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Original Articles
Prevalence and natural course of incidental gastric subepithelial tumors
Dae-Hyuk Heo, Min A Yang, Jae Sun Song, Won Dong Lee, Jin Woong Cho
Received May 4, 2023  Accepted July 16, 2023  Published online March 29, 2024  
DOI: https://doi.org/10.5946/ce.2023.124    [Epub ahead of print]
Graphical AbstractGraphical Abstract AbstractAbstract PDFPubReaderePub
Background
/Aims: Gastric subepithelial tumors (SETs) are often encountered during the upper gastrointestinal endoscopic screening. We assessed the prevalence of gastric SETs and the risk factors for their progression.
Methods
We reviewed the electronic medical records of 30,754 patients who underwent upper gastrointestinal endoscopic screening at our medical center between January 2013 and December 2016.
Results
Among the 30,754 patients examined, 599 (1.94%) had gastric SETs. The prevalence increased with age and was 9.56% in patients aged ≥70 years. In total, 262 patients underwent serial endoscopy for more than 6 months. The median age was 68 years (interquartile range [IQR], 61–74), and the number of females was 167 (63.7%). During a median follow-up of 58 months (IQR, 38–75), 22 patients (8.4%) showed significant changes in tumor size. An irregular border (odds ratio, 4.623; 95% confidence interval, 1.093–19.558; p=0.037) was a significant risk factor for progression. Seven patients underwent surgical or endoscopic resections. The pathologies of gastric SETs included leiomyomas (n=3), gastrointestinal stromal tumors (n=2), and lipomas (n=2).
Conclusions
The prevalence of gastric SETs increases with age. Most gastric SETs do not progress during long-term endoscopic examinations, and the risk of an increase in size is low in asymptomatic small SETs without irregular borders.

Citations

Citations to this article as recorded by  
  • Artificial Intelligence-Based Diagnosis of Gastric Mesenchymal Tumors Using Digital Endosonography Image Analysis
    Dong Chan Joo, Gwang Ha Kim, Moon Won Lee, Bong Eun Lee, Ji Woo Kim, Kwang Baek Kim
    Journal of Clinical Medicine.2024; 13(13): 3725.     CrossRef
  • 1,760 View
  • 77 Download
  • 1 Crossref
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Comparison of diagnostic performances of slow-pull suction and standard suction in endoscopic ultrasound-guided fine needle biopsy for gastrointestinal subepithelial tumors
Joon Seop Lee, Chang Min Cho, Yong Hwan Kwon, An Na Seo, Han Ik Bae, Man-Hoon Han
Clin Endosc 2022;55(5):637-644.   Published online August 17, 2022
DOI: https://doi.org/10.5946/ce.2021.257
AbstractAbstract PDFPubReaderePub
Background
/Aims: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is integral to the diagnosis of gastrointestinal (GI) subepithelial tumors (SETs). The impact of different EUS-FNB tissue sampling techniques on specimen adequacy and diagnostic accuracy in SETs has not been fully evaluated. This study aimed to compare the diagnostic outcomes of slow-pull (SP) and standard suction (SS) in patients with GI SETs.
Methods
In this retrospective comparative study, 54 patients were enrolled. Medical records were reviewed for location and size of the target lesion, FNB needle type/size, technical order, specimen adequacy, diagnostic yield, and adverse events. The acquisition rate of adequate specimens and diagnostic accuracy were compared according to EUS-FNB techniques.
Results
The mean lesion size was 42.6±36.4 mm, and most patients were diagnosed with GI stromal tumor (75.9%). The overall diagnostic accuracies of the SP and SS techniques were 83.3% and 81.5%, respectively (p=0.800). The rates of obtaining adequate core tissue were 79.6% and 75.9%, respectively (p=0.799). No significant clinical factors affected the rate of obtaining adequate core tissue, including lesion location and size, FNB needle size, and final diagnosis.
Conclusions
SP and SS had comparable diagnostic accuracies and adequate core tissue acquisition for GI SETs via EUS-FNB.

Citations

Citations to this article as recorded by  
  • Endoscopic ultrasound-guided fine-needle aspiration for gastrointestinal subepithelial lesions
    Takuto Hikichi, Minami Hashimoto, Takumi Yanagita, Tsunetaka Kato, Jun Nakamura
    Journal of Medical Ultrasonics.2024; 51(2): 195.     CrossRef
  • What method can we choose if rapid on-site evaluation is not available for the endoscopic ultrasound-guided tissue acquisition of upper gastrointestinal subepithelial lesions?
    Yu Kyung Cho
    Clinical Endoscopy.2024; 57(1): 53.     CrossRef
  • The Diagnostic Approach of Benign Esophageal Tumors: A Narrative Review
    Alex R. Jones, Preksha Vankawala, Tarek Sawas
    Current Treatment Options in Gastroenterology.2024; 22(2): 44.     CrossRef
  • Diagnostic yield of endoscopic and EUS-guided biopsy techniques in subepithelial lesions of the upper GI tract: a systematic review
    Cynthia A. Verloop, Jacqueline A.C. Goos, Marco J. Bruno, Rutger Quispel, Lydi M.J.W. van Driel, Lieke Hol
    Gastrointestinal Endoscopy.2024; 99(6): 895.     CrossRef
  • EUS‐guided tissue acquisition from gastric subepithelial lesions—The optimal technique still remains undecided
    Suprabhat Giri, Sridhar Sundaram
    Australasian Journal of Ultrasound in Medicine.2024;[Epub]     CrossRef
  • An Esophageal Leiomyoma with Cystic Degeneration Mimicking a Malignant Neoplasm
    Gwang Ha Kim, Dong Chan Joo, Moon Won Lee, Bong Eun Lee, Kyungbin Kim
    The Ewha Medical Journal.2023;[Epub]     CrossRef
  • Prevalence, natural progression, and clinical practices of upper gastrointestinal subepithelial lesions in Korea: a multicenter study
    Younghee Choe, Yu Kyung Cho, Gwang Ha Kim, Jun-Ho Choi, Eun Soo Kim, Ji Hyun Kim, Eun Kwang Choi, Tae Hyeon Kim, Seong-Hun Kim, Do Hoon Kim
    Clinical Endoscopy.2023; 56(6): 744.     CrossRef
  • 2,637 View
  • 128 Download
  • 5 Web of Science
  • 7 Crossref
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Reasons for Diagnostic Failure in Forty-Five Consecutive Mucosal Cutting Biopsy Examinations of Gastric Subepithelial Tumors
Yoshiko Nakano, Toshitatsu Takao, Yoshinori Morita, Shinwa Tanaka, Takashi Toyonaga, Eiji Umegaki, Yuzo Kodama
Clin Endosc 2020;53(5):575-582.   Published online February 14, 2020
DOI: https://doi.org/10.5946/ce.2019.150
AbstractAbstract PDFPubReaderePub
Background
/Aims: Mucosal cutting biopsy (MCB) is useful for the histopathological diagnosis of gastric subepithelial tumors (SETs). However, there is little information on cases in which MCB did not establish a diagnosis. In the current study, we aimed to investigate the characteristics of cases in which MCB was unsuccessful.
Methods
Cases in which MCB was used to histopathologically diagnose gastric SETs at Kobe University Hospital between August 2012 and October 2018 were retrospectively reviewed.
Results
Forty-five cases in which MCB was used to diagnose 43 gastric SETs in 43 patients were analyzed. The median tumor size was 20 mm (range, 8–50 mm). Pathological examinations resulted in definitive and suspected diagnoses and no diagnosis in 29 (gastrointestinal stromal tumor: n=17, leiomyoma: n=7, aberrant pancreas: n=3, others: n=2), 6, and 10 cases, respectively. Failure to expose the tumor according to retrospective examinations of endoscopic images was significantly associated with no diagnosis. Other possible explanations included a less elevated tumor, biopsy of the surrounding field instead of the tumor due to the mobility, and poor endoscope maneuverability due to the tumor being close to the cardia.
Conclusions
Clear exposure of gastric SETs during MCB may improve the diagnostic rate of such examinations.

Citations

Citations to this article as recorded by  
  • Technical outcomes and postprocedural courses of mucosal incision‐assisted biopsy for possible gastric gastrointestinal stromal tumors: A series of 48 cases (with video)
    Eriko Koizumi, Osamu Goto, Shun Nakagome, Tsugumi Habu, Yumiko Ishikawa, Kumiko Kirita, Hiroto Noda, Kazutoshi Higuchi, Takeshi Onda, Teppei Akimoto, Jun Omori, Naohiko Akimoto, Katsuhiko Iwakiri
    DEN Open.2024;[Epub]     CrossRef
  • Utility and advantage of the unroofing technique for gastrointestinal subepithelial tumors: A multicenter retrospective cohort study
    Masashi Yamamoto, Tsutomu Nishida, Ryotaro Uema, Takashi Kanesaka, Hiroyuki Ogawa, Shinji Kitamura, Hideki Iijima, Kengo Nagai, Shusaku Tsutsui, Masato Komori, Katsumi Yamamoto, Yoshiki Tsujii, Yoshito Hayashi, Tetsuo Takehara
    DEN Open.2024;[Epub]     CrossRef
  • Systematic Endoscopic Approach for Diagnosing Gastric Subepithelial Tumors
    Gwang Ha Kim
    Gut and Liver.2022; 16(1): 19.     CrossRef
  • The Diagnosis of Small Gastrointestinal Subepithelial Lesions by Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy
    Masanari Sekine, Takeharu Asano, Hirosato Mashima
    Diagnostics.2022; 12(4): 810.     CrossRef
  • Advancements in the Diagnosis of Gastric Subepithelial Tumors
    Osamu Goto, Mitsuru Kaise, Katsuhiko Iwakiri
    Gut and Liver.2022; 16(3): 321.     CrossRef
  • Mucosal Incision-Assisted Endoscopic Biopsy as an Alternative to Endoscopic Ultrasound-Guided Fine-Needle Aspiration/Biopsy for Gastric Subepithelial Tumor
    Cheol Woong Choi, Joo Ha Hwang
    Clinical Endoscopy.2020; 53(5): 505.     CrossRef
  • 3,639 View
  • 109 Download
  • 6 Web of Science
  • 6 Crossref
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Case Report
Endoscopic Submucosal Dissection of a Colonic Calcifying Fibrous Tumor
Jaeyoung Kim, Seongyul Ryu, Yeon-Ji Kim
Clin Endosc 2020;53(4):487-490.   Published online January 21, 2020
DOI: https://doi.org/10.5946/ce.2019.138
AbstractAbstract PDFPubReaderePub
A 49-year-old woman was referred to our hospital for further treatment due to the suspicion of a submucosal tumor in a routine screening colonoscopy. On colonoscopy, a 1-cm sized subepithelial mass with normal overlying mucosa in the hepatic flexure was found. Endoscopic ultrasonography (EUS) showed a homogenous hypoechoic lesion arising from the second and third layer. We were unable to make a final diagnosis because the lesion showed a small tumor with atypical macroscopic morphology including EUS findings. Therefore, endoscopic submucosal dissection was performed for the diagnostic treatment of the tumor. Submucosal dissection was performed just above the muscle layer, and the tumor was removed completely and reliably without any acute complications such as perforation. Based on histopathological findings, we diagnosed a benign, calcifying fibrous tumor (CFT). The present case is the first report of successful endoscopic diagnosis and treatment of colonic CFT mimicking a submucosal tumor.

Citations

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  • Feasibility of endoscopic resection and impact of endoscopic ultrasound-based surveillance on colorectal subepithelial tumors
    Eun Young Park, Dong Hoon Baek, Seung Min Hong, Bong Eun Lee, Moon Won Lee, Gwang Ha Kim, Geun Am Song
    Surgical Endoscopy.2023; 37(9): 6867.     CrossRef
  • Submucosal Necrotic Nodule of the Colon: An Enigmatic Entity Potentially Related to Anisakis Infection
    Raul S. Gonzalez, Laura G. Pastrián, Sergey Pyatibrat, Hernan Dario Quiceno Arias, Yolanda Rodriguez Gil, Adam L. Booth, Itziar de la Peña Navarro, Maddi Garmendia-Irizar, Jennifer R. Lapointe, Mousa Mobarki, Luiz Miguel Nova-Camacho, Gina Parini, Estefan
    Archives of Pathology & Laboratory Medicine.2023; 147(11): 1315.     CrossRef
  • 4,194 View
  • 96 Download
  • 2 Web of Science
  • 2 Crossref
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Focused Review Series: Recent Update of Endoscopic Ultrasonographys in Gastrointestinal Subepithelial Tumors
Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy in Gastrointestinal Subepithelial Tumors
Gyu Young Pih, Do Hoon Kim
Clin Endosc 2019;52(4):314-320.   Published online July 30, 2019
DOI: https://doi.org/10.5946/ce.2019.100
AbstractAbstract PDFPubReaderePub
The incidence of asymptomatic and incidentally found upper gastrointestinal subepithelial tumors (SETs) is increasing with the implementation of national cancer screening and the development of high-resolution endoscopy in Korea. However, endoscopy alone cannot be used to determine whether SETs are benign or malignant. Endoscopic ultrasound (EUS) is used to further characterize these lesions through the examination of their layered structure, internal echogenicity, size, and relationship to the extramural structure. These provide additional information on whether the lesion is benign or malignant. Nevertheless, the sensitivity and specificity of EUS alone in predicting malignancy is unsatisfactory. Recent guidelines have recommended deciding the timing of EUS-fine needle aspiration and biopsy (EUS-FNA/B) for SETs based on tumor size, malignant features on endoscopy, and high-risk features on EUS. The diagnostic accuracy of EUS-FNA/B is reportedly influenced by factors including needle size, number of needle passes, use of suction, use of a stylet in the needle assembly, fanning technique, availability of an on-site cytopathologist, and experience of the endosonographer. Therefore, according to the characteristics of the SETs, various subsequent methods and techniques should be appropriately employed to improve the diagnostic yield of EUS-FNA/B.

Citations

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    Patrick T. Magahis, Donevan Westerveld, Malorie Simons, David L. Carr-Locke, Kartik Sampath, Reem Z. Sharaiha, SriHari Mahadev
    Journal of Clinical Gastroenterology.2024; 58(4): 407.     CrossRef
  • The role of endoscopic ultrasound in assessment of physiological cardia insufficiency during diagnosis of hiatal hernia
    B.F. Shevchenko, O.M. Babii, N.V. Prolom, M.V. Titova, S.O. Tarabarov, S.V. Ushchina
    GASTROENTEROLOGY.2024; 58(1): 50.     CrossRef
  • Spectrum of endoscopic gastric subepithelial lesions encountered on EUS-FNA: A single center experience
    Poojan Agarwal, Pooja Bakshi, Kusum Verma, Vikas Singla, Anil Arora
    Indian Journal of Pathology and Microbiology.2024; 67(2): 374.     CrossRef
  • Ultrasound-Enhanced Fine-Needle Biopsy Improves Yield in Human Epithelial and Lymphoid Tissue
    Yohann Le Bourlout, Minna Rehell, Jetta Kelppe, Jaana Rautava, Emanuele Perra, Jouni Rantanen, Gösta Ehnholm, Nick Hayward, Kristofer Nyman, Kenneth P.H. Pritzker, Jussi Tarkkanen, Timo Atula, Katri Aro, Heikki J. Nieminen
    Ultrasound in Medicine & Biology.2024; 50(8): 1247.     CrossRef
  • Clinical course of asymptomatic duodenal subepithelial lesions
    Seokin Kang, Kwangbeom Park, Do Hoon Kim, Yuri Kim, Hee Kyong Na, Jeong Hoon Lee, Ji Yong Ahn, Kee Wook Jung, Kee Don Choi, Ho June Song, Gin Hyug Lee, Hwoon-Yong Jung
    The Korean Journal of Internal Medicine.2024; 39(4): 603.     CrossRef
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    Janak Bahirwani, Rodrigo Duarte-Chavez, Lisa Stoll, Ayaz Matin
    Cureus.2023;[Epub]     CrossRef
  • Lesiones subepiteliales gástricas únicas. ¿Existen factores predictores de tumores del estroma gastrointestinal que eviten la biopsia?
    José Ruiz Pardo, Elisabet Vidaña Márquez, Pedro Antonio Sánchez Fuentes, Iñigo Gorostiaga Altuna, Ricardo Belda Lozano, Ángel Reina Duarte
    Gastroenterología y Hepatología.2023; 46(1): 54.     CrossRef
  • Single gastric subepithelial lesions. Are there predictors of gastrointestinal stromal tumors that prevent biopsy?
    José Ruiz Pardo, Elisabet Vidaña Márquez, Pedro Antonio Sánchez Fuentes, Iñigo Gorostiaga Altuna, Ricardo Belda Lozano, Ángel Reina Duarte
    Gastroenterología y Hepatología (English Edition).2023; 46(1): 54.     CrossRef
  • Endoscopic Submucosal Dissection for Subepithelial Tumor Treatment in the Upper Digestive Tract: A Western, Multicenter Study
    Raffaele Manta, Francesco Paolo Zito, Francesco Pugliese, Angelo Caruso, Santi Mangiafico, Alessandra D’Alessandro, Danilo Castellani, Ugo Germani, Massimiliano Mutignani, Rita Luisa Conigliaro, Luca Reggiani Bonetti, Takahisa Matsuda, Vincenzo De Frances
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  • Comparison of diagnostic performances of slow-pull suction and standard suction in endoscopic ultrasound-guided fine needle biopsy for gastrointestinal subepithelial tumors
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    Clinical Endoscopy.2022; 55(5): 637.     CrossRef
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    Yu.M. Stepanov, N.V. Prolom, I.S. Konenko, S.O. Tarabarov, N.P. Dementii, I.M. Adamska
    GASTROENTEROLOGY.2022; 55(4): 270.     CrossRef
  • Peroral endoscopic tumor resection (POET) with preserved mucosa technique for management of upper gastrointestinal tract subepithelial tumors
    Chen-Shuan Chung, Kuo-Hsin Chen, Kuan-Chih Chen, Chiung-Yu Chen, Tzong-Hsi Lee, Cheng-Kuan Lin, Jiann-Ming Wu
    Surgical Endoscopy.2021; 35(7): 3753.     CrossRef
  • Gastric Angiolipoma Resected with Endoscopic Submucosal Dissection
    Sang Myung Yeo, Jae Kwang Lee, Hyun Soo Kim, Chang Geun Park, Jae Kwon Jung, Dae Jin Kim, Yun Jin Chung, Han Jun Ryu
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    Kyoungwon Jung, Moo In Park
    The Korean Journal of Helicobacter and Upper Gastrointestinal Research.2021; 21(2): 106.     CrossRef
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    Chang Kyo Oh, Taewan Kim, Yu Kyung Cho, Dae Young Cheung, Bo‐In Lee, Young‐Seok Cho, Jin Il Kim, Myung‐Gyu Choi, Han Hee Lee, Seungchul Lee
    Journal of Gastroenterology and Hepatology.2021; 36(12): 3387.     CrossRef
  • Fine needle aspiration cytology of primary and metastatic gastrointestinal stromal tumour
    Gargi Kapatia, Nalini Gupta, Uma Nahar Saikia, Parikshaa Gupta, Manish Rohilla, Ojas Gupta, Radhika Srinivasan, Arvind Rajwanshi, Pranab Dey
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    Koki Oyama, Kenoki Ohuchida, Koji Shindo, Taiki Moriyama, Yoshitaka Hata, Masafumi Wada, Eikichi Ihara, Shuntaro Nagai, Takao Ohtsuka, Masafumi Nakamura
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  • Mucosal Incision-Assisted Endoscopic Biopsy as an Alternative to Endoscopic Ultrasound-Guided Fine-Needle Aspiration/Biopsy for Gastric Subepithelial Tumor
    Cheol Woong Choi, Joo Ha Hwang
    Clinical Endoscopy.2020; 53(5): 505.     CrossRef
  • Endoscopic diagnosis and management of gastric subepithelial lesions
    Thomas R. McCarty, Marvin Ryou
    Current Opinion in Gastroenterology.2020; 36(6): 530.     CrossRef
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  • 19 Web of Science
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Contrast Enhanced Endoscopic Ultrasound Imaging for Gastrointestinal Subepithelial Tumors
Takashi Tamura, Masayuki Kitano
Clin Endosc 2019;52(4):306-313.   Published online July 23, 2019
DOI: https://doi.org/10.5946/ce.2019.056
AbstractAbstract PDFPubReaderePub
Subepithelial tumors are divided into benign subepithelial and potentially malignant gastrointestinal stromal tumors. It is difficult to distinguish between these tumor types. Contrast-enhanced harmonic endoscopic ultrasound is reportedly useful for diagnosing subepithelial tumors, can be safely and easily performed by understanding the principle and method, and can be used to distinguish between tumor types with high sensitivity on the basis of differences in contrast effect. The generated image shows a hyperenhancement pattern in gastrointestinal stromal tumors (sensitivity, 78%–100%; specificity, 60%–100%; accuracy, 60%–100%) and hypoenhancement pattern in benign subepithelial tumors. Contrast-enhanced harmonic endoscopic ultrasound can be used to estimate the malignancy potential of gastrointestinal stromal tumors by evaluating the uniformity of the contrast and the blood vessels inside the tumor, with abnormal intra-tumor blood vessels, heterogeneous enhancement, and non-enhancing spots suggesting malignancy. Contrast-enhanced harmonic endoscopic ultrasound has a higher sensitivity than other imaging modalities for the detection of vascularity within gastrointestinal stromal tumors. Additionally, it has been reported that treatment effects can be estimated by evaluating the blood flow in the gastrointestinal stromal tumor before and after treatment with tyrosine kinase inhibitors using contrastenhanced ultrasound. However, there will be subjective-bias and the results depends on the performer’s skill.

Citations

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  • The value of contrast-enhanced harmonic endoscopic ultrasound in differential diagnosis and evaluation of malignant risk of gastrointestinal stromal tumors (<50mm)
    Jiali Wu, Mengqi Zhuang, Yubao Zhou, Xiang Zhan, Weiwei Xie
    Scandinavian Journal of Gastroenterology.2023; 58(5): 542.     CrossRef
  • Endoscopic Ultrasound Advanced Techniques for Diagnosis of Gastrointestinal Stromal Tumours
    Socrate Pallio, Stefano Francesco Crinò, Marcello Maida, Emanuele Sinagra, Vincenzo Francesco Tripodi, Antonio Facciorusso, Andrew Ofosu, Maria Cristina Conti Bellocchi, Endrit Shahini, Giuseppinella Melita
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  • EUS-Guided Diagnosis of Gastric Subepithelial Lesions, What Is New?
    Thomas Vasilakis, Dimitrios Ziogas, Georgios Tziatzios, Paraskevas Gkolfakis, Eleni Koukoulioti, Christina Kapizioni, Konstantinos Triantafyllou, Antonio Facciorusso, Ioannis S. Papanikolaou
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    Sung Jin Lim, Han Mo Yoo, Seung-Woo Lee, Hae Joung Sul, Dong Soo Lee
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    Xinyu Cheng, Jianguo Xia, Qi Xu, Huawei Gui
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    Y. L. Trubacheva, E. M. Bogdanova, A. E. Pershina
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  • The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) Guidelines for Contrast-Enhanced Endoscopic Ultrasound
    Masayuki Kitano, Yasunobu Yamashita, Ken Kamata, Tiing Leong Ang, Hiroo Imazu, Eizaburo Ohno, Yoshiki Hirooka, Pietro Fusaroli, Dong-Wan Seo, Bertrand Napoléon, Anthony Yuen Bun Teoh, Tae Hyeon Kim, Christoph F. Dietrich, Hsiu-Po Wang, Masatoshi Kudo
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    Cicilia Marcella, Shakeel Sarwar, Hui Ye, Rui Hua Shi
    Clinical Endoscopy.2020; 53(4): 458.     CrossRef
  • Contrast Harmonic-Enhanced Endoscopic Ultrasound (EUS) Is the Perfect Companion of EUS-Guided Tumor Ablation
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  • 7,354 View
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  • 7 Web of Science
  • 9 Crossref
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Original Article
Comparison of the Diagnostic Ability of Endoscopic Ultrasonography and Abdominopelvic Computed Tomography in the Diagnosis of Gastric Subepithelial Tumors
Sang Yoon Kim, Ki-Nam Shim, Joo-Ho Lee, Ji Young Lim, Tae Oh Kim, A. Reum Choe, Chung Hyun Tae, Hye-Kyung Jung, Chang Mo Moon, Seong-Eun Kim, Sung-Ae Jung
Clin Endosc 2019;52(6):565-573.   Published online July 17, 2019
DOI: https://doi.org/10.5946/ce.2019.019
AbstractAbstract PDFPubReaderePub
Background
/Aims: Endoscopic ultrasonography (EUS) is the most efficient imaging modality for gastric subepithelial tumors (SETs). However, abdominopelvic computed tomography (APCT) has other advantages in evaluating the characteristics, local extension, or invasion of SETs to adjacent organs. This study aimed to compare the diagnostic ability of EUS and APCT based on surgical histopathology results.
Methods
We retrospectively reviewed data from 53 patients who underwent both EUS and APCT before laparoscopic wedge resection for gastric SETs from January 2010 to December 2017 at a single institution. On the basis of histopathology results, we assessed the diagnostic ability of the 2 tests.
Results
The overall accuracy of EUS and APCT was 64.2% and 50.9%, respectively. In particular, the accuracy of EUS vs. APCT for the diagnosis of gastrointestinal stromal tumors (GISTs), leiomyomas, and ectopic pancreas was 83.9% vs. 74.2%, 37.5% vs. 0.0%, and 57.1% vs. 14.3%, respectively. Most of the incorrect diagnoses with EUS involved hypoechoic lesions originating in the fourth echolayer, with the most common misdiagnosed lesions being GISTs mistaken for leiomyomas and vice versa.
Conclusions
APCT showed a lower overall accuracy than EUS; however, APCT remains a useful modality for malignant/potentially malignant gastric SETs.

Citations

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  • Guidelines in Practice: The Diagnosis and Management of Gastrointestinal Subepithelial Lesions
    Brian C. Jacobson, Vanessa M. Shami
    American Journal of Gastroenterology.2024; 119(3): 397.     CrossRef
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  • The value of contrast-enhanced harmonic endoscopic ultrasound in differential diagnosis and evaluation of malignant risk of gastrointestinal stromal tumors (<50mm)
    Jiali Wu, Mengqi Zhuang, Yubao Zhou, Xiang Zhan, Weiwei Xie
    Scandinavian Journal of Gastroenterology.2023; 58(5): 542.     CrossRef
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    Eun Young Park, Gwang Ha Kim
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  • 6,706 View
  • 187 Download
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Focused Review Series: Recent Update of Endoscopic Ultrasonography in Gastrointestinal Subepithelial Tumors
Current Status of Endoscopic Ultrasonography in Gastrointestinal Subepithelial Tumors
Sang Gyun Kim, Ji Hyun Song, Joo Ha Hwang
Clin Endosc 2019;52(4):301-305.   Published online July 9, 2019
DOI: https://doi.org/10.5946/ce.2019.024
AbstractAbstract PDFPubReaderePub
Gastrointestinal subepithelial tumors (GSTs) are usually detected incidentally on endoscopic or radiologic examinations. In conventional endoscopy, a GST usually presents as a protuberant lesion with an intact mucosal surface. As the lesion is located beneath the mucosal layer of the gastrointestinal tract, conventional biopsy typically does not reveal the pathologic diagnosis. First, a GST should be differentiated from an extrinsic compression through the positional change of the patient during conventional endoscopic examination. In cases of GSTs originating from the gastrointestinal wall, endoscopic ultrasonography (EUS) can be beneficial for narrowing the differential diagnosis through delineation of echo findings and by determining the layer of origin. EUS findings can also help determine the management strategies for GSTs by making a differential diagnosis according to malignant potential.

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    Mehmet Zeki Buldanlı, Oktay Yener
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Case Report
Primary Gastric Small Cell Carcinoma: A Case Identified as a Large Subepithelial Tumor from Invisible State in 6 Months
Yun Im Lee, Hong Kil Jeon, Jae Wook Im, Sang Yu Oh, Kyung Bin Kim, Byunggyu Kim
Clin Endosc 2019;52(1):76-79.   Published online July 6, 2018
DOI: https://doi.org/10.5946/ce.2018.062
AbstractAbstract PDFPubReaderePub
Primary gastric small cell carcinoma (GSCC) is one of the gastroenteropancreatic neuroendocrine tumors. It is a rare cancer with a very aggressive behavior and a poor prognosis because of the high rate of metastases. It is usually found in far advanced stage. We experienced a case of GSCC which had developed into a large subepithelial tumor (SET) from invisible state in a short period. A 65-year-old man consulted our hospital because of early gastric cancer. He underwent endoscopic submucosal dissection for the early gastric cancer at high body posterior wall. After 6 months, the follow-up endoscopy showed a large newly developed SET-like lesion with central ulceration at the gastric cardia. Endoscopic biopsy revealed GSCC. Total gastrectomy was performed. One out of the 26 perigastric lymph nodes had a metastasis. He received 6 cycles of adjuvant chemotherapy with etoposide and cisplatin. He is still in good health 12 months after operation.

Citations

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  • 125 Download
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  • 1 Crossref
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Focused Review Series: The New Era of Therapeutic Endoscopy - Endoscopic Submucosal Surgery
Endoscopic Treatment of Subepithelial Tumors
Su Young Kim, Kyoung-Oh Kim
Clin Endosc 2018;51(1):19-27.   Published online January 31, 2018
DOI: https://doi.org/10.5946/ce.2018.020
AbstractAbstract PDFPubReaderePub
Gastrointestinal subepithelial tumors (SETs) are generally found during endoscopy and their incidence has gradually increased. Although the indications for the endoscopic treatment of patients with SETs remain to be established, the feasibility and safety of endoscopic dissection, including the advantages of this method compared with surgical treatment, have been validated in many studies. The development of endoscopic techniques, such as endoscopic submucosal dissection, endoscopic enucleation, endoscopic excavation, endoscopic submucosal tunnel dissection, submucosal tunnel endoscopic resection, and endoscopic full-thickness resection has enabled the removal of SETs while reducing the occurrence of complications. Here, we discuss the endoscopic treatment of patients with SETs, outcomes for endoscopic treatment, and procedure-related complications. We also consider the advantages and disadvantages of the various endoscopic techniques.

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Focused Review Series: Advanceses in the management of upper GI SET
Advances in the Management of Upper Gastrointestinal Subepithelial Tumor: Pathologic Diagnosis Using Endoscopy without Endoscopic Ultrasound-Guided Biopsy
Hang Lak Lee
Clin Endosc 2016;49(3):216-219.   Published online May 30, 2016
DOI: https://doi.org/10.5946/ce.2016.064
AbstractAbstract PDFPubReaderePub
Until now, biopsy methods for subepithelial tumors (SETs) have focused on endoscopic ultrasound (EUS)-guided biopsy; however, these methods have several limitations. We devised a simple method for pathologic diagnosis of SETs. SETs are occasionally diagnosed during endoscopy, and lesions are generally small and asymptomatic. It can be challenging to decide on a management plan for large asymptomatic SETs. EUS imaging provides information regarding the size, layer, and echo pattern of the lesions. Patient management plans have traditionally been determined based on EUS images, whereby the endoscopist chooses to either monitor or remove the tumor. However, EUS alone cannot diagnose and evaluate upper gastrointestinal SETs with high accuracy. As sufficient tissue samples are required for the accurate diagnosis of SETs, EUS-guided biopsy techniques such as EUS fine-needle aspiration and trucut biopsy are currently used. However, these methods have a relatively low diagnostic accuracy and do not always provide information upon immunohistochemical staining. Endoscopists can easily detect a submucosal mass after creating an iatrogenic mucosal ulcer, after which tissue sampling is performed by using endoscopic biopsy. Furthermore, pathologic results can differentiate between benign and premalignant lesions. Here, we introduce a simple method for the pathologic diagnosis of SETs.

Citations

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    Yuzhu Yuan, Lixin Sun, Xiaoying Zhou, Han Chen, Xinmin Si, Weifeng Zhang, Yun Wang, Bixing Ye, Nana Tang, Guoxin Zhang, Xueliang Li, Hongjie Zhang, Chunhua Jiao
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    Ming‐Yan Cai, Francisco Martin Carreras‐Presas, Ping‐Hong Zhou
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Role of Endoscopic Ultrasonography in Guiding Treatment Plans for Upper Gastrointestinal Subepithelial Tumors
Jeong Seop Moon
Clin Endosc 2016;49(3):220-225.   Published online May 20, 2016
DOI: https://doi.org/10.5946/ce.2016.047
AbstractAbstract PDFPubReaderePub
Gastrointestinal (GI) subepithelial tumors (SETs) are usually observed incidentally by endoscopy and have diverse prognoses, varying from benign to potentially malignant. When a GI SET is suspected, endoscopic ultrasonography (EUS) is the most accurate diagnostic method to differentiate it from extraluminal compression. To determine the nature of GI SETs, EUS is also the most accurate diagnostic method, and reveals the precise sonographic nature of the lesion. There are some SETs with typical EUS findings of GI SETs, but most hypoechoic lesions are difficult to diagnose based on EUS images alone. EUS is also helpful to determine GI wall involvement in SETs and optimal treatment methods. For the diagnosis of GI SETs, obtaining a proper specimen is essential. EUS-guided cytology or biopsy methods such as fine-needle aspiration, Tru-Cut biopsy, and the newly introduced fine-needle biopsy (FNB) provide good results. To increase the diagnostic yield for GI SETs, cytology with immunocytochemical staining is used for cytological interpretation, resulting in good diagnostic yields. Recently, EUS-FNB using cheese slicer technology has been introduced, and has been reported to provide good diagnostic results for GI SETs.

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Long-Term Outcomes after Endoscopic Treatment of Gastric Gastrointestinal Stromal Tumor
Jong-Jae Park
Clin Endosc 2016;49(3):232-234.   Published online May 19, 2016
DOI: https://doi.org/10.5946/ce.2016.052
AbstractAbstract PDFPubReaderePub
Endoscopic resection of gastric subepithelial tumors (SETs) has several advantages over biopsy techniques, such as superior diagnostic yield and definite diagnosis. Removal of gastric SETs and histopathologic confirmation should be considered whenever gastric SETs are highly suspected to have malignant potential such as gastrointestinal stromal tumor (GIST) or neuroendocrine tumor. According to our clinical experience, we suggest that endoscopic resection of gastric SETs is feasible for GISTs less than 3.0 cm without positive endoscopic ultrasonography findings or for hypoechoic SETs less than 3.0 cm. However, serious complications such as macroperforation may occur during endoscopic resection, and this procedure is highly dependent on endoscopists’ skills. We recently reported the long-term clinical outcomes of endoscopic resection of gastric GIST, which showed a relatively low recurrence rate (2.2%) during long-term follow-up (46.0±28.5 months) despite the low R0 resection rate (25.0%). We suggest that endoscopic surveillance might be possible without additional surgical resection in completely resected GISTs without residual tumor confirmed to be lower risk, even if they show an R1 resection margin.

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Review
Colorectal Subepithelial Lesions
Tae Oh Kim
Clin Endosc 2015;48(4):302-307.   Published online July 24, 2015
DOI: https://doi.org/10.5946/ce.2015.48.4.302
AbstractAbstract PDFPubReaderePub

Most of subepithelial lesion (SEL) being identified was accidentally discovered as small bulging lesion covered with normal mucosa from endoscopic screening. The type of treatment and prognosis vary depending on the type of tumor, it would be crucial to perform an accurate differential diagnosis. Since the differentiation of SEL relied on the indirect findings observed from the mucosal surface using an endoscopy only in the past, it was able to confirm the presence of lesion only but difficult to identify complex detailed nature of the lesion. However, after the endoscopic ultrasonography (EUS) was introduced, it became possible to identify extrinsic compression, and size of intramural tumors, internal properties and contour so that it gets possible to have differential diagnosis of lesions and prediction on the lesion whether it is malignant or benign. In addition, the use of EUS-guided fine needle aspiration and EUS-guided core biopsy made it possible to make histological differential diagnosis. This study intended to investigate endoscopic and EUS findings, histological diagnosis, treatment regimen and impression of colorectal SELs.

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Original Article
Yields and Utility of Endoscopic Ultrasonography-Guided 19-Gauge Trucut Biopsy versus 22-Gauge Fine Needle Aspiration for Diagnosing Gastric Subepithelial Tumors
Hee Kyong Na, Jeong Hoon Lee, Young Soo Park, Ji Yong Ahn, Kwi-Sook Choi, Do Hoon Kim, Kee Don Choi, Ho June Song, Gin Hyug Lee, Hwoon-Yong Jung, Jin-Ho Kim
Clin Endosc 2015;48(2):152-157.   Published online March 27, 2015
DOI: https://doi.org/10.5946/ce.2015.48.2.152
AbstractAbstract PDFPubReaderePub
Background/Aims

To evaluate the yields and utility of 19-gauge (G) Trucut biopsy (TCB) versus 22 G fine needle aspiration (FNA) for diagnosing gastric subepithelial tumors (SETs).

Methods

We retrieved data for 152 patients with a gastric SET larger than 2 cm who had undergone endoscopic ultrasonography (EUS)-guided 19 G TCB (n=90) or 22 G FNA (n=62). Relevant clinical, tumor-specific, and EUS procedural information was reviewed retrospectively.

Results

A specific diagnosis was made for 76 gastrointestinal stromal tumors (GISTs) and 51 non-GIST SETs. The diagnostic yield of TCB was greater than that of FNA (77.8% vs. 38.7%, p<0.001). The percentage of non-diagnostic specimens (suspicious and insufficient) was significantly lower in the TCB group (6.7% and 15.5%, respectively) than in the FNA group (22.6% and 38.7%, respectively; both p<0.001). TCB accurately diagnosed 90.9% of GISTs and 81.1% of non-GIST SETs, whereas FNA accurately diagnosed 68.8% of GISTs and 14.3% of non-GIST SETs. There were nine technical failures with TCB, and the rate of adverse events did not differ between the groups (TCB vs. FNA, 3.3% vs. 8.1%; p=0.27).

Conclusions

Nineteen-gauge TCB is safe and highly valuable for diagnosing gastric SETs larger than 2 cm if technical failure can be avoided.

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Case Reports
An Extremely Rare Case of Gastric Subepithelial Tumor: Gastric Endometriosis
Jong Kun Ha, Cheol Woong Choi, Hyung Wook Kim, Dae Hwan Kang, Su Bum Park, Su Jin Kim, Jeong Beom Hong
Clin Endosc 2015;48(1):74-77.   Published online January 31, 2015
DOI: https://doi.org/10.5946/ce.2015.48.1.74
AbstractAbstract PDFPubReaderePub

Endometriosis is a disease characterized by the presence of endometrial tissue outside of the uterine cavity. It is common in women of childbearing age, and is most frequently located in the pelvic cavity. Approximately 10% of endometriosis cases occur outside of the pelvic cavity in locations such as the intestines, genitourinary system, kidneys, lungs, and skin. However, there have been few reports of endometriosis in the stomach. Here, we report a rare case of endometriosis that presented as a subepithelial stomach tumor.

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Intramural Gastric Abscess Caused by a Toothpick Presenting as a Subepithelial Tumor
Wang Guk Oh, Mun Chul Kim, Hyun Ju Yoon, Jae Woo Park, Min A Yang, Cheon Beom Lee, Ji Woong Kim, Jin Woong Cho
Clin Endosc 2014;47(3):254-257.   Published online May 31, 2014
DOI: https://doi.org/10.5946/ce.2014.47.3.254
AbstractAbstract PDFPubReaderePub

In the present report, we describe an unusual case of an intramural gastric abscess caused by a foreign body, detected in the form of a subepithelial tumor. A 64-year-old woman was referred to our gastroenterology clinic for further evaluation of a gastric subepithelial tumor. The patient presented with a 1-month history of sustained dull epigastric pain. Esophagogastroduodenoscopy revealed an ill-demarcated, round, smooth, protruding lesion with a small central erosion on the great curvature of the proximal antrum. Endoscopic ultrasonography indicated the presence of an ovoid, heterogeneous, hypoechoic lesion with small echogenic foci located in the submucosa and muscularis propria layers. An abdominal computed tomography scan showed focal gastric wall thickening and regional lymph node enlargement. Endoscopic submucosal dissection was performed for definite diagnosis and management. Thus, we detected a toothpick and removed it using grasping forceps. The final diagnosis was an intramural gastric abscess caused by a toothpick.

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Endoscopic Treatment of Various Gastrointestinal Tract Defects with an Over-the-Scope Clip: Case Series from a Tertiary Referral Hospital
Woong Cheul Lee, Weon Jin Ko, Jun-Hyung Cho, Tae Hee Lee, Seong Ran Jeon, Hyun Gun Kim, Joo Young Cho
Clin Endosc 2014;47(2):178-182.   Published online March 31, 2014
DOI: https://doi.org/10.5946/ce.2014.47.2.178
AbstractAbstract PDFPubReaderePub

Recently, increasingly invasive therapeutic endoscopic procedures and more complex gastrointestinal surgeries such as endoscopic mucosal resection, endoscopic submucosal dissection, and novel laparoscopic approaches have resulted in endoscopists being confronted more frequently with perforations, fistulas, and anastomotic leakages, for which nonsurgical closure is desired. In this article, we present our experiences with the use of over-the-scope clip (OTSC) for natural orifice transluminal endoscopic surgery (NOTES) closure, prevention of perforation, anastomotic leakages, and fistula closures. The OTSC is a valuable device for closing intestinal perforations and fistulas, for NOTES closure, and for the prevention of perforation after the excision of a tumor from the proper muscle layer. Furthermore, it seems to be quite safe to perform, even by endoscopists with little experience of the technique.

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A Case of Neuroendocrine Carcinoma Presenting as a Subepithelial Tumor Diagnosed by ESD
Dae Hyun Baek, M.D., Seong Hwan Kim, M.D., Jun Young Jung, M.D., Byoung Kwan Son, M.D., Yunju Jo, M.D., Young Sook Park, M.D. and Won Mi Lee, M.D.*
Korean J Gastrointest Endosc 2011;42(4):236-240.   Published online April 28, 2011
AbstractAbstract PDF
A gastric neuroendocrine carcinoma is very rare, and the histological diagnosis is very difficult. These carcinomas result in a poor prognosis because they are preceded by severe lymphovascular invasion and early metastasis. In particular, it is difficult to distinguish between adenocarcinoma and neuroendocrine carcinoma by endoscopy when no specific symptoms are present (e.g., dyspepsia, nausea). According to published articles in Korea, most cases were diagnosed as adenocarcinoma initially; however, they were confirmed postoperatively as neuroendocrine carcinoma based on a histological examination using immunohistochemical staining. A case of a 55-year-old man, who had an incidental finding of a subepithelial tumor during his health check-up, was recommended for an endoscopic submucosal dissection (ESD). But the patient was lost to follow-up for 4 years. When he was examined again, the size of the tumor had increased from the previous exam. He underwent ESD and was diagnosed with a well-differentiated neuroendocrine carcinoma. (Korean J Gastrointest Endosc 2011;42:236-240)
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