Subepithelial lesions: a deeper look

Comparison between endoscopic ultrasound-guided fine-needle biopsy and bite-on-bite jumbo biopsy for sampling of subepithelial lesions

BACKGROUND AND AIMS

A direct comparison between endoscopic ultrasound (EUS) fine-needle biopsy (FNB) and current endoscopic biopsy techniques in patients with subepithelial lesions (SELs) is still lacking. Aim of this multicenter study was to compare the diagnostic performance and safety profile between EUS-FNB and bite-on-bite jumbo biopsy.

METHODS

Out of 416 patients undergoing endoscopic sampling of SELs between 2017 and 2021, after propensity score matching two groups were compared: 120 undergoing EUS-FNB and 120 sampled with bite-on-bite jumbo biopsy. Primary outcome was sample adequacy. Secondary outcomes were diagnostic accuracy, sensitivity, specificity, and adverse events.

RESULTS

Median age was 61 years and most patients were male in both groups. Final diagnosis was GIST in 65 patients (54.1%) in the EUS-FNB group and 62 patients in the bite-on-bite biopsy group (51.6%; p = 0.37). Sample adequacy was significantly higher in the EUS-FNB group as compared to the bite-on-bite biopsy group (94.1% versus 77.5%, p<0.001). EUS-FNB outperformed bite-on-bite biopsy also in terms of diagnostic accuracy (89.3% versus 67.1%, p<0.001) and sensitivity (89% vs 64.5%; p<0.001), whereas specificity was 100% in both groups (p = 0.89). These findings were confirmed in subgroup analysis according to SEL location, final diagnosis, and wall layers of the sampled SEL. Adverse event rate was 6.6% in the EUS-FNB group and 30% in the bite-on-bite biopsy group (p<0.001).

CONCLUSION

EUS-FNB outperforms bite-on-bite biopsy both in terms of diagnostic yield and safety profile.

An Atypical Presentation of a Colonic Lipoma: Avoiding Surgery with a Deeper Endoscopic Look

INTRODUCTION

Colonic lipomas are common mesenchymal tumours. They are usually asymptomatic and incidentally diagnosed during endoscopic or radiological examinations. Taking into account their typical endoscopic and radiological features and benign nature, tissue sampling, resection or follow-up are generally not required.

CASE REPORT

A 61-year-old woman with poor surgical fitness presented with colonic subocclusion and lower gastrointestinal bleeding. A colonoscopy performed 1 month earlier showed a large polypoid lesion with necrotic and ulcerated areas occupying the lumen of the proximal ascending colon with inconclusive histology. An abdominopelvic computed tomography scan with intravenous contrast was done revealing a cecal-colonic intussusception of a heterogeneous mass. The patient was successfully managed conservatively. A delayed revision colonoscopy showed a significantly smaller atypical subepithelial lesion with no necrosis or ulceration. A single, large and deep incision with a pre-cut needle-knife® allowed the direct collection of lesion tissue using standard biopsy forceps through the so-called single-incision needle-knife® (SINK) biopsy technique. Histological examination was compatible with submucosal lipoma. After 18 months of follow-up, the patient remains asymptomatic.

DISCUSSION/CONCLUSION

Colonic lipoma complications are rare and can lead to misdiagnosis; in general, they are surgically managed. A conservative approach and a minimally invasive endoscopic procedure allowed a definite diagnosis avoiding the morbidity and mortality of a major surgical intervention in a high-risk patient.

Prospective comparative study of endoscopic ultrasonography-guided fine-needle biopsy and unroofing biopsy

BACKGROUND AND AIM

Adequate tissue acquisition is important in making treatment decisions for patients with upper gastrointestinal subepithelial tumors (SETs). This study aimed to compare the outcomes of endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) with those of the unroofing biopsy technique.

METHODS

This study was a single-center, prospective comparative study conducted at Severance Hospital, Yonsei University College of Medicine. A total of 39 patients with SETs ≥15 mm were enrolled between January 2016 and August 2017.

RESULTS

Of the 39 patients, 28 underwent biopsy with both techniques (4 underwent only unroofing and 7 underwent only EUS-FNB). Histological diagnosis was made with EUS-FNB in 64.3% and unroofing biopsy in 78.6% (p = 0.344), and immunohistochemical diagnosis was made with EUS-FNB in 46.4% and unroofing biopsy in 67.9% (p = 0.180). In the subgroup analysis (28 patients), there was no significant difference in diagnostic yield between the 2 methods The mean procedural time with EUS-FNB was shorter than that with unroofing biopsy (p < 0.001). The larger SET (≥ 20 mm) (p = 0.035) and satisfaction of procedure (p = 0.019) were positively associated with successful histological diagnosis by EUS-FNB.

CONCLUSIONS

There was no significant difference in the histological diagnostic yield for SETs between the EUS-FNB and unroofing biopsy techniques (CinicalTrials.gov. identifier NCT02646241).

Endosonography-Guided Fine-Needle Aspiration versus "Key-Hole Biopsy" in the diagnostics of upper gastrointestinal subepithelial tumors. A prospective randomized interventional study

BACKGROUND

The management and prognosis of subepithelial tumors (SETs) of the upper gastrointestinal tract depend on the correct preoperative evaluation, including tissue diagnosis in selected cases. Several methods providing deep tissue sampling for cytological and/or histological examinations have been described but their diagnostic yield and precise position in the diagnostic algorithm remain to be established. This prospective randomized study aims to compare the Endosonography-Guided Fine-Needle Aspiration (EUS-FNA) to Key-Hole Biopsy (KHB) in cytological or histological diagnostics of upper gastrointestinal SETs.

PATIENTS AND METHODS

This study was conducted in a single tertiary endoscopy center in Ostrava, Czech Republic between November 2010 and October 2015. Patients with endoscopically detected SETs of the upper gastrointestinal tract with a diameter ≥ 2 cm, were randomized to either the EUS-FNA with 22G needle, or to the Key Hole biopsy (forceps biopsy through mucosal incision) groups. The main study outcomes were success rate of tissue diagnostics and, in the cases of Gastrointestinal Stromal Tumours (GIST), possibility of determining mitotic activity. A cross-over examination was performed in situations where the first method had failed.

RESULTS

A total of 46 consecutive patients were randomized. Of these, 24 (52%) and 22 (48%) were randomized to EUS-FNA group and KHB arm, respectively. 5 SETs (11%) were detected in the esophagus, 40 (87%) in the stomach and 1 (2%) in the duodenum. The definitive diagnosis was established by the first sampling method in 42 (91%) patients, including 22 (92%) in the EUS-FNA group and 20 (91%) in the KHB group (P=0.999), and after a cross-over in another 3 (7%) patients. The most prevalent SET was GIST (70%). Although some mitotic activity could be observed in 11 patients, the mitotic index could be diagnosed in none of them. Of a total of 20 surgically treated patients, preoperative and postoperative tissue diagnosis corresponded in 19/20 (95%) cases, including 100% in FNA group and 91% in KHB group (P=0.999). No adverse events of tissue sampling occurred in the study.

CONCLUSIONS

Deep tissue sampling by EUS-FNA and KHB are equally effective in the diagnostics of SETs of the upper gastrointestinal tract ≥ 2 cm. However, neither EUS-FNA nor KHB provided adequate tissue sample to determine mitotic index.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT02025244).