Endoscopic ultrasonography in the diagnosis and management of suspected upper gastrointestinal submucosal tumours

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.

Endoscopic ultrasound guided brush/fine-needle aspiration cytology: A 15-month study

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become increasingly popular for the diagnosis and staging of gastrointestinal diseases and peri-gastrointestinal lesions. The application of FNA/Brush has dramatically expanded the clinical utility of EUS.

AIMS AND OBJECTIVE

To evaluate the diagnostic accuracy, study the spectrum of lesions encountered in EUS-FNAC/brush cytology of gastrointestinal and peri-gastrointestinal lesions.

MATERIALS AND METHODS

Total of 124 patients during the period from August 2015 to November 2016 was included in the study. Routine staining was done.

RESULTS

A total of 124 cases were studied with 86% (107 cases) being satisfactory for evaluation. M:F ratio was 1:1.03, mean age of 50.5 years. The most common site was common bile duct (CBD) (37%) followed by lymph node (21%), pancreas (17.7%), esophagus (17%), stomach (3.5%), liver (1.8%), gallbladder (1%), and spleen (1%). In total, 53.4% lesions were benign, in 6.5% atypical cells were seen, 12.1% were suspicious for malignancy, and 28% cases were positive for malignancy. Follow-up was available in 102 cases with cyto-histopathological concordance rate of 90%.

CONCLUSION

EUS-FNA/Brush is a reliable, sensitive, specific and minimally invasive way to establish a diagnosis. It can be utilized as a pre-operative procedure for the management of many intra-abdominal lesions and prevent unnecessary invasive procedures.

Endosonogragphic features of lesions suggesting gastricectopic pancreas: experience of a single tertiary center

BACKGROUND/AIM

We aimed to present the endoscopic ultrasound (EUS) features of gastric lesions suggesting gastric ectopic pancreas during upper gastrointestinal endoscopy that were diagnosed in our gastroenterology unit, which is a tertiary center for endoscopic procedures in Turkey.

MATERIALS AND METHODS

The data of patients who underwent upper gastrointestinal EUS in our center between April 2012 and July 2014 were retrospectively analyzed.

RESULTS

All of the lesions suggesting gastric ectopic pancreas were localized in the gastric antrum. Thirty-six of 44 lesions (81.1%) showed central dimpling. Lesion borders were shown to be definite in 10 (22.7%) lesions, whereas the borders of 34 lesions (77.3%) were indefinite. Thirty-nine lesions (88.6%) had heterogeneous and 5 lesions (11.4%) had homogeneous echo patterns; whereas 29 lesions (65.9%) were hypoechoic, 9 lesions (20.5%) were hyperechoic and 6 lesions (13.6%) had mixed echogenicity. Forty-two lesions (95.5%) were shown to affect only a single sonographic layer of the gastric wall.

CONCLUSION

EUS features of lesions that strongly suggest gastric ectopic pancreas endoscopically, without any histopathological evidence and without either endoscopic or surgical resection, are as follows: indefinite border appearance, minimal heterogeneous hypoisoechoic echo pattern, existence of anechoic duct-like structures inside the lesion, common localization in the submucosal layer, and existence of umbilication.

The Role of Endoscopic Ultrasound in the Diagnostic Assessment of Subepithelial Lesions of the Upper Gastrointestinal Tract

INTRODUCTION

The identification of subepithelial lesions is a relatively frequent finding at endoscopy however their natural history is not well known. Our aim was to analyze the role of endoscopic ultrasound (EUS) in the diagnostic approach of subepithelial lesions of the upper gastrointestinal tract.

METHODS

Retrospective study which included 324 patients undergoing upper radial EUS for evaluation of subepithelial lesions from 2008 to 2014. The EUS features, presumptive diagnosis and management decision were analyzed.

RESULTS

324 patients included, 60% with gastric subepithelial lesions, 28% oesophageal and 12% from the duodenum. Based on EUS features the presumptive diagnosis was: 25% gastrointestinal stromal tumor, 21% lipoma, 19% leiomyoma, 17% pancreatic rest, 7% submucosa cysts, 1% granular cell tumors, 1% carcinoids, 1% mucosa lesions and 8% not defined. After EUS the suggested approach was no follow-up in 45%, follow-up with re-examination with EUS in 35% and additional tissue sampling or endoscopic/surgical resection in 20%. The latter was based on EUS features of risk at the diagnosis (53%), such as size ≥2 cm, hypoechogenicity, heterogeneity, lobulation, calcifications, cystic component and regional adenopathies; impossibility to define a presumptive diagnosis (39%) or EUS features change at follow-up (8%). The combination of multiple features correlated with a higher probability of this recommended strategy (p < 0.001), in 100% when 4 or more features were present. Among the 33 patients who underwent fine needle aspiration, in 66% the result was inconclusive. During follow-up, none of the patients who were managed with surveillance radial EUS presented complications.

CONCLUSION

EUS is the method of choice in the study of subepithelial lesions of the upper gastrointestinal tract, in most cases defining a diagnosis. The need for a definitive diagnosis or therapeutic approaches can be based on ultrasound risk features, presented, in the majority, at presentation. This study shows that EUS is capable of safely and accurately define those subepithelial lesions that can be managed only with surveillance ultrasound while waiting for better results with fine needle aspiration.

Asymptomatic heterotopic pancreas in Meckel's diverticulum: a case report and review of the literature

Introduction

Heterotopic pancreas is defined as pancreatic tissue without a real anatomical or vascular connection to the pancreas. It can be found in the stomach, duodenum, jejunum, ileum, Meckel’s diverticulum, colon gall bladder, umbilicus, fallopian tube, mediastinum, spleen and liver. Complications of heterotopic pancreas are inflammation, bleeding, obstruction, malignant transformation, carcinoid syndrome, jejunojejunal intussusception and ileus, but it is usually asymptomatic and diagnosed only during examinations for other diseases.

Case presentation

An 81-year-old Lithuanian woman was diagnosed with caecal cancer and had undergone elective surgery. A right hemicolectomy was performed and a Meckel’s diverticulum was observed and excised. Histological results showed a poorly differentiated G3 adenocarcinoma of her large intestine and heterotopic pancreas tissue in the Meckel’s diverticulum and mesenteric adipose tissue.

Conclusions

Asymptomatic heterotopic pancreas is rarely diagnosed, and usually found incidentally during surgical or diagnostic interventions. Although it has no symptoms, heterotopic pancreas found during surgical procedures should be excised.

Value of submucosal tunneling endoscopic resection in treatment of upper gastrointestinal muscularis propria tumors

AIM: To assess the feasibility and safety of submucosal tunneling endoscopic resection (STER) in the treatment of upper gastrointestinal muscularis propria tumors, and the value of endoscopic ultrasonography (EUS) in pre-therapy detection of these tumors.

METHODS: All patients with muscularis propria tumors were diagnosed by EUS. Twenty-four patients were treated by STER, and the other 15 patients treated by surgery were used as controls. Clinical effects were compared for the two groups.

RESULTS: In the STER group, three patients were found to have tumors located in the muscularis mucosa and converted to other forms of treatment during operation. For the other cases, the average diameter of resected tumors was similar to that in the control group (P > 0.05). The treatment time for esophagus tumors had no significant difference between the two groups (P > 0.05). However, for stomach tumors, STER was faster than surgery (P < 0.01). Patients in the STER group needed shorter hospitalizing time (P < 0.01) and less cost (P < 0.05) compared with controls. Postoperative pathological examination demonstrated that the rate of correct preoperative diagnosis by EUS was 92.3%.

CONCLUSION: STER is safe and efficient in the treatment of upper gastrointestinal muscularis propria tumors. EUS is important in determining the tumor location and treatment manner.

Gastric subepithelial masses: evaluation of multidetector CT (multiplanar reconstruction and virtual gastroscopy) versus endoscopic ultrasonography

OBJECTIVES

To assess the role of multidetector computed tomography (MDCT) with multiplanar reconstruction (MPR) and virtual gastroscopy (VG) for detection and differentiation of gastric subepithelial masses (SEMs) by comparison with endoscopic ultrasonography (EUS).

METHODS

Forty-one patients with a suspected SEM were evaluated using EUS and MDCT. MDCT findings were analyzed based on the consensus of two radiologists who were blinded to the EUS findings. The analysis of the CT features included the location, size, and contours of the tumor, the presence of central dimpling, as well as the growth pattern, enhancement pattern, and enhancement degree. The long diameter (LD) and the short diameter (SD) of each lesion were measured and the LD/SD ratios were calculated. EUS and MDCT results were compared with histopathology for the pathologically proven lesions. For the non-pathologically proven lesions, MDCT results were compared with EUS.

RESULTS

Among the 41 patients, 34 SEMs were detected using EUS. For the detection of SEMs with MDCT, a sensitivity of 85.3%, a specificity of 85.7%, a positive predictive value of 96.7%, and a negative predictive value of 54.5% were calculated. The overall accuracy of MDCT for detecting and classifying the SEMs was 85.3 and 78.8%, respectively.

CONCLUSIONS

MDCT with MPR and VG is a valuable method for the evaluation of SEMs. Specific MDCT criteria for various SEMs may be helpful in making an accurate diagnosis.

Endoscopic ultrasonography-guided diagnosis of subepithelial tumors

Subepithelial lesions are frequently discovered during routine endoscopic examinations. These lesions represent a wide spectrum of heterogeneous benign to malignant conditions. Most of these lesions are asymptomatic. There is no consensus regarding how to manage these lesions. Over the last 2 decades, the approach to these lesions has significantly improved owing to the introduction of endoscopic ultrasonography, fine-needle aspiration, immunohistochemical staining methods, and different treatment options. This article discusses the nature of subepithelial lesions, focusing on the most recent developments that use endoscopic ultrasonography to diagnose and manage these lesions.

Endosonographic evaluation of patients with suspected extraluminal compression or subepithelial lesions during upper gastrointestinal endoscopy

BACKGROUND

The aim of this study was to evaluate the endosonographic ultrasound (EUS) findings of patients with suspected extraluminal compression or subepithelial intramural lesions observed during upper gastrointestinal endoscopy.

METHODS

EUS findings were grouped as follows; compression by an extramural pathologic lesion, compression by an adjacent vascular structure, compression by adjacent organs, subepithelial intramural lesion, and normal EUS.

RESULTS

The data of 211 patients referred to the EUS unit between February 2004 and January 2010 for further evaluation of suspected extraluminal compression or subepithelial intramural lesions after upper gastrointestinal endoscopy were retrospectively analyzed. Mean age of the patients was 51.0±15.2 years, 124 (58.9%) of which were female. EUS examination was normal in 48 (22.7%) patients. EUS confirmed the presence of a pathological finding in the esophagus in 38 (92.6%) out of 41 patients when compared with abnormal findings in 122 (73.4%) of 166 patients who were evaluated for suspected lesions of the stomach (P=0.009). Suspected extraluminal compression of the esophagus (n=41) was due to a vascular structure in 17 (41.4% ) patients, an adjacent organ in four (9.7%) patients, an extramural pathological lesion in two (4.9%) patients, and a subepithelial intramural lesions in 15 (36.6%) patients, whereas in three patients (7.4%) EUS findings were normal. Of the 166 patients referred for evaluation of gastric lesions EUS findings were normal in 44 (26.5%) patients, whereas compression due to an adjacent organ was observed in 66 (39.7%) patients followed by compression by an adjacent vascular structure in 34 (20.4%) patients. An extramural pathologic lesion was discovered in 14 (8.6%) patients, whereas suspected compression was due to a subepithelial intramural lesion in eight (4.8%) patients.

CONCLUSION

Accurate diagnosis of suspected extraluminal compression or subepithelial intramural lesions, particularly in the stomach, requires meticulous evaluation. EUS provides an invasive but effective option. In one-third of cases, suspected extraluminal compression of the esophagus is actually due to a subepithelial intramural lesion.

Heterotopia pancreática: análise clínico-patológica de 18 doentes

OBJETIVO: Analisar as características clínico-patológicas do tecido pancreático heterotópico em órgãos digestivos abdominais. MÉTODOS: Realizamos estudo retrospectivo analisando 18 portadores de pâncreas heterotópico diagnosticados histologicamente. Seus dados clínicos e histopatológicos foram revistos. O tecido pancreático heterotópico foi classificado em três modelos histológicos: tipo I constituído por três componentes do pâncreas normal (ácinos, ductos e ilhotas), tipo II com dois componentes e tipo três com somente um componente. RESULTADOS: A média de idade foi de 52,7 anos, variando de 34 a 73 anos, com nove homens e nove mulheres. Sintomas foram observados em somente quatro doentes, sendo suas lesôes diagnosticadas por gastroscopia. Os 14 restantes eram assintomáticos e suas anomalias descobertas acidentalmente. A maioria das lesões situava-se no trato superior: sete (38,9%) no estômago, seis (33,3%) no duodeno e três (16,6%) no jejuno. A heterotopia localizou-se preferencialmente na submucosa (83,3%), mas também foi observada na muscular própria e na sub-serosa. Em sete (38,9%) espécimes todos os componentes pancreáticos foram constatados (tipo I), em oito (44,4%) estavam presentes glândulas exócrinas e ductos excretores (tipo II) e em três (16,7%) somente o tecido exócrino foi observado (tipo III). CONCLUSÃO: A heterotopia pancreática é rara. Doentes com ectopia pancreática diagnosticadas pelo estudo patológico, assintomáticos ou com sintomas discretos devem permanecer em observação. As lesões detectadas acidentalmente durante procedimentos cirúrgicos necessitam ser removidas por procedimentos conservadores.

Suspected oesophageal cancer in a 33 year old lady

A previously healthy 33 year old lady presented with acute dysphagia with endoscopic and CT features of oesophageal carcinoma. Endoscopic ultrasound (EUS) revealed a large subcarinal lymph node compressing at the mid-oesophagus. Fine-needle aspiration (FNA) showed a single well-formed epithelioid granuloma with no evidence of malignancy. Molecular analysis showed the aspirate to be positive for Mycobacterium tuberculosis. She continues to improve with standard anti-TB medication without surgery.This is a rare case of acute dysphagia secondary to primary tuberculous mediastinal lymphadenopathy. EUS and FNA have completely altered the clinical management of this lady.

Use of the front-view forward-array echoendoscope to evaluate right colonic subepithelial lesions

BACKGROUND

Endosonographic evaluation and sampling of right colonic subepithelial lesions is technically difficult.

OBJECTIVE

To evaluate the feasibility, safety, and tissue yield of a prototype front-view, forward-array, curved linear array echoendoscope in the evaluation and sampling of right colonic subepithelial lesions.

SETTING

Tertiary referral center.

DESIGN

Procedural and outcome data on all patients undergoing EUS evaluation of right-sided colonic and pericolonic lesions were collected during a 1-year study period.

MAIN OUTCOME MEASUREMENTS

Patient demographics, clinical indication, EUS findings, EUS-FNA yield, technical success, and procedural complications.

RESULTS

A total of 15 patients underwent EUS examination of right-sided colonic lesions with the prototype echoendoscope. The lesions were located in the cecum (n = 12) and the ascending colon (n = 3). The cecum was reached in all examinations within 10 minutes. Twelve patients had subepithelial lesions detected during colonoscopy. Findings included 6 extrinsic compressions from an adjacent normal structure, 1 calcified lymph node, 1 ovarian cyst, 1 prolapsed appendiceal orifice, 1 GI stromal tumor, 1 appendiceal mucocele, and 1 lymphoma. Two patients were evaluated for a pericolonic lesion seen on CT; findings included focal diverticulitis and a metastatic lymph node. In the patient evaluated for an infiltrative mass with previous nondiagnostic biopsies, colonic histoplasmosis was diagnosed. FNA was performed in 6 patients and provided diagnostic samples in 5 (83%). No procedure- or FNA-related complications were reported.

CONCLUSIONS

Endosonographic evaluation and sampling of right-sided colonic subepithelial lesions with the prototype front-view, forward-array, curved linear array echoendoscope is feasible and safe. The yield of FNA is high, consistent with applications in the upper GI tract.

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.

Values of gastroscopy and endoscopic ultrasonography in diagnosis and treatment of esophageal papilloma

AIM: To explore the value of gastroscopy and endoscopic ultrasonography in diagnosis and treatment of esophageal papilloma.

METHODS: Forty nine cases with esophageal papilloma confirmed by pathological examination underwent gastroscopy and 24 of them underwent endoscopic ultrasonography. Then their manifestations of gastroscopy and endoscopic ultrasonography as well as the relationship between the pathologic and clinical characteristics were analyzed.

RESULTS: On gastroscopy, most lesions of EP cases were located at the middle or distal esophagus (89.8%), assuming feather-like or corpora mammillaria-like bulge, with floccular or fine granular-like surface and grayish-white color, and most of the EP was single with diameter ranging from 0.3-0.6 cm. Of 24 cases undergoing endoscopic ultrasonography, 17 were diagnosed as EP (70.8%), and 6 were diagnosed as inflammatory proliferation or polypus (25%). The classic endosonographic characteristics were even iso-echoic with clear boundary originating from mucosa layer, protruding into the lumen.

CONCLUSION: Esophageal papilloma is well displayed on endoscopic ultrasonography, which could be used to determine indications of endoscopy.

The value of endoscopic ultrasonography on diagnosis and treatment of esophageal hamartoma

OBJECTIVE

To examine the values of endoscopic ultrasonography (EUS) on diagnosis and treatment of esophageal hamartoma.

METHODS

We compared and analyzed various kinds of imaging examinations such as barium esophagram, contrast-enhanced computed tomography (CT) and conventional gastroscopy in retrospectively reviewing the clinical data of an esophageal hamartoma patient seen in our clinic in the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China. Having received various imaging examinations, this patient was finally diagnosed with esophageal hamartoma and underwent gastroscopic resection of hamartoma with the diagnostic information obtained from EUS. The patient had been regularly followed up for 13 months after treatment.

RESULTS

Barium esophagram, CT and conventional gastroscopy detected the lesion, but were unable to distinguish it from common esophagopolypus and other submucosal lesions, and unable to determine etiopathogenisis. EUS detected the hamartoma and identified its internal structure, echo, exact size, depth of invasion, origin and the relationship between adjacent tissues and organs, differentiating the lesion from other submucosal tumors and clearly defining the diagnosis. EUS-guided fine needle aspiration (FNA) also helped to identify the etiological diagnosis.

CONCLUSION

EUS was superior to other imaging means in diagnosis and treatment of hamartoma.

Clinical analysis of ectopic pancreas with endoscopic ultrasonography: an experience in a medical center

OBJECTIVE

To describe the endosonographic features of gastrointestinal ectopic pancreas, especially when histopathological diagnosis is unachievable with nonsurgical modalities.

METHODS

Endoscopic ultrasonography was performed in 20 patients with endoscopically recognized ectopic pancreas. We then analyzed the endosonographic features of the lesions and the clinical aspects of the patients, including age, gender, symptoms, and lesion locations.

RESULTS

Endoscopic ultrasonography revealed that the lesions originated from the second, third, and/or fourth layers of the gastrointestinal wall. Most lesions (95%, 19/20) were heterogenous, mainly hypoechoic or mixed, in echogenicity. The borders of the lesions were indistinct in 13 (13/20, 65%) and distinct in 7 (7/20, 35%) patients. Anechoic cystic or tubular structures within the lesions appeared in 7 of the 20 lesions (35%).

CONCLUSION

Ectopic pancreas usually appears as a submucosal lesion with characteristic central dimpling. Furthermore, characteristic endoscopic ultrasonographic features can readily assist in the diagnosis of ectopic pancreas without having to perform endoscopic biopsy or surgery. However, either endoscopic ultrasonography-guided fine needle aspiration or endoscopic removal of lesions should still be considered mandatory for the differential diagnosis of ectopic pancreas whenever typical endosonographic features cannot be well demonstrated.

Subepithelial mass lesions in the upper gastrointestinal tract

The finding of a mass lesion in the upper gastrointestinal tract at endoscopy with apparent normal overlying mucosa is common. The differential diagnosis of such lesions is broad and includes those of intramural or extramural origin. Endoscopic ultrasound provides accurate imaging of subepithelial mass lesions and characterizes them according to size, echogenicity, and origin including the histologic layer if the lesion is intramural which narrows the differential diagnosis. Endoscopic ultrasound allows a guided tissue sample to be obtained for histologic confirmation which is especially important for hypoechoic lesions arising from the 3rd or 4th echogenic layers. The purpose of this article is to review the diagnosis of the more common subepithelial mass lesions with an emphasis on endoscopic ultrasound and the subsequent management or monitoring.

Current utilization and performance status of endoscopic ultrasound in a community hospital

OBJECTIVE

Endoscopic ultrasound (EUS) is an essential tool for cancer staging and investigating gastrointestinal diseases. Although it is not a widespread skill, as its expanded indications became much more advanced so did its popularity and hospital acceptance. We aimed to study the utilization and indications of upper EUS in a Hong Kong community hospital. The secondary aim was to assess our accuracy in staging of esophageal and gastric cancer and in evaluating submucosal tumors.

METHODS

All patients who had undergone upper EUS in Tuen Mun Hospital from January 2002 to December 2006 were recruited. Their background data, indications, radiological investigations, upper endoscopy and operation records and histopathologic results were retrieved for analysis. The accuracy of EUS in esophageal cancer staging, gastric cancer staging and evaluating submucosal tumors was assessed by comparing surgical and histopathologic findings.

RESULTS

A total of 645 upper EUS examinations were performed and there has been a steady increase in EUS utilization in our hospital. The most common indications were evaluating submucosal tumors and staging esophageal and gastric cancer. The accuracy of T and N staging of esophageal cancer was 71.2 and 79.7%, respectively and for gastric cancer was 64.0 and 74.7%, respectively. Endoscopic ultrasound was 70% accurate in identifying lesions arising from the submucosal layer and 100% accurate in identifying lesions from the muscularis propria.

CONCLUSION

Endoscopic ultrasound is an accurate method and its demand is increasing. The performance in a community hospital can be further improved and its utilization should expand to other indications.

Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration

AIM: To evaluate the role of endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) in the preoperative diagnosis of gastrointestinal stromal tumor (GIST).

METHODS: From September 2002 to June 2006, Fifty-three consecutive EUS-FNAs of GI tract subepithelial hypoechoic tumors with continuity to proper muscle layer suspected as GIST by standard EUS were evaluated prospectively. The reference standards for the final diagnosis were surgery (n = 31), or clinical follow-up (n = 22). Additionally, immunophenotyping of specimens obtained by EUS-FNA and surgical resection specimens were compared.

RESULTS: In 2 cases puncture was not performed because of anatomical problems. The collection rate of adequate specimens from the GI tract subepithelial hypoechoic tumor with continuity to proper muscle layer was 82% (42/51). The diagnostic rate for the tumor less than 2 cm, 2 to 4 cm, and 4 cm or more were 71% (15/21), 86% (18/21), and 100% (9/9), respectively. In 29 surgically resected cases, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EUS-FNA using immunohistochemical analysis of GIST were 100% (24/24), 80% (4/5), 96% (24/25), 100% (4/4), and 97% (28/29), respectively. No major complications were encountered.

CONCLUSION: EUS-FNA with immunohistochemical analysis is a safe and accurate method in the prethera-peutic diagnosis of GIST. It should be taken into consideration in decision making, especially in early diagnosis following minimal invasive surgery for GIST.

Tumor estromal gástrico de riesgo intermedio: diagnóstico mediante ecografía hidrogástrica

Evaluation of submucosal lesions of the digestive tract with conventional endoscopy is unsatisfactory since this technique does not allow direct observation or correct evaluation of the size and layer of origin of the tumor; therefore, in most patients an etiological diagnosis cannot be established with this procedure. However, in most patients, endoscopic ultrasonography can resolve these problems: to a fair degree of certainty, this technique can differentiate malignant from benign lesions, measure their size, and establish their layer of origin. Endoscopic ultrasonography is the technique of choice to establish the presence and characteristics of submucosal tumors and their suitability for treatment. Moreover, this procedure can identify tumors that can be removed endoscopically without excessive risk. Hydrogastric ultrasonography can be an effective substitute for echoendoscopy when evaluating submucosal lesions and for staging tumors of the gastric antrum when echoendoscopy is not available or in patients in whom it cannot be performed. Hydrogastric ultrasonography is safe, inexpensive and very well tolerated by patients. We present the case of a female patient with a gastric GIST that was evaluated using hydrogastric ultrasonography. The size, layer of origin, and malignancy of the tumor were accurately established.

Appendiceal intussusception diagnosed with endoscopic sonography

Intussusception of the appendix vermiformis is an uncommon cause of abdominal pain. Several imaging modalities are of limited value in diagnosing this rare condition, including barium enema, transabdominal sonography, and CT. We report a case of intussusception of the appendix vermiformis with the clinical presentation of intermittent abdominal pain in the right lower quadrant. Colonoscopy revealed an erythematous polypoid lesion at the cecal base. Endoscopic sonography demonstrated a multiconcentric structure and enabled the tentative diagnosis of intussusception of the appendix vermiformis. Laparoscopic surgery with a reduction of the appendix and appendectomy was performed and confirmed the diagnosis.

Gastrointestinal stromal tumors

BACKGROUND

We reviewed radiologic features of gastrointestinal stromal tumors (GISTs) and correlated them with clinical and pathologic findings.

METHODS

We investigated a series of 39 c-Kit-positive GISTs. Clinical and radiologic findings and management of these patients were recorded.

RESULTS

Twenty women and 19 men (mean age 64 years) had histologically proved GIST. Tumor locations were the small bowel (n = 20), stomach (n = 14), rectum (n = 4), and omentum (n = l). Symptoms at presentation were most frequently gastrointestinal bleeding (n = 14) and abdominal pain (n = l1). Tumors were classified as very low risk (n = 2), low risk (n = 10), intermediate risk (n = 12), and high risk (n = 11). Ultrasonography, computed tomography, magnetic resonance, digital subtraction angiography, and barium series were used in the evaluation of these tumors. Most tumors were seen as well-delineated soft tissue masses with heterogeneous contrast enhancement. Necrosis, calcification, and ulceration were most commonly seen in large tumors that presented a more aggressive behavior.

CONCLUSION

GISTs can arise anywhere in the gastrointestinal tract and present a great variety of clinical and radiologic features, depending mostly on size and location.

Gastric cancer mimicking a submucosal tumor diagnosed by laparoscopic excision biopsy

We report a case of advanced gastric cancer exhibiting the features of a submucosal tumor (SMT) of the gastric body. The patient was a 50-year-old male in whom a gastric SMT was detected during a mass screening examination. Upper gastrointestinal endoscopy revealed a protuberant tumor, 2 cm in diameter, covered with normal-appearing mucosa. Examination of an endoscopic biopsy specimen of the tumor revealed chronic gastritis with regenerative and erosive changes. An endoscopic ultrasound examination demonstrated a hypoechoic mass in the third layer of the gastric wall. The clinical diagnosis was gastric SMT, and the patient's course was monitored. Twenty-six months after the initial visit to our hospital, an endosonograph-guided biopsy revealed Group III (borderline lesion). Three months after the biopsy, the size of the SMT had increased slightly. Laparoscopic wedge resection of the tumor was performed to make a pathologic diagnosis and we were able to make a diagnosis of gastric lymphoepithelioma-like carcinoma intraoperatively. Gastrectomy with lymph node dissection was followed as curative surgery. Laparoscopic total excision biopsy is a useful technique in patients with a gastric SMT whose diagnosis has not been confirmed pathologically.

SURGERY FOR GASTROINTESTINAL STROMAL TUMOUR IN THE POST-IMATINIB ERA

Gastrointestinal stromal tumour (GIST) is a rare tumour. Historically, surgery has been the only effective treatment. The prognosis of patients with gastrointestinal stromal tumour is poor. Even after apparently 'curative' surgical resection more than 50% of patients relapse. The development of an effective novel targeted therapy against GIST (imatinib mesylate) is a success story of molecular biology that has dramatically altered the management of patients with these tumours. However, as follow up of patients who have initially responded to imatinib has increased, it has become evident that such hopes of cure were premature because responses to imatinib are of limited duration. Unresolved issues include the role of imatinib as an induction (neo-adjuvant) therapy prior to surgery, or as adjuvant treatment after surgery, the role of surgery in patients with a differential or partial response and the role of surgery in patients with isolated metastatic disease. In the present paper the biology and natural history of GIST are reviewed, and the complexities of surgical management that exist in the context of an effective, but not curative, biological therapy, are addressed.

EUS features of recurrent transitional cell bladder cancer metastatic to the GI tract

BACKGROUND

Recurrent transitional cell bladder cancer (TCBC) can metastasize to the GI tract albeit uncommonly. This is the first report of the EUS appearance of metastatic TCBC to the GI tract. In addition to describing the EUS features of recurrent metastatic TCBC, this study determined the number of patients referred for evaluation of a primary GI luminal cancer in which EUS instead established the diagnosis of metastatic recurrent TCBC.

METHODS

Patients referred from July 2000 through April 2004 for EUS evaluation of a suspected primary GI luminal cancer were retrospectively reviewed. For patients with an established diagnosis of recurrent metastatic TCBC, EUS images were retrospectively reviewed to identify characteristic features.

RESULTS

Of 2216 patients undergoing EUS to evaluate a suspected primary GI luminal cancer, 3 men (0.14%: 95% confidence interval [0.02%, 0.29%]) (mean age 67 years, range 54-74 years) were found instead to have recurrent metastatic TCBC involving the duodenum (n = 1) or rectum (n = 2). The patients presented a mean of 32 months after diagnosis of the primary TCBC with change in bowel habit (n = 1) and symptoms of bowel obstruction (n = 2). In each patient, initial endoscopy revealed circumferential luminal stenosis and mucosal erythema, but mucosal biopsy specimens revealed normal tissue. EUS demonstrated hypoechoic, symmetric, circumferential wall thickening, loss of deep wall layers, and pseudopodia-like extensions into the peri-intestinal tissues. In the two patients with rectal involvement, no evidence of direct infiltration from the bladder bed was seen. EUS-guided FNA was diagnostic of metastatic TCBC in all patients.

CONCLUSIONS

Although most cases of hypoechoic bowel-wall thickening and stenosis are from primary GI neoplasia, recurrent TCBC should be considered in patients with a history of this tumor. Correct diagnosis is important, because this allows selection of appropriate therapeutic interventions. Although firm EUS criteria for TCBC cannot be established based on findings in 3 patients, certain features may prove useful. EUS-guided FNA can confirm the diagnosis.

Submucosal lesions

Most of the submucosal lesions encountered on endoscopy are benign; however, the fact that some of them may be malignant considerably influences the attitude toward the whole group. This article reviews the current status of endosonography in the management of submucosal lesions and focuses on determining the risk of malignancy. The predictive value of various endoscopic ultrasonography (EUS) features and their combinations and the capabilities and limitations of EUS-guided fine needle biopsy are discussed. Other issues addressed include differentiation between extraluminal compressions and true submucosal lesions, EUS-assisted endoscopic removal of submucosal lesions, and the potential role of catheter-based endosonography in the setting of submucosal lesions. Problems related to the surveillance of patients with submucosal lesions who are not candidates for surgical treatment are outlined. An overview of the recent changes in the pathologic classification of gastrointestinal mesenchymal tumors and their impact on the role of EUS in the management of submucosal lesions is given.

Endoscopic sonographically guided fine-needle aspiration yield in submucosal tumors of the gastrointestinal tract

OBJECTIVE

To study the yield of endoscopic ultrasonographically guided fine-needle aspiration cytologic examination in the diagnosis of submucosal masses.

METHODS

From 1999 to 2003, 10 patients underwent ultrasonographically guided fine-needle aspiration for the cytologic diagnosis of submucosal masses in our institution. The endoscopic ultrasonography records and the cytology database were consulted, and the reports were analyzed, as were slide material and the technical aspects related to these procedures. All procedures were performed under conscious sedation and cardiorespiratory monitoring on an outpatient basis. Ten patients (4 men and 6 women; mean age, 60.8 years) were studied.

RESULTS

Eight lesions were located in the stomach, and 2 were located in the esophagus, with a mean diameter of 3.3 cm. An experienced cytopathologist was present on-site during all procedures for assessment of adequacy and preliminary cytologic examination. Cytologic diagnoses were obtained in 8 cases as follows: 6 gastrointestinal stromal tumors, 1 organizing submucosal hematoma, and 1 low-grade mucosa-associated lymphoid tissue-associated lymphoma. Two cases consisted of scant gastric epithelium only and were considered nondiagnostic. The cytologic diagnoses guided further clinical treatment.

CONCLUSIONS

Ultrasonographically guided fine-needle aspiration with cytopathologic analysis has a high accuracy rate (80%) for diagnosing submucosal lesions. These findings potentially affect clinical decision making.

Miniature ultrasonic probes for diagnosis and treatment of digestive tract diseases

AIM: To investigate the clinical value of miniature ultrasonic probes (MUPs) for the diagnosis and treatment of digestive tract diseases.

METHODS: Endoscopic ultrasonography (EUS) was performed for patients with its indications with 7.5-20 MHz MUPs and double-cavity electronic endoscope. According to the diagnosis of MUPs, patients who had indications of treatment received endoscopic resection or surgical excision. Postoperative histological results were compared with the preoperative diagnosis of MUPs. A few patients without endoscopic resection or surgical excision were periodically followed up with MUPs.

RESULTS: A total of 537 patients were examined by MUPs, of them, 256 were diagnosed with gastrointestinal submucosal lesions, 146 with pseudo-submucosal lesions, 50 with digestive tract cancers, 17 with peptic ulcer, 11 with cholecystolithiasis, 8 with chronic pancreatitis, and 2 with achalasia and 47 were diagnosed as normal. After MUPs examinations, 220 patients received endoscopic resection or surgical excision, and the postoperative histological results of 211 patients were completely consistent with the preoperative diagnosis of MUPs. The diagnostic accuracy of MUPs was 95.9%. The result of follow-up with MUPs indicated that gastrointestinal leiomyoma, lipoma, phlebangioma and cyst were unchanged within 1-2 years. The patients who received endoscopic resection or centesis did not have any complications.

CONCLUSION: MUPs are of value in diagnosing gastrointestinal submucosal lesions, staging of digestive tract cancers and biliary-pancreatic diseases. They play a very important role in making therapeutic plans.

Endoscopic diagnosis and treatment of submucosal tumors of gastrointestinal tract

AIM: To improve the diagnoses and treatment for submucosal tumors of gastrointestinal tract.

METHODS: Endoscopic ultrasonograpy (EUS) was conducted in 136 patients with submucosal tumors (SMT) in gastrointestinal tract. Endoscopic therapy or surgical operation was taken according to the different layers of SMT.

RESULTS: A total of 33 cases of stromal tumors derived from mucosa; 2 cysts, 8 lipomas, 12 etopic pancreases in stomach and 5 varics in gastric fundus from submucosa; 60 benign stromal tumors and 16 malignant stromal tumors from muscularis; 24 benign stromal tumors from mucosa, 6 benign stromal tumors from muscularis, 4 gastric lipomas, 2 cysts, 6 etopic pancreas in stomach were resected by endoscopy; 28 cases of benign stromal tumors derived from muscularis, 15 malignant stromal tumors, 2 lipoma and 2 etopic pancreas were removed by surgery. 97.7% of SMTs diagnosed by EUS were confirmed further by pathology.

CONCLUSION: Different layers of gastrointestinal tract with SMTs can be distinguished clearly by EUS, leading to definite diagnosis of SMTs. EUS is important to select treating methods of SMTs in gastrointestinal tract. Endoscopic therapy is an effective method for submucosal tumor of gastrointestinal tract.

Diagnostic value of endoscopic ultrasonography for gastrointestinal leiomyoma

AIM: To investigate the clinical pathologic features of gastrointestinal leiomyoma and the diagnostic value of endoscopic ultrasonography (EUS) on gastrointestinal leiomyoma.

METHODS: A total of 106 patients with gastrointestinal leiomyoma diagnosed with EUS were studied. The location, size and layer origin of gastric and esophageal leiomyomas were analyzed and compared. The histological diagnosis of the resected specimens by endoscopy or surgery in some patients was compared with their results of EUS.

RESULTS: The majority of esophageal leiomyomas were located in the middle and lower part of the esophagus and their size was smaller than 1.0 cm, and 62.1% of esophageal leiomyomas originated from the muscularis mucosae. Most of the gastric leiomyomas were located in the body and fundus of the stomach with a size of 1-2 cm. Almost all gastric leiomyomas (94.2%) originated from the muscularis propria. The postoperative histological results of 54 patients treated by endoscopic resection or surgical excision were completely consistent with the preoperative diagnosis of EUS, and the diagnostic specificity of EUS to gastrointestinal leiomyoma was 94.7%.

CONCLUSION: The size and layer origin of esophageal leiomyomas are different from that of gastric leiomyomas. Being safe and accurate, EUS is the best method not only for gastrointestinal leiomyoma diagnosis but also for the follow-up of patients.

Gastrointestinal stromal tumors: radiologic features with pathologic correlation

Gastrointestinal stromal tumors (GISTs) are unique neoplasms that occur throughout the gastrointestinal tract, mesentery, omentum, and retroperitoneum. They are the most common mesenchymal neoplasm of the gastrointestinal tract and are defined by their expression of KIT (CD117), a tyrosine kinase growth factor receptor. The expression of KIT is important to distinguish GISTs from other mesenchymal neoplasms such as leiomyomas, leiomyosarcomas, schwannomas, and neurofibromas and to determine the appropriateness of KIT-inhibitor therapy. The series described herein was accumulated over 2 years and includes 64 pathologically proved GISTs (28 gastric, 27 small intestinal, six anorectal, one colonic, one esophageal, and one from the small bowel mesentery). Radiologic features of GISTs vary depending on tumor size and organ of origin. Since most GISTs arise within the muscularis propria of the stomach or intestinal wall, they most commonly have an exophytic growth pattern and manifest as dominant masses outside the organ of origin. Dominant intramural and intraluminal masses are less common radiologic manifestations. GISTs occurring in the gastrointestinal tract and mesentery characteristically have hemorrhage, necrosis, or cyst formation that appears as focal areas of low attenuation on computed tomographic images. Although the radiologic features of GISTs are often distinct from those of epithelial tumors, criteria to separate GISTs radiologically from other nonepithelial tumors have not yet been fully developed.

Endoscopic ultrasound and upper gastrointestinal disorders

Endoscopic ultrasound (EUS) plays a vital role in management of upper gastrointestinal disorders, particularly cancer of the esophagus, pancreas, stomach, lung (via transesophageal mediastinal staging), and bile duct. Endoscopic ultrasound has also been valuable in detection of early chronic pancreatitis (CP). In cancer of the esophagus, the primary role of EUS is to determine whether disease is localized (T1-2, N0) and appropriate for surgery, locally advanced (T3-4, N1, M1a) (which may benefit from chemoradiation with or without surgery), or metastatic. Pancreatic and bile duct cancers are more complex given the controversy over portal vein resection. In centers that resect tumors invading the portal venous system, the role of EUS is limited to tissue confirmation or identification of metastases to the liver or distant lymph nodes. In centers that do not resect the portal vein invasion, EUS plays an important role in local staging. In lung cancer, EUS is emerging as an accurate, nonsurgical alternative to staging the mediastinum through EUS fine-needle aspiration. Endoscopic ultrasound has an important role in diagnosing CP because of its high degree of sensitivity. This has also led to controversy over whether EUS can overdiagnose CP. For these reasons, we recommend the use of a high threshold for EUS and that CP be diagnosed in conjunction with other standard tests (endoscopic retrograde cholangiopancreatography, pancreatic function tests).