谢谢 Dr.Su 的意见，为了使大家对Vienna分类和Padova分类的理解，引用了我在28楼时对Dr.Yang 的提问。

上述的第3和第4点您是否同意？

再次回到对“胃异型增生（低度-低度、中度、高度）与胃上皮非浸润性肿瘤（低级别、高级别）”的主题讨论。

Vienna会议目的-请参考原文摘要：

Genta RM, Rugge M.Gastric precancerous lesions: heading for an international consensus.

Gut. 1999 Jul;45 Suppl 1:I5-8.

 

Departments of Pathology and Medicine, Baylor College of Medicine and Veterans

Affairs Medical Centre, Houston, Texas, USA.

 

As pathological criteria lie at the foundation for the classification of many diseases, a crucial requisite for such classifications to be valid is that their morphological basis be standardised. Inadequately standardised diagnostic criteria result in unacceptable interobserver variation, a factor that may influence both individual patient care and the evaluation of clinical protocols. One of the most important goals in gastric diseases today is to establish whether cure of Helicobacter pylori is an effective preventive measure against gastric cancer. To tackle this issue it is necessary to measure reliably intermediate outcomes, specifically gastric atrophy and dysplasia. However, there is little agreement on what gastric atrophy and atrophic gastritis are, and treatment and follow up results obtained at one clinical centre are often radically different from those obtained at another. Similarly, studies that examine the fate of dysplastic lesions in the stomach show a great divergence of outcomes between Europe and North America and Japan, where the concept of dysplasia has different connotations. To reach a consensus on the definitions and diagnostic criteria for atrophy and atrophic gastritis, a group of gastrointestinal pathologists and gastroenterologists met in Houston, Texas, USA, in February 1998. Substantive progress was made, but several problems remained, and a study aimed at resolving the issues that seem to stand in the way of an international agreement is currently underway. To fulfil the need for a broad discussion on the diagnostic differences of gastric dysplasia and cancer between East and West, an international group of pathologists gathered in Padova, Italy, in the spring of 1998. Their main objectives were: (1) to agree on the definitions of the spectrum of gastric preneoplastic lesions; (2) to establish an international glossary for gastric precancerous lesions; and (3) to test the consensus and eventually generate guidelines useful to clinicians for the development of management strategies. A consensus was achieved on the definition of gastric dysplasia as preinvasive neoplasia. Other validation studies are underway. The experiences achieved in the search for an international consensus on the phenotypes of atrophic gastritis and gastric dysplasia may represent a model in dealing with the new scenario of a modern evidence-based pathology.

 

Ming SC, Bajtai A, Correa P, Elster K, Jarvi OH, Munoz N, Nagayo T, Stemmerman

GN. [ Gastric dysplasia. Significance and pathologic criteria.]

Cancer. 1984;54:1794-801.

In view of uncertainty regarding the criteria and significance of gastric dysplasia as a precancerous lesion, members of the Pathology Panel of the International Study Group on Gastric Cancer (ISGGC) reviewed microslides of 93 gastric lesions showing varying degrees of mucosal abnormality, and reached the following consensus: 

(1) immature and proliferating gastric epithelium can be divided into two categories: hyperplastic and dysplastic; 

(2) the term dysplasia, especially of high-grade type, should be restricted to precancerous lesions, and hyperplasia is applied to regenerative changes; 

(3) regenerative hyperplasia may be simple or atypical, but dysplasia includes both moderate and severe abnormalities, since they often coexist and can not be sharply separated;

(4) occasionally the possibility of malignancy can not be excluded in a severely

dysplastic epithelium; in such a case rebiopsy and diligent follow-up are necessary to establish the diagnosis. 

Criteria for diagnosing dysplasia and hyperplasia are presented and discussed. The opinions are offered as guidelines for establishing the diagnosis of gastric dysplasia and for prospective studies.

1984年国际胃癌研究协会病理组专家在复习了93例不同程度异常的胃粘膜后，达成共识：

1）未成熟和增殖性粘膜异常可分成2类，增生性和异型增生性；

2）异型增生的术语，特别是高级别型，必须限制于癌前病变，增生用于再生性改变；

3）再生性增生可以是单纯性或者不典型性，而异型增生包括中度和重度异常，由于再生性增生和异型增生常常同时存在，不能被明确的区分。

4）偶尔，重度异型增生的上皮存在癌性病变的可能性不能除外，对这种病例必须重复活检和勤随访以确定诊断。

  
  Vienna GI上皮（内）肿瘤/瘤变分类

4、高级别上皮（内）肿瘤/异型增生-非浸润性
    4.1 高级别腺瘤/异型增生
    4.2 非浸润性癌（原位癌）*
    4.3 可疑浸润性癌
5、上皮（内）肿瘤-浸润性
    5.1 粘膜内癌#
    5.2 粘膜下层癌或超过粘膜肌层

备注：* 非浸润性指无浸润依据； # 粘膜内指浸润固有膜或粘膜肌层。

  
Padova胃异型增生与相关病变分类
  
 
   4、非浸润性瘤变

  4.1 低级别

  4.2 高级别

     4.2.1 癌疑无浸润（腺体内）

     4.2.2 癌无浸润（腺体内）

     4.2.3 可疑浸润性癌

5、浸润性癌

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根据上表“上皮内肿瘤/瘤形成”分5个类别：

1、无上皮内肿瘤/异型增生
2、不能确定上皮内肿瘤/异型增生
3、低级别上皮内肿瘤/异型增生
   （低级别腺瘤/异型增生）
4、高级别上皮内肿瘤/异型增生-非浸润性
   4.1 高级别腺瘤/异型增生
   4.2 非浸润性癌（原位癌）*
   4.3 可疑浸润性癌
5、上皮内肿瘤-浸润性
   5.1 粘膜内癌#
   5.2 粘膜下层癌或超过粘膜肌层

备注：* 非浸润性指无浸润依据； # 粘膜内指浸润固有膜 或粘膜肌层。

注意：
1）表中把“低级上皮内肿瘤”=“低级别异型增生”
2）表中并没有“中度异型增生”的术语， 而只有“上皮内肿瘤-高级别”
3）根据推理“中度异型增生”应该高于“低级别异型增生”， 因此“中度异型增生”可归入“上皮内肿瘤-高级别”

问题：
Vienna分类中的“GI上皮内肿瘤-高级别”组织学改变涵盖了传统异型增生中[中度异型增生-高度异型增生/原位癌-可疑浸润性癌]，跨度太大，而有些临床医生误认为新概念‘上皮内肿瘤-高级别’至少 = 原位癌， 就对部分GI粘膜活检病理诊断为‘上皮内肿瘤-高级别’患者进行根治术。

应对方法：
1）为了避免临床医生治疗过度，建议对重要部位粘膜活检诊断用Vienna分类+传统异型增生，如：直肠粘膜活检：高级别上皮内肿瘤（中度异型增生）。
2）诊断病理医生应该分清楚临床上病人是患“腺瘤”还是“进展期癌”，避免在诊断结直肠“进展期癌”活检时，还要寻找活检标本中早已不存在的“粘膜肌层”作为诊断癌的标准，造成延误诊断和临床医生不满。这也是造成临床医生把“上皮内肿瘤-高级别”误认为“至少是原位癌”的原因之一。因此，病理诊断一定要联系临床！
3）大多数结直肠癌是经历“腺瘤-癌”的过程，但是对于胃粘膜的癌发生方式并无定论。

 

胃异型增生和相关病变的Padova 分类

无异型增生

  反应性小凹上皮增生

肠腺化生（IM）

  IM， 完全型

  IM， 不完全型

异型增生不能确定

  小凹上皮增殖

  增殖型IM

非浸润性瘤变

  低级别

  高级别

 包括癌疑无浸润（腺体内）

      包括癌无浸润（腺体内）

      可疑浸润性癌

浸润性癌