Download - Subepithelial lesions
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%