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A rare case of adenocarcinoma of an ectopic pancreas: A case report. Int J Surg Case Rep 2022; 94:107061. [PMID: 35413666 PMCID: PMC9018159 DOI: 10.1016/j.ijscr.2022.107061] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction Ectopic pancreas refers to the presence of pancreatic tissue in an unusual anatomical location that has neither anatomic nor vascular continuity with the pancreas. Adenocarcinoma of an ectopic pancreas is rare; only few cases have been described in the literature. Presentation of case We reported a 69-year-old man who was admitted to the emergency department with feculent vomiting lasting two days prior to presentation. Endoscopy revealed pyloric stenosis. Biopsies performed during gastroscopy were in keeping with duodenal cancer, while those performed during endoscopic ultrasound suggested a gastric tumor. A subtotal gastrectomy was done because of results of the extemporaneous analysis and the suspicion of a gastric cancer. The final histopathological report revealed adenocarcinoma of an ectopic pancreas. Discussion Malignant transformation of an ectopic pancreas is very rare, and often occurs as an adenocarcinoma. A differential diagnosis of a gastric adenocarcinoma and a gastrointestinal stromal tumor is essential before treatment. Outcome and a literature review of the pathology, prognosis, and treatment will be discussed. Conclusion Despite adenocarcinoma of an ectopic pancreas being rare, it should be considered as a differential diagnosis of submucosal tumors. The standard treatment for ectopic pancreatic adenocarcinoma is surgery, with a higher survival rate of 5 years compared to pancreatic cancer. Frozen section analysis is essential because it will give an idea on the origin of the neoplasia and allow adaptation of the surgical procedure. This case report describes a case of adenocarcinoma of ectopic pancreas. Malignant transformation of the aberrant pancreas is very rare. Partial gastrectomy and duodenectomy of D1 was performed and sample sent for extemporaneous analysis. The standard treatment for ectopic pancreatic adenocarcinoma is surgery.
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Kim B, Kang S, Lee E, Choi J, Chung H, Cho SJ, Kim SG. Gastric subepithelial tumor: long-term natural history and risk factors for progression. Surg Endosc 2022; 36:5232-5242. [PMID: 35381879 DOI: 10.1007/s00464-021-08901-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 11/21/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Subepithelial tumors are often detected incidentally during upper gastrointestinal endoscopy. However, their natural history and clinical management have yet to be clearly established. The aim of this study was to evaluate the natural history and risk factors for progression of gastric SETs. METHODS The study retrospectively reviewed the medical records of patients who were diagnosed with gastric SET using upper gastrointestinal endoscopy between January 2005 and December 2017. Tumor progression was defined by a ≥ 25% increase in diameter. RESULTS Among 3237 patients, 1859 underwent serial upper gastrointestinal endoscopy for more than six months. Endoscopic ultrasonography was further performed in 733 (39.43%) patients. Resection was performed in 73 (3.93%) patients. Tumor progressed in 138 (7.42%) patients over a mean follow-up period of 59.41 months (range, 5-215 months). In progressed tumors, the mean initial size was 15.01 mm (range, 2-50 mm) and the mean size increment was 12.86 mm (range, 3-50 mm). Large initial tumor size (OR: 1.03, 95% CI: 1.01-1.05), surface ulcer or erosion (OR: 2.47, 95% CI: 1.21-5.06), lobulated shape (OR: 3.76, 95% CI: 2.00-7.06), and middle-third location (OR: 1.65, 95% CI: 1.08-2.52) were significant risk factors for tumor progression. Large SETs had higher rates of progression and tended to grow faster than smaller tumors (r = 0.44, p < 0.001). CONCLUSIONS The majority of gastric SETs did not increase in size during the long-term follow-up. Serial endoscopy may be sufficient as a follow-up tool for small SETs with intact overlying mucosa without lobulated shape.
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Affiliation(s)
- Bokyung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 03080, South Korea
| | - Seungkyung Kang
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 03080, South Korea
| | - Eunwoo Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 03080, South Korea
| | - Jinju Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 03080, South Korea
| | - Hyunsoo Chung
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 03080, South Korea
| | - Soo-Jeong Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 03080, South Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Daehangno 101, Jongno-gu, Seoul, 03080, South Korea.
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Lee KH, Yoo CK, Lee HL, Lee KN, Jun DW, Lee OY, Han DS, Yoon BC, Choi HS, Yoon JH. The Pathologic Confirmation in Subepithelial Tumors. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2020.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background/Aims: Subepithelial tumors (SETs) are small, mostly asymptomatic lesions with normal overlying mucosa, usually identified incidentally on endoscopy. The aim of this study was to evaluate the pathologic diagnosis of SETs, and to assess the diagnostic yield and impact of endoscopic submucosal dissection (ESD) biopsy on the management of patients with SETs.Materials and Methods: We included 52 subepithelial lesions in this study during the study period. Inclusion criteria included size of the SET >2 cm, and a gastrointestinal stromal tumor (GIST) that cannot be excluded using EUS. We performed an endoscopic biopsy of each SET using the ESD technique.Results: The mean diameter of the lesions was 24.15±6.0 mm. The diagnostic yield of this method was 96.15%. Among the 52 participants, 45 were located in the stomach, four in the esophagus, and three in the duodenum. The pathologic diagnoses included: 17 leiomyomas, 13 GISTs, 11 ectopic pancreases, two carcinomas, two inflammatory fibroid polyps, two Brunner’s gland hyperplasia, two lipomas, one glomus tumor, and two remained undiagnosed. The mean duration of the procedure was 13.44±2.41 minutes. Three complications were associated with the procedure.Conclusions: Deep biopsy via ESD is useful in determining the histopathologic nature of SETs. This method minimizes the need for unnecessary surgery in benign SETs.
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Kim DH, Park CH, Park SY, Cho E, Kim HS, Choi SK. Diagnostic yields of endoscopic ultrasound-guided fine-needle tissue acquisition according to the gastric location. Medicine (Baltimore) 2021; 100:e26477. [PMID: 34160458 PMCID: PMC8238348 DOI: 10.1097/md.0000000000026477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/08/2021] [Indexed: 01/04/2023] Open
Abstract
The diagnostic accuracy of endoscopic ultrasound-guided fine-needle tissue acquisition (EUS-FNTA) according to the gastric location of subepithelial tumors (SETs) has not been well established. We aimed to evaluate the efficacy of EUS-FNTA for the diagnosis of gastric SETs according to tumor location.Thirty-three patients diagnosed with gastric SETs via EUS-FNTA from January 2016 to May 2018 were analyzed retrospectively. Patient demographics, diagnostic yields, and complications were evaluated.Nineteen patients (57.6%) were female, with a mean age of 57.7 years. Endoscopic ultrasound revealed a mean longitudinal diameter of 25.6 mm. The most common location of SETs was in the gastric body (n = 18, 54.5%), followed by cardia and fundus (n = 10, 30.3%), and antrum (n = 5, 15.2%). A 20-gauge biopsy needle was most frequently used (90.9%). The diagnostic yield was obtained in 23 patients (69.7%). The most common diagnosis was gastrointestinal stromal tumor (73.9%), followed by leiomyoma (17.4%). The diagnostic yield of SETs in gastric antrum (0/5, 0%) was significantly lower than that in the gastric body and cardia (23/28, 82.1%, P = .001). A case of immediate bleeding after EUS-FNTA occurred in 1 patient (3.0%) who recovered uneventfully. According to related literature, the overall diagnostic yield of SETs in gastric antrum was significantly lower than that in the gastric body, fundus, and cardia (29.7% vs 71.4%, P < .001, n = 191).EUS-FNTA is ineffective in the diagnosis of SETs in the gastric antrum. Although EUS-FNTA is an advanced diagnostic tool for gastric SETs, it is essential to develop more effective methods for the diagnosis of antral SETs.
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Vaicekauskas R, Urbonienė J, Stanaitis J, Valantinas J. Evaluation of Upper Endoscopic and Endoscopic Ultrasound Features in the Differential Diagnosis of Gastrointestinal Stromal Tumors and Leiomyomas in the Upper Gastrointestinal Tract. Visc Med 2020; 36:318-324. [PMID: 33005658 DOI: 10.1159/000504327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/21/2019] [Indexed: 12/12/2022] Open
Abstract
Background Differentiation between benign and malignant subepithelial lesions (SELs) in the upper gastrointestinal tract (UGT) leads to far-reaching clinical consequences. An accurate diagnosis can be challenging because of the insufficient diagnostic yield of upper endoscopy, endoscopic ultrasound (EUS), and different types of biopsy. Aim Our aim was to reveal the efficacy of upper endoscopic and EUS features for the differential diagnosis of hypoechogenic SELs (gastrointestinal stromal tumors [GISTs] and leiomyomas) in the UGT. Materials and Methods The research covers a case series study of 27 hypoechogenic SELs in the UGT between 2012 and 2015 at Vilnius University Hospital Santaros Klinikos. Upper endoscopic and EUS features of SELs were recorded. In order to standardize the diagnostic approach to GISTs and leiomyomas, we assigned scores for seven upper endoscopic and EUS features. Results The mean total scores in the GIST group were significantly higher than those in the leiomyoma group: 3.25 ± 1.71 and 0.53 ± 0.83 (p < 0.0001), respectively. Increment by one score increased the odds ratio for GIST 5.87 times (95% CI 1.63-21.11; p = 0.007). The total score demonstrated very good discriminatory features of GISTs against leiomyomas (area under the receiver operating characteristic curve 0.94 [0.86-1]). The cutoff value of 1.5 total score indicated 83.3% sensitivity and 93.3% specificity in diagnosing GISTs. Conclusions Upper endoscopy and EUS are useful methods in making a definite diagnosis of SELs. Their diagnostic accuracy for the differential diagnosis of GISTs and leiomyomas is sufficient.
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Affiliation(s)
- Rolandas Vaicekauskas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Juozas Stanaitis
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jonas Valantinas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Ye LS, Li Y, Liu W, Yao MH, Khan N, Hu B. Clinical course of suspected small gastrointestinal stromal tumors in the stomach. World J Gastrointest Surg 2020; 12:171-177. [PMID: 32426096 PMCID: PMC7215971 DOI: 10.4240/wjgs.v12.i4.171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/24/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastric subepithelial lesions are frequently encountered during endoscopic examinations, and the majority of them are small and asymptomatic. Among these lesions, gastrointestinal stromal tumors (GISTs) are the major concern for patients and clinicians owing to their malignant potentials. Although previous guidelines suggested periodic surveillance for such small (≤ 20 mm) lesions, several patients and clinicians have still requested or prescribed repeated examinations or radical resection, posing extra medical burdens and risks.
AIM To describe the clinical course of suspected small gastric GISTs and provide further evidence for surveillance strategy for tumor therapy.
METHODS This single-center, retrospective study was conducted at West China Hospital, Sichuan University. Consecutive patients with suspected small gastric GISTs were reviewed from November 2004 to November 2018. GIST was suspected according to endoscopic ultrasonography features: hypoechoic lesions from muscularis propria or muscularis mucosa. Eligible patients with suspected small (≤ 20 mm) GISTs were included for analysis. Patients’ demographic data, lesions’ characteristics, and follow-up medical records were collected.
RESULTS A total of 383 patients (male/female, 121/262; mean age, 54 years) with 410 suspected small gastric GISTs (1 lesion in 362 patients, 2 lesions in 16, 3 lesions in 4, and 4 lesions in 1) were included for analysis. The most common location was gastric fundus (56.6%), followed by body (29.0%), cardia (12.2%), and antrum (2.2%). After a median follow-up of 28 mo (interquartile range, 16-48; range, 3-156), 402 lesions (98.0%) showed no changes in size, and size of 8 lesions (2.0%) was increased (mean increment, 10 mm). Of the 8 lesions with size increment, endoscopic or surgical resection was performed in 6 patients (5 GISTs and 1 leiomyoma). For other 2 remaining patients, unroofing biopsy or endoscopic ultrasound-guided fine-needle aspiration was carried out (2 GISTs), while no further change in size was noted over a period of 62-64 mo.
CONCLUSION The majority of suspected small (≤ 20 mm) gastric GISTs had no size increment during follow-up. Regular endoscopic follow-up without pathological diagnosis may be highly helpful for such small gastric subepithelial lesions.
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Affiliation(s)
- Lian-Song Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yan Li
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ming-Hong Yao
- Department of Epidemiology and Health Statistics, West China School of Public Health, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Naveed Khan
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Kane M, Benaboud MZ, Traore S, Lokman S, Nasri S, Aichouni N, Skiker I, Kamaoui I. Gastrointestinal hemorrhage caused by small intestinal benign tumors: 2 cases report. Pan Afr Med J 2019; 33:197. [PMID: 31692688 PMCID: PMC6814334 DOI: 10.11604/pamj.2019.33.197.18584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/23/2019] [Indexed: 11/11/2022] Open
Abstract
Gastrointestinal bleedings caused by small intestinal tumors are rare and difficult to diagnose because they are not easy to access to the conventional endoscopy. We report two cases, one of them from proximal jejunum and the other one from ileal intestine complicated by intussusception. The two cases were admitted in the emergency department for hematochezia and melena, the diagnosis was established by enhanced helical computed tomography angiography.
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Affiliation(s)
- Mohamed Kane
- Radiology Department of Mohammed VI hospital, Oujda, Morocco
| | | | - Samba Traore
- Radiology Department of Mohammed VI hospital, Oujda, Morocco
| | - Salma Lokman
- Radiology Department of Mohammed VI hospital, Oujda, Morocco
| | - Soumia Nasri
- Radiology Department of Mohammed VI hospital, Oujda, Morocco
| | | | - Imane Skiker
- Radiology Department of Mohammed VI hospital, Oujda, Morocco
| | - Imane Kamaoui
- Radiology Department of Mohammed VI hospital, Oujda, Morocco
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Zoundjiekpon V, Falt P, Fojtik P, Kundratova E, Mikolajek O, Hanousek M, Reiterova K, Ziak D, Bolek M, Tchibozo A, Kliment M, Urban O. Endosonography-Guided Fine-Needle Aspiration versus "Key-Hole Biopsy" in the diagnostics of upper gastrointestinal subepithelial tumors. A prospective randomized interventional study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 164:63-70. [PMID: 31025658 DOI: 10.5507/bp.2019.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 04/02/2019] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The management and prognosis of subepithelial tumors (SETs) of the upper gastrointestinal tract depend on the correct preoperative evaluation, including tissue diagnosis in selected cases. Several methods providing deep tissue sampling for cytological and/or histological examinations have been described but their diagnostic yield and precise position in the diagnostic algorithm remain to be established. This prospective randomized study aims to compare the Endosonography-Guided Fine-Needle Aspiration (EUS-FNA) to Key-Hole Biopsy (KHB) in cytological or histological diagnostics of upper gastrointestinal SETs. PATIENTS AND METHODS This study was conducted in a single tertiary endoscopy center in Ostrava, Czech Republic between November 2010 and October 2015. Patients with endoscopically detected SETs of the upper gastrointestinal tract with a diameter ≥ 2 cm, were randomized to either the EUS-FNA with 22G needle, or to the Key Hole biopsy (forceps biopsy through mucosal incision) groups. The main study outcomes were success rate of tissue diagnostics and, in the cases of Gastrointestinal Stromal Tumours (GIST), possibility of determining mitotic activity. A cross-over examination was performed in situations where the first method had failed. RESULTS A total of 46 consecutive patients were randomized. Of these, 24 (52%) and 22 (48%) were randomized to EUS-FNA group and KHB arm, respectively. 5 SETs (11%) were detected in the esophagus, 40 (87%) in the stomach and 1 (2%) in the duodenum. The definitive diagnosis was established by the first sampling method in 42 (91%) patients, including 22 (92%) in the EUS-FNA group and 20 (91%) in the KHB group (P=0.999), and after a cross-over in another 3 (7%) patients. The most prevalent SET was GIST (70%). Although some mitotic activity could be observed in 11 patients, the mitotic index could be diagnosed in none of them. Of a total of 20 surgically treated patients, preoperative and postoperative tissue diagnosis corresponded in 19/20 (95%) cases, including 100% in FNA group and 91% in KHB group (P=0.999). No adverse events of tissue sampling occurred in the study. CONCLUSIONS Deep tissue sampling by EUS-FNA and KHB are equally effective in the diagnostics of SETs of the upper gastrointestinal tract ≥ 2 cm. However, neither EUS-FNA nor KHB provided adequate tissue sample to determine mitotic index. TRIAL REGISTRATION Clinicaltrials.gov (NCT02025244).
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Affiliation(s)
- Vincent Zoundjiekpon
- Department of Internal Medicine II - Gastroenterology and Geriatric, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic.,Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic
| | - Premysl Falt
- Department of Internal Medicine II - Gastroenterology and Geriatric, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic.,Faculty of Medicine, Charles University in Hradec Kralove, Czech Republic
| | - Petr Fojtik
- Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic
| | - Eva Kundratova
- Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic
| | - Otto Mikolajek
- Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic
| | - Martin Hanousek
- Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic
| | - Katerina Reiterova
- Biopsy and Cytology Department, Agel Laboratories, Novy Jicin, Czech Republic
| | - Dusan Ziak
- CGB Laboratories, Ostrava, Czech Republic
| | - Martin Bolek
- Department of Surgery, Vitkovice Hospital, Ostrava, Czech Republic
| | - Anicet Tchibozo
- StatMed- Health Analytics & Business Intelligence, Saint-Jean Sur Richelieu, Quebec, Canada
| | - Martin Kliment
- Department of Internal Medicine, Gastroenterology and Hepatology- Vivantes Clinic, Berlin, Germany Corresponding author: Vincent Zoundjiekpon, e-mail
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Lopes CV, Rigon P, Zettler CG, Hartmann AA. Differential diagnosis of mesenchymal neoplasms of the digestive tract by cell block and immunohistochemistry. Cytopathology 2018; 29:531-536. [DOI: 10.1111/cyt.12630] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/26/2018] [Indexed: 12/11/2022]
Affiliation(s)
- César Vivian Lopes
- Department of Gastroenterology and Digestive Endoscopy; Santa Casa Hospital; Porto Alegre Brazil
| | - Péttala Rigon
- Department of Pathology; Santa Casa Hospital; Porto Alegre Brazil
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Ingason AB, Theodors A, Agustsson AS, Arnarson A. Giant gastric lipoma successfully removed by endoscopic submucosal dissection: case report and systematic review. Scand J Gastroenterol 2018; 53:1018-1024. [PMID: 30134740 DOI: 10.1080/00365521.2018.1495259] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Gastric lipomas are rare adipose tumors that constitute less than 1% of gastric tumors. While lipomas generally do not need removal unless symptomatic, endoscopic resection has been proposed as safe for gastric lipomas smaller than 2 cm. Yet, there is no consensus on the optimal treatment method for larger lipomas. We report a case of a giant 7-cm gastric lipoma successfully removed by endoscopic submucosal dissection (ESD) and systematically review the literature for gastric lipomas removed by ESD. METHODS Systematic review was conducted by searching PubMed and Scopus databases, up to 15 February 2018, using combinations of relevant terms. RESULTS We report a 55-year-old male with known gastroesophageal reflux disease and asthma, who sought medical attention due to chronic heartburn and asthma exacerbations. These symptoms were attributed to a large 7 cm × 3 cm gastric lipoma that caused gastric outlet obstruction. The lipoma was safely removed by ESD, allowing quick recovery and alleviation of symptoms. In our review, we identified 20 gastric lipomas treated with ESD, with 15 (75%) being 2 cm or larger. The average size of the lipomas was 4 cm (range: 1.2-9 cm). All lipomas were limited to the submucosa, with 80% of the tumors located in the antrum. Three lipomas were removed by submucosal tunneling. All tumors were successfully removed en bloc and no major complications were reported. CONCLUSION Our findings support the conclusion that ESD may be a safe alternative to conventional surgery for removal of large symptomatic gastric lipomas.
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Affiliation(s)
- Arnar B Ingason
- a Department of Medicine , University of Iceland , Reykjavik , Iceland
| | - Asgeir Theodors
- b Department of Gastroenterology , Landspitali University Hospital , Reykjavik , Iceland
| | - Arnar S Agustsson
- a Department of Medicine , University of Iceland , Reykjavik , Iceland
| | - Adalsteinn Arnarson
- c Department of General Surgery , Landspitali University Hospital , Reykjavik , Iceland
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Kim SB, Lee SH, Jeong DE, Kim KO, Gu MJ. Esophageal Basaloid Squamous Carcinoma Treated by Endoscopic Resection and Radiation. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 72:258-261. [DOI: 10.4166/kjg.2018.72.5.258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/01/2018] [Accepted: 07/01/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Sung Bum Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Si Hyung Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Da Eun Jeong
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Mi Jin Gu
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Kim JH, Yoon HH, Jeong SH, Woo HS, Lee WS, Choi SJ, Kim SG, Ha SY, Kwon KA. Spontaneous peeled ileal giant lipoma caused by lower gastrointestinal bleeding: A case report. Medicine (Baltimore) 2017; 96:e9253. [PMID: 29390483 PMCID: PMC5758185 DOI: 10.1097/md.0000000000009253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Gastrointestinal subepithelial tumors (SETs) with endoscopic features such as ulceration, a red color change, a peeled mucosal layer, and spontaneous bleeding could have malignant potential. However, we encountered a case of a lipoma that presented features different from the generally known features of gastrointestinal SETs. Therefore, we report an interesting rare case of a terminal ileal giant lipoma with a unique feature of spontaneous peeled ulceration on the surface on endoscopy that caused gastrointestinal bleeding. PATIENT An 82-year-old woman with a 1-week history of abdominal pain and hematochezia presented to our hospital. DIAGNOSES Ileocolonoscopy revealed a SET with a peeled surface and erythematous and ulcerative mucosal changes as well as exposed a submucosal mass at the terminal ileum. Macroscopically, the lesion appeared as a yellowish pedunculated polypoid mass measuring 3 × 2 cm with a peeled mucosal ulceration. Histopathological findings revealed a submucosal lipoma of the terminal ileum. INTERVENTION We thought that the endoscopic finding indicated malignant SETs or those with malignant potential rather than benign SETs. Therefore, the patient underwent an elective laparoscopic ileocecectomy. LESSONS We encountered a lipoma that did not present with the typical features of gastrointestinal SETs. Our findings suggest that clinicians should consider that benign SETs in the terminal ileum may present with various endoscopic findings similar to those of malignant SETs, which can cause fatal symptoms and signs.
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Affiliation(s)
- Jung Ho Kim
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon
| | - Hyun Hwa Yoon
- Department of Internal Medicine, Central Hospital, Siheung-si, Gyeonggi-do
| | - Seok Hoo Jeong
- Department of Internal Medicine, Catholic Kwandong University International St. Mary's Hospital
| | - Hyun Sun Woo
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon
| | | | | | | | - Seung Yeon Ha
- Department of Pathology, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, Korea
| | - Kwang An Kwon
- Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon
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Choi CW, Kang DH, Kim HW, Park SB, Kim SJ, Hwang SH, Lee SH. Direct endoscopic biopsy for subepithelial tumor larger than 20 mm after removal of overlying mucosa. Scand J Gastroenterol 2017; 52:779-783. [PMID: 28276827 DOI: 10.1080/00365521.2017.1295467] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE An accurate diagnosis of a subepithelial tumor (SET) using endoscopic ultrasound (EUS) without tissue acquisition is difficult. Treatment plan for a SET may be influenced by endoscopic tissue diagnosis. We aimed to clarify the clinical outcomes of direct endoscopic biopsy for SET after removal of the overlying mucosa. METHODS We evaluated the medical records of 15 patients. All patients underwent direct endoscopic biopsy for a SET larger than 20 mm (involving proper muscle layer) after removal of the overlying mucosa. The rate of achieving an accurate diagnosis and the treatment decision after the procedure were evaluated. RESULTS The patients' mean age was 55.1 ± 14.7 years. The patient population predominantly comprised men (9/15, 60%). The mean tumor size was 24.3 ± 7.8 mm. The mean biopsy number was 3.5 ± 1.7. No major complications occurred with the procedure. The mean procedure time was 15 ± 7.4 min. An accurate diagnosis was achieved in 93.3% of patients (14/15). The main pathological diagnoses after direct endoscopic SET biopsy were leiomyoma (33.3%, 5/15) and ectopic pancreas (33.3%, 5/15) followed by gastrointestinal stromal tumor (GIST) (13.3%, 2/15) and schwannoma (13.3%, 2/15). The treatment plan was influenced by the result of biopsy in 80% of patients (9/15), and unnecessary surgical resection was avoided. CONCLUSIONS Direct endoscopic SET biopsy after removal of the overlying mucosa using an endoscopic conventional snare was a useful diagnostic tool with high diagnostic accuracy and low risk of complications.
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Affiliation(s)
- Cheol Woong Choi
- a Department of Internal Medicine , Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan , Korea
| | - Dae Hwan Kang
- a Department of Internal Medicine , Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan , Korea
| | - Hyung Wook Kim
- a Department of Internal Medicine , Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan , Korea
| | - Su Bum Park
- a Department of Internal Medicine , Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan , Korea
| | - Su Jin Kim
- a Department of Internal Medicine , Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan , Korea
| | - Sun Hwi Hwang
- b Department of Surgery , Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan , Korea
| | - Si Hak Lee
- b Department of Surgery , Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan , Korea
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Choi CW, Kang DH, Kim HW, Park SB, Kim SJ. Endoscopic resection for small esophageal submucosa tumor: Band ligation versus conventional endoscopic mucosal resection. Medicine (Baltimore) 2017; 96:e7574. [PMID: 28767573 PMCID: PMC5626127 DOI: 10.1097/md.0000000000007574] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Because an esophageal submucosa tumor (SMT) may be malignant despite its small size, a safe endoscopic resection method is needed in some small SMTs. Conventional endoscopic mucosal resection (EMR) may be simple, but incomplete pathologic resection margin status is common. We aimed to investigate the clinical outcomes of 2 kinds of EMR techniques (conventional EMR and EMR with band ligation device) and to evaluate the factors associated with incomplete pathologic resection.We evaluated the medical records of 36 patients. All lesions were esophageal SMTs located in the submucosa or muscularis mucosa less than 10 mm in size by endoscopic ultrasound (EUS). The clinical outcomes based on the endoscopic procedures and factors associated with incomplete pathologic resection were evaluated.The mean tumor size was 6.6 ± 4.1 mm. The overall en bloc and complete resection rates were 100% and 80.6%, respectively. No procedure-related complications, such as perforation and bleeding, were found. Univariate analysis showed that complete resection rates were higher in granular cell tumors than in leiomyomas (82.8% vs 17.2%, P = .029), tumors located in the submucosa layer than in the muscularis mucosa (96.6% vs 3.4%, P = .003), and in EMR with band ligation device than in conventional EMR (82.8% vs 17.2%, P < .001). Multivariate analysis showed that conventional EMR was the only significant factor associated with incomplete resection (OR, 35.594; 95% CI, 2.042-520.329; P = .014)EMR with a band ligation device is an effective and safe treatment method for small esophageal SMT.
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Lee JH, Lee HL, Ahn YW, Lee KN, Jun DW, Lee OY, Han DS, Yoon BC, Choi HS. Prevalence of Gastric Subepithelial Tumors in Korea: A Single Center Experience. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 66:274-6. [PMID: 26586350 DOI: 10.4166/kjg.2015.66.5.274] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND/AIMS The incidental finding of gastrointestinal subepithelial tumors (SETs) is increasing with national cancer screening endoscopy. In a Swedish population, screening endoscopy found a prevalence of SETs of 0.36%. However, the prevalence of gastric SETs in Korean patients has not been described. Therefore, this study evaluated the prevalence of SETs of the stomach in a Korean patient population. METHODS We reviewed endoscopic reports of 11,712 subjects who underwent screening esophagogastroduodenoscopy (EGD) at Hanyang University Hospital between July 2012 and June 2013. RESULTS Among 11,712 patients, 194 (1.7%) had SET of the stomach. Of these, 71 (prevalence, 0.6%) were male and 123 (prevalence, 1.1%) were female. When grouped by age, the prevalence of SET was as follows: 1.0% for patients in their twenties, 6.2% for those in their thirties, 19.1% for those in their forties, 33.0% for those in their fifties, 30.4% for those in their sixties, and 10.3% for those over 70 years of age. CONCLUSIONS The overall prevalence of gastric SET among healthy examinees was 1.7%. The prevalence of gastric SET increased with age and was higher in female.
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Affiliation(s)
- Jung Hoon Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Hang Lak Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Yong Woo Ahn
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kang Nyeong Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Byung Chul Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Ho Soon Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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Dias de Castro F, Magalhães J, Monteiro S, Leite S, Cotter J. The Role of Endoscopic Ultrasound in the Diagnostic Assessment of Subepithelial Lesions of the Upper Gastrointestinal Tract. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:287-292. [PMID: 28868481 PMCID: PMC5580021 DOI: 10.1016/j.jpge.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/18/2016] [Indexed: 12/18/2022]
Abstract
Introduction The identification of subepithelial lesions is a relatively frequent finding at endoscopy however their natural history is not well known. Our aim was to analyze the role of endoscopic ultrasound (EUS) in the diagnostic approach of subepithelial lesions of the upper gastrointestinal tract. Methods Retrospective study which included 324 patients undergoing upper radial EUS for evaluation of subepithelial lesions from 2008 to 2014. The EUS features, presumptive diagnosis and management decision were analyzed. Results 324 patients included, 60% with gastric subepithelial lesions, 28% oesophageal and 12% from the duodenum. Based on EUS features the presumptive diagnosis was: 25% gastrointestinal stromal tumor, 21% lipoma, 19% leiomyoma, 17% pancreatic rest, 7% submucosa cysts, 1% granular cell tumors, 1% carcinoids, 1% mucosa lesions and 8% not defined. After EUS the suggested approach was no follow-up in 45%, follow-up with re-examination with EUS in 35% and additional tissue sampling or endoscopic/surgical resection in 20%. The latter was based on EUS features of risk at the diagnosis (53%), such as size ≥2 cm, hypoechogenicity, heterogeneity, lobulation, calcifications, cystic component and regional adenopathies; impossibility to define a presumptive diagnosis (39%) or EUS features change at follow-up (8%). The combination of multiple features correlated with a higher probability of this recommended strategy (p < 0.001), in 100% when 4 or more features were present. Among the 33 patients who underwent fine needle aspiration, in 66% the result was inconclusive. During follow-up, none of the patients who were managed with surveillance radial EUS presented complications. Conclusion EUS is the method of choice in the study of subepithelial lesions of the upper gastrointestinal tract, in most cases defining a diagnosis. The need for a definitive diagnosis or therapeutic approaches can be based on ultrasound risk features, presented, in the majority, at presentation. This study shows that EUS is capable of safely and accurately define those subepithelial lesions that can be managed only with surveillance ultrasound while waiting for better results with fine needle aspiration.
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Affiliation(s)
- Francisca Dias de Castro
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Joana Magalhães
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Sara Monteiro
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - Sílvia Leite
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Centro Hospitalar do Alto Ave, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
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Lee HL. Advances in the Management of Upper Gastrointestinal Subepithelial Tumor: Pathologic Diagnosis Using Endoscopy without Endoscopic Ultrasound-Guided Biopsy. Clin Endosc 2016; 49:216-9. [PMID: 27246253 PMCID: PMC4895931 DOI: 10.5946/ce.2016.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 05/19/2016] [Accepted: 05/19/2016] [Indexed: 12/13/2022] Open
Abstract
Until now, biopsy methods for subepithelial tumors (SETs) have focused on endoscopic ultrasound (EUS)-guided biopsy; however, these methods have several limitations. We devised a simple method for pathologic diagnosis of SETs. SETs are occasionally diagnosed during endoscopy, and lesions are generally small and asymptomatic. It can be challenging to decide on a management plan for large asymptomatic SETs. EUS imaging provides information regarding the size, layer, and echo pattern of the lesions. Patient management plans have traditionally been determined based on EUS images, whereby the endoscopist chooses to either monitor or remove the tumor. However, EUS alone cannot diagnose and evaluate upper gastrointestinal SETs with high accuracy. As sufficient tissue samples are required for the accurate diagnosis of SETs, EUS-guided biopsy techniques such as EUS fine-needle aspiration and trucut biopsy are currently used. However, these methods have a relatively low diagnostic accuracy and do not always provide information upon immunohistochemical staining. Endoscopists can easily detect a submucosal mass after creating an iatrogenic mucosal ulcer, after which tissue sampling is performed by using endoscopic biopsy. Furthermore, pathologic results can differentiate between benign and premalignant lesions. Here, we introduce a simple method for the pathologic diagnosis of SETs.
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Affiliation(s)
- Hang Lak Lee
- Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
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18
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Park HY, Jeon SW, Lee HS, Cho CM, Bae HI, Seo AN, Kweon OK. Can contrast-enhanced harmonic endosonography predict malignancy risk in gastrointestinal subepithelial tumors? Endosc Ultrasound 2016; 5:384-389. [PMID: 28000630 PMCID: PMC5206827 DOI: 10.4103/2303-9027.195871] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives: Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) is a novel technology that can identify subepithelial tumors (SETs) by detecting the degree of enhancement, but whether CEH-EUS can predict the malignancy risk of gastrointestinal stromal tumors (GISTs) remains unclear. The aim of our study was to evaluate the diagnostic accuracy of CEH-EUS and its ability to discriminate among SETs and predict the malignancy risk of GISTs. Materials and Methods: We retrospectively included patients with suspected subepithelial lesions who underwent CEH-EUS preoperatively. Thirty-five patients with histologically proven GISTs and benign neoplasms were enrolled in the study. The images of CEH-EUS were categorized in accordance with microvasculature, parenchymal perfusion, and nonenhancing spots. The diagnostic performance of CEH-EUS was evaluated by comparing these findings with the histological diagnosis. Results: When we divided the enrolled patients into high- and low-grade malignancy and benign groups, nonenhancing spots on CEH-EUS were found more frequently in the high-grade malignancy group (63.6%), followed by the low-grade malignancy (46.7%) and benign groups (25.7%) (P = 0.022). However, based on the statistical validity of the CEH-EUS findings for the discrimination of SETs, the sensitivity was 53.8% for diagnostic performance and 63.6% for prediction of malignancy risk of GISTs. Conclusions: From our study results, it is unclear whether CEH-EUS alone has a diagnostic role in the discrimination of SETs and the prediction of malignancy risk of GISTs. Further studies with larger samples from multiple centers and use of other imaging analysis modalities are needed.
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Affiliation(s)
- Hye Yoon Park
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, South Korea
| | - Seong Woo Jeon
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, South Korea
| | - Hyun Seok Lee
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, South Korea
| | - Chang Min Cho
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, South Korea
| | - Han Ik Bae
- Department of Pathology, Kyungpook National University Medical Center, Daegu, South Korea
| | - An Na Seo
- Department of Pathology, Kyungpook National University Medical Center, Daegu, South Korea
| | - Oh Kyung Kweon
- Department of Surgery, Kyungpook National University Medical Center, Daegu, South Korea
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19
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Heo J, Jeon SW. Hybrid natural orifice transluminal endoscopic surgery in gastric subepithelial tumors. World J Gastrointest Endosc 2013; 5:428-432. [PMID: 24044041 PMCID: PMC3773854 DOI: 10.4253/wjge.v5.i9.428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 07/30/2013] [Accepted: 08/06/2013] [Indexed: 02/05/2023] Open
Abstract
Diagnosis of gastric subepithelial tumor (SET) has shown a rapid increase worldwide. Although, until now, endoscopic ultrasound guided procedures such as fine needle aspiration have shown relatively high accuracy in diagnosis of SET, the most important modality for diagnosis and treatment of SETs is complete resection such as endoscopic or surgical resection. However, endoscopic resection or laparoscopic wedge resection alone also has some limitations. Endoscopic resection is difficult to perform in cases of gastric SET located within deep portion of the gastric layer or a relatively large (larger than 25 mm diameter). On the other hand, gastric SET in a difficult location, such as the gastroesophageal junction or pyloric ring is challenging for laparoscopic surgical resection. The hybrid natural orifice transluminal endoscopic surgery (NOTES) technique is a combined method, including the advantages of both laparoscopic resection and endoscopic resection for gastric SETs. This method may be performed safely with reasonable operation times, less bleeding, and adequate resection margin and regardless of tumor size. In particular, in the case of a difficult location for resection, such as the esophagogastric junction or pyloric ring, hybrid NOTES is currently believed to be an ideal treatment method.
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20
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Kong SH, Yang HK. Surgical treatment of gastric gastrointestinal stromal tumor. J Gastric Cancer 2013; 13:3-18. [PMID: 23610714 PMCID: PMC3627804 DOI: 10.5230/jgc.2013.13.1.3] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 03/09/2013] [Accepted: 03/10/2013] [Indexed: 12/13/2022] Open
Abstract
Gastrointestinal stromal tumor is the most common mesenchymal tumor in the gastrointestinal tract and is most frequently developed in the stomach in the form of submucosal tumor. The incidence of gastric gastrointestinal stromal tumor is estimated to be as high as 25% of the population when all small and asymptomatic tumors are included. Because gastric gastrointestinal stromal tumor is not completely distinguished from other submucosal tumors, a surgical excisional biopsy is recommended for tumors >2 cm. The surgical principles of gastrointestinal stromal tumor are composed of an R0 resection with a normal mucosa margin, no systemic lymph node dissection, and avoidance of perforation, which results in peritoneal seeding even in cases with otherwise low risk profiles. Laparoscopic surgery has been indicated for gastrointestinal stromal tumors <5 cm, and the indication for laparoscopic surgery is expanded to larger tumors if the above mentioned surgical principles can be maintained. A simple exogastric resection and various transgastric resection techniques are used for gastrointestinal stromal tumors in favorable locations (the fundus, body, greater curvature side). For a lesion at the gastroesophageal junction in the posterior wall of the stomach, enucleation techniques have been tried preserve the organ's function. Those methods have a theoretical risk of seeding a ruptured tumor, but this risk has not been evaluated by well-designed clinical trials. While some clinical trials are still on-going, neoadjuvant imatinib is suggested when marginally unresectable or multiorgan resection is anticipated to reduce the extent of surgery and the chance of incomplete resection, rupture or bleeding.
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Affiliation(s)
- Seong-Ho Kong
- Department of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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21
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Oh MJ, Lee SH, Park CS. Clinical Features and Risk Factors of Gastric Subepithelial Tumor Needed Surgery in Clinical Practice: A Single-center Retrospective Study. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2013. [DOI: 10.7704/kjhugr.2013.13.1.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Myung Jin Oh
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Si Hyung Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Chan Seo Park
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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22
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Alkhatib AA, Faigel DO. Endoscopic ultrasonography-guided diagnosis of subepithelial tumors. Gastrointest Endosc Clin N Am 2012; 22:187-205, vii. [PMID: 22632943 DOI: 10.1016/j.giec.2012.04.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Subepithelial lesions are frequently discovered during routine endoscopic examinations. These lesions represent a wide spectrum of heterogeneous benign to malignant conditions. Most of these lesions are asymptomatic. There is no consensus regarding how to manage these lesions. Over the last 2 decades, the approach to these lesions has significantly improved owing to the introduction of endoscopic ultrasonography, fine-needle aspiration, immunohistochemical staining methods, and different treatment options. This article discusses the nature of subepithelial lesions, focusing on the most recent developments that use endoscopic ultrasonography to diagnose and manage these lesions.
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Affiliation(s)
- Amer A Alkhatib
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
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23
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Zhang L, Ozao J, Warner R, Divino C. Review of the pathogenesis, diagnosis, and management of type I gastric carcinoid tumor. World J Surg 2011; 35:1879-86. [PMID: 21559999 DOI: 10.1007/s00268-011-1137-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastric carcinoid tumors comprise 7% of all gastrointestinal carcinoids and have significantly increased in incidence over the past few decades. Seventy to 80% of gastric carcinoids are type I, which usually are clinically asymptomatic and found incidentally at endoscopic evaluation for abdominal pain or anemia. In this review, advances in understanding the pathophysiology of type I gastric carcinoid are highlighted. In addition, various current diagnostic and treatment options are discussed. Although type I carcinoids generally hold a benign course, rigorous investigation is needed to ensure accurate diagnosis and optimal treatment. This includes appropriate diagnostic procedures and imaging and accurate staging of tumor. Tumor size, depth of invasion, presence of metastasis, and the tumor's gastrin dependency dictate treatment options. Appropriate treatments can consist of endoscopic resection, antrectomy, medical management, or frequent follow-up. This article provides a systematic method of evaluating and treating type I gastric carcinoid.
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Affiliation(s)
- Linda Zhang
- Department of Surgery, Mount Sinai School of Medicine, 5 East 98th Street, 15th Floor, Box 1259, New York, NY 10029, USA
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24
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Ardengh JC, Vaiciunas S, Kemp R, Venco F, Lima-Filho ER, dos Santos JS. Upper endoscopy versus endosonography in differential diagnosis of gastrointestinal bulging. ARQUIVOS DE GASTROENTEROLOGIA 2011; 48:236-41. [PMID: 22147127 DOI: 10.1590/s0004-28032011000400004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Accepted: 06/14/2011] [Indexed: 12/12/2022]
Abstract
CONTEXT The identification of a bulging covered by normal epithelium is a common finding during an upper gastrointestinal endoscopy. OBJECTIVE To compare the endoscopic and endosonography findings in the differential diagnosis of the gastrointestinal bulging (subepithelial tumor or extrinsic compression). METHOD Patients referred by endosonography with bulging of upper gastrointestinal tract were studied retrospectively. The size, location, consistency and presumptive diagnosis were recorded at time of endoscopy and endosonography. Endosonography-guided fine-needle aspiration was proposed in case of uncertain diagnose to increase diagnostic sensitivity. RESULTS One hundred seventy-six patients (93 women) and mean age 62.5 years (10-87). One hundred fifty-three had subepithelial tumor and 23 had extrinsic compression as a final diagnosis. Endosonography had sensitivity, specificity and accuracy higher than those found by endoscopy for both diagnosis subepithelial tumor and extrinsic compression. Endoscopy and endosonography showed poor concordance (K = 0.13) for subepithelial tumor diagnosis and unsuitable agreement for diagnosis in extrinsic compression (K = 0.01). The endosonography-guided fine-needle aspiration had sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 75%, 72.4%, 80.5%, 65.6% and 74%, respectively. CONCLUSION Endoscopy has high sensitivity and low specificity for subepithelial tumor and both are low for the extrinsic compression. Endoscopy is a good tool for diagnosis of the subepithelial tumors, but not to determine the cause of an extrinsic compression. The endosonography identifies the layer from which subepithelial tumor comes, obtain histological samples, and increasing the diagnostic accuracy.
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Affiliation(s)
- José Celso Ardengh
- Divisão de Endoscopia e Ecoendoscopia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil.
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25
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Kim JH. The Diagnosis of Subepithelial Lesions in the Upper Gastrointestinal Tract. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2011. [DOI: 10.7704/kjhugr.2011.11.2.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jie-Hyun Kim
- Department of Internal Medicine, Institute of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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26
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Kim SG. [Incidental gastrointestinal subepithelial mass]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 56:341-5. [PMID: 21173556 DOI: 10.4166/kjg.2010.56.6.341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Incidental gastrointestinal subepithelial mass is increasing with national cancer screening endoscopy. Most of gastrointestinal subepithelial mass are small-sized and asymptomatic tumor with benign nature, but gastrointestinal stromal tumor should be ruled-out because of its malignant behavior. Although conventional endoscopy alone can differentiate the nature of subepithelial mass, more accurate diagnosis can be achieved with endoscopic ultrasonography and its guided biopsy. In this review, differential diagnosis and treatment strategy of incidental gastrointestinal subepithelial mass would be presented.
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Affiliation(s)
- Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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27
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Sakamoto H, Kitano M, Kudo M. Diagnosis of subepithelial tumors in the upper gastrointestinal tract by endoscopic ultrasonography. World J Radiol 2010; 2:289-97. [PMID: 21160683 PMCID: PMC2998868 DOI: 10.4329/wjr.v2.i8.289] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 07/29/2010] [Accepted: 08/05/2010] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasonography (EUS) is the most accurate procedure for detecting and diagnosing subepithelial tumors, due to its higher sensitivity and specificity than other imaging modalities. EUS can characterize lesions by providing information on echogenic origin, size, borders, homogeneity, and the presence of echogenic or anechoic foci. Linear echoendoscopes, and recently also electronic radial echoendoscopes, can be used with color Doppler or power Doppler to assess the vascular signals from subepithelial masses, and thus permit the differentiation of vascular structures from cysts, as well as the assessment of the tumor blood supply. However, the diagnostic accuracy of EUS imaging alone has been shown to be low in subepithelial lesions with 3rd and 4th layers. It is also difficult to differentiate exactly between benign and malignant tumors and to gain an accurate picture of histology using EUS. On the other hands, EUS guided fine needle aspiration (EUS-FNA) can provide samples for cytologic or histologic analysis. Hypoechoic lesions of the 3rd and the 4th EUS layers, more than in 1 cm diameter are recommended, and histologic confirmation using endoscopic submucosal resection or EUS-FNA should be obtained when possible. Therefore, EUS-FNA plays an important role in the clinical management of subepithelial tumors. Furthermore improvements in endoscopic technology are expected to be more useful modalities in differential diagnosis and discrimination between benign and malignant subepithelial tumors.
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28
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Jeong ID, Jung SW, Bang SJ, Shin JW, Park NH, Kim DH. Endoscopic enucleation for gastric subepithelial tumors originating in the muscularis propria layer. Surg Endosc 2010; 25:468-74. [PMID: 20589510 DOI: 10.1007/s00464-010-1195-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 06/14/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Subepithelial tumors (SETs) of the stomach are considered benign. However, they have the potential for malignant transformation, especially if they originate in the muscularis propria layer. This study aimed to determine the feasibility of endoscopic enucleation (EEN) for SETs in the muscularis propria layer and to evaluate the diagnostic efficacy and safety of EEN for SETs. METHODS A total of 65 lesions in 64 patients were eligible for inclusion in the study during the period between June 2006 and September 2009. En bloc enucleation using an insulated-tip knife and snare was attempted for removal of gastric SETs from the muscularis propria. RESULTS A total of 60 tumors were successfully resected by EEN (success rate, 92.3%). The mean tumor size, determined by endoscopic ultrasound, was 13.8 mm (range, 5-30 mm). A histologic diagnosis was obtained for 63 tumors (diagnostic yield, 96.9%), which was leiomyoma for 32 lesions, gastrointestinal stromal tumor for 26 tumors, and other for 5 tumors. The rate for complete resection in relation to the location of the lesion in the stomach was higher for the cardia, the mid/lower body (100%), and the high body (96%) than for the fundus (75%) or the antrum (50%, p=0.006). The rate of perforation was significantly higher for the fundus (50%) than for other locations (0% for the cardia and 4% for the high body) (p<0.001). CONCLUSIONS Endoscopic enucleation of gastric SETs originating in the muscularis propria layer was a safe and effective method for the histologic diagnosis and removal of small gastric SETs, especially those located in the cardia and the high body of the stomach.
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Affiliation(s)
- In Du Jeong
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, 290-3, Jeonha-dong, Dong-gu, 682-714, Ulsan, South Korea
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Huang WH, Feng CL, Lai HC, Yu CJ, Chou JW, Peng CY, Yang MD, Chiang IP. Endoscopic ligation and resection for the treatment of small EUS-suspected gastric GI stromal tumors. Gastrointest Endosc 2010; 71:1076-81. [PMID: 20438899 DOI: 10.1016/j.gie.2009.12.041] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 12/30/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND GI stromal tumors (GISTs), with their potential for malignant transformation, are usually treated by surgical intervention. Endoscopic treatment remains controversial. OBJECTIVE The aim of this study was to investigate clinical outcomes associated with use of endoscopic ligation and resection for diagnosis and treatment of small EUS-suspected gastric GISTs. DESIGN Prospective case series. SETTING Academic medical center. PATIENTS Eight patients with submucosal gastric tumors <2 cm in diameter suspected to be GISTs. INTERVENTIONS Endoscopic ligation and resection. MAIN OUTCOME MEASUREMENTS Clinical/technical feasibility, success, and adverse events. RESULTS Seven patients with small EUS-suspected gastric GISTs were successfully treated by endoscopic ligation, with sloughing of residual tissue within 1 month. All were diagnosed pathologically with GISTs of low malignant potential. One additional patient required a second ligation to remove residual tumor, also diagnosed as a GIST with low malignant potential. No perforation, massive hemorrhage, or other complication requiring endoscopic or surgical intervention occurred. LIMITATIONS Small number of patients (n = 8) and limited follow-up; risk of microscopically positive margins, which limits application to lesions strongly suspected to be benign. CONCLUSIONS Endoscopic ligation and resection shows promise as a safe and feasible technique to treat small EUS-suspected gastric GISTs. Controlled clinical trials with more subjects and longer follow-up are needed to confirm the value and limitations of this method.
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Affiliation(s)
- Wen-Hsin Huang
- Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
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Lim YJ, Son HJ, Lee JS, Byun YH, Suh HJ, Rhee PL, Kim JJ, Rhee JC. Clinical course of subepithelial lesions detected on upper gastrointestinal endoscopy. World J Gastroenterol 2010; 16:439-44. [PMID: 20101768 PMCID: PMC2811795 DOI: 10.3748/wjg.v16.i4.439] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the natural history of subepithelial lesions.
METHODS: We reviewed the medical records of 104 159 patients who underwent upper gastrointestinal endoscopy at the Center for Health Promotion of Samsung Medical Center between 1996 and 2003. Subepithelial lesions were detected in 795 patients (0.76%); 252 patients were followed using upper gastrointestinal endoscopy for 82.5 ± 29.2 mo (range, 12-160 mo; median, 84 mo; 1st quartile, 60 mo; 3rd quartile, 105 mo). The median interval of follow-up endoscopy was 12 mo (range, 6-105 mo; 1st quartile, 12 mo; 3rd quartile, 24 mo).
RESULTS: The mean patient age was 53 years (range, 22-80 years), and the male-to-female ratio was 2.36:1 (177/75). The lesion size at initial measurement averaged 8.9 mm (range, 2-25 mm; median, 8 mm; 1st quartile, 5 mm; 3rd quartile, 10 mm). Of the 252 lesions, 244 (96.8%) were unchanged and 8 (3.2%) were significantly increased in size (from 12.9 ± 6.0 to 21.2 ± 12.2 mm) after a mean interval of 59.1 ± 27.5 mo (range, 12-86 mo). Surgical resection of lesions was performed when the lesions were ≥ 3 cm in diameter. Two lesions were diagnosed as gastrointestinal stromal tumors with an intermediate or high risk of malignancy and one lesion was classified as a schwannoma.
CONCLUSION: Most small subepithelial lesions do not change as shown by endoscopic examination, and regular follow-up with endoscopy may be considered in small, subepithelial lesions, especially lesions < 1 cm in size.
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Abstract
The finding of a mass lesion in the upper gastrointestinal tract at endoscopy with apparent normal overlying mucosa is common. The differential diagnosis of such lesions is broad and includes those of intramural or extramural origin. Endoscopic ultrasound provides accurate imaging of subepithelial mass lesions and characterizes them according to size, echogenicity, and origin including the histologic layer if the lesion is intramural which narrows the differential diagnosis. Endoscopic ultrasound allows a guided tissue sample to be obtained for histologic confirmation which is especially important for hypoechoic lesions arising from the 3rd or 4th echogenic layers. The purpose of this article is to review the diagnosis of the more common subepithelial mass lesions with an emphasis on endoscopic ultrasound and the subsequent management or monitoring.
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Affiliation(s)
- Jeremy L Humphris
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, and University of Sydney, Sydney, New South Wales, Australia
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