内镜黏膜下剥离术在诊断和分期 Barrett 相关肿瘤方面比内镜黏膜切除术具有更小的病理不确定性。

Endoscopic submucosal dissection is associated with less pathologic uncertainty than endoscopic mucosal resection in diagnosing and staging Barrett's-related neoplasia.

机构信息

Division of Gastroenterology and Hepatology, Stanford University Hospital, Stanford, USA.

Division of Pathology, Stanford University Hospital, Stanford, USA.

出版信息

Dig Endosc. 2020 Mar;32(3):346-354. doi: 10.1111/den.13487. Epub 2019 Aug 20.

DOI:10.1111/den.13487

PMID:31306525

Abstract

BACKGROUND & AIMS: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have demonstrated similar efficacy in removal of neoplastic esophageal lesions. However, significant controversy exists over the preferred resection technique. Our primary aim was to compare the pathologic specimens produced via EMR and ESD and secondarily gauge their effect on clinical decision making and patient outcomes.

METHODS

Using a retrospective cohort study design, all esophageal Barrett's-associated neoplastic lesions resected by a single provider from 2012 to 2017 were reviewed. The pathology was re-reviewed by two blinded authors for diagnosis, margins, and adverse outcomes and recurrence rates were also collected.

RESULTS

Thirty-one EMR and 20 ESD cases were identified. Baseline demographics and lesion characteristics were similar. ESD produced more R0 resections and more en bloc resections compared to EMR. EMR produced more equivocal lateral (13/31, 41.9% vs 1/20, 5.0%) and vertical margins (13/31, 41.9% vs. 0/20, 0%, both P < 0.05). This led to an inability to reach a definitive diagnosis in 13/31 EMR vs 0/20 ESD pathology specimens (P = 0.003). Of the 13 EMR specimens with equivocal pathology, 11 were noted to have 'at least intramucosal adenocarcinoma'. Four of the 11 patients chose to undergo elective esophagectomy with final surgical pathology demonstrating ≤T1a disease in 2, and ≥T1b disease in two.

CONCLUSION

Compared to ESD, EMR was associated with greater pathologic uncertainty in Barrett's-associated neoplasia.

摘要

背景与目的

内镜下黏膜切除术（EMR）和内镜黏膜下剥离术（ESD）在切除肿瘤性食管病变方面具有相似的疗效。然而，对于首选的切除技术仍存在较大争议。我们的主要目的是比较 EMR 和 ESD 产生的病理标本，并次要评估它们对临床决策和患者结局的影响。

方法

采用回顾性队列研究设计，对 2012 年至 2017 年间由一名医生切除的所有 Barrett 相关的肿瘤性食管病变进行回顾性研究。由两名盲法作者对病理进行重新评估，评估内容包括诊断、切缘和不良结局，同时还收集了复发率。

结果

共确定了 31 例 EMR 和 20 例 ESD 病例。基线人口统计学和病变特征相似。与 EMR 相比，ESD 产生了更多的 R0 切除和整块切除。EMR 产生了更多不确定的侧向（13/31，41.9%比 1/20，5.0%，均 P<0.05）和垂直切缘（13/31，41.9%比 0/20，0%，均 P<0.05）。这导致 13 例 EMR 病理标本中无法做出明确诊断，而 20 例 ESD 病理标本中则没有（P=0.003）。在 13 例不确定的 EMR 标本中，11 例被认为至少有黏膜内腺癌。11 例患者中有 4 例选择进行择期食管切除术，最终的手术病理显示 2 例为 T1a 期以下，2 例为 T1b 期以上。