Evaluation of gastrointestinal subepithelial lesions followed by endoscopic ultrasonography (EUS); single center experience

Introduction and Objective The frequency of diagnosis of gastrointestinal subepithelial lesions is increasing due to the widespread use of cross-sectional imaging methods such as computed tomography (CT) and gastrointestinal endoscopy. Diagnosis and management of gastrointestinal subepithelial lesions is often difficult for the clinician, therefore, for differential diagnosis; Evaluation of pathology data is important with EUS, EUS-FNAB. The aim of this study is; To investigate the contribution of endosonographic and pathological examinations of gastrointestinal subepithelial lesions to the diagnosis. Materials and Methods Patients aged 18 years and older who underwent endoscopic USG for suspected subepithelial lesion after endoscopy or abdominal imaging for any reason between March 2009 and December 2017 at the Department of Gastroenterology at Dokuz Eylül University Medical Faculty Hospital constitute the universe of our study. A total of 170 cases were included in the study. The demographic characteristics of the patients, radiological or EUS appearance reports of subepithelial lesions, cytopathologic diagnosis of patients who underwent EUS-FNAB / endoscopic biopsy, surgical operation type and surgical pathology results of patients operated for subepithelial lesion were analyzed retrospectively. Results In 170 patients who underwent EUS due to gastrointestinal subepithelial lesion, 87 (51.2%) were leiomyoma, 32 (18.8%) were GIST, 27 (15.9%) were lipoma, 13 (7.6%) were ectopic pancreas, 10 (5.8%) neuroendocrine tumor, 1 (0.6% There is a preliminary diagnosis of cyst. The most common site of subepithelial lesions is the stomach with 67.1%, and the most common source is muscularis propriqued (47.1%). When evaluated with patients with pathological sampling, 71.1% of patients were diagnosed with EUS. GISTs were defined as 94.4%, leimyomas 81.8%, and neuroendocrine tumors 75% accurate according to the definitive diagnostic method pathology. Endoscopic and / or CT imaging were performed in 41.1% of 170 patients with subepithelial lesions. The mean size of the lesions was 1.15 ± 0.6 cm for the patients who were followed-up for surgery, polypectomy and non-EMR, and their final size was 1.2 ± 0.6 cm (p <0.05). Of the 13 lesions showing size increase, 9 were leiomyomas. (69.2%). When the changes in the size of the subtypes of the lesions were examined separately, no significant results were obtained due to the low number of patients (p> 0.05). Recurrence was found in one patient who underwent endoscopic mucosal resection, polypectomy, and only one patient underwent EMR. When GIS was diagnosed with GIS, the lesion was defined and the lesion was used for malignant lesion above 3 cm, had irregular border, contained calcification, heterogeneity and cystic space, extraluminal spread, ulcerated or necrotic focus, and lymph node involvement. The most common criteria for the diagnosis were the lesion and cystic space above 3 cm, the irregular border was less visible, and the selectivity of the ulceration and necrotic focus was 100%. In patients with multiple criteria, cystic space and calcification, lesion and heterogeneity of more than 3cm were selectively selected as 100%. In patients who were operated and risk scoring, high risk patients had more than 3 cm of cystic space and cystic space and calcification were present. There was no recurrence in the mean 6.7 ± 1.5 months of endoscopic / EUS and CT follow-up of GIST patients who were operated and followed up regularly. Discussion and Suggestions As a result; In the diagnosis of subepithelial lesions, EUS and EUS-FNAB are the methods with the highest diagnostic sensitivity in terms of pre-diagnosis and prediction of malignancy. In order to identify the lesions and to evaluate them for malignancy, the appearance characteristics observed in EUS should be examined carefully and biopsy should be taken in all cases of suspicion. The lesion examined with EUS should be monitored according to the biopsy results, taking into account the characteristics and size of the appearance or should be directed to surgery when necessary. For the diagnosis of GIST, the lesion should be more than 3 cm, have irregular border, include calcification, echogenic focal and cystic space, extraluminal extension, ulcers or necrotic focus and lymph node involvement. Although the common lesions are more than 3cm lesion and cystic space, the irregular border, ulceration and necrotic focus are less frequent and their selectivity is 100%. In addition, the sensitivity of these parameters in diagnosis is lower than the sensitivity of the single parameter, but they are very successful in diagnosing because of their high selectivity. The patients with high risk of GIST patients had a lesion above 3 cm, cystic space and calcification. There are no studies suggesting that these three appearance characteristics may be associated with high risk, but in the following years the success of this association in predicting the high risk can be evaluated by increasing the number of patients. Regular follow-up of patients who have been operated or followed up is very important for the detection of recurrence or for the treatment of treatment. By increasing the number of experienced health personnel who can make EUS in our country and the number of centers having EUS, larger studies can be done about these lesions. Key words: Gastrointestinal Subepithelial Lesions, Gastrointestinal Stromal Tumors, Endoscopic Ultrasound