Utility of endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) for diagnosing small subepithelial lesions (< 20 mm)

Imaging features and preoperative diagnostic insights of esophageal schwannomas as a rare type

PURPOSE

We aimed to analyze and summarize the key features of esophageal schwannomas to provide new insights into preoperative diagnosis and enhance clinical recognition.

METHODS

Twenty-one consecutive patients with pathologically confirmed esophageal schwannoma who underwent surgical resection between January 2013 and January 2023 were enrolled. Imaging results from barium swallow, CT, MRI, 18F-FDG PET-CT, esophagoscopy, and endoscopic ultrasound were compiled and analyzed.

RESULTS

Our cohort comprised 10 males and 11 females, with mean age of 55.86 ± 9.09 years. The mean tumor size was 5.69 ± 1.32 cm, with tumors commonly located in the upper to middle esophagus. 83.3 % (10/12) presented smooth filling defects with intact canal walls in barium meal. Most tumors (71.4 %, 15/21) were oval-shaped, exhibiting intracavitary growth with well-defined borders. Mild enhancement was observed on CT with pre-contrast attenuation of 36.0 ± 53.87 HU and post-contrast enhancement of 52.75 ± 7.45 HU. Most lesions showed plateau dynamic enhancement on MRI (85.7 %, 6/7). Air crescent signs (95.2 %, 20/21) and fascicular signs (87.5 %, 7/8) were observed in most cases. Neither calcifications nor target signs were observed, and cystic changes were infrequent. All lesions showed high uptake on PET-CT (SUVmax: 11.19 ± 3.41). Endoscopic lesions typically exhibit smooth surfaces, soft textures, and colors ranging from normal to slightly lighter hues (94.7 %, 18/19). Endoscopic ultrasound indicated minimal blood flow within lesions (53.8 %, 7/13), and elastography displayed a blue-green pattern (100 %, 5/5).

CONCLUSION

Esophageal schwannomas exhibit distinct imaging characteristics. MRI provides additional diagnostic information for more accurate evaluation, while high metabolic activity on PET-CT may mimic malignancy.

Traction-assisted endoscopic ultrasound-guided fine-needle biopsy using the clip-with-thread method for small gastric subepithelial lesions: Randomized controlled trial (with video)

OBJECTIVES

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/B) is the gold standard for diagnosing gastric subepithelial lesions (SELs), but diagnosing lesions smaller than 20 mm remains challenging. We developed traction-assisted EUS-FNB (TA-EUS-FNB) using the clip-with-thread method to enhance diagnostic accuracy by stabilizing the lesion and providing counter-traction for easier needle access. This study evaluates the effectiveness of TA-EUS-FNB in diagnosing small gastric SELs.

METHODS

In this prospective, randomized, controlled cross-over trial (August 2019-November 2022), 30 patients with gastric SELs <20 mm were randomized to undergo TA-EUS-FNB or conventional EUS-FNB. Each patient underwent four punctures, two per method. The primary end-point was the adequate tissue sampling rate for both techniques. Secondary end-points included diagnostic yield and performance (sensitivity and specificity) in distinguishing gastrointestinal stromal tumors (GISTs) from non-GISTs.

RESULTS

The mean tumor size was 15.0 mm, with diagnoses comprising GISTs (n = 15, 50%), leiomyomas (n = 8, 26.7%), schwannomas (n = 2, 6.7%), aberrant pancreas (n = 3, 10%), and inflammation (n = 2, 6.7%). TA-EUS-FNB demonstrated a significantly higher adequate-tissue sampling rate (90% vs. 66.7%, P = 0.035) and diagnostic yield (86.7% vs. 63.3%, P = 0.037) than conventional EUS-FNB. Sensitivity (86.7%, 95% confidence interval [CI] 62.1-96.3% vs. 66.7%, 95% CI 41.7-84.8%; P = 0.20) and specificity (100%, 95% CI 79.6-100% vs. 100%, 95% CI 79.6-100%) were comparable between the methods. No adverse events were observed in the study.

CONCLUSION

TA-EUS-FNB demonstrated superior tissue sampling rates and diagnostic yield for SELs <20 mm compared to conventional EUS-FNB, making it a viable option. Controlling lesion mobility is essential for successful EUS-FNB in small SELs.

The diagnostic value of endoscopic ultrasound for esophageal subepithelial lesions: A review

Esophageal subepithelial lesions (ESELs) encompass a variety of diseases, including leiomyoma, granular cell tumors, hemangioma, lipoma, stromal tumors, leiomyosarcoma, schwannoma, neuroendocrine tumors and more. These lesions often present asymptomatically, leading to a generally low clinical diagnosis rate. Common imaging techniques for diagnosing ESELs include conventional endoscopy, spiral computed tomography, and endoscopic ultrasound (EUS). Among these, EUS is currently regarded as one of the most accurate methods for diagnosing ESELs. In recent years, EUS has increasingly been combined with advanced technologies such as artificial intelligence, submucosal saline injection, high-frequency impedance measurement, and enhanced imaging to improve diagnostic accuracy and reduce missed diagnoses. This article reviews the application and recent advancements of EUS in diagnosing esophageal submucosal lesions.

Endoscopic Ultrasound and Gastric Sub-Epithelial Lesions: Ultrasonographic Features, Tissue Acquisition Strategies, and Therapeutic Management

Background and objectives: Subepithelial lesions (SELs) of the gastrointestinal (GI) tract present a diagnostic challenge due to their heterogeneous nature and varied clinical manifestations. Usually, SELs are small and asymptomatic; generally discovered during routine endoscopy or radiological examinations. Currently, endoscopic ultrasound (EUS) is the best tool to characterize gastric SELs. Materials and methods: For this review, the research and the study selection were conducted using the PubMed database. Articles in English language were reviewed from August 2019 to July 2024. Results: This review aims to summarize the international literature to examine and illustrate the progress in the last five years of endosonographic diagnostics and treatment of gastric SELs. Conclusions: Endoscopic ultrasound is the preferred option for the diagnosis of sub-epithelial lesions. In most of the cases, EUS-guided tissue sampling is mandatory; however, ancillary techniques (elastography, CEH-EUS, AI) may help in both diagnosis and prognostic assessment.

Diagnostic yield of endoscopic and EUS-guided biopsy techniques in subepithelial lesions of the upper GI tract: a systematic review

BACKGROUND AND AIMS

Obtaining adequate tissue samples in subepithelial lesions (SELs) remains challenging. Several biopsy techniques are available, but a systematic review including all available techniques to obtain a histologic diagnosis of SEL is lacking. The aim of this study was to evaluate the diagnostic yield and adverse event rates of endoscopic biopsies, EUS-guided FNA (EUS-FNA), EUS-guided fine-needle biopsy (FNB) (EUS-FNB), and mucosal incision-assisted biopsy (MIAB) for SELs in the upper GI tract.

METHODS

A search strategy in multiple databases was performed. The primary outcome was diagnostic yield, defined as the percentage of procedures in which histology was obtained and resulted in a definitive histopathologic diagnosis. Secondary outcome measures included reported procedure-related adverse events, which were graded according to the AGREE (Adverse Events in Gastrointestinal Endoscopy) classification.

RESULTS

A total of 94 original articles were included. Studies were classified per endoscopic technique to obtain histopathology. This resulted in 8 included studies for endoscopic biopsy methods, 55 studies for EUS-FNA, 33 studies for EUS-FNB, and 26 studies for MIAB. Pooled rates for diagnostic yield were 40.6% (95% confidence interval [CI], 30.8-51.2) for endoscopic biopsy, 74.6% (95% CI, 69.9-78.7) for EUS-FNA, 84.2% (95% CI, 80.7-87.2) for EUS-FNB, and 88.2% (95% CI, 84.7-91.1) for MIAB. Reported procedure-related adverse events graded AGREE II or higher were 2.8% to 3.9% for endoscopic biopsies, 1.0% to 4.5% for EUS-FNA, .9% to 7.7% for EUS-FNB, and 1.9% to 7.9% for MIAB.

CONCLUSIONS

Based on the available evidence, MIAB and EUS-FNB seem to be most effective in terms of achieving a high diagnostic yield, with similar rates of adverse events.

Endoscopic ultrasound-guided fine-needle aspiration for gastrointestinal subepithelial lesions

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the first-choice procedure for obtaining pathological tissue samples from gastrointestinal (GI) subepithelial lesions (SELs). However, its diagnostic accuracy is lower than that for pancreatic masses owing to puncture difficulty and the need for immunostaining for definitive diagnosis. The advent of fine-needle biopsy needles, which have become well known in recent years, improves the diagnostic accuracy of EUS-FNA for GI SELs. The forward-viewing echoendoscope and rapid on-site evaluation (ROSE) have also helped to improve diagnostic accuracy. Furthermore, in facilities where ROSE is not available, endosonographers perform a macroscopic on-site evaluation. With these procedural innovations, EUS-FNA is now performed aggressively even for SELs smaller than 20 mm. The incidence of procedure-related adverse events such as bleeding and infection is low, and thus, EUS-FNA can be safely performed to diagnose SELs.

Efficacy of endoscopic ultrasound and endoscopic resection for esophageal schwannoma

BACKGROUND

Esophageal schwannoma (ES) is a rare submucosal tumor, and its complete and safe resection is a topic that deserves special attention.

AIM

This study aimed to investigate the clinical value of endoscopic ultrasound (EUS) in the diagnosis of ES and the clinical efficacy of endoscopic resection for ES.

METHODS

The clinical data, endoscopic characteristics, endoscopic treatment, postoperative complications, immunohistochemical results, and follow-up records of patients with ES admitted to the Tianjin Medical University General Hospital from January 2012 to January 2022 were retrospectively analyzed.

RESULTS

Under white-light endoscopy, 81.8% (9/11) of lesions were submucosal elevations, covering the normal esophageal epithelium. Two of the lesions with redness and erosive surface. Eight lesions (72.7%) appear on EUS originating from the muscularis propria were homogeneous or inhomogeneous hypoechoic signals. Two lesions were inhomogeneous hyperechoic originating from the submucosa or muscularis propria, respectively. One lesion was homogeneous hypoechoic originating from the submucosa. All lesions had no blood flow signals, cystic changes, or calcification, and were completely removed by submucosal tunnel endoscopic resection (STER) or endoscopic submucosal dissection (ESD). All patients did not experience serious adverse events as well as recurrence, metastasis, or cicatricial esophageal stenosis during the follow-up period.

CONCLUSION

ES is a rare submucosal lesion, which endoscopic characteristics are difficult to distinguish from other esophageal submucosal tumors. Endoscopic resection can provide a minimally invasive and alternative treatment for ES.

EUS-Guided Diagnosis of Gastric Subepithelial Lesions, What Is New?

Gastric subepithelial lesions (SELs) are intramural lesions that arise underneath the gastric mucosa. SELs can be benign, but can also be malignant or have malignant potential. Therefore, correct diagnosis is crucial. Endosonography has been established as the diagnostic gold standard. Although the identification of some of these lesions can be carried out immediately, solely based on their echo characteristics, for certain lesions histological examination is necessary. Sometimes histology can be inconclusive, especially for smaller lesions. Therefore, new methods have been developed in recent years to assist decision making, such as contrast enhanced endosonography, EUS elastography, and artificial intelligence systems. In this narrative review we provide a complete overview of the gastric SELs and summarize the new data of the last ten years concerning the diagnostic advances of endosonography on this topic.

Diagnostic performance of endoscopic ultrasonography-guided fine-needle biopsy in upper gastrointestinal subepithelial tumors measuring 2-5 cm in size

BACKGROUND

Subepithelial tumors (SETs) in the upper gastrointestinal (GI) tract are frequently discovered during upper endoscopy, and their management is determined based on size and histopathological diagnosis. We aimed to evaluate the diagnostic performance of endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) in upper GI SETs of 2-5 cm in size.

METHODS

We included 63 patients who underwent EUS-FNB for upper GI SETs of 2-5 cm in size between January 2013 and February 2020. The diagnostic yield of EUS-FNB, ability of EUS-FNB in discriminating malignant from non-malignant lesions, and histopathological concordance between EUS-FNB specimens and resected specimens were evaluated.

RESULTS

Successful acquisition of macroscopic tissue cores was possible in all 63 cases, and the diagnostic yield of EUS-FNB was 92.1% (58/63). The sensitivity, specificity, and accuracy of EUS-FNB in discriminating malignant from non-malignant lesions were 100% (95% confidence interval [CI] 85.3-100%), 87.8% (95% CI 79.9-87.8%), and 92.1% (95% CI 81.8-92.1%), respectively. Of the 26 SETs that were endoscopically or surgically resected after EUS-FNB, the histopathological concordance rate between the EUS-FNB specimens and resected specimens was 100% (24/24), except in two cases of inadequate results with EUS-FNB specimens.

CONCLUSION

EUS-FNB provides high diagnostic yield and high capability in discriminating malignant from non-malignant lesions in upper GI SETs of 2-5 cm in size.

Franseen Needles May Be Promising for Improving the Sampling Adequacy of EUS-FNA for Subepithelial Lesions

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is useful in diagnosing subepithelial lesions (SELs), and adequate tissue sampling is necessary to differentiate between benign and malignant diseases to determine therapeutic strategies. This study aimed to evaluate sampling adequacy and diagnostic performance of EUS-FNA for SELs with Franseen needles. This retrospective study enrolled 130 patients who underwent EUS-FNA with a 22-gauge needle for SELs from January 2010 to March 2021. We compared sampling adequacy and predictive factors influencing the sampling adequacy of EUS-FNA for SELs between Franseen and conventional needles. The sampling adequacy rates were 95.0% (38/40) with Franseen needles and 76.7% (69/90) with conventional needles (p = 0.011). The mean number of punctures with Franseen needles (2.80) was significantly less than that with conventional needles (3.42) (p < 0.001). In the multivariate analysis, the use of Franseen needles (p = 0.029; odds ratio [OR], 5.37; 95% confidence interval [CI], 1.18−23.36) was an independent factor influencing the sampling adequacy. Compared to conventional needles, the Franseen needle could play a vital role in accurately diagnosing SELs by yielding better sampling adequacy and reducing the number of passes.

The Diagnosis of Small Gastrointestinal Subepithelial Lesions by Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy

Endoscopic ultrasonography (EUS) has been widely accepted in the diagnosis of all types of tumors, especially pancreatic tumors, lymph nodes, and subepithelial lesions (SELs). One reason is that the examination can provide a detailed observation, with tissue samples being immediately obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Many SELs are detected incidentally during endoscopic examinations without symptoms. Most SELs are mesenchymal tumors originating from the fourth layer, such as gastrointestinal stromal tumors (GISTs), leiomyomas, and schwannomas. GISTs are potentially malignant. Surgical treatment is recommended for localized GISTs of ≥20 mm. However, the indications for the diagnosis and follow-up of GISTs of <20 mm in size are controversial. There are several reports on the rapid progression or metastasis of small GISTs. Therefore, it is important to determine whether a SEL is a GIST or not. The main diagnostic method is EUS-FNA. Recently, endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) using a new biopsy needle has been reported to obtain larger tissue samples. Additionally, various biopsy methods have been reported to have a high diagnostic rate for small GISTs. In local gastric SELs, regardless of the tumor size, EUS can be performed first; then, EUS-FNA/B or various biopsy methods can be used to obtain tissue samples for decision-making in relation to therapy and the follow-up period.