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tw4ld6 发表于 2024-6-25 03:07:26

结直肠癌的临床表现及诊断

    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">我国结直肠癌(colorectal cancer，CRC)的发病率和死亡率均保持<span style="color: black;">提升</span>趋势。</span><span style="color: black;"><strong style="color: blue;">2020中国癌症统计报告<span style="color: black;">表示</span>：我国结直肠癌发病率和死亡率在<span style="color: black;">所有</span>恶性肿瘤中分别位居第二和第五，其中2020年新发病例55.5万，死亡病例28.6万。</strong></span><span style="color: black;">其中，城市远高于农村，且结肠癌的发病率<span style="color: black;">提升</span><span style="color: black;">明显</span>。<span style="color: black;">都数</span><span style="color: black;">病人</span>在确诊时已属于中晚期。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">结直肠癌筛查可使结直肠癌的发病率和死亡率下降。我国在天津、上海、浙江和广州等地由政府组织的全人群结直肠癌筛查结果<span style="color: black;">亦</span>证明了结直肠癌筛查的效益。</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">日前</span><span style="color: black;">举荐</span>的结直肠癌筛查<span style="color: black;">方法</span><span style="color: black;">重点</span>是危险度<span style="color: black;">评定</span>和粪便潜血，若为阳性，再进行结肠镜<span style="color: black;">检测</span>。</strong></span><span style="color: black;"><strong style="color: blue;">近年来粪便DNA检测<span style="color: black;">能够</span>进一步<span style="color: black;">加强</span>结直肠癌粪便初筛的效益</strong></span><span style="color: black;">。国外的经验还<span style="color: black;">显示</span>在医疗资源较为发达的地区直接应用3~5年1次的结肠镜<span style="color: black;">检测</span><span style="color: black;">亦</span><span style="color: black;">能够</span>取得较好的筛查效果。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;">本文结合中国结直肠癌诊疗规范（23版）对结直肠癌的诊断做了整理，完整版资料可在资料群获取！</p><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/zpjEmK0TFNax1h221gic3jekzCVsumtic5AbZK7CtI3O1FPbF3eYraOZelebticYnN4kiafy9ib5GibSewZZ7ciaXHy0Q/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">临床表现</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">初期</span>结直肠癌可<span style="color: black;">没</span><span style="color: black;">显著</span>症状，病情发展到<span style="color: black;">必定</span>程度可<span style="color: black;">显现</span>下列症状：</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1.排便习惯改变。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2.大便性状改变(变细、血便、黏液便等)。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3.腹痛或腹部不适。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">4.腹部肿块。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">5.肠梗阻<span style="color: black;">关联</span>症状。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">6.全身症状：如贫血、消瘦、乏力、低热等，晚期<span style="color: black;">能够</span><span style="color: black;">显现</span>腰骶部<span style="color: black;">病痛</span>、黄疸、腹水等。</span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/zpjEmK0TFNax1h221gic3jekzCVsumtic5AbZK7CtI3O1FPbF3eYraOZelebticYnN4kiafy9ib5GibSewZZ7ciaXHy0Q/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">疾患</span>史和家族史</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1、结直肠癌发病可能与以下<span style="color: black;">疾患</span><span style="color: black;">关联</span>：溃疡性结肠炎、结直肠息肉、结直肠腺瘤、克罗恩病(Crohns disease)、血吸虫病等，应<span style="color: black;">仔细</span>询问<span style="color: black;">病人</span><span style="color: black;">关联</span>病史。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2、遗传性结直肠癌发病率约占结直肠癌总体发病率的6%<span style="color: black;">上下</span>，应<span style="color: black;">仔细</span>询问<span style="color: black;">病人</span><span style="color: black;">关联</span>家族史，如林奇<span style="color: black;">综合症</span>(Lynch syndrome,LS)、家族性腺瘤性息肉病(familial adenomatous polyposis,FAP)等。</span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/zpjEmK0TFNax1h221gic3jekzCVsumtic5AbZK7CtI3O1FPbF3eYraOZelebticYnN4kiafy9ib5GibSewZZ7ciaXHy0Q/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">体格<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1、<span style="color: black;">通常</span><span style="color: black;">情况</span><span style="color: black;">评估</span>、营养<span style="color: black;">情况</span><span style="color: black;">评估</span>、全身浅表淋巴结<span style="color: black;">尤其</span>是腹股沟及锁骨上淋巴结的<span style="color: black;">状况</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2、腹部视诊和触诊，<span style="color: black;">检测</span>有<span style="color: black;">没</span>腹部隆起、肠型、肠蠕动波，腹部<span style="color: black;">是不是</span>可触及肿块；腹部叩诊及听诊<span style="color: black;">检测</span><span style="color: black;">认识</span>有<span style="color: black;">没</span>移动性浊音及肠鸣音<span style="color: black;">反常</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3、直肠指检：对疑似结直肠癌者<span style="color: black;">必要</span>常规做直肠指检。<span style="color: black;">病人</span><span style="color: black;">通常</span>采取膝胸位或左侧屈膝位，<span style="color: black;">仔细</span>记录直肠肿瘤<span style="color: black;">体积</span>、形状、质地、占据的时针方位、占肠壁周径的范围、基底部活动度、肿瘤下缘距肛</span><span style="color: black;">缘及齿状线的距离、肿瘤向肠外浸润<span style="color: black;">情况</span>、与<span style="color: black;">周边</span>脏器的关系及有<span style="color: black;">没</span>盆底种植等，<span style="color: black;">同期</span>观察有<span style="color: black;">没</span>指套血染。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">4、三合诊：<span style="color: black;">针对</span>女性直肠癌<span style="color: black;">病人</span>，<span style="color: black;">可疑</span>肿瘤侵犯阴道壁者，<span style="color: black;">举荐</span>行三合诊，<span style="color: black;">认识</span>肿块与阴道后壁关系。</span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/zpjEmK0TFNax1h221gic3jekzCVsumtic5AbZK7CtI3O1FPbF3eYraOZelebticYnN4kiafy9ib5GibSewZZ7ciaXHy0Q/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">实验室<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1、血常规：<span style="color: black;">认识</span>有<span style="color: black;">没</span>贫血。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2、尿常规：观察有<span style="color: black;">没</span>红细胞、白细胞及细菌计数，结合影像学<span style="color: black;">检测</span><span style="color: black;">认识</span>肿瘤<span style="color: black;">是不是</span>侵犯泌尿系统。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3、大便常规：<span style="color: black;">重视</span>有<span style="color: black;">没</span>红细胞、白细胞。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">4、粪便隐血<span style="color: black;">实验</span>：针对消化道少量<span style="color: black;">流血</span>的诊断有<span style="color: black;">要紧</span>价值。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">5、生化、电解质及肝肾功能等。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">6、结直肠癌<span style="color: black;">病人</span>在诊断时、治疗前、<span style="color: black;">评估</span>疗效和随访时，<span style="color: black;">必要</span>检测外周血CEA、CA19-9；有肝转移<span style="color: black;">病人</span><span style="color: black;">意见</span>检测AFP;疑有腹膜、卵巢转移<span style="color: black;">病人</span>建</span><span style="color: black;">议检测CA125。</span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/zpjEmK0TFNax1h221gic3jekzCVsumtic5AbZK7CtI3O1FPbF3eYraOZelebticYnN4kiafy9ib5GibSewZZ7ciaXHy0Q/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">内窥镜<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">所有疑似结直肠癌<span style="color: black;">病人</span>均<span style="color: black;">举荐</span>全结肠镜<span style="color: black;">检测</span>，但以下<span style="color: black;">状况</span>除外：</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1、<span style="color: black;">通常</span><span style="color: black;">情况</span><span style="color: black;">不良</span>，难以耐受。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2、急性腹膜炎、肠穿孔、腹腔内广泛粘连。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3、肛周或严重肠道感染。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">内窥镜<span style="color: black;">检测</span>报告<span style="color: black;">必要</span><span style="color: black;">包含</span>：进镜深度、肿物<span style="color: black;">体积</span>、距肛缘位置、形态、局部浸润的范围及有<span style="color: black;">没</span>肠腔狭窄，对可疑病变<span style="color: black;">必要</span>行病理学活体组织<span style="color: black;">检测</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">因为</span>结肠肠管在<span style="color: black;">检测</span>时可能<span style="color: black;">显现</span>皱缩，<span style="color: black;">因此呢</span>内窥镜所见肿物远侧与肛缘的距离可能存在误差，<span style="color: black;">意见</span>结合CT、MRI或钡剂灌肠<span style="color: black;">知道</span>病灶部位。</span></p><img src="https://mmbiz.qpic.cn/sz_mmbiz_gif/zpjEmK0TFNax1h221gic3jekzCVsumtic5AbZK7CtI3O1FPbF3eYraOZelebticYnN4kiafy9ib5GibSewZZ7ciaXHy0Q/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;">
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">影像学<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">常用<span style="color: black;">检测</span><span style="color: black;">办法</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">(1)CT<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1)前处置及图像重建<span style="color: black;">办法</span>：CT平扫及<span style="color: black;">加强</span>扫描，在临床<span style="color: black;">准许</span>的<span style="color: black;">状况</span>下<span style="color: black;">举荐</span>清洁结肠后，让<span style="color: black;">病人</span></span><span style="color: black;">饮含有2.5%甘露醇水2000mL充盈肠道；不常规<span style="color: black;">举荐</span>注射东莨菪碱或山莨菪碱<span style="color: black;">控制</span>肠道蠕动；<span style="color: black;">举荐</span><span style="color: black;">包括</span>轴位、矢状位、冠状位及多<span style="color: black;">方向</span>重建。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2)<span style="color: black;">举荐</span>CT用于诊断和鉴别诊断结肠癌，判断结肠癌临床分期和直肠癌远处转移，<span style="color: black;">评估</span>结直肠癌新辅助或转化治疗效果及随访筛查局部复发和远处转移。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">①<span style="color: black;">举荐</span>CT<span style="color: black;">加强</span>扫描判断结肠癌临床分期</span><span style="color: black;">(cTNM)和直肠癌非区域淋巴结转移及远处转移</span><span style="color: black;">(cM)；<span style="color: black;">举荐</span>胸部CT平扫判断结直肠癌肺转移；<span style="color: black;">举荐</span>CT<span style="color: black;">加强</span>扫描在随访中判断结直肠癌局部复发、淋巴结转移和远处转移。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">②<span style="color: black;">举荐</span>CT<span style="color: black;">加强</span>扫描<span style="color: black;">评估</span>结肠癌原发灶及结直肠癌转移瘤新辅助治疗或转化治疗效果。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">③存在MRI<span style="color: black;">检测</span>禁忌证<span style="color: black;">病人</span>，<span style="color: black;">举荐</span>CT<span style="color: black;">加强</span>扫描判断直肠癌cTNM分期，但CT判断壁外血管侵犯(extramural vascular invasion，EMVI)潜在环周切缘(circumferential resection margin，CRM)及低位直肠<span style="color: black;">周边</span>肛管复合体价值有限。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">④<span style="color: black;">举荐</span>CT<span style="color: black;">加强</span>扫描判断内窥镜所示黏膜下肠壁内或外在压迫性病变性质；<span style="color: black;">举荐</span>CT<span style="color: black;">加强</span>扫描鉴别诊断与结直肠癌<span style="color: black;">类似</span>肿瘤及肿瘤样病变，如淋巴瘤、胃肠间质瘤、转移瘤及炎性假瘤等。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">(2)MRI<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1)MRI<span style="color: black;">检测</span>前处置：<span style="color: black;">意见</span>盆腔MRI扫描前排空肠道，不常规<span style="color: black;">举荐</span>过度充盈直肠，不常规<span style="color: black;">举荐</span>注射东莨菪碱或山莨菪碱<span style="color: black;">控制</span>肠道蠕动。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2)MRI<span style="color: black;">举荐</span><span style="color: black;">影像</span><span style="color: black;">方法</span>：非脂肪<span style="color: black;">控制</span>、高分辨率T2加权相，<span style="color: black;">包含</span>矢状位、垂直于肿瘤轴和平行于肿瘤轴的斜位<span style="color: black;">影像</span>；扩散加权<span style="color: black;">影像</span>(diffusion weighted imaging，DWI)轴位<span style="color: black;">影像</span>；可<span style="color: black;">增多</span><span style="color: black;">包含</span>矢状位、冠状位及轴位<span style="color: black;">加强</span>扫描<span style="color: black;">影像</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3)<span style="color: black;">举荐</span>盆腔MRI判断直肠癌cTNM分期；<span style="color: black;">举荐</span>上腹MRI诊断肝脏转移瘤；<span style="color: black;">评估</span>直肠癌原发灶及肝脏转移瘤新辅助或转化治疗效果，以及随访筛查局</span><span style="color: black;">部复发。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">①<span style="color: black;">举荐</span>盆腔MRI判断直肠癌手术前、新辅助治疗或转化治疗前cTNM分期，侧方淋巴结转移，EMVI和潜在CRM<span style="color: black;">情况</span>；<span style="color: black;">举荐</span>盆腔MRI<span style="color: black;">评估</span>新辅</span><span style="color: black;">助治疗或转化治疗效果；<span style="color: black;">举荐</span>盆腔MRI平扫及<span style="color: black;">加强</span>扫描判断CT<span style="color: black;">不可</span>确诊的直肠癌的局部复发。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">②CT<span style="color: black;">加强</span>扫描<span style="color: black;">不可</span>确定诊断时，或新辅助治疗、转化治疗后肝脏转移瘤于CT<span style="color: black;">加强</span>扫描不可见时，<span style="color: black;">举荐</span>上腹MRI平扫及<span style="color: black;">加强</span>扫描或必要时行肝细胞特异性对比剂(如Gd-EOB-DTPA)<span style="color: black;">加强</span>MRI<span style="color: black;">做为</span>进一步诊断<span style="color: black;">办法</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">③CT<span style="color: black;">加强</span>扫描<span style="color: black;">不可</span>确诊与直肠癌<span style="color: black;">类似</span>肿瘤及肿瘤样病变，<span style="color: black;">举荐</span>MRI平扫及<span style="color: black;">加强</span>扫描进一步诊断。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">(3)超声<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">首要</span><span style="color: black;">举荐</span>直肠内置超声判断T2及以下直肠癌</span><span style="color: black;">肿瘤分期，仍<span style="color: black;">举荐</span>CT和MRI诊断淋巴结转移</span><span style="color: black;">(cN)和远处转移(cM)。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">新辅助治疗或转化治疗后，肝脏转移瘤于CT或MRI<span style="color: black;">加强</span>扫描中未见<span style="color: black;">表示</span>，<span style="color: black;">举荐</span>术前或术中行超声造影<span style="color: black;">检测</span><span style="color: black;">帮助</span>诊断转移瘤。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">(4)PET/CT<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">18</span><span style="color: black;">F</span><span style="color: black;">-FDG PET/CT可<span style="color: black;">举荐</span>为结直肠癌临床分期及<span style="color: black;">评估</span>治疗效果的备选<span style="color: black;">办法</span>，</span><span style="color: black;">18</span><span style="color: black;">F</span><span style="color: black;">-FDG PET/CT有助于<span style="color: black;">发掘</span>或确定其他影像<span style="color: black;">办法</span>漏诊或疑诊的远处转</span><span style="color: black;">移病灶。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">(5)X线<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">气钡双重X线造影<span style="color: black;">再也不</span><span style="color: black;">举荐</span><span style="color: black;">做为</span>结直肠癌常规<span style="color: black;">检测</span><span style="color: black;">办法</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">特殊类型<span style="color: black;">病人</span>影像<span style="color: black;">检测</span>策略</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">(1)直肠癌新辅助化疗后MRI扫描<span style="color: black;">方法</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">直肠癌<span style="color: black;">病人</span>新辅助化疗后最先的变化<span style="color: black;">表现</span>在肿瘤细胞密度减低而不是肿瘤体积的缩小。<span style="color: black;">因此呢</span>应<span style="color: black;">首要</span><span style="color: black;">明显</span>DWI、IVIM-DWI等功能<span style="color: black;">影像</span>的<span style="color: black;">功效</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">另外</span>，<span style="color: black;">加强</span>序列能有效鉴别直肠癌放化疗后肿瘤组织的炎性反应、纤维化及囊变坏死，<span style="color: black;">能够</span>清晰<span style="color: black;">表示</span>肿瘤实性<span style="color: black;">成份</span>范围。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">DWI、IVIM-DWI联合常规T2WI序列能在<span style="color: black;">初期</span>有效<span style="color: black;">评定</span>直肠癌新辅助化疗的疗效，更准确地识别新辅助治疗后的完全缓解。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">(2)其他肿瘤样病变扫描<span style="color: black;">方法</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">结直肠神经内分泌肿瘤，在DWI和(或)IVIM-DWI序列能更准确地反映肿瘤的细胞密度与微循环灌注<span style="color: black;">状况</span>；</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">结直肠黏液腺癌<span style="color: black;">举荐</span><span style="color: black;">运用</span>T2WI脂肪<span style="color: black;">控制</span>序列及<span style="color: black;">加强</span>序列，能有效<span style="color: black;">表示</span>瘤<span style="color: black;">身体</span>黏液湖；</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">肛管癌<span style="color: black;">举荐</span><span style="color: black;">运用</span>小FOV高分辨斜横轴位T2WI序列，能高清<span style="color: black;">表示</span>肛管癌的浸润深度及肛管癌与肛门括约肌复合体的关系。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">术后随访的影像学<span style="color: black;">办法</span><span style="color: black;">举荐</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">术后<span style="color: black;">定时</span>影像学<span style="color: black;">检测</span>在癌症监测中起着<span style="color: black;">要紧</span>的<span style="color: black;">功效</span>，</span><span style="color: black;"><strong style="color: blue;">常规<span style="color: black;">意见</span>在切除后的前5年每年进行胸中部、腹部和盆腔CT扫描。</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">针对</span>直肠癌术后<span style="color: black;">病人</span>，有<span style="color: black;">前提</span>者优先<span style="color: black;">选取</span>直肠MRI随访；</span><span style="color: black;">结直肠癌术后初次复发率约40%,且大<span style="color: black;">都数</span>会在3年内出</span><span style="color: black;">现，其中，盆腔局部复发性结直肠癌又可细分为吻合口/会阴部复发型、前部复发型、后部复发型及侧方复发型，<span style="color: black;">经过</span>盆腔CT/MRI确定以上复发分型<span style="color: black;">能够</span><span style="color: black;">帮忙</span><span style="color: black;">评定</span>盆腔结构受侵<span style="color: black;">状况</span>、<span style="color: black;">评定</span>再次手术的可行性及<span style="color: black;">帮忙</span><span style="color: black;">指点</span>手术方式；</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">针对</span>某些临床、结肠镜和(或)实验室<span style="color: black;">检测</span><span style="color: black;">可疑</span><span style="color: black;">疾患</span>复发但既往影</span><span style="color: black;">像学<span style="color: black;">检测</span>结果不<span style="color: black;">知道</span>或正常的<span style="color: black;">病人</span>，仍可能<span style="color: black;">必须</span>PET/CT和(或)MRI<span style="color: black;">检测</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">直肠癌临床<span style="color: black;">重要</span>问题的影像学<span style="color: black;">评估</span>：超低位直肠癌的MRI扫描及诊断</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">肿瘤下缘距齿状线<span style="color: black;">少于</span>2cm或距肛缘<span style="color: black;">少于</span>5cm的直肠癌为超低位直肠癌。MRI扫描时应进行与肛管平行的高分辨率T2WI斜冠状<span style="color: black;">影像</span>，以<span style="color: black;">评定</span>肿瘤与括约肌复合体的关系。MRI适合<span style="color: black;">评定</span>远端全直肠系膜切除术(total mesorectal excision，</span><span style="color: black;">TME)平面安全性。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">在超低位直肠癌的分期中，肛门直肠环上方<span style="color: black;">运用</span>的T1~T4分期系统是<span style="color: black;">不足</span>的，应基于肿瘤的径向范围和括约肌间平面的安全性进行<span style="color: black;">评定</span>来<span style="color: black;">指点</span>手术计划。关于超低位直肠癌的分期诊断，<span style="color: black;">日前</span>有MERCURY Ⅱ<span style="color: black;">科研</span>提出的“1~4级”</span><span style="color: black;">分期系统，另还有<span style="color: black;">科研</span>提出肛管侵犯深度<span style="color: black;">也</span>可用于<span style="color: black;">评估</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;">截止</span><span style="color: black;">日前</span>，<span style="color: black;">运用</span>何种<span style="color: black;">评估</span>或分期系统尚未达成共识。相当多的影像与外科<span style="color: black;">大夫</span>认为<span style="color: black;">运用</span>清晰的语言描述肿瘤与内括约肌、括约肌间隙和外括约肌之间的关系，便于<span style="color: black;">知道</span>传达重要的信息。M分期和EMVI的诊断参考中上段直肠癌。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">举荐</span><span style="color: black;">运用</span>直肠癌MRI结构式报告</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/zpjEmK0TFNax1h221gic3jekzCVsumtic5CVibdibLqGvh1icuWdOBOOycVnsPxQRoMhazicFcF1ZbR5GicvhbfGtDTLw/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">直肠癌MRI结构式报告</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">可<span style="color: black;">运用</span>结肠癌CT结构式报告</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/zpjEmK0TFNax1h221gic3jekzCVsumtic5jicpibDAkLsiaM8icsjicSwp4q4g9WEWrGOfrDVicJ9XYqg9ABjevUPlr16w/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">结肠癌CT结构式报告</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">可<span style="color: black;">运用</span>结肠癌CT结构式报告</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/zpjEmK0TFNax1h221gic3jekzCVsumtic5jicpibDAkLsiaM8icsjicSwp4q4g9WEWrGOfrDVicJ9XYqg9ABjevUPlr16w/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">结肠癌CT结构式报告</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;"><span style="color: black;">针对</span>腹部<span style="color: black;">检测</span><span style="color: black;">思虑</span>肝转移的病例，可<span style="color: black;">运用</span>肝转移瘤CT及MRI结构式报告</strong></span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/zpjEmK0TFNax1h221gic3jekzCVsumtic5TYNJqSqYR0V9S3Qn3IXxicv6VKLqUsaO6oSic9CxkUUDIY8zzWtSc6Sg/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">肝转移瘤CT结构式报告</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/zpjEmK0TFNax1h221gic3jekzCVsumtic51EzicTiawVHunjv8JrZjicTkUcHGkI2GsLp84Ou1M6a1dXVafbJ4Fq4qA/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">肝转移瘤MRI结构式报告</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">(仅适用于腹部<span style="color: black;">加强</span>MRI<span style="color: black;">思虑</span>肝转移的病例；肝转移治疗后病例不适用)</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">病理组织学<span style="color: black;">检测</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">病理活检报告是结直肠癌治疗的依据。</strong></span><span style="color: black;">活检诊断为浸润性癌的病例进行规范性结直肠癌治疗。活检病理应<span style="color: black;">尽可能</span><span style="color: black;">知道</span>有<span style="color: black;">没</span>黏膜下层浸润，对高级别上皮内瘤变或黏膜内癌的病例，<span style="color: black;">意见</span>综合其他临床信息<span style="color: black;">包含</span>内窥镜或影像学<span style="color: black;">评定</span>的肿瘤<span style="color: black;">体积</span>、浸润深度、<span style="color: black;">是不是</span>可疑淋巴结转移等，进行多学科讨论以便正确诊治。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">低位直肠肿瘤可能<span style="color: black;">触及</span>临床治疗决策时，<span style="color: black;">意见</span>病理医师在报告中备注说明活检组织有<span style="color: black;">没</span>达到“癌变”程度。</span><span style="color: black;"><strong style="color: blue;"><span style="color: black;">举荐</span>对临床确诊为复发或转移性结直肠癌<span style="color: black;">病人</span>进行KRAS、NRAS、BRAF基因突变检测，以<span style="color: black;">指点</span>肿瘤治疗。<span style="color: black;">意见</span><span style="color: black;">初期</span>结直肠癌<span style="color: black;">病人</span><span style="color: black;">经过</span>KRAS、NRAS、BRAF基因突变检测来进行预后和复发<span style="color: black;">危害</span><span style="color: black;">评定</span>。</strong></span><span style="color: black;">对所有新诊断的结直肠癌<span style="color: black;">病人</span>进行错配修复蛋白(mismatch repair protein，MMR)表达或微卫星不稳定(microsatellite instability，MSI)检测，用于林奇<span style="color: black;">综合症</span>筛查、预后分层及<span style="color: black;">指点</span>免疫治疗等。MLH1缺失的MMR缺陷型肿瘤应行BRAF突变分子和(或)MLH1甲基化检测，以<span style="color: black;">评定</span><span style="color: black;">出现</span>林奇<span style="color: black;">综合症</span>的<span style="color: black;">危害</span>。有<span style="color: black;">前提</span>的单位可结合临床需求开展HER2及NTRK等指标的检测。</span></p><strong style="color: blue;">NATION</strong>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">开腹或腹腔镜探查术</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">以下<span style="color: black;">状况</span>，<span style="color: black;">意见</span>行开腹或腹腔镜探查术。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">1.经过<span style="color: black;">各样</span>诊断手段尚<span style="color: black;">不可</span><span style="color: black;">知道</span>诊断且高度<span style="color: black;">可疑</span>结直肠肿瘤。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">2.<span style="color: black;">显现</span>肠梗阻，进行保守治疗<span style="color: black;">没</span>效。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">3.可疑<span style="color: black;">显现</span>肠穿孔。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">4.保守治疗<span style="color: black;">没</span>效的下消化道大<span style="color: black;">流血</span>。</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">结直肠癌的诊断<span style="color: black;">过程</span></strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;">诊断结束后<span style="color: black;">举荐</span>行cTNM分期</span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><img src="https://mmbiz.qpic.cn/sz_mmbiz_png/zpjEmK0TFNax1h221gic3jekzCVsumtic5X7j3V5KwGY6jVMHYvU0fX431muriafrj0Vcq1LfmobdwzUuShSDjy4g/640?tp=webp&amp;wxfrom=5&amp;wx_lazy=1&amp;wx_co=1" style="width: 50%; margin-bottom: 20px;"></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">结直肠癌的诊断流程</strong></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><span style="color: black;"><span style="color: black;"><strong style="color: blue;">本文<span style="color: black;">源自</span>：中华人民共和国国家卫生健康委员会.中国结直肠癌诊疗规范(2023版).中华消化外科杂志,2023,22(6):667-698.</strong></span></span></span></p>
    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><span style="color: black;"><strong style="color: blue;">作者：中华人民共和国国家卫生健康委员会</strong></span></p>
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    <p style="font-size: 16px; color: black; line-height: 40px; text-align: left; margin-bottom: 15px;"><a style="color: black;">投稿指南｜放疗前沿诚邀您投稿！</a></p>

jxwysz 发表于 2024-9-7 09:48:23

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