Submucosal lesions

Penile Prosthetic Pump Reservoir Mimicking a Cecal Subepithelial Mass

Intestinal subepithelial lesions are often encountered during endoscopy. Etiologies can include lesions intrinsic or extrinsic to the gastrointestinal wall. They can present a diagnostic dilemma as simple mucosal biopsies are often nondiagnostic. The combination of characteristic radiographic, endoscopic, and endosonographic features can aid in a definitive diagnosis precluding the need for unnecessary tissue sampling of extrinsic compressive etiologies. The location of the space of Retzius which is the traditional site of penile prosthetic pump reservoir insertion can predispose to cecal compression. We present a rare case of a penile prosthetic pump reservoir presenting as a cecal subepithelial mass on endoscopy.

Feasibility and clinical value of linear endoscopic ultrasonography imaging in the lower gastrointestinal subepithelial lesions

Linear endoscopic ultrasonography (EUS) has been extensively utilized as a novel diagnostic and therapeutic modality across various fields. However, there have been relatively few studies focusing on lower gastrointestinal lesions. The aim of our study was to investigate the feasibility, safety and clinical value of linear EUS in the lower gastrointestinal subepithelial lesions. This was a retrospective study involving patients with lower gastrointestinal subepithelial lesions diagnosed by linear EUS from August 2019 to April 2023 at the Second Affiliated Hospital of Anhui Medical University. The data, including basic clinical information, linear EUS features, technical success rate, complications, and follow-up, were retrospectively collected and analyzed. A total of 69 patients with lower gastrointestinal subepithelial lesions underwent examination by linear EUS. Excluding the rectum, the technical success rate of linear EUS was 90.6% (29/32). Apart from the 7 patients whose diagnosis remained unknown, 3 patients with no abnormal EUS findings, and 3 patients failed the procedure, 56 patients were included in the final diagnostic performance analysis. The most common locations of the lesions were the rectum (37/56, 66.1%) and sigmoid colon (7/56, 12.5%). Based on endoscopy findings and pathological results, the most prevalent types of subepithelial lesions in the lower gastrointestinal tract were neuroendocrine tumor (NET) (12/56, 20.3%), lipoma (8/56, 13.6%) and extraluminal compression (8/56, 13.6%). The majority of lesions ranged in diameter from 1 to 3 cm (χ2 = 18.750, p < 0.001). After undergoing linear EUS examination, 36 patients received EUS-FNA (3/36), biopsy (5/36), endoscopic resection (25/36), or surgical excision (3/36) respectively. The pathological results of 29 patients were entirely consistent with the diagnosis made using linear EUS, with an 80.6% (29/36) diagnostic accuracy rate. Follow-up indicated that the lesions remained unchanged within 6-36 months. All patients tolerated the procedure well without any complications. In conclusion, linear EUS demonstrates technical feasibility, safety, and a high diagnostic accuracy for subepithelial lesions in the lower gastrointestinal tract.

Clinicopathologic and Endosonographic Characteristics of Colon Subepithelial Tumors Discovered Incidentally

BACKGROUND/AIMS

Colonoscopy is commonly used for colorectal cancer screening; therefore, the detection of colon subepithelial tumors (SETs) has also increased. Several research studies have been undertaken to diagnose and treat stomach and rectal SETs. The purpose of this study was to determine a diagnostic point for colon SETs by comparing histological findings with the endoscopic characteristics of colon SETs discovered by chance.

METHODS

A total 194 patients underwent an endoscopic ultrasound (EUS) for suspicious colon SETs during a colonoscopy from May 2014 to December 2021. A total of 105 colon SETs, which were histologically diagnosed, were finally included. Fisher's exact test was used to determine the factors associated with malignant SETs.

RESULTS

Colon SETs were predominantly present in the right colon (n = 73, 69.5%), particularly in the transverse colon (n = 32, 30.5%). The majority were smaller than 10 mm (n = 88, 83.8%), and they had hard consistencies (n = 84, 80%) and exhibited no surface changes (n = 96, 91.4%). Most of them were found in the submucosal layers (n = 54, 51.4%) and had a hypoechoic pattern (n = 56, 53.3%) in the EUS. Of the histologically confirmed cases, only three (3/105, 2.9%) were malignant. Most benign lesions were lipomas, suspected parasitic infections, or lesions caused by various inflammatory reactions, including fibrous/fibrocalcific lesions and necrotic nodules. All soft lesions were benign. Two of the three malignant lesions were adenocarcinomas, and the other was lymphoma. For the malignant SETs, there was a statistically significant alteration in the surface of the tumors (p < 0.001), and they were located where the muscularis mucosa layer was included (p = 0.008). The potential malignant SETs, granular cell tumors, and neuroendocrine tumors (NETs) had similar features, such as yellowish hypoechoic masses. Colon NETs were only found in the rectosigmoid junction. Parasitic infections and lesions, resulting in various inflammatory reactions, were observed as pale and hard SETs and mostly revealed as mixed echogenic masses located in the muscularis mucosa, submucosa, or multi-layers in the EUS.

CONCLUSION

This study showed that small colon SETs were mostly benign lesions. Despite its rarity, pathological confirmation is crucial in cases where the SET has surface changes and has been located in a position where the muscularis mucosa layer was included on the EUS, due to the risk of malignancy.

A CT-based nomogram established for differentiating gastrointestinal heterotopic pancreas from gastrointestinal stromal tumor: compared with a machine-learning model

OBJECTIVE

To identify CT features and establish a nomogram, compared with a machine learning-based model for distinguishing gastrointestinal heterotopic pancreas (HP) from gastrointestinal stromal tumor (GIST).

MATERIALS AND METHODS

This retrospective study included 148 patients with pathologically confirmed HP (n = 48) and GIST (n = 100) in the stomach or small intestine that were less than 3 cm in size. Clinical information and CT characteristics were collected. A nomogram on account of lasso regression and multivariate logistic regression, and a RandomForest (RF) model based on significant variables in univariate analyses were established. Receiver operating characteristic (ROC) curve, mean area under the curve (AUC), calibration curve and decision curve analysis (DCA) were carried out to evaluate and compare the diagnostic ability of models.

RESULTS

The nomogram identified five CT features as independent predictors of HP diagnosis: age, location, LD/SD ratio, duct-like structure, and HU lesion/pancreas A. Five features were included in RF model and ranked according to their relevance to the differential diagnosis: LD/SD ratio, HU lesion/pancreas A, location, peritumoral hypodensity line and age. The nomogram and RF model yielded AUC of 0.951 (95% CI: 0.842-0.993) and 0.894 (95% CI: 0.766-0.966), respectively. The DeLong test found no statistically significant difference in diagnostic performance (p > 0.05), but DCA revealed that the nomogram surpassed the RF model in clinical usefulness.

CONCLUSION

Two diagnostic prediction models based on a nomogram as well as RF method were reliable and easy-to-use for distinguishing between HP and GIST, which might also assist treatment planning.

Comparison of 22G Fork-Tip and Franseen Needles and Usefulness of Contrast-Enhanced Endoscopic Ultrasound for Diagnosis of Upper Gastrointestinal Subepithelial Lesions

Endoscopic ultrasound (EUS)-guided tissue acquisition (EUS-TA) is less accurate in obtaining samples from gastrointestinal subepithelial lesions (SELs) ≤2 cm than from pancreatic cancers. The present study compared the usefulness of 22G Fork-tip and Franseen needles for EUS-TA and assessed the ability of contrast-enhanced harmonic EUS (CH-EUS) to diagnose SELs ≤2 cm. Fifty-seven patients who underwent EUS-TA for SELs ≤2 cm were evaluated. The primary endpoint was to compare the rate of acquisition of sufficient samples by these two needles. Secondary endpoints included technical success rate, adverse events, numbers of needle passes, and diagnostic ability of CH-EUS for SELs. Of the 57 included patients, 23 and 34 underwent EUS-TA with Fork-tip and Franseen needles, respectively. Technical success rates were 100% with both needles and adverse events occurred in zero (0%) and one (2.9%) patient with Fork-tip and Franseen needles, respectively. The rate of adequate sample acquisition was significantly higher using Fork-tip than Franseen needles (96% vs. 74%; p = 0.038). The hyper- or iso-vascular pattern on CH-EUS correlated significantly with a diagnosis of gastrointestinal stromal tumor (p < 0.001). EUS-TA with Fork-tip needles were superior to EUS-TA with Franseen needles in acquiring sufficient samples and CH-EUS was also useful for the diagnosis of SELs ≤2 cm.

The Diagnosis of Small Gastrointestinal Subepithelial Lesions by Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy

Endoscopic ultrasonography (EUS) has been widely accepted in the diagnosis of all types of tumors, especially pancreatic tumors, lymph nodes, and subepithelial lesions (SELs). One reason is that the examination can provide a detailed observation, with tissue samples being immediately obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Many SELs are detected incidentally during endoscopic examinations without symptoms. Most SELs are mesenchymal tumors originating from the fourth layer, such as gastrointestinal stromal tumors (GISTs), leiomyomas, and schwannomas. GISTs are potentially malignant. Surgical treatment is recommended for localized GISTs of ≥20 mm. However, the indications for the diagnosis and follow-up of GISTs of <20 mm in size are controversial. There are several reports on the rapid progression or metastasis of small GISTs. Therefore, it is important to determine whether a SEL is a GIST or not. The main diagnostic method is EUS-FNA. Recently, endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) using a new biopsy needle has been reported to obtain larger tissue samples. Additionally, various biopsy methods have been reported to have a high diagnostic rate for small GISTs. In local gastric SELs, regardless of the tumor size, EUS can be performed first; then, EUS-FNA/B or various biopsy methods can be used to obtain tissue samples for decision-making in relation to therapy and the follow-up period.

Endoscopic ultrasound-guided sampling of gastrointestinal subepithelial lesions: just wet it

INTRODUCTION

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the main method for acquisition of tissue from gastrointestinal subepithelial lesions (SELs). Despite the development of new needles, diagnostic yield remains low. A new method of aspiration has been described, where the needle is filled with saline [wet-suction technique (WST)], with promising results in pancreatic lesions. This method has not been tested in SELs.

AIMS AND METHODS

Prospective single center study to assess the diagnostic yield of EUS-FNA+WST in the diagnosis of SELs, without the use of rapid on-site evaluation. In mesenchymal tumors, the diagnosis was considered positive only when immunohistochemistry could differentiate between gastrointestinal stromal tumor and leiomyoma.

RESULTS

Eighty-seven patients with SELs were included (55% male, mean age 66 years). Mean SEL size was 25 mm (min 10 mm, max 120 mm), mean number of passes was 3 (±0.8). A 22G needle was used in 72 patients (83%), 19G in 10 (12%) and 25G in 5 (6%). We obtained a conclusive cytopathological diagnosis in 74 cases (diagnostic yield of 85%) and immunohistochemistry was performed in 70 cases (81%). The most frequent diagnoses were gastrointestinal stromal tumor (n = 34, 37%), leiomyoma (n = 13, 15%) and metastases (n = 10, 11%).

CONCLUSION

Wet suction technique allowed an excellent diagnostic yield in the EUS-guided evaluation of SELs. We suggest that, after proper replication of these results, WST may become the first-line method in the management of these lesions.

Efficacy and safety of endoscopic resection in treatment of small gastric stromal tumors: A state-of-the-art review

Gastrointestinal stromal tumors can occur in any part of the gastrointestinal tract, but gastric stromal tumors (GSTs) are the most common. All GSTs have the potential to become malignant, and these can be divided into four different grades by risk from low to high: Very low risk, low risk, medium risk, and high risk. Current guidelines all recommend early complete excision of GSTs larger than 2 cm in diameter. However, it is not clear whether small GSTs (sGSTs, i.e., those smaller than 2 cm in diameter) should be treated as early as possible. The National Comprehensive Cancer Network recommends that endoscopic ultrasonography-guided (EUS-guided) fine-needle aspiration biopsy and imaging (computed tomography or magnetic-resonance imaging) be used to assess cancer risk for sGSTs detected by gastroscopy to determine treatment. When EUS indicates a higher risk of tumor, surgical resection is recommended. There are some questions on whether sGSTs also require early treatment. Many studies have shown that endoscopic treatment of GSTs with diameters of 2-5 cm is very effective. We here address whether endoscopic therapy is also suitable for sGSTs. In this paper, we try to explain three questions: (1) Does sGST require treatment? (2) Is digestive endoscopy a safe and effective means of treating sGST? and (3) When sGSTs are at different sites and depths, which endoscopic treatment method is more suitable?

Outcomes of endoscopic ultrasound and endoscopic resection of gastrointestinal subepithelial lesions: a single-center retrospective cohort study

Background

Endoscopic resection (ER) is an emerging therapeutic alternative for subepithelial gastrointestinal lesions (SELs). We aimed to determine whether size, layer of origin, and histology based on endoscopic ultrasound (EUS) and EUS-guided sampling (EUS-GS) influenced the outcomes and selection of patients for ER.

Methods

We performed a retrospective review of patients who underwent EUS, EUS-GS and resection of SELs from 2012-2019. Two pathologists reviewed the histology and layer of origin of all resected specimens, serving as the criterion for EUS accuracy.

Results

Seventy-three patients were included, of whom 59 (81%) were gastric SELs. Per EUS, median lesion size was 21 mm (interquartile range 15-32), and 63 (86%) originated from the 4th layer. The overall accuracy of EUS and EUS-GS in predicting the layer of origin and histology was 88% (95% confidence interval [CI] 77-94%) and 96% (95%CI 87-98%), respectively. Based on EUS, 18 (25%) patients were referred for ER, 5 (7%) to laparoscopic-endoscopic cooperative surgery, and 50 (68%) to surgery. Size >20 mm was associated with the type of resection approach (P=0.005), while layer of origin and histology were not (P=0.06 and P=0.09, respectively). When SELs were inaccurately classified (n=4) there were no adverse events or revision of the resection approach.

Conclusions

EUS plays an important role in the outcome of resection approach for SELs, with size significantly influencing the selection for ER. In patients undergoing ER, no revised resections were needed when EUS was inaccurate.

Comparison of Endoscopic Submucosal Dissection Application on Mucosal Tumor and Subepithelial Tumor in stomach

Background: Endoscopic submucosal dissection is minimal invasive endoscopic procedure to deal with gastric tumor. Initially, it was developed to resect mucosal neoplasm since 2000 and extended its application to submucosal tumor in the following years. Although the basic ESD skills are similar in gastric mucosal tumor and subepithelial tumor, the success rate, complication may be different between the two types of gastric tumor resection. This retrospective study is conducted to analyze the ESD procedure in gastric mucosal tumor and subepithelial tumor.

Methods: From 2007 to 2016, we reviewed all patients who underwent endoscopic submucosal dissection for gastric mucosal tumor and subepithelial tumor in Kaohsiung Medical University Hospital.

Results: Totally, 35 patients with gastric subepithelial tumor and 41 patients with gastric mucosal tumor received endoscopic submucosal dissection are enrolled. Among 35 patients with subepithelial tumor, 32 (91.4%) patients achieved curative treatment. 1 patient received emergent operation and 2 patients received salvage operation to complete tumor resection. 8 patients (22.9%) occurred perforation and no delay bleeding was found. Among 41 patients with mucosal neoplasm, 30 (71.4%) patients achieved curative treatment. 2 patients received emergent operation and 9 patients received salvage operation to complete tumor resection. 9 patients (21.9%) occurred complication, 6 patients occurred delay bleeding and 3 patients had perforation.

Conclusions: Comparing ESD between gastric mucosal tumor and subepithelial tumor, ESD had similar efficiency in curative treatment. However, ESD in subepethelial tumor encountered higher perforation and lesser delay bleeding.

Polypoid lesions detected in the upper gastrointestinal endoscopy: A retrospective analysis in 19560 patients, a single-center study of a 5-year experience in Turkey

OBJECTIVE:

In our study, we aimed to evaluate the endoscopic features such as prevalence and localization of polypoid lesions determined by us using esophagogastroduodenoscopy and histopathological characteristics of biopsy specimens taken in detail.

METHODS:

The data of 19,560 patients undergoing upper gastrointestinal endoscopy for any reason between 2009 and 2015 in our endoscopy unit were screened retrospectively and endoscopic and histopathological findings were analyzed in detail.

RESULTS:

In our study, the polypoid lesion was detected in 1.60% (n=313) of 19,560 patients. The most common localization of the polypoid lesions was determined to be gastric localization (n=301, 96.2%) and antrum with a rate of 33.5% (n=105). When 272 patients in whom biopsy specimen could be taken was investigated, the most frequently seen lesion was polyp (n=115, 43.4%). Hyperplastic polyps (n=81, 29.8%) were the most frequently seen type among all polyps. In histopathological evaluation of the lesions, the prevalence rates of intestinal metaplasia (IM), surrounding tissue IM, atrophy, dysplasia, and neoplasia (adenocarcinoma, squamous cell carcinoma, gastrointestinal stromal tumor, neuroendocrine tumor, and metastatic tumor) among premalignant lesions were determined to be 16.9%, 11.2%, 4.1%, 1.1%, and 3.7%, respectively.

CONCLUSION:

Polypoid lesions can be seen in endoscopic investigations. In histopathological investigations, while the vast majority of these lesions are benign polyps, some of them are diagnosed as premalignant or malignant lesions. In our study, we determined malignant lesions higher than the similar studies in the literature. This condition shows how effective endoscopic procedure and histopathological evaluation are of vital importance.

EUS and EUS-guided FNA/core biopsies in the evaluation of subepithelial lesions of the lower gastrointestinal tract: 10-year experience

Background and Objective:

The widespread use of colonoscopy has led to an increasing number of subepithelial lesions (SELs) being detected in the lower gastrointestinal (GI) tract. This study aimed to analyze the utility of EUS and its role in the management of lower GI SELs.

Patients and Methods:

Records of all patients who were referred for lower EUS evaluation of a SEL at a tertiary center between 2007 and 2018 were retrospectively reviewed after IRB approval. Data collection included patient/lesion characteristics, technical details of procedure, and pathology results.

Results:

A total of 47 patients underwent EUS examinations for the evaluation of 49 suspected SEL in the lower GI tract (2 patients had 2 SELs each). Out of the 49 suspected lesions, the most frequent location was in the rectum (30/49, 61.2%). EUS showed extraluminal compression in 2 cases (2/49, 4.1%) and intraluminal lesions were identified in 40 cases (40/49, 81.6%). In 7 patients (7/49, 14.3%), no lesion could be identified by EUS. Twenty (20/49, 40.8%) SELs were malignant or had malignant potential. Twenty-six EUS-guided fine-needle aspirations (FNAs) and 14 EUS-core biopsies were performed. EUS-FNA alone was able to correctly diagnose 15/26 (57.7%) of the lower SELs. When EUS-guided fine needle biopsies (FNB) were performed during the same procedure, the final diagnosis was confirmed in 21/26 (80.8%) cases. There was only one procedure-related complication caused by use of narcotics.

Conclusion:

EUS-guided FNA/FNB are feasible and safe techniques for assessing lower GI SELs and provide valuable information regarding lesion characteristics and their malignant potential with high diagnostic accuracy.

Submucosal tunneling endoscopic resection: An effective and safe therapy for upper gastrointestinal submucosal tumors originating from the muscularis propria layer

AIM

To evaluate the effectiveness and safety of submucosal tunneling endoscopic resection (STER) and compare its outcomes in esophageal and cardial submucosal tumors (SMTs) of the muscularis propria (MP) layer.

METHODS

From May 2012 to November 2017, 173 consecutive patients with upper gastrointestinal (GI) SMTs of the MP layer underwent STER. Overall, 165 patients were included, and 8 were excluded. The baseline characteristics of the patients and SMTs were recorded. The en bloc resection rate, complete resection rate, residual rate, and recurrence rate were calculated to evaluate the effectiveness of STER, and the complication rate was recorded to evaluate its safety. Effectiveness and safety outcomes were compared between esophageal and cardial SMTs.

RESULTS

One hundred and twelve men and 53 women with a mean age of 46.9 ± 10.8 years were included. The mean tumor size was 22.6 ± 13.6 mm. Eleven SMTs were located in the upper esophagus (6.7%), 49 in the middle esophagus (29.7%), 46 in the lower esophagus (27.9%), and 59 in the cardia (35.7%). Irregular lesions accounted for 48.5% of all lesions. STER achieved an en bloc resection rate of 78.7% (128/165) for GI SMTs with an overall complication rate of 21.2% (35/165). All complications resolved without intervention or were treated conservatively without the need for surgery. The en bloc resection rates of esophageal and cardial SMTs were 81.1% (86/106) and 72.1% (42/59), respectively (P = 0.142), and the complication rates were 19.8% (21/106) and 23.7% (14/59), respectively, (P = 0.555). The most common complications for esophageal SMTs were gas-related complications and fever, while mucosal injury was the most common for cardial SMTs.

CONCLUSION

STER is an effective and safe therapy for GI SMTs of the MP layer. Its effectiveness and safety are comparable between SMTs of the esophagus and cardia.

The roles of CT and EUS in the preoperative evaluation of gastric gastrointestinal stromal tumors larger than 2 cm

OBJECTIVE

This study aimed to investigate the endoscopic ultrasound (EUS) and computed tomography (CT) features of gastric gastrointestinal stromal tumors (GISTs) for assessing potential malignancy and prognosis.

METHODS

Fifty consecutive patients with primary gastric GISTs larger than 2 cm were retrospectively enrolled in this study. The association of CT and EUS features with malignancy was analyzed using univariate and stepwise logistic regression method. The agreement between EUS/CT lesion size and pathologic tumor size was analyzed by calculating the intraclass correlation coefficient (ICC) value, and the association of imaging features with mitotic counts was further analyzed using univariate analysis. The Kaplan-Meier method and Cox proportional hazards models were used to assess the value of imaging features for predicting the prognosis of GIST patients.

RESULTS

Tumor size > 5 cm and an exophytic/mixed growth pattern on CT as well as tumor size > 5 cm and the presence of cystic spaces on EUS were independent predictors of highly malignant GISTs (all p < 0.05). The ICC values of CT/EUS lesion size relative to pathologic tumor size showed very good reliability (0.853 for EUS and 0.831 for CT). Only tumor shape and growth pattern on CT were significant for predicting mitotic index (both p < 0.05). Direct organ invasion on CT (p = 0.036; hazard ratio [HR] = 11.891) and serosal invasion on EUS (p = 0.015; HR = 8.223) were independent adverse prognostic factors.

CONCLUSIONS

CT features may be more useful than EUS features for predicting tumor mitotic index. In addition, preoperative imaging features can help predict the prognosis of gastric GISTs.

KEY POINTS

• Both CT and EUS features can be used for risk stratification of gastric GISTs larger than 2 cm. • CT features performed better than EUS features for predicting tumor mitotic index. • Preoperative imaging features can help predict the prognosis of gastric GISTs.

Characterization of subepithelial lesions of the stomach and esophagus by contrast-enhanced EUS: A retrospective study

Background and Objectives:

Subepithelial lesions (SELs) of the upper part of the digestive tract are rare, and it can be difficult to characterize them. Recently, contrast-enhanced endosonography (EUS) and elastometry have been reported as useful adjuncts to EUS and EUS-guided fine needle aspiration (EUS-FNA) in cases of pancreatic mass and lymph node involvement. The aim of this retrospective analysis was to evaluate whether contrast-enhanced EUS can discriminate benign submucosal lesions from malignant ones. We describe our retrospective experience using the contrast agent SonoVue^® (Bracco Imaging, Milan, Italy) in an attempt to increase the diagnostic yield.

Patients and Methods:

Between May 2011 and September 2014, 14 patients (5 men, 9 women; median age 64 years, range 31–80 years) with SELs of the stomach or esophagus underwent EUS with SonoVue^® (low mechanical index). There were 3 esophageal lesions and 11 gastric lesions. Mean size of the lesions was 30 mm (range 11–50 mm). They were discovered after anemia (n = 5), dysphagia (n = 1), and pain (n = 4) and during follow-up for resected gastrointestinal stromal tumors (GISTs) (n = 1) and a standard upper gastrointestinal endoscopy (n = 3). On endoscopic sonograms, 10 of these lesions were hypoechoic and located in the fourth layer (muscularis), and 4 were in the second or third layer (mucosa and submucosa). Contrast enhancement was assessed in the early phase (after several seconds) and late phase (>30 seconds); a final diagnosis was made based on the findings of EUS-FNA using a 19-gauge ProCore (Cook Medical, Bloomington, IN) (n = 9) or 22-gauge FNA system (Cook Medical) (n = 1), the resected specimen (n = 3), or deep biopsy (n = 1). Different immunostaining was used in the pathologic studies (RNA was analyzed later using the C-kit, CD-117, CD-34, desmin, DOG-1, α-smooth actin, caldesmon, PS-100, and Ki-67 antibodies).

Results:

Final diagnoses were leiomyoma (n = 4), GIST (n = 5), schwannoma (n = 1), inflammatory tumor of Helvig (n = 1), pancreas rest (n = 2), and fibrosis (n = 1). No complications occurred. All 5 GISTs showed enhancement in the early and late phases, whereas the 8 remaining lesions did not show any enhancement. Only 1 leiomyoma showed heterogeneous enhancement.

Limitations:

The monocentric and retrospective study design and small number of patients.

Conclusions:

In cases of SELs of the stomach or esophagus, SonoVue^® could be a complementary tool to endosonography to differentiate GISTs (early and clear enhancement) from other SELs (few or no enhancement), such as leiomyomas or pancreatic rest. These results are similar to those of the few, small studies published on this topic, but more studies with a larger number of patients are needed to confirm these findings.

Comparison between submucosal tunneling endoscopic resection and video-assisted thoracoscopic enucleation for esophageal submucosal tumors originating from the muscularis propria layer: a randomized controlled trial

BACKGROUND AND AIMS

Surgical resection is considered the first treatment option for submucosal tumors (SMTs) originating from the muscularis propria layer while submucosal tunneling endoscopic resection (STER) is proved to be a safe and effective method for treating SMTs. This study aimed to compare video-assisted thoracoscopic enucleation (VATE) with STER for treating esophageal SMTs.

METHODS

Sixty-six patients with small esophageal SMTs were prospectively randomized from July 2014 to December 2015. After exclusion of 8 patients, 58 subjects scheduled for STER or VATE were enrolled. Clinicopathological, endoscopic, and adverse events (AEs) data were collected and analyzed between STER and VATE.

RESULTS

Forty-six males and 12 females with a mean age of 46.1 ± 9.4 years were randomized to the STER (n = 30) and VATE (n = 28) groups, respectively. Demographics and lesion features were similar between the two groups. Median procedure time was shorter in the STER group than the VATE group (44.5 vs. 106.5 min, P < 0.001); cost was lower in the STER group (4499.46 vs. 6137.32 USD, P = 0.010). Median decrease in hemoglobin levels post-procedure was - 1.6 g/L in the STER group and 14.7 g/L after VATE (P = 0.001). Lower postoperative pain scores were found in the STER group compared with the VATE group (2 vs. 4, P < 0.001). No recurrent or residual tumors were found in either group. En bloc resection rates, complete resection rates, hospital times, and post-procedure AEs were similar between two groups. The en bloc resection rates for SMTs < 20.0 mm were 100% in both groups while STER achieved only 71.4% en bloc resection rate for SMTs ≥ 20.0 mm.

CONCLUSION

STER and VATE are comparably effective for esophageal SMTs; however, STER is superior to VATE with shorter operation time and decreased cost, and seems safer than VATE. STER is recommended for SMTs < 20.0 mm while VATE is recommended for SMTs with a transverse diameter > 35.0 mm. Clinical trail registration statement: This study is registered at http://www.chictr.org.cn/showproj.aspx?proj=4814 . The registration identification number is ChiCTR-TRC-14004759. The registration date is April 30, 2014.

Ectopic pancreas in the upper gastrointestinal tract: Is endosonographic diagnosis reliable? Data from the German Endoscopic Ultrasound Registry and review of the literature

Background:

Ectopic pancreas (EP) belongs to the most frequent subepithelial lesions (SELs) of the upper gastrointestinal (GI) tract. In the majority of cases, it is detected incidentally. Differential diagnosis from mesenchymal subepithelial tumors may be difficult.

Methods:

Among 24,308 endosonographic examinations and interventions, which were prospectively enrolled in the database of the German Endoscopic Ultrasound (EUS) Registry from January 2009 to August 2013, 575 were performed for suspected SELs of the upper GI tract. Sixty three cases of EP of the upper GI tract (stomach, n = 53; duodenum, n = 10; esophagus, n = 0) were extracted and retrospectively reviewed.

Results:

In 65.1% of cases, radial echoendoscopes or radial miniprobes were used for examination. Nearly 84% of EP was found in the stomach, 16% in the duodenum, none in the esophagus. In 88.9% of cases, the EUS examination discerned the layer of origin. In 59% of cases EP was described as a heterogeneous, in 28.6% as a homogeneous-hypoechoic and in 7.9% as a homogeneous-echogenic subepithelial mass lesion. Mean diameter was 13.0 mm × 8.1 mm, the mean ratio between long and short axis diameter was 1.75. EUS-guided fine needle aspiration (EUS-FNA) was used to accomplish cytological or histological diagnosis in only 6.3% of cases.

Conclusions:

EP accounts for 11% of all EUS examinations performed for subepithelial lesions of the upper GI tract and prospectively enrolled in the German EUS registry. Rather than being an eyecatcher, EP is a chameleon with numerous differential diagnoses. In selected cases, EUS-FNA may help clarifying the diagnosis.

The impact of age and sex on the occurrence of pathology in the wall of the upper gastrointestinal tract

Introduction

The growing incidence of gastrointestinal diseases forces to improve both imaging techniques and the identification of the population with a greater risk of a disease. Identification of lesions located inside the wall of intestinal tract or in close proximity often was not possible using endoscopy or computed tomography.

Aim

The study was a retrospective evaluation of the occurrence of submucosal lesions (SML) and thickened wall (TW) of the upper gastrointestinal tract (UGIT) depending on age and sex.

Material and methods

Out of 20012 gastroscopies during the 4-year follow-up study, we enrolled 199 patients with pathological lesions in the wall of the UGIT. All patients underwent computed tomography and endoscopic ultrasound (EUS).

Results

We analysed a total of 122 (78 males, 44 females, age: 64.0 ±12.9 years) out of 187 patients. 23.91% of SML in the oesophagus, 56.52% in the stomach, and 19.57% in the duodenum. A higher number of SMLs was found in men than in women (57.14% vs. 40.45%, p = 0.023), and the difference was greater over 50 years of age (85.71% vs. 40.00%, p = 0.031). We found less malignant SMLs compared to benign (35.87% vs. 64.13%, p = 0.026), especially in women (22.86% vs. 47.46%, p = 0.006). 26.67% of TW were in the oesophagus, 66.67% in the stomach, and 6.67% in the duodenum. There was a tendency towards increased incidence of TW over 50 years of age (8.58% vs. 18.30%, p = 0.074), which concerned men in particular (24.10% vs. 11.43%, p = 0.043). Until 65 years of age, these differences were significant for the oesophagus (27.27% vs. 0.00%, p = 0.044) and the stomach (25.93% vs. 4.00%, p = 0.029). As many as 70% of TW pathologies were malignant.

Conclusions

Submucosal lesions and TW of the upper gastrointestinal tract account for 0.61% of performed gastroscopies. They occur in men and usually over 50 years of age.

Endoscopic submucosal tunnel dissection of upper gastrointestinal submucosal tumors: A comparative study of hook knife vs hybrid knife

AIM

To compare the efficacy and safety of a hook knife (HO) with a hybrid knife (HK) during endoscopic submucosal tunnel dissection (ESTD) procedure.

METHODS

Between August 2012 and December 2015, the ESTD procedure was performed for 83 upper GI submucosal lesions, which originated from the muscularis propria layer identified by upper endoscopy and endoscopic ultrasonography. Of these, 34 lesions were treated by a HO, whereas 49 lesions were treated by a HK. Data regarding age, gender, presenting symptoms, tumor location and size, procedure time, complications, en bloc resection rate and others were analyzed and compared between the two groups.

RESULTS

There were no significant differences in the age, gender, presenting symptoms and tumor location between the two groups. ESTD was successfully completed in all the patients, and no case was converted to laparoscopy. The mean procedure time was significantly shorter in the HK group than in the HO group (41.3 ± 20.3 min vs 57.2 ± 28.0 min, P = 0.004). The mean frequency of device exchange was 1.4 ± 0.6 in the HK group and significantly less than 3.3 ± 0.6 in the HO group (P < 0.001). The differences in tumor size and histopathological diagnoses were not significant between the two groups (P = 0.813, P = 0.363, respectively). Both groups had an equal en bloc resection rate and complete resection rate. Additionally, the complication rate was similar between the two groups (P = 0.901). During the follow-up, no recurrence occurred in either group.

CONCLUSION

We demonstrate for the first time that HO and HK do not differ in efficacy or safety, but HK reduces the frequency of device exchange and procedure time.

Diagnostic performance of stomach CT compared with endoscopic ultrasonography in diagnosing gastric subepithelial tumors

PURPOSE

To evaluate the diagnostic ability of multi-detector computed tomography (MDCT) compared to endoscopic ultrasonography (EUS) as a standard reference, and investigate the factors influencing the detection of small gastric subepithelial tumors (SETs) (<5 cm) on MDCT with stomach protocol.

METHODS

We retrospectively investigated 70 patients who were suspected with gastric SETs on esophagogastroduodenoscopy (EGD), and underwent both EUS and computed tomographic (CT) scanning. EUS was performed by two gastroenterologists, and location, size, echotexture, echogenicity, and layer of origin were described when gastric SETs were detected on EUS. MDCTs were reviewed based on consensus of two radiologists blinded to the EUS result. Size, location, enhancement pattern, and contour of the lesion detected on CT were described. We calculated the diagnostic ability of CT compared to EUS with respect to detection of gastric SETs, and investigated the factors influencing detection of SETs on CT. We also used receiver operating characteristic (ROC) curve to obtain optimal cut-off size for predicting CT visibility of small SETs.

RESULTS

Of the 70 patients, who underwent both CT and EUS due to suspicious presence of SET on EGD, EUS detected 56 probable cases of SET and 14 cases of external compression. CT led to detection of 39 cases of SET out of the 56 cases. Sensitivity and specificity of CT was 69.6% and 100.0%, respectively. Positive predictive value (PPV) and negative predictive value (NPV) of CT were 100.0% and 45.2%, respectively. There was a significant difference in mean size of CT-detected lesions compared to CT-invisible lesions (14.36 mm vs. 8.52 mm, p < 0.001), but no significant differences in terms of layer of origin and location between these two groups (p > 0.5) were observed. The ROC analysis revealed that the optimal cut-off value, also referred to prediction of CT visibility, was 10 mm. Out of 70 cases, 26 cases (37.14%) were identified as external compression or insignificant lesions such as lipoma, hemangioma, lymphangioma, or gastritis cystica on CT, and do not require regular follow-up.

CONCLUSIONS

Stomach CT shows good feasibility with respect to depiction of small SETs, especially in cases where size is larger than 10 mm. Henceforth, it is proposed that stomach CT would be a complimentary or problem-solving tool for SET in evaluating the presence of external compression and characterization of tumors.

The role of EUS and EUS-guided FNA in the management of subepithelial lesions of the esophagus: A large, single-center experience

BACKGROUND

Referral for endosonographic evaluation of subepithelial lesions seen in the gastrointestinal (GI) tract is fairly common. Although rarely studied separately in details, esophageal lesions have some unique differences from other GI sites and might deserve some special considerations regarding follow-up and management.

MATERIALS AND METHODS

All cases referred for endoscopic ultrasound (EUS) evaluation of subepithelial esophageal lesions at Bezmialem University Hospital, a tertiary center in Istanbul, Turkey were retrospectively reviewed. Data were collected for patient and lesion characteristics as well as for pathology results and follow-up if available. Lesions were subcategorized according to their size, location, and final diagnosis.

RESULTS

A total of 164 EUS examinations were identified. In 22.5% of cases, the lesion could not be identified by EUS. Of the remaining cases, 57.6% had a lesion larger than 1 cm in size. Extramural compression was the diagnosis in 12% and leiomyoma in around 60%. Thirteen patients had follow-up examinations with only two showing an increase in size after 12 months. Sixty-five EUS-guided fine needle aspirations (EUS-guided FNAs) were performed, with around 50% having nondiagnostic samples and 94% of the remaining samples confirming the presumptive diagnosis.

CONCLUSIONS

The majority of subepithelial lesions in the esophagus are benign with extremely low malignancy potential. EUS examinations performed for lesions smaller than 2 cm as well as FNAs taken from lesions smaller than 3 cm might have minimal impact on their ultimate management and outcome. More than one FNA pass should be attempted in order to improve the yield.

Endoscopic ultrasound with tissue sampling is accurate in the diagnosis and subclassification of gastrointestinal spindle cell neoplasms

Background and Objectives:

Mesenchymal (spindle cell) neoplasms (SCN) of the gastrointestinal (GI) tract are an important subtype of subepithelial lesions that need subclassification to assess their malignant potential. Reported success rates of accurate subclassification with endoscopic ultrasound (EUS)-guided biopsies are variable. Our goal was to analyze our experience using EUS-guided TruCut biopsy (EUS-TCB) in the majority of patients.

Methods:

Retrospective analysis in patients who underwent EUS with biopsies for suspected SCN at our tertiary referral center between 2004 and 2013.

Results:

A total of 146 patients with suspected SCN underwent EUS with tissue acquisition. Thirteen patients were excluded from analysis because tissue acquisition established a definite diagnosis other than SCN. In the remaining 133 patients, tissue acquisition was diagnostic of SCN in 118 (88.7%) and nondiagnostic in 15 (11.3%). Subclassification based on immunohistochemistry (IHC) was possible in 109 of the 133 cases (81.9%). The final diagnosis was GI stromal tumor in 64, leiomyoma in 39, and schwannoma in 6 cases. The percentage of patients who were subclassified by the various EUS-guided techniques together was 72.18%, and the percentage of patients who were subclassified specifically with EUS-TCB was 61.65%. Tissue specimens that enabled a specific diagnosis based on histological or cytological characteristics in conjunctions with IHC were obtained with EUS core biopsy in 83 (TCB in 82 and ProCore needle biopsy in 1), fine-needle aspiration in 13, mucosal resection in 10, and forceps biopsies (bite-on-bite) in 3 cases.

Conclusion:

EUS with endoscopic tissue acquisition is accurate in the diagnosis and subclassification of SCN. In experienced hands, the EUS-TruCut needle is a valuable tool with a high success rate for this indication.

Heterotopic pancreas: a clinicopathological study of 184 cases from a single high-volume medical center in China

Heterotopic pancreas (HP) is often an incidental finding during operative or endoscopic procedures and described in case reports and small series in the literature. Large clinicopathological studies with a systematic analysis remain lacking. Herein, we identified 184 (0.18%; 184/99 544) consecutive histology-proven HP cases of 89 770 surgical resections and 9774 upper endoscopic biopsies carried out at a single medical center in China. Each case was diagnosed by unequivocal identification of pancreatic acini at a location outside the pancreas. The patients' median age was 49 years (range, 14-82) with a slight female predominance (male/female ratio, 0.94). Clinical presentation at diagnosis was nonspecific. Preoperatively, most (54.9%; 101/184) HP lesions were misdiagnosed. Only 26 HP lesions (14.1%) were correctly diagnosed, all in the stomach except for 1 in the duodenum; 57 (31%) were detected during operative procedures for other conditions. The most frequent location of HP was, in descending order, the stomach (97; 52.7%), small intestine (48; 26%), lesser and greater curvature omentum (18; 10%), spleen and hilar region (5; 2.7%), porta hepatis (2; 1%), gallbladder (1; 0.5%), peridistal esophageal tissue (4; 2.2%), and mesentery (7; 3.8%). The size of HP varied from smaller than 0.5 cm (35.3%), 0.6 to 1 cm (34.8%), to larger than 1.1 cm (29.9%). Because of difficulty in preoperative diagnosis, careful workup for upper gastrointestinal diseases with HP as a differential diagnosis may increase the chance of accurate diagnosis and appropriate patient management.

Feasibility of endoscopic submucosal dissection for upper gastrointestinal submucosal tumors treatment and value of endoscopic ultrasonography in pre-operation assess and post-operation follow-up: a prospective study of 224 cases in a single medical center

BACKGROUND AND AIMS

Diagram, diagnosis, and treatment with endoscopic submucosal dissection (ESD) for upper gastrointestinal submucosal tumors (SMTs) remain controversial, although endoscopic ultrasonography (EUS) and ESD have been established in diagnosis and treatment of SMTs in decades, respectively. In this study, we have investigated prospectively the profile of upper gastrointestinal SMTs, assessed the effect and feasibility of ESD in upper gastrointestinal SMTs treatment, as well as value of EUS in pre-ESD diagnosis and post-ESD follow-up for gastrointestinal SMTs.

METHODS

The upper gastrointestinal SMTs patients detected with endoscopy were further checked by EUS, then received series ESD treatment, and fulfilled 3- and 12-month follow-up EUS detection between July 2011 and March 2015. The parameters of SMTs with EUS examination (size, original layer) and treatment with ESD (en bloc resection rate, procedure time, procedure-related complications) were investigated and analyzed.

RESULTS

A total number of 224 patients with upper gastrointestinal SMTs were enrolled, and 108 (48.2 %) were men. The mean age was 50.4 ± 12.0 years (range 19-77 years). In total, 92 (41.1 %), 14 (6.3 %), 61 (27.2 %), 22 (9.8 %), 25 (11.2 %), and 10 (4.5 %) SMTs were located in esophagus, cardiac, fundus, body and antrum of stomach, duodenum, respectively. Two hundred and eight (92.9 %) patients were successfully treated with an en bloc ESD, while other 16 patients (7.1 %) suffered ESD failure (5.3 %, 12 case) or severe complications (1.8 %, 4 cases). The mean procedure time of ESD was 47.4 ± 27.3 min (range 10-180 min). The mean size of the SMTs measured with ESD samples was 13.6 ± 9.5 mm (range 4-113 mm). In total, 87 (38.8 %), 23 (10.3 %), and 114 (50.9 %) tumors originated from muscularis mucosa, submucosa, and muscularis propria, respectively. The majority of SMTs were leiomyoma (109, 48.7 %) and gastrointestinal stromal tumors (GIST) (77, 34.4 %), while other SMTs were confirmed as ectopic pancreas (21, 9.4 %), adenoid tumor (8, 3.6 %), lipoma (5, 2.2 %), neuroendocrine tumor (3, 1.3 %), and granulosa cell tumor (1, 0.4 %). The accuracy rate of EUS in pathological diagnosis or original layer was 82.6 % (185/224) or 74.6 % (167/224). Residual tumors were detected with EUS in 3 patients (1.3 %) in 3-month follow-up and no recurrence during 12-month follow-up period.

CONCLUSIONS

The predominant SMTs in upper gastrointestinal tract were leiomyoma in esophageal tumors which originated from muscularis mucosae and GIST in stomach which originated from muscularis propria detected satisfactorily with EUS. This study showed that ESD was a safe and effective treatment for upper gastrointestinal SMTs.

Efficiency and safety of endoscopic resection in the management of subepithelial lesions of the stomach

BACKGROUND

Gastric subepithelial tumors represent a diagnostic and therapeutic challenge, given their histologic heterogeneity and potential malignant behavior.

OBJECTIVE

The objective of this article is to evaluate the interest, efficiency and safety of endoscopic resection for subepithelial gastric lesions of size <20 mm.

METHODS

We conducted a single-center retrospective study in a tertiary care center.

RESULTS

A total of 33 lesions (10 malignant/23 benign lesions) were studied. Mean histological size was 14.5 mm. Nine EMR, 18 ESD and six hybrid resections were performed. A total of 93.9% lesions were resected in one piece. At six months' follow-up, complete and definitive resection was obtained in 96.7% of cases. A vertical resection was insufficient in four cases. One GIST needed a complementary surgical resection, one neuroendocrine tumor was successfully treated by a new ESD session and two pancreatic rests were not additionally treated given the benign character and the absence of residual tissue in endoscopic control after six months. There was only one severe adverse event (2.9%); one pneumoperitoneum with ESD, three bleeding with one ESD and two EMR, always treated conservatively or endoscopically.

CONCLUSION

Endoscopic resection is safe and should be the procedure of choice for both diagnosis and definitive resection of subepithelial gastric lesions of size under 20 mm.

Colorectal Subepithelial Lesions

Most of subepithelial lesion (SEL) being identified was accidentally discovered as small bulging lesion covered with normal mucosa from endoscopic screening. The type of treatment and prognosis vary depending on the type of tumor, it would be crucial to perform an accurate differential diagnosis. Since the differentiation of SEL relied on the indirect findings observed from the mucosal surface using an endoscopy only in the past, it was able to confirm the presence of lesion only but difficult to identify complex detailed nature of the lesion. However, after the endoscopic ultrasonography (EUS) was introduced, it became possible to identify extrinsic compression, and size of intramural tumors, internal properties and contour so that it gets possible to have differential diagnosis of lesions and prediction on the lesion whether it is malignant or benign. In addition, the use of EUS-guided fine needle aspiration and EUS-guided core biopsy made it possible to make histological differential diagnosis. This study intended to investigate endoscopic and EUS findings, histological diagnosis, treatment regimen and impression of colorectal SELs.

Submucosal tunneling and endoscopic resection of submucosal tumors at the esophagogastric junction

AIM: To evaluate the safety and efficacy of submucosal tunneling and endoscopic resection (STER) for treating submucosal tumors (SMTs).

METHODS: Between August 2012 and October 2013, 21 patients with SMTs originating from the muscularis propria (MP) layer at the esophagogastric junction were treated by STER of their tumors. Key steps of the procedure include: (1) mucosal incision: a 2-cm longitudinal mucosal incision was made 5 cm proximal to the tumor; (2) submucosal tunneling: a submucosal tunnel was created 5 cm proximal to and 1 to 2 cm distal to the tumor; (3) tumor resection: the SMT was resected under direct endoscopic viewing; (4) hemostasis: while finishing the tumor resection, careful hemostasis of the MP defect and the tunnel was performed; and (5) mucosal closure: the mucosal incision site was closed by using hemostatic clips. During the operation, equipment used included a cap-fitted endoscope, an insulated-tip knife, a hook knife, hemostatic forceps, an injection needle, a snare, an endoclip, and a high-frequency generator. Carbon dioxide (CO₂) insufflation was achieved by using a CO₂ insufflator.

RESULTS: The median age of the patients was 46.2 years (range, 35-59 years), and the majority were male (18 male vs 3 female). Complete resection rate was 100% (21/21). Eighteen lesions were resected en bloc. Mean tumor size was 23 mm (range, 10-40 mm), and mean procedure time was 62.9 min (range, 45-90 min). Pathological diagnosis of these tumors included leiomyoma (15 out of 21) and gastrointestinal stromal tumor (6 out of 21). Full-thickness MP resection was performed in 9 of 21 patients (42.9%), with mediastinal and subcutaneous emphysema occurring in all nine. At the completion of the procedure, all patients received closure of the incision with hemoclips. One patient required percutaneous drainage. The remaining 20 patients required no further endoscopic or surgical intervention. There were no incidents of massive or delayed bleeding. The median follow-up period after the procedure was 6 mo (range, 2-14 mo). During follow-up, no patients were found to have residual or recurrent tumor or esophageal stricture.

CONCLUSION: STER is safe, effective and feasible, which provides accurate histopathologic evaluation and curative treatment for SMTs originating from the MP layer at the esophagogastric junction.

Angiolipoma of the stomach presenting with anaemia

Angiolipoma is a morphological variation of the lipoma and is a benign tumour that consists of mature adipose tissue and proliferating blood vessels. It occurs very rarely in the digestive tract, especially the stomach. We report a gastric angiolipoma in a 58-year-old woman admitted for anaemia and melena. Endoscopy showed a large polypoid mass with superficial ulceration in the anterior wall of the gastric antrum. Endoscopic ultrasound showed an about 2 cm sized isoechoic lesion at the third echo layer, with the echogenic portion on the luminal side of the lesion. Laparoscopic wedge resection was performed and histological examination showed that the lesion had encapsulated adipose tissue at the submucosal layer and stromal fibrosis just below superficial ulceration. There were blood vessels with thick walls among the mature fat cells. Therefore, the lesion was diagnosed as an angiolipoma.

Endoscopic management of upper gastrointestinal submucosal tumors arising from muscularis propria

Small (<2 cm) or incidentally found gastrointestinal submucosal tumors pose challenges to gastroenterologists due to the potential malignancy of tumors and current suboptimal diagnostic methods. On the basis of the development of endoscopic submucosal dissection, recent technical advances, including endoscopic submucosal excavation, submucosal tunneling and endoscopic resection, and endoscopic full-thickness resection, have been able to resect submucosal tumors in the muscularis propria. These techniques provide definitive histologic diagnosis as well as a minimally invasive therapeutic approach to such tumors. Current studies, despite with promising results, are limited to small, retrospective studies, focusing on introducing new methods and varied in technical details. This review provides a thorough discussion of technical details of each endoscopic method, and compares different methods in terms of tumor sites, to ensure safety and optimize treatment outcomes.

Acute ectopic pancreatitis occurring after endoscopic biopsy in a gastric ectopic pancreas

Ectopic pancreas is a congenital anomaly and the most common type of ectopic tissue in the gastrointestinal tract. Most patients with an ectopic pancreas are asymptomatic and rarely have complications. Ectopic pancreatitis after an endoscopic biopsy has not been reported. We report a patient who developed acute ectopic pancreatitis in the stomach after an endoscopic biopsy. A 71-year-old male patient presented with a subepithelial tumor (SET) in the stomach and had no symptoms. Endoscopic ultrasonography demonstrated a 30-mm hypoechoic mural mass, lobulated margins, and anechoic duct-like lesions. To obtain proper tissue specimen, endoscopic biopsy was performed through the opening on the surface of the mass. The pathologic results confirmed an ectopic pancreas. One day after the endoscopic biopsy, he developed persistent epigastric pain. His serum amylase and lipase elevated. Computed tomography of the abdomen showed swelling of the SET and diffuse edema of the gastric wall. His condition was diagnosed as acute ectopic pancreatitis occurring after endoscopic biopsy.

Ectopic pancreas in upper gastrointestinal tract: MRI findings with emphasis on differentiation from submucosal tumor

BACKGROUND

Ectopic pancreas can frequently be mistaken for other submucosal masses. Ectopic pancreas may follow the signal intensity of mother pancreas on various magnetic resonance (MR) sequences, which might be helpful for differentiation between ectopic pancreas and other submucosal tumors in upper gastrointestinal (UGI) tract.

PURPOSE

To evaluate the value of MR imaging (MRI) in differentiating ectopic pancreases from submucosal tumors in UGI tract.

MATERIAL AND METHODS

Fifteen patients with ectopic pancreas and 26 patients with UGI submucosal tumors were included. All patients underwent abdominal MRI with diffusion-weighted imaging (DWI) and gadoxetic acid-enhanced MRI. Qualitative (location, contour, growth pattern, lesion border, and presence of intralesional cystic portion and duct-like structure) and quantitative (long diameter [LD], short diameter [SD], LD/SD ratio, signal intensities and apparent diffusion coefficients [ADC], and signal intensity - and ADC ratios of UGI submucosal lesions to pancreas) parameters were compared between ectopic pancreases and UGI submucosal tumors using Fisher's exact test, the Mann-Whitney U test, and receiver-operating characteristic (ROC) analysis.

RESULTS

Duodenum was the most common location for ectopic pancreas (12/15, 79.9%), and the gastric body for UGI submucosal tumors (15/26, 57.7%) (P = 0.005). Round shape was an imaging feature more common in UGI submucosal tumors (12/26, 46.2%) than in ectopic pancreas (1/15, 6.7%; P = 0.021). On all of the various pulse sequences of MR images, ectopic pancreas showed isointensity comparable to that of pancreas more frequently than did sequences of UGI submucosal tumors (P < 0.01).The means (0.95 ± 0.09, 0.99 ± 0.06, 1.07 ± 0.08) of the signal intensity ratio of ectopic pancreas to pancreas on fat-suppressed unenhanced T1-weighted, arterial, and portal phase images were significantly higher than those (0.60 ± 0.09, 0.62 ± 0.28, 0.86 ± 0.27) of UGI submucosal tumors (P < 0.05). In contrast, the means (1.05 ± 0.12, 0.93 ± 0.18) of the signal intensity ratios of ectopic pancreas on T2-weighted images and DW images (b = 800 s/mm(2)) were significantly lower than those (1.82 ± 0.39, 2.35 ± 0.94) of UGI submucosal tumors (P < 0.001). On ROC analysis, if absolute value of difference between 1.0 and signal intensity ratio of submucosal lesions to the pancreas on T1-weighted images is <0.21, the sensitivity and specificity reach 100.0% for diagnosis ectopic pancreas from submucosal tumors.

CONCLUSION

Abdominal MRI with DWI can be a valuable tool for differentiating ectopic pancreases from UGI submucosal tumors.

Endoscopic ultrasonography for gastrointestinal submucosal lesions

Advances in endoscopic imaging technology have led to the detection of more cases of gastrointestinal submucosal lesions (SMLs). Endoscopic ultrasonography (EUS) was previously known as the best imaging procedure to characterize SMLs. However, the progress of endoscopic submucosal dissection (ESD) has raised some new questions concerning the role of EUS in the diagnosis of SMLs. What is the diagnostic accuracy of EUS for SMLs? How is the nature of SMLs determined? How is the layer of origin identified? What is the preoperative value of EUS for ESD? In this review, we will discuss the endosonographic features of SMLs, the diagnostic accuracy of EUS, the ability of EUS to distinguish benign and malignant SMLs, the value of EUS-guided fine-needle aspiration (FNA), and the value of EUS in clinical surveillance.

Gastric calcifying fibrous tumor removed by endoscopic submucosal dissection

The World Health Organization describes calcifying fibrous tumors (CFTs) as rare, benign lesions characterized by hypocellular, densely hyalinized collagenization with lymphoplasmacytic infiltration. These tumors rarely involve the gastrointestinal (GI) tract. A routine endoscopic upper gastrointestinal screen detected a 10-mm submucosal tumor (SMT) in the lesser curvature of the lower corpus of the stomach of an apparently healthy, 37-year-old woman with no history of Helicobacter pylori infection. Endoscopic ultrasonography (EUS) localized the internally isoechoic, homogeneous SMT mainly within the submucosa. Malignancy was ruled out using endoscopic submucosal dissection (ESD). A pathological examination confirmed complete resection of the SMT, and defined a hypocellular, spindle-cell tumor with a densely hyalinized, collagenous matrix, scattered lymphoplasmacytic aggregates as well as a few psammomatous, dystrophic calcified foci. The mass was immunohistochemically positive for vimentin and negative for CD117 (c-kit protein), CD34, desmin, smooth muscle actin (SMA) and S100. Therefore, the histological findings were characteristic of a CFT. To date, CFT resection by ESD has not been described. This is the first case report of a gastric calcifying fibrous tumor being completely resected by ESD after endoscopic ultrasonography.

Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia

BACKGROUND AND AIMS

Endoscopic resection of esophageal or cardial subepithelial tumors (SETs) originating from the muscularis propria (MP) is rarely done due to the high risk of perforation, fistula formation, and secondary infection. The aim of this study was to evaluate the preliminary clinical feasibility and safety of tunneling endoscopic muscularis dissection (tEMD) for resection of SETs located in the esophagus and gastric cardia

METHODS

Twelve patients with SETs originating from the MP of the esophagus (n = 7) or cardia (n = 5) were treated by tEMD. The procedure included creation of a submucosal tunnel to reach the tumor, dissection of the tumor from the surrounding submucosal tissue and the unaffected MP layer, full-thickness resection of the tumor and affected MP, and subsequent closure of the tunnel mucosal entry with endoscopic clips.

RESULTS

The en bloc resection rate was 100 % (seven lesions affected the deep MP so complete MP resection was performed; five lesions affected the superficial MP for a partial MP resection). The average tumor size was 18.5 ± 6.9 (range 10-30) mm. The mean operating time was 78.3 ± 25.5 (range 50-130) min. The histological diagnoses were two gastrointestinal stromal tumors with very low risk, nine leiomyomas, and one schwannoma. Air leakage and effusion included subcutaneous and mediastinal emphysema in eight patients (66.7 %), pneumothorax in four (33.3 %), pneumoperitoneum in three (25.0 %), and small pleural effusion in two (16.7 %). All air leakage and effusion cases were resolved with conservative management. No patient developed delayed hemorrhage and chronic fistula after tEMD. During the mean follow-up time of 7.1 ± 4.3 (range 2-15) months, no tumor recurrence was found in any patient.

CONCLUSIONS

tEMD appears to be a feasible minimally invasive and effective treatment for patients with SETs originating from the MP layer of the esophagus and cardia.

[Clinicopathologic feature of esophageal submucosal tumors treated by surgical approach]

BACKGROUND/AIMS

Submucosal tumors of the esophagus are rare lesions among all esophageal neoplasms. The purpose of this study was to evaluate the clinicopathologic features of esophageal submucosal tumors treated by surgical approach.

METHODS

We analyzed the clinicopathologic and endoscopic ultrasonographic features of 18 esophageal submucosal tumors which were treated by surgical approach at Boramae Medical Center and Seoul National University Bundang Hospital from January 2005 to June 2012.

RESULTS

The mean age was 48.9 years old and male to female ratio was 2.6 : 1. Asymptomatic patients were most common (77.8%). In endoscopic ultrasonographic finding, the majority tumor arouse in the middle (55.6%) and lower (44.4%) esophagus, and appeared as hypoechoic lesion (72.2%) in the 4th layer (83.3%). The most common indication for surgical approach was unclear biological behavior of the tumor. Minimally-invasive technique using thoracoscopy was applied for the enucleation (83.3%). The mean diameter of the tumor was 5.4 cm, and the final diagnosis was leiomyoma (89.9%) and gastrointestinal stromal tumor (11.1%).

CONCLUSIONS

Leiomyoma was the most common submucosal tumor in esophagus. However, endoscopic ultrasonography was not able to differentiate between leiomyoma and gastrointesinal stromal tumor. For more accurate diagnosis and treatment, minimally-invasive approaches may be suitable for the surgical enucleation of indicated esophageal submucosal tumor.

Upper endoscopy versus endosonography in differential diagnosis of gastrointestinal bulging

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.

Digital image analysis is a useful adjunct to endoscopic ultrasonographic diagnosis of subepithelial lesions of the gastrointestinal tract

OBJECTIVE

The purpose of this study was to explore the role of digital image analysis in differentiating endoscopic ultrasonographic (EUS) features of potentially malignant gastrointestinal subepithelial lesions (SELs) from those of benign lesions.

METHODS

Forty-six patients with histopathologically confirmed gastrointestinal stromal tumors (GISTs), carcinoids, and lipomas who had undergone EUS evaluation were identified from our database. Representative regions of interest (ROIs) were selected from the EUS images, and features were extracted by texture analysis. On the basis of these features, an artificial neural network (ANN) was built, trained, and internally validated by unsupervised learning followed by supervised learning. Outcomes were the performance characteristics of the ANN.

RESULTS

A total of 106, 111, and 124 ROIs were selected from EUS images of 8, 10, and 28 patients with lipomas, carcinoids, and GISTs, respectively. For each ROI, 228 statistical parameters were extracted and later reduced to the 11 most informative features by principal component analysis. After training with 50% of the data, the remainder of the data were used to validate the ANN. The model was "good" in differentiating carcinoids and GISTs, with area under the receiver operating characteristic curve (AUC) values of 0.86 and 0.89, respectively. The model was "excellent" in identifying lipomas correctly, with an AUC of 0.92.

CONCLUSIONS

Digital image analysis of EUS images is a useful noninvasive adjunct to EUS evaluation of SELs.

Diagnosis of subepithelial tumors in the upper gastrointestinal tract by endoscopic ultrasonography

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.

Clinical course of subepithelial lesions detected on upper gastrointestinal endoscopy

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.

The role of endosonography in submucosal tumours

Submucosal tumours (SMTs) are relatively common findings in patients undergoing endoscopy, especially in upper gastrointestinal (GI) tract. This term includes various non-neoplastic and neoplastic conditions. Endoscopic ultrasonography (EUS) is the best imaging procedure to characterise SMT and to determine the need for further explorations. In this review, the following issues will be addressed: the endosonographic features of SMT; the diagnostic accuracy of EUS; the ability of EUS to distinguish benign and malignant SMTs; the value of EUS-guided fine-needle aspiration (FNA); and the influence of EUS on clinical management.

Role of EUS and MDCT in the diagnosis of gastric submucosal tumors according to the revised pathologic concept of gastrointestinal stromal tumors

Gastric submucosal tumors (SMTs) consist of various lesions arising from the deep layers of the stomach. Gastrointestinal stromal tumors (GISTs) are undoubtedly the commonest malignant SMTs of the stomach, and therefore the attitude towards the general diagnostic approach for GISTs defines the extended diagnostic plan for SMTs. Two recent consensus meetings were assembled concerning the classification and therapeutic plans for GISTs. These meetings shed light upon the need for the modification of the current role of imaging modalities, including endoscopic ultrasound (EUS) and computed tomography (CT). According to the revised concepts of GISTs, the most important and plausible current role of imaging for the diagnostic approach of gastric SMTs is to differentiate GISTs from other gastric SMTs. This review discusses the newly established diagnostic role of radiology according to the revised classification of GISTs and provides the differential diagnoses based on EUS and CT findings.

[Not Available]

B. Landi Gastrointestinal stromal tumors (GISTs) are the most frequent intramural mesenchymal tumors of the GI tract, mainly developed in the stomach (65% of cases). Endoscopy is the main diagnostic tool for tumors of moderate diameter (<5cm). Endoscopic ultrasonography (EUS) is the best procedure to differenciate GISTs from other submucosal tumors. Fine-needle aspiration biopsies (FNABs) allow to obtain an histological diagnosis if necessary. Surgery remain the gold standard of treatment for localized GISTs, whereas endoscopic resection is not recommended for these tumors.

Endosonographic features of gastric ectopic pancreases distinguishable from mesenchymal tumors

BACKGROUND AND AIMS

Gastric ectopic pancreas is the second common submucosal lesion in the stomach, and differs from mesenchymal tumors with respect to clinical approach and prognosis. The purpose of our study was to evaluate the endoscopic ultrasound (EUS) findings for differentiating between gastric ectopic pancreases and mesenchymal tumors.

METHODS

All patients (n = 71) were diagnosed pathologically as having gastric ectopic pancreas (n = 18) or mesenchymal tumors (n = 53) between 2002 and 2006. The EUS images of the patients were retrospectively reviewed by two observers who were unaware of the pathological results, regarding location, size, growth pattern, layer of origin, presence or absence of layer disruption, margin, and internal echo pattern. These EUS imaging findings were compared for ectopic pancreases and mesenchymal tumors.

RESULTS

Compared with mesenchymal tumors, ectopic pancreases showed a significant difference in the lesion location, growth pattern, layer of origin, presence of layer disruption, margin, and internal echo (P < 0.05). The longest/shortest diameter ratio was also larger in ectopic pancreases (p < 0.05). There was no statistical difference in the lesion size and presence of focal anechoic portion.

CONCLUSION

Careful assessment of the EUS findings may be a useful aid in the differentiation of ectopic pancreases from mesenchymal tumors in the stomach.

Gastric calcifying fibrous tumor

Intramucosal gastric tumours are most commonly found to be gastrointestinal stromal tumours or leiomyomas (smooth muscle tumours); however, a variety of other uncommon mesenchymal tumours can occur in the stomach wall. A rare benign calcifying fibrous tumour is reported and the endoscopic appearance, ultrasound findings and morphology are documented. A review of the literature found only two similar cases.