SUBMUCOSAL LESIONSEUS and EUS-FNA

Hakan Senturk, MDProfessor of Medicine, Chief of Gastroenterology Division

Faculty of Medicine Bezmialem Vakif University

SUBEPITHELIAL LESION

• A luminal protruding lesion with normal mucosal covering

• Prevalance in upper GI endoscopy: % 0.36

– 8-year data

– 54 out of 15104 endoscopy

• Intramural ? External compression ?

• EUS

Hedenbro JL Surg Endosc. 1991;5:20-3.

Duodenum

Esophagus

Stomach

Esophagus

Mide

Stomach Stomach

EUS

1- Layer of origin

2- Size

3- Echotexture

4- Border

5- Internal structure

6- Vascularisation

7- Lymphadenopathy

Etiology EUS -layer EUS –appearance

GIST 2,4 Hypoechoic 1

Ectopic pancreas 2, 3, and/or 4 Hypoechoic/mixt

Lipoma 3 Hyperechoic

Carcinoid 2 and/or 3 Mild hypoechoic, homogenous

Cyst 3 Anechoic

1 Irregular border,, echogenic foci, anechoic areas are in favour of malignancy

External compression-Esophagus

• Aortic arch

• Vertebra

• Aneurysm

• Vascular abnormalities

• Left atrial dilatation

• Mediastinal LAP/tumor

• Lung cancer

• Lymphoma

External compression – Stomach

• Normal structures:– Spleen : Gastric fundus or upper corpus – Gallbladder: Antrum– The images of temporary compression: Intestinal loops– Left lobe of liver – Vascular structures in splenic hilum– Tail of pancreas

• Abnormal structures:– Pancreatic pseudocyst – Aortic aneurysm – Left atrial dilatation

GIST

• 2 (muscularis mucosa) or 4 (muscularis propria)

• Well-defined border• Hypoechoic• Homogenous

• Characteristics of malignant GIST:

Heterogenous structure

Hyperechoic foci and/or anechoic necrotic areas

Irregular extraluminal border

Associated LAP with malignant features

Large dimension (> 4 cm)

GIST-2

• The most common intramural subepithelial lesion encountered during upper GI endoscopy

• Originated from the interstitial cells of Cajal• Kit expression • C-kit ( CD117) positive• CD 34 positive• Desmin negative• 10-30%; malignant

– Mitotic index and dimension of lesion – No lesion can be definitively labeled as benign

Ectopic Pancreas

• 2, 3 and/or 4

• Hypoechoic and/or mixt echogenicity and internal

anechoic ductal structure

• Antrum large curvature

• Endoscopy: central umbilicus (draining duct)

Lipoma

• 3 (submucosa)

• Hyperechoic homogenous lesion with regular border

• Endoscopy: Solitary, yellow coloured. Pillow sign (+)

• Follow up is not recommended.

Neuroendocrine tumors

• 2 or 3

• Homogenous, well-defined border, hypoechoic/isoechoic

• Malignant potential is present

• EMR– < 2 cm

– 3rd layer

– No associated LAP

Concordance of EUS diagnosis with the final diagnosis at subepithelial lesions

Erkan Caglar1, Billur Canbakan1, Rana Senturk2, Ibrahim Hatemi1, Hakan Senturk1

Istanbul University, Cerrahpaşa medical Faculty, Division of Gastroenterology

Istanbul Gastroenterology Center, Radiology

Method

• Retrospective

• Between 2006 – 2010

• Submucosal lesions

• The analysis of EUS ve EUS-FNA findings

• Comparison with final diagnosis

• Final diagnosis

– Surgery

– Clinical and endoscopic follow up

Results

• 127 submucosal lesion

• 73 pt had the final diagnosis

• Average age ± SD : 51.55 ± 13.37

• 60% male

• 68 pt had FNA

• 12 pt had inadequate material for diagnosis (17.6%)

N %

Location

Esophagus 23 31

Stomach 48 65

Duodenum 2 2.7

EUS echogenicity

Hypoechoic 42 57

Hyperechoic 8 10.9

Hypoechoic + echogenic focus 23 32

Origin

Mucosa 14 19

Muscularis mucosa 8 10

Submucosa 7 9

Muscularis propria 40 54

Extramural 4 5

Diameter

<2.5 25 34

2.5-5 40 54

5 8 11

EUS-FNA results

GIST 19 (26%)

Leomyoma 17 (23.3%)

Esophageal cancer 7 ( 9.6%)

Gastric cancer 4 (5.5%)

Metastatic M. Melanoma 1 (1.4%)

Lung cancer 1 (1.4%)

MALT lymphoma 1 (1.4%)

Granular cell tumor 1 (1.4%)

Hyperplastic polyp 1 (1.4%)

EUS preliminary diagnosis Final diagnosis

GIST 29 23

Leomyoma 19 22

Esophageal cancer 6 8

Lung cancer 1 1

Gastric cancer 6 6

MALT lymphoma 0 1

Duplication cyst 4 4

Ectopic pancreas 0 2

Lipoma 2 2

Fibroma 2 0

Hyperplastic polyp 1 1

Granular cell tumor 1 1

73 73

EUS-FNA diagnosis Final diagnosis

GIST 19 21

Leomyoma 17 22

Esophageal cancer 7 8

Lung cancer 1 1

Gastric cancer 4 5

MALT lypmhoma 1 1

Duplication cyst 4 4

Ectopic pancreas 0 2

Hyperplastic polyp 1 1

Granular cell tumor 1 1

Lypmh node 2 Metastasis of M. MelanomaLangerhans c. Histiocytosis

Inadequate 12

68 68

• 23 GIST diagnosis (surgical material)

• EUS-FNA; c-kit positivity: 7/20 positive (35%)

• EUS/EUS-FNA; accuracy of GIST diagnosis (90.4%)

• EUS; accordance with final diagnosis: 76.7%

• EUS-FNA; accordance with final diagnosis: 98% (in

case of excluding inadequate material)

• EUS-FNA guided differential diagnosis between

benign and malignant lesions: spesificity:100%

sensitivity:86.8%