Advertisement

Evaluation and Management of Mucosal and Submucosal Lesions in the Foregut

  • Dino Beduya
  • Gulshan ParasherEmail author
Chapter
  • 702 Downloads

Abstract

Submucosal or, more appropriately, subepithelial lesions are occasionally seen during upper gastrointestinal endoscopy. A minority turn out to be structures outside the gut wall but most are true intramural lesions. A majority of these lesions are found incidentally and are asymptomatic. Examples of these lesions include malignant or potentially malignant tumors such as gastrointestinal stromal tumors (GISTs) and carcinoids as well as benign lesions (lipoma, duplication cyst, heterotopic pancreas). Diagnosis often cannot be made by endoscopy alone. Endoscopic ultrasound helps narrow the differential diagnosis of a subepithelial lesion based on echogenicity and layer of origin. It also allows for deeper tissue acquisition and evaluation for candidacy for endoscopic resection. Management including endoscopic resection, surgical resection, or surveillance depends on the presence of symptoms, size, and histology if obtained.

Keywords

Submucosal tumor Subepithelial lesion Upper gastrointestinal endoscopy Endoscopic ultrasound Immunohistochemistry 

Supplementary material

Video 12.1

EUS of a gastric spindle cell neoplasm (MP4 116736 kb)

References

  1. 1.
    Hwang JH, Saunders MD, Rulyak SJ, Shaw S, Nietsch H, Kimmey MB. A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses. Gastrointest Endosc. 2005;62(2):202–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Rösch T, Kapfer B, Will U, Baronius W, Strobel M, Lorenz R, et al. Accuracy of endoscopic ultrasonography in upper gastrointestinal submucosal lesions: a prospective multicenter study. Scand J Gastroenterol. 2002;37(7):856–62.CrossRefPubMedGoogle Scholar
  3. 3.
    Oztas E, Oguz D, Kurt M, Etik DO, Cicek B, Kekilli M, et al. Endosonographic evaluation of patients with suspected extraluminal compression or subepithelial lesions during upper gastrointestinal endoscopy. Eur J Gastroenterol Hepatol. 2011;23(7):586–92.CrossRefPubMedGoogle Scholar
  4. 4.
    Ardengh JC, Vaiciunas S, Kemp R, Venco F, Lima-Filho ER, dos Santos JS. Upper endoscopy versus endosonography in differential diagnosis of gastrointestinal bulging. Arq Gastroenterol. 2011;48(4):236–41.CrossRefPubMedGoogle Scholar
  5. 5.
    Lim YJ, Son HJ, Lee J-S, Byun YH, Suh HJ, Rhee PL, et al. Clinical course of subepithelial lesions detected on upper gastrointestinal endoscopy. World J Gastroenterol. 2010;16(4):439–44.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Imaoka H, Sawaki A, Mizuno N, Takahashi K, Nakamura T, Tajika M, et al. Incidence and Clinical Course of Submucosal Lesions of the Stomach. Gastrointest Endosc. 2005;61(5):AB167.Google Scholar
  7. 7.
    Kushnir VM, Keswani RN, Hollander TG, Kohlmeier C, Mullady DK, Azar RR, et al. Compliance with surveillance recommendations for foregut subepithelial tumors is poor: results of a prospective multicenter study. Gastrointest Endosc. 2015;81(6):1378–84.CrossRefPubMedGoogle Scholar
  8. 8.
    Brand B, Oesterhelweg L, Binmoeller KF, Sriram PVJ, Bohnacker S, Seewald S, et al. Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract. Dig Liver Dis. 2002;34(4):290–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Seo SW, Hong SJ, Han JP, Choi MH, Song J-Y, Kim HK, et al. Accuracy of a scoring system for the differential diagnosis of common gastric subepithelial tumors based on endoscopic ultrasonography. J Dig Dis. 2013;14(12):647–53.CrossRefPubMedGoogle Scholar
  10. 10.
    Kim M-Y, Jung H-Y, Choi KD, Song HJ, Lee JH, Kim DH, et al. Natural history of asymptomatic small gastric subepithelial tumors. J Clin Gastroenterol. 2011;45(4):330–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Chen J-J, Lee H-C, Yeung C-Y, Chan W-T, Jiang C-B, Sheu J-C. Meta-analysis: the clinical features of the duodenal duplication cyst. J Pediatr Surg. 2010;45(8):1598–606.CrossRefPubMedGoogle Scholar
  12. 12.
    Boyce GA, Sivak MV, Rösch T, Classen M, Fleischer DE, Boyce HW, et al. Evaluation of submucosal upper gastrointestinal tract lesions by endoscopic ultrasound. Gastrointest Endosc. 1991;37(4):449–54.CrossRefPubMedGoogle Scholar
  13. 13.
    Yasuda K, Cho E, Nakajima M, Kawai K. Diagnosis of submucosal lesions of the upper gastrointestinal tract by endoscopic ultrasonography. Gastrointest Endosc. 1990;36(2 Suppl):S17–20.CrossRefPubMedGoogle Scholar
  14. 14.
    Zhang X-C, Li Q-L, Yu Y-F, Yao L-Q, Xu M-D, Zhang Y-Q, et al. Diagnostic efficacy of endoscopic ultrasound-guided needle sampling for upper gastrointestinal subepithelial lesions: a meta-analysis. Surg Endosc. 2015.Google Scholar
  15. 15.
    Karaca C, Turner BG, Cizginer S, Forcione D, Brugge W. Accuracy of EUS in the evaluation of small gastric subepithelial lesions. Gastrointest Endosc. 2010;71(4):722–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Nickl N, Gress F, McClave S, Fockens P, Chak A, Savides T, et al. Hypoechoic Intramural Tumor Study: Final Report. Gastrointest Endosc. 2002;55(5):AB98.Google Scholar
  17. 17.
    ASGE Technology Committee, Kantsevoy SV, Adler DG, Conway JD, Diehl DL, Farraye FA, et al. Endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc. 2008;68(1):11–8.Google Scholar
  18. 18.
    Varas MJ, Gornals JB, Pons C, Espinós JC, Abad R, Lorente FJ, et al. Usefulness of endoscopic ultrasonography (EUS) for selecting carcinoid tumors as candidates to endoscopic resection. Rev Esp Enferm Dig. 2010;102(10):577–82.CrossRefPubMedGoogle Scholar
  19. 19.
    Bhatt A, Abe S, Kumaravel A, Vargo J, Saito Y. Indications and Techniques for Endoscopic Submucosal Dissection. Am J Gastroenterol. 2015;110(6):784–91.CrossRefPubMedGoogle Scholar
  20. 20.
    Huang LY, Cui J, Lin SJ, Zhang B, Wu CR. Endoscopic full-thickness resection for gastric submucosal tumors arising from the muscularis propria layer. World J Gastroenterol. 2014;20(38):13981–6.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Li B, Liang T, Wei L, Ma M, Huang Y, Xu H, et al. Endoscopic interventional treatment for gastric schwannoma: a single-center experience. Int J Clin Exp Pathol. 2014;7(10):6616–25.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Taylor AJ, Stewart ET, Dodds WJ. Gastrointestinal lipomas: a radiologic and pathologic review. AJR Am J Roentgenol. 1990;155(6):1205–10.CrossRefPubMedGoogle Scholar
  23. 23.
    Regge D, Lo Bello G, Martincich L, Bianchi G, Cuomo G, Suriani R, et al. A case of bleeding gastric lipoma: US, CT and MR findings. Eur Radiol. 1999;9(2):256–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Okten RS, Kacar S, Kucukay F, Sasmaz N, Cumhur T. Gastric subepithelial masses: evaluation of multidetector CT (multiplanar reconstruction and virtual gastroscopy) versus endoscopic ultrasonography. Abdom Imaging. 2012;37(4):519–30.CrossRefPubMedGoogle Scholar
  25. 25.
    Hwang JH, Rulyak SD, Kimmey MB. American Gastroenterological Association Institute. American Gastroenterological Association Institute technical review on the management of gastric subepithelial masses. Gastroenterology. 2006;130(7):2217–28.CrossRefPubMedGoogle Scholar
  26. 26.
    Matsushita M, Hajiro K, Okazaki K, Takakuwa H. Gastric aberrant pancreas: EUS analysis in comparison with the histology. Gastrointest Endosc. 1999;49(4 Pt 1):493–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Karita M, Tada M. Endoscopic and histologic diagnosis of submucosal tumors of the gastrointestinal tract using combined strip biopsy and bite biopsy. Gastrointest Endosc. 1994;40(6):749–53.PubMedGoogle Scholar
  28. 28.
    Eckardt AJ, Wassef W. Diagnosis of subepithelial tumors in the GI tract. Endoscopy, EUS, and histology: bronze, silver, and gold standard? Gastrointest Endosc. 2005;62(2):209–12.CrossRefPubMedGoogle Scholar
  29. 29.
    Alberti D, Grazioli L, Orizio P, Matricardi L, Dughi S, Gheza L, et al. Asymptomatic giant gastric lipoma: what to do? Am J Gastroenterol. 1999;94(12):3634–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Lemer J. Haemorrhage from a polypoid lipoma of duodenum. Proc R Soc Med. 1971;64(4):395.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Nakamura S, Iida M, Suekane H, Matsui T, Yao T, Fujishima M. Endoscopic removal of gastric lipoma: diagnostic value of endoscopic ultrasonography. Am J Gastroenterol. 1991;86(5):619–21.PubMedGoogle Scholar
  32. 32.
    Lai EC, Tompkins RK. Heterotopic pancreas. Review of a 26 year experience. Am J Surg. 1986;151(6):697–700.CrossRefPubMedGoogle Scholar
  33. 33.
    Trifan A, Târcoveanu E, Danciu M, Huţanaşu C, Cojocariu C, Stanciu C. Gastric heterotopic pancreas: an unusual case and review of the literature. J Gastrointestin Liver Dis. 2012;21(2):209–12.PubMedGoogle Scholar
  34. 34.
    Faigel DO, Gopal D, Weeks DA, Corless C. Cap-assisted endoscopic submucosal resection of a pancreatic rest. Gastrointest Endosc. 2001;54(6):782–4.CrossRefPubMedGoogle Scholar
  35. 35.
    Bain AJ, Owens DJ, Tang RS, Peterson MR, Savides TJ. Pancreatic rest resection using band ligation snare polypectomy. Dig Dis Sci. 2011;56(6):1884–8.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Otani Y, Yoshida M, Saikawa Y, Wada N, Kubota T, Kumai K, et al. Discrimination between gastric ectopic pancreas and mesenchymal tumours, including GIST—from 12 years‘ surgical experience in one institute. Aliment Pharmacol Ther. 2006;2(1):292–6.CrossRefGoogle Scholar
  37. 37.
    Kim J-H, Lim JS, Lee YC, Hyung WJ, Lee JH, Kim M-J, et al. Endosonographic features of gastric ectopic pancreases distinguishable from mesenchymal tumors. J Gastroenterol Hepatol. 2008;23(8 Pt 2):e301–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Miettinen M, Lasota J. Gastrointestinal stromal tumors–definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch Int J Pathol. 2001;438(1):1–12.CrossRefGoogle Scholar
  39. 39.
    National Comprehensive Cancer Network. Soft Tissue Sarcoma (Version 1.2015) [Internet] [cited 6 Nov 2015]. Available from http://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf.
  40. 40.
    Miettinen M, Lasota J. Gastrointestinal stromal tumors. Gastroenterol Clin North Am. 2013;42(2):399–415.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Kim GH, Park DY, Kim S, Kim DH, Kim DH, Choi CW, et al. Is it possible to differentiate gastric GISTs from gastric leiomyomas by EUS? World J Gastroenterol. 2009;15(27):3376–81.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Kuhlgatz J, Sander B, Golas MM, Gunawan B, Schulze T, Schulten H-J, et al. Differential diagnosis of gastrointestinal leiomyoma versus gastrointestinal stromal tumor. Int J Colorectal Dis. 2006;21(1):84–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Stelow EB, Murad FM, Debol SM, Stanley MW, Bardales RH, Lai R, et al. A limited immunocytochemical panel for the distinction of subepithelial gastrointestinal mesenchymal neoplasms sampled by endoscopic ultrasound-guided fine-needle aspiration. Am J Clin Pathol. 2008;129(2):219–25.CrossRefPubMedGoogle Scholar
  44. 44.
    Kim MN, Kang SJ, Kim SG, Im JP, Kim JS, Jung HC, et al. Prediction of risk of malignancy of gastrointestinal stromal tumors by endoscopic ultrasonography. Gut Liver. 2013;7(6):642–7.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    de la Serna-Higuera C, Pérez-Miranda M, Díez-Redondo P, Gil-Simón P, Herranz T, Pérez-Martín E, et al. EUS-guided single-incision needle-knife biopsy: description and results of a new method for tissue sampling of subepithelial GI tumors (with video). Gastrointest Endosc. 2011;74(3):672–6.CrossRefPubMedGoogle Scholar
  46. 46.
    Yao JC, Hassan M, Phan A, Dagohoy C, Leary C, Mares JE, et al. One hundred years after “carcinoid”: epidemiology of and prognostic factors for neuroendocrine tumors in 35,825 cases in the United States. J Clin Oncol. 2008;26(18):3063–72.CrossRefPubMedGoogle Scholar
  47. 47.
    Godwin JD. Carcinoid tumors. An analysis of 2837 cases. Cancer. 1975;36(2):560–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Crowder BL, Judd ES, Dockerty MB. Gastrointestinal carcinoids and the carcinoid syndrome: clinical characteristics and therapy. CA Cancer J Clin. 1968;18(4):212–8.CrossRefPubMedGoogle Scholar
  49. 49.
    National Comprehensive Cancer Network. Neuroendocrine tumors (Version 1.2015) [Internet] [cited 9 Nov 2015]. Available from http://www.nccn.org/professionals/physician_gls/pdf/neuroendocrine.pdf.
  50. 50.
    Thomas RM, Baybick JH, Elsayed AM, Sobin LH. Gastric carcinoids. An immunohistochemical and clinicopathologic study of 104 patients. Cancer. 1994;73(8):2053–8.CrossRefPubMedGoogle Scholar
  51. 51.
    Yasuda K, Nakajima M, Yoshida S, Kiyota K, Kawai K. The diagnosis of submucosal tumors of the stomach by endoscopic ultrasonography. Gastrointest Endosc. 1989;35(1):10–5.CrossRefPubMedGoogle Scholar
  52. 52.
    Oberg K. Neuroendocrine gastrointestinal tumours. Ann Oncol. 1996;7(5):453–63.CrossRefPubMedGoogle Scholar
  53. 53.
    Saund MS, Al Natour RH, Sharma AM, Huang Q, Boosalis VA, Gold JS. Tumor size and depth predict rate of lymph node metastasis and utilization of lymph node sampling in surgically managed gastric carcinoids. Ann Surg Oncol. 2011;18(10):2826–32.Google Scholar
  54. 54.
    Daimaru Y, Kido H, Hashimoto H, Enjoji M. Benign schwannoma of the gastrointestinal tract: a clinicopathologic and immunohistochemical study. Hum Pathol. 1988;19(3):257–64.CrossRefPubMedGoogle Scholar
  55. 55.
    Naus PJ, Tio FO, Gross GW. Esophageal schwannoma: first report of successful management by endoscopic removal. Gastrointest Endosc. 2001;54(4):520–2.CrossRefPubMedGoogle Scholar
  56. 56.
    Voltaggio L, Murray R, Lasota J, Miettinen M. Gastric schwannoma: a clinicopathologic study of 51 cases and critical review of the literature. Hum Pathol. 2012;43(5):650–9.CrossRefPubMedGoogle Scholar
  57. 57.
    Takemura M, Yoshida K, Takii M, Sakurai K, Kanazawa A. Gastric malignant schwannoma presenting with upper gastrointestinal bleeding: a case report. J Med Case Rep. 2012;6:37.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Seno K, Itoh M, Endoh K, Joh T, Yokoyama Y, Takeuchi T, et al. Schwannoma of the duodenum causing melena. Intern Med Tokyo Jpn. 1994;33(10):621–3.CrossRefGoogle Scholar
  59. 59.
    Hong HS, Ha HK, Won HJ, Byun JH, Shin YM, Kim AY, et al. Gastric schwannomas: radiological features with endoscopic and pathological correlation. Clin Radiol. 2008;63(5):536–42.CrossRefPubMedGoogle Scholar
  60. 60.
    Vinhais SN, Cabrera RA, Nobre-Leitão C, Cunha TM. Schwannoma of the esophagus: computed tomography and endosonographic findings of a special type of schwannoma. Acta Radiol. 2004;45(7):718–20.CrossRefPubMedGoogle Scholar
  61. 61.
    Wang S, Zheng J, Ruan Z, Huang H, Yang Z, Zheng J. Long-term survival in a rare case of malignant esophageal schwannoma cured by surgical excision. Ann Thorac Surg. 2011;92(1):357–8.CrossRefPubMedGoogle Scholar
  62. 62.
    Voskuil JH, van Dijk MM, Wagenaar SS, van Vliet AC, Timmer R, van Hees PA. Occurrence of esophageal granular cell tumors in The Netherlands between 1988 and 1994. Dig Dis Sci. 2001;46(8):1610–4.CrossRefPubMedGoogle Scholar
  63. 63.
    Chen W, Zheng X, Jin L, Pan X, Ye M. Novel diagnosis and treatment of esophageal granular cell tumor: report of 14 cases and review of the literature. Ann Thorac Surg. 2014;97(1):296–302.CrossRefPubMedGoogle Scholar
  64. 64.
    Nie L, Xu G, Wu H, Huang Q, Sun Q, Fan X. Granular cell tumor of the esophagus: a clinicopathological study of 31 cases. Int J Clin Exp Pathol. 2014;7(7):4000–7.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Lack EE, Worsham GF, Callihan MD, Crawford BE, Klappenbach S, Rowden G, et al. Granular cell tumor: a clinicopathologic study of 110 patients. J Surg Oncol. 1980;13(4):301–16.CrossRefPubMedGoogle Scholar
  66. 66.
    An S, Jang J, Min K, Kim M-S, Park H, Park YS, et al. Granular cell tumor of the gastrointestinal tract: histologic and immunohistochemical analysis of 98 cases. Hum Pathol. 2015;46(6):813–9.CrossRefPubMedGoogle Scholar
  67. 67.
    Palazzo L, Landi B, Cellier C, Roseau G, Chaussade S, Couturier D, et al. Endosonographic features of esophageal granular cell tumors. Endoscopy. 1997;29(9):850–3.CrossRefPubMedGoogle Scholar
  68. 68.
    Eom JS, Kim GH, Song GA, Baek DH, Ryu KD, Lee KN, et al. Gastric duplication cyst removed by endoscopic submucosal dissection. Korean J Gastroenterol. 2011;58(6):346–9.CrossRefPubMedGoogle Scholar
  69. 69.
    Kim DH, Kim JS, Nam ES, Shin HS. Foregut duplication cyst of the stomach. Pathol Int. 2000;50(2):142–5.CrossRefPubMedGoogle Scholar
  70. 70.
    Scatizzi M, Calistri M, Feroci F, Girardi LR, Moraldi L, Rubio CA, et al. Gastric duplication cyst in an adult: case report. Vivo. 2005;19(6):975–8.Google Scholar
  71. 71.
    Geng Y-H, Wang C-X, Li J-T, Chen Q-Y, Li X-Z, Pan H. Gastric foregut cystic developmental malformation: case series and literature review. World J Gastroenterol. 2015;21(2):432–8.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Soares R, Gasparaitis A, Waxman I, Chennat J, Patti M. Esophageal duplication cyst. Dis Esophagus. 2011;24(3):E21–2.CrossRefPubMedGoogle Scholar
  73. 73.
    Agarwal A, Singla S, Bansal M, Ozdemir A. Infected esophageal duplication cyst masquerading as pericarditis. Intern Med Tokyo Jpn. 2012;51(6):689–90.CrossRefGoogle Scholar
  74. 74.
    Carbognin G, Guarise A, Biasiutti C, Pagnotta N, Procacci C. Duodenal duplication cyst identified with MRCP. Eur Radiol. 2000;10(8):1277–9.CrossRefPubMedGoogle Scholar
  75. 75.
    Lee YC, Kim YB, Kim JK, Shin SJ, Hwang JC, Lim SG, et al. Endoscopic treatment of a large gastric duplication cyst with hook-knife and snare (with video). Gastrointest Endosc. 2011;73(5):1039–40.CrossRefPubMedGoogle Scholar
  76. 76.
    Kuraoka K, Nakayama H, Kagawa T, Ichikawa T, Yasui W. Adenocarcinoma arising from a gastric duplication cyst with invasion to the stomach: a case report with literature review. J Clin Pathol. 2004;57(4):428–31.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Division of Gastroenterology and HepatologyUniversity of New Mexico School of MedicineAlbuquerqueUSA

Personalised recommendations