Endoscopic Ultrasound for the Characterization of Subepithelial Lesio

7/29/2019 Endoscopic Ultrasound for the Characterization of Subepithelial Lesio

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;;-l ,"$r:li*rs lr.iLi',r,iqi [;4;fof-l*s' Official reprint from UpToDate@ir,,.il ,, illi ,,\ ,/, . l.i fl l l,ti iiil L-ij , t * ilr@2O72 UpToDate@.'ji :l ,i;"' .;;. I :

S*th*lr'* 1-il;:::,r1 ffir-iit*r #*prL9,y.' ffi#1i*ril,t*ry |** ilt'iit:llty. ** li*r:Sillli A il*r,vr:ll. fu]*, il/:l$#L:, r\r*:: {l -j'r*.ri*, r,\4*, fi$S,:: l ilill[ir]rrf:*tl #in+l:,,*1ir:i, I'J{-t 1;:i--fiAll topics are updated as new evidence becomes available and our ,1 _;. *lli{, . |, ti.,$s is complete.Literature review current through: May 2012. I This topic last updated: Nov 17, 2010.INTRODUCTION - A subepithelial mass or a bulge encountered during an endoscopy can arise from withinany layer of the gastrointestinal tract wall (intramural) or outside of the wall (extramural). They are usuallyfound incidentally during routine imaging with **riilrrcontrast radiography orendoscopy. The differentialdiagnosis includes a number of benign and malignant non-epithelial gastric wall tumors, intramural vessels, andextrinsic compression f rom extramural structures.Endoscopy alone cannot accurately distinguish between intramural and extramural lesions t"il By contrast,endoscopic ultrasonography (EUS) has provided a major breakthrough for characterizing such masses. Thistopic review will provide an overview of the most common subepithelial lesions that can be identifiedendosonographically. Discussions on the individual lesions are also available on the corresponding topicreviews.GENERAL PRINCIPLES FOR IMAGING - EUS provides a number of methods for characterizingsubepithelial lesions:

. lt provides an understanding of whether the lesion arises from the bowel wall (intramural) or from astructure outside the bowelwall (extramural) compressing the gastrointestinal wall. Extramural lesionsmay be a normal adjacent structure (eg, spleen, aorta, gallbladder) or pathologic structures (eg, splenicartery aneurysm, cyst, tumor). Rarely, the distinction between an intra- and extramural lesion may bedifficult when there is invasion into the gastrointestinalwall.

. lt can determine the originating layer of intramural lesions, an important clue for achieving a diagnosis(i*iilt J ) Stromal cell tumors, for example, can typically be seen as evolving from the muscularispropria or muscularis mucosa, whereas lipomas typically evolve from the submucosa.o The echogenicity, vascularity, margins, size of the lesion, and absence or presence of adjacent lymphnodes also help to narrow the differential diagnosis.. EUS-guided fine-needle aspiration or trucut biopsy of the lesion may be helpful in some settings. (See

Ln t :rj,;15rpgli iii rfi_!$l tili{ r;;; :;'.i *ri t rtl r r;,**t,:;.1 )Technical considerations - The following are basic principles that should be understood byendosonographers attempting to visualize subepithelial lesions.

. The lesions should be localized endoscopically or by cross-sectional imaging (CT, MRl, US) prior todin24 61261201210:09 PM


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ultrasound for the characterization of subepithelial lesion... http://www.uptodate.com/contents/endoscopic-uhasound-for-the-cha...endosonographic evaluation.The gastrointestinal tract wall echo structure, five layers of alternating bright (hyperechoic) and dark(hypoechoic) lines of approximately 3 to 4 mm thickness should be understood (J_t*i,:.* l).Endoscopic ultrasound imaging should be performed adjacent to the lesion. Water instillation may behelpful to provide adequate acoustic coupling while achieving a focal distance that permits optimalimaging. The focal length for a7.5 MHztransducer is approximately 2.0 centimeters. lmaging can beoptimized by using a minimally inflated, water filled balloon and instilling deaerated water to distend thelumen while providing a medium to transmit the ultrasound waves without reflection.For small (


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ultrasound for the characterization of subepithelial lesion... http://www.uptodate.com/contents/endoscopic-ultrasound-for-the-cha..Although this technique improved diagnostic yield, it may also increase complications such as bleeding[.:1]. (See --*t'*1,1,'1*;,i',:' ,: ' , . ' " '+ ,ril,lj,'1i]i ili;t$lj-i;lill:*$iliji1tlt+ryr;lsl_.)

o Endoscopic submucosal dissection - An alternative to EMR is the use of the needle-knife to incise theoverlying mucosa. This approach, known as endoscopic submucosal dissection, was first described in2003 in a patient with a metastasis from colon cancer presenting as a submucosal gastric tumor [:i].Endoscopic submucosal dissection has been used primarily for the treatment of mucosal gastric andesophageal cancers in Japan and Germany [fr,iij More recently, ESD has been described for theresection of subepithelial tumors [,:,*].Carefuldissection using a modified needle-knife such as the lnsulated Tip (lT) knife enables en blocresection of a submucosal tumor. ESD requires an exceptional level of operator skill, is time consuming,and is associated with significant complication rates, especially bleeding and perforation. As a result,ESD should be reserved for centers specialized in this advanced procedure. (See "{ii;;q1:11;1t;;;;;; 1:!^aar..a..5 .---l r- *, i.'/;ii ,i r, :lr ^r...;- -. \'..:.... '. '' " ' t '" IFine needle aspiration (EUS-FNA) - Standard 19,22, or 25 gauge needles may be used for fineneedle aspiration to provide an adequate tissue sample for cytological diagnosis. This is often used inconjunction with immunohistochemical staining, such as for c-kit (CD 117). A larger guillotine biopsyneedle has been used [t]1, but larger needles increase the risk of bleeding and it is unclear if these'::...Y.F. v " ; :..- ." *. "" /

Trucut biopsy - EUS-FNA typically yields a small tissue sample that is insufficient for histologicalexamination. Large caliber cutting needles were designed to acquire larger tissue specimens withpreserved tissue architecture that can provide a histologic diagnosis. (See "il:*d*s-c+ilf ril|irltr::tii:.rj

ACCURACY - Multiple studies have evaluated the accuracy of EUS in characterizing subepithelial lesions.Studies focusing on specific lesions are presented below. As a general rule, the ability of EUS alone todistinguish among subepithelial lesions is variable. As a result, histology is still considered to be the "goldstandard."Some representative studies have shown the following:

A prospective study evaluating the accuracy of EUS in characterizing 100 consecutive patients withsubepithelial lesions found that EUS findings alone correctly predicted the specific lesion type in only 48percent of cases where biopsy confirmation had been obtained [j]. Most misclassifications occurred inhypoechoic lesions in the third and fourth layers, which include carcinoids, GlSTs, aberrant pancreas,and granular cell tumors.ln a second study, the results of endoscopic resection or biopsies after unroofing in 54 submucosallesionswerecomparedwiththeEUSfindings[11] Theoverallaccuracyof EUSindeterminingthelayerof origin and location of lesion was 80 percent; six lesions were located deeper in the Gl wall thanestimated by EUS and five were more superficial. EUS and pathology findings coincided in 74 percentof lesions.

o ln a third study, 22 patients underwent EUS prior to endoscopic resection of gastric subepithelial lesionsIif i]. EUS alone correctly diagnosed 10 (46 percent) of the lesions. The lesions that were incorrectlydiagnosed included pancreatic rests (n = 5) and gastritis cystica profunda (n = 2)

EXTRAMURAL LESIONS - Normal anatomic structures and extraluminat benign and malignant tumors can61261201210:09 PM


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ultrasorutd for the characterizationof subepithelial lesion... http://www.uptodate.com,/contents/endoscopic-ultrasound-for-the-cha.compress the gastrointestinaltract and mimic an intramuraltumor. lncidental lesions are being detected morecommonly with the increasing use of total body scans in healthy patients. EUS can assist in furthercharacterizing such findings.Endoscopic appearance - Extramural lesions are commonly seen as a bulge located in the gastrointestinal(Gl) tract with normal overlying mucosa, usually with a smooth border and no significant irregularity (lt$.r*,--).Endosonographic findings - A normal appearing five-layer gastrointestinal wall structure is seen interposedbetween the lesion and the bowel lumen. Specific echo features vary depending upon the type of structureidentified. As an example, the splenic vessels appear as an anechoic structure that can be followedlongitudinally' The spleen may appear to have a homogeneous echogenicity. A pancreatic pseudocystoriginates from a region of the pancreas, and is commonly hypoechoic or anechoic.Diagnosis - Knowledge of normal endoscopic ultrasound anatomy is required to determine if a structure isnormal or abnormal. Common normal extrinsic structures include the splenic artery, spleen, gallbladder, leftlobe of the liver, and the pancreas [1li]. Abnormalstructures include pancreatic pseudocysts, enlarged lymphnodes, aneurysms, omental metastasis, and hepatic and pancreatic tumors. one group reported 100 percentaccuracy in distinguishing extramural from intramural structures [1L].GASTRoINTESTINAL STRoMAL TUMoRS - The nomenclature of gastrointestinal mesenchymal tumors isevolving with an increased understanding of molecular, histologic, and clinical features that distinguish differenttypes of tumors [i4:i1]. One of the most common mesenchymaltumors in the gastrointestinaltract,gastrointestinal stromal tumors (GlSTs), were initially thought to be of smooth muscle origin. However, a morecomplete understanding of their molecular markers and biologic behavior has demonstrated that theyencompass a heterogeneous group of tumors with respect to cell of origin, cellular differentiation, and-tjif;-lk-r;il:l,l'fr:*trt:ir:l+:iltrul,tqgi1rt:;1-t'il,ti lll6-p1g;.1g if:*.USl_*jilir-j. )Glsrs are most frequently diagnosed in older individuals, in whom they are most common in the stomach (60to 70 percent), small intestine (20 to 25 percent), colon/rectum (5 percent), and esophagus (


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Endosonographic findings in GISTs - GISTs are typically hypoechoic, homogeneous lesions withwell-defined margins, although they can rarely have irregular margins and ulcerations. Most GISTs originatefrom within the muscularis propria (fourth layer of the Gl tract); small lesions may originate from the muscularismucosa (second layer). lnfrequently, the tumors are inhomogeneous, which has been attributed to liquefactionnecrosis, connective tissue, and cystic and hyaline degeneration fif,.11)lSpecific endosonographic characteristics can be helpful for predicting benign versus malignant tumors. Largetumors with a heterogeneous echo texture (particularly those in the esophagus) are more likely to beleiomyosarcomas and leiomyoblastomas.One study demonstrated that endosonographically determined tumor size (diameter >4 cm), irregularextraluminal border, heterogeneity, echogenic foci, and cystic spaces greater than 4 mm were associated withmalignancy Iii]1. The sensitivity for detecting malignancy by preoperative EUS ranged from 80 to 100 percent.However, overall interobserver agreement for specific echo features was poor.Other endosonographic features suggestive of malignancy in another report that included 56 histologicallyproven tumors were irregular extraluminal margins, the presence of cystic spaces, and enlarged lymph nodes[i!]. The presence of at least one of these features had a sensitivity, specificity, and positive predictive valueof 91, 88, and 93 percent, respectively. The presence of two of these features had a positive predictive valueof 100 percent for malignant or borderline malignant tumors. The features most predictive of benign tumorswere regular margins, a tumor size s3 cm, and a homogeneous echo pattern. All lesions that demonstrated allthree of these features were benign.Histologic diagnosis - A definitive diagnosis of a GIST can only be made histologically. Endoscopic biopsyis unlikely to be helpful because the lesion is beyond the mucosa and thus the grasp of the forceps.Endosonography-guided fine needle aspiration (EUS-FNA) can target the lesion, but the diagnostic yield ofcytology is low.Some investigators have found that the addition of immunohistochemical characterization of specimensobtained by EUS-FI'.IA may improve ihe accuracy for diagnosis of malignant GISTs compared to EUS alone[:,iJ,?:i] lnonereport,theoverall accuracyof EUSwithfineneedleaspirationandhistologicstainingcomparedwith EUS alone for determining malignancy was 91 versus 78 percent [?l] The addition of Ki-67immunohistochemical staining increased the accuracy to 100 percent. Experience with EUS guided trucutbiOpSyiSlimited.(See ,'t. --. ::, ' ' 'ii':il f ;;' ., ,, ,,'t 'ili,' ;r'!' : ,r t'i.r' fiilniliand il*d***+li:i t':tt _+ td 'r"_ :* .tiilt liiitil*rj )Endoscopic resection using endoscopic submucosaldissection has been described in two series Ir',ir1].Successful endoscopic resection is reported, but remains controversial because of the risk of positive margins,tumor spillage, and perforation [I"i]. Surgical and endoscopic options for treatment of localized GISTs arediscussed in detail elsewhere, as is neoadjuvant rm*tlnih for large or borderline resectable tumors. (See "i.-,-;;:t

: and'A+,11i1i,',t '1i1* ili -r* l1v '1! i,ll ,;: }#-$lf+ r"+' *l *l' r';-:: ' ,*l ".)Observation versus resection - lt was previously thought that intramural mesenchymal tumors of thegastrointestinal tract smaller than 3 cm in maximal diameter had a low enough malignant potential to justifyobservation rather than resection. However, many of these tumors prove to be GlSTs, and the current thinkingis that all GISTs have the potential to behave in a malignant fashion, particularly if they are over '1 cm in size.(See"t'; lt::r+l+g;.i* ii' ;ll 11. , 'l' :rii: -',.'-'-r:1'l-.; :tr.: 1: #r:- r .'.''rr+tl *l.: .:.,1.:: :i. . .1.., lYl .i',". .): ,1'" ./

Stable submucosal lesions


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is advised if lesions become symptomatic, increase in size, or show sonographic malignant features. (See

Given that endoscopic appearance is almost never diagnostic, and that an EUS-guided fine-needle aspirationbiopsy may not be sufficient to distinguish between a GIST and a leiomyoma, larger tumors should besurgically resected. ln addition, these lesions should be resected because of an increased frequency ofcomplications and the difficulty in excluding malignancy preoperatively. (See 111".;,;;*1!r*qj,:,:f *t;.;,;;;; ;;;;,;;;;_ ;;;;;; ;",, ;..,'""," ;",;;; ro'. o,asnosins,eiomyomasand distinguishing them from other submucosal lesions including leiomyosarcomas (i-:ii":i.r":i* i). These lesionsarise from the fourth and rarely the second gastric wall layer. lmmunohistochemical studies on aspirates arepositive for smooth muscle actin and desmin and negative for c-kit (CD 117). (See llLpttllrl::*i*1,ii;,

4 a_: \' 11,..i..1 ' .:li ..::i.Y. ' :.' lYi

The epidemiology, clinical presentation, diagnosis, and surgical management of leiomyomas and

i#'t 'LIPOMA - Lipomas are benign intramucosal tumors of mature lipocytes that are commonly incidental findingson colonoscopy and endoscopy. They can be seen in any part of the gastrointestinaI tract, although they aremost common in the lower gastrointestinal tract. Lipomas are rarely symptomatic, but may result inhemorrhage, abdominal pain, and intestinal obstruction [i{]. They have no malignant potential.Endoscopic appearance - A lipoma commonly appears as an isolated solitary bulge located in the Gl tractwith normal overlying mucosa, a yellowish hue, and a smooth regular appearance. When probed, they are softand usually collapse to create an indentation known as the "pillow or cushion sign." Biopsy forceps may graspthe overlying mucosa to create the "tenting sign," by pulling the mucosa away from the submucosal growth.They are commonly small (less than 4 centimeters). ln one report of seven lesions (six of which were provento be a lipoma by EUS) a pillow sign on endoscopy had low sensitivity (40 percent) but high specificity (99percent) [1].Endosonographic findings - The five layers of the gastrointestinal tract should be easily identified using lowfrequency imaging. Lipomas are hyperechoic, homogeneous lesions with regular margins arising from thesubmucosa (third layer of the Gl tract) (i::r;lrrr"ii .5).Diagnosis and treatment - The diagnosis is almost always made by a characteristic endoscopic andendosonographic appearance. Biopsies usually show only normal mucosa. However, a tissue diagnosis maybe made by either fine needle aspiration or a technique called a "tunnel biopsy," which permits the acquisitionof lipocytes. The technique involves creation of a mucosal defect (using a needle knife incision, the biopsyforceps itself, or electrocoagulation) through which deeper biopsies can be obtained.Lipomas found incidentally should be followed expectantly. Endoscopic and endosonographic surveillance arenot necessary. Local excision is advised for symptomatic lipomas or when the lesion cannot be distinguishedfrom a malignant neoplasm (such as a liposarcoma). Endoscopic snare resection using polypectomy techniquehas been described l?i;*?.fi However, snare excision may be associated with perforation and hemorrhage, therisk of which is particularly increased for lesions greater than 2 cm in diameter [!l;i,ff;]. To reduce the risk,endoloop ligation prior to resection has been reported ffii-1. Endoloop ligation as stand-alone therapy (withoutresection) has also been reported [r'-r,] This approach was successful in a series of 10 patients with

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pedunculated submucosal tumors [tt:], six of whom had lipomas, with no reported complication. However, adrawback was the lack of a reliable surgical specimen for pathology. Patients were instructed to retrievespecimens from stool, but this was successful in only 60 percent of cases.CARCINOID TUMOR - Carcinoids are rare intramucosal tumors of endocrine cell origin with malignantpotential and are commonly asymptomatic. (See,,i.i.ri:ir:;ii *j.iirt;"frtij: ri,t+t 'l r.*r ;it.'il l. "r't,;.;is".) They arecommonly discovered incidentally during endoscopy, surgery, orautopsy. lnthe United States, carcinoids aremost commonly found in the appendix, rectum, and ileum, while in Japan they are often located in the stomach,rectum, and duodenum [?*,.1i1] Rare complications include hemorrhage, abdominal pain, intestinalobstruction,and endocrine syndromes due to secretion of functionally active substances (particularly when theyUln-m*i;:r"r*j-u]1*fuf:;:il lillLUt''1. )Endoscopic appearance - Carcinoids appear as small, round sessile or polypoid lesions with normaloverlying mucosa that rarely ulcerates ["f]1. They range in size from a few millimeters to a few centimeters.Gastric and ilealcarcinoids are commonly multiple, while those arising elsewhere are typically solitary (fit;,;litt-ll4)Endosonographic appearance - Carcinoids are homogeneous hypo- or isoechoic with regular margins.They arise from the mucosai lamina propria (second layer of the Gl tract) and can invade the submucosal layer(third layer) (1:i,r,i1,1ry *) [*:11]Diagnosis and treatment - The diagnosis and treatment of carcinoid tumors is discussed separately. (SeeGRANULAR CELL TUMOR - Granular cell tumors (GCT) are rare submucosal tumors of Schwann cell originthat are usually incidental findings on endoscopy and colonoscopy. They are most common in the oropharynx,skin, subcutaneous tissue, or breasts, but they can involve any part of the intestinal tract and the biliary tree[.i.i:.iii] Most intestinaltract lesions are found in the middle to lower third of the esophagus. lmmunostaining isusually positive for the S-100 protein. (See ,$g*l,i;-:ltriti:* tf *t-i:ii1rlfi:,i.i;.1;;*.)Granular cells tumors are considered benign, although malignant GCTs have been reported particularly whenlarger than 4 cm []lLl. These lesions are rarely associated with complications such as bleeding and lumenobstruction []/ :i[]Endoscopic appearance - Granular cell tumors usually appear as small isolated nodules or polyps locatedin the Gl tract with normal overlying mucosa and a yellowish hue. The majority are small (


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The cysts are typically discovered incidentally on endoscopy or radiologic imaging since they only uncommonlycause symptoms. Complications are rare but may include dysphagia, abdominal pain, bleeding, andpancreatitis when located near the ampulla of Vater hl:l!]. While they are believed to have a low malignantpotential, case reports have described malignant transformation ['i'i].Endoscopic appearance - Duplication cysts can appear as a bulge with normal overlying mucosa, or as adiverticulum that can vary in size from several millimeters to over 5 cm. They have a smooth and regularappearance without mucosal irregularities. They are most commonly diagnosed by CT scan or MRI since theyare infrequently seen endoluminallY (fii.i:.rit* j)Endosonographic findings - Duplication cysts are usually anechoic homogeneous lesions with regularmargins arising from the submucosal (third layer) or extrinsic to the gastrointestinalwall. Their walls can becharacterized by three- or five-layer structures. They also can contain septae, fluid levels, or echogenicmaterial conslsting of layering debris or mucin (piri;,;;,i. r,i). Occasionally, a cyst appears as a solid lesion on CTscan due to the higher density elicited from debris particles within a cyst. EUS is helpful in discriminating aduplication cyst from a solid mass.Diagnosis and treatment - The diagnosis can usually be made by the characteristic endoscopic andendosonographic appearance. EUS-guided FNA has been used to establish a diagnosis of an esophageal cyst[,lil], although this is not necessary and has a risk of causing infection ['ri;:r].Management of asymptomatic cysts is usually expectant, but resection has been recommended based upontheir potentialfor complications, including malignant transformation. However, prospective studies evaluatingthe natural history of duplication cysts are lacking. When symptomatic, duplication cysts can be treatedsurgically or endoscopically [",:]. Successfulendoscopic management of endoluminalcysts has beendescribed using fine needle aspiration, needle knife cystostomy, and, when small, snare excision [411]PANCREATIC REST - A pancreatic rest (also known as ectopic pancreas, aberrant pancreas, andheterotopic pancreas) refers to ectopic pancreatic tissue. These rare submucosal tumors most commonlyconsist of cystically dilated exocrine cells. Endocrine pancreatic tissue or a combination of exocrine andendocrine celltypes may also be seen ['1]il.Pancreatic rests are most frequently found in the distal stomach, duodenum, or proximaljejunum, but havealso been reported within a Meckel's diverticulum, the gallbladder, bile ducts, and the minor and major papillae[,.;:,:]. They are typically discovered incidentally during endoscopy, surgery, or autopsy. They are alsooccasionally found on CT scan. CT findings that may help differentiate pancreatic rests from other submucosallesions identified in one study included [:i#]:. A flat-ovoid shape (long diameter to short diameter ratio of greater than 1.4). Location of the lesion in the antrum, pylorus, or duodenum. An endoluminal growth pattern

. An ill-defined bordero Prominent enhancement of the overlying mucosaThe study found ihat the presence of at least two of the above findings had a sensitivity of '100 percent and aspecificity of 82.5 percent for diagnosing a pancreatic rest in the upper gastrointestinaltract []']1. Thespecificity increased to 100 percent if three of the above findings were present.However, while pancreatic rests may be detected with CT scan, if a submucosal lesion is noted on upperendoscopy, we suggest endoscopic ultrasound with endoscopic mucosal resection for further evaluation, assmall lesions may be missed on CT scan. (See lf;:rllt,;r,;ll illltq1li;1elr,: ilj lis*t,t* i!*.1lli::1';l!ll above.)Complications of pancreatic rests are rare, but may include ulceration, gastric outlet obstruction, and

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malignancy 1tt;,5'iEndoscopic appearance - A pancreatic rest appears as a submucosal nodule, usually with a centralumbilication that corresponds to a draining duct.Endosonographic findings - Pancreatic rests are hypoechoic or intermediate echogenic heterogeneouslesions with indistinct margins. They most commonly arise from the third or fourth layer, or a combination ofthe two layers of the Gl tract. Anechoic areas within the lesion correlate with ductal structures [..1r1].Diagnosis and treatment - The diagnosis can be made histologically from tissue obtained by biopsy forcepsor snare excision, although techniques to obtain deeper biopsies (using jumbo biopsy forceps, tunnel biopsy,endoscopic mucosal resection, or EUS-guided Ff,lA) may be required [a*]. The management strategy shouldbe guided by symptoms and suspicion for malignancy. Asymptomatic lesions can be followed expectantly.Endoscopic resection can be performed by standard snare, band ligation-assisted, or cap-assistedpolypectomy technique [fi:]. Surgical resection is preferred to endoscopic resection when the muscularispropria is involved.VARICES - Varices are blood vessels that distend as a result of a hypertensive portal or splenic venoussystem.Endoscopic appearance - Varices can be visualized in the esophagus, stomach, duodenum, and rectum.They typically appear as bluish enlarged vessels that are commonly tortuous and easily compressed withinstrumental pressure. Gastric varices may be confused with thickened folds or a submucosal lesion.Endosonographic findings - Varices are round anechoic structures arising from the lamina propria orsubmucosa Color Doppler can be used to detect blood flow, which will immediately confirm a vascularstructure, distinguishing a varix from other anechoic subepithelial lesions such as a cyst. A potential problemusing a dedicated echoendoscope to image small varices is the tendency to compress the varix by theinstrument or with inflation of the transducer balloon. This can be overcome by using a catheter ultrasoundprobe (miniprobe) inserted through the working channel of an endoscope. The miniprobe permits preciseendoscopic targeting of the varixwith a small diameter (about 3 mm) transducer that will not compress thevarix. However, miniprobes lack Doppler capability.Diagnosis and treatment - The diagnosis is based on the typical endoscopic and endosonographicUNCOMMON LESIONS - A variety of uncommon submucosal lesions can be seen endosonographically,including esophageal fibrovascular polyps, inflammatory fibroid polyps, pneumatosis cystoides, thickenedfolds, fibromas, Brunner's gland nodules, gastrointestinalwall hematomas, and esophageal hemangiomas.However, their endosonographic descriptions have been heterogeneous and scarce [::j;]il. Thus, use of EUS todiagnose these lesions should be made on an individual case basis.AMERICAN GASTROENTEROLOGICAL ASSOCIATION GUIDELINES - The American GastroenterologicalAssociation has issued a guideline on the management of gastric subepithelial masses [li-,,i], which can begeneral comments were included:

Endoscopy alone is not reliable for detecting the etiology of a subepithelial gastric mass.Cross-sectional imaging techniques such as transabdominal ultrasonography, computed tomography,and magnetic resonance imaging are adequate for detecting the presence of normal or abnormalstructures outside the gastric wall, but do not reliably distinguish between the various causes of masses

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arising within the gastric wall.. EUS is the most accurate imaging test for detecting the component of the gastric wall from which the

mass arises, information which, combined with the echogenicity of the mass, helps narrow thedifferential diag nosis.

. Patients with symptoms attributable to the mass should undergo endoscopic or surgical resection.

. Optimal management of incidentally detected, asymptomatic masses is unclear.SUMMARY AND RECO MME NDATIO NS

r Endoscopic ultrasonography (EUS) has provided a major breakthrough for characterizing subepitheliallesions. lt is complementary to other methods for diagnosis (and treatment) of subepithelial lesions(i:il**,itii:iu .j)

. The sonographic appearances of some lesions are highly suggestive of the diagnosis for some lesions,while for others EUS provides complementary information to other diagnostic modalities. Hypoechoiclesions in the third and fourth layers are most prone to misclassification.

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Topic 2666 Version 3.0

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ultrasound for the characterization of subepithelial 1esion... h@://www.uptodate.com/contents/endoscopic-ultrasound-for-the-cha...

GRAPHICSOriginating gastrointestinal tract layer of submucosal tumors

SMT/layer Mucosa MuscularismucosaRare

Common

submucosa I MuscularisI propflaGISTLipomaFibromaCarcinoidGranular celltumorPancreatic restDuplication cyst(intramural)

Most commonAlwaysAlwaysMost commonMost commonCommonAlways

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ultrasound for the charactetizationof subepithelial lesion... http:i/www.uptodate.com/contents/endoscopic-ultrasound-for-the-cha...Diagram of the five-tayer echo pattern of the normargastrointestinal wall

s.tr{S s{S{*a-}Sg.++a4frf\{i Uf; (}$A {su,Ferrtr*iat & m,u${rrlsris !-nil*+sil}

${JBMU.COSA

HT$$CULARIS FROFRTA

ADVHT*TIA {SEHfigA}Courtesy of Mary Lee Krinsky, DO and Kenneth Binmoeller, MD.

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ultrasorurd for the characterization of subepithelial lesion... http://www.uptodate.com/contents/endoscopic-ultrasor.nd-for-the-cha.

Duplication cyst"..':r:+*ax*p* * * **, *., * zz'l,*\\

JEndoscopic view of esophageal compression (arrow) due toduplication cYst. Couftesy of Mary Lee Krinsky, DO and KennethBinmoeller, MD.

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for the characterization of s ubep ithel i al 1 esion. http://www.uptodate.com/contents/endoscopic-ultrasound-for-the-cha...

Rates of progression-free survival for GISTs of stomach, smallintestine, and rectum grouped by mitotic rate and tumor sizex

Tumorsize, cmMitoticrate,HPFs

Percent ofttf isffi t&:r: iizttttff 'ti\\i::\:iv,.zutfi

Duodenum10091.766x

patients progression-free duringlong-term follow-upPrimary site

10

5/50> 5/50> 5/50> 5/50

Gastric10098.196.4B8

Jejunum/ileum10095.77648

Rectum10091.543x

510

100.8445I4

50.271510

464B29x

50l4x

Based on long-term follow-up studies on 1055 gastric,629 small intestinal, 144duodenal, and 111 rectal cancers, x Data are combined fortumors >5 cm.. Small number of cases. Adapted from: Miettinen, M, et al. Semin Diagn Pathol 2006; 23:70.

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Leiomyomas cop i c ultras ound for the charac terization of subep ithe I i al I e s i on. .. http://www.uptodate.com/contents/endoscopic-ultrasound-for-the-cha"..

Endosonographic view of a leiomyoma. Note that the lesion arisesfrom the muscularis propria (layer 4) and the hypoechoic,homogenous and well demarcated appearance. Couftesy of Mary LeeKrinsky, DO and Kenneth Binmoeller, MD.

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ultras ound for the characterization of subepithe l ial les i on... h@ : //www.uptodate. com/contents/endoscopic-ultrasound-for-the-cha...

Endosonographic view of a lipoma. Note the hyperechoic andhomogenous character, and originating from the submucosal layer.Courtesy of Mary Lee Krinsky, DO, and Kenneth Binmoeller, MD.

: r;'

f ::,

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ultras ound for the characterization of subepithel ial lesion... http://www.uptodate.com/contents/endoscopic-ultrasotutd-for-the-cha...

Duodenal carcinoid

Endoscopic view of a duodenal carcinoid (arrow). Carcinoids canappear as small, round sessile or polypoid lesions, They usuallyhave normal overlying mucosa and rarely ulcerate, Courtesy ofMary Lee Krinsky, DO and Kenneth Binmoeller, MD.

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s c op i c ultras ound for the charac ter ization o f sub epithe I i al le s i on.. . http://www.uptodate.com/contents/endoscopic-ulhasound-for-the-cha...

Carcinoid tumor

Endosonographic view of a duodenal carcinoid tumor (arrow),Carcinoids are hypo- or isoechoic with regular margins. Theyarise from the mucosa/lamina propria (second layer of the GItract) and can invade the submucosal layer. Couftesy of Mary LeeKrinsky, DO and Kenneth Binmoeller, MD.

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s cop i c ultras ound for the charac ter ization o f subep i the l ial 1 e s i on... htp ://www.uptodate. com/contents/endoscop i c-ultrasound- for-the- cha.

Granular cell tumor

A) Endoscopic image of a subepithelial 3,5 cm esophageal masslater shown to be a granular cell tumor. B) Endosonographic imagerevealing a hypoechoic mass arising from the submucosa. Courtesyof Mary Lee Krinsky, DO.

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Duplication cystfor the characterization of subepithelial lesion... http://www.uptodate.com/contents/endoscopic-ulfiasound-for-the-cha...

Endosonographic view of an esophageal duplication cyst.Duplication cysts are usually anechoic homogeneous lesions withregular margins arising from the submucosal (third layer) orextrinsic to the gastrointestinal wall. Courtesy of Mary Lee Krinsky, DOand Kenneth Binmoeller, MD.

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s copi c uhas ound for the charac terizrtion of subepithe lial les ion.. . h@ : //www.uptodate.com/contents/endoscopic-ulhasound-for-the-cha...

Stepwise evaluation of subepithelial tumorsr_.1I Str:p 1l E-nddl{o$y I?

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Reproduced with permission from: Eckardt, AJ, Wassef, W. Diagnosis of subepithelial tumors inthe GItract. Endoscopy, EUS, and histology: bronze, silver, and gold. Gastroint Endosc 2005;62:209. Copyright @ 2005 American Society of Gastrointestinal Endoscopy.

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Endoscopic Ultrasound for the Characterization of Subepithelial Lesio

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