When to puncture, when not to puncture: Submucosal tumors

Abstract

Subepithelial masses of the gastrointestinal (GI) tract are a frequent source of referral for endosonographic evaluation. Subepithelial tumors most often appear as protuberances in the GI tract with normal overlying mucosa. When there is a need to obtain a sample of the mass for diagnosis, endoscopic ultrasound (EUS) - guided fine-needle aspiration (FNA) is superior to other studies and should be the first choice to investigate any subepithelial lesion. When the decision is made to perform EUS-guided FNA several technical factors must be considered. The type and size of the needle chosen can affect diagnostic accuracy, adequacy of sample size and number of passes needed. The use of a stylet or suction and a fanning or standard technique during EUS-guided FNA are other factors that must be considered. Another method proposed to improve the efficacy of EUS-guided FNA is having an on-site cytopathologist or cytotechnician. Large or well-differentiated tumors may be more difficult to diagnose by standard EUS-FNA and the use of a biopsy needle can be used to acquire a histopathology sample. This can allow preservation of tissue architecture and cellularity of the lesion and may lead to a more definitive diagnosis. Alternatives to FNA such as taking bite-on-bite samples and endoscopic submucosal resection (ESMR) have been studied. Comparison of these two techniques found that ESMR has a significantly higher diagnostic yield. Most complications associated with EUS-FNA such as perforation, infection and pancreatitis are rare and the severity and incidence of these adverse events is not known. Controversy exists as to the optimal method in which to perform EUS-FNA and larger prospective trials are needed.

The role of endoscopy in subepithelial lesions of the GI tract

“…On EUS examination, metastases to the GI tract typically appear as hypoechoic and/or heterogeneous lesions and usually can be diagnosed with FNA if standard biopsies are nondiagnostic. 107 Varices in the esophagus and stomach are diagnosed easily in the appropriate clinical setting, but they may present incidentally during routine endoscopy. 108 Varices can be found in more atypical locations such as the duodenum and rectum, even when absent in the esophagus and stomach.…”

Evaluation of Transabdominal Ultrasound with Oral Cellulose-Based Contrast Agent in the Detection and Surveillance of Gastric Ulcer

“…The use of gastroscopy for opportunistic screening of gastric cancers is widely accepted, while the use of this procedure for mass screening of gastric cancers remains questionable, even in developed countries such as Japan (Leung et al 2008). Various imaging modalities are used to detect gastric lesions, including endoscopy, barium studies, computed tomography, magnetic resonance imaging and ultrasound (Altonbary et al 2015;Liu and Adler 2014;Liu et al 2014aLiu et al , 2014bMachicado et al 2014;Rana et al 2015;Salah and Faigel, 2014). Among these, the double-contrast barium meal continues to be the most common mass screening tool for gastric cancers in Japan and Korea (Lee et al 2011;Leung et al 2008;Nakajima 2012).…”

Canalization technique to obtain deep tissue biopsy of gastrointestinal subepithelial tumors as an alternative to conventional known techniques

“…One of the most recent reviews about the convenience of the puncture of SETs establishes that the EUS-FNA succeeds in making a diagnosis in the 75%–100% of the cases (mean 87%) with a very low mortality rate (0%–2%). [ 13 ] Using ProCore ® , the diagnostic sensitivity seems to be between 80% and 90%, mean 85% although more exhaustive studies might be necessary since the sample size in these two studies was n = 11 and 13, respectively. [ 8 9 ] Our data are similar to their results with EUS-FNA and upper to ProCore ® .…”