EUS Practice in Gastric

Subepithelial Lesions 0 21
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Dr Rajkumar Wadhwa MD.,DM.,FSGEI.,FASGE

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Chief Gastroenterologist
Apollo BGS Hospitals, Mysore

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 Subepithelial Lesions

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The term “subepithelial lesion” has been more

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frequently used than “submucosal lesion” because

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underneath the epithelium. 2
intramural lesions may arise from any layer of GI wall

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Subepithelial Lesions- Layers of Gut Wall

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 Examination Checklist
1.Carefully examine the transition zone between the normal gut wall and the lesion

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to determine the layer of origin.

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2.Measure the size of the lesion and observe the echo pattern (e.g., echogenicity,

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internal features, vascularity, and smoothness of the border).

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3.Check the presence of adjacent lymphadenopathy.

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4.Small lesions measuring less than 1 to 2 cm may be better imaged using high-
frequency catheter ultrasound probes.

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5.For better imaging of the wall layers and evaluation of subepithelial lesions, it
may be necessary to instill water or jelly into the luminal tract to obtain better
acoustic coupling. Aspiration precautions should be taken under these
circumstances.
 EUS Evaluation of Subepithelial Lesions

Size – measured on two planes

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Transition zone– To determine the layer of origin.

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Echo pattern of the tumor- Anechoic/hypoechoic/ iso or hyperechoic

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Internal features: homogenous/ heterogenous
Solid/cystic/ calcifications
Vascularity

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Margins: well defined/poorly defined/ breached

Relationship with other adjacent organs

Ascites or Hepatic lesion

Submucosal or Extraluminal?

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U 2 • EUS for Submucosal/Extraluminal:

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11% due to pathologic lesions
• USG/CT Vs EUS: 16% vs 100%
• US/CT/ EUS: 22%/28%/100%
• Endoscopy:
Sensitivity/specificity of 87%/29%
 Comparison- US/CT/EUS for Subepithelial lesions

Authors (yr) n Accuracy Diagnostic method

Hoda (2009)
Polkowski(2009)
112
49
(%)
84
63
EUS FNA
EUS TCB

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Akahoshi (2007) 51 82 EUS FNA
• US: only for large lesions
Chen & Eloubeidi (2005) 42 98 EUS FNA
82.5 tumor visualized with fluid filled stomach

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• CT:2/3 of EUS visualized tumors visualized
Vander Noot (2004) 51 82 EUS FNA Seen>27.4 mms

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Missed< 11 mms
Levy (2003) 5 80 EUS TCB • MDCT detection/classification

Kojima (1999)
Matsui (1998)
Matsui(1998)
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54
15
15
74
93
60
EUS
EUS FNA
EUS
of suepithelial lesion: 85.3%/78.8%
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SG
Layer of Origin

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 EUS Anechoic,
Cause EUS Layersa
Appearance round or oval
Hypoechoic (three- or five-
(irregular Cyst Third layer walls
borders, suggest
echogenic foci duplication

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Gastrointestinal Fourth (rarely cyst)
with mixed
stromal tumor second) Anechoic,
echogenicity;

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anechoic areas Varices Third tubular,
suggest serpiginous

EUS
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malignancy) Hypoechoic,
homogeneous

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Leiomyoma Fourth, second Hypoechoic
Inflammatory Second and/or or mixed
Characteristics Hypoechoic or
mixed
fibroid polyp third echogenicity,
indistinct
of Subepithelial

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Aberrant Second, third, echogenicity margin
pancreas and/or fourth (anechoic ductal
Hypoechoic,
Lesions structure may be
smooth margin,

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present)
internal
Lipoma Third Hyperechoic Glomus tumor Third or fourth heterogeneous

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Mildly echo mixed
Second and/or with high
Carcinoid hypoechoic,
third echoic spots
homogeneous

Second, third,
Homogeneous Lymphoma Hypoechoic
and/or fourth
Granular cell hypoechoic
Second or third
tumor mass with
smooth borders Metastatic Hypoechoic,
Any or all
deposits heterogeneous
 Gastric
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Lesions
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Antral Bulge: Courvoisier’s GB

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 Gastric Lipoma

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 Lipoma
• Yellow submucosal lesions
• More in lower GI track
• Asymptomatic, incidentally
detected

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• Pillow/cushion sign, Tent sign
• Hyperechoic lesions in third layer
(submucosa)
• No follow up required
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• Resection if

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symptoms/complications like
pain/bleeding/obstruction or
malignancy
(liposarcoma) can’t be ruled out
Prominent Folds- Varices

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 0 21
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Prominent Folds- Gastrinoma

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Prominent Folds- Linitis Plastica

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 GIST
• Well-circumscribed, hypoechoic, relatively
homogeneous mass in second or fourth layer of EUS
• Stomach most common (60-70%), small intestine (20-
30%), rare in esophagus
• Asymptomatic; nonspecific pain, bleeding & anemia for
the ulcer, intestinal obstruction

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• Features suggesting malignancy (sensitivity 80-100%
for 2/4 features)
• large size (>4cms)

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• heterogeneous echo texture with hyperechoic foci
and/or anechoic necrotic zones

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• irregular extraluminal border
• adjacent malignant-looking lymphadenopathy
• CEH-EUS: higher intensity, irregular intratumoral
vessels
• Positive Ki-67 for malignancy
 EUS FNA for GIST

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 Markers in GIST
 CD 117 (C-KIT)

 CD 34 (80% GIST)
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 Smooth muscle actin (leiomyoma, glomus)

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S100 (schwannoma)

 Ki-67 (cell proliferation)

 Immunostaining of spindle cell aspirates

C-kit
(CD 117)
CD 34

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Actin S-100 Malignancy risk

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GIST (+) (+) in 70% (-) in70% to 80% (-) in 90% All potentially
malignant

Leiomyoma (-)

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especially < 5cm

Schwannoma S (-) (-) (-) (+) Benign

 Gastric GIST

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SG
 Bleeding GIST

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SG
 EUS Characterisics

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EUS characteristics of malignant GISTs include the following:

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•Size larger than 4 cm (the only independent predictor)
•Heterogeneous echogenicity
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•Internal cystic areas

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•Irregular borders on the extraluminal surfaces
EUS features that may help differentiate gastric GISTs from leiomyomas are
as follows :

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•Inhomogenicity
•Hyperechogenic spots
•A marginal halo
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•Higher echogenicity than the surrounding muscle layer
 Malt Lymphoma

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 Gastric Carcinoids

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with normal-appearing
overlying mucosa,
umblicated

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lesion , well defined in
deep mucosa or

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submucosa
Look for invasion,

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node
Location – Stomach,
duodenum , rectal
Gastric Carcinoids: Characteristics

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Diagnostic Work up for Gastric/Duodenal NENs
Gastric/
Duodenal

Gastrin/Chromo
Carcinoids

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Confirm the diagnosis1
Endoscopy

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PlanA Therapy:
granin +
Stage, Infiltration, depth, LN,Bx
Metastasis
& IHC
Prognosis

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Gastric pH < 2 or
gastric acid

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>10mmol/h
EUS
Depth,
characteristics,
invasion, LNs
CT/MR
Dotatoc PET/CT
scan in high risk
of Metastasis

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Achlorhydria
Type 1 Gastric
carcinoids
Secretin
stimulations test
to confirm ZES
(Gastrin>120pg/ml
with sen 94%,
spec. 100%)
Size > 2 cm
Infiltration of muscularis propria
Angio-invasion
G2-G3 histological grading
Metastatic spread to lymph nodes
 Gastric NEN

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 Aberrant pancreas:
• Ectopic pancreatic tissue without anatomical or vascular
connection to pancreas proper

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• Incidental detection: 1/500 upper abdominal Sx, 0.6 to
13.7% of the autopsies

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• Anywhere in GI tract; more commonly seen in the stomach
• Asymptomatic with rarely symptoms of pancreatitis, cyst
formation, ulceration, bleeding, gastric outlet obstruction,
obstructive jaundice, and malignancy

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• Submucosal lesion with central umblication corresponding to
the draining duct on endoscopy

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• Hypoechoic or mixed echogenicity with internal anechoic
ductal structure with origin in the second, third, and/or fourth
layers on EUS
• Followed up without intervention
• Resection if symptoms/possible malignancy
 Key Points

1.EUS can accurately differentiate a mural lesion from extrinsic compression against
the gut wall.

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2.Determination of the cause of an intramural lesion is based on its layer of origin
and internal echo characteristics.

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3.The finding of an intact submucosal layer running deep into a mural lesion
indicates that the lesion can be removed safely by endoscopic mucosal resection.

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4.Carcinoid tumors cannot usually be diagnosed with standard mucosal biopsies
because these tumors emanate from the deep mucosal layer.

5.Gastrointestinal stromal tumors can be differentiated from leiomyomas by

immunohistochemical staining for CD117 (c-kit proto-oncogene protein product).