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中华胃肠内镜电子杂志 ›› 2020, Vol. 07 ›› Issue (02) : 49 -83. doi: 10.3877/cma.j.issn.2095-7157.2020.02.001

所属专题: 指南与规范 文献 指南共识

共识与指南

英国胃肠病学会关于胃癌风险患者的诊断和管理指南
Matthew Banks, David Graham, Marnix Jansen   
  1. 1. 100191 北京,北京大学第三医院消化科
  • 收稿日期:2020-02-10 出版日期:2020-05-15

British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma

Matthew Banks, David Graham, Marnix Jansen   

  • Received:2020-02-10 Published:2020-05-15
引用本文:

Matthew Banks, David Graham, Marnix Jansen. 英国胃肠病学会关于胃癌风险患者的诊断和管理指南[J]. 中华胃肠内镜电子杂志, 2020, 07(02): 49-83.

Matthew Banks, David Graham, Marnix Jansen. British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma[J]. Chinese Journal of Gastrointestinal Endoscopy(Electronic Edition), 2020, 07(02): 49-83.

胃癌预后较差,部分原因在于诊断较晚。胃癌的危险因素包括幽门螺杆菌(H.pylori,HP)感染和胃癌家族史,尤其是遗传性弥漫性胃癌和恶性贫血。胃癌发展的阶段包括慢性胃炎、胃黏膜萎缩(GA)、胃黏膜肠化生(GIM)和异型增生。胃癌早期发现和提高生存率的关键是在内镜检查前以非侵入性方式识别高危人群。然而,尽管生物标志物可能有助于检测慢性萎缩性胃炎,但尚无足够的证据支持其用于人群筛查。高质量内镜检查是胃癌早期发现的重要组成部分,图像增强内镜结合组织病理学活检是GA和GIM最佳的诊断方法,并能准确进行风险分层。按照悉尼标准从胃窦、角切迹、小弯和大弯进行活检,既能明确诊断,也能对胃癌进行风险分层。理想状态应当是在高质量内镜检查中对GA或GIM区域活检。英国属于低危地区,可根据需要接受常规诊断性胃镜检查,但没有足够证据支持筛查,对于广泛GA或GIM的患者,每3年检查内镜。对于胃异型增生和早期癌,只要满足标准,内镜下黏膜切除术或内镜黏膜下剥离术的治疗有效,成功率高,复发率低。

图1A BSG指南对CAG的管理
图1B BSG指南对异型增生的管理
图1C BSG指南对胃息肉的管理
表1 关键问题、组长和亚组成员
问题 组长 亚组
诊断:概述 ? ?
胃癌前病变是什么?其在英国的患病率如何?它们的风险有哪些? Dr David Graham Matthew Banks,Ernst Kuipers,Mario Dinis-Ribeiro,Marnix Jansen,Marco Novelli, Manuel Rodriguez-Justo, Neil Shepherd
是否存在已知的胃癌高危人群(无癌前病变),例如家族史、种族、基因型和表型? Dr Massimiliano Di Pietro Matthew Banks,Sergio Coda,David Graham,NoriyaUedo
哪类人群应筛查HP以减少胃癌?如何筛查?根除HP能否预防进展为胃癌? Professor Mark Pritchard Matthew Banks,TakujiGotoda,Ernst Kuipers,David Graham
哪些血液化验有助于胃癌前病变的诊治?是否可以用于人群筛查、高危人群监测或已知病变人群的监测? Dr David Graham Matthew Banks,Mario Dinis-Ribeiro,Mark Pritchard
诊断:内镜 ? ?
在英国指南推荐的内镜质量控制外,对于胃癌前病变或早期胃癌,是否有其他的检测和诊断建议? Professor TakujiGotoda Matthew Banks,KrishRagunath,David Graham,Sergio Coda
如何报告癌前病变或早期胃癌,并在报告中准确记录?基于工作站的方法是否有益,能否留存病变可识别的黏膜特征(包括识别黏膜的萎缩边界)? Mr Sergio Coda Matthew Banks,TakujiGotoda,NoriyaUedo,Pradeep Bhandari,KrishRagunath,David Graham
胃癌前病变或早期胃癌的活检如何采样和报告?所有常规内镜检查均活检,还是特定人群活检? Dr Marnix Jansen Matthew Banks,David Graham,Sergio Coda, Marco Novelli,Manuel Rodriguez-Justo,Neil Shepherd
对于胃癌前病变和早期胃癌的分期,建议采用何种组织病理学和影像学模式? Mr Sergio Coda Marnix Jansen,Matthew Banks,David Graham, Sergio Coda,Marco Novelli,Manuel Rodriguez-Justo,Neil Shepherd
监测 ? ?
胃癌前病变是否需要监测?如果需要,监测的建议是什么? Dr Matthew Banks Mario Dinis-Ribeiro, David Graham, Massimiliano di Pietro, Ernst Kuipers
治疗:内镜 ? ?
哪些病变需要内镜下切除?切除方法如何选择?是否有组织病理学标准用于明确预后和随访策略? Professor Pradeep Bhandari Matthew Banks,KrishRagunath,TakujiGotoda,NoriyaUedo,David Graham
治疗:药理 ? ?
药物治疗是否有益?例如,COX-2抑制剂和抗氧化剂? Dr David Graham Matthew Banks
筛查 ? ?
是否有证据支持人群筛查胃癌? Dr Matthew Banks Mark Pritchard,David Graham
胃息肉 ? ?
胃息肉是什么?如何处理? Dr Matthew Banks Sergio Coda,Mark Pritchard,Pradeep Bhandari
研究 ? ?
关于胃癌前病变或早期胃癌,针对诊断和治疗的研究有何建议? Dr Matthew Banks Marnix Jansen,David Graham
表2 证据水平
表3 GA和GIM的癌症风险
框1 遗传咨询的标准概述
图2 胃部系统检查方案。基于定位点的方法,以顺时针或逆时针方向观察和拍摄胃的每个区域。22张图片按照程序顺序排列。Q:象限;L:胃小弯;A前壁;G:胃大弯;P:后壁;SSS:胃部系统筛查方案
图3 WLE、IEE和放大内镜下正常胃体、胃窦黏膜的表面形态。无需放大或增强即可看到胃体(Ai)的圆形"小凹形态"和胃窦(Di)的长型"小凹形态"。胃体(Ai)有明显的红色集合小静脉(collecting venules,CV)以及圆形的暗红色隐窝开口(crypt openings,CO)。NBI(Aii&Dii)所见血管结构更明显。放大NBI可见的结构包括深褐色的"CO",深褐色的上皮下毛细血管网(sub-epithelial capillary network,SECN)和浅褐色的边缘隐窝上皮细胞(marginal crypt epithelia,MCE)。胃体黏膜深色的圆形"CO",被较浅的MCE包围,再外层是较暗的圆形SECN(Aii和Aiii)。相比之下,胃窦黏膜深色斜行的"CO"具有凹槽结构,亮脊或绒毛状上皮(MCE)包绕深色的SECN,称为"凹槽型结构"(Dii和Diii)。胃体(B和C)和胃窦(E和F)显示了对应的组织病理结构
图4 CAG和萎缩性边界的WLE和IEE图像。CAG的四个内镜特征:黏膜苍白(A,B,C, D和E),皱襞消失(A,B,C,D和E),血管显露(A,B,C和D)和萎缩性边界(A和B)。IEE观察GA的黏膜苍白同样很明显(F)。
图5 改良木村(Kimura)分期&悉尼活检系统。改良木村分期根据GA范围分为仅有胃窦(胃窦)、胃窦至角切迹(胃窦占优势)、胃窦至小弯(胃体占优势)以及胃窦、小弯、大弯(广泛萎缩)。该系统集成了悉尼活检系统,取胃窦(部位1和2)、角切迹(部位3),小弯(部位4)和大弯(部位5)。胃CAG在剖开(A)和冠状位(B)截面的边界和活检部位。内镜活检部位(C)和前视图(D)
图6 WLE、IEE和放大内镜的GIM图。GIM的典型表现是灰白色的隆起性结节,被分布不均匀的粉红色和苍白色黏膜所形成的不规则粗糙黏膜围绕(A);IEE图像更明显(B);胃体GIM通过类似于胃窦的"凹槽状结构"或肠的绒毛样结构与正常的直行/管状腺体区分,高分辨率WLE观察更明显(C);胃窦的正常腺体是斜行的,因此,很难描述胃窦的GIM。有助于诊断胃窦GIM的结构包括亮蓝脊(Light Blue Crest,LBC)和边缘混浊带(Marginal Turbid Band,MTB)(D);LBC是NBI观察到的上皮表面脊部一条细的蓝白色线(D图中细箭头所示)。粗箭头之间可见MTB。大量的杯状细胞是GIM的特征(E和F)
表4 胃萎缩和肠化诊断中的内镜成像模式及性能特点
作者(年) 地点 患者 研究设计 内镜模式 灵敏度(%) 特异性(%) 病变
Dinis-Ribeiro等[290](2003) 葡萄牙 136 前瞻 ME MB 76.4 86.6 GIM
Redeen等[155](2003) 瑞典 488 前瞻 WLE 67-90(皱襞消失)48-80(胃体血管显露)14(胃窦血管显露) 85-84(皱襞消失)87-87(胃体血管显露)91(胃窦血管显露) AG
Uedo等[166](2006) 日本 107 前瞻 NBI ME 89 93 GIM
Anagnostopoulos等[149](2007) 英国 95 前瞻 ME 90(胃体4型) 96(胃体4型) AG
Bansa等[147](2008) 美国 47 试点可行性 NBI 80(脊状/绒毛状结构) 100(脊状/绒毛状结构) GIM
Guo等[291](2008) 中国 53 前瞻 WLE CLE 36.88(WLE)98.13(CLE) 91.59(WLE)95.33(CLE) GIM
Tahara等[292](2009) 日本 106 前瞻 ME NBI(体) 73.3(3型NBI IM)50(3型NBI AG)66.7(WLE开放型) 95.6(3型NBI IM)96.3(3型NBI AG)72(WLE开放型) GIM AG
Capelle等[293](2010) 荷兰 43 前瞻 NBI WLE 71(NBI)51(WLE) 58(NBI)67(WLE) GIM
Eshmuratov等[170](2010) 韩国 1330 多中心前瞻 WLE 61.5(胃窦)-46.8(体) 57.7(胃窦)-76.4(体) AG
Kawamura等[294](2011) 日本 EGC n=95,伴活动性DU(n=24),弥漫型(n=24),肠型(n=47) 观察 ME NBI A-1型和A-2型(改进Yagi A-B分级系统)肠型EGC在小弯可见严重AG-IM(未提供准确数字) AG GIM ?
Rerknimitr等[295](2011) 泰国 38(I监测)26(II监测) 前瞻 NBI 78.8/91.3(I/II监测),3个标准:LBC,VP和LLC 82.5/89.1(I/II监测),3个标准:LBC,VP和LLC GIM
Pimentel-Nunes等[150](2012) 欧洲 85 多中心确证 NBI 89(管状绒毛状)48(LBC) 90(管状绒毛状)96(LBC) GIM
Dutta等[296](2013) 印度 200 随机前瞻交叉 NBI WLE NBI优于WLE(未提供准确数据) AG IM ?
An等[167](2012) 韩国 47 前瞻 ME NBI 100(MTB)72(LBC) 66(MTB)96(LBC) GIM
Kanzaki等[297](2012) 日本 50ECG和CAFG 横断面 AFI+ME NBI体小弯,凹槽型VS小凹型 凹槽型的AG-IM的级别比小凹型更高(未提供准确度数据) GIM AG ?
Savarino等[298](2013) 意大利 100 前瞻 NBI ME 80 96 GIM
Fukuta等[299](2013) 日本 163 多中心前瞻 WLE IC WLE:94.6(胃窦)-86.1(胃体)IC:78.4(胃窦)-86(胃体) WLE:69.1(胃窦)-65.9(胃体)IC:57.9(胃窦)-82.6(胃体) GIM
Lim等[160](2013) 韩国 1333 前瞻 WLE GIM:24(胃窦)-24.2(胃体)AG:61.5(胃窦)-46.8(胃体) GIM:91.9(胃窦)-88(胃体)AG:57.7(胃窦)-76.4(胃体) GIM AG
Pittayanon等[300](2013) 泰国 45 前瞻 ME FICE+PCLE ME FICE:95.6ME FICE + pCLE:96.5 ME FICE:79.2ME FICE + pCLE:90.5 GIM
Xirouchakis等[301](2013) 希腊 119 前瞻开放 WLE-USP NBI AG:86(WLE-USP) 62(NBI)GIM:80(WLE-USP)-72(NBI) AG:100(WLE-USP) 97(NBI)IM:100(WLE-USP) 93(NBI) AG IM
Nomura等[302](2014) 日本 275 多中心前瞻 WLE+IC 77(胃体)-64胃窦 79(胃体)-54(胃窦) AG
Panteris等[161](2014) 希腊 234 前瞻横断面 WLE 74.6 94 GIM
Kikuste等[163](2014) 拉脱维亚 126 队列 FICE 60(诊断)-71(OLGIM III-IV) 87(诊断)-87(OLGIM III-IV) GIM
Ang等[164](2015) 亚太 579 MC前瞻随机对照 WLE NBI 59.1(WLE)-92.3(NBI) 98.6(WLE)-94.3(NBI) GIM
Pimentel-Nunes等[162](2016) 欧洲、美国 238 MC前瞻 WLE NBI 53(WLE)-87(NBI) 98(WLE)-97(NBI) GIM
Sha等[303](2017) 中国 132 队列 AA-NBI vs NBI vs WLE 33.3(WLE)66.7(NBI)87.9(AA-NBI) 28.8(WLE)68.2(NBI)68.2(AA-NBI) GIM
表5 eCura系统
图7 胃底腺息肉和增生性息肉。(A)胃体可见胃底腺息肉。颜色比周围黏膜更浅或相同。(B)近景观察,通过图像增强,可以从半透明的表面看到血管,并且表面可见细小灰色圆点。(C)增生性息肉表面呈光滑的红色,带有白色渗出液(纤维蛋白),圆顶状。表面血管形态在图像增强(D)时更明显
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