修回日期: 2014-08-22
接受日期: 2014-09-03
在线出版日期: 2014-10-18
目的: 探讨窄带成像技术(narrow-band imaging, NBI)诊断早期食管癌及其癌前病变的临床价值.
方法: 回顾性分析中国人民解放军兰州军区乌鲁木齐总医院消化科内镜检查诊断为早期食管癌及癌前病变的82例患者行普通内镜、NBI及碘染色内镜检查的临床资料, 比较NBI与普通内镜、碘染色内镜观察病变部位的清晰度, NBI放大与普通内镜放大观察病变部位腺管开口形态和毛细血管结构形态的清晰度以及NBI和碘染色对早期食管癌及其癌前病变检出情况与病理诊断结果的差异.
结果: NBI与碘染色内镜观察病变部位清晰度均显著高于普通内镜(287分 vs 197分)、(294分 vs 197分), 差异具有统计学意义(P<0.01); NBI与碘染色内镜清晰度比较(287分 vs 294分), 差异无统计学意义(P>0.05); NBI放大观察病变部位腺管开口形态和毛细血管结构形态清晰度均显著高于普通内镜放大(290分 vs 154分)、(286分 vs 155分), 差异具有统计学意义(P<0.01); NBI组对低级别黏膜内瘤变检出率显著低于碘染色组(77.50% vs 100.00%), 漏诊率显著高于碘染色(13.41% vs 0.00%), 差异具有统计学意义(P<0.01); NBI和碘染色组对高级别黏膜内瘤变检测敏感性、特异性及准确率均显著高于低级别黏膜内瘤变(73.81% vs 23.81%)、(77.50% vs 47.50%)、(75.61% vs 35.37%)、(59.52% vs 40.48%)、(65.00% vs 35.00%)、(62.20% vs 37.80%), 差异具有统计学意义(P<0.05); NBI组对高级别黏膜内瘤变检测敏感性、特异性及准确率均显著高于碘染色组(73.81% vs 59.52%)、(77.50% vs 65.00%)、(75.61% vs 62.20%), 差异具有统计学意义(P<0.05).
结论: NBI在显示病变部位及病变部位腺管开口形态和毛细血管结构形态上清晰度较高, 有助于观察病变部位病理改变, 与碘染色检查结合能够提高对早期食管癌及其癌前病变诊断的准确率.
核心提示: 本研究对窄带成像技术(narrow-band imaging, NBI)、普通内镜以及碘染色内镜在早期食管癌及癌前病变检查中的效果进行了比较, 结果显示碘染色内镜对早期食管癌及癌前病变检出率高达100%, NBI检出率达86.59%, 仅次于碘染色内镜, 但NBI对高级别黏膜内瘤变检出率与碘染色内镜无明显差异. 分析原因可能为NBI在对发生轻度异型增生改变的食管黏膜诊断中敏感性较差导致NBI对低级别黏膜内瘤变检出率较低.
引文著录: 游云, 游庆霞. 应用NBI与普通内镜、碘染色内镜观察早期食道癌及其癌前病变. 世界华人消化杂志 2014; 22(29): 4473-4477
Revised: August 22, 2014
Accepted: September 3, 2014
Published online: October 18, 2014
AIM: To assess the clinical value of narrow band imaging endoscopy in the diagnosis of superficial esophageal carcinoma and precancerous lesions.
METHODS: Eighty-two patients diagnosed with superficial esophageal carcinoma and precancerous lesions by endoscopy were included. The data of endoscopy, narrow-band imaging (NBI), and chromoendoscopy were analyzed. The three methods were compared in terms of the definition of lesions, the opening of glands in the lesion site and capillary structure. The detection rates of superficial esophageal carcinoma and precancerous lesion by NBI and iodine staining were assessed by comparing with pathological results.
RESULTS: The definition of diseased region by NBI and iodine staining was significantly better than that by endoscopy (287 vs 197, 294 vs 197, P < 0.01), although there was no significant difference between NBI and iodine staining (287 vs 294, P > 0.05). The definition of the opening of glands in the lesion site and capillary structure by NBI was significantly better than that by endoscopy (290 vs 154, 286 vs 155, P < 0.01). The detection rate of low-grade mucosal neoplasia in the NBI group was significantly lower than that in the iodine staining group (77.50% vs 100.00%, P < 0.01), and the rate of missed diagnosis of low-grade mucosal neoplasia was significantly higher in the NBI group than in the iodine staining group (13.41% vs 0.00%, P < 0.01). The sensitivity, specificity, and accuracy of NBI and iodine staining for detecting high-grade mucosal neoplasia were significantly higher than those for detecting low-grade mucosal neoplasia (73.81% vs 23.81%, 77.50% vs 47.50%, 75.61% vs 35.37%, 59.52% vs 40.48%, 65.00% vs 35.00%, 62.20% vs 37.80%, P < 0.05). The sensitivity, specificity and accuracy of NBI for detecting high-grade mucosal neoplasia were significantly higher than those of iodine staining (73.81% vs 59.52%, 77.50% vs 65.00%, 75.61% vs 62.20%, P < 0.05).
CONCLUSION: NBI can better define lesions, the opening of glands in the lesion site and vascular structure. NBI combined with iodine staining is helpful for improving the accuracy of diagnosis of superficial esophageal carcinoma and precancerous lesions.
- Citation: You Y, You QX. Clinical value of narrow band imaging endoscopy in diagnosis of superficial esophageal carcinoma and precancerous lesions. Shijie Huaren Xiaohua Zazhi 2014; 22(29): 4473-4477
- URL: https://www.wjgnet.com/1009-3079/full/v22/i29/4473.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v22.i29.4473
食管癌是常见消化系恶性肿瘤之一, 我国是食管癌高发国家, 其发病率和死亡率一直居高不下[1]. 早期诊断食管癌是根治性治疗的关键, 能够有效提高患者生存率[2]. 目前内镜检查是诊断早期食管癌及癌前病变的主要手段, 但普通内镜图像清晰度不足, 对食管黏膜细微结构的观察效果不佳, 而染色内镜操作较为复杂, 检查结果收到染色效果的影响[3]. 内镜窄带成像技术(narrow-band imaging, NBI)有效解决了上述问题, 由于操作简单, 视野清晰, 能够清楚显示黏膜形态以及血管结构, 因此受到了临床医师的普遍关注[4]. 现回顾性分析中国人民解放军兰州军区乌鲁木齐总医院消化科行NBI诊断早期食管癌及其癌前病变的效果, 探讨其临床应用价值, 报道如下.
选取2012-05/2014-05中国人民解放军兰州军区乌鲁木齐总医院消化科内镜检查诊断为早期食管癌及癌前病变的82例患者作为研究对象. 所有患者均经常规影像学检查及病理检查证实, 排除有淋巴结转移、远处转移及肌层浸润者、有内镜操作禁忌者、碘过敏者以及有甲亢病史者. 患者年龄为35-70岁, 平均年龄为56.51岁±8.77岁, 其中男性患者54例, 女性患者28例. 所有患者确诊后均行内镜下黏膜切除术(endoscopic mucosal resection, EMR)或内镜黏膜下层剥离术(endoscopic submucosal dissection, ESD)或外科手术治疗. 本研究经中国人民解放军兰州军区乌鲁木齐总医院伦理委员会审核通过, 所有患者或其家属均签署知情同意书.
1.2.1 检查前准备: 所有患者检查当日需禁食、禁水10 h, 检查前15 min咽部含服麻醉剂(主要成分地卡因、硅油)5 mL, 3 min后吞服, 然后给予山莨菪碱和地西泮各10 mg肌注[5].
1.2.2 内镜检查: 由同一名经验丰富内镜医师对所有患者进行内镜检查, 进镜后按照普通内镜→NBI→普通内镜放大→NBI放大→染色内镜(卢戈氏碘染色)的顺序进行观察, 观察: (1)普通内镜与NBI状态下患者食管黏膜病变大小、范围以及NBI分级情况; (2)普通内镜放大与NBI放大状态下病变部位的腺管开口形态及毛细血管结构形态的观察效果[6]; (3)NBI分级、碘染色分级与病理诊断结果差异. 对NBI阴性而碘染色阳性患者需再次进行NBI放大检查. 对所有NBI阳性及碘染色阳性部位均取活检进行病理组织学检查, 以病理组织学检查结果为金标准[7].
1.2.3 判断标准: 图像清晰度评价标准: 1分: 图像看不清楚; 2分: 图像可见, 但模糊; 3分: 图像较清晰; 4分: 图像十分清晰[8]. NBI分级标准: 高级别黏膜内瘤变: 边界清楚, 有明显褐色区域, 表面可见粗糙不平、隆起或凹陷; 低级别黏膜内瘤变: 有浅色褐色区, 边界清楚或不清; 阴性: 未见明显褐色区[9]. 碘染色分级标准: 高级别黏膜内瘤变: 有边界清晰的不着色区域, 病变部位有隆起或凹陷感; 低级别黏膜内瘤变: 有浅色不着色区域, 边界清晰或不清晰; 阴性: 黏膜染色后变为棕色[10]. 内镜诊断标准: 高级别黏膜内瘤变: 早期食管癌及重度不典型增生; 低级别黏膜内瘤变: 中度或轻度不典型增生; 阴性: 正常组织[11].
统计学处理 使用SPSS19.0统计分析, 计量资料采用t检验, 计数资料采用χ2检验, P<0.05表示差异有统计学意义.
NBI与碘染色内镜观察病变部位清晰度均显著高于普通内镜, 差异具有统计学意义(P<0.01); NBI与碘染色内镜清晰度比较, 差异无统计学意义(P>0.05)(表1).
NBI放大观察病变部位腺管开口形态和毛细血管结构形态清晰度均显著高于普通内镜放大, 差异具有统计学意义(P<0.01); NBI放大观察病变部位腺管开口形态和毛细血管结构形态清晰度比较, 差异无统计学意义(P>0.05)(表2).
食管癌的临床发病率和死亡率均较高, 早期确诊和及时采取治疗措施是改善患者预后、提高生存率的关键[12]. 目前, 内镜检查是诊断食管病变的主要手段, 随着近几年内镜技术的不断更新, 对食管病变的诊断效果越来越好. NBI利用特殊滤光器, 将氙气灯光波长变窄并限制红、绿、蓝三色光的透过深度维持在黏膜表层, 通过调节光谱实现病变边界界定、电子染色等一系列效果[13]. 而NBI与放大内镜联合应用能够清晰显示黏膜腺管开口形态和毛细血管结构形态, 发现普通内镜下难以发现和容易遗漏的平坦型病变或微小病变, 大大提高了早期食管癌及其癌前病变的检出率[14].
本研究对NBI、普通内镜以及碘染色内镜在早期食管癌及癌前病变检查中的效果进行了比较, 结果显示碘染色内镜对早期食管癌及癌前病变检出率高达100%, NBI检出率达86.59%, 仅次于碘染色内镜, 但NBI对高级别黏膜内瘤变检出率与碘染色内镜无明显差异. 分析原因可能为NBI在对发生轻度异型增生改变的食管黏膜诊断中敏感性较差导致NBI对低级别黏膜内瘤变检出率较低. 而通过对NBI与碘染色在诊断高级或低级别黏膜内瘤变敏感性、特异性等的计算可见, NBI和碘染色组对高级别黏膜内瘤变检测敏感性、特异性及准确率均显著高于低级别黏膜内瘤变, 证实了上述内容. NBI组对高级别黏膜内瘤变检测敏感性、特异性及准确率均显著高于碘染色组, 提示NBI诊断早期食管癌及癌前病变敏感性、特异性和准确性更佳, 但需注意其漏诊率较高, 需与碘染色联合诊断. 另外, 临床实践表明, 碘染色可导致患者呛咳和胸骨后烧灼感等不良反应, 且碘过敏以及有甲亢史者不能使用, 因此具有一定局限性[15].
Singh等[16]的研究表明, 资深NBI操作者与初学者对同一患者的诊断并无明显差异, 表明NBI操作简单, 可重复性强, 更利于临床推广. 另外, 本研究结果显示, NBI在观察食管病变以及放大后观察病变部位腺管开口形态和毛细血管结构形态时清晰度均显著高于普通内镜, 能够提高诊断准确性, 指导对病变的精确活检.
总之, NBI在显示病变部位及病变部位腺管开口形态和毛细血管结构形态上清晰度较高, 有助于观察病变部位病理改变, 与碘染色检查结合能够提高对早期食管癌及其癌前病变诊断的准确率.
目前, 内镜检查是诊断食管病变的主要手段, 随着近几年内镜技术的不断更新, 对食管病变的诊断效果越来越好. 内镜窄带成像技术(narrow-band imaging, NBI)利用特殊滤光器, 将氙气灯光波长变窄并限制红、绿、蓝三色光的透过深度维持在黏膜表层, 通过调节光谱实现病变边界界定、电子染色等一系列效果. 而NBI与放大内镜联合应用能够清晰显示黏膜腺管开口形态和毛细血管结构形态, 发现普通内镜下难以发现和容易遗漏的平坦型病变或微小病变, 大大提高了早期食管癌及其癌前病变的检出率.
茅爱武, 教授, 上海同仁医院介入中心
目前内镜检查是诊断早期食管癌及癌前病变的主要手段, 但普通内镜图像清晰度不足, 对食管黏膜细微结构的观察效果不佳, 而染色内镜操作较为复杂, 检查结果收到染色效果的影响.
Singh等的研究表明, 资深NBI操作者与初学者对同一患者的诊断并无明显差异, 表明NBI操作简单, 可重复性强, 更利于临床推广.
NBI有效解决了上述问题, 由于操作简单, 视野清晰, 能够清楚显示黏膜形态以及血管结构, 因此受到了临床医师的普遍关注.
本研究选题实用, 操作描述清晰, 有一定的参考价值.
编辑:韦元涛 电编:都珍珍
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