacy of magnifying chromoendoscopy for the differential diagnosis of cororectal lesions. Dig Endosc 2005;17(2)105-116
[38] Sano Y, Kobayashi M, Hamamoto Y, et al. New diagnostic method based on color imaging using narrow band imaging system for gastrointestinal tract. Gastrointest Enodsc 2001;53:AB125.
[39] Gono K, Obi T, Yamaguchi M, et al. Appearance of enhanced tissurefeatures in narrow-band endoscopic imaging.J Biomed Opt 2004;9(3):568-77.
[40] Sano Y, Muto M, Tajiri H, et al. Optical\digital chromoendoscopy during coloscopy using narrow band imaging system. Dig Endosc 2005;17:S60-65
[41] Machida H, Sano Y, Hamamoto Y, et al. Narrow band imaging for differential diagnosis colorectal mocosal lesions:a pilot study. Endoscopy 2004;36:1094-98
[42] Sano Y, Horimatsu T, Fu KI, et al. Magnified observation of microvascular architecture using narrow band imaging for diffrential diagnosis betweem non-neoplastic and neoplastic colorectal lesion:a prospective study.Gastrointest Endosc 2006;64(40:604-613
[43] Tanaka S, Kaltenbach T, Chayama K, et al. High-magnification coloscopy. Gastrointest Endosc 2006;64(4):604-13.
[44] MJ Carter, AJ Lobo, SPL Travis. Guidlines for the management of inflammatory bowel disease in adults. Gut 2004;53:v1-16.
[45] van Rijn JC, Reitsma JB, Stoker J, et al. Polyp miss rate determined by randem coloscopy:a systematic review. Am J Gastroenterol 2006;101:343-50.
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