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导读：2014年，日本胃肠内镜学会与日本胃癌学会共同制定了《早期胃癌内镜黏膜下剥离术和内镜下黏膜切除术指南》，近年来，大量证据设计良好的临床研究的数量在不断增加，为指南增加了许多新的证据，并使很多问题得以明确，于是，2020年，他们更新了第二版指南。为了促进ESD及EMR技术在早期胃癌领域的规范化发展，柳叶新潮特此将新版指南做了摘译，与大家分享，供各位学习交流。 Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition) 早期胃癌内镜黏膜下剥离术和内镜下黏膜切除术指南（第二版） In response to the rapid and wide acceptance and use of endoscopic treatments for early gastric cancer, the Japan Gastroenterological Endoscopy Society, in collaboration with the Japanese Gastric Cancer Association, produced “Guidelines for Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection for Early Gastric Cancer” in 2014, as a set of basic guidelines in accordance with the principles of evidencebased medicine. At the time, a number of statements had to be established by consensus (the lowest evidence level), as evidence levels remained low for many specific areas in this field. However, in recent years, the number of well-designed clinical studies has been increasing. Based on new findings, we have issued the revised second edition of the above guidelines that cover the present state of knowledge. These guidelines are divided into the following seven categories: indications, preoperative diagnosis, techniques, evaluation of curability, complications, long-term postoperative surveillance, and histology. 早期胃癌的内镜治疗得到了迅速广泛的接受和应用，因此日本胃肠内镜学会与日本胃癌学会于2014年共同制定了《早期胃癌内镜黏膜下剥离术和内镜下黏膜切除术指南》，作为符合循证医学原则的基本指南。当时，由于该领域中某些内容的证据水平仍然很低，多条声明都必须以“共识”（最低证据水平）的方式来确定。但近年来，设计良好的临床研究的数量在不断增加。因此，根据新的研究结果，我们发布了上述指南的修订第二版，以呈现当前的研究状态。这些指南分为以下7类内容：适应症、术前诊断、技术、可治愈性评估、并发症、术后长期监测以及组织学检查。 INDICATIONS 适应症 Basic approach 基本治疗方式 Once EGC has been diagnosed, endoscopic or surgical treatment is recommended. (evidence level B, grade of recommendation 1) 一旦诊断为EGC，建议进行内镜或手术治疗（证据水平B；推荐等级1）。 In general, endoscopic resection should be carried out when the likelihood of lymph node metastasis is extremely low, and when lesion size and site are amenable to resection en bloc. (evidence level B, grade of recommendation 1) 一般情况下，当淋巴结转移的可能性极低，且病变的大小和部位适合进行整块切除时，建议进行内镜切除。（证据水平B，推荐等级1） Indications for tumor-related factors are classified as absolute indications, expanded indications, and relative indications (Fig. 1). 根据肿瘤相关的因素将适应症分为绝对适应症、扩大适应症和相对适应症（图1）。
图1. 根据肿瘤相关因素对适应症进行分类。cT1a（M）、黏膜内癌（术前诊断）、cT1b（SM）、黏膜下浸润性癌（术前诊断）。UL，发现溃疡（或溃疡瘢痕）；UL0，无溃疡或溃疡瘢痕；UL1，存在溃疡或溃疡瘢痕。 Absolute indication lesions 符合绝对适应症的病变 Absolute indications for EMR/ ESD are “clinically intramucosal (cT1a) differentiated-type carcinomas with a long diameter measuring 2 cm or less with UL0.” Absolute indications for ESD are “(i) UL0 cT1a differentiated-type carcinomas with a long diameter greater than 2 cm; (ii) UL1 cT1a differentiated-type carcinomas with a long diameter measuring 3 cm or less; and (iii) UL0 cT1a undifferentiated-type carcinomas with a long diameter 2 cm or less” (evidence level B, grade of recommendation 1). EMR/ESD的绝对适应症为“临床上最大直径≤2 cm的分化型黏膜内癌（cT1a）且无溃疡或溃疡瘢痕（即UL0）”。ESD的绝对适应症为“（i）UL0，直径>2 cm的cT1a分化型癌；（ii）UL1，直径≤3 cm的cT1a分化型癌；和（iii）UL0，直径≤2 cm的cT1a未分化型癌”（证据水平B，推荐等级1）。 Expanded indication lesions 符合扩大适应症的病变 Only in cases of differentiated-type carcinomas, lesions can be regarded as expanded indications for ESD, provided that the absolute indication lesions locally recur as intramucosal cancer after initial ESD/EMR with a C-1 grade of endoscopic curability (eCura) (evidence level C, grade of recommendation 2). 只有在病变属于分化型癌的情况下，才能作为ESD的扩大适应症，前提是绝对适应症病变在初始ESD/EMR后局部复发为黏膜内癌，且内镜可治愈性级别为C-1级（eCura）（证据水平C，推荐等级2）。 Relative indication lesions 符合相对适应症的病变 Some cases of EGC, for which surgical gastrectomy is the standard treatment, may be curable by endoscopic treatment although the cure expectancy is lower. The unreliability of preoperative diagnosis is covered in detail in Preoperative diagnosis. In particular, the preoperative diagnosis accuracy rate is unsatisfactory for lesions that are diagnosed histopathologically as submucosal invasion (pT1b). Thus, endoscopic treatments would be indicated for EGCs that do not meet the requirements for absolute indications or expanded indications for endoscopic treatment, in order to take into account the patient’s condition where surgery cannot be recommended or establish an accurate histopathological diagnosis of the whole lesions before surgery. 对于某些EGC病例，外科胃切除术是标准治疗，内镜治疗虽然预期的治愈率不高，不过也有可能治愈。“术前诊断”部分详细描述了术前诊断中的不可靠性。尤其是对于组织病理学检查诊断为黏膜下浸润（pT1b）的病变，术前诊断的准确率不是很理想。因此，内镜治疗将适用于那些不符合绝对适应症或扩大适应症的EGC，从而把不建议进行外科手术的患者考虑进来，或在进行外科手术之前对整个病变进行准确的组织病理学诊断。 PREOPERATIVE DIAGNOSIS 术前诊断 Information to assist the determination of the indication for endoscopic treatment 有助于确定内镜治疗适应症的信息 In order to determine whether ESD or EMR is indicated, it is necessary to determine: (1) histopathological type; (2) size; (3) depth of invasion; and (4) whether ulceration is present. (evidence level D, grade of recommendation 1) 为了确定是否符合ESD或EMR适应症，必须做如下判断：（1）组织病理学分型；（2）病变大小；（3）浸润深度；和（4）是否存在溃疡。（证据水平D，推荐等级1） Information to assist the determination of horizontal resection margins 有助于确定水平切缘的信息 In general, conventional endoscopy with dye spraying or equipment-based image-enhanced endoscopy using a magnifying endoscope is used to determine the horizontal resection margins. (evidence level B, grade of recommendation 1) 一般情况下，使用常规内镜配合染料喷洒、或使用放大内镜的基于设备的图像增强内镜来确定水平切缘（证据水平B，推荐等级1）。 TECHNIQUES 技术 Because the risk of incomplete resection is high when EMR is used for lesions with absolute or expanded indications for ESD, ESD should be carried out instead of EMR for these lesions. (evidence level B, grade of recommendation 1) 当对符合ESD绝对适应症或扩大适应症的病变进行EMR时，不完全切除的风险会比较高，因此，对于这些病变，应进行ESD而不是EMR。（证据水平B，推荐等级1） EVALUATION OF CURABILITY 可治愈性评估 Evaluation of endoscopic curability is based on local factors and risk factors for lymph node metastasis. (evidence level B, grade of recommendation 1) 基于淋巴结转移的局部因素和风险因素对内镜治疗的可治愈性进行评估。（证据水平B，推荐等级1） Endoscopic curability A: curative resection 内镜可治愈性A级：治愈性切除 When the lesion is resected en bloc, the following conditions: (i) predominantly differentiated type, pT1a, UL0, HM0 VM0, Ly0, V0, regardless of size; (ii) long diameter ≤2 cm, predominantly undifferentiated type, pT1a, UL0, HM0, VM0, Ly0, V0; or (iii) long diameter ≤3 cm, predominantly differentiated type, pT1a, UL1, HM0, VM0, Ly0, V0, are considered for endoscopic curability A (eCuraA). However, evidence is lacking for cases of differentiated-type cancers with undifferentiated components. The above-mentioned type (1) lesions with the undifferentiated components measuring >2 cm in long diameter are defined as endoscopic curability C (eCuraC)-2 (see the measuring method in Fig. 2). 如果一个病变是整块切除，并符合以下情况：（i）主要为分化型，pT1a、UL0、HM0 VM0、Ly0、V0，任意尺寸；（ii）最大直径≤2 cm，主要为未分化型，pT1a、UL0、HM0、VM0、Ly0、V0；或（iii）最大直径≤3 cm，主要为分化型，pT1a、UL1、HM0、VM0、Ly0、V0，可视为内镜可治愈性A级（eCuraA）。然而，对于具有未分化成分的分化型肿瘤，相关证据尚且不足。将上述具有未分化成分且最大直径> 2 cm的（i）类病变定义为内镜可治愈性C（eCuraC）-2级病变（测量方法见图2）。
图2. 未分化型癌的大小测量。（a）重建未分化型癌区域，并测量该区域的最大直径。（b）如果不止一个区域存在未分化型癌，则测量所有区域的最大直径（x，y，z），并记录这些值的总和。 Endoscopic curability B 内镜可治愈性B级 When the lesion is resected en bloc, is ≤3 cm in long diameter, predominantly of the differentiated type, and satisfies the following criteria: pT1b1(SM1) (within <500 μm from the muscularis mucosae), HM0, VM0, Ly0, and V0, it is considered endoscopic curability B (eCuraB). However, the lesion is considered eCuraC-2 (see the measuring method in Fig. 6) if undifferentiated components are present in the submucosally invasive part of the lesion. 如果一个病变是整块切除，病变最大直径≤3 cm，病理类型以分化型肿瘤为主，并满足以下标准：pT1b1（SM1）（距黏膜肌层 < 500 μm）、HM0、VM0、Ly0、V0时，可视为内镜可治愈性B级（eCuraB）。然而，如果病变的黏膜下浸润部分存在未分化成分，则认为该病变的可治愈性分级为eCuraC-2（见图2中的测量方法）。 Endoscopic curability C 内镜可治愈性C级 When a lesion meets neither of the above-mentioned eCuraA and B conditions, it is considered eCuraC, which has a likelihood of remnant tumor. When eCuraC lesions are differentiated-type lesions and fulfill other criteria to be classified into either eCuraA or eCuraB but was either not resected en bloc or had positive HM, they are considered eCuraC-1. All other eCuraC lesions are considered eCuraC-2. 当病变既不符合上述eCuraA级的条件也不符合eCuraB级的条件时，可视为eCuraC级病变，对eCuraC级病变进行内镜治疗后有可能存在残余肿瘤。当eCuraC级病变为分化型病变，并符合eCuraA级或eCuraB级的分类标准，但未整块切除或水平切缘（HM）为阳性时，将其分为eCuraC-1级病变。其他所有的eCuraC病变均视为eCuraC-2级病变。 The risk of metastasis is low in eCuraC-1 lesions. In addition to surgical resection, repeat ESD, diathermy, and follow-up without treatment are possible options, with the patient’s informed consent, according to the policy of the treating institution. However, in general, open or laparoscopic surgical resection is indicated in the following cases: (i) long diameter ≤3 cm, predominantly differentiated type, pT1a, and UL1; or (ii) long diameter ≤3 cm, predominantly differentiated type, and pT1ba (SM1) lesions, if the combined size of endoscopically determined remnant lesion plus the lesion in the resected specimen exceeds 3 cm, or if the submucosally invasive part of a lesion is either resected piecemeal or has positive margins (Figs 3 and 4). eCuraC-1病变的转移风险较低。根据治疗机构的政策，在患者知情同意的情况下，除了手术切除外，重复ESD、透热疗法和随访无治疗也是可能的选择。然而，一般而言，开放式或腹腔镜手术切除适用于以下情况：（i）最大直径≤3 cm，主要为分化型，pT1a和UL1；或（ii）直径≤3 cm，主要为分化型和pT1ba（SM1）病变，假如内镜下确定的残余病变的尺寸加上切除标本中病变尺寸的总和超过3 cm，或者如果病变的黏膜下浸润部分是分块切除或切缘阳性（图3和图4）。
图3. 根据肿瘤相关因素评估可治愈性。*，局限于整块切除和HM0、VM0、Ly0和V0的病变。pT1a（M），黏膜内癌（组织病理学诊断）；pT1b（SM），黏膜下浸润性癌（组织病理学诊断）。UL，发现溃疡（或溃疡瘢痕）；UL0，无溃疡或溃疡瘢痕；UL1，存在溃疡或溃疡瘢痕。
图4. 内镜黏膜下剥离术（ESD）或内镜下黏膜切除术（EMR）后的治疗流程图。 In general, open or laparoscopic surgical resection should be performed in cases of eCuraC-2, in view of the risk of metastasis and recurrence (evidence level C, grade of recommendation 1). 一般情况下，考虑到存在转移和复发的风险，建议对eCuraC-2病变进行开放式或腹腔镜手术切除（证据水平C，推荐等级1）。 COMPLICATIONS并发症 Management of intraoperative bleeding 术中出血的治疗 The appropriate management of bleeding during the procedure is extremely important for the safe performance of ESD and EMR of gastric cancers. In particular, in cases of ESD, coagulation of bleeding vessels using hemostatic forceps, which does not interfere with subsequent resection, is the first-choice technique. Depending on the circumstances, clips and injections may also be used. 为了提高胃癌ESD和EMR的安全性，操作过程中出血的适当管理极为重要。特别是对于进行ESD的病例，使用止血钳电凝出血血管（不会对后续的切除造成干扰）是首选技术。根据具体情况，也可能会使用到钛夹和注射剂。 Prevention of postoperative bleeding 预防术后出血 Appropriate preventive measures should be applied to visible remnant vessels on the post-resection ulcer surface (evidence level C, grade of recommendation 1). 应对切除术后溃疡表面上的残留血管采取适当的预防措施（证据水平C，推荐等级1）。 Administration of a gastric acid secretion inhibitor following ESD or EMR (evidence level B, grade of recommendation 1) is required. ESD或EMR后需要给予胃酸分泌抑制剂（证据水平B，推荐等级1）。 Second-look endoscopy following ESD or EMR is not necessary (evidence level B, grade of recommendation 1). ESD或EMR后无需再次进行内镜检查（证据水平B，推荐等级1）。 Management of perforation 穿孔的管理 When perforation occurs during ESD or EMR, endoscopic closure should first be considered (evidence level B, grade of recommendation 1). 当发生ESD或EMR术中穿孔，应首先尝试内镜下闭合（证据等级B，建议等级1）。 LONG-TERM POSTOPERATIVE SURVEILLANCE 术后长期监测 Post-treatment follow-up 治疗后随访 Even when histological examination indicates endoscopic curability A (eCuraA), esophagogastroduodenoscopy should be performed with the primary aim of detecting metachronous gastric cancers (evidence level B, grade of recommendation 1). 即使组织学检查显示内镜可治愈性为A级（eCuraA），也应进行食管胃十二指肠镜检查，其主要目的是为了发现异时性胃癌（证据水平B，推荐等级1）。 When histological examination indicates resection of endoscopic curability B (eCuraB), follow-up with esophagogastroduodenoscopy, as well as ultrasonography or computed tomography (CT) scanning for the detection of metastases, is desirable. (evidence level C, grade of recommendation 2) 当组织学检查结果显示内镜可治愈性为B级（eCuraB）时，为了检测是否存在转移，随访时最好进行食管胃十二指肠镜检查，以及超声检查或计算机断层扫描（CT）（证据水平C，推荐等级2）。 When histological examination indicates resection of endoscopic curability C-1 (eCuraC-1) not requiring additional surgery, and observation without further treatment is selected for further management, careful follow-up with esophagogastroduodenoscopy should be performed (evidence level C, grade of recommendation 2). 当组织学检查显示内镜可治愈性为C-1级（eCuraC-1）又不需要额外进行外科手术，且选择的后续管理是随访观察而非进一步治疗时，应使用食管胃十二指肠镜检查进行仔细随访（证据水平C，推荐等级2）。 Helicobacter pylori (H. pylori) eradication 幽门螺杆菌（H. pylori）根除治疗 Eradication therapy is recommended in H. pylori-positive patients (evidence level A, grade of recommendation 2). 建议对幽门螺杆菌阳性患者进行根除治疗（证据水平A，推荐等级2）。 HISTOLOGY 组织学检查 Processing of resected specimens and recording of histological findings are in accordance with the Japanese classification of gastric carcinoma (3rd English edition). (grade of recommendation 1) 应根据日本胃癌分类（英文版第三版），处理切除标本并记录组织学检查结果。（推荐等级1） Processing of resected specimens 切除标本的处理 Stretching and attaching the fresh specimen onto a plate 将新鲜组织标本展开并固定在平板上 The fresh specimen should be stretched and fixed on a plate (foam polystyrene, rubber plate, or corkboard) with the mucosal surface facing upward, using mounting pins, to obtain the tumor size consistent with endoscopic observation (Fig. 5). 应使用固定针将新鲜标本展开并固定在平板（泡沫聚苯乙烯、橡胶板或软木板）上，黏膜表面朝上，以与内镜下观察到的肿瘤大小一致（图5）。
图5. 铺平展开切除标本。使用固定针，在平板上充分铺开新鲜切除的标本，并迅速固定到平板上，黏膜表面朝上。 Fixation in formalin 使用福尔马林进行固定 The region where the fresh specimen is attached should be promptly immersed in a 10% neutral buffered formalin solution for fixation at room temperature for about 24-48 h. The formalin solution should be renewed for each specimen. 应立即将附着新鲜标本的部分浸入到10%中性缓冲福尔马林溶液中，在室温下固定的时间约为24-48h。每份标本的福尔马林溶液都应进行更新。 Sectioning of the fixed specimen 对固定的标本进行切片 The first incision is made to allow histopathological examination of the part of the lesion with the minimum distance between the margin of the lesion and the lateral edge of the specimen. Further incisions are then made parallel to the first incision at intervals of 2.0–3.0 mm (grade of recommendation 1) (Fig. 6a,b). 为了对病变进行组织病理学检查，进行标本切片，第一个切片部位应选择病变边缘与标本外侧边缘最近的部位。随后的切片按照间隔2.0-3.0 mm的要求与第一个切片平行切割。（推荐等级1）（图6a和b）。
图6. 固定标本的切片和肿瘤扩散的重建（示例）。（a）想象一条与病变边缘相切的线（图中的虚线），接近于标本的水平切缘，并垂直于该虚线制作第一个切片。（b）以2.0-3.0 mm的间隔制作其他切片，与第一个切片平行切割。应为带有切线的固定标本拍摄肉眼下图像，并在标本附近放置一个刻度标记。对每个切片进行编号。（c）在固定标本（带有切线）的宏观图像中记录混合、未分化的成分以及肿瘤的浸润范围和深度（重建或绘制）。通过重建的图像测量最大直径。图中箭头表示切片的切开方向。切片1的切开方向与切片2-8的方向相反。 Photography 拍照 For reconstructing (mapping) the extent and depth of invasion of the tumor and the portions comprising mixed undifferentiated components, it is desirable to take macroscopic photographs of the fixed specimen along with the incisions (grade of recommendation 2) (Fig. 5c). 为了重建（绘制）肿瘤以及包含未分化成分部分的浸润范围和深度，最好拍摄固定标本和多个切片的肉眼下图像（推荐等级2）（图5c）。 Recording of histopathological findings 组织病理学检查结果记录 The items to be recorded in the histopathological report include tumor site, macroscopic type, size, histological type, distribution of undifferentiated-type carcinoma, depth of invasion, presence/absence of ulceration within the lesion, presence/absence of vascular infiltration, and evaluation of resection margins. 组织病理学检查报告中需记录的项目包括肿瘤部位、肉眼评估的类型、大小、组织学类型、未分化型癌的分布、浸润深度、病灶内有无溃疡、有无血管浸润以及切缘评估等。 When multiple histopathological types coexist in the tumor lesion, each histopathological type should be recorded, in descending order of relative surface area within the lesion (e.g., tub1 > pap > por) (grade of recommendation 1). 当肿瘤病变中同时存在多种组织病理学类型时，每一种组织病理学类型都应该记录，应用降序的方式表示所占面积（如tub1 > pap > por）（推荐等级1）。 In cases where a differentiated-type carcinoma coexists with an undifferentiated-type carcinoma within the respective demarcated area, the extent of the undifferentiated-type carcinoma should also be reconstructed to measure and record the long diameter of the area (Fig. 2a). If undifferentiated-type carcinoma is present in several areas in the tumor lesion, the long diameter of each area should be measured and the sum of the values should be recorded (Fig. 2b). However, if the area of the undifferentiated-type carcinoma is too small to allow measurement of its long diameter on the reconstructed figure, this should be specified accordingly. Differentiated and undifferentiated-type carcinomas may either be mixed to varying degrees, or differentiated-type carcinoma may be predominant in the surface layer with the deep layer being composed of undifferentiated-type carcinoma. In such cases, the entire area in question is considered to be an undifferentiated-type carcinoma, and its long diameter is measured and recorded. 如果分化型癌与未分化型癌在各自的分界区域内同时存在，则为了测量和记录未分化型癌区域的最大直径，也应重建未分化型癌的范围（图2a）。如果肿瘤病变的多个区域都存在未分化型癌，应测量每个区域的最大直径并记录数值总和（图2b）。然而，如果未分化型癌区域的面积太小，在重建图上无法测量其最大直径，则应视具体情况而定。分化型癌和未分化型癌可能会以不同的比例混合生长，或者是表层以分化型癌为主，深层则由未分化型癌组成。在这种情况下，则将有疑问的整个区域视为未分化型癌，并测量和记录该区域的直径。 Assessment of the depth of invasion 浸润深度评估 The depth of invasion is assessed as the deepest layer that the cancer has infiltrated and recorded by T classification. 按癌症浸润的最深层评估浸润深度，并通过T分期进行记录。 Assessment of ulceration or ulcer scar within the lesion 病变内溃疡或溃疡瘢痕的评估 This is an essential factor for evaluation of curability. If ulceration or ulcer scar is found within the lesion, the lesion is classified as pUL1, whereas it is classified as pUL0 when there is no ulceration or ulcer scar. 这是评估可治愈性的一个关键因素。如果发现病变内存在溃疡或溃疡瘢痕，则将该病变归类为pUL1，而当无溃疡或溃疡瘢痕时，则将其归类为pUL0。 Assessment of vascular infiltration 血管浸润评估 Assessment of vascular infiltration should be carried out using specific staining strategies (grade of recommendation 2). Immunohistochemical staining with anti-lymphatic endothelial antibodies (D2-40) is useful for identifying lymphatic vessels, whereas elastic fiber stains (Elastica van Gieson or Victoria blue/ hematoxylin-eosin) are effective for identifying veins. 应使用特定的染色策略评估血管浸润（推荐等级2）。抗淋巴管内皮细胞抗体（D2-40）的免疫组织化学染色可用于识别淋巴管，而弹性纤维染色（Elastica van Gieson或Victoria blue/苏木精-伊红）可有效识别静脉。 Evaluation of resection margins 切缘评估 Surgical margins are classified as HM and vertical margins (VM). If tumor tissue is present in these resection margins, positive HM and VM are expressed as pHM1 and pVM1, respectively. If no tumor tissue is present, they are expressed as pHM0 and pVM0, respectively. 手术切缘分为水平切缘（HM）和垂直切缘（VM）。如果这些切缘中存在肿瘤组织，HM和VM阳性分别表达为pHM1和pVM1。如果不存在肿瘤组织，则分别表示为pHM0和pVM0。 If the exposure of tumor tissue in resection margins cannot be evaluated, they are expressed as pHMX and pVMX, respectively. 如果无法评估切缘中是否存在肿瘤组织，则分别表示为pHMX和pVMX。 ###本文翻译来自柳叶新潮，仅供学习交流，不作为临床操作标准。具体问题仍应以原文为主。翻译水平有限，如有问题，欢迎批评指正，共同进步！ Reference: Ono H, Yao K, Fujishiro M, Oda I, Uedo N, Nimura S, Yahagi N, Iishi H, Oka M, Ajioka Y, Fujimoto K. Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition). Dig Endosc. 2021 Jan;33(1):4-20. doi: 10.1111/den.13883. Epub 2020 Dec 9. PMID: 33107115. 声明： 本文翻译为来自柳叶新潮团队编辑整理，仅供学习交流 |
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来自： 将臣gfl0l09u7e > 《待分类》
Figure 1 Classification of indications according to tumor-related factors. cT1a (M), intramucosal cancer (preoperative diagnosis), cT1b (SM), submucosally invasive cancer (preoperative diagnosis). UL, finding of ulceration (or ulcer scar); UL0, absence of ulceration or ulcer scar; UL1, presence of ulceration or ulcer scar.
Figure 2 Measurement of the size of the coexisting undifferentiated-type carcinoma. (a) Reconstruct the area of the undifferentiated-type carcinoma, and measure the long diameter of that area. (b) If undifferentiated-type carcinoma is present in more than one area, measure the long diameters (x, y, z) of all these areas and record the sum of these values.
Figure 3 Evaluation of curability according to tumor-related factors. *, Confined to en bloc resection and HM0, VM0, Ly0, and V0. pT1a (M), intramucosal cancer (histopathological diagnosis); pT1b (SM), submucosally invasive cancer (histopathological diagnosis). UL, finding of ulceration (or ulcer scar); UL0, absence of ulceration or ulcer scar; UL1, presence of ulceration or ulcer scar.
Figure 4 Therapeutic flowchart following endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR).
Figure 5 Stretching of the resected specimen. Using mounting pins, the fresh resected specimen should be stretched adequately on a plate, and attached promptly onto the plate with the mucosal surface facing upward.
Figure 6 Sectioning of the fixed specimen and reconstruction of the tumor spread (example). (a) Imagine a line tangential to the margin of the lesion where it is closest to the horizontal margin of the specimen (broken line in the figure), and make the first incision perpendicular to this tangential line. (b) Make additional incisions parallel to the first at intervals of 2.0–3.0 mm. Take macroscopic photographs of the fixed specimen with the incisions, with a scale placed adjacent to the specimen. Number each section. (c) Document the mixed, undifferentiated components as well as the extent and depth of invasion of the tumor in the macroscopic photograph of the fixed specimen, including the incisions (reconstructing or mapping). Measure the long diameter using the reconstructed figure. The arrows in the figure show the directions of sectioning. Section 1 is sliced in the direction opposite to those in sections 2–8.
