| BackgroundGastric cancer is one of most common malignant tumors in our country and the mortality rate is high. The curative effect and prognosis of gastric cancer is closely related to the tumor staging, so the early diagnosis and treatment can improve the quality of life of patients with gastric cancer.Early gastric cancer(EGC) refers to the cancerous tissue infiltration into the submucosa, regardless of its size, and presence of lymph node metastasis. The prognosis of early gastric cancer is far better than the medium and advanced gastric cancer, and the 5-year survival rate is more than 90%. In Japan, the detection rate of EGC can reach more than 70%. In China, the diagnostic ratio of EGC can reach 18% ~ 20% in some medical centers.But in most hospitals of China, the ratio is less than 10%. The reasons of this gap including:Japan has a national endoscopic screening system, the doctor did the endoscopic examination too fast to observe the whole stomach carefully, insufficient understanding of endoscopic manifestation of early gastric cancer and so on.We haven’t effective techniques on screening of early gastric cancer except endoscopic examination. most hospitals are still found in lesions, and is lack of an effective means of recognized the nature of the lesion, scope and depth of lesions.It is urgently need to analyze the clinical features of early cancer in upper gastrointestinal tract and risk factors, to explore the diagnosis and screening effect of serological detection in atrophic gastritis and gastric cancer,to explore the technology of endoscopic image recognition software based on the essence technology,improving the screening and dignosis ability of early cancer in upper gastrointestinal tract in China.Objectives 1. In the clinical practice of early upper gastrointestinal tract cancer, we analysis the clinical pathological features of early gastric cancer with lymph node metastasis.In order to find the rational selection of treatment of early gastric cancer(EGC),we analysis the risk factors associated lymph node metastasis and high level intraepithelial neoplasia. 2. In order to find the serological detection method suitable for the Chinese people,we evaluated the role of serological method in diagnosis and screening atrophic gastritis and gastric cancer, 3. We evaluated the role of NBI- ME, endoscopic ultrasonography and multislice CT(MDCT) diagnostic technique in the diagnosis of early carcinoma of upper gastrointestinal tract, and exploratory research on OCT technology and image recognition software development.Methods 1. The clinical practice and research of early cancer in upper gastrointestinal tract 1) We retrospectively analyzed the clinical pathological features of early gastric cancer patients in our hospital between 2009 and 2014, and find risk factors of lymph node metastasis. 2) From April 2013 to July 2015, we carried out “diagnostic ESD ” in gastric mucosa intraepithelial neoplasia cases in our hospital,looking forword to find some signs of gastric mucous membrane of the endoscopic in the progression of intraepithelial neoplasia, and providing clinical basis for the treatment of reasonable selection. 2. The role of serological detection in atrophic gastritis and gastric cancer diagnosis and screening 1) We evaluate whether serum PG Ⅰ, PG Ⅰ/PG Ⅱ ratio(PGR), G- 17 and h. pylori Ig G antibody can screening atrophic gastritis. 2) In part place of the high-risk gastric cancer of our province,we screened the gastric cancerby using blood pepsin and the gastrin17,the "ABC" method is prone to gastric cancer screening value in anhui province partial areas. 3. The exploratory researches of diagnosic techniques and the image processing software in early cancer of upper gastrointestinal tract 1) From August 2014 to December 2015,we checked the early gastric cancer patients with MDCT and endoscopic ultrasonography(EUS) to evaluate the infiltration depth,and compared with postoperative observation of pathological results. 2)In vitro study,we evaluated the OCT imaging of hogwash tube wall. At the same time OCT and endoscopic ultrasonography were used to scan 25 patients with diagnosis of digestive tract malignant tumor resection by organization. 3)From January 2013 to February 2015,we select some patients with clinical suspicion of early esophageal cancer in the First Affiliated Hospital of Anhui Medical University, integrated the white light endoscopy and NBI- ME endoscopic technique to identify small lesions, and use the computer aided image processing, image recognition software to identify white light endoscopy lesions and IPCL form images.Results 1. The clinical features and risk factors of early cancer in upper gastrointestinal tract 1) 976 patients with EGC(718 men and 258 women, average age was 59.6 + /- 10.7 years) were included in this study. There were 120 patients(12.3%) with lymph node metastasis(LNM). LNM rates of differentiated and undifferentiated type EGC were 6.6%(38/576) and 20.5%(82/400). Lymph node metastasis were occurred in 20 cases(4.2%) among 481 patients with tumor infiltrating through the mucosa layer; while LNM were occurred in 71 cases(18.4%) among 385 cases of patients with tumor infiltrating through submucosa shallow(SM1) layer; and LNM were occurred in 28 cases(25.5%) among 110 cases of patients with tumor infiltrating through deep submucosa(SM2) layer. 2) Deep concave lesion, ulcer, larger tumor size, invasion and vascular invasion and differentiation of the deeper type of EGC were related to LNM by univariate analysis. In undifferentiated EGC, the related risk factors are age, location, shape, size, depth of invasion, macro and vascular invasion. Size, depth, and vascular invasion are independent predictors in differentiated EGC. 3)According to the standard indication under endoscopy and expand the indications, 1, 2, 3 and 4,the LNM rate of differentiated EGC cases were 0.65%, 0.65%, 3.6% and 9.0%, respectively. 2.The research about “diagnostic ESD” in gastric intraepithelial neoplasia 1) a total of 92 cases of gastric mucosal lesions were treated by “diagnostic ESD”.23 cases were diagnosed as low grade intraepithelial neoplasia through biopsy pathology. Among them,6 were diagnosed as low neoplasia by the “diagnostic ESD”, 11 were diagnosed as high grade intraepithelial neoplasia and 6 were diagnosed as cancer after “diagnostic ESD”. The rate of postoperative pathological upgraded to a high level of intraepithelial neoplasia and early gastric cancer is 73.9%. The biopsy pathology of 36 high level intraepithelial neoplasia cases were diagnosed with cancer after “diagnostic ESD”. 2) The associated risk factors of canceration in intraepithelial neoplasia lesions were age, classification, cardiac lesions, size and ulcers.3) The accuracy of NBI- ME in diagnosis of early gastric cancer was 93.1%, and 5.5% patients were over-diagnosed, 1.4% patients were under-diagnosed. And the accuracy of depth diagnosis by endoscopic ultrasonography in the intraepithelial neoplasia was 58.9%. About 35.7% patients were over-diagnosed, 5.4% patients were under-diagnosed. 3. The value of pepsin, gastrin 17, and of Hp antibody in the diagnosis of atrophic gastritis 1) There were 499 cases in our study. The mean age was 53.84±9.5 years, including 269 male and 230 female. 2) We found the level of PGI and PGR were decreased in the opened atrophic gastritis by the endoscopic atrophy serological indexes.The level of fasting G17 was higher in the opened atrophic gastritis than closed atrophic gastritis. The value between fasting and postprandial G17 was significantly decreased in the opened atrophic gastritis. 3) According to OLGA, we found that the level of serum PGI, PGII significantly decreased in the phase IV. And the PGR levels increased in higher OLGA degree. Fasting serum G17 levels increased significantly in phase III and IV. 4) According to OLGIM, we found that serum PGI declined obviously in phase IV. With OLGIM aggravating severity,the PGR levels declined, obviously in stage III and IV. Fasting serum G17 levels significantly decreased in phase III and IV. 5) According to the Japan values, the positive rate of PG in atrophic gastritis were 3.1%(6/195); According to our recommendationvalues,the positive rate of PG were 5.6%(11/195). 4. Useing "ABC" method to evaluate the gastic cancer screening abiliy by serume pepsin and gastrin 17 in some high gastric cancer risk areas of Anhui province 1) About 1939 cases were screened.The mean age was 53.6±8.5 years, including 925 male and1014 female.There were 1546 normal cases, 10 ulcers,, 273 atrophic gastritis, 105 low level neoplasia, 5 gastric cancer.2) Acording the ABC screening method of Japan, the incidence rate of atrophic gastritis in A, B, C and D group was 11.5%, 17.6%, 16.3% and 6.9%. The incidence of atrophic gastritis in group B and group C was higher than that of group A and group D. There was no significant difference in the incidence of gastric cancer in four groups(P > 0.05). Japan’s ABCD screening project were not fitted in some high gastric cancer risk areas in anhui province. 3) The value of ombination of G- 17 and PG was significantly higher than that of single PG project screening in early gastric cancer, and greatly reduces the crowd positive rate.The incidence of atrophic gastritis in A, B, C program was10%,13.3% and 15.8%. 5. A preliminary study of the role of MDCT in the depth diagnosis of early gastric cancer infiltration 1) There were 41 patients, including 10 male and 31 female.The mean age was 64.2±8.9 years old. There were 13 cases well-differentiated adenocarcinomas, 6 cases low differentiated adenocarcinoma, and 22 cases high level intraepithelial neoplasia in pathological diagnosis after endoscopic resection or surgical removal. A total of 22 cases of were cardiac disease, 8 cases were corpus lesions, 3 cases were gastric angle lesions, 9 cases were antrum lesions.The number of T1 a lesions,T1 b lesions,T2 lesions and T3 lesions was 30, 8, 3 and 1 respectively. 2) The accuracy of MDCT in the depth diagnosis is 76.2%. The diagnostic accuracy of mucosal layer,submucosa layer,muscular layer and serous layer was 70%, 87.5%, 100% and 100% respectively. 3)The accuracy of MDCT in judgment of depth in cardiac lesions,cardiac lesions, corpus lesions, gastric angle lesions and antrum lesions was 72.7%, 75%,0%,100% and 100% respectively. 4) The accuracy of endoscopic ultrasonography in judgment of depth is 69.6%, lower than MDCT.. The depth of the mucosa, submucosa, muscular layer judgment accuracy of 83.3%, 25%, 83.3% and 25% respectively. Compared with the CT, the mainly difference is in judgment of submucosal lesions. Compared with the MDCT, the judgment of depth in gastric angle lesions is not clear. 5) There were 2 patients had lymph nodes through MDCT, and they were confirmed as reactive hyperplasia by postoperative pathology. 6. A exploratory study of optical coherence tomography(OCT) imaging in the upper digestive tract cancer 1) We can see four layer structure in OCT images clearly, including less reflective layer, strong reflective layer, weak reflection layer and a strong reflective layer respectively. After the injection of titanium dioxide markers, the OCT images of hogwash wall and corresponding pathological can be seen one-to-one correspondence. 2) In the ESD resection tissues of normal esophageal, we found that the visible mucosal epidermal layer(EP), mucosal lamina propria(LP), mucosal muscularis(MM), submucosa(SM) in OCT images. The OCT images in 16 cases of the esophagus tumors tissue were difference with the normal structure.The integrity of EP layer was damaged, and characterized by high brightness and low brightness mixed area, light enlargement, no significant level. 3) In the ESD resection tissues of normal gastric cardia tissue, we found that the stratification of OCT images was not obvious. We can see mucosal epidermal layer(EP), mucosal lamina propria(LP), mucosal muscularis(MM). 7. An exploratory study of image recognition based on the texture characteristics 1)According to the result of pathology, we gathered 180 images by white light endoscopy. We gathered 261 images by NBI- ME of which type A 22, B1 type 161 pieces, B2 type 35 pages, B3 type 43. 2) Using CNN characteristics identification, the white light computer image recognition can be completely detect the abnormal area, with less false alarm region. 3) As described by the local texture, PHOW feature extracting by CHI2 kernel function to transform characteristics on the SVM classifier achieved higher classification accuracy, implements the NBI- ME, the automatic classification of IPCL parting the image. Each separate classification accuracy rate were 76.3%, 88.1% and 84.7%. The overall classification accuracy was 85.2%. 4) The endoscopic interns in the identification of A group and B2B3 accuracy is higher, main fallibility recognition for B1 group, but less B2B3 group between group A misjudgment, overall is high accuracy some computer recognition software. But in group B1, we found that the endoscopic interns accuracy between 57.8% and 79.5%, easily mistaken for group A and group B2B3. And computer software recognition accuracy rate at 88.1%, significantly higher than that of endoscopic interns, clinical guidance to choose the best treatment plan.Conclusions(1)Size, depth, and vascular invasion are independent predictors of LNM in differentiated EGC. Even after endoscopic resection treatment limited to mucous membrane of the differentiated early gastric cancer, we should also follow up the possibility of a transfer.(2)In gastric mucosa intraepithelial neoplasia,the factors of cardia lesion,greater than 1 cm, need to consider the possibility of canceration. NBI-ME can be used in preoperative diagnosis of lesions properties.(3)The serum pepsinogen and G17 can estimate the scope and extent of atrophy and intestinal metaplasia in the stomach.(4) It is more suitable for the combination with G- 17 and PG screening of early gastric cancer in China. Utilizing the new ABC method to evaluate the risk of gastic cancerc in some area of high-risk gastric cancer in anhui province(5) Using MDCT to diagnose infiltration depth of early gastric cancer will be completely ruled out infiltration deeper depth cases, avoiding inappropriate endoscopic treatment,and ensuring the safety of clinical.(6) The optical coherence tomography can clearly display hogwash tube wall’s four layer structure, and by inserting markers, we found the OCT images and pathological images can be saw one-to-one correspondence. In ESD specimens of esophageal cancer, we can obtain good effect and find the difference between normal code in OCT images.(7) Based on the texture characteristics of image recognition can improve the ability of endoscopic physicians, avoid misdiagnosis, and distinguish the NBI- ME endoscopic IPCL classification. |
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