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Yamazaki H, Yamashita Y, Tamura T, Kawaji Y, Tamura T, Itonaga M, Ashida R, Shimokawa T, Kojima F, Hayata K, Maekita T, Iguchi M, Kitano M. Value of image enhancement of endoscopic ultrasound for diagnosis of gastrointestinal subepithelial lesions. DEN OPEN 2025; 5:e70026. [PMID: 39398257 PMCID: PMC11470742 DOI: 10.1002/deo2.70026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 09/17/2024] [Accepted: 09/30/2024] [Indexed: 10/15/2024]
Abstract
Objectives Among subepithelial lesions (SELs), gastrointestinal stromal tumors (GISTs) should be identified and surgically treated at an early stage. However, it is difficult to diagnose SELs smaller than 20 mm. In recent years, endoscopic ultrasound (EUS) elastography (EUS-EG) and contrast-enhanced harmonic EUS (CH-EUS) have been reported to be useful for the diagnosis of SELs, although the diagnostic accuracy of a combination of EUS techniques with image enhancement is unknown. Methods Patients with SELs who underwent EUS-guided tissue acquisition, EUS shear-wave elastography (EUS-SWE), EUS strain elastography (EUS-SE), and CH-EUS from January 2019 to June 2023 were enrolled. To assess the diagnostic accuracy for differentiating GISTs from other SELs, shear-wave velocity on EUS-SWE, the strain ratio on EUS-SE, and vascularity on CH-EUS were determined and their diagnostic accuracies were compared. Results Forty-three patients were enrolled. When the cut-off value was set at 3.27 m/s, the sensitivity, specificity, and diagnostic accuracy of shear-wave velocity were 28.6%, 86.2%, and 34.9%, respectively. When the cut-off value was set at 3.79, the sensitivity, specificity, and diagnostic accuracy of the strain ratio were 93.1%, 64.3%, and 83.7%, respectively. The sensitivity, specificity, and diagnostic accuracy of CH-EUS were 79.3%, 92.3%, and 83.7%, respectively. When EUS-SE was combined with CH-EUS, the sensitivity and diagnostic accuracy were the highest among binary combinations of image enhancement modalities. Conclusions EUS-SE and CH-EUS are useful for differentiating GISTs from other SELs. Furthermore, the use of both modalities may further improve the identification of GISTs.
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Affiliation(s)
- Hirofumi Yamazaki
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Yasunobu Yamashita
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Takaaki Tamura
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
- Department of Human PathologyWakayama Medical UniversityWakayamaJapan
| | - Yuki Kawaji
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Takashi Tamura
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Masahiro Itonaga
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Reiko Ashida
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Toshio Shimokawa
- Clinical Study Support CenterWakayama Medical UniversityWakayamaJapan
| | - Fumiyoshi Kojima
- Department of Human PathologyWakayama Medical UniversityWakayamaJapan
| | - Keiji Hayata
- Second Department of SurgeryWakayama Medical UniversityWakayamaJapan
| | - Takao Maekita
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Mikitaka Iguchi
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
| | - Masayuki Kitano
- Second Department of Internal MedicineWakayama Medical UniversityWakayamaJapan
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2
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Li T, Li J, Hu Z, Lu M. An ultrasound based method for predicting the malignant potential of primary gastrointestinal stromal tumors preoperatively. Abdom Radiol (NY) 2024:10.1007/s00261-024-04341-5. [PMID: 38849537 DOI: 10.1007/s00261-024-04341-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVE Gastrointestinal stromal tumors (GISTs) are difficult to identify the risk level accurately without surgical pathological confirmation. The purpose of our study was to propose a noninvasive prediction method for predicting the malignant potential of GISTs preoperatively by using contrast-enhanced ultrasound (CEUS) with gastric distention. METHODS We reviewed 47 GISTs who underwent CEUS from April 2017 to August 2023 retrospectively, all the lesions were certificated by pathology after surgery. The age of the patient, size of the lesion, shape, necrosis, calcification in the lesion, perfusion parameters including arrival time (AT), peak intensity (PI), time to peak (TTP), and area under the curve (AUC) of the lesion and surrounding normal tissue were analyzed. Logistic regression analyses were performed. Of the 47 GISTs, 26 were high-risk and 21 low-risk tumors respectively. RESULTS Compared with low-risk GISTs, high-risk GIST had faster AT (7.7s vs. 11.5s, p < 0.05), higher PI (15.2dB vs. 12.5dB, p < 0.05), and larger size (4.4 cm vs. 2.2 cm, p < 0.001). In multivariate logistic regression, AT, PI, and size were significant features. The corresponding regression equation In (p/(1-p)=-5.9 + 4.5 size + 4.6 PI + 4.0 AT). CONCLUSION The size, AT, and PI of the GISTs on CEUS can be used as parameters for a noninvasive risk level prediction model of GISTs. This model may help identify the different risk levels of GISTs before surgery.
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Affiliation(s)
- Tingting Li
- Department of Ultrasound, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Juan Li
- Department of Ultrasound, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - ZiYue Hu
- Department of Ultrasound, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Man Lu
- Department of Ultrasound, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, China.
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Vasilakis T, Ziogas D, Tziatzios G, Gkolfakis P, Koukoulioti E, Kapizioni C, Triantafyllou K, Facciorusso A, Papanikolaou IS. EUS-Guided Diagnosis of Gastric Subepithelial Lesions, What Is New? Diagnostics (Basel) 2023; 13:2176. [PMID: 37443568 DOI: 10.3390/diagnostics13132176] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/18/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
Gastric subepithelial lesions (SELs) are intramural lesions that arise underneath the gastric mucosa. SELs can be benign, but can also be malignant or have malignant potential. Therefore, correct diagnosis is crucial. Endosonography has been established as the diagnostic gold standard. Although the identification of some of these lesions can be carried out immediately, solely based on their echo characteristics, for certain lesions histological examination is necessary. Sometimes histology can be inconclusive, especially for smaller lesions. Therefore, new methods have been developed in recent years to assist decision making, such as contrast enhanced endosonography, EUS elastography, and artificial intelligence systems. In this narrative review we provide a complete overview of the gastric SELs and summarize the new data of the last ten years concerning the diagnostic advances of endosonography on this topic.
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Affiliation(s)
- Thomas Vasilakis
- Hepatology and Gastroenterology Clinic, Charité Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Dimitrios Ziogas
- 1st Department of Internal Medicine, 251 Hellenic Air Force & VA General Hospital, 3 Kanellopoulou Str., 11525 Athens, Greece
| | - Georgios Tziatzios
- Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital, 3-5, Theodorou Konstantopoulou Str., Nea Ionia, 14233 Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, "Konstantopoulio-Patision" General Hospital, 3-5, Theodorou Konstantopoulou Str., Nea Ionia, 14233 Athens, Greece
| | - Eleni Koukoulioti
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Christina Kapizioni
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Antonio Facciorusso
- Department of Medical Sciences, University of Foggia, Section of Gastroenterology, 71122 Foggia, Italy
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
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Pallio S, Crinò SF, Maida M, Sinagra E, Tripodi VF, Facciorusso A, Ofosu A, Conti Bellocchi MC, Shahini E, Melita G. Endoscopic Ultrasound Advanced Techniques for Diagnosis of Gastrointestinal Stromal Tumours. Cancers (Basel) 2023; 15:1285. [PMID: 36831627 PMCID: PMC9954263 DOI: 10.3390/cancers15041285] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Gastrointestinal Stromal Tumors (GISTs) are subepithelial lesions (SELs) that commonly develop in the gastrointestinal tract. GISTs, unlike other SELs, can exhibit malignant behavior, so differential diagnosis is critical to the decision-making process. Endoscopic ultrasound (EUS) is considered the most accurate imaging method for diagnosing and differentiating SELs in the gastrointestinal tract by assessing the lesions precisely and evaluating their malignant risk. Due to their overlapping imaging characteristics, endosonographers may have difficulty distinguishing GISTs from other SELs using conventional EUS alone, and the collection of tissue samples from these lesions may be technically challenging. Even though it appears to be less effective in the case of smaller lesions, histology is now the gold standard for achieving a final diagnosis and avoiding unnecessary and invasive treatment for benign SELs. The use of enhanced EUS modalities and elastography has improved the diagnostic ability of EUS. Furthermore, recent advancements in artificial intelligence systems that use EUS images have allowed them to distinguish GISTs from other SELs, thereby improving their diagnostic accuracy.
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Affiliation(s)
- Socrate Pallio
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | | | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | | | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy
| | - Andrew Ofosu
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH 45201, USA
| | | | - Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology—IRCCS “Saverio de Bellis” Castellana Grotte, 70013 Castellana Grotte, Italy
| | - Giuseppinella Melita
- Human Pathology of Adult and Child Department, University of Messina, 98100 Messina, Italy
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Gao F, Li H, Du C, Han K, Linghu E. Causes of endoscopic misdiagnosis of gastrointestinal cyst as solid lesion. BMC Gastroenterol 2023; 23:10. [PMID: 36631782 PMCID: PMC9835244 DOI: 10.1186/s12876-022-02545-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/17/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND To explore the causes of endoscopic misdiagnosis of gastrointestinal cyst as solid lesion and the diagnostic value and limitations of EUS, guide clinicians to develop appropriate treatment strategies and improve the ability to identify SMT. METHODS We enrolled patients diagnosed with gastrointestinal SMT between January 2001 and December 2021 who underwent endoscopic resection with postoperative pathological diagnosis of cyst. Age, sex, maximum lesion diameter, judge the texture of lesion, origin and echo are potential factors affecting the diagnostic accuracy of cysts. RESULTS The diagnostic accuracy of EUS assessment 39.3% higher than that without EUS assessment (6.7%). The error rate was 60.7%, lower than that without EUS assessment (93.3%), suggesting that preoperative EUS assessment improved the diagnostic accuracy of gastrointestinal cyst (Fisher's accurate test, P = 0.033). The diagnostic accuracy of "judge the texture of lesion" was higher than that of no touch (P = 0.031). When the lesion size increased by 1 cm, the diagnostic accuracy decreased by about 21%. Hypoechoic lesions were less likely to be diagnosed correctly than anechoic lesions (P = 0.003). CONCLUSIONS The main cause of misdiagnosing gastrointestinal cyst as solid lesion is that no EUS assessment was performed before endoscopic resection or anechoic lesion was judged as hypoechoic lesion by preoperative EUS assessment.
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Affiliation(s)
- Fei Gao
- grid.414252.40000 0004 1761 8894Senior Department of Gastroenterology, the First Medical Center of PLA General Hospital, Beijing, China
| | - Huikai Li
- grid.414252.40000 0004 1761 8894Senior Department of Gastroenterology, the First Medical Center of PLA General Hospital, Beijing, China
| | - Chen Du
- grid.414252.40000 0004 1761 8894Senior Department of Gastroenterology, the First Medical Center of PLA General Hospital, Beijing, China
| | - Ke Han
- grid.414252.40000 0004 1761 8894Senior Department of Gastroenterology, the First Medical Center of PLA General Hospital, Beijing, China
| | - Enqiang Linghu
- grid.414252.40000 0004 1761 8894Senior Department of Gastroenterology, the First Medical Center of PLA General Hospital, Beijing, China
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6
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Wu J, Zhuang M, Zhou Y, Zhan X, Xie W. The value of contrast-enhanced harmonic endoscopic ultrasound in differential diagnosis and evaluation of malignant risk of gastrointestinal stromal tumors (<50mm). Scand J Gastroenterol 2022; 58:542-548. [PMID: 36369879 DOI: 10.1080/00365521.2022.2144437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) has been used in the differential diagnosis of benign and malignant tumors by visualization of tumor microcirculation and perfusion. However, its diagnostic role in submucosal tumors (SMTs), especially leiomyomas and gastric submucosal tumors (GISTs) was rarely studied. The aim of this study was to analyze the diagnostic role of CEH-EUS for SMTs (<50 mm) and the value of assessing the malignant potential of GISTs. MATERIALS AND METHODS We retrospectively included patients with tumors <50 mm in diameter who underwent preoperative EUS and CEH-EUS examination and had pathologically confirmed as leiomyomas and GISTs. To analyze the imaging features of CEH-EUS with pathological diagnosis as the gold standard and evaluate its diagnostic value. RESULTS This study included 10 cases of leiomyomas and 38 cases of GISTs. Under CEH-EUS detection, 86.9% of GISTs showed hyper-enhancement, 89.5% showed diffuse enhancement, 39.5% showed non-enhancing spots, and 97.4% showed obvious capsule enhancement. In contrast, the leiomyoma cases mostly showed hypo-enhancement (50.0%) or non-enhancement (30.0%) (p < 0.05). Then, the value of CEH-EUS in the differential diagnosis of benign and malignant tumors based on blood flow is significantly higher than that of B-EUS. Signal appearance time was significantly faster in the intermediate-high risk GISTs than in the very low-low risk group (5.1 s versus 15.5 s, p < 0.05), and the AUROC values predicted the risk at this time to be 0.903 (0.763-0.975). Heterogeneous perfusion and non-enhancing spots were also more common in the intermediate-high risk group. Univariate and multivariate analysis revealed that intratumoral irregularitie was an independent predictor of moderate to high risk (OR 3.99, 95%CI 1.04-90.95), with sensitivity, specificity and accuracy of 73.33%, 91.30% and 84.21%, respectively. CONCLUSIONS Through this study, CEH-EUS has a good differential diagnostic ability for leiomyomas and GISTs, and has a high value in predicting the risk of GISTs.
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Affiliation(s)
- Jiali Wu
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Mengqi Zhuang
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Yubao Zhou
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Xiang Zhan
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Weiwei Xie
- Department of Gastroenterology, The Second Hospital of Anhui Medical University, Hefei, China
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Deprez PH, Moons LMG, OʼToole D, Gincul R, Seicean A, Pimentel-Nunes P, Fernández-Esparrach G, Polkowski M, Vieth M, Borbath I, Moreels TG, Nieveen van Dijkum E, Blay JY, van Hooft JE. Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:412-429. [PMID: 35180797 DOI: 10.1055/a-1751-5742] [Citation(s) in RCA: 127] [Impact Index Per Article: 63.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Leon M G Moons
- Divisie Interne Geneeskunde en Dermatologie, Maag-, Darm- en Leverziekten, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Dermot OʼToole
- Neuroendocrine Tumor Service, ENETS Centre of Excellence, St. Vincent's University Hospital and Department of Clinical Medicine, Trinity College Dublin, University of Dublin St. James's Hospital, Dublin, Ireland
| | - Rodica Gincul
- Service de Gastroentérologie et Endoscopie Digestive, Hôpital Privé Jean Mermoz, Lyon, France
| | - Andrada Seicean
- Regional Institute of Gastroenterology and Hepatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Pedro Pimentel-Nunes
- Department of Gastroenterology, Portuguese Oncology Institute of Porto; Department of Surgery and Physiology, Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Portugal
| | | | - Marcin Polkowski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Center for Postgraduate Medical Education, and Department of Oncological Gastroenterology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Michael Vieth
- Institut of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Ivan Borbath
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Tom G Moreels
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Els Nieveen van Dijkum
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, The Netherlands
| | - Jean-Yves Blay
- Centre Léon Bérard, Université Claude Bernard Lyon 1, Lyon, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Möller K, Dietrich CF, Faiss S, Mutze S, Goelz L. [Alternatives of histological material collection - When and how is histological confirmation by ultrasound (US), computer tomography (CT) or endosonography (EUS) useful?]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 60:937-958. [PMID: 34781389 DOI: 10.1055/a-1482-9448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Histological classifications of tumorous lesions together with adequate staging are necessary for stage-appropriate and personalized therapies. The indications, technical possibilities, and limitations as well as potential complications of image-guided needle biopsy by ultrasound, computed tomography, and endosonography are described. Which procedure for which organ and which lesion?
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Affiliation(s)
- Kathleen Möller
- Klinik für Innere Medizin/Gastroenterologie, Berlin, Germany, SANA-Klinikum, Berlin, Germany
| | | | - Siegbert Faiss
- Klinik für Innere Medizin/Gastroenterologie, Berlin, Germany, SANA-Klinikum, Berlin, Germany
| | - Sven Mutze
- Institut für Radiologie und Neuroradiologie, BG Unfallkrankenhaus Berlin, Berlin, Germany.,Institut für Radiologie, SANA-Klinikum, Berlin, Germany.,Institut für Diagnostische Radiologie, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Leonie Goelz
- Institut für Radiologie und Neuroradiologie, BG Unfallkrankenhaus Berlin, Berlin, Germany.,Institut für Diagnostische Radiologie, Universitätsmedizin Greifswald, Greifswald, Germany
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9
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Lefort C, Gupta V, Lisotti A, Palazzo L, Fusaroli P, Pujol B, Gincul R, Fumex F, Palazzo M, Napoléon B. Diagnosis of gastric submucosal tumors and estimation of malignant risk of GIST by endoscopic ultrasound. Comparison between B mode and contrast-harmonic mode. Dig Liver Dis 2021; 53:1486-1491. [PMID: 34272196 DOI: 10.1016/j.dld.2021.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/03/2021] [Accepted: 06/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND standard B-mode EUS assessment and EUS-guided tissue acquisition present sub-optimal diagnostic yield in the differential diagnosis of gastric submucosal tumors (SMTs). AIMS to evaluate the performances of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) to differentiate gastric SMTs and predict malignancy risk of gastrointestinal stromal tumors (GIST). METHODS a retrospective analysis was performed retrieving consecutive patients with gastric SMTs who underwent EUS between 2009 and 2014. Patients with available EUS video recordings and histological diagnosis were included. De-identified videos were presented to experts who made a diagnosis on B-mode EUS and CH-EUS. RESULTS fifty-four patients (29 female, 64-year-old) were included. Final diagnoses were 40 GISTs (8 high-grade), 9 leiomyomas, 5 rare SMTs. The sensitivity, specificity, and accuracy of B-mode and CH-EUS for the differential diagnosis of GIST were 95.0% vs. 85.0%, 57.1% for both techniques, and 85.2% vs. 77.8%, respectively. The sensitivity, specificity, and accuracy of B-mode and CH-EUS for the estimation of the malignancy GISTs risk were 62.5% vs. 100%, 83.3% vs. 82.1%, and 78.9% vs. 86.1%, respectively. CONCLUSIONS CH-EUS showed better diagnostic performance than B-mode EUS in differentiating leiomyomas and risk stratification of GIST. When considering high-grade GISTs, the addition of CH-EUS allowed an improvement in diagnostic accuracy.
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Affiliation(s)
- Christine Lefort
- Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, Lyon 69008, France.
| | - Vikas Gupta
- Gastroenterology Unit, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Andrea Lisotti
- Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, Lyon 69008, France; Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | | | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola, Italy
| | - Bertrand Pujol
- Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, Lyon 69008, France
| | - Rodica Gincul
- Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, Lyon 69008, France
| | - Fabien Fumex
- Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, Lyon 69008, France
| | | | - Bertrand Napoléon
- Hopital Privé Jean Mermoz, Ramsay Générale de Santé, 55 avenue Jean Mermoz, Lyon 69008, France
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10
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Yamashita Y, Yoshikawa T, Kawaji Y, Tamura T, Hatamaru K, Itonaga M, Ida Y, Maekita T, Iguchi M, Murata SI, Kitano M. Novel endoscopic ultrasonography imaging technique for visualizing microcirculation without contrast enhancement in subepithelial lesions: Prospective study. Dig Endosc 2021; 33:955-961. [PMID: 33145842 DOI: 10.1111/den.13889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/22/2020] [Accepted: 11/02/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Detective flow imaging for endoscopic ultrasonography (DFI?EUS) is a new imaging modality developed for detecting fine vessels without using ultrasound contrast agents. This study aimed to evaluate its utility by comparing it with a type of directional power Doppler (eFLOW) for subepithelial lesions (SELs). METHODS Between January 2019 and January 2020, 28 patients with SELs undergoing DFI?EUS and eFLOW?EUS were enrolled. DFI?EUS and eFLOW?EUS assessing the vascularity in SELs were compared in terms of the rates of identification of intratumoral vessels. We also investigated how large vessels were depicted in both modalities based on surgical specimens as well as the detection rates of intratumoral vessels in gastrointestinal stromal tumors (GISTs) and non?GISTs using either DFI?EUS or eFLOW?EUS. RESULTS Among 28 patients, 23 with pathological confirmation by EUS?guided fine?needle aspiration biopsy (EUS?FNAB) specimens were included. Of those 23 patients, the 10 who underwent surgical resection were selected for analysis. The rate of detection of intratumoral vessels in SELs was significantly higher on DFI?EUS (80%) than on eFLOW?EUS (30%) (P\xA0=\xA00.03). Comparison with surgical specimens revealed that detection rate for vessels with maximum size of less 1000\xA0μm was higher in DFI?EUS (66%) than that in eFLOW?EUS (0%). GIST patients had significantly higher positive rates (90%) of intratumoral vessels than non?GIST patients (31%) on DFI in 23 cases including EUS?FNAB specimens (P\xA0=\xA00.045). CONCLUSIONS Detective flow imaging?EUS is more sensitive for depicting intratumoral vessels than eFLOW?EUS. Evaluation of intratumoral vessels on DFI?EUS is useful for identifying GISTs without contrast agents.
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Affiliation(s)
- Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takanori Yoshikawa
- Clinical Study Support Center, Wakayama Medical University Hospital, Wakayama, Japan
| | - Yuki Kawaji
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Tamura
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Keiichi Hatamaru
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Itonaga
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yoshiyuki Ida
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takao Maekita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Mikitaka Iguchi
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shin Ichi Murata
- Department of Human Pathology, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Goto O, Kaise M, Iwakiri K. Advancements in the Diagnosis of Gastric Subepithelial Tumors. Gut Liver 2021; 16:321-330. [PMID: 34456187 PMCID: PMC9099397 DOI: 10.5009/gnl210242] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 11/04/2022] Open
Abstract
A diagnosis of subepithelial tumors (SETs) is sometimes difficult due to the existence of overlying mucosa on the lesions, which hampers optical diagnosis by conventional endoscopy and tissue sampling with standard biopsy forceps. Imaging modalities, by using computed tomography and endoscopic ultrasonography (EUS) are mandatory to noninvasively collect the target's information and to opt candidates for further evaluation. Particularly, EUS is an indispensable diagnostic modality for assessing the lesions precisely and evaluating the possibility of malignancy. The diagnostic ability of EUS appears increased by the combined use of contrast-enhancement or elastography. Histology is the gold standard for obtaining the final diagnosis. Tissue sampling requires special techniques to break the mucosal barrier. Although EUS-guided fine-needle aspiration (EUS-FNA) is commonly applied, mucosal cutting biopsy and mucosal incision-assisted biopsy are comparable methods to definitively obtain tissues from the exposed surface of lesions and seem more useful than EUS-FNA for small SETs. Recent advancements in artificial intelligence (AI) have a potential to drastically change the diagnostic strategy for SETs. Development and establishment of noninvasive methods including AI-assisted diagnosis are expected to provide an alternative to invasive, histological diagnosis.
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Affiliation(s)
- Osamu Goto
- Department of Gastroenterology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
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12
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Kitano M, Yamashita Y, Kamata K, Ang TL, Imazu H, Ohno E, Hirooka Y, Fusaroli P, Seo DW, Napoléon B, Teoh AYB, Kim TH, Dietrich CF, Wang HP, Kudo M. The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) Guidelines for Contrast-Enhanced Endoscopic Ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1433-1447. [PMID: 33653627 DOI: 10.1016/j.ultrasmedbio.2021.01.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 06/12/2023]
Abstract
The Asian Federation of Societies for Ultrasound in Medicine and Biology aimed to provide information on techniques and indications for contrast-enhanced harmonic endoscopic ultrasound (CH-EUS), and to create statements including the level of recommendation. These statements are based on current scientific evidence reviewed by a Consensus Panel of 15 internationally renowned experts. The reliability of clinical questions was measured by agreement rates after voting. Six statements were made on techniques, including suitable contrast agents for CH-EUS, differences between contrast agents, setting of mechanical index, dual imaging and duration and phases for observation. Thirteen statements were made on indications, including pancreatic solid masses, pancreatic cancer staging, pancreatic cystic lesions and mural nodules, detection of subtle pancreatic lesions, gallbladder sludge and polyps, hepatic lesions, lymph nodes, subepithelial lesions, visceral vascular diseases, guidance of fine needle aspiration and evaluation for local therapy. These international expert consensus guidelines will assist endosonographers in conducting CH-EUS according to evidence-based information.
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Affiliation(s)
- Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Hiroo Imazu
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School, Nagoya, Japan
| | - Yoshiki Hirooka
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University, Aichi, Japan
| | - Pietro Fusaroli
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Bologna/Hospital of Imola, Imola, Italy
| | - Dong-Wan Seo
- Department of Gastroenterology, Asan Medical Centre, Seoul, Korea
| | - Bertrand Napoléon
- Department of Gastroenterology, Jean Mermoz Private Hospital, Ramsay Generale de Sante, Lyon, France
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - Tae Hyeon Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, South Korea
| | - Christoph F Dietrich
- Department of Internal Medicine (DAIM), Hirslanden Kliniken Beau Site, Salem und Permanence Bern, Switzerland
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
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Yang YT, Shen N, Ao F, Chen WQ. Diagnostic value of contrast-enhanced harmonic endoscopic ultrasonography in predicting the malignancy potential of submucosal tumors: a systematic review and meta-analysis. Surg Endosc 2020; 34:3754-3765. [DOI: 10.1007/s00464-020-07585-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 04/22/2020] [Indexed: 12/12/2022]
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Tamura T, Kitano M. Contrast Enhanced Endoscopic Ultrasound Imaging for Gastrointestinal Subepithelial Tumors. Clin Endosc 2019; 52:306-313. [PMID: 31331161 PMCID: PMC6680002 DOI: 10.5946/ce.2019.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 04/26/2019] [Indexed: 02/06/2023] Open
Abstract
Subepithelial tumors are divided into benign subepithelial and potentially malignant gastrointestinal stromal tumors. It is difficult to distinguish between these tumor types. Contrast-enhanced harmonic endoscopic ultrasound is reportedly useful for diagnosing subepithelial tumors, can be safely and easily performed by understanding the principle and method, and can be used to distinguish between tumor types with high sensitivity on the basis of differences in contrast effect. The generated image shows a hyperenhancement pattern in gastrointestinal stromal tumors (sensitivity, 78%-100%; specificity, 60%-100%; accuracy, 60%-100%) and hypoenhancement pattern in benign subepithelial tumors. Contrast-enhanced harmonic endoscopic ultrasound can be used to estimate the malignancy potential of gastrointestinal stromal tumors by evaluating the uniformity of the contrast and the blood vessels inside the tumor, with abnormal intra-tumor blood vessels, heterogeneous enhancement, and non-enhancing spots suggesting malignancy. Contrast-enhanced harmonic endoscopic ultrasound has a higher sensitivity than other imaging modalities for the detection of vascularity within gastrointestinal stromal tumors. Additionally, it has been reported that treatment effects can be estimated by evaluating the blood flow in the gastrointestinal stromal tumor before and after treatment with tyrosine kinase inhibitors using contrastenhanced ultrasound. However, there will be subjective-bias and the results depends on the performer's skill.
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Affiliation(s)
- Takashi Tamura
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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Cho IR, Park JC, Roh YH, Choi SI, Lee JE, Kim EH, Shin SK, Lee SK, Lee YC. Noninvasive prediction model for diagnosing gastrointestinal stromal tumors using contrast-enhanced harmonic endoscopic ultrasound. Dig Liver Dis 2019; 51:985-992. [PMID: 30926282 DOI: 10.1016/j.dld.2019.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Subepithelial tumors (SETs) are difficult to diagnose accurately without invasive pathological confirmation. We created a noninvasive prediction model for diagnosing gastrointestinal stromal tumors (GISTs) using contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS). METHODS We retrospectively reviewed 176 patients who underwent CEH-EUS from October 2011 to August 2017. Seventy patients with a diagnosis of GIST (n = 37) or leiomyoma (n = 33) were included. The long-to-short axis ratio (LSR) and enhancement patterns (vascularity, diffuse enhancement) on CEH-EUS were assessed. Logistic regression and classification and regression tree (CART) analyses were performed. RESULTS The mean age of all patients was 54.9 ± 13.68 years. The GIST group showed significantly higher rates of positive vascularity (81.1% vs. 15.2%, p < 0.001) and diffuse enhancement (51.4% vs. 15.2%, p = 0.001), and lower LSR (1.30 vs. 1.76, p < 0.001). In multivariate logistic regression, positive vascularity (odds ratio [OR] 27.765, 95% confidence interval [CI] 5.336-144.458) and low LSR (OR 18.940, 95% CI 3.623-99.007) were independent predictors of GIST. A noninvasive prediction model for GISTs was developed using the CART model, by allocating patients according to statistically significant variables. CONCLUSIONS The LSR and vascularity of SETs on CEH-EUS can be used as parameters for a noninvasive prediction model of GISTs. This model may be helpful in the early identification and treatment of GISTs.
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Affiliation(s)
- In Rae Cho
- Department of Internal Medicine, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, 03722, Seodaemun-gu, Seoul, Republic of Korea; Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Yun Ho Roh
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soo In Choi
- Department of Internal Medicine, Yonsei University College of Medicine, 03722, Seodaemun-gu, Seoul, Republic of Korea
| | - Jeung Eun Lee
- Department of Internal Medicine, Yonsei University College of Medicine, 03722, Seodaemun-gu, Seoul, Republic of Korea
| | - Eun Hye Kim
- Department of Internal Medicine, Yonsei University College of Medicine, 03722, Seodaemun-gu, Seoul, Republic of Korea; Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Kwan Shin
- Department of Internal Medicine, Yonsei University College of Medicine, 03722, Seodaemun-gu, Seoul, Republic of Korea; Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Yonsei University College of Medicine, 03722, Seodaemun-gu, Seoul, Republic of Korea; Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, 03722, Seodaemun-gu, Seoul, Republic of Korea; Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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16
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Tang JY, Tao KG, Zhang LY, Wu KM, Shi J, Zeng X, Lin Y. Value of contrast-enhanced harmonic endoscopic ultrasonography in differentiating between gastrointestinal stromal tumors: A meta-analysis. J Dig Dis 2019; 20:127-134. [PMID: 30714350 DOI: 10.1111/1751-2980.12710] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) is a valuable device to diagnose and determine the malignant potential of gastrointestinal stromal tumors (GIST) as early as possible when making clinical therapeutic decisions. This study aimed to estimate the ability of CH-EUS to discriminate between GIST and benign submucosal lesions (SML) and to predict their malignant potential. METHODS PubMed, MEDLINE, EMBASE, the Web of Science, and Cochrane Central Register of Controlled Trials databases were screened. Using the data provided in the literatures, 2 × 2 tables were constructed to obtain the pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. A receiver operating characteristic (ROC) curve was generated and the area under the ROC curve (AUROC) was calculated. RESULTS Four studies with a total of 187 patients were identified to evaluate the value of CH-EUS in discriminating between GIST and benign SML. The pooled sensitivity, specificity, and AUROC were 89% (95% CI 0.82-0.93), 82% (95% CI 0.66-0.92), and 0.89, respectively. Five studies including 143 patients were analyzed to assess the accuracy of CH-EUS in determining the malignant potential of GIST. The pooled sensitivity, specificity, and AUROC curve of CH-EUS were 96% (95% CI 0.90-0.99), 53% (95% CI 0.40-0.66), and 0.92, respectively. CONCLUSIONS CH-EUS is a safe, noninvasive method that can distinguish between GIST and benign subepithelial lesions and to predict their malignant potential to a certain extent. Large-scale, multicenter prospective studies are needed in the future.
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Affiliation(s)
- Jia Yue Tang
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Ke Gong Tao
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Li Yuan Zhang
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Kai Ming Wu
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jian Shi
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xin Zeng
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yong Lin
- Department of Gastroenterology, Changzheng Hospital, Second Military Medical University, Shanghai, China
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17
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Kannengiesser K, Mahlke R, Petersen F, Peters A, Kucharzik T, Maaser C. Instant evaluation of contrast enhanced endoscopic ultrasound helps to differentiate various solid pancreatic lesions in daily routine. World J Clin Cases 2019; 7:19-27. [PMID: 30637249 PMCID: PMC6327129 DOI: 10.12998/wjcc.v7.i1.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 12/04/2018] [Accepted: 12/21/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Contrast enhanced harmonic endoscopic ultrasound (CEH-EUS) is a spreading technique; some studies have shown its value in the diagnosis of pancreatic adenocarcinoma using quantitative analysis.
AIM To examine the value of CEH-EUS for differentiating various pancreatic lesions in everyday routine with qualitative and quantitative analysis.
METHODS Data of 55 patients with pancreatic lesions who underwent CEH-EUS were analysed retrospectively. Perfusion characteristics were classified by the investigator qualitatively immediately upon investigation, quantitative analysis was performed later on. Samples from fine needle aspiration (EUS-FNA) or surgical specimen served as gold standard.
RESULTS CEH-EUS showed 39 hypoenhanced lesions, 3 non-enhanced and 13 hyperenhanced lesions. Concordance of the investigators qualitative classification of peak contrast enhancement with quantitative analysis later on was 100%, while other parameters such as arrival time, time to peak or area under the curve did not show additional value. 34 of 39 hypoenhanced lesions were pancreatic adenocarcinoma; of the hyperenhanced lesions 4 were inflammatory, 3 neuroendocrine carcinomas, 1 lymphoma, 1 insulinoma and 4 metastases (2 of renal cell carcinoma, 2 of lung cancer). Non-enhanced lesions showed up as necroses. Sensitivity for the detection of pancreatic adenocarcinoma was 100%, specificity 87.2% for hypoenhancement alone; in otherwise healthy pancreatic tissue all hypoenhanced lesions were pancreatic adenocarcinoma (sensitivity and specificity 100%, PPV and NPV for adenocarcinoma 100%).
CONCLUSION This study again shows the excellent value of CEH-EUS in everyday routine for diagnostics of various focal pancreatic lesions suggesting that qualitatively assessed hypoenhancement is highly predictive for adenocarcinoma. Additional quantitative analysis of perfusion parameters does not add diagnostic yield. In case of the various hyperenhanced pancreatic lesions in our data set, histologic sampling is essential for further treatment.
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Affiliation(s)
- Klaus Kannengiesser
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg 21339, Germany
| | - Reiner Mahlke
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg 21339, Germany
| | - Frauke Petersen
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg 21339, Germany
| | - Anja Peters
- Department of Pathology, University Teaching Hospital Lueneburg, Lueneburg 21339, Germany
| | - Torsten Kucharzik
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg 21339, Germany
| | - Christian Maaser
- Department of General Internal Medicine and Gastroenterology, University Teaching Hospital Lueneburg, Lueneburg 21339, Germany
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Pesenti C, Bories E, Caillol F, Ratone JP, Godat S, Monges G, Poizat F, Raoul JL, Ries P, Giovannini M. Characterization of subepithelial lesions of the stomach and esophagus by contrast-enhanced EUS: A retrospective study. Endosc Ultrasound 2019; 8:43-49. [PMID: 30264741 PMCID: PMC6400084 DOI: 10.4103/eus.eus_89_17] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
| | - Erwan Bories
- Endoscopic Unit, Paoli Calmettes Institute, Marseille, France
| | - Fabrice Caillol
- Endoscopic Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Sebastien Godat
- Endoscopic Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Flora Poizat
- Pathology Unit, Paoli Calmettes Institute, Marseille, France
| | - Jean Luc Raoul
- Oncology Unit, Paoli Calmettes Institute, Marseille, France
| | - Pauline Ries
- Oncology Unit, Paoli Calmettes Institute, Marseille, France
| | - Marc Giovannini
- Endoscopic Unit, Paoli Calmettes Institute, Marseille, France
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Williet N, Kassir R, Casteillo F, Yvorel V, Habougit C, Roblin X, Phelip JM. First Characterization with Ultrasound Contrast Agent of a Fibrovascular Polyp Before Its Endoscopic Resection: A Case Report (with Videos). Clin Endosc 2018; 52:186-190. [PMID: 30300986 PMCID: PMC6453852 DOI: 10.5946/ce.2018.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/25/2018] [Indexed: 11/14/2022] Open
Abstract
We described for the first time the contrast enhancement of a giant fibrovascular esophageal polyp using ultrasound contrast agent, Sonovue® (Bracco, Milan, Italy) during echoendoscopy. Fine Doppler was unsuccessful in showing vascularization due to the mobile characteristic of the tumor. In contrast, via Sonovue®, tissue microcirculation was highlighted inside the entire head of the polyp, leading to better appreciate the risk of bleeding related to its resection. In a second part, we showed the feasibility of classic polypectomy for this giant polyp (5×5 cm) without complication and results of control endoscopy at 3 months. The present case is summarized in a video.
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Affiliation(s)
- Nicolas Williet
- Department of Hepatogastroenterology, University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Radwan Kassir
- Department of General Surgery, University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Francois Casteillo
- Department of Pathology, University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Violaine Yvorel
- Department of Pathology, University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Cyril Habougit
- Department of Pathology, University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Xavier Roblin
- Department of Hepatogastroenterology, University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
| | - Jean-Marc Phelip
- Department of Hepatogastroenterology, University Hospital of Saint-Etienne, Saint-Priest en Jarez, France
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20
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Chhoda A, Jain D, Surabhi VR, Singhal S. Contrast Enhanced Harmonic Endoscopic Ultrasound: A Novel Approach for Diagnosis and Management of Gastrointestinal Stromal Tumors. Clin Endosc 2018; 51:215-221. [PMID: 29874903 PMCID: PMC5997070 DOI: 10.5946/ce.2017.170] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/26/2018] [Indexed: 12/13/2022] Open
Abstract
The histologic analysis of gastrointestinal stromal tumors (GISTs) is a common method to detect the mitotic activity and to subsequently determine the risk of GISTs for malignancy. The potential false negative error due to inadequate yield of specimens and actual determination of malignancy risk requires analysis of the whole tumor. We aimed to assess the role of contrast enhanced endoscopic ultrasound (CE-EUS) in the management of GISTs. Two authors individually did review of English literatures to identify nine peer-reviewed original articles using keywords- contrast endoscopic ultrasound, GIST and submucosal tumor. Studies were heterogeneous in their aims looking either at differentiating submucosal lesions from GISTs, estimating malignant potential of GISTs with histologic correlation or studying the role of angiogenesis in malignant risk stratification. CE-EUS had moderate to high efficacy in differentiating GISTs from alternative submucosal tumors. CE-EUS had a higher sensitivity than EUS-guided fine needle aspiration, contrast computed tomography and Doppler EUS for detection of neo-vascularity within the GISTs. However, the evidence of abnormal angiogenesis within GIST as a prognostic factor needs further validation. CE-EUS is a non-invasive modality, which can help differentiate GISTs and provide valuable assessment of their perfusion patterns to allow better prediction of their malignant potential but more experience is needed.
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Affiliation(s)
- Ankit Chhoda
- Department of Internal Medicine, Yale-Waterbury Internal Medicine Program, Yale school of medicine, Waterbury, CT, USA
| | - Deepanshu Jain
- Division of Gastroenterology and Hepatology, Department of Digestive Diseases and Transplantation, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Venkateswar R Surabhi
- Department of Radiology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shashideep Singhal
- Division of Gastroenterology, Hepatology and Nutrition, University of Texas Health Science Center at Houston, Houston, TX, USA
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Hocke M, Braden B, Jenssen C, Dietrich CF. Present status and perspectives of endosonography 2017 in gastroenterology. Korean J Intern Med 2018; 33:36-63. [PMID: 29161800 PMCID: PMC5768548 DOI: 10.3904/kjim.2017.212] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/16/2017] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ultrasound has become an essential tool in modern gastroenterology and abdominal surgery. Compared with all other endoscopic methods, it has the most potential for innovation and its future looks bright. Thus, we compiled this summary of established and novel applications of endoscopic ultrasound methods to inform the reader about what is already possible and where future developments will lead in improving patient care further. This review is structured in four parts. The first section reports on developments in diagnostic endoscopic ultrasound, the second looks at semi-invasive endoscopic ultrasound, and the third discusses advances in therapeutic endoscopic ultrasound. An overview on the future prospects of endoscopic ultrasound methods concludes this article.
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Affiliation(s)
- Michael Hocke
- Internal Medicine II, Helios Hospital Meiningen, Germany
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | | | - Christoph F. Dietrich
- Medical Department 2, Caritas Hospital Bad Mergentheim, Bad Mergentheim, Germany
- Correspondence to Christoph F. Dietrich, M.D. Medical Department 2, Caritas Hospital Bad Mergentheim, Uhlandstraße 7, Bad Mergentheim 97980, Germany Tel: +49-7931-582201 Fax: +49-7931-582290 E-mail:
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22
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Kitano M, Yamashita Y. New Imaging Techniques for Endoscopic Ultrasonography: Contrast-Enhanced Endoscopic Ultrasonography. Gastrointest Endosc Clin N Am 2017; 27:569-583. [PMID: 28918799 DOI: 10.1016/j.giec.2017.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Conventional endoscopic ultrasonography (EUS) has limitations in the diagnosis of solid masses. Because most are depicted as a hypoechoic mass, without cytology or biopsy, it can be difficult to distinguish inflammatory masses from malignancy. Recently developed, contrast-enhanced harmonic EUS (CH-EUS) has improved characterization of digestive lesions by depicting microvessels and parenchymal perfusion, particularly for differentiating pancreatic cancer from other pancreatic solid lesions, identifying mural nodules in intraductal papillary mucinous neoplasms, and estimating malignant potential of gastrointestinal stromal tumors. CH-EUS is complementary to EUS-guided fine-needle aspiration for diagnosing pancreatic lesions, staging, and predicting chemotherapy response.
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Affiliation(s)
- Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Japan
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23
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Kamata K, Takenaka M, Kitano M, Omoto S, Miyata T, Minaga K, Yamao K, Imai H, Sakurai T, Watanabe T, Nishida N, Chikugo T, Chiba Y, Imamoto H, Yasuda T, Lisotti A, Fusaroli P, Kudo M. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of submucosal tumors of the upper gastrointestinal tract. J Gastroenterol Hepatol 2017; 32:1686-1692. [PMID: 28220958 DOI: 10.1111/jgh.13766] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/14/2017] [Accepted: 02/19/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM The study aims to evaluate contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for the differential diagnosis of submucosal tumors (SMT) of the upper gastrointestinal tract. METHODS Between June 2008 and May 2015, 157 consecutive patients with submucosal lesions of the upper gastrointestinal tract were evaluated by CH-EUS. This was a single-center retrospective analysis of prospectively collected data in a registry. The data from 73 patients who later underwent surgical resection were analyzed in this study. Surgical specimens served as the final diagnoses. The two CH-EUS variables of blood flow (hyper-enhancement vs hypo-enhancement) and homogeneity of enhancement pattern were evaluated. RESULTS The final diagnoses were 58 gastrointestinal stromal tumors (GISTs) and 15 benign SMTs (two lipomas, five leiomyomas, five schwannomas, two glomus tumors, and one ectopic pancreas). On CH-EUS, 49 of 58 (84.5%) GISTs presented with hyper-enhancement, whereas 4 of 15 (26.7%) benign SMTs showed hyper-enhancement; 21 of 58 (36.2%) GISTs showed inhomogeneous contrast enhancement, while only 2 of 15 (13.3%) benign SMTs demonstrated inhomogeneous contrast enhancement. If hyper-enhancement was considered to indicate GISTs, the sensitivity, specificity, and accuracy were 84.5%, 73.3%, and 82.2%, respectively. If inhomogeneous enhancement was considered to indicate GISTs, the sensitivity, specificity, and accuracy were 36.2%, 86.7%, and 46.6%, respectively. In lesions of less than 2 cm, hyper-enhancement was a more sensitive indicator of GISTs than inhomogeneous enhancement. CONCLUSIONS Hyper-enhancement and inhomogeneous enhancement were found to be a characteristic of GISTs. CH-EUS was useful for discrimination of benign SMTs from GISTs.
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Affiliation(s)
- Ken Kamata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Shunsuke Omoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Takeshi Miyata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Kentaro Yamao
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Hajime Imai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Toshiharu Sakurai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Tomohiro Watanabe
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Takaaki Chikugo
- Department of Pathology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Yasutaka Chiba
- Clinical Research Center, Kindai University Hospital, Osaka-sayama, Japan
| | - Haruhiko Imamoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Takushi Yasuda
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
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Schlag C, Menzel C, Götzberger M, Nennstiel S, Klare P, Wagenpfeil S, Schmid RM, Weirich G, von Delius S. Endoscopic ultrasound-guided tissue sampling of small subepithelial tumors of the upper gastrointestinal tract with a 22-gauge core biopsy needle. Endosc Int Open 2017; 5:E165-E171. [PMID: 28299351 PMCID: PMC5348295 DOI: 10.1055/s-0042-119948] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and study aims The optimal approach to small subepithelial tumors (SETs) of the upper gastrointestinal tract remains inconclusive. The aim of this study was to evaluate endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for less invasive tissue sampling of small SETs of the upper gastrointestinal tract. Patients and methods In this prospective observational study patients with small ( ≤ 3 cm) SETs of the upper gastrointestinal tract were eligible and underwent EUS-FNB with a 22-gauge core biopsy needle. The main outcome measure was the diagnostic yield. The number of obtained core biopsies was also assessed. Results Twenty patients were included. The mean SET size was 16 mm (range 10 - 27 mm). EUS-FNB was technically feasible in all cases and no complications were observed. The diagnostic yield was 75 %. Core biopsy specimens were obtained in only 25 % of cases. Conclusion EUS-FNB with a 22-gauge core biopsy needle of small SETs can achieve a definite diagnosis in the majority of cases. However, because core samples cannot regularly be obtained, EUS-FNB seems not to be convincingly superior to standard EUS-FNA in this setting.
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Affiliation(s)
- Christoph Schlag
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany,Corresponding author PD Dr. med. Christoph Schlag II. Medizinische Klinik und PoliklinikKlinikum rechts der Isar der Technischen Universität MünchenIsmaninger Straße 2281675 MünchenGermany089-4140-4871
| | - Christoph Menzel
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Manuela Götzberger
- Gastroenterologie, Klinikum Freising, Akademisches Lehrkrankenhaus der Technischen Universität München, Freising, Germany
| | - Simon Nennstiel
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Peter Klare
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stefan Wagenpfeil
- Institut für Medizinische Biometrie, Epidemiologie und Medizinische Informatik, Universität des Saarlandes, Campus Homburg, Homburg, Germany
| | - Roland M. Schmid
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Gregor Weirich
- Institut für Allgemeine Pathologie und Pathologische Anatomie, Technische Universität München, Munich, Germany
| | - Stefan von Delius
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Seicean A, Mosteanu O, Seicean R. Maximizing the endosonography: The role of contrast harmonics, elastography and confocal endomicroscopy. World J Gastroenterol 2017; 23:25-41. [PMID: 28104978 PMCID: PMC5221284 DOI: 10.3748/wjg.v23.i1.25] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/17/2016] [Accepted: 12/08/2016] [Indexed: 02/07/2023] Open
Abstract
New technologies in endoscopic ultrasound (EUS) evaluation have been developed because of the need to improve the EUS and EUS-fine needle aspiration (EUS-FNA) diagnostic rate. This paper reviews the principle, indications, main literature results, limitations and future expectations for each of the methods presented. Contrast-enhanced harmonic EUS uses a low mechanical index and highlights slow-flow vascularization. This technique is useful for differentiating solid and cystic pancreatic lesions and assessing biliary neoplasms, submucosal neoplasms and lymph nodes. It is also useful for the discrimination of pancreatic masses based on their qualitative patterns; however, the quantitative assessment needs to be improved. The detection of small solid lesions is better, and the EUS-FNA guidance needs further research. The differentiation of cystic lesions of the pancreas and the identification of the associated malignancy features represent the main indications. Elastography is used to assess tissue hardness based on the measurement of elasticity. Despite its low negative predictive value, elastography might rule out the diagnosis of malignancy for pancreatic masses. Needle confocal laser endomicroscopy offers useful information about cystic lesions of the pancreas and is still under evaluation for use with solid pancreatic lesions of lymph nodes.
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26
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Dietrich CF, Dong Y, Froehlich E, Hocke M. Dynamic contrast-enhanced endoscopic ultrasound: A quantification method. Endosc Ultrasound 2017; 6:12-20. [PMID: 28218195 PMCID: PMC5331837 DOI: 10.4103/2303-9027.193595] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 06/05/2016] [Indexed: 12/12/2022] Open
Abstract
Dynamic contrast-enhanced ultrasound (DCE-US) has been recently standardized by guidelines and recommendations. The European Federation of Societies for US in Medicine and Biology position paper describes the use for DCE-US. Comparatively, little is known about the use of contrast-enhanced endoscopic US (CE-EUS). This current paper reviews and discusses the clinical use of CE-EUS and DCE-US. The most important clinical use of DCE-US is the prediction of tumor response to new drugs against vascular angioneogenesis.
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Affiliation(s)
- Christoph F. Dietrich
- Department of Internal Medicine 2, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Germany
| | - Yi Dong
- Department of Internal Medicine 2, Caritas-Krankenhaus Bad Mergentheim, Academic Teaching Hospital of the University of Würzburg, Germany
| | | | - Michael Hocke
- Department of Internal Medicine 2, Helios Hospital Meiningen GmbH, Academic Teaching Hospital of the University of Jena, Germany
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27
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Ignee A, Jenssen C, Hocke M, Dong Y, Wang WP, Cui XW, Woenckhaus M, Iordache S, Saftoiu A, Schuessler G, Dietrich CF. Contrast-enhanced (endoscopic) ultrasound and endoscopic ultrasound elastography in gastrointestinal stromal tumors. Endosc Ultrasound 2017; 6:55-60. [PMID: 28218202 PMCID: PMC5331845 DOI: 10.4103/2303-9027.200216] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives: Gastrointestinal stromal tumors (GISTs) represent the largest group of subepithelial tumors (SET) of the upper gastrointestinal (GI) tract. They may show malignant behavior, in contrast to other SET. Endoscopic ultrasound (EUS) is frequently used to characterize SET. With the introduction of contrast-enhanced ultrasound (CEUS) into EUS (CE-EUS), distinct enhancement patterns can be detected. In the presented study, the characteristic features of CE-EUS in GIST are analyzed and compared with those of other SET. Materials and Methods: Consecutive patients from four centers with SET of the upper and middle GI tract were included and received endoscopic or transcutaneous CEUS. The results were compared with EUS-guided tissue acquisition, forceps biopsy, or surgical resection. Results: Forty-two out of 62 (68%) patients had SET of the stomach, 17/62 (27%) of the small intestine, 2/62 (3%) of the esophagus, and 1/62 (2%) extraintestinal. Eighty-one percent underwent surgery. Leiomyoma was found in 5/62 (8%) and GIST in 57/62 patients (92%). Thirty-nine out of 57 (68%) patients had GIST lesions in the stomach, 17/57 (30%) had GIST of the small intestine, and 1/57 (2%) patients had extraintestinal GISTs. GIST size was 62.6 ± 42.1 (16–200) mm. Hyperenhancement had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 98%, 100%, 100%, 93%, and 98% for the diagnosis of GIST. Fifty out of 57 patients with GIST (88%) showed avascular areas in the center of the lesions. Conclusion: CE-EUS and CEUS show hyperenhancement and avascular areas in a high percentage of GIST but not in leiomyoma. Thus, GIST and leiomyoma can be discriminated accurately.
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Affiliation(s)
- Andre Ignee
- Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - Christian Jenssen
- Krankenhaus Märkisch Oderland, Wriezen, Akademisches Lehrkrankenhaus Medizinische Hochschule Brandenburg, Germany
| | | | - Yi Dong
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Ping Wang
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin-Wu Cui
- The Department of Medical Ultrasound, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | | | - Adrian Saftoiu
- Research Center in Gastroenterology and Hepatology, Craiova, Romania
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Fusaroli P, Napoleon B, Gincul R, Lefort C, Palazzo L, Palazzo M, Kitano M, Minaga K, Caletti G, Lisotti A. The clinical impact of ultrasound contrast agents in EUS: a systematic review according to the levels of evidence. Gastrointest Endosc 2016; 84:587-596.e10. [PMID: 27311654 DOI: 10.1016/j.gie.2016.06.006] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The use of contrast-harmonic EUS (CH-EUS) in routine clinical practice is increasing rapidly but is not yet standardized. We present the levels of evidence (LEs) found in the literature to put its clinical outcomes in the appropriate perspective. METHODS We conducted a systematic review of the available English-language articles. The LEs were stratified according to the Oxford Centre for Evidence-Based Medicine guidelines. RESULTS Overall, 210 articles were included and presented according to different pathologic conditions. For pancreatic solid neoplasms, the pooled sensitivity and specificity in the diagnosis of pancreatic carcinoma were very high (LE 1); quantitative analysis and guidance of FNA were reported as investigational research (LE 2-3). For pancreatic cystic lesions, the identification of neoplastic solid components as hyperenhanced lesions represented a promising application of CH-EUS (LE 2). For lymph nodes, CH-EUS increased the diagnostic yield of B-mode EUS for the detection of malignancy (LE 2). For submucosal tumors, CH-EUS seemed useful for differential diagnosis and risk stratification (LE 2-3). For other applications, differential diagnosis of gallbladder and vascular abnormalities by CH-EUS were reported (LE 2-3). CONCLUSIONS The LEs of CH-EUS in the literature have evolved from the initial descriptive studies to multicenter and prospective trials, and even meta-analyses. The differential diagnosis between benign and malignant lesions is the main field of application of CH-EUS. With regard to pancreatic solid neoplasms, the concomitant use of both CH-EUS and EUS-FNA may have additive value in increasing the overall accuracy by overcoming the false-negative results associated with each individual technique. Other applications are promising but still investigational.
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Affiliation(s)
- Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Bertrand Napoleon
- Department of Gastroenterology, Private Hospital Jean Mermoz, Lyon, France
| | - Rodica Gincul
- Department of Gastroenterology, Private Hospital Jean Mermoz, Lyon, France
| | - Christine Lefort
- Department of Gastroenterology, Private Hospital Jean Mermoz, Lyon, France
| | | | | | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka-Sayama, Japan
| | - Giancarlo Caletti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
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29
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Tomizawa M, Shinozaki F, Motoyoshi Y, Sugiyama T, Yamamoto S, Ishige N. A Case of Gastrointestinal Stromal Tumor That Underwent Endoscopic Ultrasound-Guided Aspiration with a 25-Gauge Biopsy Needle. Case Rep Gastroenterol 2016; 10:168-73. [PMID: 27403121 PMCID: PMC4929380 DOI: 10.1159/000443269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/09/2015] [Indexed: 11/19/2022] Open
Abstract
Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is performed to obtain specimens for pathological analysis. For this procedure, 19-gauge (19G), 22-guage (22G), and 25-guage (25G) needles are available. The needles are classified into aspiration type and biopsy type. A 56-year-old woman underwent upper gastrointestinal endoscopy that showed a 38-mm-diameter submucosal tumor. The elevated lesion was diagnosed as a submucosal tumor of the stomach. Contrast-enhanced computed tomography showed a low-density area on the luminal surface of the gastric wall, which was covered with a thin layer of gastric mucosa. EUS showed a hypoechoic lesion in the submucosal layer. Color Doppler image showed a pulsating vascular signal extending into the center of the hypoechoic lesion from the periphery. EUS-FNA was performed with a 25G biopsy needle. The specimen tissue consisted of spindle-shaped cells. The cells were positive for CD117 and CD34. The submucosal tumor was diagnosed as a gastrointestinal stromal tumor.
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Affiliation(s)
- Minoru Tomizawa
- Department of Gastroenterology, National Hospital Organization, Shimoshizu Hospital, Yotsukaido, Japan
| | - Fuminobu Shinozaki
- Department of Radiology, National Hospital Organization, Shimoshizu Hospital, Yotsukaido, Japan
| | - Yasufumi Motoyoshi
- Department of Neurology, National Hospital Organization, Shimoshizu Hospital, Yotsukaido, Japan
| | - Takao Sugiyama
- Department of Rhuematology, National Hospital Organization, Shimoshizu Hospital, Yotsukaido, Japan
| | - Shigenori Yamamoto
- Department of Pediatrics, National Hospital Organization, Shimoshizu Hospital, Yotsukaido, Japan
| | - Naoki Ishige
- Department of Neurosurgery, National Hospital Organization, Shimoshizu Hospital, Yotsukaido, Japan
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30
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Zhao Y, Qian L, Li P, Zhang S. The diagnostic value of endoscopic ultrasonography and contrast-enhanced harmonic endoscopic ultrasonography in gastrointestinal stromal tumors. Endosc Ultrasound 2016; 5:111-7. [PMID: 27080610 PMCID: PMC4850790 DOI: 10.4103/2303-9027.180475] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective: To evaluate the diagnostic value of endoscopic ultrasonography (EUS) and contrast-enhanced harmonic (CEH) EUS in patients with gastrointestinal stromal tumors (GISTs). Patients and Methods: About 19 patients with suspected GISTs underwent EUS and CEH-EUS before tumor resection. The malignant potential was assessed according to the modified Fletcher classification system. Patients were divided into lower (Group I) and higher (Group II) malignant potential group. The clinical characteristics and EUS/CEH-EUS features were compared between two groups. Results: The tumor size in Group II was significantly larger than that in Group I (14.6 ± 5.8 mm vs. 32.1 ± 8.4 mm, P < 0.05). Heterogeneous echogenicity was observed in 4 (4/8) cases in Group II and none in Group I (P < 0.05). Irregular intratumoral vessels were detected in 6 cases in Group II and none in Group I (P < 0.05). The sensitivity and specificity of irregular vessel detection for discriminating higher from lower malignant potential GISTs were 75% and 100%, respectively. The positive predictive value and negative predictive value of detection of irregular vessels to high malignant potential GISTs were 33% and 100%, respectively. Conclusion: Detection of irregular intratumoral vessels can predict higher malignant potential before tumor resection. The tumor size and echogenicity are assistant factors for malignant potential assessment. Endoscopic resection is an efficacious treatment with good security for appropriate patients.
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Affiliation(s)
| | - Linxue Qian
- Department of Ultrasound, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
| | | | - Shutian Zhang
- Department of Gastroenterology and Hepatology, Beijing Friendship Hospital Affiliated to Capital Medical University, Beijing, China
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31
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Yegin EG, Duman DG. Small EUS-suspected gastrointestinal stromal tumors of the stomach: An overview for the current state of management. Endosc Ultrasound 2016; 5:69-77. [PMID: 27080604 PMCID: PMC4850798 DOI: 10.4103/2303-9027.180469] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors found in the gastrointestinal (GI) tract, with the stomach being the most common site. They represent a distinct group of GI tumors originating from the interstitial cells of Cajal and are characterized by gain-of-function mutations of KIT. KIT oncoprotein serves as both diagnostic and therapeutic targets. Prognosis is related to size, mitotic activity, and site of the tumor. Asymptomatic, small endoscopic ultrasonography (EUS)-suspected GISTs are increasingly encountered with the wide availability of endoscopic/endosonographic examination. The majority of small GISTs are biologically indolent, albeit possibly harboring c-KIT gene mutations. An ongoing controversy exists regarding the management and surveillance policy for small gastric GISTs. A number of reports on the management of GISTs have been published, not confidently addressing the issue of gastric GISTs of small size. This work provides an overview on the current state of management considerations, specifically focusing on small EUS-suspected gastric GISTs, which are increasingly encountered by clinicians.
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Affiliation(s)
- Ender Gunes Yegin
- Department of Gastroenterology, Bozyaka State Hospital, Izmir, Turkey
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32
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Aso A, Yoshinaga S. Future potential means of diagnosing gastric subepithelial lesions: Beyond conventional endoscopic ultrasound and endoscopic ultrasound-guided fine-needle aspiration. Dig Endosc 2016; 28 Suppl 1:32-3. [PMID: 26763076 DOI: 10.1111/den.12606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/08/2016] [Accepted: 01/12/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Akira Aso
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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33
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Cârțână ET, Gheonea DI, Săftoiu A. Advances in endoscopic ultrasound imaging of colorectal diseases. World J Gastroenterol 2016; 22:1756-1766. [PMID: 26855535 PMCID: PMC4724607 DOI: 10.3748/wjg.v22.i5.1756] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 10/21/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
The development of endoscopic ultrasound (EUS) has had a significant impact for patients with digestive diseases, enabling enhanced diagnostic and therapeutic procedures, with most of the available evidence focusing on upper gastrointestinal (GI) and pancreatico-biliary diseases. For the lower GI tract the main application of EUS has been in staging rectal cancer, as a complementary technique to other cross-sectional imaging methods. EUS can provide highly accurate in-depth assessments of tumour infiltration, performing best in the diagnosis of early rectal tumours. In the light of recent developments other EUS applications for colorectal diseases have been also envisaged and are currently under investigation, including beyond-rectum tumour staging by means of the newly developed forward-viewing radial array echoendoscope. Due to its high resolution, EUS might be also regarded as an ideal method for the evaluation of subepithelial lesions. Their differential diagnosis is possible by imaging the originating wall layer and the associated echostructure, and cytological and histological confirmation can be obtained through EUS-guided fine needle aspiration or trucut biopsy. However, reports on the use of EUS in colorectal subepithelial lesions are currently limited. EUS allows detailed examination of perirectal and perianal complications in Crohn’s disease and, as a safe and less expensive investigation, can be used to monitor therapeutic response of fistulae, which seems to improve outcomes and reduce the need for additional surgery. Furthermore, EUS image enhancement techniques, such as the use of contrast agents or elastography, have recently been evaluated for colorectal indications as well. Possible applications of contrast enhancement include the assessment of tumour angiogenesis in colorectal cancer, the monitoring of disease activity in inflammatory bowel disease based on quantification of bowel wall vascularization, and differentiating between benign and malignant subepithelial tumours. Recent reports suggest that EUS elastography enables highly accurate discrimination of colorectal adenocarcinomas from adenomas, while inflammatory bowel disease phenotypes can be distinguished based on the strain ratio calculation. Among EUS-guided therapies, the drainage of abdominal and pelvic collections has been regarded as a safe and effective procedure to be used as an alternative for the transcutaneous route, while the placing of fiducial markers under EUS guidance for targeted radiotherapy in rectal cancer or the use of contrast microbubbles as drug-delivery vehicles represent experimental therapeutic applications that could greatly impact the forthcoming management of patients with colorectal diseases, pending on further investigations.
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Park HY, Jeon SW, Lee HS, Cho CM, Bae HI, Seo AN, Kweon OK. Can contrast-enhanced harmonic endosonography predict malignancy risk in gastrointestinal subepithelial tumors? Endosc Ultrasound 2016; 5:384-389. [PMID: 28000630 PMCID: PMC5206827 DOI: 10.4103/2303-9027.195871] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives: Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) is a novel technology that can identify subepithelial tumors (SETs) by detecting the degree of enhancement, but whether CEH-EUS can predict the malignancy risk of gastrointestinal stromal tumors (GISTs) remains unclear. The aim of our study was to evaluate the diagnostic accuracy of CEH-EUS and its ability to discriminate among SETs and predict the malignancy risk of GISTs. Materials and Methods: We retrospectively included patients with suspected subepithelial lesions who underwent CEH-EUS preoperatively. Thirty-five patients with histologically proven GISTs and benign neoplasms were enrolled in the study. The images of CEH-EUS were categorized in accordance with microvasculature, parenchymal perfusion, and nonenhancing spots. The diagnostic performance of CEH-EUS was evaluated by comparing these findings with the histological diagnosis. Results: When we divided the enrolled patients into high- and low-grade malignancy and benign groups, nonenhancing spots on CEH-EUS were found more frequently in the high-grade malignancy group (63.6%), followed by the low-grade malignancy (46.7%) and benign groups (25.7%) (P = 0.022). However, based on the statistical validity of the CEH-EUS findings for the discrimination of SETs, the sensitivity was 53.8% for diagnostic performance and 63.6% for prediction of malignancy risk of GISTs. Conclusions: From our study results, it is unclear whether CEH-EUS alone has a diagnostic role in the discrimination of SETs and the prediction of malignancy risk of GISTs. Further studies with larger samples from multiple centers and use of other imaging analysis modalities are needed.
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Affiliation(s)
- Hye Yoon Park
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, South Korea
| | - Seong Woo Jeon
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, South Korea
| | - Hyun Seok Lee
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, South Korea
| | - Chang Min Cho
- Department of Internal Medicine, Kyungpook National University Medical Center, Daegu, South Korea
| | - Han Ik Bae
- Department of Pathology, Kyungpook National University Medical Center, Daegu, South Korea
| | - An Na Seo
- Department of Pathology, Kyungpook National University Medical Center, Daegu, South Korea
| | - Oh Kyung Kweon
- Department of Surgery, Kyungpook National University Medical Center, Daegu, South Korea
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Alvarez-Sanchez MV, Gincul R, Lefort C, Napoleon B. Role of contrast-enhanced harmonic endoscopic ultrasound in submucosal tumors. Endosc Ultrasound 2016; 5:363-367. [PMID: 28000626 PMCID: PMC5206823 DOI: 10.4103/2303-9027.190928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
With the widespread use of endoscopy, gastrointestinal submucosal lesions are now more commonly discovered. Although endoscopic ultrasound (EUS) is superior to all other imaging techniques for the diagnosis of submucosal tumors (SMTs), it is still suboptimal for differentiating hypoechoic lesions arising from the fourth sonographic gastrointestinal wall layer, which encompass tumors with very different prognosis. EUS tissue acquisition has provided with the unique opportunity to obtain histological confirmation, but it is not accurate enough to evaluate the malignant potential of gastrointestinal stromal tumors (GISTs). In the last years, contrast-enhanced harmonic EUS (CH-EUS) emerged as a powerful imaging modality to assess the microperfusion patterns of pancreatic tumors. Based on the distinct microvascularity of malignant SMTs, it was hypothesized that CH-EUS might also assist in the differential diagnosis of SMTs. Preliminary experience in this field is now available and suggests CH-EUS as a performant modality to distinguish between benign SMTs and GISTs and to evaluate the malignant potential of GISTs. High expectations are also relied on CH-EUS for the monitoring of antiangiogenic treatments of GISTs and the evaluation of gastrointestinal neuroendocrine tumors (NETs).
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Affiliation(s)
| | - Rodica Gincul
- Department of Gastroenterology, Ramsay Générale de Santé, Private Hospital Jean Mermoz, Lyon; Department of Gastroenterology, Edouard Herriot Hospital, Lyon, France
| | - Christine Lefort
- Department of Gastroenterology, Ramsay Générale de Santé, Private Hospital Jean Mermoz, Lyon, France
| | - Bertrand Napoleon
- Department of Gastroenterology, Ramsay Générale de Santé, Private Hospital Jean Mermoz, Lyon, France
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Franco MC, Schulz RT, Maluf-Filho F. Opinion: How to manage subepithelial lesions of the upper gastrointestinal tract? World J Gastrointest Endosc 2015; 7:1262-1267. [PMID: 26675266 PMCID: PMC4673388 DOI: 10.4253/wjge.v7.i18.1262] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/28/2015] [Accepted: 11/11/2015] [Indexed: 02/05/2023] Open
Abstract
Subepithelial lesions (SELs) in the upper gastrointestinal (GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach of conventional biopsy forceps, may pose a diagnostic challenge for the gastroenterologist, especially when SELs are indeterminate after endoscopy and endoscopic ultrasound (EUS). The decision to proceed with further investigation should take into consideration the size, location in the GI tract, and EUS features of SELs. Gastrointestinal stromal tumor (GIST) is an example of an SEL that has a well-recognized malignant potential. Unfortunately, EUS is not able to absolutely differentiate GISTs from other benign hypoechoic lesions from the fourth layer, such as leiomyomas. Therefore, EUS-guided fine needle aspiration (EUS-FNA) is an important tool for correct diagnosis of SELs. However, small lesions (size < 2 cm) have a poor diagnostic yield with EUS-FNA. Moreover, studies with EUS-core biopsy needles did not report higher rates of histologic and diagnostic yields when compared with EUS-FNA. The limited diagnostic yield of EUS-FNA and EUS-core biopsies of SELs has led to the development of more invasive endoscopic techniques for tissue acquisition. There are initial studies showing good results for tissue biopsy or resection of SELs with endoscopic submucosal dissection, suck-ligate-unroof-biopsy, and submucosal tunneling endoscopic resection.
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Abstract
Submucosal gastrointestinal tumors represent a unique, diverse and challenging group of lesions found in modern medical practice. While management has traditionally been surgical, the development of advanced endoscopic techniques is challenging this approach. This review aims to investigate the role of endotherapy in treatment pathways, with a focus on carcinoid and gastrointestinal stromal tumors. In particular, we will discuss which lesions can be safely treated endoscopically, the evidence base behind such approaches and the limitations of the current evidence. The review will consider how these techniques may change the management of submucosal tumors in the future.
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Meng FS, Zhang ZH, Ji F. New endoscopic ultrasound techniques for digestive tract diseases: A comprehensive review. World J Gastroenterol 2015; 21:4809-4816. [PMID: 25944994 PMCID: PMC4408453 DOI: 10.3748/wjg.v21.i16.4809] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/14/2015] [Accepted: 03/12/2015] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS) is one of the most important modalities for the diagnosis of digestive tract diseases. EUS has been evolving ever since it was introduced. New techniques such as elastography and contrast enhancement have emerged, increasing the accuracy, sensitivity and specificity of EUS for the diagnosis of digestive tract diseases including pancreatic masses and lymphadenopathy. EUS-elastography evaluates tissue elasticity and therefore, can be used to differentiate various lesions. Contrast-enhanced EUS can distinguish benign from malignant pancreatic lesions and lymphadenopathy using the intravenous injection of contrast agents. This review discusses the principles and types of these new techniques, as well as their clinical applications and limitations.
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Alvarez-Sánchez MV, Napoléon B. Contrast-enhanced harmonic endoscopic ultrasound imaging: Basic principles, present situation and future perspectives. World J Gastroenterol 2014; 20:15549-15563. [PMID: 25400439 PMCID: PMC4229520 DOI: 10.3748/wjg.v20.i42.15549] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 04/23/2014] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
Over the last decade, the development of stabilised microbubble contrast agents and improvements in available ultrasonic equipment, such as harmonic imaging, have enabled us to display microbubble enhancements on a greyscale with optimal contrast and spatial resolution. Recent technological advances made contrast harmonic technology available for endoscopic ultrasound (EUS) for the first time in 2008. Thus, the evaluation of microcirculation is now feasible with EUS, prompting the evolution of contrast-enhanced EUS from vascular imaging to images of the perfused tissue. Although the relevant experience is still preliminary, several reports have highlighted contrast-enhanced harmonic EUS (CH-EUS) as a promising noninvasive method to visualise and characterise lesions and to differentiate benign from malignant focal lesions. Even if histology remains the gold standard, the combination of CH-EUS and EUS fine needle aspiration (EUS-FNA) can not only render EUS more accurate but may also assist physicians in making decisions when EUS-FNA is inconclusive, increasing the yield of EUS-FNA by guiding the puncture with simultaneous imaging of the vascularity. The development of CH-EUS has also opened up exciting possibilities in other research areas, including monitoring responses to anticancer chemotherapy or to ethanol-induced pancreatic tissue ablation, anticancer therapies based on ultrasound-triggered drug and gene delivery, and therapeutic adjuvants by contrast ultrasound-induced apoptosis. Contrast harmonic imaging is gaining popularity because of its efficacy, simplicity and non-invasive nature, and many expectations are currently resting on this technique. If its potential is confirmed in the near future, contrast harmonic imaging will become a standard practice in EUS.
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Dietrich CF, Jenssen C. Endoscopic ultrasound-guided sampling in gastroenterology: European society of gastrointestinal endoscopy technical guidelines. Endosc Ultrasound 2014; 2:117-22. [PMID: 24949378 PMCID: PMC4062259 DOI: 10.7178/eus.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 07/10/2013] [Indexed: 02/06/2023] Open
Abstract
At present, the European Society of Gastrointestinal Endoscopy (ESGE) guidelines on endoscopic ultrasound-guided sampling are almost complete and express state of the art developments. However, future developments are anticipated. This editorial focuses on a few recently published papers with some additional information and on two important additional techniques, elastography and contrast enhanced ultrasound (CEUS), which are mentioned, but not explained in detail in the current ESGE guidelines. Elastography and CEUS might be of importance in the near future to improve the biopsy techniques.
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Affiliation(s)
| | - C Jenssen
- Klinik für Innere Medizin, Krankenhaus Märkisch Oderland Strausberg/Wriezen, Germany
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Jang SI, Lee DK. Contrast-enhanced endoscopic ultrasonography: advance and current status. Ultrasonography 2014; 33:161-9. [PMID: 25038805 PMCID: PMC4104959 DOI: 10.14366/usg.14017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/30/2014] [Indexed: 12/11/2022] Open
Abstract
Endoscopic ultrasonography (EUS) technology has undergone a great deal of progress along with the color and power Doppler imaging, three-dimensional imaging, electronic scanning, tissue harmonic imaging, and elastography, and one of the most important developments is the ability to acquire contrast-enhanced images. The blood flow in small vessels and the parenchymal microvasculature of the target lesion can be observed non-invasively by contrast-enhanced EUS (CE-EUS). Through a hemodynamic analysis, CE-EUS permits the diagnosis of various gastrointestinal diseases and differential diagnoses between benign and malignant tumors. Recently, mechanical innovations and the development of contrast agents have increased the use of CE-EUS in the diagnostic field, as well as for the assessment of the efficacy of therapeutic agents. The advances in and the current status of CE-EUS are discussed in this review.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Huang YQ. Advances in research of gastrointestinal stromal tumors. Shijie Huaren Xiaohua Zazhi 2014; 22:1633-1641. [DOI: 10.11569/wcjd.v22.i12.1633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, arising from the interstitial cells of Cajal (ICCs), primarily in the stomach and small intestine. The growth of most GISTs is driven by the mutations of genes encoding oncogenic receptor tyrosine kinase KIT or platelet derived growth factor receptor alpha (PDGFRα). The pathogenesis of GISTs may involve ICCs, microRNAs (miRNAs), signaling pathways, DNA methylation, and KIT or PDGFRα gene mutations. This article systematically describes the advances in research of GISTs in terms of clinical features, imaging characteristics, endoscopic features, histopathological features, diagnosis and therapies.
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Park JS, Kim HK, Bang BW, Kim SG, Jeong S, Lee DH. Effectiveness of contrast-enhanced harmonic endoscopic ultrasound for the evaluation of solid pancreatic masses. World J Gastroenterol 2014; 20:518-24. [PMID: 24574720 PMCID: PMC3923026 DOI: 10.3748/wjg.v20.i2.518] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 10/25/2013] [Accepted: 11/12/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the usefulness of contrast-enhanced harmonic endoscopic ultrasound (CH-EUS) in differentiating between pancreatic adenocarcinomas and other pancreatic disease. METHODS This retrospective cohort study evaluated 90 patients who were seen between November 2010 and May 2013. All these patients had solid pancreatic masses that had a hypoechoic appearance on EUS. All patients underwent CH-EUS to evaluate this diagnostic method's usefulness. The mass lesions observed on CH-EUS were classified into three categories based on their echo intensity: hypoenhanced, isoenhanced, and hyperenhanced lesions. We adjusted the sensitivity and the specificity of each category for detecting malignancies. We also estimated the accuracy of CH-EUS by comparing it to a pathological diagnosis. RESULTS Of the 90 patients, 62 had a pancreatic adenocarcinoma. Fifty-seven out of 62 pancreatic adenocarcinomas showed a hypoenhanced pattern on CH-EUS. The sensitivity was 92%, the specificity 68% and the accuracy approximately 82%. The area under the curve of the receiver operating characteristic analysis for CH-EUS was 0.799. There is a significant association between the hypoenhanced pattern on CH-EUS and pancreatic duct adenocarcinoma (χ(2) = 35.264, P < 0.001). In pathological examinations, the number of specimens for EUS-fine needle aspiration (EUS-FNA) was considered insufficient for diagnosis in three patients, and in two patients, the results were reported to be negative for malignancy. Pancreatic masses in all five patients revealed a hypoenhanced pattern with CH-EUS. Three patients were diagnosed with pancreatic adenocarcinoma based on the pathology results of a biopsy, and the remaining two patients were clinically diagnosed with malignancy. CONCLUSION CH-EUS is useful for distinguishing between pancreatic adenocarcinoma and other pancreatic disease. When a pancreatic mass shows a hypoenhanced pattern on CH-EUS but involves either insufficient samples or negative results with EUS-FNA, clinicians might consider performing another pathologic diagnosis on the basis of an EUS-FNA sample or a biopsy.
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Kitano M, Sakamoto H, Kudo M. Contrast-enhanced endoscopic ultrasound. Dig Endosc 2014; 26 Suppl 1:79-85. [PMID: 24118242 DOI: 10.1111/den.12179] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/21/2013] [Indexed: 12/14/2022]
Abstract
Compared to other imaging modalities, endoscopic ultrasound (EUS) has limitations in terms of image enhancement. However, with the availability of contrast agents in ultrasonography, EUS has evolved. Contrast-enhanced Doppler EUS (CD-EUS) enhances Doppler signals from vessels and is useful for characterizing lesions detected by EUS. Moreover, contrast-enhanced harmonic EUS (CH-EUS) with second-generation ultrasound contrast agents and a broad band transducer allows microvessels and parenchymal perfusion to be visualized. Vascularity can also be quantitatively analyzed during CH-EUS by generating a time-intensity curve. CE-EUS is useful for characterizing pancreatic lesions and can detect pancreatic adenocarcinomas with a sensitivity of 94%and a specificity of 89% as a result of the hypo-enhancement of these lesions. Indeed, CH-EUS is superior to multiple detector-computed tomography in terms of the differential diagnosis of small lesions that are ≤2 cm. CH-EUS complements EUS-guided fine-needle aspiration (EUS-FNA) as it identifies the EUS-FNA target and lesions with false-negative EUS-FNA findings. CH-EUS is also used to estimate the malignant potential of gastrointestinal stromal tumors and helps to differentiate between malignant and benign lymphadenopathy.
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Affiliation(s)
- Masayuki Kitano
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kinki University, Osaka-sayama, Japan
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Cui XW, Jenssen C, Saftoiu A, Ignee A, Dietrich CF. New ultrasound techniques for lymph node evaluation. World J Gastroenterol 2013; 19:4850-4860. [PMID: 23946589 PMCID: PMC3740414 DOI: 10.3748/wjg.v19.i30.4850] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 04/04/2013] [Accepted: 05/08/2013] [Indexed: 02/06/2023] Open
Abstract
Conventional ultrasound (US) is the recommended imaging method for lymph node (LN) diseases with the advantages of high resolution, real time evaluation and relative low costs. Current indications of transcutaneous ultrasound and endoscopic ultrasound include the detection and characterization of lymph nodes and the guidance for LN biopsy. Recent advances in US technology, such as contrast enhanced ultrasound (CEUS), contrast enhanced endoscopic ultrasound (CE-EUS), and real time elastography show potential to improve the accuracy of US for the differential diagnosis of benign and malignant lymph nodes. In addition, CEUS and CE-EUS have been also used for the guidance of fine needle aspiration and assessment of treatment response. Complementary to size criteria, CEUS could also be used to evaluate response of tumor angiogenesis to anti-angiogenic therapies. In this paper we review current literature regarding evaluation of lymphadenopathy by new and innovative US techniques.
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