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Endoscopic Ultrasonography in the Diagnosis of Upper Gastrointestinal Submucosal Tumors
Rayadh A. Zaydan
Gsatroenterology and hepatology teaching hospital
Background and Study Aims
Endoscopic ultrasonography(EUS) has recently been reported to be useful in the diagnosis of submucosal tumors (SMT). The aim of this study was to show that EUS may help to differentiate the SMT in the upper gastrointestinal tract by comparing and analyzing the EUS finding of SMT and it is pathology.
Patients and Methods
A total of 22 patients with gastrointestinal SMT diagnosed with EUS were studied. The location and layer of origin of gastrointestinal SMT were analyzed and compared. The histological diagnosis of resected specimen by surgery in most patients was compared with their results of EUS.
Results
The majority of gastrointestinal SMT (20 patients) were myogenic tumors (leiomyoma and leiomyosarcoma) which originated from muscularis properia. Two patients had lipomas that originated from submucosa. The histopathological results of resected specimen were consistent with preoperative diagnosis of EUS.
Conclusion
EUS is the best diagnostic method not only for gastrointestinal SMT diagnosis but also for determine the layer of origin and subsequently differentiate different types of SMT.
Introduction
Submucosal tumors (SMT) are frequently incidental finding on radialogic and endoscopic examination (1).
Endoscoipc ultrasonography (EUS) is the investigative procedure of choice when a submucosal lesion has been visualized endoscopically. EUS can accurately show the exact origin of lesion, whether inside or out side the gastrointestinal wall. Inside the gastrointestinal wall EUS can detect the layer of origin, for instance the 4th layer in leiomymas or the 3rd layer in lipomas (2,3). However high frequency ultrasonic probe enables a proper diagnosis of esophageal leiomyoma derived from musculair propria (4).
Unfortunately, EUS can not reliably show the difference between the benign and malignant submucasal tumors.
However EUS characteristic such size, borders, homogeneity and presence of necrosis can help to decide whether a lesion should be surgically removed or followed by EUS.(5,6). Like other gastrointestinal tract tumors, EUS may identify SMT as hypoechoic intramural masses except lipomas which identify as hyperechois intramural masses (7).
Nevertheless, the diagnosis on the basis of EUS is presumptive and can not replace the histological diagnosis of SMT (8,9 ).
Patients and Methods
From April 2002 to March 2005, 22 patients diagnosed by EUS as having upper gastro- intestinal SMT at the gastroenterology and hepatology teaching hospital. There were 14 males and 8 females, and the mean age was 55 years. Initially all 22 patients were examined by conventional endoscopy which revealed submucosal protruding lesion that suspected submucasal tumors. EUS examination was performed using Pntax FG34UX convex array endosonography. The echoendoscope was connected to Hitachi ultrasound scanner EUB 525. EUS study of these SUT was performed to assess size of the tumor, echo characteristics of the lesions, irregularity of border, and presence or absence of calcification and internal necrosis.
Eighteen out of 22 patients received surgical resection.
The other 4 patients were followed up with upper endoscopy and EUS examination every 6 months.
Results
Results were summarized in table (1). EUS imaging provided a presumptive diagnosis of myogenic tumors (hypoechoic lesions arising from 4th wall layer ) in 20/22 patients, these were classified as leiomyoma in 13 patients and liomyosarcoma in 7 patients. Other 2/22 patients had hyperechoic lesions arising from 3rd wall layer (submucosa) diagnosed as lipomas.
The SMT size ranged from 1.5 cm to 10 cm. Most of these tumors located in the stomach, while two tumors located in the distal esophagus and one tumor in the descending duodenum. EUS images showed heterogeneous echogenicity and / or calcification and necrosis in tumors over 5 cm diameter (7 myogenic tumors).
Pathological diagnosis revealed leiomyoma 12,leiomyosarcoma 4, and lipoma 2.
Table (1).EUS and pathological Features of SMT of upper gastrointestinal tract.
No. of SMT Site Size (mm) Presumptive EUS diagnosis Pathological Diagnosis Follow up(months)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Stomach (body)
Stomach (body)
Stomach (fundus)
Stomach (body)
Stomach (body)
Stomach (body)
Stomach (fundus)
Stomach (fundus)
Lower esophagus
Stomach (body)
Descending duodenum
Stomach (fundus)
Stomach (Antrum)
Lower esophagus
Stomach (Antrum)
Stomach (fundus)
Stomach (Antrum)
Stomach (body)
Stomach (body)
Stomach (body)
Stomach (Antrum)
Stomach (body)
100
95
82
43
51
20
72
15
35
40
22
75
30
15
13
56
62
75
27
54
34
25
Leiomyosarcoma
Leiomyosarcoma
Leiomyosarcoma
Leiomyoma
Leiomyoma
Leiomyoma
Leiomyosarcoma
Leiomyoma
Leiomyoma
Leiomyoma
Leiomyoma
Leiomyosarcoma
Leiomyoma
Leiomyoma
Leiomyoma
Leiomyoma
Leiomyosarcoma
Leiomyoma
Leiomyoma
Leiomyoma
Lipoma
Lipoma
Leiomyosarcoma
leiomyosarcoma
leiomyosarcoma
leiomyoma
leiomyoma
leiomyoma
leiomyosarcoun
leiomyoma
leiomyoma
leiomyoma
leiomyomaleiomyoma
 
 
leiomyoma
 
leiomyoma
leiomyoma
 
leiomyoma
leiomyoma
Lipoma
Lipoma
 
 
 
 
 
 
 
 
 
 
 
9
12
 
14
 
 
10
 
 
 
 
Discussion
Gastrointestinal SMTs is a common kind of tumor in gastrointestinal tract. Because it is originate from the muscular mucosa, muscaloris propria and / or submucosa, conventional endoscpy can not diagnose SMT accurately.
Sine EUS used in the clinical diagnosis, the diagnostic situation of SMT has changed greatly (10,11).
In this study we used linear array transducer, while in the other studies (2,3,4,7) the mechanical radial transducer was used. Our study showed that EUS head a very important diagnostic value for gastrointestinal leiomyoma. However it is still possible to mistake the diagnosis of leiomyoma because the ultrasonic images of other gastrointestinal wall lesion like panereatic rest and carcinoid tumor are similar to that of leiomyoma (12).
Although EUS can determine the originating layer of SMT in the small size tumors, but il is difficult to assess the layer of origin in the large tumor (> 6 cm in diameter). However EUS still the most accurate diagnostic modality for assessing the upper gastrointestinal SMT, and it is more accurate than CT scanning or other radiological studies (13). In this study we depend on the echo features of SMT like; size (> 5 cm indiameter), heterogenicity,and borders for assessing the nature of tumor, but this is not always possible to distinguish leiomyoma from leiomyosarcoma. Several studies have shown that FNA is accurate and useful in the diagnosis of myogaic tumor (8,9). In addition EUS makes the therapy of gastrointestinal SMT more rational, safe and effective. For those patients who can not be treated by surgery, we follow up them by EUS periodically.The results showed that SMT grew slowly and show no marked charges in short time.
In conclusion, EUS is safe and effective diagnostic method for gastrointestinal SMT.
References
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  10. Shen EF, Arnott ID, Plevris J, et al. Endoscopic ultrasonography in the diagnosis and management to suspected upper gastrointestinal submucosal tumors. Bar J swgery 2002;89:231-235.
  11. Varas Larenzo MJ. Mealuenela MD, Pou JM, et al. The value of endoscopic ultrasonogaphy in the study of submucosal tumor at dugertive tract. Gastro enterol hepatol 1998;21:121-124.
  12. Guo-Qiang XU, Bing- Ling Zhng, et al. Diagnostic value of endoscopic ultrasongraphy for gastro intestinal leiomyoma. World Journal of gastroent 2003;9:2088-2091.
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