A Prospective Study on Endoscopic Ultrasonography Criteria to Guide Management in Upper GI Submucosal Tumors

Open access

A Prospective Study on Endoscopic Ultrasonography Criteria to Guide Management in Upper GI Submucosal Tumors

Endoscopic ultrasonography (EUS) can differentiate between impression and submucosal tumor (SMT) but it is not known whether EUS criteria can reliably guide management.

The aim of this prospective study was to assess an approach to recommend removal versus follow-up investigation based on clinical and EUS criteria, with respect to the predictive values to recognize malignancy versus benign lesions.

Material and methods. Over a 7-years time period, all patients referred for the EUS assessment of submucosal upper GI lesions were prospectively enrolled. Extraluminal impressions diagnosed with EUS were not further considered. If submucosal tumors seen with EUS were clearly symptomatic or one of several parameters (tumor size >3 cm, irregular margins, inhomogeneous echotexture and/or enlarged lymph nodes) were found, resection was recommended. The remaining cases were subjected to EUS follow-up.

Results. Of cases with 241 submucosal lesions, 65 had impressions and 176 had true submucosal lesions. Of the latter, 29 cases had non-neoplastic lesions (cysts, varices). In 59 cases, removal was deemed necessary due to clinical symptoms and suspicious findings in conventional endoscopy. These subjects underwent either surgical (originating layer, muscularis propria) or endoscopic resection (submucosal origin): 35.6% were malignant, more frequently in the surgical group (41.6% vs 20%). However, in 52.5% (n=31) of the 59 cases with no severe symptoms and true SMT, EUS suggested removal because of their additional criteria. Eighteen patients (12.2%) refused SMT removal and even regular EUS-based follow-up investigation. Clinical follow-up investigation by the family practitioner did not show frank malignancy in these cases (retransferal not registered). Follow-up investigation with EUS was recommended in 70 cases (mean follow-up period, 5 years; range, 1-7 years). The pattern remained unchanged in 67/70, and 2 of the 3 cases with changes underwent surgery for benign leiomyoma (patient refusal, n=1 with no change in the one-year follow-up MRI).

Conclusions. An EUS strategy based on defined characteristics to remove SMT with no severe symptoms and suspicious finding in the conventional endoscopy shows a good adherence to the recommended approach and has a reasonable positive predictive value for malignancy (88%). Clinical symptoms alone or with endoscopic finding are frequently too vague to decide for a reasonable SMT resection. The chosen EUS criteria are valuable to: 1) achieve the primary resection of all potentially malignant SMT and 2) avoid to overlook them as shown by the results of the follow-up investigations with no detected malignant lesion.

Brand B, Oesterhelweg L, Binmoeller KF et al.: Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract. Dig Liver Dis 2002; 34(4): 290-97.

Rosch T, Kapfer B, Will U et al.: Endoscopic ultrasonography. Accuracy of endoscopic ultrasonography in upper gastrointestinal submucosal lesions: a prospective multicenter study. Scand J Gastroenterol 2002; 37(7): 856-62.

Rosch T, Lorenz R, Dancygier H et al.: Endosonographic diagnosis of submucosal upper gastrointestinal tract tumors. Scand J Gastroenterol 1992; 27(1): 1-8.

Palazzo L, Landi B, Cellier C et al.: Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours. Gut 2000; 46(1): 88-92.

Adani GL, Marcello D, Sanna A et al.: Gastrointestinal stromal tumours: evaluation of biological and clinical current opinions. Chir Ital 2002; 54(2): 127-31.

Abdulkader I, Cameselle-Teijeiro J, Gude F et al.: Predictors of malignant behaviour in gastrointestinal stromal tumours: a clinicopathological study of 34 cases. Eur J Surg 2002; 168(5): 288-96.

Chak A, Canto MI, Rosch T et al.: Endosonographic differentiation of benign and malignant stromal cell tumors. Gastrointest Endosc 1997; 45(6): 468-73.

Tsai TL, Changchien CS, Hu TH et al.: Differentiation of benign and malignant gastric stromal tumors using endoscopic ultrasonography. Chang Gung Med J 2001; 24(3): 167-73.

Kinoshita K, Isozaki K, Tsutsui S et al.: Endoscopic ultrasonography-guided fine needle aspiration biopsy in follow-up patients with gastrointestinal stromal tumours. Eur J Gastroenterol Hepatol 2003; 15(11): 1189-93.

Soweid AM: Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumors. Gastrointest Endosc 2001; 53(7): 836-38.

Goldblum JR: Gastrointestinal stromal tumors. A review of characteristics morphologic, immunohistochemical, and molecular genetic features. Am J Clin Pathol 2002; 117 Suppl: S49-S61.

Trupiano JK, Stewart RE, Misick C et al.: Gastric stromal tumors: a clinicopathologic study of 77 cases with correlation of features with nonaggressive and aggressive clinical behaviors. Am J Surg Pathol 2002; 26(6): 705-14.

Fu K, Eloubeidi MA, Jhala NC et al.: Diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration biopsy-a potential pitfall. Ann Diagn Pathol 2002; 6(5): 294-301.

Okubo K, Yamao K, Nakamura T et al.: Endoscopic ultrasound-guided fine-needle aspiration biopsy for the diagnosis of gastrointestinal stromal tumors in the stomach. J Gastroenterol 2004; 39(8): 747-53.

Vander Noot MR 3rd, Eloubeidi MA, Chen VK et al.: Diagnosis of gastrointestinal tract lesions by endoscopic ultrasound-guided fine-needle aspiration biopsy. Cancer 2004; 102(3): 157-63.

Emile JF, Theou N, Tabone S et al.: Clinicopathologic, phenotypic, and genotypic characteristics of gastrointestinal mesenchymal tumors. Clin Gastroenterol Hepatol 2004; 2(7): 597-605.

Medeiros F, Corless CL, Duensing A et al.: KIT-negative gastrointestinal stromal tumors: proof of concept and therapeutic implications. Am J Surg Pathol 2004; 28(7): 889-94.

Muro-Cacho CA, Cantor AB, Morgan M: Prognostic factors in malignant gastrointestinal stromal tumors. Ann Clin Lab Sci 2000; 30(3): 239-47.

Polish Journal of Surgery

The Journal of Foundation of the Polish Journal of Surgery

Journal Information


CiteScore 2016: 0.29

SCImago Journal Rank (SJR) 2016: 0.166
Source Normalized Impact per Paper (SNIP) 2016: 0.207

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 106 106 11
PDF Downloads 33 33 3