目的 分析内镜黏膜下剥离术（ESD）切除的浅表浸润性鳞状细胞癌的病理特征。方法 收集2016年1月23日至2017年12月31日ESD术后的浸润性鳞状细胞癌病例187例。对每例标本的肿瘤分化程度、侵犯深度、浸润生长方式、肿瘤是否出芽、脉管是否侵犯、切缘状态进行判读。查询所有患者术后内镜活检记录及手术根治记录，进行分析总结。结果 患者年龄42～83岁，男性147例，女性40例。9.1%患者合并其他部位的癌/上皮内瘤变，以胃腺癌最常见。高、中、低分化鳞状细胞癌分别占0.5%、41.7%、15.0%，其余42.8%的病例仅有微灶浸润，难以分级。黏膜固有层、黏膜肌层及黏膜下层浸润者，分别占39.6%、32.6%、27.8%。黏膜下层浸润＜200 μm（SM1）占9.1%，黏膜下层浸润≥200 μm（SM2）占18.7%。淋巴管侵犯与肿瘤侵犯深度、肿瘤出芽、浸润生长方式有关。淋巴管侵犯率随着浸润深度增加及出芽级别增加而增高。浸润方式为混合型和弥漫型的淋巴管侵犯率高于膨胀型。高、中分化鳞状细胞癌与低分化鳞状细胞癌之间淋巴管侵犯率差异无统计学意义。多因素分析显示肿瘤出芽是淋巴管侵犯的独立危险因素。肿瘤完整切除130例（占69.5%）。非完整切除者（57例，30.5%）切缘多为低级别上皮内瘤变。69例再次内镜下活检，病理证实无复发46例（66.67%），复发19例(27.54%)，其他部位新发4例(5.80%)。完整切除者与非完整切除者之间病理活检复发率〔28.3%（13/46） vs. 31.6%(6/19)〕差异无统计学意义。结论 肿瘤浸润深度、肿瘤生长方式、肿瘤出芽、淋巴管侵犯均应作为ESD标本病理报告的必要指标，其中肿瘤出芽是淋巴管侵犯的独立危险因素。
英文摘要:
Objective To analyze the pathological characteristics of superficial infiltrating squamous cell carcinoma of endoscopic submucosal dissection (ESD). Methods 187 cases of invasive squamous cell carcinoma after ESD operation were collected from 2016 Jan 31 to 2017 Dec 31. The tumor differentiation, invasion depth, infiltrative growth pattern (INF), tumor budding, angiovascular lymphatic invasion and margin were determined. The pathological diagnosis of endoscopic biopsy and surgical operation after ESD were searched. Results The patients were aged from 42 to 83 years old, including 147 males and 40 females. 9.1% patients had carcinoma/intraepithelial neoplasia in other sites, among which gastric adenocarcinoma was the most common one. Well, moderately and poorly differentiated squamous cell carcinoma accounted for 0.5%, 41.7% and 15.0%, respectively, while the remaining 42.8% cases were microinvasion and were difficult to be graded. Mucosa lamina propria, muscularis mucosa and submucosa invasion accounted for 39.6%, 32.6% and 27.8%, respectively. Submucosa infiltration ＜200 μm (SM1) accounted for 9.1% and submucosa infiltration ≥200 μm (SM2) accounted for 18.7%. Lymphatic vessel invasion was related to the depth of tumor invasion, tumor budding, INF. The invasion rate of lymphatic vessels increased with the increase of infiltration depth and the grade of tumor budding. The lymphatic invasion rate in INFb/c group was higher than that in INFa group. There was no statistical difference in the incidence of lymphatic vessel invasion between well/moderately differentiated squamous cell carcinoma and poorly differentiated squamous cell carcinoma. Multivariate analysis showed that tumor budding was an independent risk factor for lymphatic vessel invasion. The complete resection occupied 69.5% (130 cases), while most ofincomplete resection cases (57 cases) were involved by low-grade intraepithelial neoplasia. 69 cases had biopsy ]after ESD, among which there were 46 cases (66.67%) with no recurrence, 19 cases (27.54%) with recurrence, and 4 cases (5.80%) occurring in other sites. There was no statistical difference in recurrent rate between the complete resection (28.3%, 13/46) and the incomplete resection (31.6%, 6/19, P>0.05). Conclusion Tumor invasion depth, INF, tumor budding andlymphatic vessel invasion should all be disclosed for the ESD specimen pathological report. Tumor budding was an independent risk factor for lymphatic vessel invasion.
