The Clinicopathological Characteristics,endoscopic Findings And Treatment Correlation Analysis Of Colorectal Laterally Spreading Tumors

BackgroundStudies show that the 5-year survival rate for early-stage colorectal cancer can be more than 90 percent,compared with only 10 percent for late-stage patients with metastatic disease.Therefore,early detection and timely treatment of colorectal cancer are particularly important.Laterally spreading tumors(LSTs)is a precancerous lesion of colorectal cancer,which has been intensively studied by domestic and international scholars due to its special morphology,growth pattern and biological behavior.LSTs have different forms and subtypes.The clinicopathological characteristics of different subtypes of LSTs are different,and the risk of submucosal infiltration carcinoma is also different.Therefore,it is of clinical significance to differentiate subtype of LSTs.Currently,narrow band imaging(NBI)is widely used in clinical practice.There are few studies on the effectiveness of the Japan NBI Expert Team(JNET)classification based on NBI magnifying endoscopy in predicting the histopathology of LSTs,and few studies have compared the diagnostic effect of JNET classification and Pit Pattern classification for the same LST.Endoscopic submucosal dissection(ESD)is the standard treatment if LSTs are required to complete resection after endoscopic evaluation.Submucosal fibrosis is an important factor affecting the success of ESD.At present,there are few studies on the relationship between the degree of submucosal fibrosis of LSTs and the prognosis of ESD.Chapter 1 The Clinicopathological characteristics of laterally spreading tumorsObjectiveTo compare the clinicopathological features of each subtype of LST and explore the related factors of LST carcinogenesis.MethodsThe clinical data of patients with LST diagnosed by electronic colonoscopy in the Digestive Endoscopy Center of Nanfang Hospital of Southern Medical University from September 2016 to August 2020 were collected.The lesion diameter,lesion location,Paris classification and postoperative pathology of subtype of LST were compared,and the related factors of LST carcinogenesis were discussed by univariate and multivariate analysis.Results327 patients containing 342 lesions were included.The submucosal infiltration rates of each subtype were LST-G-H0%,LST-G-M4.4%,LST-NG-F1.0%and LSTNG-PD20%,respectively.The risk of submucosal infiltration in pseudo-depressed type was significantly higher than that in the other three types(P<0.05).The results of univariate analysis showed that the carcinogenesis of LST was significantly correlated with the subtype,location and diameter of LST.The results of multivariate analysis showed that nodular mixed type(OR=2.625,P=0.002),pseudo-depressed type(OR=3.530,P=0.049)and diameter of LST≥30mm(OR=2.577,P=0.001)were independent risk factors for carcinogenesis of LST.ConclusionThere are significant differences in the clinicopathological characteristics of subtype of LST,and the subtype of LST can preliminarily judge the risk of submucosal infiltration.When LST is nodular mixed type,pseudo-depressed type or diameter of LST≥ 30mm,the risk of canceration of LST is higher,so it needs to be treated by block resection,while for H type with almost no invasion of submucosa,EMR or EPMR can be chosen.Chapter 2 The value of Pit pattern classification and JNET classification in predicting histopathology of colorectal laterally spreading tumorsObjectiveTo evaluate the diagnostic value of Pit pattern classification and JNET classification in differentiating precancerous lesions from early cancer in LST.MethodsTo collect the case data of patients who underwent electronic colonoscopy and diagnosed as LST and received ESD in the Digestive Endoscopy Center of Nanfang Hospital of Southern Medical University from September 2016 to August 2020.The diagnostic value of Pit pattern typing and JNET typing in LST was compared by consistency test and chi-square test.Results106 patients containing 112 lesions were included.The predicted results of endoscopic JNET classification were moderately consistent with pathological findings(Kappa value=0.50).The predicted results of Pit pattern classification were in good agreement with the pathological results(Kappa value=0.61).The specificity(92.0%vs 75.0%),negative predictive value(90.9%vs 63.8%)and overall accuracy(86.6%vs 75.9%)of JNET classification in distinguishing LST from precancerous lesions was significantly higher than Pit pattern classification.ConclusionThe diagnostic efficacy of JNET classification in differential.diagnosis of precancerous lesions and early cancer is better than that of Pit pattern classification.It is much simpler and more convenient than chemical staining endoscopy.For the lesions that are difficult to be judged by JNET classification,Pit pattern classification can be used to improve the accuracy.Chapter 3 Endoscopic features and histological changes of laterally spreading tumors with white plaqueObjectiveTo summarize the clinicopathological characteristics and endoscopic findings of LST with white plaque,we try to clarify the possible causes of white plaque.MethodsThe data of patients with LST diagnosed by electronic colonoscopy and white plaque on the surface of the lesions were collected from September 2016 to August 2020 in the Digestive Endoscopy Center of Nanfang Hospital of Southern Medical University.Also,in the rest of the LST without white plaque,matched controls were examined in terms of age,sex,tumor diameter and macroscopic types.The expression of ADRP and CD68 in the two groups was detected by immunohistochemical method.Results36 lesions were included,including white plaque group(n=18)and non-white plaque group(n=18).In white plaque group,27.8%(5/18)were conventional adenomas and 72.2%(13/18)were serrated lesions.The positive expression rate of ADRP in the white plaque group was higher than that in the non-white plaque group(61.1%vs 38.9%,χ2=4.050,P=0.044).The positive expression rate of CD68 in the white plaque group was higher than that in the non-white plaque group(66.7%vs 5.6%,χ2=14.569,P<0.001).ConclusionThe cause of white plaque may be the accumulation of lipids in the mucosal epithelium,which induces the accumulation of macrophages in the mucosal epithelium.Its pathology highly suggests serrated lesions,which can serve as a hint for the preliminary determination of the pathological types of LST under endoscope.Chapter 4 The effectiveness of ESD in the treatment of laterally spreading tumors and analysis of related factorsObjectiveTo evaluate the effectiveness of ESD in the treatment of LST,and explore the relationship between submucosal fibrosis and the effectiveness of ESD and the relevant factors of submucosal fibrosis.MethodsTo collect the case data of patients who underwent electronic colonoscopy and were diagnosed as LST and received ESD treatment in the Digestive Endoscopy Center of Nanfang Hospital of Southern Medical University from September 2016 to August 2020.To analyze effectiveness of ESD in the treatment of LST,and explore the risk factors of mild and severe submucosal fibrosis by univariate and multivariate analysis.Results220 patients containing 229 lesions were included.The rate of en-bloc resection and R0 resection,the incidence of bleeding and perforation were 97.4%,94.3%,3.1%,and 2.2%,respectively.Univariate analysis showed that lesion diameter,lesion location,LST subtype,pathological type and biopsy were significantly correlated with mild and severe fibrosis(P<0.05).Furthermore,mild fibrosis is also related to the location of the lesion.Multivariate analysis revealed that lesion diameter≥ 40mm(OR=2.376,P=0.021),intramucosal carcinoma(OR=6.301,P=0.011)and biopsy(OR=4.215,P=0.034)were dependent risk factors for mild fibrosis,and lesion diameter≥40mm(OR=6.427,P=0.02),pseudo-depressed type(OR=94.411,P=0.03),submucosal carcinoma(OR=131.035,P=0.008)and biopsy(OR=7.772,P=0.047)were dependent risk factors for severe fibrosis.ConclusionEndoscopic submucosal dissection is an important method for the treatment of laterally spreading tumors.Most of the related complications are mild and satisfactory results can be obtained after conservative treatment in internal medicine.Severe fibrosis is the main risk factor for the decrease of R0 resection rate of lesions.When the lesion diameter≥40mm,pseudo-depressed type,suspicious submucosal and preoperative biopsy is present,we should proceed with caution.