本研究由龙岩市科技计划项目资助（批准号2020LYF17029）。

本研究中描述的方案已由福建医科大学龙岩第一附属医院伦理委员会根据《赫尔辛基宣言》确立的伦理准则进行审查和批准。人类参与者的安全和福祉是我们最关心的问题，所有程序都旨在将潜在的风险和不适降至最低。所有收集的数据将被保密处理，并仅用于本研究的目的。受试者可以随时自由退出研究，他们参与或退出的决定不会影响他们与研究人员或机构的关系。
1. 一般信息
<ol><li>选择诊断为胃 LGIN 的患者。本回顾性分析纳入2020年11月至2022年6月在龙岩第一医院、邢台第三医院、甘肃省肿瘤医院经组织病理学检查诊断为胃LGIN并接受ESD治疗的120例患者。</li>
</ol>2. 纳入和排除标准
<ol><li>纳入标准<ol><li>包括通过组织病理学检查诊断为胃 LGIN 并在诊断后 3 个月内接受 ESD 治疗的患者。</li>
		<li>确保所有活检和手术标本均根据世界卫生组织（WHO）消化系统肿瘤病理诊断标准7进行诊断，并在手术前后由两名病理学家审查所有病理切片。</li>
		<li>完整的临床数据。</li>
	</ol></li>
	<li>排除标准<ol><li>排除最近接受过抗生素、质子泵抑制剂 （PPI）、铋制剂和抑酸剂治疗 幽门螺 杆菌 （HP） 感染的患者。</li>
		<li>排除通过组织病理学检查诊断为胃高级别上皮内瘤变 （HGIN）、胃癌或其他转移性肿瘤的患者。</li>
		<li>排除接受手术的患者。</li>
		<li>排除接受放疗或化疗的患者。</li>
		<li>排除临床数据不完整的患者。</li>
	</ol></li>
</ol>3. 研究方法
<ol><li>内窥镜检查和手术<ol><li>让所有通过组织病理学检查诊断为胃 LGIN 的患者接受常规白光内窥镜检查 （WLE）。<ol><li>在进行内窥镜检查之前，请确保患者进行一些准备工作，包括禁食 6 小时以上。 注意：检查通常涉及喉咙局部麻醉，以尽量减少不适。</li>
			<li>将内窥镜插入患者的口腔，并逐渐通过食道将其推进到胃中。在WLE下观察消化道内部，包括粘膜中血管的颜色、形状、质地和分布，寻找可能的病变。</li>
			<li>根据观察结果采集组织样本或进行其他治疗操作。检查完成后，逐渐撤出内窥镜并结束检查。</li>
		</ol></li>
		<li>使用ME-NBI技术观察胃黏膜表面的微观结构，以进一步确定病变的程度。 注意：ME-NBI是一种形成模式，在WLE模式下观察近似粘膜后，通过内窥镜上的按钮进行切换。它可以观察传统内窥镜检查无法观察到的微血管 （MV） 和微观结构 （MS）。<ol><li>在 WLE 中发现可疑病灶后，从远处到近处，从正常到病灶中心放大。</li>
			<li>通过ME-NBI检查，判断是否存在分界线（DL）、MV和MS各向异性、病灶表面的一些特殊征象，更好地观察胃肠道黏膜表面的微观结构，进而判断病灶的性质，可能是病灶。</li>
		</ol></li>
		<li>接下来，用一次性粘膜切刀在患者病变边界外 3-5 毫米处做一个电凝标记，标记点之间的距离约为 2 毫米。</li>
		<li>通过特殊的内窥镜注射针将制备的注射液（250mL生理盐水+3mg肾上腺素+2mL靛蓝）注射到粘膜下层。 注意：生理盐水主要用于保持粘膜下层湿润，并将粘膜层与肌肉层分开。肾上腺素收缩血管，减少出血。靛蓝胭脂红是一种染料，可帮助医生更好地可视化粘膜下层血管的分布。分配的成分包括 250 mL 生理盐水 + 3 mg 肾上腺素 + 2 mL 靛蓝胭脂。</li>
		<li>病灶完全抬高后，用一次性粘膜切刀在距病灶标记点约 3 mm 处做一个环形切口，然后进行黏膜下夹层，直到病灶完全切除。</li>
		<li>解剖后，仔细观察伤口并使用电凝钳进行电凝。如有必要，使用金属止血夹夹住伤口。</li>
	</ol></li>
	<li>病理检查<ol><li>完全切除后，使用抽吸或圈套取出组织样本。<ol><li>固定并保存取出的组织样本，并在口腔和肛门两侧标记以进行病理检查和诊断。将样品在20-25°C下用10%福尔马林固定24-48小时。 注：病理描述包括病变的一般形态、体积和大小、边缘、组织学分类、浸润深度和胃粘膜病变的信息。</li>
		</ol></li>
	</ol></li>
	<li>HP检测方法<ol><li>使用快速脲酶试验或 13C 呼气试验。<ol><li>在快速脲酶试验中，在内窥镜检查下用活检钳取患者胃壁样本，并将其放入含有脲酶的试剂中。</li>
			<li>检查胃壁中是否存在 幽门螺杆 菌。脲酶分解尿素产生氨，使试剂呈碱性并变红。观察试剂颜色的变化并确定是否存在 幽门螺杆 菌感染。 注意：13C 呼气测试是一种非侵入性、无痛且无副作用的测试，通过口服含有 13C 标记尿素的尿素并使用同位素比质谱仪检测患者呼出的呼吸中 13C 标记的二氧化碳的含量。如果胃中存在 幽门 螺杆菌，细菌会分解13C标记的尿素产生13C标记的二氧化碳，通过测量呼出气体中13C标记的二氧化碳的量，可以确定是否存在 幽门螺 杆菌感染。需要注意的是，在进行快速脲酶试验或 13C 呼气试验之前，患者必须停止质子泵抑制剂 （PPI） 至少 2 周，并停止抗菌药物、铋和某些具有抗菌特性的草药至少 4 周。这些药物会影响检测结果的准确性。在13C呼气试验期间，患者还必须禁食或避免进食至少2小时，以避免食物对检测结果的影响。</li>
		</ol></li>
	</ol></li>
	<li>数据收集和分组<ol><li>汇总患者的一般临床资料，包括性别、年龄、 幽门螺杆菌 （HP）感染、病灶大小、病灶位置、形态、胃黏膜充血、结节状态、表面溃疡和糜烂、ME观察。</li>
		<li>根据所进行的评估，根据ESD后病理诊断是否升级，将研究中的所有患者分为升级组和非升级组。 注：升级组术后病理诊断为胃HGIN、早期胃癌（EGC）或晚期胃癌，而未升级组术后病理诊断为胃LGIN或炎症。</li>
	</ol></li>
</ol>4. 统计方法
<ol><li>使用统计软件来组织和分析所有数据。以频率（百分比）统计方式分析分类数据，并使用卡方检验或费舍尔精确检验进行比较。 注：本研究使用了 SPSS 软件。</li>
	<li>采用逻辑回归分析来识别诊断为胃 LGIN 的患者与 ESD 后病理升级相关的危险因素。小于 0.05 的 P 值表示存在统计显著差异。</li>
</ol>

胃低级别上皮内瘤变风险预测模型

<ol>
	<li>Bray, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Global+cancer+statistics+2018:+Globocan+estimates+of+incidence+and+mortality+worldwide+for+36+cancers+in+185+countries.">Global cancer statistics 2018: Globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries.</a> CA Cancer J Clin. 68 (6), 394-424 (2018).</li><li>Migita, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rnf126+as+a+marker+of+prognosis+and+proliferation+of+gastric+cancer.">Rnf126 as a marker of prognosis and proliferation of gastric cancer.</a> Anticancer Res. 40 (3), 1367-1374 (2020).</li><li>Zhang, H., Yang, X., Zhang, X., Huang, X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+significance+of+endoscopic+kyoto+classification+of+gastritis+in+the+gastric+cancer+risk+assessment:+A+systematic+review+and+meta-analysis.">The significance of endoscopic kyoto classification of gastritis in the gastric cancer risk assessment: A systematic review and meta-analysis.</a> Medicine. 102 (22), e33942 (2023).</li><li>Cheng, H. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evolution+of+the+correa's+cascade+steps:+A+long-term+endoscopic+surveillance+among+non-ulcer+dyspepsia+and+gastric+ulcer+after+H.+pylori+eradication.">Evolution of the correa's cascade steps: A long-term endoscopic surveillance among non-ulcer dyspepsia and gastric ulcer after H. pylori eradication.</a> J Formos Med Assoc. 122 (5), 400-410 (2023).</li><li>Kim, B., Cho, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+screening+and+surveillance+for+gastric+cancer.">Endoscopic screening and surveillance for gastric cancer.</a> Gastrointest Endosc Clin N Am. 31 (3), 489-501 (2021).</li><li>Choi, C. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+risk+factors+for+discrepancy+after+endoscopic+submucosal+dissection+of+gastric+category+3+lesion+(low+grade+dysplasia).">The risk factors for discrepancy after endoscopic submucosal dissection of gastric category 3 lesion (low grade dysplasia).</a> Dig Dis Sci. 59 (2), 421-427 (2014).</li><li>Nagtegaal, I. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+2019+who+classification+of+tumours+of+the+digestive+system.">The 2019 who classification of tumours of the digestive system.</a> Histopathology. 76 (2), 182-188 (2020).</li><li>Zou, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+characteristics+in+predicting+prognosis+of+biopsy-diagnosed+gastric+low-grade+intraepithelial+neoplasia.">Endoscopic characteristics in predicting prognosis of biopsy-diagnosed gastric low-grade intraepithelial neoplasia.</a> Chin Med J (Engl). 135 (1), 26-35 (2022).</li><li>Ryu, D. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+outcomes+of+endoscopic+submucosa+dissection+for+high-grade+dysplasia+from+endoscopic+forceps+biopsy.">Clinical outcomes of endoscopic submucosa dissection for high-grade dysplasia from endoscopic forceps biopsy.</a> Gastric Cancer. 20 (4), 671-678 (2017).</li><li>Xu, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+factors+for+under-diagnosis+of+gastric+intraepithelial+neoplasia+and+early+gastric+carcinoma+in+endoscopic+forceps+biopsy+in+comparison+with+endoscopic+submucosal+dissection+in+Chinese+patients.">Risk factors for under-diagnosis of gastric intraepithelial neoplasia and early gastric carcinoma in endoscopic forceps biopsy in comparison with endoscopic submucosal dissection in Chinese patients.</a> Surg Endosc. 30 (7), 2716-2722 (2016).</li><li>Kim, M. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+lesion+size+an+independent+indication+for+endoscopic+resection+of+biopsy-proven+low-grade+gastric+dysplasia.">Is lesion size an independent indication for endoscopic resection of biopsy-proven low-grade gastric dysplasia.</a> Dig Dis Sci. 59 (2), 428-435 (2014).</li><li>Zhao, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+commonly+is+the+diagnosis+of+gastric+low+grade+dysplasia+upgraded+following+endoscopic+resection?+A+meta-analysis.">How commonly is the diagnosis of gastric low grade dysplasia upgraded following endoscopic resection? A meta-analysis.</a> PLoS One. 10 (7), e0132699 (2015).</li></ol>

作者声明他们没有利益冲突。

胃LGIN是一种常见的胃肠道疾病，随着患者人数的不断增加，该病的预防和治疗变得越来越重要。建立风险预测模型对于指导临床治疗和预防疾病发生至关重要8.胃LGIN的病理升级是指LGIN性质在一定时期内恶化，这可能导致LGIN转化为HGIN甚至更严重的情况。在临床实践中，病理升级的预测已成为医务人员关注的焦点。目前，已经研究了一些基于临床表现、影像学表现和生物标志物的预测模型，但这些模型存在指标复杂、长期消耗的缺点。因此，有必要开发一个简单有效的预测模型。根据目前国内共识建议，应积极采用ESD治疗具有病理升级高危因素的胃LGIN患者。然而，越来越多的研究表明，胃 LGIN 患者的活检病理结果与术后病理结果之间存在显着差异9。 
研究显示，在观察的120例胃LGIN患者中，有49例在术后进行了病理升级，病理升级率为40.83%。与其他相关研究相比，这一比率相对较高。这些发现的可能原因包括低估了病理活检的结果。内窥镜医师资格的差异可能导致患者病情和活检部位评估的差异，导致表面或不充分的取样和部位偏差。结果的准确性也可能受到病理学家的认知能力和知识的影响。此外，活检的准确性可能会受到不同内窥镜技术的影响。例如，应用高清胃镜观察病变的微血管和微观结构形态，确定靶向活检最显眼的部位，可以大大提高活检的精确度。
本研究表明，胃LGIN患者年龄越大，术后病理升级的风险越高，这与国内其他研究结果相似10。因此，对于60岁以上的胃LGIN患者，应进行密切随访，如果患者有更多危险因素，建议及时手术。关于病灶大小，本研究表明，病灶大小≥2 cm是病理升级的独立危险因素，与其他研究结果基本一致11。胃LGIN患者手术治疗后可能影响病理升级发生的病灶大小临界值仍存在争议，需要临床研究寻找最合适的临界值。应使用大样本量方法进行进一步研究。结果显示，黏膜表面充血、溃疡、糜烂是胃LGIN患者术后病理升级的独立危险因素，与相关研究相似12。病变表面溃疡和糜烂更容易引起手术后病理升级，这可能是因为胃黏膜反复损伤会促进异型增生和肠上皮化生，从而增加胃癌的风险。 
然而，这项研究遇到了一定的局限性。首先，作为一项回顾性研究，无法完全控制偏倚和其他混杂因素。今后应开展前瞻性研究，以验证结论，增强客观性和推理能力。其次，由于样本数量有限，无法将样本分离到验证集中，以便对模型进行外部验证。因此，必须从多个中心收集额外的患者数据，以增加样本数量并扩大观察到的变量范围。这将提高模型的预测效果和结果的可信度。此外，进行外部验证将增强模型的可靠性。 
综上所述，本研究通过分析接受手术的胃LGIN患者病理升级的独立危险因素而生成的风险预测模型具有显著的预测价值，可为临床环境中的LGIN治疗提供有益的指导。

胃癌是最常见的恶性肿瘤之一，尤其是在东亚地区，发病率和死亡率都很高。它是中国最常见的癌症之一，新诊断和死亡约占全球总数的一半 1.它是中国人群发病和死亡的主要原因2.胃癌在肿瘤中死亡率最高，居世界第三位，其预后高度依赖于病变的分期1。晚期患者的 5 年生存率低于 30%，而早期患者的 5 年生存率通常在 90% 以上。因此，胃癌的早期诊断和治疗对于预防和控制疾病至关重要3. 
Correa级联反应被广泛认为是胃癌发展的主要模式之一，表明胃癌的致癌过程逐渐从萎缩性胃炎发展为肠上皮化生、上皮内瘤变，最后发展为腺癌4。随着现代技术的应用和胃镜检查的日益普及，越来越多的胃黏膜癌前病变被检测到，包括放大内窥镜 （ME）、染色内窥镜和窄带成像 （NBI）5。 
低级别上皮内瘤变（LGIN）是胃癌的癌前病变之一，与胃癌密切相关。然而，与活检结果相比，一些低级别上皮内瘤变患者在内镜黏膜下夹层 （ESD） 后表现出病理升级6。因此，在临床实践中，对于活检证实的LGIN患者的随访或治疗选择存在一些争议。本文探讨了胃LGIN患者ESD治疗后病理升级的危险因素，建立并评价了LGIN发生的风险预测模型，为胃LGIN患者的临床管理提供了更科学、更有价值的参考意见。

<table><tbody><tr><td>Disposable mucosal incision knife</td><td>Olympus (Japan)</td><td>KD-650Q</td><td></td></tr><tr><td>Endoscopic image processing device</td><td>Olympus (Japan)</td><td>CV-290</td><td></td></tr><tr><td>Hemostasis Clips</td><td>MICRO-TECH(Nanjing)</td><td>ROCC-D-26-195</td><td></td></tr><tr><td>High-frequency hemostatic forceps</td><td>Olympus (Japan)</td><td>FD-410LR</td><td></td></tr><tr><td>Indicarminum</td><td>MICRO-TECH(Nanjing)</td><td>MTN-DYZ-15</td><td></td></tr><tr><td>Injection Needles</td><td>MICRO-TECH(Nanjing)&amp;nbsp;</td><td>IN02-25423230</td><td></td></tr><tr><td>Magnifying gastroscope</td><td>Olympus (Japan)</td><td>GIF-H290Z</td><td></td></tr><tr><td>Orthodontic rubber band</td><td>3M Unitek Corporation</td><td></td><td>6.4 mm 3.5 oz</td></tr><tr><td>Therapeutic gastroscopy</td><td>Olympus (Japan)</td><td>GIF-2TQ260M</td><td></td></tr><tr><td>Transparent cap</td><td>Olympus (Japan)</td><td>D-201-11804</td><td></td></tr></tbody></table>

establishment and evaluation of a risk prediction model for pathological escalation of gastric low-grade intraepithelial neoplasia

本研究旨在探讨胃低级别上皮内皮瘤变（LGIN）内镜手术后病理升级的危险因素，并建立和评估LGIN的风险预测模型。回顾性分析了 2020 年 11 月至 2022 年 6 月期间通过活检和内窥镜粘膜下剥离术 （ESD） 诊断为胃 LGIN 的 120 例患者。收集所有患者的性别、 年龄、 HP感染、病灶大小、病灶位置、形态、胃黏膜充血、结节状态、表面溃疡和糜烂、ME观察，根据活检和ESD术后病理诊断结果分为升级组和非升级组。采用logistic回归分析筛选ESD手术治疗后病理升级的独立危险因素，建立风险预测模型。120例胃LGIN患者中，49例出现术后病理升级;病理升级率为40.83%。其中，42例患者升级为高级别上皮内瘤变（HGIN），1例升级为晚期胃癌，6例升级为早期胃癌（EGC）。单因素分析显示，两组患者年龄、病灶大小、胃黏膜充血、表面溃疡、糜烂等差异有统计学意义（p < 0.05）。多因素Logistic回归分析显示，年龄≥60岁、焦距≥2 cm、胃黏膜淤血、表面溃疡和糜烂是胃LGIN患者术后病理恶化的独立危险因素。P = 1/[1 + e（26.515-0.161 x β1-0.357 x β2+0.039 x β3-0.269 x β4）] 的最终联合概率预测模型。年龄、病灶大小≥2 cm、胃黏膜充血、病灶表面溃疡和糜烂是胃LGIN患者术后病理升级的危险因素。本研究建立的基于危险因素的风险预测模型具有预测价值，可为胃LGIN患者的临床治疗提供科学参考。

ESD后胃LGIN患者病理升级的发生率 本研究共纳入120例胃LGIN患者，其中49例（40.83%）在ESD后出现病理升级。其中，42例升级为HGIN，1例升级为晚期胃癌，6例升级为EGC。共有71例未经历病理升级，其中2例降级为炎症，69例仍为LGIN，病理降级率为1.67%。
胃LGIN患者ESD后病理升级的单因素分析 如 表1所示，胃LGIN患者术后病理升级组与非升级组在性别、HP感染、病灶位置、表面结节、ME层分界线（DL）、病灶形态、微观结构（MS）和微血管形态方面差异无统计学意义（p > 0.05）。然而，在年龄、病灶大小、胃黏膜充血以及表面溃疡和糜烂方面存在统计学差异（p < 0.05）。
胃LGIN患者ESD后病理升级的多因素logistic回归分析 单因素分析筛选出p<0.05的因素，包括年龄、病灶大小、胃黏膜充血、表面溃疡和糜烂等因素，作为自变量，胃LGIN患者ESD后病理升级作为logistic回归分析的因变量（表2）。 表3 显示，年龄≥60岁、病灶直径≥2 cm、胃黏膜充血、表面溃疡和糜烂是胃LGIN患者ESD后病理升级的独立危险因素。基于逻辑回归的预测公式，最终的联合概率预测模型为 P = 1 / [1 + e（26.515-0.161xβ1-0.357xβ2+0.039xβ3-0.269xβ4）]：P（y = 1/x） = 1/（1+e-（β0+β1x1+β2x2+β3x3+β4x4）），其中 y 表示二分因变量，x 表示自变量向量，β 表示回归系数，e 表示自然对数的底数。此外，技术术语缩写将在首次使用时定义。该公式表明，给定自变量 x，事件发生 y = 1 的概率为 P（y = 1/x）。当 β0 + β1 x 1 + β2 x 2 + β3 x 3 + β4 x 4 的总和增加时，P（y = 1/x） 的值也增加，表明事件发生 y = 1 的概率更高;相反，事件发生 y = 1 的概率较低。其中，β1为年龄回归系数，β2为病灶大小回归系数，β3为胃黏膜淤血回归系数，β4为表面溃疡糜烂回归系数。
案例介绍 代表性病例为一名50岁女性患者，体格检查时出现黏膜粗糙、胃角糜烂。内镜活检证实低级别上皮内瘤变 （LGIN）。使用放大内窥镜检查、窄带成像 （NBI） 和色素内窥镜检查的进一步研究表明，患者有发生高级别上皮内瘤变 （HGIN） 的风险。建议患者接受内镜黏膜下剥离（ESD）治疗，最终病理诊断为HGIN（ 如图1所示）。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65868/65868fig01.jpg"> 图1：案例介绍。 （A、B） 术前，WLE 显示胃黏膜粗糙伴糜烂。（C，D）在ME + NBI观察到的病变中观察到不规则的MV和MS。（E）靛蓝染色可以看到病变的轮廓。（F）在内窥镜下标记病灶。（G） 粘膜下水注射后剥离。（八）伤口止血治疗。（一）将固定标本送去进行病理检查。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65868/65868fig01large.jpg" target="_blank">请点击这里查看此图的较大版本.</a>
表1：ESD后病理升级的单因素分析（%）。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65868/Table1.xlsx" target="_blank">请按此下载此表格。</a>
表2：ESD后病理升级的多变量logistic回归分析变量分配表。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65868/Table%202.xlsx" target="_blank">请按此下载此表格。</a>
表3：ESD后病理升级的多因素logistic回归分析。<a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65868/Table%203.xlsx" target="_blank">请按此下载此表格。</a>

Watch this Scientific Journal Video about Establishment and Evaluation of a Risk Prediction Model for Pathological Escalation of Gastric Low-Grade Intraepithelial Neoplasia at JoVE.com

作者聚焦：推进胃肠道肿瘤的早期检测和治疗

在这里，我们对既往内镜活检诊断为胃低级别上皮内瘤变的患者进行了系统评估，并通过内镜粘膜下剥离术 （ESD） 完全切除病灶获得病理诊断，分析可能增加病理升级风险的因素。

胃低级别上皮内瘤变病理升级风险预测模型的建立与评价

The study aims to explore the risk factors for pathological escalation after endoscopic surgery for gastric low-grade intraepithelial neoplasia (LGIN) and ...

我们的研究范围是早期胃肠道肿瘤的检测、诊断和治疗。我想回答的问题是如何预测胃核病理性升级为上皮核的风险，以便对患者进行诊断和首次治疗。消化内窥镜检查的最新发展涉及微创技术、改进成像方式、翻修活检和机器人辅助，这当然可以改善诊断和可怕的结果。未来，我们将重点研究如何提高早期胃癌的诊断率，包括通过人工智能和先进的内窥镜技术对早期胃癌的诊断设想。

establishment-evaluation-risk-prediction-model-for-pathological

Nanyang Technological University

Research

JoVE Journal

Cancer Research

Establishment and Evaluation of a Risk Prediction Model for Pathological Escalation of Gastric Low-Grade Intraepithelial Neoplasia

940 次观看.  Longyan First Affiliated Hospital of Fujian Medical University. 我们的研究范围是早期胃肠道肿瘤的检测、诊断和治疗。我想回答的问题是如何预测胃核病理性升级为上皮核的风险，以便对患者进行诊断和首次治疗。消化内窥镜检查的最新发展涉及微创技术、改进成像方式、翻修活检和机器人辅助，这当然可以改善诊断和可怕的结果。未来，我们将重点研究如何提高早期胃癌的诊断率，包括通过人工智能和先进的内窥镜技术对早期?...

视频: 作者聚焦：推进胃肠道肿瘤的早期检测和治疗

Important Endpoints and Proliferative Markers to Assess Small Intestinal Injury and Adaptation using a Mouse Model of Chemotherapy-Induced Mucositis

Intestinal adaptation is the natural compensatory mechanism that occurs when the bowel is lost due to trauma. The adaptive responses, such as crypt cell proliferation and increased nutrient absorption, are critical in recovery, yet poorly understood. Understanding the molecular mechanism behind the adaptive responses is crucial to facilitate the identification of nutrients or drugs to enhance adaptation. Different approaches and models have been described throughout the literature, but a detailed descriptive way to essentially perform the procedures is needed to obtain reproducible data. Here, we describe a method to estimate important endpoints and proliferative markers of small intestinal injury and compensatory hyperproliferation using a model of chemotherapy-induced mucositis in mice. We demonstrate the detection of proliferating cells using a cell cycle specific marker, as well as using small intestinal weight, crypt depth, and villus height as endpoints. Some of the critical steps within the described method are the removal and weighing of the small intestine and the rather complex software system suggested for the measurement of this technique. These methods have the advantages that they are not time-consuming, and that they are cost-effective and easy to carry out and measure.

Here, we present a protocol to establish important endpoints and proliferative markers of small intestinal injury and compensatory hyperproliferation using a model of chemotherapy-induced mucositis. We demonstrate the detection of proliferating cells using a cell cycle specific marker and using small intestinal weight, crypt depth, and villus height as endpoints.

使用小鼠化疗引起的粘炎模型评估小肠损伤和适应的重要端点和增殖标记

Intestinal adaptation is the natural compensatory mechanism that occurs when the bowel is lost due to trauma. The adaptive responses, such as crypt cell ...

科研

癌症研究

Diagnosis of Neoplasia in Barrett&#8217;s Esophagus using Vital-dye Enhanced Fluorescence Imaging

The ability to differentiate benign metaplasia in Barrett&#8217;s Esophagus (BE) from neoplasia in vivo remains difficult as both tissue types can be flat and indistinguishable with white light imaging alone. As a result, a modality that highlights glandular architecture would be useful to discriminate neoplasia from benign epithelium in the distal esophagus. VFI is a novel technique that uses an exogenous topical fluorescent contrast agent to delineate high grade dysplasia and cancer from benign epithelium. Specifically, the fluorescent images provide spatial resolution of 50 to 100 &#956;m&#160;and a field of view up to 2.5 cm,&#160;allowing endoscopists to visualize glandular morphology. Upon excitation, classic Barrett&#8217;s metaplasia appears as continuous, evenly-spaced glands and an overall homogenous morphology; in contrast, neoplastic tissue appears crowded with complete obliteration of the glandular framework. Here we provide an overview of the instrumentation and enumerate the protocol of this new technique. While VFI affords a gastroenterologist with the glandular architecture of suspicious tissue, cellular dysplasia cannot be resolved with this modality. As such, one cannot morphologically distinguish Barrett&#8217;s metaplasia from BE with Low-Grade Dysplasia via this imaging modality. By trading off a decrease in resolution with a greater field of view, this imaging system can be used at the very least as a red-flag imaging device to target and biopsy suspicious lesions; yet, if the accuracy measures are promising, VFI may become the standard imaging technique for the diagnosis of neoplasia (defined as either high grade dysplasia or cancer) in the distal esophagus.

Vital-dye enhanced fluorescence imaging (VFI) is a novel in vivo technique that combines high-resolution epithelial imaging with exogenous topical fluorescent contrast to highlight glandular morphology and delineate neoplasia (high grade dysplasia and cancer) in the distal esophagus.

用生命染增强荧光成像瘤在Barrett食管诊断

The ability to differentiate benign metaplasia in Barrett&#8217;s Esophagus (BE) from neoplasia in vivo remains difficult as both tissue types can be flat ...

生物工程

Establishing a Competing Risk Regression Nomogram Model for Survival Data

The Kaplan&#8211;Meier method and Cox proportional hazards regression model are the most common analyses in the survival framework. These are relatively easy to apply and interpret and can be depicted visually. However, when competing events (e.g., cardiovascular and cerebrovascular accidents, treatment-related deaths, traffic accidents) are present, the standard survival methods should be applied with caution, and real-world data cannot be correctly interpreted. It may be desirable to distinguish different kinds of events that may lead to the failure and treat them differently in the analysis. Here, the methods focus on using the competing regression model to identify significant prognostic factors or risk factors when competing events are present. Additionally, nomograms based on a proportional hazard regression model and a competing regression model are established to help clinicians make individual assessments and risk stratifications in order to explain the impact of controversial factors on prognosis.

Presented here is a protocol to build nomograms based on the Cox proportional hazards regression model and competing risk regression model. The competing method is a more rational method to apply when competing events are present in the survival analysis.

为生存数据建立竞争风险回归 Nomogram 模型

The Kaplan&#8211;Meier method and Cox proportional hazards regression model are the most common analyses in the survival framework. These are relatively ...

Genome-Wide Analysis of DNA Methylation in Gastrointestinal Cancer

DNA methylation is an important epigenetic change that is biologically meaningful and a frequent focus of cancer research. Genome-wide DNA methylation is a useful measure to provide an accurate analysis of the methylation status of gastrointestinal (GI) malignancies. Given the multiple potential translational uses of DNA methylation analysis, practicing clinicians and others new to DNA methylation studies need to be able to understand step by step how these genome-wide analyses are performed. The goal of this protocol is to provide a detailed description of how this method is used for the biomarker identification in GI malignancies. Importantly, we describe three critical steps that are needed to obtain accurate results during genome-wide analysis. Clearly and concisely written, these three methods are often lacking and not noticeable to those new to epigenetic studies. We used 48 samples of a GI malignancy (gastric cancer) to highlight practically how genome-wide DNA methylation analysis can be performed for GI malignancies.

Herein, we describe a procedure for genome-wide analysis of DNA methylation in gastrointestinal cancers. The procedure is of relevance to studies that investigate relationships between methylation patterns of genes and factors contributing to carcinogenesis in gastrointestinal cancers.

胃肠癌DNA甲基化基因组全谱分析

DNA methylation is an important epigenetic change that is biologically meaningful and a frequent focus of cancer research. Genome-wide DNA methylation is ...

Modeling Oral-Esophageal Squamous Cell Carcinoma in 3D Organoids

Esophageal squamous cell carcinoma (ESCC) is prevalent worldwide, accounting for 90% of all esophageal cancer cases each year, and is the deadliest of all human squamous cell carcinomas. Despite recent progress in defining the molecular changes accompanying ESCC initiation and development, patient prognosis remains poor. The functional annotation of these molecular changes is the necessary next step and requires models that both capture the molecular features of ESCC and can be readily and inexpensively manipulated for functional annotation. Mice treated with the tobacco smoke mimetic 4-nitroquinoline 1-oxide (4NQO) predictably form ESCC and esophageal preneoplasia. Of note, 4NQO lesions also arise in the oral cavity, most commonly in the tongue, as well as the forestomach, which all share the stratified squamous epithelium. However, these mice cannot be simply manipulated for functional hypothesis testing, as generating isogenic mouse models is time- and resource-intensive. Herein, we overcome this limitation by generating single cell-derived three-dimensional (3D) organoids from mice treated with 4NQO to characterize murine ESCC or preneoplastic cells ex vivo. These organoids capture the salient features of ESCC and esophageal preneoplasia, can be cheaply and quickly leveraged to form isogenic models, and can be utilized for syngeneic transplantation experiments. We demonstrate how to generate 3D organoids from normal, preneoplastic, and SCC murine esophageal tissue and maintain and cryopreserve these organoids. The applications of these versatile organoids are broad and include the utilization of genetically engineered mice and further characterization by flow cytometry or immunohistochemistry, the generation of isogeneic organoid lines using CRISPR technologies, and drug screening or syngeneic transplantation. We believe that the widespread adoption of the techniques demonstrated in this protocol will accelerate progress in this field to combat the severe burden of ESCC.

This protocol describes the key steps to generate and characterize murine oral-esophageal 3D organoids that represent normal, preneoplastic, and squamous cell carcinoma lesions induced via chemical carcinogenesis.

在 3D 类器官中模拟口腔-食管鳞状细胞癌

Esophageal squamous cell carcinoma (ESCC) is prevalent worldwide, accounting for 90% of all esophageal cancer cases each year, and is the deadliest of all ...

Nomogram Development for Survival Prediction in MPCC Patients

Competing-Risk Nomogram for Predicting Cancer-Specific Survival in Multiple Primary Colorectal Cancer Patients after Surgery

Cancer-specific survival (CSS) in multiple primary colorectal cancer (MPCC) patients is competitively affected by death from other causes. This study aimed to investigate CSS and associated risk factors by competing risk analysis in MPCC patients. The data of this study is from the SEER database. Using univariable and multivariable analysis of the competitive risk model to weaken the impact of competitive events, it explores the risk factors of CSS and develops a nomogram model. Then, the performance of the model is verified by the ROC curve, calibration curve, and DCA. The study encompasses a total of 8931 patients, with 6255 in the training cohort and 2676 in the validation cohort. Univariable and multivariable analyses showed that sex, Tumor Node Metastasis (TNM) stage, and tumor grade are independent risk factors for cancer-specific survival in MPCC patients. Based on the risk factors, we developed a diagram model to predict CSS. ROC curve, calibration curve, and DCA also show good results. In conclusion, a nomogram is developed that serves as a valuable tool for predicting CSS in MPCC patients, providing clinicians with crucial insights for personalized treatment planning.

The study found that male gender, poor tumor grade, and advanced Tumor Node Metastasis stage were associated with poorer cancer-specific survival (CSS) in multiple primary colorectal cancer (MPCC) patients after surgery. We developed a nomogram to predict the CSS of MPCC patients and contribute to clinical treatment decision-making.

Cancer-specific survival (CSS) in multiple primary colorectal cancer (MPCC) patients is competitively affected by death from other causes. This study ...

Surgical Models of Gastroesophageal Reflux with Mice

Multiple surgical procedures have been reported to induce gastroesophageal reflux in animals. Herein, we report three surgical models with mice aiming to induce reflux of gastric contents, duodenal contents or mixed contents. Surgical procedures and general principles have been described in detail. A researcher with surgical experience should be able to grasp the technique after a short period of practice. After surgery, most mice can survive and develop reflux esophagitis similar to that in humans. However, it should be noted that histological differences between mouse and human esophagus are the inherent limitations of these surgical models. If used for research on Barrett&#8217;s esophagus and adenocarcinoma, these procedures may need to be combined with genetic modifications.

This article demonstrates surgical procedures of gastroesophageal reflux with mice. These models are useful tools for research on mechanisms and treatment of gastroesophageal reflux disease and potentially Barrett&#8217;s esophagus and esophageal adenocarcinoma.

胃食管反流与小鼠手术模型

Multiple surgical procedures have been reported to induce gastroesophageal reflux in animals. Herein, we report three surgical models with mice aiming to ...

医学

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

胃镜检查术在腹腔镜手术的肿瘤定位于胃腺癌

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Gene Regulation and Targeted Therapy in Gastric Cancer Peritoneal Metastasis: Radiological Findings from Dual Energy CT and PET/CT

Gastric cancer remains fourth in cancer incidence worldwide with a five-year survival of only 20%-30%. Peritoneal metastasis is the most frequent type of metastasis that accompanies unresectable gastric cancer and is a definitive determinant of prognosis. Preventing and controlling the development of peritoneal metastasis could play a role in helping to prolong the survival of gastric cancer patients. A non-invasive and efficient imaging technique will help us to identify the invasion and metastasis process of peritoneal metastasis and to monitor the changes in tumor nodules in response to treatments. This will enable us to obtain an accurate description of the development process and molecular mechanisms of gastric cancer. We have recently described experiment using dual energy CT (DECT) and positron emission tomography/computed tomography (PET/CT) platforms for the detection and monitoring of gastric tumor metastasis in nude mice models. We have shown that weekly continuous monitoring with DECT and PET/CT can identify dynamic changes in peritoneal metastasis. The sFRP1-overexpression in gastric cancer mice models showed positive radiological performance, a higher FDG uptake and increasing enhancement, and the SUVmax (standardized uptake value) of nodules demonstrated an obvious alteration trend in response to targeted therapy of TGF-&#946;1 inhibitor. In this article, we described the detailed non-invasive imaging procedures to conduct more complex research on gastric cancer peritoneal metastasis using animal models and provided representative imaging results. The use of non-invasive imaging techniques should enable us to better understand the mechanisms of tumorigenesis, monitor tumor growth, and evaluate the effect of therapeutic interventions for gastric cancer.

This protocol describes the value of dual energy CT and PET/CT imaging methods in tumor imaging and efficacy evaluation. This article demonstrates the research methods and results acquired by dual energy CT and PET/CT to evaluate the gene regulation and targeted treatment of gastric cancer peritoneal metastasis.

胃癌腹膜转移的基因调控及靶向治疗: 双能量 ct 与 PET/ct 的影像学研究

Gastric cancer remains fourth in cancer incidence worldwide with a five-year survival of only 20%-30%. Peritoneal metastasis is the most frequent type of ...

A Preclinical Human-Derived Autologous Gastric Cancer Organoid/Immune Cell Co-Culture Model to Predict the Efficacy of Targeted Therapies

Tumors expressing programmed cell death-ligand 1 (PD-L1) interact with programmed cell death protein 1 (PD-1) on CD8+ cytotoxic T lymphocytes (CTLs) to evade immune surveillance leading to the inhibition of CTL proliferation, survival, and effector function, and subsequently cancer persistence. Approximately 40% of gastric cancers express PD-L1, yet the response rate to immunotherapy is only 30%. We present the use of human-derived autologous gastric cancer organoid/immune cell co-culture as a preclinical model that may predict the efficacy of targeted therapies to improve the outcome of cancer patients. Although cancer organoid co-cultures with immune cells have been reported, this co-culture approach uses tumor antigen to pulse the antigen-presenting dendritic cells. Dendritic cells (DCs) are then cultured with the patient's CD8+ T cells to expand the cytolytic activity and proliferation of these T lymphocytes before co-culture. In addition, the differentiation and immunosuppressive function of myeloid-derived suppressor cells (MDSCs) in culture are investigated within this co-culture system. This organoid approach may be of broad interest and appropriate to predict the efficacy of therapy and patient outcome in other cancers, including pancreatic cancer.

The goals of the protocol are to use this approach to 1) understand the role of the immunosuppressive gastric tumor microenvironment and 2) predict the efficacy of patient response, thus increasing the survival rate of patients.

Tumors expressing programmed cell death-ligand 1 (PD-L1) interact with programmed cell death protein 1 (PD-1) on CD8+ cytotoxic T lymphocytes (CTLs) to ...