Subepithelial lesions

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Endoscopic ultrasonography of subepithelial lesions.

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Subepithelial lesions

  1. 1. SUBMUCOSAL LESIONS EUS and EUS-FNA Hakan Senturk, MD Professor of Medicine, Chief of Gastroenterology Division Faculty of Medicine Bezmialem Vakif University
  2. 2. SUBEPITHELIAL LESION <ul><li>A luminal protruding lesion with normal mucosal covering </li></ul><ul><li>Prevalance in upper GI endoscopy: % 0.36 </li></ul><ul><ul><li>8-year data </li></ul></ul><ul><ul><li>54 out of 15104 endoscopy </li></ul></ul><ul><li>Intramural ? External compression ? </li></ul><ul><li>EUS </li></ul>Hedenbro JL Surg Endosc. 1991;5:20-3.
  3. 3. Duodenum Esophagus Stomach
  4. 4. Esophagus Mide Stomach Stomach
  5. 9. EUS <ul><li>1- Layer of origin </li></ul><ul><li>2- Size </li></ul><ul><li>3- Echotexture </li></ul><ul><li>4- Border </li></ul><ul><li>5- Internal structure </li></ul><ul><li>6- Vascularisation </li></ul><ul><li>7- Lymphadenopathy </li></ul>
  6. 12. 1 Irregular border , , echogenic foci, anechoic areas are in favour of malignancy 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
  7. 13. External compression-Esophagus <ul><li>Aortic arch </li></ul><ul><li>Vertebra </li></ul><ul><li>Aneurysm </li></ul><ul><li>Vascular abnormalities </li></ul><ul><li>Left atrial dilatation </li></ul><ul><li>Mediastinal LAP/tumor </li></ul><ul><li>Lung cancer </li></ul><ul><li>Lymphoma </li></ul>
  8. 14. External compression – Stomach <ul><li>Normal structures: </li></ul><ul><ul><li>Spleen : Gastric fundus or upper corpus </li></ul></ul><ul><ul><li>Gallbladder: Antrum </li></ul></ul><ul><ul><li>The images of temporary compression: Intestinal loops </li></ul></ul><ul><ul><li>Left lobe of liver </li></ul></ul><ul><ul><li>Vascular structures in splenic hilum </li></ul></ul><ul><ul><li>Tail of pancreas </li></ul></ul><ul><li>Abnormal structures: </li></ul><ul><ul><li>Pancreatic pseudocyst </li></ul></ul><ul><ul><li>Aortic aneurysm </li></ul></ul><ul><ul><li>Left atrial dilatation </li></ul></ul>
  9. 15. GIST <ul><li>2 (muscularis mucosa) or 4 (muscularis propria) </li></ul><ul><li>Well-defined border </li></ul><ul><li>Hypoechoic </li></ul><ul><li>Homogenous </li></ul><ul><li>Characteristics of malignant GIST: </li></ul><ul><li>Heterogenous structure </li></ul><ul><li>Hyperechoic foci and/or anechoic necrotic areas </li></ul><ul><li>Irregular extraluminal border </li></ul><ul><li>Associated LAP with malignant features </li></ul><ul><li>Large dimension (> 4 cm) </li></ul>
  10. 16. GIST-2 <ul><li>The most common intramural subepithelial lesion encountered during upper GI endoscopy </li></ul><ul><li>Originated from the interstitial cells of Cajal </li></ul><ul><li>Kit expression </li></ul><ul><li>C-kit ( CD117) positive </li></ul><ul><li>CD 34 positive </li></ul><ul><li>Desmin negative </li></ul><ul><li>10-30%; malignant </li></ul><ul><ul><li>Mitotic index and dimension of lesion </li></ul></ul><ul><ul><li>No lesion can be definitively labeled as benign </li></ul></ul>
  11. 18. Ectopic Pancreas <ul><li>2, 3 and/or 4 </li></ul><ul><li>Hypoechoic and/or mixt echogenicity and internal anechoic ductal structure </li></ul><ul><li>Antrum large curvature </li></ul><ul><li>Endoscopy: central umbilicus (draining duct) </li></ul>
  12. 20. Lipoma <ul><li>3 (submucosa) </li></ul><ul><li>Hyperechoic homogenous lesion with regular border </li></ul><ul><li>Endoscopy: Solitary, yellow coloured. Pillow sign (+) </li></ul><ul><li>Follow up is not recommended. </li></ul>
  13. 22. Neuroendocrine tumors <ul><li>2 or 3 </li></ul><ul><li>Homogenous, well-defined border, hypoechoic/isoechoic </li></ul><ul><li>Malignant potential is present </li></ul><ul><li>EMR </li></ul><ul><ul><li>< 2 cm </li></ul></ul><ul><ul><li>3rd layer </li></ul></ul><ul><ul><li>No associated LAP </li></ul></ul>
  14. 23. <ul><li>Concordance of EUS diagnosis with the final diagnosis at subepithelial lesions </li></ul><ul><li>  </li></ul><ul><li>Erkan C a g lar 1 , Billur Canbakan 1 , Rana S ent u rk 2 , I brahim Hatemi 1 , Hakan S ent u rk 1 </li></ul><ul><li>Istanbul University, Cerrahpaşa medical Faculty, Division of Gastroenterology </li></ul><ul><li>Istanbul Gastroenterology Center, Radiology </li></ul>
  15. 24. Method <ul><li>Retrospective </li></ul><ul><li>Between 2006 – 2010 </li></ul><ul><li>Submucosal lesions </li></ul><ul><li>The analysis of EUS ve EUS-FNA findings </li></ul><ul><li>Comparison with final diagnosis </li></ul><ul><li>Final diagnosis </li></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Clinical and endoscopic follow up </li></ul></ul>
  16. 25. Results <ul><li>127 submucosal lesion </li></ul><ul><li>73 pt had the final diagnosis </li></ul><ul><li>Average age ± SD : 51.55 ± 13.37 </li></ul><ul><li>60% male </li></ul><ul><li>68 pt had FNA </li></ul><ul><li>12 pt had inadequate material for diagnosis (17.6%) </li></ul>
  17. 26. 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 <ul><li>5 </li></ul>8 11
  18. 27. 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%)
  19. 28. 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
  20. 29. 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. Melanoma Langerhans c. Histiocytosis Inadequate 12 68 68
  21. 30. <ul><li>23 GIST diagnosis (surgical material) </li></ul><ul><li>EUS-FNA; c-kit positivity: 7/20 positive (35%) </li></ul><ul><li>EUS/EUS-FNA; accuracy of GIST diagnosis (90.4%) </li></ul><ul><li>EUS; accordance with final diagnosis: 76.7% </li></ul><ul><li>EUS-FNA; accordance with final diagnosis: 98% (in case of excluding inadequate material) </li></ul><ul><li>EUS-FNA guided differential diagnosis between benign and malignant lesions: spesificity:100% sensitivity:86.8% </li></ul>

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