Histological diagnosis of gastric submucosal tumors: A pilot study of endoscopic ultrasonography-guided fine-needle aspiration biopsy vs mucosal cutting biopsy

Diagnostic ability and adverse events of mucosal incision-assisted biopsy for gastric subepithelial tumors: Systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to evaluate the diagnostic ability and examine the efficacy of countermeasures to adverse events of mucosal incision-assisted biopsy (MIAB) for gastric subepithelial tumors (SETs).

METHODS

We performed a literature search and identified 533 relevant articles. Eleven articles, including 339 lesions, were ultimately used in the meta-analysis. The primary end-point was the pathological diagnostic rate of MIAB for gastric SETs, and the secondary end-point was the incidence of adverse events. The efficacy of acid secretion inhibitors in preventing postoperative bleeding and that of local injection before incision to prevent perforation were also examined.

RESULTS

Nine studies were conducted in Japan and two in South Korea, of which only two were prospective studies. The pooled pathological diagnostic rate of MIAB for gastric SETs was 87.8% (95% confidence interval [CI] 80.2-94.0; I2 = 68.7%). The adverse event rate of the pooled population was 0.2% (95% CI 0-1.4; I2 = 0%). The acid secretion inhibitors significantly reduced postoperative bleeding (odds ratio 0.06, 95% CI 0.01-0.66, P = 0.02). Perforation occurred in 0% and 2.6% of the local and nonlocal injection cohorts, respectively, and the pathological diagnostic rates were 50% and 66.7%, respectively.

CONCLUSIONS

MIAB is a reliable technique with a favorable diagnostic rate and few adverse events. Acid secretion inhibitors may effectively prevent postoperative bleeding; however, the efficacy of local injection remains unclear. This technique could be an option for tissue sampling in gastric SETs.

Endoscopic resection in subepithelial lesions of the upper gastrointestinal tract: Experience at a tertiary referral hospital in The Netherlands

Background and study aims Histological confirmation of subepithelial lesions (SELs) in the upper gastrointestinal tract remains challenging. Endoscopic resection of SELs is increasingly used for its excellent diagnostic yield and opportunity to do away with continued surveillance. In this study, we aimed to evaluate the indications, success rates and complications of different endoscopic resection techniques for SELs at a large, tertiary referral hospital in Rotterdam, The Netherlands. Patients and methods Data between October 2013 and December 2021 were retrospectively collected and analyzed. Main outcomes were R0-resection rate, en bloc resection rate, recurrence rate, and procedure-related adverse events (AEs) (Clavien-Dindo). Secondary outcomes were procedure time, need for surgical intervention, and clinical impact on patient management. Results A total of 58 patients were referred for endoscopic resection of upper gastrointestinal SELs. The median diameter of lesions was 20 mm (range 7-100 mm). Median follow-up time was 5 months (range 0.4-75.7). Forty-eight procedures (83%) were completed successfully leading to en bloc resection in 85% and R0-resection in 63%. Procedure-related AEs occurred in six patients (13%). Severe complications (CD grade 3a) were seen in three patients. The local recurrence rate for (pre)malignant diagnosis was 2%. Additional surgical intervention was needed in seven patients (15%). A total of 32 patients (67%) could be discharged from further surveillance after endoscopic resection. Conclusions Endoscopic resection is a safe and effective treatment for SELs and offers valuable information about undetermined SELs for which repeated sampling attempts have failed to provide adequate tissue for diagnosis.

Diagnostic yield of endoscopic and EUS-guided biopsy techniques in subepithelial lesions of the upper GI tract: a systematic review

BACKGROUND AND AIMS

Obtaining adequate tissue samples in subepithelial lesions (SELs) remains challenging. Several biopsy techniques are available, but a systematic review including all available techniques to obtain a histologic diagnosis of SEL is lacking. The aim of this study was to evaluate the diagnostic yield and adverse event rates of endoscopic biopsies, EUS-guided FNA (EUS-FNA), EUS-guided fine-needle biopsy (FNB) (EUS-FNB), and mucosal incision-assisted biopsy (MIAB) for SELs in the upper GI tract.

METHODS

A search strategy in multiple databases was performed. The primary outcome was diagnostic yield, defined as the percentage of procedures in which histology was obtained and resulted in a definitive histopathologic diagnosis. Secondary outcome measures included reported procedure-related adverse events, which were graded according to the AGREE (Adverse Events in Gastrointestinal Endoscopy) classification.

RESULTS

A total of 94 original articles were included. Studies were classified per endoscopic technique to obtain histopathology. This resulted in 8 included studies for endoscopic biopsy methods, 55 studies for EUS-FNA, 33 studies for EUS-FNB, and 26 studies for MIAB. Pooled rates for diagnostic yield were 40.6% (95% confidence interval [CI], 30.8-51.2) for endoscopic biopsy, 74.6% (95% CI, 69.9-78.7) for EUS-FNA, 84.2% (95% CI, 80.7-87.2) for EUS-FNB, and 88.2% (95% CI, 84.7-91.1) for MIAB. Reported procedure-related adverse events graded AGREE II or higher were 2.8% to 3.9% for endoscopic biopsies, 1.0% to 4.5% for EUS-FNA, .9% to 7.7% for EUS-FNB, and 1.9% to 7.9% for MIAB.

CONCLUSIONS

Based on the available evidence, MIAB and EUS-FNB seem to be most effective in terms of achieving a high diagnostic yield, with similar rates of adverse events.

Technical outcomes and postprocedural courses of mucosal incision-assisted biopsy for possible gastric gastrointestinal stromal tumors: A series of 48 cases (with video)

Objective

Mucosal incision-assisted biopsy (MIAB) has been introduced as an alternative to endoscopic ultrasound-guided fine needle aspiration for tissue sampling of subepithelial lesions. However, there have been few reports on MIAB, and the evidence is lacking, particularly in small lesions. In this case series, we investigated the technical outcomes and postprocedural influences of MIAB for gastric subepithelial lesions 10 mm or greater in size.

Methods

We retrospectively reviewed cases with the intraluminal growth type of possible gastrointestinal stromal tumors, in which MIAB was performed at a single institution between October 2020 and August 2022. Technical success, adverse events, and clinical courses following the procedure were evaluated.

Results

In 48 MIAB cases with a median tumor diameter of 16 mm, the success rate of tissue sampling and the diagnostic rate were 96% and 92%, respectively. Two biopsies were considered sufficient for making the definitive diagnosis. Postoperative bleeding occurred in one case (2%). In 24 cases, surgery has performed a median of two months after MIAB, and no unfavorable findings caused by MIAB were seen intraoperatively. Finally, 23 cases were histologically diagnosed as gastrointestinal stromal tumors, and no patients who underwent MIAB experienced recurrence or metastasis during a median observation period of 13 months.

Conclusions

The data indicated that MIAB appears feasible, safe, and useful for histological diagnosis of gastric intraluminal growth types of possible gastrointestinal stromal tumors, even those of a small size. Postprocedural clinical effects were considered negligible.

Endoscopic full‑thickness resection with clip‑ and snare‑assisted traction for gastric submucosal tumours in the fundus: A single‑centre case series

Exposed endoscopic full-thickness resection (Eo-EFTR) has been recognized as a feasible therapy for gastrointestinal submucosal tumours (SMTs) originating deep in the muscularis propria layer; however, Eo-EFTR is difficult to perform in a retroflexed fashion in the gastric fundus. As a supportive technique, clip- and snare-assisted traction may help expose the surgical field and shorten the operation time in endoscopic resection of difficult regions. However, the application of clip- and snare-assisted traction in Eo-EFTR of SMTs in the gastric fundus is limited. Between April 2018 and December 2021, Eo-EFTR with clip- and snare-assisted traction was performed in 20 patients with SMTs in the gastric fundus at The First Affiliated Hospital of Soochow University. The relevant clinical data were collected retrospectively for all of the patients and analysed. All 20 patients underwent Eo-EFTR successfully without conversion to open surgery or severe adverse events. The en bloc resection rate and R0 resection rate were both 100%. Two patients had abdominal pain and fever after the operation, and five patients had fever, which recovered with medical therapy. No complications, such as delayed bleeding or delayed perforation, were observed. The postoperative pathology indicated that 19 cases were gastrointestinal stromal tumours and one case was leiomyoma. During the follow-up, no residual tumour, local recurrence or distant metastasis was detected by endoscopy or abdominal computed tomography. In conclusion, Eo-EFTR with clip- and snare-assisted traction appears to be a relatively safe and effective treatment for gastric SMTs in the fundus. However, prospective studies on a larger sample size are required to verify the effect of the clip- and snare-assisted traction in Eo-EFTR.

Negligible procedure-related dissemination risk of mucosal incision-assisted biopsy for gastrointestinal stromal tumors versus endoscopic ultrasound-guided fine-needle aspiration/biopsy

BACKGROUND

Mucosal incision-assisted biopsy (MIAB) is a valuable alternative to endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNAB) for sampling gastric subepithelial lesions (SELs). This study aimed to evaluate the potential risk of dissemination and impact on postoperative prognosis associated with MIAB, which has not yet been investigated.

METHODS

Study 1: A prospective observational study was conducted to examine the presence or absence and growth rate of tumor cells in gastric juice before and after the procedure in patients with SELs who underwent MIAB (n = 25) or EUS-FNAB (n = 22) between September 2018 and August 2021. Study 2: A retrospective study was conducted to examine the impact of MIAB on postoperative prognosis in 107 patients with gastrointestinal stromal tumors diagnosed using MIAB (n = 39) or EUS-FNAB (n = 68) who underwent surgery between January 2001 and July 2020.

RESULTS

In study 1, although no tumor cells were observed in gastric juice in MIAB before the procedure, they were observed in 64% of patients after obtaining samples (P < 0.001). In contrast, no tumor cells were observed in the gastric juice in EUS-FNAB before and after the procedure. In study 2, there was no significant difference in 5-year disease-free survival between MIAB (100%) and EUS-FNAB (97.1%) (P = 0.27).

CONCLUSION

MIAB is safe, with little impact on postoperative prognosis, although the procedure releases some tumor cells after damaging the SEL's pseudocapsule.

Efficacy, Feasibility, and Safety of Endoscopic Ultrasound-guided Fine-needle Biopsy for the Diagnosis of Gastrointestinal Subepithelial Lesions: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic ultrasound (EUS) fine-needle biopsy (FNB) has become an efficient method for diagnosing gastrointestinal (GI) subepithelial lesions (SELs). However, recent guidelines have not regarded FNB as the primary strategy for diagnosing GI SELs. We performed this study to systematically measure the efficacy, feasibility, and safety of EUS-FNB in diagnosing GI SELs.

MATERIALS AND METHODS

Relevant studies were searched in PubMed and EMBASE and published after January 2015 were included. The overall rates of diagnostic yield, technical success, and adverse events were calculated as outcome measures. The Jadad scale and the Newcastle-Ottawa scale were used to evaluate the quality of the trials, funnel plots and Egger's test were used to measure publication bias, and sensitivity and subgroup analyses were performed to explore the variance of heterogeneity and sensitivity, respectively.

RESULTS

Sixteen studies analyzing 969 patients between 2015 and 2020 were included. Studies showed little change in sensitivity, and 13 were considered high quality. A certain degree of publication bias existed in the diagnostic accuracy rate. The overall rates of diagnostic yield, technical success, and adverse events were [85.69% (95% confidence interval (CI): 82.73-88.22, I2=41.8%), 98.83% (95% CI: 96.73-99.97, I2=54.3%), and 1.26% (95% CI: 0.35-2.54, I2=0.0%)]. No clinical influencing factors were identified in the subgroup analysis.

CONCLUSIONS

EUS-FNB is a promising technology with a relatively superior diagnostic yield, technical success, and security, which is an optimal option for the diagnosis of SELs.

Comparison between endoscopic ultrasound-guided fine-needle biopsy and bite-on-bite jumbo biopsy for sampling of subepithelial lesions

BACKGROUND AND AIMS

A direct comparison between endoscopic ultrasound (EUS) fine-needle biopsy (FNB) and current endoscopic biopsy techniques in patients with subepithelial lesions (SELs) is still lacking. Aim of this multicenter study was to compare the diagnostic performance and safety profile between EUS-FNB and bite-on-bite jumbo biopsy.

METHODS

Out of 416 patients undergoing endoscopic sampling of SELs between 2017 and 2021, after propensity score matching two groups were compared: 120 undergoing EUS-FNB and 120 sampled with bite-on-bite jumbo biopsy. Primary outcome was sample adequacy. Secondary outcomes were diagnostic accuracy, sensitivity, specificity, and adverse events.

RESULTS

Median age was 61 years and most patients were male in both groups. Final diagnosis was GIST in 65 patients (54.1%) in the EUS-FNB group and 62 patients in the bite-on-bite biopsy group (51.6%; p = 0.37). Sample adequacy was significantly higher in the EUS-FNB group as compared to the bite-on-bite biopsy group (94.1% versus 77.5%, p<0.001). EUS-FNB outperformed bite-on-bite biopsy also in terms of diagnostic accuracy (89.3% versus 67.1%, p<0.001) and sensitivity (89% vs 64.5%; p<0.001), whereas specificity was 100% in both groups (p = 0.89). These findings were confirmed in subgroup analysis according to SEL location, final diagnosis, and wall layers of the sampled SEL. Adverse event rate was 6.6% in the EUS-FNB group and 30% in the bite-on-bite biopsy group (p<0.001).

CONCLUSION

EUS-FNB outperforms bite-on-bite biopsy both in terms of diagnostic yield and safety profile.

Advancements in the Diagnosis of Gastric Subepithelial Tumors

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.

What About Gastric Schwannoma? A Review Article

PURPOSE

Gastric schwannomas (GSs) are rare mesenchymal neoplasms of the gastrointestinal tract. Diagnosis is often achieved postoperatively, based on pathology reports of retrieved specimens. The aim of the present study is to follow up all patients with gastric schwannoma (Gs) undergoing endoscopic, partial, or more extended surgery and to evaluate the appearance of local or distant recurrence.

METHODS

A PubMed, Cochrane, and Embase systematic review of the literature has been performed. Original papers, review articles, and case reports published between 1988 and 2019 were considered eligible. All the studies who met the inclusion criteria were analyzed. Statistical analysis of data has been performed using GraphPad Prism 7 software.

RESULTS

Three hundred twenty-eight articles were found, and a total of 102 were included and analyzed in depth. Fifty-three papers reported the follow-up information, ranging from 1 to 417 months across different studies. Among them, 31 patients underwent endoscopic removal of the gastric lesions; 140 patients underwent local surgery, including wedge resection or partial gastrectomy; and 148 patients underwent subtotal or total gastrectomy. The median follow-up was of 27-38-33 months, respectively. No recurrence or distant metastasis was detected in the endoscopy group. Among local surgery group, liver metastasis was reported in one case; in extended surgery group, one patient died for multiple liver metastases.

CONCLUSIONS

Local or more extended surgery involved a larger cohort of patients and reported satisfactory long-term results compared with endoscopy group. Surgery in absence of a definite preoperative diagnosis is considered the gold standard treatment for resectable Gs.

Endoscopic diagnosis and management of gastric subepithelial lesions

PURPOSE OF REVIEW

The purpose of this manuscript is to provide an in-depth review of gastric subepithelial lesions (SELs) and describe the current approach to endoscopic diagnosis and management of these lesions.

RECENT FINDINGS

Gastric SELs are a relatively frequent finding on routine endoscopy (incidence 0.2-3%). A systematic approach to diagnosis and management is key because many SELs are of little consequence, while others carry a high risk of malignant transformation. Because esophagogastroduodenoscopy (EGD) cannot delineate depth of invasion or subepithelial appearance, endoscopic ultrasound (EUS) should be considered a first-line modality. Recent data suggest EUS-guided fine needle biopsy (FNB) may be superior to traditional fine needle aspiration (FNA) for the diagnosis of gastric SELs due to its ability to obtain histologic specimens for immunohistochemical staining. Alternative techniques for tissue sampling (combined with simultaneous resection) include submucosal resection, endoscopic submucosal dissection (ESD), submucosal tunnelling with endoscopic resection (STER) or endoscopic full-thickness resection (EFTR).

SUMMARY

This review details the endoscopic diagnosis and management of gastric SELs. Although EUS-guided sampling remains a first-line strategy (preferably with FNB), recent techniques including ESD, STER and EFTR have the potential to provide additional diagnostic and therapeutic options.

In vivo real-time diagnosis of endoscopic ultrasound-guided needle-based confocal laser endomicroscopy in gastric subepithelial lesions

BACKGROUND AND AIM

The effect of real-time analysis of needle-based confocal laser endomicroscopy (nCLE) for gastric subepithelial lesions (SELs) on the diagnostic value is unclear. The study aimed to investigate the diagnostic efficacy of real-time nCLE for gastric SELs and to assess the technical aspects and safety of real-time nCLE.

METHODS

Consecutive patients with gastric SELs ≥ 1 cm were prospectively investigated by endoscopic ultrasound (EUS), followed by nCLE. During EUS-nCLE, real-time nCLE diagnosis was made by an expert endoscopist. The procedure-relative adverse events were assessed and recorded. One-month washout period later, nCLE videos were reviewed off-line by the same endoscopist. The nCLE diagnoses were compared with corresponding pathological results. Additionally, image quality and interobserver agreements for the criteria were evaluated by three experienced endomicroscopists.

RESULTS

Except for one failing to be punctured, 60 patients completed EUS-nCLE procedures successfully. Real-time nCLE had high diagnostic accuracies of ≥ 88.3% for gastric SELs. There were no significant differences between real-time and off-line nCLE diagnoses for gastric SELs (P > 0.05). The overall accuracy of real-time nCLE for diagnosis of gastric SELs was 86.7%. There were no procedure-relative adverse events occurred. In addition, the mean image quality score was 3.6 (1 = poor and 5 = excellent). The interobserver agreement was "almost perfect" for ectopic pancreas and "substantial" for gastrointestinal stromal tumor, leiomyoma, and carcinoma.

CONCLUSIONS

Endoscopic ultrasound-nCLE could provide in vivo real-time diagnostic imaging with a high diagnostic accuracy. Meanwhile, real-time nCLE was feasible and had a satisfactory safety profile.

Reasons for Diagnostic Failure in Forty-Five Consecutive Mucosal Cutting Biopsy Examinations of Gastric Subepithelial Tumors

BACKGROUND/AIMS

Mucosal cutting biopsy (MCB) is useful for the histopathological diagnosis of gastric subepithelial tumors (SETs). However, there is little information on cases in which MCB did not establish a diagnosis. In the current study, we aimed to investigate the characteristics of cases in which MCB was unsuccessful.

METHODS

Cases in which MCB was used to histopathologically diagnose gastric SETs at Kobe University Hospital between August 2012 and October 2018 were retrospectively reviewed.

RESULTS

Forty-five cases in which MCB was used to diagnose 43 gastric SETs in 43 patients were analyzed. The median tumor size was 20 mm (range, 8-50 mm). Pathological examinations resulted in definitive and suspected diagnoses and no diagnosis in 29 (gastrointestinal stromal tumor: n=17, leiomyoma: n=7, aberrant pancreas: n=3, others: n=2), 6, and 10 cases, respectively. Failure to expose the tumor according to retrospective examinations of endoscopic images was significantly associated with no diagnosis. Other possible explanations included a less elevated tumor, biopsy of the surrounding field instead of the tumor due to the mobility, and poor endoscope maneuverability due to the tumor being close to the cardia.

CONCLUSION

Clear exposure of gastric SETs during MCB may improve the diagnostic rate of such examinations.

Superiority of mucosal incision-assisted biopsy over ultrasound-guided fine needle aspiration biopsy in diagnosing small gastric subepithelial lesions: a propensity score matching analysis

BACKGROUND

Gastric subepithelial lesions, including gastrointestinal stromal tumors, are often found during routine gastroscopy. While endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) has been the gold standard for diagnosing gastric subepithelial lesions, alternative open biopsy procedures, such as mucosal incision-assisted biopsy (MIAB) has been reported useful. The aim of this study is to evaluate the efficacy of MIAB for the diagnosis of gastric SELs compared with EUS-FNAB.

METHODS

We retrospectively analyzed medical records of 177 consecutive patients with gastric SELs who underwent either MIAB or EUS-FNAB at five hospitals in Japan between January 2010 and January 2018. Diagnostic yield, procedural time, and adverse event rates for the two procedures were evaluated before and after propensity-score matching.

RESULTS

No major procedure-related adverse events were observed in either group. Both procedures yielded highly-accurate diagnoses once large enough samples were obtained; however, such successful sampling was more often accomplished by MIAB than by EUS-FNAB, especially for small SELs. As a result, MIAB provided better diagnostic yields for SELs smaller than 20-mm diameter. The diagnostic yields of both procedures were comparable for SELs larger than 20-mm diameter; however, MIAB required significantly longer procedural time (approximately 13 min) compared with EUS-FNAB.

CONCLUSIONS

Although MIAB required longer procedural time, it outperformed EUS-FNAB when diagnosing gastric SELs smaller than 20-mm diameter.

Comparison between fine-needle biopsy and fine-needle aspiration for EUS-guided sampling of subepithelial lesions: a meta-analysis

BACKGROUND AND AIMS

There is limited evidence on the diagnostic performance of EUS-guided fine-needle biopsy (FNB) sampling in patients with subepithelial lesions. The aim of this meta-analysis was to compare EUS-guided FNB sampling performance with FNA in patients with GI subepithelial lesions.

METHODS

A computerized bibliographic search on the main databases was performed through May 2019. The primary endpoint was sample adequacy. Secondary outcomes were diagnostic accuracy, histologic core procurement rate, and mean number of needle passes. Summary estimates were expressed in terms of odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Ten studies (including 6 randomized trials) with 669 patients were included. Pooled rates of adequate samples for FNB sampling were 94.9% (range, 92.3%-97.5%) and for FNA 80.6% (range, 71.4%-89.7%; OR, 2.54; 95% CI, 1.29-5.01; P = .007). When rapid on-site evaluation was available, no significant difference between the 2 techniques was observed. Optimal histologic core procurement rate was 89.7% (range, 84.5%-94.9%) with FNB sampling and 65% (range, 55.5%-74.6%) with FNA (OR, 3.27; 95% CI, 2.03-5.27; P < .0001). Diagnostic accuracy was significantly superior in patients undergoing FNB sampling (OR, 4.10; 95% CI, 2.48-6.79; P < .0001) with the need of a lower number of passes (mean difference, -.75; 95% CI, -1.20 to -.30; P = .001). Sensitivity analysis confirmed these findings in all subgroups tested. Very few adverse events were observed and did not impact on patient outcomes.

CONCLUSIONS

Our results speak clearly in favor of FNB sampling, which was found to outperform FNA in all diagnostic outcomes evaluated.

Upper gastrointestinal submucosal lesions: Endoscopic ultrasonographic features and endoscopic curative effects

BACKGROUND

Upper gastrointestinal submucosal lesions (SMLs) are common gastrointestinal conditions, and their diagnosis and treatment are very complicated. Therefore, it is especially important to select a reasonable treatment method based on the clinical features of the patients. With the wide use of endoscopic techniques, the efficacy of endoscopic treatment of upper gastrointestinal SMLs has been greatly improved. It is important to improve the clinical diagnosis and treatment efficacy by summarizing clinical experience.

AIM

To investigate the endoscopic ultrasonographic features of upper gastrointestinal SMLs and their endoscopic curative effects.

METHODS

Three hundred and twenty patients with SMLs treated at Department of Gastroenterology of Affiliated Xiang'an Hospital of Xiamen University from January 2015 to February 2017 were included. All the cases underwent ultrasonic endoscopic examination. The diseased region, disease type, the layer where lesions originated, disease type by location, lesion size, and endoscopic curative effects were analyzed.

RESULTS

The lesions of 320 cases were mainly located in the stomach, which accounted for 53.75% of all cases, followed by 39.69% in the esophagus, 4.38% in the duodenum, and 2.19% in the cardia of stomach. The common disease categories of SMLs were leiomyoma, interstitialoma, and heterotopic pancreas. The esophageal lesions mainly originated from the muscularis mucosa layer, followed by the muscularis propria layer; the duodenal lesions mainly originated from the submucosa layer; the lesions of the cardia of the stomach mainly originated from the muscularis mucosa layer and muscularis propria layer; the gastric lesions mainly originated from the muscularis propria layer and submucosal layer. The main types of lesions in the esophagus, the cardia of the stomach, the duodenum, and stomach were leiomyoma, interstitialoma and leiomyoma, interstitialoma and heterotopic pancreas, and interstitialoma and heterotopic pancreas, respectively. The majority of lesions had a size of 3 cm or below. Of all 320 cases, 128 (40.00%) underwent endoscopic treatment, including 56 (43.75%) cases of endoscopic mucosal resection (EMR), 4 (3.13%) cases of submucosal tunnel endoscopic resection (STER), and 68 (53.13%) cases of endoscopic submucosal dissection (ESD). The lesions in the ESD group were mainly located in the stomach, while those in the EMR group and STER group were mainly located in the esophagus; the difference was statistically significant (P < 0.05). The lesions in the ESD group and STER group mainly originated from the muscularis propria layer, while those in the EMR group mainly originated from the muscularis mucosa; the difference was statistically significant (P < 0.05). The size of lesions in the ESD group, EMR group, and STER group was mainly 1-3 cm, < 1 cm, and < 1 cm, respectively, and the difference was statistically significant (P < 0.05). There was no statistical difference in the incidence of perforation, bleeding, or the coincidence rate of ultrasonic endoscopic diagnosis of the source of lesions with the operative diagnosis among the three groups (P > 0.05).

CONCLUSION

The most common types of SMLs detected by ultrasonic endoscopy are leiomyoma, interstitialoma, and heterotopic pancreas, and the lesions mainly occur in the stomach, especially in the antrum of the stomach. The lesions mainly originate from the muscularis propria layer, muscularis mucosa layer, and submucosa layer. The size of lesions is mostly 3 cm or below. EMR and ESD are common procedures for the treatment of SML, and different procedures are suitable for patients with different lesion sources and sizes.

Endoscopic ultrasound-guided fine-needle aspiration biopsy of gastric schwannoma: Cytomorphologic features and diagnostic pitfalls

Schwannoma rarely occurs in the stomach. We present a case of gastric schwannoma, which was initially evaluated by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy and confirmed by surgical resection. The patient was a 57-years-old woman with history of dyspepsia, who was found to have a large submucosal mass in the stomach. EUS-FNA showed scant spindle cells with abundant lymphocytes. The spindle cells were immunoreactive with S100, while negative for CD117, desmin, and CD34. The lymphocytes were mixed B-cells and T-cells. Immunostaining, flow cytometry, and molecular testing showed no evidence of B-cell lymphoma. The diagnosis of gastric schwannoma was confirmed by histopathological evaluation of the resected tumor. Gastric schwannoma has unique features of mixed spindle cells and lymphocytes. The tumor should be differentiated from other gastric mesenchymal tumors, and lymphoproliferative disorder is a pitfall.

Mucosal incision-assisted biopsy versus endoscopic ultrasound-guided fine-needle aspiration with a rapid on-site evaluation for gastric subepithelial lesions: A randomized cross-over study

OBJECTIVES

This study aimed to compare the diagnostic yield of mucosal incision-assisted biopsy (MIAB) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) with a rapid on-site evaluation (ROSE) for gastric subepithelial lesions (SEL) suspected of being gastrointestinal stromal tumors (GIST) with an intraluminal growth pattern.

METHODS

This was a prospective randomized, cross-over multicenter study. The primary outcome was the diagnostic yield of EUS-FNA and MIAB. The secondary outcomes were the technical success rate, complication rate, procedure time and biopsy frequency.

RESULTS

A total of 47 patients were randomized to the MIAB group (n = 23) and EUS-FNA group (n = 24). There was no significant difference in the diagnostic yield of MIAB and EUS-FNA (91.3% vs 70.8%, P = 0.0746). The complication rates of MIAB and EUS-FNA did not differ to a statistically significant extent. The mean procedure time in the MIAB group was significantly longer than that in the EUS-FNA group (34 vs 26 min, P = 0.0011).

CONCLUSIONS

The diagnostic yield of MIAB was satisfactorily as high as EUS-FNA with ROSE for gastric SEL with an intraluminal growth pattern.

Examine the Availability and Safety of Mucosal Cutting Biopsy Technique for Diagnosis of Gastric Submucosal Tumor

Objectives

Differentiating gastrointestinal stromal tumor (GIST) from other submucosal tumors (SMTs) is important in diagnosing SMT. GIST is an immunohistological diagnosis that cannot be made from images alone. Tissue sampling of tumor sites is thus becoming increasingly important. In this study, the utility and associated complications of mucosal cutting biopsy (MCB) for gastric SMTs were investigated.

Methods

This was a case series study. The subjects were patients aged ≥20 years old in whom an SMT was seen on esophagogastroduodenography and who underwent MCB between January 2012 and December 2016. Patient information, endoscopy findings, gastric SMT size, pathological diagnosis, and other information were gathered from medical records. The SMT size was the maximum diameter that could be visualized on EUS. The pathological diagnosis was made with hematoxylin-eosin staining, with immunostaining added to diagnose GIST. The endpoint was the histopathological diagnostic yield. Risk assessment using the Miettinen classification and modified Fletcher classification was also done for GISTs treated with surgery.

Results

The mean tumor diameter was 15.4 mm. The tumor diameter was ≥20 mm in seven patients and <20 mm in 23 patients. The tissue-acquiring rate was 93.3%. A histological diagnosis could not be made in two patients. The only complication was that bleeding required endoscopic hemostasis during the procedure in one patient, but no subsequent bleeding or no postoperative bleeding was seen.

Conclusions

MCB is an appropriate and safe procedure in the diagnosis of gastric SMTs. Many hospitals will be able to perform MCB if they have the environment, including skills and equipment, to perform endoscopic submucosal dissection.

Efficacy of Mucosal Cutting Biopsy for the Histopathological Diagnosis of Gastric Submucosal Tumors

Background

Gastrointestinal stromal tumors occur frequently. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is performed commonly for diagnosis. However, the success rate of histological diagnosis is insufficient when the submucosal tumor (SMT) is small. Recently, another technique, mucosal cutting biopsy (MCB) has been reported. The aim of this study is to evaluate the efficacy and safety of MCB.

Method

Between January 2012 and August 2018, MCB and EUS-FNA were performed 16 and 31 times for diagnosing gastric SMT. The diagnostic rate, the rate of successful immunohistochemistry, and the safety were reviewed. Difficult locations for EUS-FNA were also evaluated.

Results

The mean SMT sizes measured on MCB and EUS-FNA were 21.2 and 36.2 mm. The diagnostic rates of MCB and EUS-FNA were almost the same (88 vs. 81%), but successful immunohistochemistry was significantly higher in the MCB group (93 vs. 59%, p = 0.03). In the subgroup of SMTs < 20 mm, the successful histological diagnosis rate from EUS-FNA was relatively low. There were no complications. Failures of EUS-FNA were more frequent in the middle third of the stomach.

Conclusions

MCB was an effective procedure for diagnosing gastric SMT, especially in the case of small SMTs located at the middle third of the stomach.

Concise review on the comparative efficacy of endoscopic ultrasound-guided fine-needle aspiration vs core biopsy in pancreatic masses, upper and lower gastrointestinal submucosal tumors

Endoscopic ultrasound (EUS)-guided fine needle aspiration with or without biopsy (FNA/FNB) are the primary diagnostic tools for gastrointestinal submucosal tumors. EUS-guided fine needle aspiration (EUS-FNA) is considered a first line diagnostic method for the characterization of pancreatic and upper gastrointestinal lesions, since it allows for the direct visualization of the collection of specimens for cytopathologic analysis. EUS-FNA is most effective and accurate when immediate cytologic assessment is permitted by the presence of a cytopathologist on site. Unfortunately, the accuracy and thus the diagnostic yield of collected specimens suffer without this immediate analysis. Recently, a EUS-FNB needle capable of obtaining core samples (fine needle biopsy, FNB) has been developed and has shown promising results. This new tool adds a new dimension to the diagnostic and therapeutic utility of this technique. The aim of the present review is to compare the efficacy of EUS-FNA to that afforded by EUS-FNB in the characterization of pancreatic masses and of upper and lower gastrointestinal submucosal tumors.

Total-Laparoscopic Intragastric Surgery for Cardia Endogenous Gastric Submucosal Tumors: A Single-Center Short-Term Experience

BACKGROUND

Total-laparoscopic intragastric surgery (T-LIGS) has gradually been accepted for the treatment of endogenous gastric submucosal tumors. However, it is difficult to perform T-LIGS when the tumor is located at the esophagogastric junction (cardia endogenous gastric submucosal tumor [CEGSMT]) without special laparoscopic instruments that are not available in most developing countries. We have successfully treated 12 cases of CEGSMTs using conventional laparoscopic instruments and achieved acceptable outcomes. This study was conducted to evaluate the surgical techniques for CEGSMT management.

METHODS

A retrospective analysis was conducted involving all the CEGSMT patients who were treated with T-LIGS in the General Surgery Department of Guangdong General Hospital from August 2014 to June 2016.

RESULTS

There were 12 patients successfully treated with T-LIGS. The surgical time ranged from 56 to 108 minutes, and the blood loss was 5-70 mL. The distance to the tumor from the dentate line was 12-24 mm, and the tumor diameter was 17-28 mm. The tumor margins were 9-15 mm, and the eating time was 2-4 days. The drainage tube indwelling time was 2-4 days, and the discharge time was 4-6 days. The follow-up exams revealed no recurrences, dysphagia, acid reflux, or other digestive symptoms.

CONCLUSIONS

It is safe and feasible to perform T-LIGS using conventional laparoscopic instruments to treat CEGSMTs. We suggest that T-LIGS can be performed for endogenous mucosal tumors within 3 cm from the cardiac dentate line and less than 3 cm in size.

A Novel Method of Diagnosing Aberrant Pancreas: Needle-based Confocal Laser Endomicroscopy

Aberrant pancreas is defined as pancreatic tissue present outside of the pancreas and is often found incidentally during esophagogastroduodenoscopy. Obtaining sufficient tissue to differentiate aberrant pancreas from other subepithelial lesions is sometimes difficult. Due to the lack of a definitive diagnosis, patients often undergo unnecessary surgery. We herein report the first case of aberrant pancreas in which the concomitant use of needle-based probe confocal laser endomicroscopy and fine-needle aspiration supported the final diagnosis. Needle-based probe confocal laser endomicroscopy provides a real-time in vivo histopathology evaluation and may be a feasible means of diagnosing aberrant pancreas.

[Primary Hepatic Schwannoma]

A primary benign schwannoma of the liver is extremely rare. Only 30 cases have been reported in the medical literature worldwide, and only one case has been reported in Korea previously. A 56-year-old man was admitted to Gil Medical Center with incidental findings of a hepatic mass by abdominal computed tomography. The computed tomography and magnetic resonance image revealed a 3×2 cm-sized solid mass in the left lobe of the liver. Histological examination confirmed the diagnosis of a benign schwannoma, proven by positive immunoreaction with the neurogenic marker S-100 protein and a negative response to CD34, CD117, and smooth muscle actin. We report a primary benign schwannoma of the liver and review the literature.

Endoscopic Full-thickness Resection for Gastric Subepithelial Tumors Originating From the Muscularis Propria: A 69-Case Series

OBJECTIVE

This report describes a mini-invasive technique called endoscopic full-thickness resection (EFR) for the treatment of gastric subepithelial tumors (SETs) originating from the muscularis propria (MP).

MATERIALS AND METHODS

We retrospectively analyzed 69 patients with gastric SETs originating from the MP at our hospital between September 2009 and July 2016. The data from each patient were reviewed, including patient information, tumor characteristics, procedure-related data, and recurrence rates.

RESULTS

Successful complete resection by EFR was achieved in 69 cases. The complete resection rate was 100%, and the mean resected tumor size was 2.25±1.40 (range, 0.6 to 6) cm. No residual tumor recurrence was detected during the follow-up period in 57 patients. The other 12 patients were lost to follow-up.

CONCLUSIONS

EFR seems to be a safe and effective technique for the treatment of patients with gastric SETs originating from the MP.

Cytohistological and immunohistochemical characteristics of spindle-shaped mesenchymal neoplasms occurring in the gastrointestinal tract

The purpose of the present review is to analyze the cytohistological and immunohistochemical characteristics of spindle-shaped mesenchymal gastrointestinal neoplams (MGNs), a group of unusual neoplastic conditions with different biological behavior. These tumors exhibit clinical pictures strictly related to the site of origin and dimensions, even if they appear generally with an intramural localization. This latter point may suggest an useful application of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), mainly followed by the cell-block procedure (CBP) in the differential diagnostic approach. First of all, we discuss the most common entity of MGNs represented by gastrointestinal stromal tumors (GISTs), analyzing the morphologic characteristics and stressing the strength of immunohistochemical algorithm for diagnostic purposes. Successively, we have reported the less common group of spindle-shaped MGNs comprehensive of those arising elsewhere the soft tissues, such as leiomyomas, leiomyosarcomas, schwannomas, inflammatory myofibroblastic tumor and intra-abdominal desmoid fibromatosis. Finally, very uncommon spindle-shaped MGNs, like clear cell, follicular dendritic cell, undifferentiated pleomorphic and radiation-induced sarcomas as well as spindle cell dedifferentiated liposarcomas, have been briefly mentioned.

Effectiveness of Endoscopic Ultrasonography during Double Balloon Enteroscopy for characterization and management of small bowel submucosal tumours

BACKGROUND

Characterization of small bowel submucosal tumours is challenging, requiring additional investigations. Endoscopic Ultrasonography performed during Double Balloon Enteroscopy, appeared a promising technique although it has not been fully evaluated. The aim was to determine the effectiveness of this technique for characterization and management of sub mucosal tumours in a large cohort of patients.

METHODS

Patients with suspected small bowel tumours, who underwent Endoscopic Ultrasonography performed during Double Balloon Enteroscopy in our Institution between 2005 and 2013, were reviewed. Demographic data, clinical, endoscopic and radiological findings, therapeutic management, final diagnosis and follow-up were analyzed.

RESULTS

30 patients (19 male; median age 61.5) affected by submucosal tumours were included in the study. Endoscopic Ultrasonography performed during Double Balloon Enteroscopy was successfully performed in all cases providing a correct characterization of 19 submucosal tumours (63%). Based on the ultrasonographic characteristics 8 patients were treated endoscopically, 16 were referred to surgery, and 6 were managed conservatively.

CONCLUSION

Our results suggest that Endoscopic Ultrasonography performed during Double Balloon Enteroscopy is a safe and useful technique for submucosal tumours characterization. This procedure may be applied in clinical practice when small bowel tumours are encountered, to confirm the diagnosis and provide the most appropriate management.