《中国巴雷特食管及其早期腺癌筛查与诊治共识》解读

2017-09-15 张澍田 中华医学信息导报

虽然我国食管癌的组织类型以食管鳞癌为主,但是随着世界范围内胃食管反流病的增加,我国巴雷特食管(Barrett's esophagus)/食管下段柱状上皮化生和食管腺癌的发病率也在增加,同样威胁着人们的生命。有报道显示,在食管腺癌中有80%与巴雷特食管密切相关,而我国巴雷特食管的癌变率和西方国家相近,为61%左右。


解读人:张澍田教授

食管癌发病率在我国大陆已居各类肿瘤第5位,病死率居第4位,越来越受到人们的重视。食管癌在组织类型上分为食管鳞状细胞癌(简称食管鳞癌)和食管腺癌。虽然我国食管癌的组织类型以食管鳞癌为主,但是随着世界范围内胃食管反流病的增加,我国巴雷特食管(Barrett's esophagus)/食管下段柱状上皮化生和食管腺癌的发病率也在增加,同样威胁着人们的生命。有报道显示,在食管腺癌中有80%与巴雷特食管密切相关,而我国巴雷特食管的癌变率和西方国家相近,为61%左右。

食管癌患者的预后与诊断时的肿瘤分期密切相关,所以对于早期食管腺癌的筛查是治愈食管腺癌和提高生存率的关键所在,而对巴雷特食管的筛查、诊治是预防食管腺癌的关键所在。因此,制定我国巴雷特食管、早期食管腺癌的筛查与诊治共识亦尤为重要。然而巴雷特食管的诊断标准各国尚不统一,为避免采用不同诊断标准引起的争论,同时体现内涵及符合中国语言习惯,国家消化系统疾病临床医学研究中心、中华医学会消化内镜学分会、中国医师协会消化医师分会制定了新版《中国巴雷特食管及其早期腺癌筛查与诊治共识》(简称新共识),并在新共识中采用“巴雷特食管”这一称谓。新共识由国内31位消化病学、消化内镜学以及消化病理学专家结合国内巴雷特食管及食管腺癌筛查与诊治情况共同制订,旨在规范国内对巴雷特食管及早期食管腺癌的筛查、诊断和治疗,提高国人的健康水平。


图片来源:视觉中国

巴雷特食管是胃食管反流病的并发症,内镜下可见食管鳞状上皮与胃柱状上皮的交界线(齿状线,又称Z线、SCJ)相对于胃食管结合部上移≥1cm。病理证实,食管下段的正常复层鳞状上皮被化生的柱状上皮所取代,其化生可为胃底上皮样化生、贲门上皮样化生以及特殊肠型化生,其中伴有肠上皮化生的巴雷特食管发生癌变的风险最大。巴雷特食管腺癌的癌前病变是指可以发展为癌的一种病理变化,主要指巴雷特食管黏膜从无异型增生(世界卫生组织称为上皮内瘤变)到低级别异型增生(低级别上皮内瘤变),到高级别异型增生(高级别上皮内瘤变),最后到食管腺癌。早期巴雷特食管腺癌是指来源于巴雷特食管黏膜并局限于食管黏膜层的腺癌,不论有无淋巴结转移。

研究发现,对早期患者进行诊治是降低食管癌病死率的关键之一。筛查有助于食管癌的预防、早发现、早诊断和早治疗,是降低食管癌发病率和累积病死率的重中之重。由于巴雷特食管是食管腺癌唯一被公认的癌前病变,所以巴雷特食管的诊断很重要。对于巴雷特食管的诊断既要包括内镜下诊断也要包括病理诊断。对于难以发现的病变则要依靠色素内镜及电子染色内镜发现并靶向活检,通过组织病理学予以诊断,另外还应对恶性程度、浸润深度以及有无淋巴结转移做出诊断。巴雷特食管的确诊需要内镜检查结合病理学诊断。参照日本食管癌分类,活检组织被覆的柱状上皮下见食管腺体或腺管、被覆的柱状上皮间见鳞状上皮岛、被覆的柱状上皮下见双黏膜肌层等有助于巴雷特食管的病理学诊断。对于巴雷特食管的治疗和随访观察方面,需注意的原则是控制胃食管反流、消除症状,以及预防或治愈高级别异型增生(高级别上皮内瘤变)、早期食管腺癌。主要方法有生活方式干预、药物治疗和内镜下治疗。随访建议用高分辨率内镜监测;对于巴雷特食管<3cm,不伴有肠上皮化生或异型增生(上皮内瘤变)者,经重复4个象限内镜下黏膜活检证实无肠上皮化生,建议退出监测;巴雷特食管<3cm伴有肠上皮化生者,建议每3~5年行1次内镜检查;对于巴雷特食管≥3cm者,建议每2~3年行1次内镜检查。

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    2018-03-01 秀红

    学习了

    0

  3. 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    2017-09-21 cscdliu

    非常好.学习了.谢谢

    0

  4. 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    2017-09-20 yfjms

    学习了

    0

  5. 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    2017-09-17 往日如昨

    学习了谢谢分享

    0

  6. 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  7. [GetPortalCommentsPageByObjectIdResponse(id=1948425, encodeId=5a6e194842538, content=<a href='/topic/show?id=e7f5e59259e' target=_blank style='color:#2F92EE;'>#筛查与诊治#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75925, encryptionId=e7f5e59259e, topicName=筛查与诊治)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/kbRUeosenzlejlNGWXdWjSYhBKL1QYGQwfehJOkMXHiavh5wl7pKeju5Kcxdvr50ic6FWML3x6NMCxhG1bOaVjyA/132, createdBy=20872500216, createdName=ms4657536712156177, createdTime=Sun Nov 19 08:44:00 CST 2017, time=2017-11-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=291854, encodeId=07d929185449, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/01/15/8213228fe923915543544ad3da7e1c64.jpg, createdBy=6bd82014262, createdName=秀红, createdTime=Thu Mar 01 03:37:58 CST 2018, time=2018-03-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=246305, encodeId=dc532463058e, content=非常好.学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/23/557c1f19aaf5459a8405411e38903c4b.jpg, createdBy=dfc02088287, createdName=cscdliu, createdTime=Thu Sep 21 11:10:45 CST 2017, time=2017-09-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245922, encodeId=0d9224592212, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Wed Sep 20 07:52:38 CST 2017, time=2017-09-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=245058, encodeId=a4f624505844, content=学习了谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c0a61971598, createdName=往日如昨, createdTime=Sun Sep 17 17:56:29 CST 2017, time=2017-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1338372, encodeId=8ebc13383e2c7, content=<a href='/topic/show?id=f3c848321b4' target=_blank style='color:#2F92EE;'>#巴雷特食管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=48321, encryptionId=f3c848321b4, topicName=巴雷特食管)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/XhttJCp4Aq9gKA5n4v9elclQlVQTDenMiaEiadlI5D3gtmfSiaicoIY4ZsuibrQKLibDdxBKVY8oS6B2FicqJlT93clow/132, createdBy=03202500144, createdName=ms7258648636991762, createdTime=Sun Sep 17 14:44:00 CST 2017, time=2017-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1437250, encodeId=1c20143e2500a, content=<a href='/topic/show?id=0e311010591a' target=_blank style='color:#2F92EE;'>#食管#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=101059, encryptionId=0e311010591a, topicName=食管)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Sun Sep 17 14:44:00 CST 2017, time=2017-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=244977, encodeId=d0492449e7f8, content=文章很好.赞赞赞, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzdAIB7UwTkHt6fQkBP8ictliaXtc5gCUmYdAW1sAETC2nhO3q6YjRHkUibyOCtP8ibmXNObTyd63A076/0, createdBy=d4111948983, createdName=1e10c84am36(暂无匿称), createdTime=Sun Sep 17 11:23:35 CST 2017, time=2017-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=244440, encodeId=5e4b24444014, content=这个要好好学习才行, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Sat Sep 16 00:12:45 CST 2017, time=2017-09-16, status=1, ipAttribution=)]
    2017-09-17 zhouqu_8
  8. 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    2017-09-17 1e10c84am36(暂无匿称)

    文章很好.赞赞赞

    0

  9. 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    2017-09-16 飛歌

    这个要好好学习才行

    0

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