早期结直肠癌及癌前病变内镜黏膜下剥离术(ESD)后病理升级的研究进展

Research Progress on Pathological Upstaging after Endoscopic Submucosal Dissection (ESD) for Early Colorectal Cancer and Precancerous Lesions

摘要: 内镜黏膜下剥离术(ESD)是一种用于治疗早期结直肠癌和癌前病变的微创技术，具有高整块切除率、保留器官结构和功能以及长期预后良好的优势。然而，ESD后的病理升级，例如腺瘤被升级为癌症，或发现比术前评估更深的黏膜下浸润，对临床决策和患者预后有显著影响。本综述系统总结了ESD后病理升级的定义、临床意义、评估标准、危险因素及管理策略，并探讨了技术优化的潜在方向。病理升级的危险因素包括术前内镜评估的敏感性不足(34.9%)、复杂病变形态(≥20 mm)、非治愈性切除(27.7%)以及操作者经验的差异。临床管理应基于浸润深度(SM1/SM2分层)、切缘状态以及淋巴结转移风险，通过多学科团队讨论制定个体化治疗方案。本综述强调，精准评估、标准化操作流程以及动态反馈系统可以系统性降低病理升级的风险，为早期结直肠肿瘤及癌前病变的个体化治疗提供循证医学支持。

Abstract: Endoscopic submucosal dissection (ESD) is a minimally invasive technology for early colorectal cancer and precancerous lesions, offering multiple advantages such as high en bloc resection rates, organ preservation, and excellent long-term prognosis. However, pathological upstaging after ESD, such as adenomas being upgraded to cancer or deeper submucosal invasion than initially assessed, significantly impacts clinical decision-making and patient outcomes. This review systematically summarizes the definition, clinical significance, assessment criteria, risk factors, and management strategies for pathological upstaging after ESD. It also explores potential directions for technical optimization. Risk factors for pathological upstaging include insufficient sensitivity of preoperative endoscopic assessment (34.9%), complex lesion morphology (≥20 mm), non-curative resection (27.7%), and operator experience variability. Clinical management should be based on the depth of invasion (SM1/SM2 stratification), margin status, and lymph node metastasis risk, with individualized treatment plans formulated through multidisciplinary team discussions. This review emphasizes that precise assessment, standardized procedures, and a dynamic feedback system can systematically reduce the risk of pathological upstaging, providing evidence-based support for the individualized treatment of early colorectal tumors and precancerous lesions.