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Deprez PH, Moons LMG, OʼToole D, Gincul R, Seicean A, Pimentel-Nunes P, Fernández-Esparrach G, Polkowski M, Vieth M, Borbath I, Moreels TG, Nieveen van Dijkum E, Blay JY, van Hooft JE. Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:412-429. [PMID: 35180797 DOI: 10.1055/a-1751-5742] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
1: ESGE recommends endoscopic ultrasonography (EUS) as the best tool to characterize subepithelial lesion (SEL) features (size, location, originating layer, echogenicity, shape), but EUS alone is not able to distinguish among all types of SEL.Strong recommendation, moderate quality evidence. 2: ESGE suggests providing tissue diagnosis for all SELs with features suggestive of gastrointestinal stromal tumor (GIST) if they are of size > 20 mm, or have high risk stigmata, or require surgical resection or oncological treatment.Weak recommendation, very low quality evidence. 3: ESGE recommends EUS-guided fine-needle biopsy (EUS-FNB) or mucosal incision-assisted biopsy (MIAB) equally for tissue diagnosis of SELs ≥ 20 mm in size.Strong recommendation, moderate quality evidence. 4: ESGE recommends against surveillance of asymptomatic gastrointestinal (GI) tract leiomyomas, lipomas, heterotopic pancreas, granular cell tumors, schwannomas, and glomus tumors, if the diagnosis is clear.Strong recommendation, moderate quality evidence. 5: ESGE suggests surveillance of asymptomatic esophageal and gastric SELs without definite diagnosis, with esophagogastroduodenoscopy (EGD) at 3-6 months, and then at 2-3-year intervals for lesions < 10 mm in size, and at 1-2-year intervals for lesions 10-20 mm in size. For asymptomatic SELs > 20 mm in size that are not resected, ESGE suggests surveillance with EGD plus EUS at 6 months and then at 6-12-month intervals.Weak recommendation, very low quality evidence. 6: ESGE recommends endoscopic resection for type 1 gastric neuroendocrine neoplasms (g-NENs) if they grow larger than 10 mm. The choice of resection technique should depend on size, depth of invasion, and location in the stomach.Strong recommendation, low quality evidence. 7: ESGE suggests considering removal of histologically proven gastric GISTs smaller than 20 mm as an alternative to surveillance. The decision to resect should be discussed in a multidisciplinary meeting. The choice of technique should depend on size, location, and local expertise.Weak recommendation, very low quality evidence. 8: ESGE suggests that, to avoid unnecessary follow-up, endoscopic resection is an option for gastric SELs smaller than 20 mm and of unknown histology after failure of attempts to obtain diagnosis.Weak recommendation, very low quality evidence. 9: ESGE recommends basing the surveillance strategy on the type and completeness of resection. After curative resection of benign SELs no follow-up is advised, except for type 1 gastric NEN for which surveillance at 1-2 years is advised.Strong recommendation, low quality evidence. 10: For lower or upper GI NEN with a positive or indeterminate margin at resection, ESGE recommends repeating endoscopy at 3-6 months and another attempt at endoscopic resection in the case of residual disease.Strong recommendation, low quality evidence.
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Affiliation(s)
- Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Leon M G Moons
- Divisie Interne Geneeskunde en Dermatologie, Maag-, Darm- en Leverziekten, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Dermot OʼToole
- Neuroendocrine Tumor Service, ENETS Centre of Excellence, St. Vincent's University Hospital and Department of Clinical Medicine, Trinity College Dublin, University of Dublin St. James's Hospital, Dublin, Ireland
| | - Rodica Gincul
- Service de Gastroentérologie et Endoscopie Digestive, Hôpital Privé Jean Mermoz, Lyon, France
| | - Andrada Seicean
- Regional Institute of Gastroenterology and Hepatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Pedro Pimentel-Nunes
- Department of Gastroenterology, Portuguese Oncology Institute of Porto; Department of Surgery and Physiology, Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Portugal
| | | | - Marcin Polkowski
- Department of Gastroenterology, Hepatology and Clinical Oncology, Center for Postgraduate Medical Education, and Department of Oncological Gastroenterology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Michael Vieth
- Institut of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Ivan Borbath
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Tom G Moreels
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Els Nieveen van Dijkum
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, The Netherlands
| | - Jean-Yves Blay
- Centre Léon Bérard, Université Claude Bernard Lyon 1, Lyon, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Seven G, Arici DS, Senturk H. Correlation of Endoscopic Ultrasonography Features with the Mitotic Index in 2- to 5-cm Gastric Gastrointestinal Stromal Tumors. Dig Dis 2021; 40:14-22. [PMID: 33794522 DOI: 10.1159/000516250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/26/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Predicting the malignancy potential of gastrointestinal stromal tumor (GIST) before resection could improve patient management strategies as gastric GISTs with a low malignancy potential can be safely treated endoscopically, but surgical resection is required for those tumors with a high malignancy potential. This study aimed to evaluate endoscopic ultrasound (EUS) features of 2- to 5-cm gastric GISTs that might be used to predict their mitotic index using surgical specimens as the gold standard. PATIENTS AND METHODS Forty-nine patients (30 females and 19 males; mean age 55.1 ± 12.7 years) who underwent EUS examinations, followed by surgical resections of 2- to 5-cm gastric GISTs, were retrospectively reviewed. RESULTS The mean tumor size was 3.44 ± 0.97 (range 2.1-5.0) cm. A univariate analysis revealed no significant differences in age, sex, and tumor location in the low mitotic index and high mitotic index groups (all p > 0.05). In terms of EUS features, there were no significant differences in the mitotic indexes with respect to the shape, surface lobulation, border regularity, echogenicity, homogeneity, growth patterns, presence of mucosal ulceration, hyperechogenic foci, anechoic spaces, and hypoechoic halos (all p > 0.05). However, the tumor size was larger in the high mitotic index group than that in the low mitotic index group (3.97 ± 1.05 vs. 3.27 ± 0.9 cm, p = 0.03). CONCLUSION Conventional EUS features are not reliable for predicting the mitotic index of 2- to 5-cm gastric GISTs. Further modalities for predicting the mitotic index are needed to prevent unnecessary surgical resections in patients with a low risk of malignancy.
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Affiliation(s)
- Gulseren Seven
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
| | - Dilek Sema Arici
- Division of Pathology, Bezmialem Vakif University, Istanbul, Turkey
| | - Hakan Senturk
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
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3
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Seven G, Kochan K, Caglar E, Kiremitci S, Koker IH, Senturk H. Evaluation of Ki67 Index in Endoscopic Ultrasound-Guided Fine Needle Aspiration Samples for the Assessment of Malignancy Risk in Gastric Gastrointestinal Stromal Tumors. Dig Dis 2020; 39:407-414. [PMID: 33017820 DOI: 10.1159/000511994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The risk of malignancy in resected gastrointestinal stromal tumors (GISTs) depends on tumor size, location, and mitotic index. Reportedly, the Ki67 index has a prognostic value in resected GISTs. We aimed to analyze the accuracy of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) samples with reference to Ki67 index, using surgical specimens as the gold standard. METHODS Fifty-five patients who underwent EUS-FNA followed by surgical resection for gastric GISTs were retrospectively analyzed. Patients' age and sex; tumors' size and location; mitotic index, cell type, cellularity, pleomorphism, presence of ulceration, hemorrhage, necrosis, mucosal or serosal invasion, growth pattern, and Ki67 index based on pathology were investigated. RESULTS Location in fundus, ulceration, hemorrhage, mucosal invasion, and Ki67 index in surgical specimens were significant in predicting high-risk groups (p < 0.05) on univariate analysis. Frequency of bleeding (p = 0.034) and the Ki67 index (p = 0.018) were the only independent significant factors in multivariate analysis. The optimal cutoff level of Ki67 was 5%, with 88.2% sensitivity and 52.8% specificity (p = 0.021). The mean Ki67 index was lower in EUS-FNA samples than in surgical specimens (2% [1-15] versus 10% [1-70], p = 0.001). The rank correlation coefficient value of Ki67 was 0.199 (p = 0.362) between EUS-FNA and surgical samples and showed no reliability for EUS-FNA samples. CONCLUSION The Ki67 index in resected specimens correlated with high-risk GISTs, although it had no additive value to the current criteria. The Ki67 index in EUS-guided FNA samples is not a reliable marker of proliferation in GISTs.
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Affiliation(s)
- Gulseren Seven
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
| | - Koray Kochan
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
| | - Erkan Caglar
- Division of Gastroenterology, Balikesir University School of Medicine, Balikesir, Turkey
| | - Sercan Kiremitci
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Hakan Senturk
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
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Dhaliwal A, Kolli S, Dhindsa BS, Mashiana HS, Bhogal N, Bhat I, Singh S, Adler DG. Diagnostic yield of deep biopsy via endoscopic submucosal dissection for the diagnosis of upper gastrointestinal subepithelial tumors: a systematic review and meta-analysis. Ann Gastroenterol 2020; 33:30-37. [PMID: 31892795 PMCID: PMC6928476 DOI: 10.20524/aog.2019.0444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/14/2019] [Indexed: 12/14/2022] Open
Abstract
Background: Conventionally, endoscopic ultrasound-guided fine-needle aspiration and biopsy (EUS-FNA)/EUS-FNB) has been used for tissue diagnosis of upper gastrointestinal (GI) subepithelial tumors (SETs). However, deep biopsy (DB) via endoscopic submucosal dissection (ESD) is emerging as an alternative technique, given the inadequate tissue sampling with EUS-FNA/EUS-FNB. Our aim was to conduct a systematic review and meta-analysis to report the overall diagnostic yield of DB via ESD for upper GI SETs. Methods: PubMed, Cochrane Library and Web of Science databases were searched to identify studies (from commencement to Oct 2017) that reported the DB via ESD technique for diagnosis of upper GI SETs. The primary outcome of interest was the method’s overall diagnostic yield and the secondary outcome was to the occurrence of complications. The meta-analysis was performed using the DerSimonian and Laird random-effects model. Results: A total of 7 studies, comprising 209 patients with a mean age of 57.3 years, were included in the final meta-analysis. The overall pooled diagnostic yield of DB via ESD for upper GI SETs was 95% (95% confidence interval [CI] 84.91-99.98, I2=78.2%). Overall, pooled outcomes of major bleeding and perforation in our meta-analysis was noted in 0.07% (95%CI 0.00-2.32, I2=0%) and 0% (95%CI 0.00-1.70, I2=0%) respectively. Data regarding major bleeding and perforation rates were not reported in 2 studies. Substantial heterogeneity was observed in our meta-analysis. Conclusion: DB via ESD is an effective and safe procedure for diagnosing upper GI SETs. Further multicenter randomized controlled trials are needed to validate these findings.
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Affiliation(s)
- Amaninder Dhaliwal
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha (Amaninder Dhaliwal, Singh Mashiana, Neil Bhogal, Ishfaq Bhat, Shailender Singh)
| | - Sindhura Kolli
- Department of Internal Medicine, The Brooklyn Hospital Center, New York (Sindhura Kolli)
| | - Banreet Singh Dhindsa
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine (Banreet Singh Dhindsa)
| | - Harmeet Singh Mashiana
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha (Amaninder Dhaliwal, Singh Mashiana, Neil Bhogal, Ishfaq Bhat, Shailender Singh)
| | - Neil Bhogal
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha (Amaninder Dhaliwal, Singh Mashiana, Neil Bhogal, Ishfaq Bhat, Shailender Singh)
| | - Ishfaq Bhat
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha (Amaninder Dhaliwal, Singh Mashiana, Neil Bhogal, Ishfaq Bhat, Shailender Singh)
| | - Shailender Singh
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha (Amaninder Dhaliwal, Singh Mashiana, Neil Bhogal, Ishfaq Bhat, Shailender Singh)
| | - Douglas G Adler
- Department of Gastroenterology and Hepatology, University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, Utah (Douglas G. Adler), USA
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Ricci R, Chiarello G, Attili F, Fuccio L, Alfieri S, Persiani R, Di Pietro S, Martini M, Costamagna G, Larocca LM, Larghi A. Endoscopic ultrasound-guided fine needle tissue acquisition biopsy samples do not allow a reliable proliferation assessment of gastrointestinal stromal tumours. Dig Liver Dis 2015; 47:291-5. [PMID: 25596931 DOI: 10.1016/j.dld.2014.12.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/15/2014] [Accepted: 12/18/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current prognostication of gastrointestinal stromal tumours is validated on/applies to resected tumours, mainly because surgery is recommended whenever possible. However, pre-treatment prognostication is increasingly warranted, considering the follow-up strategy recently admitted for expectedly low-risk tumours and the possible distinctive molecular features/spontaneous regression of some small cases. AIMS To investigate whether endoscopic ultrasound-guided fine-needle tissue acquisition-biopsies reflect prognosticators of resected gastrointestinal stromal tumours, for possibly developing reliable pre-treatment prognostic criteria. METHODS The applicability/reliability of mitotic index/5mm(2) and MIB1 proliferative index/1000 cells were tested in 35 endoscopic ultrasound-guided fine-needle tissue acquisition-biopsies diagnosed as gastrointestinal stromal tumour, subsequently resected without intervening therapy, consecutively collected in thirty months. Size and mitotic/proliferative indexes were compared with resection specimens. The feasibility of bioptic genotyping was also tested. RESULTS 35 patients were studied (45.7% males; mean age 61.6 years, range 26-83 years). Mitotic/proliferative indexes were determinable in 68.6%/88.6% of biopsies, respectively; they were nevertheless underestimated, as happened with endoscopic ultrasound-determined tumour size. Bioptic genotyping revealed reliable. CONCLUSIONS Endoscopic ultrasound-guided fine-needle tissue acquisition does not reliably reflect gastrointestinal stromal tumours' proliferation and size. Alternative parameters should be validated for a pre-surgical prognostic classification. Considering the emerging potentially prognostic genetic markers in gastrointestinal stromal tumours, the reliability of bioptic genotyping is a promising result.
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Affiliation(s)
- Riccardo Ricci
- Department of Pathology, Catholic University, Rome, Italy.
| | - Gaia Chiarello
- Department of Pathology, Catholic University, Rome, Italy
| | - Fabia Attili
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | | | | | | | | | | | | | - Alberto Larghi
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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