Endoscopic ultrasonography-guided diagnosis of subepithelial tumors

Diagnosis by Endoscopic Ultrasonography-Guided Sampling through the Lower Gastrointestinal Tract

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) is very safe and has a high diagnostic rate for upper gastrointestinal lesions, especially pancreatic lesions, but its application in the lower gastrointestinal tract has rarely been reported. Due to the tortuous course of the colorectum, with the sigmoid colon particularly prone to perforation, most endoscopists are reluctant to perform lateral-sector endoscopic ultrasound scanning without a water-bag protection for the puncture. The ultrasonic endoscopy and flexible puncture needle techniques recently introduced into clinical practice have made ultrasound-guided puncture safer and more convenient. In addition, endoscopists have carefully tested various protective measures to improve the safety of the lower gastrointestinal puncture, substantially increasing its clinical feasibility. In this article, we review the iterations of endoscopic ultrasound equipment introduced in recent years and the many ingenious ideas proposed by endoscopists regarding lower gastrointestinal puncture.

Endoscopic ultrasound artificial intelligence-assisted for prediction of gastrointestinal stromal tumors diagnosis: A systematic review and meta-analysis

BACKGROUND

Subepithelial lesions (SELs) are gastrointestinal tumors with heterogeneous malignant potential. Endoscopic ultrasonography (EUS) is the leading method for evaluation, but without histopathological analysis, precise differentiation of SEL risk is limited. Artificial intelligence (AI) is a promising aid for the diagnosis of gastrointestinal lesions in the absence of histopathology.

AIM

To determine the diagnostic accuracy of AI-assisted EUS in diagnosing SELs, especially lesions originating from the muscularis propria layer.

METHODS

Electronic databases including PubMed, EMBASE, and Cochrane Library were searched. Patients of any sex and > 18 years, with SELs assessed by EUS AI-assisted, with previous histopathological diagnosis, and presented sufficient data values which were extracted to construct a 2 × 2 table. The reference standard was histopathology. The primary outcome was the accuracy of AI for gastrointestinal stromal tumor (GIST). Secondary outcomes were AI-assisted EUS diagnosis for GIST vs gastrointestinal leiomyoma (GIL), the diagnostic performance of experienced endoscopists for GIST, and GIST vs GIL. Pooled sensitivity, specificity, positive, and negative predictive values were calculated. The corresponding summary receiver operating characteristic curve and post-test probability were also analyzed.

RESULTS

Eight retrospective studies with a total of 2355 patients and 44154 images were included in this meta-analysis. The AI-assisted EUS for GIST diagnosis showed a sensitivity of 92% [95% confidence interval (CI): 0.89-0.95; P < 0.01), specificity of 80% (95%CI: 0.75-0.85; P < 0.01), and area under the curve (AUC) of 0.949. For diagnosis of GIST vs GIL by AI-assisted EUS, specificity was 90% (95%CI: 0.88-0.95; P = 0.02) and AUC of 0.966. The experienced endoscopists' values were sensitivity of 72% (95%CI: 0.67-0.76; P < 0.01), specificity of 70% (95%CI: 0.64-0.76; P < 0.01), and AUC of 0.777 for GIST. Evaluating GIST vs GIL, the experts achieved a sensitivity of 73% (95%CI: 0.65-0.80; P < 0.01) and an AUC of 0.819.

CONCLUSION

AI-assisted EUS has high diagnostic accuracy for fourth-layer SELs, especially for GIST, demonstrating superiority compared to experienced endoscopists' and improving their diagnostic performance in the absence of invasive procedures.

ACG Clinical Guideline: Diagnosis and Management of Gastrointestinal Subepithelial Lesions

Subepithelial lesions (SEL) of the GI tract represent a mix of benign and potentially malignant entities including tumors, cysts, or extraluminal structures causing extrinsic compression of the gastrointestinal wall. SEL can occur anywhere along the GI tract and are frequently incidental findings encountered during endoscopy or cross-sectional imaging. This clinical guideline of the American College of Gastroenterology was developed using the Grading of Recommendations Assessment, Development, and Evaluation process and is intended to suggest preferable approaches to a typical patient with a SEL based on the currently available published literature. Among the recommendations, we suggest endoscopic ultrasound (EUS) with tissue acquisition to improve diagnostic accuracy in the identification of solid nonlipomatous SEL and EUS fine-needle biopsy alone or EUS fine-needle aspiration with rapid on-site evaluation sampling of solid SEL. There is insufficient evidence to recommend surveillance vs resection of gastric gastrointestinal stromal tumors (GIST) <2 cm in size. Owing to their malignant potential, we suggest resection of gastric GIST >2 cm and all nongastric GIST. When exercising clinical judgment, particularly when statements are conditional suggestions and/or treatments pose significant risks, health-care providers should incorporate this guideline with patient-specific preferences, medical comorbidities, and overall health status to arrive at a patient-centered approach.

Gastric submucosal mass lesions

PURPOSE OF REVIEW

Gastric submucosal mass lesions are a collection of tumours that arise in the stomach and are deep to the mucosal layer. Distinct from gastric epithelial carcinomas, these tumours are generally more indolent. They are often found incidentally on upper endoscopy. Most often they present as smooth protuberant masses covered by normal intact gastric mucosa. The majority are asymptomatic. Endoscopic ultrasound (EUS) is frequently employed to further characterize the lesions. EUS can be diagnostic of some lesions, such as lipomas, and can be used to guide fine needle aspiration to diagnose others. Adding to the traditional management approaches of observation and surgical resection, numerous new and emerging endoscopic therapies are now being used to resect these gastric tumours.

RECENT FINDINGS

This review focuses on evolving strategies in the diagnosis and management of submucosal mass lesions. Although surgical intervention was once the lone option for intervention, there are an increasing number of endoscopic therapies. There have also been advancements in neoadjuvant therapies and in distinguishing the malignant potential of submucosal mass lesions.

SUMMARY

Gastric submucosal lesions are common. EUS is frequently indicated in the evaluation and diagnosis. For tumours for which observation is not recommended, novel endoscopic therapies may offer less invasive management options.

Experience with Esophageal Granular Cell Tumors: Clinical and Endoscopic Analysis of 22 Cases

BACKGROUND

Esophageal granular cell tumors (GCTs) are rare tumors. Differences in reports on the clinical features of GCTs in the esophagus and some controversies about the diagnostic strategy for esophageal GCTs exist.

OBJECTIVES

We aimed to investigate the clinical features and diagnosis of esophageal GCTs. Additionally, we sought to determine the prevalence of gastroesophageal reflux disease and reflux esophagitis in patients with esophageal GCTs.

METHODS

We retrospectively studied the clinical features, endoscopic features, and management of 22 patients with esophageal GCTs.

RESULTS

Esophageal GCTs were more common in men than in women with a ratio of 1.2:1 and were predominantly found in the distal esophagus. Ten patients with esophageal GCTs had regurgitation and/or heartburn symptoms, and eight patients were confirmed to have reflux esophagitis by endoscopy. All esophageal GCTs were protuberant lesions covered by normal esophageal epithelium. The endoscopic morphology of esophageal GCTs was diverse. On endoscopic ultrasonography, these tumors appeared as homogeneous or inhomogeneous hypoechoic lesions with clear borders originating from the submucosal or mucosal layer. Eleven patients underwent endoscopic forceps biopsy at the first endoscopy, and only six patients were correctly diagnosed by pathology. Nevertheless, the 18 lesions treated with endoscopic resection were all correctly diagnosed without complications, and no patients developed recurrence during the follow-up period.

CONCLUSIONS

The occurrence of esophageal GCTs may be related to esophageal inflammation. As a method for obtaining an accurate pathological diagnosis and for treatment, endoscopic resection should be offered as the primary option for patients with esophageal GCTs.

Standard reporting elements for the performance of EUS: Recommendations from the FOCUS working group

Background and Objectives

Quality indicators for the performance of EUS have been developed to monitor and improve service value and patient outcomes. To support the incorporation of these indicators and standardize EUS documentation, we propose standard EUS reporting elements for endosonographers and endoscopy units.

Methods

A comprehensive literature search and review was performed to identify EUS quality indicators and key components of high-quality standardized EUS reporting. Guidance statements regarding standard EUS reporting elements were developed and reviewed at the Forum for Canadian Endoscopic Ultrasound (FOCUS) 2019 Annual Meeting.

Results

EUS reporting elements can be divided into preprocedural, intraprocedural, and postprocedural items. Preprocedural components include the type, indication, and urgency of the procedure and patient clinical information and consent. Intraprocedural components include the adequacy and extent of examination, relevant landmarks, lesion characteristics, sampling method, specimen quality, and intraprocedural adverse events. Postprocedural components include a summary and synthesis of relevant findings as well as recommended management and follow-up.

Conclusions

Standardizing reporting elements may help improve the care of patients undergoing EUS procedures. Our review provides a practical guide and compilation of recommended reporting elements to ensure ongoing best practices and quality improvement in EUS.

Evaluation of Upper Endoscopic and Endoscopic Ultrasound Features in the Differential Diagnosis of Gastrointestinal Stromal Tumors and Leiomyomas in the Upper Gastrointestinal Tract

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.

Reliability of Endoscopic Ultrasound Using Miniprobes and Grayscale Histogram Analysis in Diagnosing Upper Gastrointestinal Subepithelial Lesions

Background

To assess the role of endoscopic ultrasound (EUS) in the diagnosis of upper gastrointestinal subepithelial lesions (SELs) and to investigate EUS combined with a grayscale histogram analysis for the differentiation of leiomyomas and gastrointestinal stromal tumors (GISTs).

Methods

A retrospective study of 709 patients with upper gastrointestinal SELs was conducted by EUS before endoscopic resection. The EUS findings of SELs and pathological results after endoscopic resection were compared. The EUS images of SELs, particularly, leiomyoma and GIST, were further analyzed via a grayscale histogram to differentiate between the two tumors.

Results

Of the 709 patients, 47 cases were pathologically undetermined. The diagnostic consistency of EUS with endoscopic resection was 88.2% (584/662), including 185 muscularis mucosa, 61 submucosa, and 338 muscularis propria, respectively. The diagnostic consistency of EUS with pathology was 80.1% (530/662). The gray value of GISTs was significantly higher than that of leiomyomas (58.9 ± 8.3 vs. 39.5 ± 5.9, t = 57.0, P < 0.0001). The standard deviation of leiomyomas was significantly lower than that of GISTs (20.6 ± 7.0 vs. 39.8 ± 9.3, t = 23.7, P < 0.0001). The grayscale histogram analysis of GISTs showed higher echo ultrasound, and the echo of leiomyoma was more uniform.

Conclusion

EUS is the preferred procedure for the evaluation of upper gastrointestinal SELs. EUS combined with a grayscale histogram analysis is an effective method for the differentiation of leiomyomas and GISTs.

Rectal Endoscopic Ultrasound in Clinical Practice

PURPOSE OF REVIEW

Endoscopic ultrasound (EUS) is routinely utilized for evaluation of disorders of the lower gastrointestinal tract. In this review, we summarize the current status of rectal EUS in clinical practice and describe recent developments in diagnostic and therapeutic rectal EUS.

RECENT FINDINGS

Recent guidelines recommend rectal EUS for rectal cancer staging as a second line modality in cases where MRI is contraindicated. Forward-viewing echoendoscopes and through the scope EUS miniprobes allow for EUS imaging of lesions through the entire colon and for evaluation beyond stenoses or luminal narrowings. EUS can be used to assess perianal disease and drain pelvic abscess associated with IBD, along with newer applications currently under investigation. For rectal varices, EUS can confirm the diagnosis, assess the optimal site for banding, guide therapy placement with sclerotherapy and/or coils, and assess response to treatment by confirming absence of flow. Therapeutic rectal EUS is emerging as a promising modality for drainage of pelvic fluid collection drainage and fiducial placement for rectal or prostatic cancer. Drug delivery mechanisms and substances that may increase the scope of therapy with rectal EUS are in varying stages of development. Rectal EUS continues to be an important modality for evaluation of benign and malignant disorders of the lower gastrointestinal tract, although its use as a cancer staging modality has declined due to improvements in MRI technology. Various technologies to enhance ultrasound imaging and for therapeutics have been developed that have or may contribute to expanded indications for rectal EUS.

The use of endoscopic ultrasonography in the detection and differentiation of pathology in the wall of the upper gastrointestinal tract

Introduction

The growing incidence of gastrointestinal diseases forces to improve imaging techniques. Identification of lesions located inside the wall of intestinal tract or in close proximity often was not possible using endoscopy or computed tomography.

Aim

To assess the usefulness of endosonography (EUS) in the differentiation between compression from the outside and intramural lesions of the upper gastrointestinal tract.

Material and methods

For 4 years 20,012 patients with performed gastroscopies were enrolled in the study. One hundred and ninety-nine patients (96 females, 103 males; age 62.2 ±14.1 years) with pathology of the wall of the upper gastrointestinal tract qualified for further diagnosis. Endosonography and computed tomography (CT) were performed in each patient. A chest CT was performed in patients with a lesion in the oesophagus. An abdomen CT was performed in patients with pathology in the stomach or duodenum. Based on the results of EUS, histopathology, and imaging, each patient qualified for treatment, endoscopic observation, surgery, or cancer treatment.

Results

In EUS 129 (64.8%) intramural lesions were identified. Five (2.5%) diagnoses were false negative. In 62 (31.2%) patients no intramural changes were recognised and three (1.5%) results were false positive. The sensitivity and specificity of EUS was 96.3% and 95.4%, respectively, with positive predictive value 90.7%, negative predictive value 97.8%, and overall accuracy 95% (p < 0.05). Endoscopic therapy was performed in 31 (15.6%) patients, and 99 (49.8%) were classified for endoscopic observation. Surgery was performed in 50 (25.1%) patients, and 19 (9.5%) patients required oncologic treatment.

Conclusions

Endosonography exceeds computed tomography in differentiating compression from the outside and intramural lesions of the upper gastrointestinal tract.

Systematic review of giant gastric lipomas reported since 1980 and report of two new cases in a review of 117110 esophagogastroduodenoscopies

AIM

To systematically review the syndrome of giant gastric lipomas, report 2 new illustrative cases.

METHODS

Literature systematically reviewed using PubMed for publications since 1980 with following medical subject heading/keywords: (“giant lipoma”) AND (“gastric”) OR [(“lipoma”) and (“gastric”) and (“bleeding”)]. Two authors independently reviewed literature, and decided by consensus which articles to incorporate. Computerized review of pathology/endoscopy records at William Beaumont Hospitals, Royal Oak and Troy, Michigan, January 2005-December 2015, revealed 2 giant gastric lipomas among 117110 consecutive esophagogastroduodenoscopies (EGDs), which were thoroughly reviewed, including re-review of original endoscopic photographs, radiologic images, and pathologic slides.

RESULTS

Giant gastric lipomas are extremely rare: 32 cases reported since 1980, and 2 diagnosed among 117110 consecutive EGDs. Average patient age = 54.5 ± 17.0 years old (males = 22, females = 10). Maximal lipoma dimension averaged 7.9 cm ± 4.1 cm. Ulcerated mass occurred in 21 patients. Lipoma locations: antrum-17, body-and-antrum-4, antrum-intussuscepting-into-small-intestine-3, body-2, fundus-1, and unspecified-5. Intramural locations included submucosal-22, subserosal-2, and unspecified-8. Presentations included: acute upper gastrointestinal (UGI) bleeding-19, abdominal pain-5, nausea/vomiting-5, and asymptomatic-3. Symptoms among patients with UGI bleeding included: weakness/fatigue-6, abdominal pain-4, nausea/vomiting-4, early-satiety-3, dizziness-2, and other-1. Their hemoglobin on admission averaged 7.5 g/dL ± 2.8 g/dL. Patients with GI bleeding had significantly more frequently ulcers than other patients. EGD was extremely helpful diagnostically (n = 31 patients), based on characteristic endoscopic findings, including yellowish hue, well-demarcated margins, smooth overlying mucosa, and endoscopic cushion, tenting, or naked-fat signs. However, endoscopic mucosal biopsies were mostly non-diagnostic (11 of 12 non-diagnostic). Twenty (95%) of 21 abdominal CTs demonstrated characteristic findings of lipomas, including: well-circumscribed, submucosal, and homogeneous mass with attenuation of fat. Endoscopic-ultrasound showed characteristic findings in 4 (80%) of 5 cases: hyperechoic, well-localized, mass in gastric-wall-layer-3. Transabdominal ultrasound and UGI series were generally less helpful. All 32 patients underwent successful therapy without major complications or mortality, including: laparotomy and full-thickness gastric wall resection of tumor using various surgical reconstructions-26; laparotomy-and-enucleation-2; laparoscopic-transgastric-resection-2; endoscopic-mucosal-resection-1, and other-1. Two new illustrative patients are reported who presented with severe UGI bleeding from giant, ulcerated, gastric lipomas.

CONCLUSION

This systematic review may help standardize the endoscopic and radiologic evaluation and therapy of patients with this syndrome.

Endoscopic ultrasound without tissue acquisition has poor accuracy for diagnosing gastric subepithelial tumors

Incidental gastric subepithelial tumor (SET) is frequently found during endoscopy. Although endoscopic ultrasonography (EUS) can provide useful information, its diagnostic accuracy varies. Most of the potentially malignant tumors observed on EUS are hypoechoic lesions. Therefore, we aimed to investigate the diagnostic accuracy of EUS for hypoechoic lesions located in the submucosa or proper muscle layer. We also evaluated various characteristics for potential associations with diagnostic accuracy.A retrospective review was conducted of the medical records of 99 patients who were diagnosed with gastric SET and who underwent EUS with pathologic confirmation between March 2008 and April 2015. After reviewing the endoscopic and pathologic findings, we attempted to analyze factors that were associated with the diagnostic accuracy of EUS.The mean ± standard deviation size of the lesions was 20.0 ± 12.7 mm. The most common location was the upper third of the stomach (43.4%). The overall accuracy of EUS was 66.7%. No statistically significant difference in EUS accuracy was observed according to the location, size, or layer of the lesion. The following pathologic diagnostic methods were used: EUS-guided fine needle aspiration (3.0%), forceps biopsy (16.2%), deep tissue biopsy using cap-assisted mucosal resection (8.1%), endoscopic submucosal dissection (25.2%), and operation (47.5%). The accuracy of EUS according to the expected diagnosis of the lesion was 77.1% for gastrointestinal stromal tumor, 50% for neuroendocrine tumor, and 50% for ectopic pancreas.Although EUS is a useful tool for gastric SET in clinical practice, the accuracy of diagnostic EUS is suboptimal. When considering whether to treat gastric SET, the decision should be made based on the pathologic diagnosis.

Compliance with surveillance recommendations for foregut subepithelial tumors is poor: results of a prospective multicenter study

BACKGROUND

American Gastroenterological Association guidelines recommend performing EUS to characterize subepithelial lesions (SELs) discovered on upper endoscopy (EGD), followed by surveillance if no high-risk features are identified. However, limited data are available on the impact of and compliance with surveillance recommendations.

OBJECTIVE

To determine the natural history of SELs<30 mm in size evaluated by EUS and to determine the degree of patient compliance with surveillance recommendations.

DESIGN

Prospective registry.

SETTING

Two tertiary centers.

PATIENTS

We studied 187 consecutive adult patients referred for EUS evaluation of foregut SELs.

MAIN OUTCOME MEASUREMENTS

Proportion of patients in whom SELs change in size or echo-features and compliance with follow-up recommendations.

RESULTS

Surveillance was recommended in 65 patients with hypoechoic SELs (44.6% women, age 59.5±13.2 years); of these, 29 (44.6%) underwent surveillance EUS as recommended and were followed for a median of 30 months (range, 12-105). During follow-up, 16 SELs (25%) increased in size, with a mean increase of 3.4±3.9 mm (range, 1-15). No changes in echo-texture of the SELs were observed. One patient was referred to surgery during follow-up (because of SEL growth>30 mm).

LIMITATIONS

Short follow-up duration; compliance was a secondary aim.

CONCLUSIONS

During a median follow-up of 30 months, growth in size was observed in 25% of small foregut SELs. However, change in size was minimal, and only 1 patient was referred for surgery based on surveillance EUS findings. Compliance with surveillance recommendations is poor, with fewer than 50% of patients undergoing surveillance EUS as recommended.

Endosonography-assisted diagnosis and therapy of gastrointestinal submucosal tumors

Submucosal tumors (SMTs) are usually discovered fortuitously during routine endoscopy, including various non-neoplastic and neoplastic conditions. Endoscopic ultrasound (EUS) is considered to be the best imaging procedure to characterize SMTs and to determine the need for further treatment. In this review, the following issues will be addressed: The role of EUS in diagnosis for SMTs, tissue diagnosis for SMTs and the influence of EUS on endoscopic resection techniques for SMTs.

Endosonography-assisted diagnosis and therapy of gastrointestinal submucosal tumors

Submucosal tumors (SMTs) are usually discovered fortuitously during routine endoscopy, including various non-neoplastic and neoplastic conditions. Endoscopic ultrasound (EUS) is considered to be the best imaging procedure to characterize SMTs and to determine the need for further treatment. In this review, the following issues will be addressed: The role of EUS in diagnosis for SMTs, tissue diagnosis for SMTs and the influence of EUS on endoscopic resection techniques for SMTs.

The role of endoscopic ultrasound in the diagnosis and therapy of gastrointestinal disorders

Endoscopic ultrasound is one of those diagnostic methods in gastrointestinal endoscopy which has developed rapidly in the last decade and has became exceedingly available to visualize the walls of the internal organs in details corresponding to histological layers, or analyze the adjacent structures. Fine needles and other endoscopic accessories can be introduced into the neighbouring tissues under the guidance of endoscopic ultrasound, and diagnostic and minimally invasive therapeutic interventions can be performed. The endoscopic ultrasound became more widely available in Hungary in the recent years. This review focuses on the indications, benefits and complications of diagnostic and therapeutic endoscopic ultrasound. We dedicate this article for gastroenterologists, surgeons, internists, pulmonologists, specialists in oncology and radiology. This recommendation was based on the consensus of the Board members of the Endoscopic Ultrasound Section of the Hungarian Gastroenterological Society. Orv. Hetil., 2014, 155(14), 526–540.

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.