Diagnosis of gastrointestinal tract lesions by endoscopic ultrasound-guided fine-needle aspiration biopsy

English version of Japanese Clinical Practice Guidelines 2022 for gastrointestinal stromal tumor (GIST) issued by the Japan Society of Clinical Oncology

The Japan Society of Clinical Oncology Clinical Practice Guidelines 2022 for gastrointestinal stromal tumor (GIST) have been published in accordance with the Minds Manual for Guideline Development 2014 and 2017. A specialized team independent of the working group for the revision performed a systematic review. Since GIST is a rare type of tumor, clinical evidence is not sufficient to answer several clinical and background questions. Thus, in these guidelines, we considered that consensus among the experts who manage GIST, the balance between benefits and harms, patients' wishes, medical economic perspective, etc. are important considerations in addition to the evidence. Although guidelines for the treatment of GIST have also been published by the National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO), there are some differences between the treatments proposed in those guidelines and the treatments in the present guidelines because of the differences in health insurance systems among countries.

Analysis of Thoracoscopic Enucleation Combined with Esophagoscopy in the Prone Position for Esophageal Submucosal Tumor

Background: Esophageal submucosal tumors (SMTs) are rare, occurring in less than 1% of esophageal neoplasms. For surgical treatment of esophageal SMTs, enucleation is usually the procedure of choice for benign tumors. This study aimed at evaluating the surgical technique and outcomes of thoracoscopic enucleation with esophagoscopy for esophageal SMTs. Methods: Patients with esophageal SMTs who underwent thoracoscopic enucleation between 2015 and 2022 were retrospectively investigated. Surgery was performed with the patient in the prone position. First, an esophagoscope was inserted, and a sodium hyaluronate solution with indigo carmine dye was injected into the submucosal layer just below the tumor. Next, under thoracoscopy, the tumor was exposed through a thoracoscopic incision and dissection of the muscularis propria and adventitia was performed at the tumor site. The colored layer resulting from the previously injected dye was identified, and tumor enucleation was performed under guidance of the dye so as not to damage the mucosa or pseudocapsule. Results: In total, 5 surgeries were performed. The mean operative time was 122.6 minutes (range 84-168 minutes), mean blood loss was 21.1 mL (range 0-80 mL), and mean postoperative hospital stay was 8 days (range 7-10 days). There were no postoperative complications. Pathological diagnosis revealed 2 cases of gastrointestinal stromal tumors, 2 cases of schwannoma, and 1 case of leiomyoma. Conclusions: We believe that this technique is a useful and safe method of performing thoracoscopic enucleation of esophageal SMTs because the injected dye provides an indicator of the resection line during enucleation.

Molecular Advances in the Treatment of Advanced Gastrointestinal Stromal Tumor

Most gastrointestinal stromal tumors (GIST) are driven by activating mutations in Proto-oncogene c-KIT (KIT) or PDGFRA receptor tyrosine kinases (RTK). The emergence of effective therapies targeting these mutations has revolutionized the management of advanced GIST. However, following initiation of first-line imatinib, a tyrosine kinase inhibitor (TKI), nearly all patients will develop resistance within 2 years through the emergence of secondary resistance mutations in KIT, typically in the Adenosine Triphosphate (ATP)-binding site or activation loop of the kinase domain. Moreover, some patients have de novo resistance to imatinib, such as those with mutations in PDGFRA exon 18 or those without KIT or PDGFRA mutation. To target resistance, research efforts are primarily focused on developing next-generation inhibitors of KIT and/or PDGFRA, which can inhibit alternate receptor conformations or unique mutations, and compounds that impact complimentary pathogenic processes or epigenetic events. Here, we review the literature on the medical management of high-risk localized and advanced GIST and provide an update on clinical trial approaches to this disease.

Natural History of Asymptomatic Esophageal Subepithelial Tumors of 30 mm or Less in Size

BACKGROUND

No definite guidelines for the management of small esophageal subepithelial tumors (SETs) have been established, because there are limited data and studies on their natural history. We aimed to assess the natural history and propose optimal management strategies for small esophageal SETs.

METHODS

Patients diagnosed as esophageal SETs ≤ 30 mm in size between 2003 and 2017 using endoscopic ultrasound (EUS) with a minimal follow-up of 3 months were enrolled, and their esophagogastroduodenoscopy (EGD) and EUS were retrospectively reviewed.

RESULTS

Of 275 esophageal SETs in 262 patients, the initial size was < 10 mm, 10-20 mm, and 20-30 mm in 104 (37.8%), 105 (38.2%), and 66 (24.0%) lesions, respectively. Only 22 (8.0%) SETs showed significant changes in size and/or echogenicity and/or morphology at a median of 40 months (range, 4-120 months). Tissues of 6 SETs showing interval changes were obtained using EUS-guided fine needle aspiration biopsy; 1 was identified as a gastrointestinal stromal tumor (GIST) and was surgically resected, while the other 5 were leiomyomas and were regularly observed. Eight SETs showing interval changes were resected surgically or endoscopically without pathological confirmation; 1 was a GIST, 2 were granular cell tumors, and the other 5 were leiomyomas.

CONCLUSION

Regular follow-up with EGD or EUS may be necessary for esophageal SETs ≤ 30 mm in size considering that small portion of them has a possibility of malignant potential. When esophageal SETs ≤ 30 mm show significant interval changes, pathological confirmation may precede treatment to avoid unnecessary resection.

Needle tract seeding and abdominal recurrence following pre-treatment biopsy of gastrointestinal stromal tumors (GIST): results of a systematic review

BACKGROUND

Gastrointestinal stromal tumors (GIST) are rare abdominal tumors. Pretreatment biopsies may be used to diagnose a GIST and enable tailored treatment. Some experts are skeptical about biopsies because they fear tumor cell seeding. The objective of this study was to determine if pretreatment biopsy is associated with increased tumor recurrence.

METHODS

We performed a systematic literature search and included studies assessing the oncological outcome of GIST patients who underwent a pre-treatment core needle biopsy or fine needle aspiration. We assessed methodological quality with the Newcastle-Ottawa-Scale for non-randomized studies. This review was registered in the PROSPERO database (CRD42021170290).

RESULTS

Three non-randomized studies and eight case reports comprising 350 patients were eligible for inclusion. No prospective study designed to answer the review question was found. One case of needle tract seeding after percutaneous core needle biopsy of GIST was reported. None of the studies reported an increased rate of abdominal recurrence in patients with pretreatment biopsy.

CONCLUSIONS

The existing evidence does not indicate a relevant risk of needle tract seeding or abdominal recurrence after pre-treatment biopsy of GIST. Biopsy can safely be done to differentiate GIST from other tumors and to select the most appropriate treatment.

Endoscopic ultrasound-guided fine-needle biopsy in patients with unexplained diffuse gastrointestinal wall thickening

Background and study aims  Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) is recommended after non-diagnostic biopsy in gastrointestinal wall thickening, although the performance of currently available FNB needles in this setting is unknown. We aimed to assess the diagnostic accuracy and safety of EUS-FNB and to evaluate the "T" wall staging in malignant pathology. Patients and methods  This was a single center retrospective study that included all consecutive patients undergoing EUS-FNB for diffuse gastrointestinal wall thickening with at least one previous negative conventional endoscopic biopsy between January 2016 and November 2019. EUS-FNB was performed using linear-array echoendoscopes with slow-pull/fanning technique. Tissue acquisition was done with 19- or 22-gauge biopsy needles. Samples were included in formalin without rapid on-site evaluation and submitted for histopathological processing. The final diagnosis was based on conclusive histology or absence of evidence of disease progression after follow-up at least 6 months. Results  Twenty-nine patients (21 men), with a median age of 68 (IQR: 56-77), were included. EUS-FNB was technically feasible and the sample quality was adequate for full histological assessment in all patients (100 %). Sensitivity, specificity, positive and negative predictive values, and overall accuracy for diagnosis of malignancy were 95.5 %, 100 %, 100 %, 83.3 %, and 96.3 %, respectively. In patients with malignant disease, the samples obtained allowed detection of signs of deep layer infiltration ("histological staging") in 17 of 21 cases (81 %). No adverse events were noted. Conclusions  The EUS-FNB technique demonstrated excellent diagnostic performance and safety in the study of unexplained diffuse gastrointestinal wall thickening. Histological staging was obtained in a high percentage of samples.

Diagnostic yields of endoscopic ultrasound-guided fine-needle tissue acquisition according to the gastric location

The diagnostic accuracy of endoscopic ultrasound-guided fine-needle tissue acquisition (EUS-FNTA) according to the gastric location of subepithelial tumors (SETs) has not been well established. We aimed to evaluate the efficacy of EUS-FNTA for the diagnosis of gastric SETs according to tumor location.Thirty-three patients diagnosed with gastric SETs via EUS-FNTA from January 2016 to May 2018 were analyzed retrospectively. Patient demographics, diagnostic yields, and complications were evaluated.Nineteen patients (57.6%) were female, with a mean age of 57.7 years. Endoscopic ultrasound revealed a mean longitudinal diameter of 25.6 mm. The most common location of SETs was in the gastric body (n = 18, 54.5%), followed by cardia and fundus (n = 10, 30.3%), and antrum (n = 5, 15.2%). A 20-gauge biopsy needle was most frequently used (90.9%). The diagnostic yield was obtained in 23 patients (69.7%). The most common diagnosis was gastrointestinal stromal tumor (73.9%), followed by leiomyoma (17.4%). The diagnostic yield of SETs in gastric antrum (0/5, 0%) was significantly lower than that in the gastric body and cardia (23/28, 82.1%, P = .001). A case of immediate bleeding after EUS-FNTA occurred in 1 patient (3.0%) who recovered uneventfully. According to related literature, the overall diagnostic yield of SETs in gastric antrum was significantly lower than that in the gastric body, fundus, and cardia (29.7% vs 71.4%, P < .001, n = 191).EUS-FNTA is ineffective in the diagnosis of SETs in the gastric antrum. Although EUS-FNTA is an advanced diagnostic tool for gastric SETs, it is essential to develop more effective methods for the diagnosis of antral SETs.

Using naso- and oro-intestinal catheters in physiological research for intestinal delivery and sampling in vivo: practical and technical aspects to be considered

Intestinal catheters have been used for decades in human nutrition, physiology, pharmacokinetics, and gut microbiome research, facilitating the delivery of compounds directly into the intestinal lumen or the aspiration of intestinal fluids in human subjects. Such research provides insights about (local) dynamic metabolic and other intestinal luminal processes, but working with catheters might pose challenges to biomedical researchers and clinicians. Here, we provide an overview of practical and technical aspects of applying naso- and oro-intestinal catheters for delivery of compounds and sampling luminal fluids from the jejunum, ileum, and colon in vivo. The recent literature was extensively reviewed, and combined with experiences and insights we gained through our own clinical trials. We included 60 studies that involved a total of 720 healthy subjects and 42 patients. Most of the studies investigated multiple intestinal regions (24 studies), followed by studies investigating only the jejunum (21 studies), ileum (13 studies), or colon (2 studies). The ileum and colon used to be relatively inaccessible regions in vivo. Custom-made state-of-the-art catheters are available with numerous options for the design, such as multiple lumina, side holes, and inflatable balloons for catheter progression or isolation of intestinal segments. These allow for multiple controlled sampling and compound delivery options in different intestinal regions. Intestinal catheters were often used for delivery (23 studies), sampling (10 studies), or both (27 studies). Sampling speed decreased with increasing distance from the sampling syringe to the specific intestinal segment (i.e., speed highest in duodenum, lowest in ileum/colon). No serious adverse events were reported in the literature, and a dropout rate of around 10% was found for these types of studies. This review is highly relevant for researchers who are active in various research areas and want to expand their research with the use of intestinal catheters in humans in vivo.

Endoscopic Ultrasound-guided Fine Needle Aspiration for the Diagnosis of Duodenal Stenosis Due to Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) initially presents with hematuria and hydronephrosis. We report a case of UTUC presenting with initial findings of duodenal stenosis before the appearance of hydronephrosis. A 59-year-old man presented with upper abdominal symptoms on his initial visit. Esophagogastroduodenoscopy (EGD) revealed circumferential stenosis at the descending part of the duodenum. However, the underlying cause of duodenal stenosis was unknown as repeated histopathological examinations of endoscopic biopsy specimens showed no specific findings. We then performed endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of the thickened duodenal wall, and successfully diagnosed duodenal metastasis of UTUC. EUS-FNA is an effective diagnostic method in cases in which the cause of duodenal stenosis is unknown.

Endoscopic ultrasound-guided fine needle aspiration cytology diagnosis of upper gastrointestinal tract mesenchymal tumors: Impact of rapid onsite evaluation and correlation with histopathologic follow-up

BACKGROUND

Mesenchymal tumors (MTs) of upper gastrointestinal tract (UGIT) can show morphologic overlap thus posing a diagnostic challenge. This study evaluated the role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) cytology in the diagnosis of UGIT-MTs and impact of rapid onsite evaluation (ROSE).

METHODS

We retrospectively search our electronic database between January 2001 and August 2019 for cases that underwent EUS-FNA for a submucosal/or intramural upper GI tract mass forming lesions. Data pertinent to immunostain expression in UGIT-MTs was also collected.

RESULTS

We identified 139 cases, of which 72 cases had subsequent surgical resection. The cytologic diagnoses included nondiagnostic, negative, atypical, suspicious for neoplasm and positive for neoplasm (PFN) in 11, 7, 11, 10, and 100 cases, respectively. Diagnosis of PFN was rendered in 51 of 69 cases with ROSE (74%) and in 49 of 70 cases without ROSE (70%). However, the cases with ROSE had a higher percentage of cases being precisely classified than without ROSE (86% vs 61%, P < .05). On comparison of cytologic cases with cell block (CB) (n = 118) and without CB (n = 21), ROSE was performed in 67 (57%) and 2 (10%) cases, respectively (P < .01). All the cases with diagnosis of PFN were confirmed on subsequent surgical resection.

CONCLUSION

EUS-FNA has a diagnostic yield of 72% for UGIT-MTs. ROSE could improve diagnostic performance by further classifying MTs, probably via securing adequate lesional material for cell block for additional ancillary testing and precise diagnosis.

Mesenchymal neoplasms of the tubular gut and adjacent structures: experience with EUS-guided fine-needle aspiration cytopathology

INTRODUCTION

Unlike epithelial malignancies, mesenchymal neoplasms arising within the tubular gut are less often encountered in endoscopic ultrasound-guided (EUS) fine-needle aspiration biopsies (FNABs). Nonetheless, preoperative diagnosis of such neoplasms has important therapeutic and prognostic value. We report our experience with this category of neoplasms from the past decade.

MATERIALS AND METHODS

We performed a 10-year retrospective search at our respective institutions to identify EUS-guided FNAB cases of mesenchymal neoplasms arising from the tubular gut wall and closely adjacent structures. Cytopathologic diagnoses were compared to corresponding surgical pathology (SP) when available. Cases with either no confirmatory cell block (CB) immunohistochemical (IHC) staining, or no SP were excluded.

RESULTS

Two-hundred eighty-two cases (M:F = 1:1; age range: 25-94 years, mean age = 60 years) of EUS-guided FNAB from the tubular gut met our criteria. Onsite adequacy was performed on nearly all cases. Case numbers: 209 gastrointestinal stromal tumors (GIST), 58 smooth muscle neoplasms, and 15 miscellaneous neoplasms. Of these, 188 (67%) had SP follow-up. We found that 258 (91%) aspirates had a correct specific diagnosis, 3 (1%) were nondiagnostic, 18 (6%) had indeterminate diagnoses, and 3 (1%) had incorrect diagnoses (2 leiomyosarcomas mistaken as leiomyoma, and 1 fibrosclerotic lesion mistaken as inflammatory pseudotumor). Of 94 cases with no SP, all had a specific cytologic diagnosis based on confirmatory IHC staining from the CB including 61 GISTs, 29 smooth muscle neoplasms, and 4 miscellaneous tumors.

CONCLUSION

This study endorses the clinical utility of EUS-guided FNAB in the diagnosis of tubular gut mesenchymal neoplasms. A definitive and accurate diagnosis is possible in over 90% of cases, chiefly when cytomorphology is coupled with optimal cellularity and IHC from a concurrent CB. EUS-guided FNAB diagnosis of mesenchymal tubular gut neoplasms may play an important role in determining neoadjuvant therapy as targeted therapy evolves.

Endoscopic ultrasound-guided fine-needle aspiration cytology in the diagnosis of the gastrointestinal stromal tumor of the stomach

BACKGROUND

This study aims to evaluate the usefulness of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) in the diagnosis of the gastric gastrointestinal stromal tumor (GIST).

METHODS

We retrospectively investigated the efficacy and accuracy of EUS-FNAC in the diagnosis of gastric GIST. Cytological smears and cytoblock sections including immunohistochemistry and mutational studies from patients diagnosed as gastric GISTs were retrieved.

RESULTS

Thirty patients (mean age 68.8 years, range 32-88 years, Male:Female 1:1.7) were diagnosed by cytological and cytoblock study to have GIST. The size of tumors ranged from 1.6 to 25 cm (mean 6.0 cm). 7 (23%) cases were incidentally discovered. Location was: gastric body 13 (43.3%), fundus 8 (26.7%), antrum 7 (23.3%), cardia 2 (6.7%). The study of removed tumors was correlated with the cytological findings. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 75%, 100%, 100%, 46%, and 96%. There were no false-positive cases. The preoperative risk assessment of 27 cases with cytoblock were: none 3 (11.1%), very low 8 (29.6%), low 12 (44.4%), high 3 (11.1%), insufficient clinical data 1 (3.7%). The follow-up varied from 2 to 120 months (mean 46.7 months). Only 1 patient of the high-risk group died. The most frequent mutations found were those of c-KIT in exon 11.

CONCLUSIONS

Pathological diagnosis was based on a combination of cytological, histopathological, and immunohistochemical features. EUS-FNAC is a reliable, accurate, and safe method for the diagnosis of GIST. The cytoblock allows tumor risk classification and mutational study of the cases.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy in gastrointestinal subepithelial lesions: Feasibility study

BACKGROUND AND AIM

Needle-based confocal laser endomicroscopy (nCLE) allows for real-time optical biopsies during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Little is known about nCLE imaging of gastrointestinal subepithelial lesions (GI-SEL); therefore, we determined its feasibility.

METHODS

We carried out EUS, nCLE, and finally FNA in 25 patients with GI-SEL between November 2015 and December 2018. We retrospectively compared nCLE findings with pathological findings of EUS-FNA or surgical specimens. For concordance analysis, two endoscopists independently validated representative nCLE images 5 months or more after examinations.

RESULTS

Adequate sample acquisition rate of EUS-FNA was 67% per needle pass and 96% per patient. EUS-FNA was diagnostic in 80% (20/25), suspicious in 4% (1/25), and nondiagnostic in 16% (4/25). nCLE image acquisition rate was 100% and its concordance rate with final pathology was 88% (22/25), which was not significantly different from diagnostic and suspicious EUS-FNA. nCLE could differentiate GI stromal tumors (GISTs) from leiomyoma, in that GISTs were characterized by contrast-enhanced densely populated spindle cell tumors with unenhanced rod-shaped nuclei in 93% of 14 patients, whereas leiomyomas were characterized by narrower spindle cell tumors with fewer and smaller unenhanced nuclei in 100% of three patients. In rectal metastasis from lung adenocarcinoma, some pleomorphic dark nests were observed. At concordance analysis between the two endoscopists' validation results, κ value was 0.560 (P < 0.001), indicating moderate agreement. There were no adverse events associated with nCLE and EUS-FNA.

CONCLUSION

Needle-based confocal laser endomicroscopy can be safe and useful for on-site detection of abnormalities of GI-SEL (UMIN 000013857).

Clinical outcomes of per-oral endoscopic tumor resection for submucosal tumors in the esophagus and gastric cardia

OBJECTIVES

The clinical success of per-oral endoscopic myotomy (POEM) has led to the development of a new field of 'submucosal endoscopy'. This study aimed to evaluate the safety, efficacy, and limitations of per-oral endoscopic tumor resection (POET) in the management of submucosal tumors (SMTs) in the esophagus and the gastric cardia.

METHODS

POET was performed in 47 patients from January 2011 to December 2017. The indication for POET was SMTs ≤ 30 mm in minor axis diameter. Patient and tumor characteristics (age, gender, tumor location, size, and histology), operative and clinical results of POET (procedure time and completion rate, en bloc resection rate, length of hospitalization, adverse events and tumor recurrence) were analyzed retrospectively.

RESULTS

POET was successfully completed in 43 patients (91.5%) without any major adverse events (Clavien-Dindo IIIb-IV). Four patients required conversion to an open surgical procedure due to suboptimal visualization during POET. Four patients underwent piecemeal resection of their SMTs including GISTs. Median follow-up was 44 months (10-96 months), during that time, there were no incidences of tumor recurrence. Tumors that had a minor axis diameter > 30 mm or a tumor mass index (TMI) [major axis diameter (mm) × minor axis diameter (mm)] >1000 had a high likelihood of being converted to surgical resection.

CONCLUSIONS

POET is a safe and effective treatment for SMTs. However, in patients where the minor axis diameter is > 30 mm or the TMI > 1000, surgical excision should be considered. Furthermore, application of POET for SMTs with malignant potential should be carefully considered to ensure optimal oncologic outcomes.

Gastric Duplication Cyst With Occult GIST Component

A 37-year-old man underwent screening examinations, and a pale-colored submucosal tumor was detected on gastric cardia. Endosonography showed a 15-mm cyst with hypoechoic nodules in the muscularis propria, and endoscopic ultrasound-guided fine-needle aspiration obtained mucinous fluid with atypical spindle cells positive for c-kit, indicating a gastrointestinal stromal tumor. Surgical resection was recommended, but he initially agreed to surveillance. After becoming larger for 8 years, partial gastrectomy was performed for the 22 × 22 × 15-mm capsulized lesion. Surprisingly, its histology was gastric duplication cyst without gastrointestinal stromal tumor. Gastric duplication cyst is a rare entity with the possibility of malignant complications, but careful assessment of endoscopic ultrasound-guided fine-needle aspiration might also be required.

Isolated colonic neurofibroma in the setting of Lynch syndrome: A case report and review of literature

BACKGROUND

Gastrointestinal neurofibromas are commonly found in patients diagnosed with neurofibromatosis type 1. However, isolated gastrointestinal neurofibromas are a rare entity and only fourteen cases of isolated colorectal neurofibromas have been documented in literature. Isolated gastrointestinal neurofibromas have not been associated with Lynch syndrome (LS). Patients with LS are at an increased risk of colorectal cancer, and are recommended to undergo screening colonoscopy.

CASE SUMMARY

A 33-year-old healthy female with a family history of LS was found to have unresectable polyp in the ascending colon on screening colonoscopy suspicious for malignancy. The patient was asymptomatic and had no stigmata of neurofibromatosis. A staging workup for colorectal cancer revealed no evidence of metastatic disease. A discussion with the patient resulted in the decision to undergo a segmental resection with ongoing surveillance. The patient underwent a laparoscopic right hemicolectomy. Histopathology was consistent with a gastrointestinal neurofibroma. Post-operatively, the patient recovered well. She will not require further treatment with regards to her colonic neurofibroma, but will continue to follow-up for ongoing surveillance of her LS.

CONCLUSION

We present the first case of an isolated colonic neurofibroma in a patient with LS. This case explores considerations for the management of isolated gastrointestinal neurofibromas given the lack of guidelines in literature.

Ultrasound-guided fine-needle aspiration of a rectal submucosal nodule

Although endoscopic biopsy of a rectal submucosal nodule may be nondiagnostic, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can be an important tool to make diagnosis. We report a case of a female patient who had an EUS-FNA of a submucosal nodule after a nondiagnostic rectal biopsy. The original diagnosis was erroneously rendered as concerning for necrotic neoplasm. The correct diagnosis of Solesta-induced foreign body reaction was made on reviewing the slides once the history of remote Solesta injection was made available. This case illustrates the pathognomonic features of Solesta-induced rectal nodule and underscores the importance of detailed history as well as inclusion of iatrogenic diseases in the differential to prevent erroneous diagnosis and management. Potential pitfalls in cytopathological diagnosis are discussed.

Sigmoid endometriosis diagnosed preoperatively using endoscopic ultrasound-guided fine-needle aspiration

We report a case of sigmoid endometriosis diagnosed preoperatively based on endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) findings. A 42-year-old female came to us with left lower abdominal pain and bloating that had started 3 months prior. CT and MRI results showed wall thickening of the sigmoid colon. A colonoscopy procedure could not be completed because passage through the sigmoid colon was blocked due to severe stenosis, while mucosal biopsy samples obtained during that procedure could not confirm a diagnosis. EUS-FNA was then performed and specimens were obtained from the muscular layer with stenosis, which revealed a thickened hypoechoic lesion. Histological findings obtained by use of EUS-FNA demonstrated a large amount of fibrosis in endometrial glands and a diagnosis of sigmoid endometriosis was confirmed by additional immunostaining. Thus, a laparoscopic sigmoidectomy was performed, with sigmoid endometriosis finally diagnosed. Confirmation of a diagnosis of intestinal endometriosis based on histological findings of mucosal biopsy specimens obtained by colonoscopy is difficult, because endometrial implants are primarily located in the serosal and/or muscular layer. When safe aspiration is possible, we consider that EUS-FNA can be an effective method for preoperative diagnosis of intestinal endometriosis, which may contribute to avoidance of unnecessary or excessive surgery.

High diagnostic adequacy and accuracy of the new 20G procore needle for EUS-guided tissue acquisition: Results of a large multicentre retrospective study

BACKGROUND AND OBJECTIVE

EUS-guided fine-needle biopsy has become the standard for tissue sampling. A new 20G ProCore™ (PC) needle has been developed to overcome the limitations of tissue acquisition of the smaller needles (22G, 25G) and the rigidity of the larger one (19G). The aim of this study is to assess the performance of the 20G PC needle.

MATERIALS AND METHODS

Patients who underwent EUS-guided tissue acquisition with the 20G PC needle of pancreatic and extra-pancreatic mass lesions were retrospectively identified at three Italian centers (Bologna, Fermo, and Palermo). Diagnostic adequacy, accuracy, and tissue core acquisition were the outcome measures. All the cases were performed without rapid on-site evaluation.

RESULTS

A total of 384 patients with pancreatic (62.2%) and extra-pancreatic lesions were included in the study. For pancreatic lesions, adequacy, accuracy, sensitivity, and specificity were 92.4%, 91.5%, 90.8%, and 100%, respectively, with a number needed to misdiagnose (NNM) of 11.8. The tissue core was obtained in 72% of cases. Transduodenal approach was performed in 150 pancreatic lesions; adequacy, accuracy, and tissue core acquisition were 88.7%, 90%, and 66%, respectively (NNM 10). For extrapancreatic lesions, adequacy, accuracy, sensitivity, specificity, and tissue core sampling were 95.3%, 95.3%, 92.6%, 100%, and 84.5% (NNM 21.3).

CONCLUSIONS

The 20G PC needle showed high diagnostic adequacy and accuracy, regardless the access route.

Transhepatic forceps biopsy combined with biliary drainage in obstructive jaundice: safety and accuracy

PURPOSE

This study was conducted in order to investigate the safety and accuracy of percutaneous transluminal forceps biopsy (PTFB) during percutaneous biliary drainage (PTBD) in patients with a suspicion of malignant biliary stricture.

MATERIAL AND METHODS

Fifty consecutive patients with obstructive jaundice underwent PTFB during PTBD. Biopsy specimens were obtained using 5.2-F flexible biopsy forceps and these specimens were independently analysed by two pathologists. Consensus was obtained in case of discrepancy. Biopsy was considered as a true positive when tumour cells were retrieved. In the absence of tumour cells, comparison with available surgical findings and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) and/or percutaneous liver biopsy and/or imaging or clinical follow-up was made to distinguish true and false negatives. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were calculated. Influence of tumour location and pre-operative imaging findings was evaluated. Adverse events were reported.

RESULTS

Biliary drainage and tissue sampling were achieved in 100% of patients. Sensitivity and specificity were 70 and 100%, respectively, while overall accuracy was 72%. After excluding the first 25 patients, accuracy and sensitivity for tissue sampling reached 80 and 78%, respectively. Sensitivity was better (87%) if stenosis was located at the upper part of the biliary tree, compared to the lower part (55%). In case of cholangiocarcinoma or intraductal invasion suspected on imaging, biopsy was contributive in 84 and 81% of patients, respectively. Four complications occurred consisting of one bile leak, two haemobilia and one pneumoperitoneum.

CONCLUSION

PTFB combined with PTBD is a safe and effective technique for both histopathological diagnosis and biliary decompression of biliary strictures.

KEY POINTS

Implications for patient care: • Percutaneous transbiliary forceps biopsy is technically feasible (100% of tissue sampling in our study) and is a safe technique. • Radiological management combining PTFB plus PTBD may allow diagnosis and treatment of the biliary stricture at the same time. • Sensitivity and accuracy for PTFB reached 78 and 80%, respectively, with a 100% specificity.

[Retrorectal stromal tumor: macroscopic entity and surgical difficulties]

Gastrointestinal stromal tumors are uncommon mesenchymal tumors that very rarely occur in the rectum. They pose preoperative diagnostic and therapeutic problems. We report the case of retrorectal stromal tumor in order to highlight the clinical, radiological and therapeutic features of this rare entity.

A Novel Method of Diagnosing Aberrant Pancreas: Needle-based Confocal Laser Endomicroscopy

Aberrant pancreas is defined as pancreatic tissue present outside of the pancreas and is often found incidentally during esophagogastroduodenoscopy. Obtaining sufficient tissue to differentiate aberrant pancreas from other subepithelial lesions is sometimes difficult. Due to the lack of a definitive diagnosis, patients often undergo unnecessary surgery. We herein report the first case of aberrant pancreas in which the concomitant use of needle-based probe confocal laser endomicroscopy and fine-needle aspiration supported the final diagnosis. Needle-based probe confocal laser endomicroscopy provides a real-time in vivo histopathology evaluation and may be a feasible means of diagnosing aberrant pancreas.

Fluoroscopic guidance biopsy for severe anastomotic stricture after esophagogastrostomy of esophageal carcinoma: A STROBE-compliant article

To determine the safety and effectiveness of fluoroscopic guidance biopsy in the diagnosis of serve anastomotic stricture after esophagogastrostomy for esophageal carcinoma.A total of 55 patients with severe anastomotic stricture were enrolled for forceps biopsy between June 2013 and July 2017. Chest computed tomography (CT) and esophagogram were used to determine the location and extent of stricture. Specimens were collected from the site of stricture by using biopsy forceps under fluoroscopic guidance. Stooler's dysphagia score was compared before and after treatment.The technical success rate of fluoroscopic guidance biopsy was 100%, with no serious complications occurred. A total of 38 patients were diagnosed as benign stricture, of which, 2 patients were further diagnosed as cancer by further biopsy, with a missed diagnosis rate of 5.3%, and 1 patient developed squamous cell carcinoma after 5 months. Thus 20 cases were diagnosed as cancer, 3 cases were adenocarcinoma and 17 cases were squamous cell carcinoma. Balloon dilation was performed for 20 patients (33 times) of benign stricture, and 9 patients (10 times) of malignant stricture. A total of 26 esophageal covered stents were implanted for benign restenosis after repeated balloon dilation. A total of 8 esophageal covered stents were implanted for malignant stricture. After esophagus stenting, dysphagia was immediately alleviated. The dysphagia score decreased from 3.4 ± 0.1 to 0.7 ± 0.1 (P < .001) after treatment.Fluoroscopic guidance biopsy is a safe and effective procedure for directing appropriate treatment of anastomotic stricture after esophagogastrostomy, and it may be an alternative approach for patients who cannot tolerate fibergastroscopy.

Importance of Early Diagnosis of Gastrointestinal Stromal Tumors of the Stomach: Our 5-Year, Single-Center Experience

Objective:

The aim of this study was to investigate clinicopathologic characteristics, diagnosis, treatment, and prognosis of patients who underwent surgery with a diagnosis of a gastrointestinal stromal tumor (GIST) of the stomach.

Methods:

In this single center study, the data of a total of 42 patients diagnosed with a GIST of the stomach in our center between 2010 and 2015 were retrospectively analyzed. The mean age was 60.6 years, with a male-to-female ratio of 1.47/1. Patients presented with various complaints (21 patients had stomach pain,14 patients were asymptomatic, 3 patients had hemorrhage, 2 patients had heartburn and acidity,1 patient had intumescence,1 patient had nausea and vomiting), and all patients underwent surgery. The initial diagnosis was made with endoscopy in 19 patients, with computed tomography in 21 patients, and with magnetic resonance imaging in 2 patients. Local excision or wedge resection was performed in 27 patients, whereas subtotal gastrectomy was performed in 15 patients.

Results:

The mean tumor diameter was 5.66 cm. Pathologically, 25 patients had very low, 5 patients had low, 6 patients had moderate, and 6 patients had high-grade malignancy. The patients with moderate- to high-grade malignancy received imatinib. Liver metastasis occurred in 2 patients. The mean follow-up was 33 months. The mean disease-free survival time was 31.72 months, and the mean disease-specific (n = 2) survival time was 31.25 months. All patients including metastatic ones were still alive.

Conclusions:

Our study results show that frequent use of imaging studies and increased use of endoscopic scans for various reasons may increase the rate of incidentally detected gastric stromal tumors. High rates of disease-free survival can be achieved in GIST patients who are in the low-risk group due to the early diagnosis.

The use of endoscopic ultrasonography in the detection and differentiation of pathology in the wall of the upper gastrointestinal tract

Introduction

The growing incidence of gastrointestinal diseases forces to improve imaging techniques. Identification of lesions located inside the wall of intestinal tract or in close proximity often was not possible using endoscopy or computed tomography.

Aim

To assess the usefulness of endosonography (EUS) in the differentiation between compression from the outside and intramural lesions of the upper gastrointestinal tract.

Material and methods

For 4 years 20,012 patients with performed gastroscopies were enrolled in the study. One hundred and ninety-nine patients (96 females, 103 males; age 62.2 ±14.1 years) with pathology of the wall of the upper gastrointestinal tract qualified for further diagnosis. Endosonography and computed tomography (CT) were performed in each patient. A chest CT was performed in patients with a lesion in the oesophagus. An abdomen CT was performed in patients with pathology in the stomach or duodenum. Based on the results of EUS, histopathology, and imaging, each patient qualified for treatment, endoscopic observation, surgery, or cancer treatment.

Results

In EUS 129 (64.8%) intramural lesions were identified. Five (2.5%) diagnoses were false negative. In 62 (31.2%) patients no intramural changes were recognised and three (1.5%) results were false positive. The sensitivity and specificity of EUS was 96.3% and 95.4%, respectively, with positive predictive value 90.7%, negative predictive value 97.8%, and overall accuracy 95% (p < 0.05). Endoscopic therapy was performed in 31 (15.6%) patients, and 99 (49.8%) were classified for endoscopic observation. Surgery was performed in 50 (25.1%) patients, and 19 (9.5%) patients required oncologic treatment.

Conclusions

Endosonography exceeds computed tomography in differentiating compression from the outside and intramural lesions of the upper gastrointestinal tract.

Subepithelial esophageal tumors: a single-center review of resected and surveilled lesions

BACKGROUND AND AIMS

Subepithelial esophageal tumors (SETs) are frequent incidental findings. Although symptomatic tumors are surgically or endoscopically resected, there is no consensus on the management of asymptomatic esophageal leiomyomas.

METHODS

Appropriate International Classification of Diseases, Ninth Revision codes followed by medical record review were used to identify patients with SETs from January 1992 to March 2017, with abstraction of basic demographics, surveillance intervals, and mortality. Patients were contacted to complete a phone questionnaire to assess follow-up as well as the validated Brief Esophageal Dysphagia Questionnaire (BEDQ).

RESULTS

Eighty-four leiomyomas, 5 leiomyosarcomas, 13 GI stromal tumors (GISTs), and 4 granular cell tumors were found. Among patients with leiomyomas, 58 (69%) were resected and 26 (31%) were followed under surveillance. Resected esophageal leiomyomas were larger than those under surveillance (49.7 mm vs 17.9 mm, P < .003). Esophageal leiomyoma growth during surveillance was only .5 mm over a mean 70-month follow-up (range, 4-288). No malignant transformation was seen, and only 2 patients required subsequent resection. The phone survey was completed by 35 patients and revealed minimal symptom burden, with only 2 patients (15%) under esophageal leiomyoma surveillance reporting symptoms (BEDQ score ≥10) over a mean 96.7-month follow-up. EUS had high diagnostic accuracy with a positive predictive value of 68% and a negative predictive value of 100% for leiomyomas or GISTs compared with surgical pathology.

CONCLUSIONS

EUS demonstrated high diagnostic accuracy in resected SETs. Esophageal leiomyomas demonstrate minimal growth or symptomatic progression. Therefore, long-term EUS surveillance of small asymptomatic esophageal leiomyomas may be unnecessary.

Effect of Gastrointestinal Bleeding on Gastrointestinal Stromal Tumor Patients: A Retrospective Cohort Study

Background

The contemporary risk classification criteria of gastrointestinal stromal tumors (GISTs) may still have room to improve. The aim of our research was to analyze the impact factors for GIST patients’ relapse-free survival (RFS). Furthermore, we explore whether gastrointestinal (1) bleeding will be a valuable indicator to predict GIST patients’ prognosis.

Material/Methods

R0 resection GISTs patients were retrospectively enrolled during an 8-year period at West China Hospital of Sichuan University, and all patients’ data were from the WCHSU-GIST database. Of a total of 333 GIST patients, 164 patients had GI bleeding. Univariate analysis and Cox regression analysis were used to calculate the survival and recurrence rates.

Results

Compared with non-GI-bleeding patients, GI-bleeding patients had a shorter relapse-free survival (RFS, P=0.003), but among the different risk groups, GI bleeding only affected the RFS rate of the high-risk group. A Cox regression analysis illustrated that tumor site (P<0.001), tumor size (P=0.009), mitotic index (P<0.001), tumor rupture (P<0.001), and GI-bleeding (P=0.01) were independent indicators for GIST patients’ RFS.

Conclusions

Our study demonstrates that the RFS of GIST patients with GI bleeding was significantly shorter than that of non-GI-bleeding patients, and GI bleeding was an independent negative factor predicting RFS, while GI bleeding had more influence among high-risk patients.

Efficacy of endoscopic ultrasound-guided fine-needle aspiration and core needle biopsy in the diagnosis of upper gastrointestinal submucosal lesions

INTRODUCTION

Endoscopic ultrasonographically guided fine-needle aspiration (EUS-FNA) has been increasingly utilized to evaluate submucosal lesions of the upper gastrointestinal (UGI) tract. Our study aims to determine the efficacy of UGI EUS-FNA/core needle biopsy (CNB), including the frequency and cytomorphologic features of encountered submucosal lesions, and to investigate contributing factors including the role of rapid on-site evaluation (ROSE).

METHODS

We analyzed all UGI submucosal lesions diagnosed at our institution by EUS-FNA/CNB from September 2008 through August 2015.

RESULTS

During this 8-year study period, 94 patients underwent 110 UGI EUS-FNA/CNB, including 89 (81%) gastric, 11 (10%) duodenal, and 10 (9%) esophageal lesions. Twenty-seven (25%) were gastrointestinal stromal tumors (GISTs), followed by 13 (12%) leiomyomas, 5 (5%) schwannomas, 4 (4%) gastric adenocarcinomas, 3 (3%) neuroendocrine tumors (NETs), and 3 (3%) pancreatic heterotopias. All GISTs, leiomyomas, and NETs were ultimately diagnosed by EUS biopsies, as well as 75% of adenocarcinomas, 60% of schwannomas, and 33% of pancreatic heterotopias. The specificity of EUS-FNA/CNB for these 6 most commonly encountered lesions was 100%, with sensitivity of 82%. Sensitivity was 100% for esophageal and duodenal biopsies, and 80% and 75% for gastric and gastroesophageal procedures, respectively. Factors that contributed to poor yield included the lack of ROSE, small lesional size, lesion location and histology, and needle type. Neither number of needle passes nor operator experience appeared to influence specimen adequacy.

CONCLUSION

EUS-FNA/CNB is an effective modality for diagnosing UGI submucosal lesions. Awareness of potential errors due to sampling of the bowel wall, lesional cystic degeneration, as well as pancreatic heterotopia and Brunner gland hamartoma is essential in order to avoid false diagnoses.

Computer-assisted cytologic diagnosis in pancreatic FNA: An application of neural networks to image analysis

BACKGROUND

Fine-needle aspiration (FNA) biopsy is an accurate method for the diagnosis of solid pancreatic masses. However, a significant number of cases still pose a diagnostic challenge. The authors have attempted to design a computer model to aid in the diagnosis of these biopsies.

METHODS

Images were captured of cell clusters on ThinPrep slides from 75 pancreatic FNA cases (20 malignant, 24 benign, and 31 atypical). A K-means clustering algorithm was used to segment the cell clusters into separable regions of interest before extracting features similar to those used for cytomorphologic assessment. A multilayer perceptron neural network (MNN) was trained and then tested for its ability to distinguish benign from malignant cases.

RESULTS

A total of 277 images of cell clusters were obtained. K-means clustering identified 68,301 possible regions of interest overall. Features such as contour, perimeter, and area were found to be significantly different between malignant and benign images (P <.05). The MNN was 100% accurate for benign and malignant categories. The model's predictions from the atypical data set were 77% accurate.

CONCLUSIONS

The results of the current study demonstrate that computer models can be used successfully to distinguish benign from malignant pancreatic cytology. The fact that the model can categorize atypical cases into benign or malignant with 77% accuracy highlights the great potential of this technology. Although further study is warranted to validate its clinical applications in pancreatic and perhaps other areas of cytology as well, the potential for improved patient outcomes using MNN for image analysis in pathology is significant. Cancer Cytopathol 2017;125:926-33. © 2017 American Cancer Society.

Plexiform Angiomyxoid Myofibroblastic Tumor of the Stomach: a Rare Case

Plexiform angiomyxoid myofibroblastic tumor (PAMT) of the stomach is a very rare mesenchymal tumor of the gastrointestinal tract. We report a case of asymptomatic gastric PAMT that was pathologically confirmed after surgical resection. The tumor had a multinodular plexiform growth pattern, bland-looking spindle cells, and an Alcian blue-positive myxoid stromal matrix rich in small blood vessels. Immunohistochemistry analysis revealed that the tumor cells of the PAMT were positive for smooth muscle actin (SMA) and negative for c-kit, CD34, S-100 protein, epithelial membrane antigen (EMA), and desmin. PAMT should be differentiated from other submucosal tumors of the stomach by immunohistochemical findings. Considering the benign features of this tumor, observation without resection may be an option for the treatment of PAMT if the tumor is asymptomatic.

Clinicopathological and Prognostic Analysis of Primary Gastrointestinal Stromal Tumor Presenting with Gastrointestinal Bleeding: a 10-Year Retrospective Study

OBJECTIVES

The objectives of this paper were to investigate the clinicopathological characteristics and prognostic factors of GI-bleeding GIST patients and explore whether GI bleeding is a risk factor for GIST relapse.

METHODS

Primary GIST patients with initial symptoms of GI bleeding or no GI bleeding were retrospectively studied.

RESULTS

Up to 178 GI-bleeding GIST patients including 108 (60.7%) males and 70 (39.3%) females were evaluated for the clinicopathological characteristics. The stomach, small bowel, and colorectum were the tumor sites in 82 (46.1%), 85 (47.8%), and 11 (6.2%) patients. Of the 178 patients, 163 GI-bleeding patients had follow-up while another 363 patients from the total population presented without GI bleeding were followed up. Up to 526 patients who received postoperative follow-up were included in the survival analysis. Compared with the 363 non-GI-bleeding patients, GI-bleeding patients developed smaller tumors (P = 0.015) and had a longer relapse-free survival (RFS; P = 0.014). For the 163 GI-bleeding patients, a Cox regression analysis showed that the mitotic count and the platelet-lymphocyte ratio before surgery were independent prognostic predictors for poor outcome regarding RFS. For all 526 patients, a Cox regression analysis indicated that tumor location, mitotic index, platelet-lymphocyte ratio, and GI bleeding were independent prognosis predictors.

CONCLUSION

Compared to non-GI-bleeding GIST patients, patients with GI bleeding were more likely to be male and to have more small intestine GISTs, smaller tumors, and a longer RFS. For GI-bleeding patients, mitotic count and platelet-lymphocyte ratio were independent prognostic indicators. GI bleeding served as a surrogate for smaller GIST and was a protective factor for GIST recurrence.

A meta-analysis of endoscopic ultrasound-fine-needle aspiration compared to endoscopic ultrasound-fine-needle biopsy: diagnostic yield and the value of onsite cytopathological assessment

Background The diagnostic yield of endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is variable, and partly dependent upon rapid onsite evaluation (ROSE) by a cytopathologist. Second generation fine-needle biopsy (FNB) needles are being increasingly used to obtain core histological tissue samples. Aims Studies comparing the diagnostic yield of EUS guided FNA versus FNB have reached conflicting conclusions. We therefore conducted a systematic review and meta-analysis to compare the diagnostic yield of FNA with FNB, and specifically evaluating the diagnostic value of ROSE while comparing the two types of needles. Methods We searched several databases from inception to 10 April 2016 to identify studies comparing diagnostic yield of second generation FNB needles with standard FNA needles. Risk ratios (RR) were calculated for categorical outcomes of interest (diagnostic adequacy, diagnostic accuracy, and optimal quality histological cores obtained). Standard mean difference (SMD) was calculated for continuous variables (number of passes required for diagnosis). These were pooled using random effects model of meta-analysis to account for heterogeneity. Meta-regression was conducted to evaluate the effect of ROSE on various outcomes of interest. Results Fifteen studies with a total of 1024 patients were included in the analysis. We found no significant difference in diagnostic adequacy [RR 0.98 (0.91, 1.06), (I² = 51 %)]. Although not statistically significant (P = 0.06), by meta-regression, in the absence of ROSE, FNB showed a relatively better diagnostic adequacy. For solid pancreatic lesions only, there was no difference in diagnostic adequacy [RR 0.96 (0.86, 1.09), (I² = 66 %)]. By meta-regression, in the absence of ROSE, FNB was associated with better diagnostic adequacy (P = 0.02). There was no difference in diagnostic accuracy [RR 0.99 (0.95, 1.03), (I² = 27 %)] or optimal quality core histological sample procurement [RR 0.97 (0.89, 1.05), (I² = 9.6 %)]. However, FNB established diagnosis with fewer passes [SMD 0.93 (0.45, 1.42), (I² = 84 %)]. The absence of ROSE was associated with a higher SMD, i. e., in the presence of an onsite pathologist, FNA required relatively fewer passes to establish the diagnosis than in the absence of an onsite pathologist. Conclusions There is no significant difference in the diagnostic yield between FNA and FNB, when FNA is accompanied by ROSE. However, in the absence of ROSE, FNB is associated with a relatively better diagnostic adequacy in solid pancreatic lesions. Also, FNB requires fewer passes to establish the diagnosis.

Primary Small Bowel GIST Presenting as a Life-Threatening Emergency: A Report of Two Cases

Gastrointestinal stromal tumor (GIST) is a rare stromal neoplasm, which represents the most common mesenchymal tumor of the gastrointestinal tract. It is characterized by indolent clinical symptoms, although it can present as a life-threatening emergency. Herein, we present two cases of primary small bowel GIST treated at our department. A 68-year-old female patient presented to our emergency department with a diffuse abdominal pain of acute onset. Imaging studies revealed a mass at proximal jejunum, with a nearby free air and fluid. At surgery, a mass of 9 cm was found at proximal jejunum, 3 cm distal to the treitz ligament, with perforation on the lateral wall of the mass. En bloc resection was performed. Pathology report was positive for gastrointestinal stromal tumor. A 70-year-old male patient presented to our emergency department with 3 days of dark tarry stool and few hours of hematochezia. Computed tomography angiography revealed a mass at the pelvis, with calcifications, attached to the distal ileum, with intraluminal blush of intravenous iodine. At surgery, a mass of 8 cm at the distal ileum was found. Resection of the mass along with a 20 cm of ileum was completed. Histopathology report was positive for malignant gastrointestinal stromal tumor.

Thoracoscopic enucleation in the left decubitus position for leiomyoma of the upper thoracic esophagus: Utility of preoperative diagnosis applying endoscopic ultrasound-guided fine needle aspiration

•

We report a case of esophageal leiomyoma enucleated by thoracoscopic procedures.

•

Preoperative EUS-FNA is useful to decide the operative procedure.

•

Preoperative EUS-FNA does not adversely influence subsequent enucleation.

•

Precise preoperative diagnosis is necessary to avoid excessive surgery.

Introduction

We report a relatively rare case of esophageal leiomyoma in the upper thoracic esophagus enucleated by thoracoscopic procedures. The usefulness of preoperative diagnosis and an adequate surgical approach are described along with a review of the relevant literature.

Presentaion of case

A submucosal tumor 45 mm in diameter was detected in the upper thoracic esophagus of a 69-year-old man. The tumor was preoperatively diagnosed from histopathological biopsy under endoscopic ultrasound-guided fine needle aspiration. Thoracoscopic enucleation was therefore preoperatively scheduled under the left decubitus position in consideration of the low risk of malignant disease. Histopathological diagnosis of the resected specimen was benign leiomyoma and patient outcomes were good.

Discussion

The need for preoperative biopsy of esophageal submucosal tumor is a controversial issue. However, preoperative biopsy provided the benefits to decide the operative procedure or confirm adequate resection, and our experience suggested that preoperative biopsy did not adversely influence subsequent enucleation.

Conclusion

Precise preoperative diagnosis is necessary to avoid excessive surgery when managing esophageal submucosal tumor.

Endoscopic ultrasound-guided tissue sampling of small subepithelial tumors of the upper gastrointestinal tract with a 22-gauge core biopsy needle

Background and study aims The optimal approach to small subepithelial tumors (SETs) of the upper gastrointestinal tract remains inconclusive. The aim of this study was to evaluate endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for less invasive tissue sampling of small SETs of the upper gastrointestinal tract. Patients and methods In this prospective observational study patients with small ( ≤ 3 cm) SETs of the upper gastrointestinal tract were eligible and underwent EUS-FNB with a 22-gauge core biopsy needle. The main outcome measure was the diagnostic yield. The number of obtained core biopsies was also assessed. Results Twenty patients were included. The mean SET size was 16 mm (range 10 - 27 mm). EUS-FNB was technically feasible in all cases and no complications were observed. The diagnostic yield was 75 %. Core biopsy specimens were obtained in only 25 % of cases. Conclusion EUS-FNB with a 22-gauge core biopsy needle of small SETs can achieve a definite diagnosis in the majority of cases. However, because core samples cannot regularly be obtained, EUS-FNB seems not to be convincingly superior to standard EUS-FNA in this setting.

Role of endoscopic ultrasound and endoscopic-ultrasound-guided fine-needle aspiration in endoscopic biopsy negative gastrointestinal lesions

BACKGROUND AND OBJECTIVES

Many cases of gastrointestinal (GI) tumors as lymphoma, adenocarcinoma, and most of submucosal tumors (SMT) such as gastrointestinal stromal tumor (GIST) and leiomyoma are difficult to diagnose as they frequently yield negative endoscopic biopsies. We evaluated the accuracy of endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) in the diagnosis of endoscopic biopsy negative GI tumors.

PATIENTS AND METHODS

One hundred and nine patients with biopsy negative GI tumors were included in this prospective study. EUS and EUS-FNA were performed to all patients with cytopathologic examination.

RESULTS

There were 109 patients with endoscopic biopsy negative GI lesions, including 61 males (56%) and 48 females (44%), with the mean age of 54 years. Sixty-three cases (57.8%) were proved to have malignant lesions, among them there were 15 cases with high-risk GIST as proved by FNA and excision biopsy. Forty-six cases (42.2%) were proved to be benign; among them there were 21 cases presented with non-high-risk GIST. Endoscopic ultrasound had a sensitivity of 96.8%, specificity of 89.1%, positive predictive value (PPV) of 92.4%, negative predictive value (NPV) of 95.3%, and accuracy of 93.6%. EUS-FNA had a sensitivity of 87.3%, specificity of 100%, PPV of 100%, NPV of 85.2%, and accuracy of 92.7%.

CONCLUSION

EUS with EUS-FNA is an accurate procedure in the diagnosis of GI tumors with negative endoscopic biopsies.

The role of EUS and EUS-guided FNA in the management of subepithelial lesions of the esophagus: A large, single-center experience

BACKGROUND

Referral for endosonographic evaluation of subepithelial lesions seen in the gastrointestinal (GI) tract is fairly common. Although rarely studied separately in details, esophageal lesions have some unique differences from other GI sites and might deserve some special considerations regarding follow-up and management.

MATERIALS AND METHODS

All cases referred for endoscopic ultrasound (EUS) evaluation of subepithelial esophageal lesions at Bezmialem University Hospital, a tertiary center in Istanbul, Turkey were retrospectively reviewed. Data were collected for patient and lesion characteristics as well as for pathology results and follow-up if available. Lesions were subcategorized according to their size, location, and final diagnosis.

RESULTS

A total of 164 EUS examinations were identified. In 22.5% of cases, the lesion could not be identified by EUS. Of the remaining cases, 57.6% had a lesion larger than 1 cm in size. Extramural compression was the diagnosis in 12% and leiomyoma in around 60%. Thirteen patients had follow-up examinations with only two showing an increase in size after 12 months. Sixty-five EUS-guided fine needle aspirations (EUS-guided FNAs) were performed, with around 50% having nondiagnostic samples and 94% of the remaining samples confirming the presumptive diagnosis.

CONCLUSIONS

The majority of subepithelial lesions in the esophagus are benign with extremely low malignancy potential. EUS examinations performed for lesions smaller than 2 cm as well as FNAs taken from lesions smaller than 3 cm might have minimal impact on their ultimate management and outcome. More than one FNA pass should be attempted in order to improve the yield.

A rare case of plexiform angiomyxoid myofibroblastic tumor in the stomach which was diagnosed at the earliest stage in the literature

Plexiform angiomyxoid myofibroblastic tumor (PAMT) is a rare gastric mesenchymal entity with a peculiar plexiform pattern, bland spindle cells and myxoid stroma rich in arborizing blood vessels. Here we report a 44-year-old Chinese woman with PAMT. Initially she was admitted for removal of a gastric antral‘polyp’ found on a routine examination 5 months previously. Our gastroscopy showed a 0.8 × 0.8 cm polyp-like mass in the antrum which protruded into the lumen. Endoscopic submucosal dissection (ESD) was performed to remove this mass en bloc. The specimen was carefully examined by pathologists, and the correct diagnosis of PAMT was finally made. The tumor in this case depicted typical histopathological and immunohistochemical features of gastric PAMT. This PAMT was not only the smallest on endoscopic examination in the literature but also—unlike the already reported PAMTs—exhibited a focal hyperechogenic lesion on endoscopic ultrasonography (EUS). This information highlights its value on how to identify a PAMT at its early stage.

Endoscopic ultrasound without tissue acquisition has poor accuracy for diagnosing gastric subepithelial tumors

Incidental gastric subepithelial tumor (SET) is frequently found during endoscopy. Although endoscopic ultrasonography (EUS) can provide useful information, its diagnostic accuracy varies. Most of the potentially malignant tumors observed on EUS are hypoechoic lesions. Therefore, we aimed to investigate the diagnostic accuracy of EUS for hypoechoic lesions located in the submucosa or proper muscle layer. We also evaluated various characteristics for potential associations with diagnostic accuracy.A retrospective review was conducted of the medical records of 99 patients who were diagnosed with gastric SET and who underwent EUS with pathologic confirmation between March 2008 and April 2015. After reviewing the endoscopic and pathologic findings, we attempted to analyze factors that were associated with the diagnostic accuracy of EUS.The mean ± standard deviation size of the lesions was 20.0 ± 12.7 mm. The most common location was the upper third of the stomach (43.4%). The overall accuracy of EUS was 66.7%. No statistically significant difference in EUS accuracy was observed according to the location, size, or layer of the lesion. The following pathologic diagnostic methods were used: EUS-guided fine needle aspiration (3.0%), forceps biopsy (16.2%), deep tissue biopsy using cap-assisted mucosal resection (8.1%), endoscopic submucosal dissection (25.2%), and operation (47.5%). The accuracy of EUS according to the expected diagnosis of the lesion was 77.1% for gastrointestinal stromal tumor, 50% for neuroendocrine tumor, and 50% for ectopic pancreas.Although EUS is a useful tool for gastric SET in clinical practice, the accuracy of diagnostic EUS is suboptimal. When considering whether to treat gastric SET, the decision should be made based on the pathologic diagnosis.

Endoscopic ultrasound-guided fine needle aspiration biopsy of pancreatic lesions. An 8-year analysis of single institution material focusing on efficacy and learning progress

OBJECTIVE

To evaluate the efficacy and the learning curve of the endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) diagnostics of pancreatic lesions over 8 years (2007-2014).

MATERIAL AND METHODS

EUS-FNAB using a Linear Echoendoscope Olympus was performed in 531 patients, mostly without rapid on-site evaluation (ROSE). Smears plus cytoblock sections were used routinely. Immunocytochemistry was utilised as indicated.

RESULTS

The average, satisfactory sampling rate increased from the 61.2% in the first 3-year period to 72.9% in the last 3-year period (P = 0.008). The availability of the material for cytoblocks increased from 36.4% in the first period to 75.3% in the last period (P = 0.017). The efficacy of cytoblocks increased from 39.6% to 46.2% (P = 0.086). Comparing the first and last 3-year periods, the indication for immunocytochemistry did not rise substantially (5.2% and 8.5% respectively), but the predictive value of immunocytochemistry rose from 56.3% to 100.0% (P = 0.001). The most frequent diagnostic result was malignancy confirmation - both primary (41.2%) and metastatic (2.1%). In cases with representative samples and follow-up information, the specificity, sensitivity, positive predictive value and accuracy were high from the beginning. The negative predictive value decreased slightly in the last 3-year period.

CONCLUSION

The pancreatic EUS-FNAB without ROSE represents a suboptimal arrangement conditioned with our staff/time/location reality. Nevertheless, within the last 3 years of our activity, nearly three-quarters of patients profit from the diagnostic contribution of this procedure.

Characterization of residual tumours at the primary site in patients with a near pathological complete response after neoadjuvant chemoradiotherapy for oesophageal cancer

BACKGROUND

A 'surgery as needed' strategy has been proposed for patients with oesophageal cancer who truly achieve a pathological complete response (pCR) following neoadjuvant chemoradiotherapy (nCRT). However, the ability to detect residual disease remains problematic. This study investigated the anatomical locations and pathological characteristics of residual cancer in patients with oesophageal squamous cell carcinoma (SCC) who achieved a near pCR following nCRT.

METHODS

Patients with oesophageal SCC who achieved a near pCR after nCRT were eligible. Near pCR was defined as residual cancer in the resection specimen representing less than 10 per cent of the apparent original tumour area.

RESULTS

Detailed histopathological reassessment of 76 consecutive patients (mean age 54·4 years) with a near pCR was undertaken. Some 32 patients (42 per cent) with a near pCR had no detectable mucosal lesions. Residual tumour was identified most frequently in the submucosal layer (54, 71 per cent), followed by the mucosa (44, 58 per cent), muscle layer (36, 47 per cent) and adventitia (22, 29 per cent) (P < 0·001). Among patients without ypT1a disease, increasing depth of tumour invasion correlated negatively with the likelihood of mucosal involvement. Of patients with ypT3 disease, 16 of 22 had no detectable cancer located in the mucosa, compared with six of 29 with ypT1b disease (P < 0·001).

CONCLUSION

Better tools for predicting pCR are required before considering a 'surgery as needed' approach in the management of oesophageal cancer.

EUS and EUS-Guided Interventions Alter Clinical Management in Children With Digestive Diseases

OBJECTIVES

Endoscopic ultrasound (EUS) ± fine needle aspiration (FNA) is a useful tool to evaluate gastrointestinal tract disorders in adults because of its established feasibility and safety. Its role in children has not been well established and continues to evolve. Our objective was to evaluate the utility and impact on clinical management of EUS and EUS-guided interventions in the pediatric population at our institution.

METHODS

Retrospective, single-center study including 43 patients undergoing EUS and EUS-FNA between August 2005 and January 2012.

RESULTS

Fifty-one EUS procedures were performed in 43 patients, 30 girls, median age 14.5 (range 4-18). The most common indications were suspected biliary obstruction in 11 of 51 (22%), pancreatic cysts in 10 of 51 (20%), acute or recurrent pancreatitis in 9 of 51 (18%), and abdominal pain in 8 of 51 (16%). The most common findings of EUS included normal 11 of 51 (22%), pancreas cyst 6 of 51 (12%), pancreatic pseudocyst 5 of 51 (10%), biliary system sludge or stones 9 of 51 (18%), and acute and chronic pancreatitis 5 of 51 (10%). EUS-FNA was performed in 13 cases: 7 solid masses or nodes, 4 pancreatic pseudocyst, 1 pancreatic cyst, and 1 celiac plexus block. FNA cyst drainage was successful in resolving all 4 pancreatic pseudocysts. EUS prompted a surgical procedure in 13 cases (25%), ERCP in 5 cases (10%), and repeat EUS in 5 cases (10%). EUS led to a new diagnosis in 34 of 43 (79%) patients and prompted further intervention in 24 of 51 (47%) procedures.

CONCLUSIONS

In this large cohort study, we found that EUS and EUS-guided interventions assist in diagnosing and altering clinical management in pediatric patients and should be considered in cases with vexing pancreaticobiliary disorders.

Differentiating gastrointestinal stromal tumors from gastric adenocarcinomas and normal mucosae using confocal Raman microspectroscopy

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract, and gastric adenocarcinomas are a common cancer worldwide. To differentiate GISTs from adenocarcinomas is important because the surgical processes for both are different; the former excises the tumor with negative margins, while the latter requires radical gastrectomy with lymph node dissection. Endoscopy with biopsy is used to distinguish GISTs from adenocarcinomas; however, it may cause tumor bleeding in GISTs. We reported here the confocal Raman microspectroscopy as an effective tool to differentiate GISTs, adenocarcinomas, and normal mucosae. Of 119 patients enrolled in this study, 102 patients underwent gastrectomy (40 GISTs and 62 adenocarcinomas), and 17 patients with benign lesions were obtained as normal mucosae. Raman signals were integrated for 100 s for each spot on the specimen, and 5 to 10 spots, depending on the sample size, were chosen for each specimen. There were significant differences among those tissues as evidenced by different Raman signal responding to phospholipids and protein structures. The spectral data were further processed and analyzed by using principal component analysis. A two-dimensional plot demonstrated that GISTs, adenocarcinomas, and normal gastric mucosae could be effectively differentiated from each other.

Endoluminal high-resolution MR imaging protocol for colon walls analysis in a mouse model of colitis

OBJECTIVE

An endoluminal magnetic resonance (MR) imaging protocol including the design of an endoluminal coil (EC) was defined for high-spatial-resolution MR imaging of mice gastrointestinal walls at 4.7 T.

MATERIALS AND METHODS

A receive-only radiofrequency single-loop coil was developed for mice colon wall imaging. Combined with a specific protocol, the prototype was first characterized in vitro on phantoms and on vegetables. Signal-to-noise ratio (SNR) profiles were compared with a quadrature volume birdcage coil (QVBC). Endoluminal MR imaging protocol combined with the EC was assessed in vivo on mice.

RESULTS

The SNR measured close to the coil is significantly higher (10 times and up to 3 mm of the EC center) than the SNR measured with the QVBC. The gain in SNR can be used to reduce the in-plane pixel size up to 39 × 39 µm(2) (234 µm slice thickness) without time penalty. The different colon wall layers can only be distinguished on images acquired with the EC.

CONCLUSION

Dedicated EC provides suitable images for the assessment of mice colon wall layers. This proof of concept provides gains in spatial resolution and leads to adequate protocols for the assessment of human colorectal cancer, and can now be used as a new imaging tool for a better understanding of the pathology.

Endoscopic Ultrasonography-Guided Biopsy for Differentiation of Benign and Malignant Pelvic Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

Preoperative diagnosis of pelvic lesions remains challenging despite advances in imaging technologies. Endoscopic ultrasonography (EUS)-guided biopsy is an effective diagnostic modality for sampling the digestive tract and surrounding areas. However, a meta-analysis summarizing the diagnostic efficacy of EUS-guided biopsy for pelvic lesions has not been published.

AIMS

We aimed to evaluate the utility of EUS-guided biopsy in the diagnosis of pelvic lesions.

METHODS

Articles were identified via structured database search; only studies where pelvic lesions were confirmed by surgery or clinical follow-up were included. Data extracted were selected with strict criteria. A fixed-effects model was used to estimate the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). A summary receiver operating characteristic curve (SROC) was also constructed.

RESULTS

Ten studies containing a total of 246 patients were included. The pooled sensitivity of EUS-guided biopsy for differential diagnosis of pelvic masses was 0.89 (95% CI 0.83-0.94), and the specificity was 0.93 (95% CI 0.86-0.97). The area under the SROC was 0.9631. The combined PLR, NLR, and DOR were 11.75 (95% CI 5.90-23.43), 0.12 (95% CI 0.07-0.20), and 100.06 (95% CI 37.48-267.10) respectively. There is potential presence of publication bias in this meta-analysis.

CONCLUSIONS

Our meta-analysis shows that EUS-guided biopsy is a powerful tool for differentiating pelvic masses with a high sensitivity and specificity. Furthermore, it is a safe procedure with low rate of complication, although more high-quality prospective studies are required to be done.

Efficiency and safety of endoscopic resection in the management of subepithelial lesions of the stomach

BACKGROUND

Gastric subepithelial tumors represent a diagnostic and therapeutic challenge, given their histologic heterogeneity and potential malignant behavior.

OBJECTIVE

The objective of this article is to evaluate the interest, efficiency and safety of endoscopic resection for subepithelial gastric lesions of size <20 mm.

METHODS

We conducted a single-center retrospective study in a tertiary care center.

RESULTS

A total of 33 lesions (10 malignant/23 benign lesions) were studied. Mean histological size was 14.5 mm. Nine EMR, 18 ESD and six hybrid resections were performed. A total of 93.9% lesions were resected in one piece. At six months' follow-up, complete and definitive resection was obtained in 96.7% of cases. A vertical resection was insufficient in four cases. One GIST needed a complementary surgical resection, one neuroendocrine tumor was successfully treated by a new ESD session and two pancreatic rests were not additionally treated given the benign character and the absence of residual tissue in endoscopic control after six months. There was only one severe adverse event (2.9%); one pneumoperitoneum with ESD, three bleeding with one ESD and two EMR, always treated conservatively or endoscopically.

CONCLUSION

Endoscopic resection is safe and should be the procedure of choice for both diagnosis and definitive resection of subepithelial gastric lesions of size under 20 mm.

Diagnostic efficacy of endoscopic ultrasound-guided needle sampling for upper gastrointestinal subepithelial lesions: a meta-analysis

BACKGROUND

An increasing number of studies have been conducted on the use of endoscopic ultrasound (EUS)-guided needle sampling for upper gastrointestinal subepithelial lesions (SEL). However, reported diagnostic efficacy varies greatly.

OBJECTIVE

To summarize up current evidences on the diagnostic efficacy of EUS-guided needle sampling for upper GI SEL.

METHOD

A reproducible strategy was used to search four databases. Search results were evaluated for eligibility, and the quality of eligible studies was assessed by QUADAS-2. Pooled efficacy of EUS-guided needle sampling in upper GI SEL was calculated. Procedure-related complications, diagnostic errors, and independent factors related to a higher success rate were also recorded and analyzed.

RESULTS

Seventeen studies, comprising 978 attempts of EUS-guided needle sampling, were included in a meta-analysis. Pooled diagnostic rate of EUS-guided needle sampling was 59.9 %, with a heterogeneity I (2) of 55.2 %. Subgroup analysis showed no difference in diagnostic rate among fine needle aspiration (FNA), trucut needle biopsy (TCB), and fine needle biopsy (FNB), or among 19-, 22-, and 25-G needles. Subgroup analysis and meta-regression suggested that the cell block method might be correlated with a higher diagnostic rate. Few severe complications were reported. Diagnosis errors were rare.

CONCLUSION

EUS-guided needle sampling is a safe, but only moderately effective method for pathology diagnosis of upper GI SEL. Choice of FNA/TCB/FNB, or 19 G/22 G/25 G does not seem to alter the overall diagnostic rate.

In Vitro and in vivo characterization of wireless and passive micro system enabling gastrointestinal pressure monitoring

This paper presents a wireless and passive micro pressure system based on the LC mutual inductance detection mechanism for gastrointestinal (GI) pressure monitoring. The micro pressure system is composed of a sensor capsule (a pressure sensitive micro capacitive sensor in series with an induction coil to form an LC tank) and a detection unit (a detection coil connected with a network analyzer). The pressure variations under measurement lead to changes in the capacitance of the pressure sensor and therefore a shift in the LC tank resonant frequency, quantified by the impedance measurement of the detection coil. The pressure sensor was fabricated using microfabrication processes with key parameters optimized. The in vitro characterization of the micro pressure system recorded a sensitivity of 0.2491 kHz/kPa (-10 kPa to 30 kPa). One-month rabbit stomach pressure monitoring was conducted based on the developed micro pressure system as a confirmation of device long term in vivo stability. Furthermore, rabbit stomach pressure variations before and after food feeding was recorded and compared where three distinctive contraction patterns (random contraction with low amplitude, irregular strong contractions and regular contraction in a cyclic manner) following food feeding were located. Compared to previous reported GI pressure sensors, this LC tank is featured with simple device structure without batteries and electrical components for energy transfer. Both in vitro and in vivo characterization confirm the functionality of the system, which may enable the gastrointestinal motility study in the near future.