【作者】 邹晓平；

【导师】 许国铭； 李兆申；

【作者基本信息】 第二军医大学 ， 内科学， 2003， 博士

【摘要】 80年代初期，内镜超声检查(Endoscopic ultrasonography，EUS)开始出现，美国的Di Magno首先报导了应用线阵式超声胃镜所做的动物实验，而Olympus公司生产的GF-UM3是最先应用于临床的成熟机型。尽管最初发展EUS是为了改善胰腺的超声图像，进一步运用后发现，EUS在胃肠道肿瘤的分期及判断肠壁起源肿瘤的性质方面具有极大的优势，经过20年的实践和改进，在解决上述方面问题时，EUS是重要的或是首选的检查。 内镜对诊断胃癌的部位和范围意义较大，但判断侵犯深度较困难，更无法估计淋巴转移情况，CT在发现周围及远处转移方面具有一定的优点，但也很难准确判断癌的浸润深度。EUS能够比较准确地判断癌的浸润深度及周围淋巴结转移情况，因此对胃癌的存在诊断和侵犯深度均有极大的价值。 本课题是我们在1992年5月至2002年12月近10年中，共对284例胃癌行EUS检查，其中资料完整有217例。通过比较这些患者术前EUS检查结果和术后病理，以探讨EUS在判断肿瘤浸润深度、术前TNM分期、肿瘤可切除性及鉴别诊断方面的价值。 本课题包括三部分内容，分述如下： 一、内镜超声检查对胃癌侵犯深度的判断 目的：通过对15例切除标本的体外EUS检查以及217例术前EUS检查，以进一步探讨EUS对正常胃壁结构和胃癌浸润深度判断的准确性。 材料和方法：从1992年5月～2002年12月在EUS检查的217例胃癌中，术后病理证实其中早期胃癌13例，进展期胃癌204例，均于手术前2周内进行EUS检查，其中男151例，女66例；年龄24～79岁，平均54.4岁。手术切除标本15例，其中5例为因其他疾病而切除的部分正常胃，另10例为胃癌标本。 所用超声内镜为Olympus公司GF-UM3型、GF-UM200型，具有7.5MHz和12MHz多二军医大学…~_._._二_.博士学位论文_一一一一一一一一一立塑壑七二种超声频率可换用。GF一UMP23O型，具有7.SMHz一种超声频率。经内镜超声小探头，探头的型号有olympus UM一ZR、UM一3R，探头频率分别为12MHz和20MHz。 结果:1.正常胃壁结构:离体实验结果显示，EUS下胃壁图像与组织学5层结构相对应，分别为:第一层高回声和第二层低回声对应于豁膜界面和勃膜豁膜层:第三层对应于勃膜下层;第四层低回声结构对应于固有肌层;第五层对应于浆膜层及浆膜外层结构。2.EUS对早期胃癌的诊断价值:对于13例早期胃癌，EUS对判断准确5例，基本准确4例，准确率692%，判断失误的4例均将早期胃癌过度判断为进展期胃癌，但其中2例为溃疡癌变。3.EUS对进展期胃癌侵犯深度的诊断价值:对于204例进展期胃癌，其中mP癌18例，s癌186例;EUS判断侵犯深度的准确181例，基本准确18例，准确率97.5%失误仅5例，均为mp癌被低估为早期胃癌，另有10例mp癌被过高估计为s癌;以侵犯至浆膜层的诊断准确率最高，有8例估计不足将s癌判为mp癌。4.不同部位对EUS判断的影响:本组病灶位于责门76例，胃体35例，胃角33例，胃窦52例，吻合口6例，全胃癌巧例。不同部位EUS诊断的准确率不尽相同，其中胃体因显示最充分，判断的准确性最高;胃窦和胃角有时需水囊紧贴病灶，过低评估或过高评估均较多:责门狭窄似乎并不影响侵犯深度的判断;本组吻合口癌及全胃癌均为晚期，均已侵犯至浆膜，判断也较容易，准确率均达100%。 结论:EUS无论对离体标本还是体内检查，均可显示胃壁正常的五层结构。EUS对早期胃癌的诊断明显优于内镜，但EUS较难区分低回声病灶是肿瘤还是炎症或纤维化，还需依靠胃镜活检检查。EUS在判断癌侵犯深度具有较高的准确性，能够为术前判断病灶的可切除性提供较大的帮助。「} 二、EUS对术前TNM分期和可切除性判断的价值 目的:探讨EUS对胃癌术前TNM分期及可切除性判断的可行性和准确性，并比较EUS和TEMP应用的优缺点。 材料和方法:对217例经内镜活检证实的胃癌患者术前2周内行EUS检查，将EUS结果与手术所见及病理结果进行比较;在同一时期，对16例行TEMP检查，另17例行EUS检查，以进行比较。所用的超声内镜及操作方法同前所述。EUS的胃癌不可切除征象:腹水;远处转移，主要是肝转移及后腹膜转移;侵犯胰腺、腹主动脉、下腔静脉、腹腔干等重要脏器及血管。 结果:1.肿瘤浸润深度(T):Tl癌诊断准确率为69.2%，4例被过度判断为第二军医大学博士学位论文中文担墓乃癌，而其中2例为溃疡癌变，术中肉眼也认为肿瘤已浸润浆膜。几癌诊断准确率为33.3%，7例被过度判断为T3癌，5例被低估为T，癌。T3癌90.3%诊断正确，仅8例被低估为TZ癌;7例过度判断为几癌，其中l例因认为胃癌己侵犯胰腺。T;癌正确诊断为64.5%，其中发现8例贵门癌侵犯食管下段，3例侵及十二指肠球部，5例侵犯胰腺，1例侵犯胆总管，3例侵犯相邻的肝脏。有n例被低估为T3癌，其中7例因幽门或贵门梗阻，内镜未能通过病灶，即使换用超声小探头，也很难充分显示病变浸润情况。EUS对浸润深度T的判断总准确率为80.6%，高估和低估率分别为8.3%和H.l%。口2.淋巴结转移(N):本组EUS淋巴结转移准确率为124/161，其余37例为假阴性，然而按照NI和N:标准准确分期的仅95例，Nl准确判断为67.0%，而N:为40.8，其中34更多还原

【Abstract】 Endoscopic ultrasonography (EUS) was first reported in the early 1980s by Di Magno in USA who carried the experiment in animals using linear EUS. GF-UM3 produced by Olympus Company was first clinically used. Though it was initially developed to obtain a better view of pancreas which was quite difficult to explore by conventional ultrasound, the further using EUS has become apparent that it has great advantage of accurate TNM staging in gastrointestinal cancer and evaluating the characters of neoplasms originated from intestinal tract. Nowadays EUS has turned to be a very important tool in these diseases.Endoscopy is of great importance in the diagnosis of gastric cancer in the site and dimension, but of great difficulty in the invasion depth of the stomach wall, not to mention the metastasis of lymph nodes. Computered tomography(CT) has advantages in local and distant metastasis .however it cannot detect the accurate invasion depth of the tumor. EUS is of great value in the diagnosis of gastric cancer and invading depth of the stomach wall, for it can accurate invading depth local metastasis of lymph nodes , EUS could accurately determine the invading depth of tumor and the local involving lymph nodes.Between May 1992 and December 2002, EUS was performed in a total of 284 patients with gastric carcinoma, this study investigated the 217 cases of which with integrated data . We compared the preoperative EUS results and the detailed histological examination of the resected specimens in order to enhance our knowledge of EUS in defining the invasion depth of the tumor , preoperative TNM staging , resectability of the tumor.There are three parts in this study, that is : 1. EUS for determining the depth of gastric cancer invasion Objective: to evaluate the accuracy of EUS in assessing normal stomach wall and the invading depth in gastric carcinoma, EUS was performed in 15 resected specimens in vitro and 217 patients in vivo preoperatively.Material and methods: EUS was performed in 217 cases of gastric cancer between May 1992 and December 2002, of which 13 were early gastric cancer, 204 were advanced cancer confirmed by postoperatively histological results. EUS was all performed 2 weeks before the operation in 151 male ,66 female with ages ranged from 24~79 ,mean 54.4. There were 15 resected specimens, 10 were gastric cancer and 5 were normal gastric wall excised for other diseases.EUS used in this study were GF-UM3 .GF-UM 200 (Olympus, Japan) with probe frequency that could alter between 7. 5MHz and 12MHz . GF-UMP230 has only a 7. 5MHz probe. Olympus UM-2R UM-3R are the miniprobes passing through the channel of the conventional endoscopy with 12MHz and 20MHz frequency respectively .Results: 1. the normal stomach wall structure: EUS showed that the stomach wall corresponded to a five layer in vitro, correlation with the various histological layers was as follows: The first hyperechoic and the second hypoechoic structure bordering the gastric lumen correspond to the mucosa and muscularis mucosae, the third echogenic structure corresponds to the submucosa, the fourth echo-poor structure corresponds to the muscularis propia, the fifth echogenic structure corresponds to the serosa and adventitia. 2. EUS for diagnosis of early gastric cancer: Of the 13 cases with early gastric cancer confirmed by histological examination, 5 were accurately interpreted by EUS , 4 weremainly accurate, the overall accuracy rates were 69.2%; 4 were overstaged to be advanced tumors, 2 of which were malignant ulcers. 3. BUS for diagnosis of advanced gastric cancer: Among the 204 advanced gastric cancers, 18 were mp(muscularis propria) cancer, 186were s(serosa) cancer . 181 were accurately staged by BUS , mainly accurate 18 the overall accuracy rates were 97.5%, 5 histologically confirmed mp lesions were understaged to be early gastric lesions. 10 histologically mp cancers were overstaged to be s cancers; 8 histologically s cancers were understaged to be mp cancers ; the accuracy rates were highest for s lesions. 4. the effect of differ更多还原