Diagnostic yield of deep biopsy via endoscopic submucosal dissection for the diagnosis of upper gastrointestinal subepithelial tumors: a systematic review and meta-analysis

Is canalization to obtain a deep biopsy of gastrointestinal subepithelial tumors miniprobe-guided an alternative to conventional known techniques?

Multicenter, retrospective database review and topical of 46 patients consecutives with subepithelial gastrointestinal tumors (SET). The diagnostic accuracy of deep biopsy miniprobe-guidded: 87%. Complications: seven minor bleeding (15%). The samples obtained of deep biopsy miniprobe-guidded, confirm abnormal submucosal arteries mimicking theappearance of SET, are sufficient for histophatological and immunohistochemical diagnosis.

Comparative diagnostic yield of different endoscopic techniques for tissue sampling of upper gastrointestinal subepithelial lesions: a network meta-analysis

BACKGROUND

There is limited evidence on the comparative diagnostic performance of endoscopic tissue sampling techniques for subepithelial lesions. We performed a systematic review with network meta-analysis to compare these techniques.

METHODS

A systematic literature review was conducted for randomized controlled trials (RCTs) comparing the sample adequacy and diagnostic accuracy of bite-on-bite biopsy, mucosal incision-assisted biopsy (MIAB), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), and EUS-guided fine-needle biopsy (FNB). Results were expressed as relative risk (RR) and 95%CI.

RESULTS

Eight RCTs were identified. EUS-FNB was significantly superior to EUS-FNA in terms of sample adequacy (RR 1.20 [95%CI 1.05-1.45]), whereas none of the other techniques significantly outperformed EUS-FNA. Additionally, bite-on-bite biopsy was significantly inferior to EUS-FNB (RR 0.55 [95%CI 0.33-0.98]). Overall, EUS-FNB appeared to be the best technique (surface under cumulative ranking [SUCRA] score 0.90) followed by MIAB (SUCRA 0.83), whereas bite-on-bite biopsy showed the poorest performance. When considering lesions <20 mm, MIAB, but not EUS-FNB, showed significantly higher accuracy rates compared with EUS-FNA (RR 1.68 [95%CI 1.02-2.88]). Overall, MIAB ranked as the best intervention for lesions <20 mm (SUCRA score 0.86 for adequacy and 0.91 for accuracy), with EUS-FNB only slightly superior to EUS-FNA. When rapid on-site cytological evaluation (ROSE) was available, no difference between EUS-FNB, EUS-FNA, and MIAB was observed.

CONCLUSION

EUS-FNB and MIAB appeared to provide better performance, whereas bite-on-bite sampling was significantly inferior to the other techniques. MIAB seemed to be the best option for smaller lesions, whereas EUS-FNA remained competitive when ROSE was available.

Mucosal incision-assisted biopsy versus endoscopic ultrasound-assisted tissue acquisition for subepithelial lesions: a systematic review and meta-analysis

Background/Aims

Mucosal incision-assisted biopsy (MIAB) for tissue acquisition (TA) from subepithelial lesions (SELs) is emerging as an alternative to endoscopic ultrasound (EUS)-guided TA. Only a limited number of studies compared the diagnostic utility of MIAB and EUS for upper gastrointestinal (GI) SELs; therefore, we conducted this systematic review and meta-analysis.

Methods

A comprehensive literature search from January 2020 to January 2022 was performed to compare the diagnostic accuracy and safety of MIAB and EUS-guided TA for upper GI SELs.

Results

Seven studies were included in this meta-analysis. The pooled technical success rate (risk ratio [RR], 0.96; 95% confidence interval [CI], 0.89–1.04) and procedural time (mean difference=–4.53 seconds; 95% CI, –22.38 to 13.31] were comparable between both the groups. The overall chance of obtaining a positive diagnostic yield was lower with EUS than with MIAB for all lesions (RR, 0.83; 95% CI, 0.71–0.98) but comparable when using a fine-needle biopsy needle (RR, 0.93; 95% CI, 0.83–1.04). The positive diagnostic yield of MIAB was higher for lesions <20 mm (RR, 0.75; 95% CI, 0.63–0.89). Six studies reported no adverse events.

Conclusions

MIAB can be considered an effective alternative to EUS-guided TA for upper GI SELs without an increased risk of adverse events.

Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends endoscopic ultrasonography (EUS) as the best tool to characterize subepithelial lesion (SEL) features (size, location, originating layer, echogenicity, shape), but EUS alone is not able to distinguish among all types of SEL.Strong recommendation, moderate quality evidence. 2: ESGE suggests providing tissue diagnosis for all SELs with features suggestive of gastrointestinal stromal tumor (GIST) if they are of size > 20 mm, or have high risk stigmata, or require surgical resection or oncological treatment.Weak recommendation, very low quality evidence. 3: ESGE recommends EUS-guided fine-needle biopsy (EUS-FNB) or mucosal incision-assisted biopsy (MIAB) equally for tissue diagnosis of SELs ≥ 20 mm in size.Strong recommendation, moderate quality evidence. 4: ESGE recommends against surveillance of asymptomatic gastrointestinal (GI) tract leiomyomas, lipomas, heterotopic pancreas, granular cell tumors, schwannomas, and glomus tumors, if the diagnosis is clear.Strong recommendation, moderate quality evidence. 5: ESGE suggests surveillance of asymptomatic esophageal and gastric SELs without definite diagnosis, with esophagogastroduodenoscopy (EGD) at 3-6 months, and then at 2-3-year intervals for lesions < 10 mm in size, and at 1-2-year intervals for lesions 10-20 mm in size. For asymptomatic SELs > 20 mm in size that are not resected, ESGE suggests surveillance with EGD plus EUS at 6 months and then at 6-12-month intervals.Weak recommendation, very low quality evidence. 6: ESGE recommends endoscopic resection for type 1 gastric neuroendocrine neoplasms (g-NENs) if they grow larger than 10 mm. The choice of resection technique should depend on size, depth of invasion, and location in the stomach.Strong recommendation, low quality evidence. 7: ESGE suggests considering removal of histologically proven gastric GISTs smaller than 20 mm as an alternative to surveillance. The decision to resect should be discussed in a multidisciplinary meeting. The choice of technique should depend on size, location, and local expertise.Weak recommendation, very low quality evidence. 8: ESGE suggests that, to avoid unnecessary follow-up, endoscopic resection is an option for gastric SELs smaller than 20 mm and of unknown histology after failure of attempts to obtain diagnosis.Weak recommendation, very low quality evidence. 9: ESGE recommends basing the surveillance strategy on the type and completeness of resection. After curative resection of benign SELs no follow-up is advised, except for type 1 gastric NEN for which surveillance at 1-2 years is advised.Strong recommendation, low quality evidence. 10: For lower or upper GI NEN with a positive or indeterminate margin at resection, ESGE recommends repeating endoscopy at 3-6 months and another attempt at endoscopic resection in the case of residual disease.Strong recommendation, low quality evidence.

Retrospective analysis of the outcomes of endoscopic submucosal dissection for the diagnosis and treatment of subepithelial lesions in a center with high expertise

Background

Use of endoscopic submucosal dissection (ESD) for the diagnosis and treatment of subepithelial lesions (SELs) is limited in the West, and the best approach for these lesions is still debated. In this study we describe our experience regarding the usefulness, safety and outcomes of ESD for SELs.

Method

We performed a retrospective analysis of ESD in the diagnosis and treatment of SELs between November 2010 and February 2021.

Results

A total of 634 ESDs were reviewed. Fifty-five (9%) were performed in SELs, 6 in the esophagus, 34 in the stomach, and 15 in the rectum. ESD was technically successful in 53 lesions (96%). Most of them (82%) had previous endoscopic ultrasound evaluation, but only 20% had a histological diagnosis previous to the ESD. Neuroendocrine tumors, gastrointestinal stromal tumors, and granular cell tumors accounted for 38% of the procedures, with a 100% rate of en bloc resection and 65% of R0 resection; the main criterion for non-curative resection was a deep positive margin, and none of the patients treated with complementary surgery had lesions on the gastrointestinal wall. Most of the procedures (62%) were performed in lesions with very low malignant potential, providing the definitive diagnosis of SELs where the previous diagnostic workup was inconclusive. We had a total of 2 delayed bleedings and 1 perforation, all treated endoscopically.

Conclusion

Our real-life experience showed that ESD can be an effective and safe diagnostic tool for undetermined SELs, as well as an effective treatment for neoplastic SELs with malignant potential.