Libânio Diogo, Ortigão Raquel, Pimentel-Nunes Pedro, Dinis-Ribeiro Mário
Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.
MEDCIDS - Department of Community Medicine, Health Information and Decision of the Faculty of Medicine of the University of Porto, Porto, Portugal.
GE Port J Gastroenterol. 2021 Dec 7;29(5):299-310. doi: 10.1159/000520529. eCollection 2022 Sep.
Gastric cancer is the third leading cause of cancer-related death. In Western countries, its lower prevalence and the absence of mass screening programmes contribute to late diagnosis and a slower implementation of minimally invasive treatments. A secondary prevention strategy through endoscopic surveillance of patients at high risk of intestinal-type gastric adenocarcinoma or by screening gastric cancer within colorectal screening programmes is cost-effective in intermediate-risk countries, though the identification of these patients remains challenging. Virtual chromoendoscopy with narrow-band imaging improves the accuracy of endoscopic diagnosis, significantly increasing the sensitivity for intestinal metaplasia while preserving specificity. Endoscopic grading of gastric intestinal metaplasia is feasible, correlates well with histological staging systems and also with gastric neoplasia risk and can be used to stratify risk. Endoscopic submucosal dissection (ESD) in the West achieves efficacy and safety outcomes similar to those reported for Eastern countries, and the long-term disease-specific survival is higher than 95%. A prospective comparative study with gastrectomy confirms its higher safety and its benefits concerning health-related quality of life. However, ESD is associated with a 5% risk of postprocedural bleeding and a 20% risk of non-curative resection. The knowledge of risk factors for adverse events and non-curative resection can improve patient selection. The risk of metachronous lesions after ESD is high (3-5% per year), and endoscopic surveillance is needed. The management of patients with non-curative resection can be optimized using risk scoring systems for lymph node metastasis.
胃癌是癌症相关死亡的第三大主要原因。在西方国家，其较低的发病率以及缺乏大规模筛查项目导致诊断延迟，微创治疗的实施也较为缓慢。在中等风险国家，通过对肠型胃腺癌高危患者进行内镜监测或在结直肠癌筛查项目中筛查胃癌的二级预防策略具有成本效益，不过识别这些患者仍然具有挑战性。窄带成像虚拟染色内镜检查提高了内镜诊断的准确性，在保持特异性的同时显著提高了肠化生的敏感性。胃肠化生的内镜分级是可行的，与组织学分期系统以及胃癌发生风险密切相关，可用于分层风险。西方国家的内镜黏膜下剥离术（ESD）取得的疗效和安全性结果与东方国家报道的相似，长期疾病特异性生存率高于95%。一项与胃切除术的前瞻性比较研究证实了其更高的安全性以及在健康相关生活质量方面的益处。然而，ESD术后出血风险为5%，非根治性切除风险为20%。了解不良事件和非根治性切除的风险因素有助于改善患者选择。ESD术后异时性病变的风险很高（每年3 - 5%），需要进行内镜监测。对于非根治性切除的患者，可使用淋巴结转移风险评分系统优化管理。
