早期胃癌的临床筛选研究
吴云林,陈颖,上海第二医科大学附属瑞金医院消化内科 上海市 200025
项目负责人 吴云林,200025,上海市,上海第二医科大学附属瑞金医院消化内科.
电话:021-64370045-665246
收稿日期 2002-08-06 接受日期 2002-09-10
摘要胃癌是严重威胁人类健康的恶性疾病.对胃癌疾病演进过程的研究表明，癌细胞仅浸润至胃黏膜层和黏膜下层，无论有无淋巴结转移的早期胃癌患者的预后明显优于进展期胃癌患者.所以筛选早期胃癌具有重要的价值.临床筛选早期胃癌的对象包括自然人群，门诊患者，高危人群.筛选方法包括对血液，胃液及组织中胃癌标志物，相关癌基因的测定;胃癌特异抗原的检测;潜血珠法;胃癌概率计算机模型筛选法;放射影像学检查;普通内镜检查结合色素染色,多点黏膜活检，细胞刷活细胞涂片等检查;超声内镜检查可明确胃癌浸润深度.
吴云林,陈颖.早期胃癌的临床筛选研究.世界华人消化杂志 2002;10(12):1372-1375
0 引言胃癌是世界上第二大癌症死因,他也是威胁我国人民健康最常见的恶性肿瘤,每年死于胃癌的人数约有16万.近年来青年人和65岁以上的老年人胃癌发生率有上升趋势.改善胃癌患者预后的关键是作好二级预防即早期发现和早期治疗.进展期胃癌手术切除后患者 的5 a生存率约 30-40 %，而在早期胃癌(EGC)，癌细胞仅浸润至胃黏膜层和黏膜下层，无论有无淋巴结转移，手术治疗后 5 a生存率在80-90 %，其中始发阶段小胃癌( SGC)及微小胃癌( MGC) 10 a生存率可达100 %.故胃癌的早期及时准确检出和治疗，对于降低胃癌死亡率具有十分重要的意义[1] .
1 早期胃癌的发现途径
1.1自然人群的普查 有资料表明间隔期为1.5-2 a的大规模筛查有助于检测早期胃癌.胃癌在日本是最常见的恶性肿瘤，医学界将重点放在胃癌早期诊断上.他们采用放射影像学的气钡双对比方法进行普查，在此基础上对可疑病灶再行胃镜精检.早癌手术率达到50 %以上，5 a存活率达90 %以上.目前我国主要在胃癌高发区进行选择性局部普查，如年龄>35岁，具不良的饮食习惯和食用高盐，霉变食物等,有肿瘤家族史等，然后综合分析筛选出高危个体，再行内镜，及X线摄片检查.其中应用计算机模式普查方法较为简便可行 . 综合我国各地普查结果,普查中胃癌检出率约0.037-0.6 %[2-5] ,在检出的胃癌中，早期胃癌占15-25 %.通过普查筛选可大大提高无症状患者胃癌的发现率.根据统计，无症状胃癌中半数左右手术病理证实为早期胃癌，绝大部分无淋巴结转移.然而有症状胃癌患者中只有33 %是早期胃癌，并且其中57 %已经发生了淋巴结转移.所以对自然人群的普查是一项艰巨但又重要的工作.
1.2门诊筛选 凡有相关症状前来就诊者，即进入筛选，这是胃癌早期诊断的重要环节.早期胃癌表现有上腹部隐痛、 腹胀、 食欲不振、 嗳气、 恶心和呕吐等症状. 这些症状均不为早期胃癌所特有， 故易被当作一般胃病而被忽视， 这也是患者就诊过晚的原因之一.所以应强调在40岁以上的男性(嗜烟酒者应放宽到35岁)稍有上腹部不适，应予筛查，以达到早期发现早期诊断之目的.此外消化不良症状明显且持续时间较长， 经临床治疗症状改善不明显者， 应考虑有胃癌的可能性. 对于有慢性萎缩性胃炎、 恶性贫血、 胃息肉、 残胃及良性胃溃疡等疾病者， 更应警惕其演变为胃癌.我国门诊筛选早期胃癌检出率0.27 %低于日本(0.88 %)而介于西欧(0.37 %)和美国(0.1 %)之间.现在普遍认为胃镜检查是早期胃癌最好的筛选方法.上海瑞金医院门诊胃镜检查26 634例，检出胃癌951例，占胃镜检查术的3.57 %，其中早期胃癌72例，占全部胃癌的7.6 %.由于患者的传统习惯以及部分医院胃镜检查适应证偏严，致使早期胃癌的检出率难以提高[8-10] .
在延误诊断早期胃癌的众多原因中，有一种原因是要特别警惕的，即在行内窥镜检查之前投用抗溃疡药物，导致部分早期胃癌患者因为症状暂时缓解或消失，错过了获得及时诊断的时机.因此当出现上腹部相关临床症状时，应避免传统的应用H2受体阻断剂或质子泵抑制剂等诊断性治疗方法
1.3 高危人群随访 胃癌高危人群包括癌前状态和癌前病变者，前者指一些发生胃癌危险性明显增高的疾病，如慢性萎缩性胃炎、胃溃疡、胃息肉、残胃、巨大胃黏膜皱襞病等.后者主要指病理上的胃黏膜不典型增生.高危人群随访法对胃癌及早期胃癌检出率高于普查法和门诊筛选法.现在认为胃癌的自然病程是一个较缓慢的过程[6,7]，从早期阶段发展到进展期约需要3-4 a时间，因此对高危人群每6-12 mo随访复查胃镜较为合适.Hp感染与胃癌有关的观点已经被广泛接受.已证明Hp感染者发生胃癌的危险性是无感染者的3-6倍.在感染病例中细菌基因型，环境因素，以及宿主基因因素等在决定胃癌发生发展中起重要作用.还不清楚治疗Hp是否可以预防胃癌，但有胃部恶性疾病家族史者的Hp感染者且有临床症状者应列为胃癌高危人群，开展随访研究，必要时可进行干预性治疗[11-19] .
2 早期胃癌的发现方法
2.1实验室检查 (1)胃癌标志物:胃癌细胞产生的多种物质能在胃液，血液及其他组织中被检测到，可作为胃癌的标志物应用于胃癌筛选普查.胃癌标志物包括：(a)各种酶，如b-葡萄糖醛酸酶，乳酸脱氢酶及其同工酶，蛋白激酶C等；(b)来源于胚胎的标志物，如胎儿硫糖蛋白FSA，癌胚抗原CEA，甲胎蛋白AFP[20-24].(2)癌基因, ras基因家族编码p21ras的表达，ras基因的异常扩增或者点突变使得p21ras持续处于激活状态，一般认为p21ras 高表达与肠型胃癌有关，但在发育不良，肠化生，肿瘤附近正常黏膜中均有高表达，所以认为该基因在胃癌发生过程中较早阶段起作用.APC 基因的缺失突变也多见于胃癌早期，且多发生于未分化型胃癌.研究显示p53基因，CD44v6基因表达与胃癌发生及胃癌生物学行为有关，他们在胃黏膜高度发育不良，早期胃癌，进展期胃癌标本中的表达依次增高.胃癌的演进是多种基因改变的结果，以上这些胃癌相关癌基因对早期胃癌的基因诊断具有重要的意义.但特异性尚待提高.目前趋向于几种标志物的联合应用，可提高对早期胃癌诊断的特异性和敏感性[25-46]. (3)胃癌单克隆抗体 应用单克隆抗体诊断早期胃癌是当前胃癌研究中的一大课题.例如应用单克隆抗体MG7.通过1 090例患者的研究发现MG7抗原的阳性率为41.8 %，用MG7单抗检测病理标本诊断为异型增生者,发现阳性浓度指数为++者有高度癌变危险. (4)胃癌潜血珠法全国23万余人普查表明，胃液潜血阳性率为12 %，581例确诊为食管癌和胃癌，其中70 %患者的病理学检查为早中期癌.本法特异性不高，但方法简便，受检者可多次重复或作连续动态观察，在大规模人群普查中有较大使用价值.(5)胃癌概率计算机模型筛选 普查时，根据当地胃癌的各危险因素，选出有意义的因子，建立概率数学模型，将每位受检者的资料输入计算机，经回归分析，阳性者为高危人群，行进一步检查.此法若结合胃癌标志物法，可提高胃癌的检出率.
2.2放射学检查 虽然病变绝大多数能被发现，但恶性漏诊率仍然较高，其原因除了因为早期恶性病变部分征象不明显外，常规钡餐检查对黏膜的微细结构显示不足也是一个重要因素.胃部影像学检查包括双对比像，黏膜像，充盈像，压迫像等多种检查方法.通过比较可以发现双对比像与黏膜像能清晰地显示病变，压迫像对胃下部前壁病变的显示尤其重要，4种检查方法可相互补充证实，提高恶性病变的检出率.日本每年用放射影像方法普查大约500万人,胃癌检出率0.12 %，其敏感性为82.4 %，特异性77.2 %.我国也开展了该项普查，胃癌检出率为0.1 %，其中早期胃癌占71.4 %.该法可疑者必须经内镜检查明确性质.
近年来,计算机断层扫描(CT)技术有了显著发展,特别是双相螺旋CT和CT模拟胃镜的临床应用,使得影像学方法检测早期胃癌的敏感性得以大大提高.根据目前统计CT模拟胃镜诊断早期胃癌的阳性符合率达到70 %以上,最小可显示黏膜病灶的直径达到1 cm左右.但尚存在诊断费用高的问题,不适用于普查 [47-53] .
2.3内镜检查法 早期胃癌并不具有特异性临床症状， 所以对40岁以上， 有明显消化不良症状或癌前期病变患者，应常规作胃镜检查.与影像学检查比较，内镜具有显著优势.他可以直接观察病变形态，视野阔，分辨力强，活检准确率高.1962年日本胃肠道内镜协会将早期胃癌分为三型，即I型(隆起型)，II型(表面型)，III型(溃疡型).其中II型又分为3个亚型，分别称为IIa型，IIb型,IIc型.IIa型指隆起高度>5 mm的早期癌；IIb型指癌组织的隆起或者凹陷几乎肉眼观察不到；IIc型指癌的凹陷度未穿透黏膜下层.临床报道显示IIb型早期胃癌的发现较少也较为困难，发现可疑病变应行多块多方向活检. 若结合色素喷洒及活检，可以协助诊断， 不论应用何种染色方法， 早期胃癌的染色阳性率为80 %， 最高可达90 %.活检加细胞刷检查也可以提高早期胃癌的诊断率. 有作者认为内镜加活检对早期胃癌的诊断准确率达96 %.掌握内镜活检取材要点和准确方法是诊断早期胃癌的关键，因为初始阶段的早期胃癌非常微小,第一钳活检后会有出血而影响到以后的活检准确性,因此第一钳活检非常重要[54-63] .
根据日本学者Yoshida et al 的分析显示出内镜诊断早期胃癌的水平有了显著提高.我国对早期胃癌的识别能力有待提高，对可疑的凹陷型病灶影以及胃内隆起性病变形态学似良性者，仍需在病灶区域多处活检， 才能提高早期胃癌的诊断率.掌握早期胃癌黏膜的形态学特点以及好发部位有助于降低早期胃癌漏诊率.如IIc型早期胃癌边缘与正常黏膜境界不清，中心部呈不规则颗粒状，如有岛状黏膜的出现，该处活检阳性率高.早期胃癌好发部位顺序各资料报道不一，多以胃窦，胃体，胃角，贲门为序.萎缩性胃炎、 胃黏膜上皮肠化生、 不典型增生等， 这些组织学的变化与胃癌的发生有着密切的关系. 特别是胃上皮细胞异型增生内镜下并无特征性表现. 故内镜检查出的萎缩性胃炎、 胃溃疡、 残胃及胃息肉等须严格随访， 这对早期发现胃癌是很重要的.由于黏膜下层有丰富的毛细血管网和淋巴管网，肿瘤一旦侵犯此层，发生转移的机会就增多，预后不良，因此强调要早期诊断.此外早期胃癌存在多发癌现象，当发现一处病变后，不要忽视对其他部位的仔细检查.根据条件联合应用色素内镜、放大内镜、超声内镜检查，可提高早期胃癌的诊断率[64-68].
超声内镜检查增加了内镜的诊断范围，同时缩短了超声探头与靶器官的距离，使超声分辨率更高.超声胃镜检查早期胃癌和进展期胃癌的准确率达90%,判断癌种类型以及浸润深度的准确率可达70-80%.超声内镜还有助于发现早期胃癌有无局部淋巴结转移[69-71] .
总之，胃癌早期发现和早期诊断是早期治疗的基础，也是减低胃癌死亡率的关键一环.在诊断技术手段不断提高的今天，是完全有希望做好早期胃癌的临床筛选工作的.
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of submucosal invasion in early gastric cancer. J Gastroenterol 2000;35:326-331, 百拇医药(吴云林,陈 颖)
项目负责人 吴云林,200025,上海市,上海第二医科大学附属瑞金医院消化内科.
电话:021-64370045-665246
收稿日期 2002-08-06 接受日期 2002-09-10
摘要胃癌是严重威胁人类健康的恶性疾病.对胃癌疾病演进过程的研究表明，癌细胞仅浸润至胃黏膜层和黏膜下层，无论有无淋巴结转移的早期胃癌患者的预后明显优于进展期胃癌患者.所以筛选早期胃癌具有重要的价值.临床筛选早期胃癌的对象包括自然人群，门诊患者，高危人群.筛选方法包括对血液，胃液及组织中胃癌标志物，相关癌基因的测定;胃癌特异抗原的检测;潜血珠法;胃癌概率计算机模型筛选法;放射影像学检查;普通内镜检查结合色素染色,多点黏膜活检，细胞刷活细胞涂片等检查;超声内镜检查可明确胃癌浸润深度.
吴云林,陈颖.早期胃癌的临床筛选研究.世界华人消化杂志 2002;10(12):1372-1375
0 引言胃癌是世界上第二大癌症死因,他也是威胁我国人民健康最常见的恶性肿瘤,每年死于胃癌的人数约有16万.近年来青年人和65岁以上的老年人胃癌发生率有上升趋势.改善胃癌患者预后的关键是作好二级预防即早期发现和早期治疗.进展期胃癌手术切除后患者 的5 a生存率约 30-40 %，而在早期胃癌(EGC)，癌细胞仅浸润至胃黏膜层和黏膜下层，无论有无淋巴结转移，手术治疗后 5 a生存率在80-90 %，其中始发阶段小胃癌( SGC)及微小胃癌( MGC) 10 a生存率可达100 %.故胃癌的早期及时准确检出和治疗，对于降低胃癌死亡率具有十分重要的意义[1] .
1 早期胃癌的发现途径
1.1自然人群的普查 有资料表明间隔期为1.5-2 a的大规模筛查有助于检测早期胃癌.胃癌在日本是最常见的恶性肿瘤，医学界将重点放在胃癌早期诊断上.他们采用放射影像学的气钡双对比方法进行普查，在此基础上对可疑病灶再行胃镜精检.早癌手术率达到50 %以上，5 a存活率达90 %以上.目前我国主要在胃癌高发区进行选择性局部普查，如年龄>35岁，具不良的饮食习惯和食用高盐，霉变食物等,有肿瘤家族史等，然后综合分析筛选出高危个体，再行内镜，及X线摄片检查.其中应用计算机模式普查方法较为简便可行 . 综合我国各地普查结果,普查中胃癌检出率约0.037-0.6 %[2-5] ,在检出的胃癌中，早期胃癌占15-25 %.通过普查筛选可大大提高无症状患者胃癌的发现率.根据统计，无症状胃癌中半数左右手术病理证实为早期胃癌，绝大部分无淋巴结转移.然而有症状胃癌患者中只有33 %是早期胃癌，并且其中57 %已经发生了淋巴结转移.所以对自然人群的普查是一项艰巨但又重要的工作.
1.2门诊筛选 凡有相关症状前来就诊者，即进入筛选，这是胃癌早期诊断的重要环节.早期胃癌表现有上腹部隐痛、 腹胀、 食欲不振、 嗳气、 恶心和呕吐等症状. 这些症状均不为早期胃癌所特有， 故易被当作一般胃病而被忽视， 这也是患者就诊过晚的原因之一.所以应强调在40岁以上的男性(嗜烟酒者应放宽到35岁)稍有上腹部不适，应予筛查，以达到早期发现早期诊断之目的.此外消化不良症状明显且持续时间较长， 经临床治疗症状改善不明显者， 应考虑有胃癌的可能性. 对于有慢性萎缩性胃炎、 恶性贫血、 胃息肉、 残胃及良性胃溃疡等疾病者， 更应警惕其演变为胃癌.我国门诊筛选早期胃癌检出率0.27 %低于日本(0.88 %)而介于西欧(0.37 %)和美国(0.1 %)之间.现在普遍认为胃镜检查是早期胃癌最好的筛选方法.上海瑞金医院门诊胃镜检查26 634例，检出胃癌951例，占胃镜检查术的3.57 %，其中早期胃癌72例，占全部胃癌的7.6 %.由于患者的传统习惯以及部分医院胃镜检查适应证偏严，致使早期胃癌的检出率难以提高[8-10] .
在延误诊断早期胃癌的众多原因中，有一种原因是要特别警惕的，即在行内窥镜检查之前投用抗溃疡药物，导致部分早期胃癌患者因为症状暂时缓解或消失，错过了获得及时诊断的时机.因此当出现上腹部相关临床症状时，应避免传统的应用H2受体阻断剂或质子泵抑制剂等诊断性治疗方法
1.3 高危人群随访 胃癌高危人群包括癌前状态和癌前病变者，前者指一些发生胃癌危险性明显增高的疾病，如慢性萎缩性胃炎、胃溃疡、胃息肉、残胃、巨大胃黏膜皱襞病等.后者主要指病理上的胃黏膜不典型增生.高危人群随访法对胃癌及早期胃癌检出率高于普查法和门诊筛选法.现在认为胃癌的自然病程是一个较缓慢的过程[6,7]，从早期阶段发展到进展期约需要3-4 a时间，因此对高危人群每6-12 mo随访复查胃镜较为合适.Hp感染与胃癌有关的观点已经被广泛接受.已证明Hp感染者发生胃癌的危险性是无感染者的3-6倍.在感染病例中细菌基因型，环境因素，以及宿主基因因素等在决定胃癌发生发展中起重要作用.还不清楚治疗Hp是否可以预防胃癌，但有胃部恶性疾病家族史者的Hp感染者且有临床症状者应列为胃癌高危人群，开展随访研究，必要时可进行干预性治疗[11-19] .
2 早期胃癌的发现方法
2.1实验室检查 (1)胃癌标志物:胃癌细胞产生的多种物质能在胃液，血液及其他组织中被检测到，可作为胃癌的标志物应用于胃癌筛选普查.胃癌标志物包括：(a)各种酶，如b-葡萄糖醛酸酶，乳酸脱氢酶及其同工酶，蛋白激酶C等；(b)来源于胚胎的标志物，如胎儿硫糖蛋白FSA，癌胚抗原CEA，甲胎蛋白AFP[20-24].(2)癌基因, ras基因家族编码p21ras的表达，ras基因的异常扩增或者点突变使得p21ras持续处于激活状态，一般认为p21ras 高表达与肠型胃癌有关，但在发育不良，肠化生，肿瘤附近正常黏膜中均有高表达，所以认为该基因在胃癌发生过程中较早阶段起作用.APC 基因的缺失突变也多见于胃癌早期，且多发生于未分化型胃癌.研究显示p53基因，CD44v6基因表达与胃癌发生及胃癌生物学行为有关，他们在胃黏膜高度发育不良，早期胃癌，进展期胃癌标本中的表达依次增高.胃癌的演进是多种基因改变的结果，以上这些胃癌相关癌基因对早期胃癌的基因诊断具有重要的意义.但特异性尚待提高.目前趋向于几种标志物的联合应用，可提高对早期胃癌诊断的特异性和敏感性[25-46]. (3)胃癌单克隆抗体 应用单克隆抗体诊断早期胃癌是当前胃癌研究中的一大课题.例如应用单克隆抗体MG7.通过1 090例患者的研究发现MG7抗原的阳性率为41.8 %，用MG7单抗检测病理标本诊断为异型增生者,发现阳性浓度指数为++者有高度癌变危险. (4)胃癌潜血珠法全国23万余人普查表明，胃液潜血阳性率为12 %，581例确诊为食管癌和胃癌，其中70 %患者的病理学检查为早中期癌.本法特异性不高，但方法简便，受检者可多次重复或作连续动态观察，在大规模人群普查中有较大使用价值.(5)胃癌概率计算机模型筛选 普查时，根据当地胃癌的各危险因素，选出有意义的因子，建立概率数学模型，将每位受检者的资料输入计算机，经回归分析，阳性者为高危人群，行进一步检查.此法若结合胃癌标志物法，可提高胃癌的检出率.
2.2放射学检查 虽然病变绝大多数能被发现，但恶性漏诊率仍然较高，其原因除了因为早期恶性病变部分征象不明显外，常规钡餐检查对黏膜的微细结构显示不足也是一个重要因素.胃部影像学检查包括双对比像，黏膜像，充盈像，压迫像等多种检查方法.通过比较可以发现双对比像与黏膜像能清晰地显示病变，压迫像对胃下部前壁病变的显示尤其重要，4种检查方法可相互补充证实，提高恶性病变的检出率.日本每年用放射影像方法普查大约500万人,胃癌检出率0.12 %，其敏感性为82.4 %，特异性77.2 %.我国也开展了该项普查，胃癌检出率为0.1 %，其中早期胃癌占71.4 %.该法可疑者必须经内镜检查明确性质.
近年来,计算机断层扫描(CT)技术有了显著发展,特别是双相螺旋CT和CT模拟胃镜的临床应用,使得影像学方法检测早期胃癌的敏感性得以大大提高.根据目前统计CT模拟胃镜诊断早期胃癌的阳性符合率达到70 %以上,最小可显示黏膜病灶的直径达到1 cm左右.但尚存在诊断费用高的问题,不适用于普查 [47-53] .
2.3内镜检查法 早期胃癌并不具有特异性临床症状， 所以对40岁以上， 有明显消化不良症状或癌前期病变患者，应常规作胃镜检查.与影像学检查比较，内镜具有显著优势.他可以直接观察病变形态，视野阔，分辨力强，活检准确率高.1962年日本胃肠道内镜协会将早期胃癌分为三型，即I型(隆起型)，II型(表面型)，III型(溃疡型).其中II型又分为3个亚型，分别称为IIa型，IIb型,IIc型.IIa型指隆起高度>5 mm的早期癌；IIb型指癌组织的隆起或者凹陷几乎肉眼观察不到；IIc型指癌的凹陷度未穿透黏膜下层.临床报道显示IIb型早期胃癌的发现较少也较为困难，发现可疑病变应行多块多方向活检. 若结合色素喷洒及活检，可以协助诊断， 不论应用何种染色方法， 早期胃癌的染色阳性率为80 %， 最高可达90 %.活检加细胞刷检查也可以提高早期胃癌的诊断率. 有作者认为内镜加活检对早期胃癌的诊断准确率达96 %.掌握内镜活检取材要点和准确方法是诊断早期胃癌的关键，因为初始阶段的早期胃癌非常微小,第一钳活检后会有出血而影响到以后的活检准确性,因此第一钳活检非常重要[54-63] .
根据日本学者Yoshida et al 的分析显示出内镜诊断早期胃癌的水平有了显著提高.我国对早期胃癌的识别能力有待提高，对可疑的凹陷型病灶影以及胃内隆起性病变形态学似良性者，仍需在病灶区域多处活检， 才能提高早期胃癌的诊断率.掌握早期胃癌黏膜的形态学特点以及好发部位有助于降低早期胃癌漏诊率.如IIc型早期胃癌边缘与正常黏膜境界不清，中心部呈不规则颗粒状，如有岛状黏膜的出现，该处活检阳性率高.早期胃癌好发部位顺序各资料报道不一，多以胃窦，胃体，胃角，贲门为序.萎缩性胃炎、 胃黏膜上皮肠化生、 不典型增生等， 这些组织学的变化与胃癌的发生有着密切的关系. 特别是胃上皮细胞异型增生内镜下并无特征性表现. 故内镜检查出的萎缩性胃炎、 胃溃疡、 残胃及胃息肉等须严格随访， 这对早期发现胃癌是很重要的.由于黏膜下层有丰富的毛细血管网和淋巴管网，肿瘤一旦侵犯此层，发生转移的机会就增多，预后不良，因此强调要早期诊断.此外早期胃癌存在多发癌现象，当发现一处病变后，不要忽视对其他部位的仔细检查.根据条件联合应用色素内镜、放大内镜、超声内镜检查，可提高早期胃癌的诊断率[64-68].
超声内镜检查增加了内镜的诊断范围，同时缩短了超声探头与靶器官的距离，使超声分辨率更高.超声胃镜检查早期胃癌和进展期胃癌的准确率达90%,判断癌种类型以及浸润深度的准确率可达70-80%.超声内镜还有助于发现早期胃癌有无局部淋巴结转移[69-71] .
总之，胃癌早期发现和早期诊断是早期治疗的基础，也是减低胃癌死亡率的关键一环.在诊断技术手段不断提高的今天，是完全有希望做好早期胃癌的临床筛选工作的.
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