Gleeson - EUS Evaluation of GI Lumps and Bumps - revised ...s3.gi.org/meetings/bp2014/14ACG_Best_Practices_0030.pdf · The The differential diagnosis of GI differential diagnosis

Ferga C. Gleeson, MD, FACG, FASGE

EUS Evaluation of EUS Evaluation of GI GI Lumps and BumpsLumps and Bumps

The The differential diagnosis of GI differential diagnosis of GI subepithelialsubepitheliallesions from the esophagus to lesions from the esophagus to rectum with rectum with the aid the aid

of of EUS FNAEUS FNA

FergaFerga C. Gleeson, MD, FACG, FASGEC. Gleeson, MD, FACG, FASGE

A subepithelialA subepithelial lesion can arise from:lesion can arise from:A subepithelial A subepithelial lesion can arise from: lesion can arise from:

AAny ny layer layer within the within the gastrointestinal tract wall (intramuralgastrointestinal tract wall (intramural))oror

Outside the Outside the wall (extramural)wall (extramural)

ACG Board of Governors/ASGE Best Practices Course - Las Vegas, NV Copyright 2014 American College of Gastroenterology

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EUSEUS

Extramural structures or lesions: Spleen

EUS, EUS FNA and Core BiopsEUS, EUS FNA and Core Biopsyy

Aorta Gallbladder Splenic artery aneurysm Cyst Tumor

Originating lesion layer

Echogenicity, vascularity, margins, size of the lesion ± lymph nodes

Sampling & immunostaining

Hyperechoic 3rd layer


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h iEchogenicityEchogenicity Common Lesions & LayerCommon Lesions & Layer

GISTs - muscularis propria

Leiomyoma – muscularis propria

Lipoma - Submucosa

Carcinoid - Submucosa

Granular Cell Tumor - Submucosa

Duplication Cyst - Submucosa

Anechoic - cysts, vessels, and the gallbladder

Hypoechoic- leiomyomas, GISTs

Hyperechoic- lipoma

p y

Pancreatic rest - Submucosa

Varices – Lamina propria or submucosa

Isoechoic- somewhere in between hyperechoic & hypoechoic

EUS, EUS FNA and Core BiopsyEUS, EUS FNA and Core Biopsy

Cellular morphology alone is often insufficient to yield a definitive diagnosis i i dl ll h l GIST l ii.e. spindle cell morphology; GIST vs. leiomyoma

Immunohistochemistry with cKIT, DOG‐1, SMA, and S100

FNA yield ~ 62% for a definitive tissue diagnosis

A superior method for tissue acquisition to perform IHCI T t dl (Q i k )I.Trucut needle (Quickcore)II.EchoTip® ProCore™

ProCoreProCore


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Concordance Concordance of of EUS FNA Diagnosis EUS FNA Diagnosis with the with the Final Diagnosis in Subepithelial LesionsFinal Diagnosis in Subepithelial Lesions

EUS FNA → surgical pathology of gastric subepithelial lesions → accuracy 20-84%

What do these images represent?What do these images represent?


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1 Li1. Lipoma2. Carcinoid3. Cystic Pancreas Neuroendocrine Tumor4. Duplication cyst5. GIST


1 Li1. Lipoma2. Carcinoid3. Cystic Pancreas Neuroendocrine Tumor4. Duplication cyst5.5. GISTGIST


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GIST FactoidsGIST Factoids Most common mesenchymal neoplasm of the GI tract

Stomach (60-70% ), small intestine (20-25%), colon/rectum (5%) and esophagus ( %)(<5%)

85-95% have c-KIT mutation

Additional markers : smooth muscle actin (20-30%), and s100 protein

Main factors associated with malignant potential: tumor size, mitotic rate and primary location (small intestinal > stomach)

EUS tumor size (>4 cm), irregular extraluminal border, heterogeneity, echogenic foci cystic spaces greater than 4 mm and enlarged lymph nodes werefoci, cystic spaces greater than 4 mm and enlarged lymph nodes were associated with malignancy

EUS-FNA: sensitivity and specificity; 82% &100%, with an accuracy of 86%. Onsite presence of a cytopathologist to confirm the adequacy of tissue samples, gastric vs. duodenal lesion location and lesion size significantly influence diagnostic yield.

Watson RR, Binmoeller KF, Hamerski CM, et al. Yield and performance characteristics of endoscopic ultrasound-guided fine needle aspiration for diagnosing upper GI tract stromal tumors. Dig Dis Sci. 2011;56:1757–1762


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1 Li1. Lipoma2. Carcinoid3. Leiomyoma4. Duplication cyst5. GIST


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1 Li1. Lipoma2. Carcinoid3.3. LeiomyomaLeiomyoma4. Duplication cyst5. GIST



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Immunohistochemical studies are positive for smooth muscle

Leiomyoma FactoidsLeiomyoma Factoids ESDESD

actin and desmin and negative for c-kit

Zhang Y, Ye LP, Zhou XB et al. Safety and efficacy of endoscopic excavation for gastric subepithelial tumors originating from the muscularis propria layer: results from a large study in China. J Clin Gastroenterol. 2013 Sep;47(8):689-94



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1 GIST1. GIST2. Carcinoid3. Hemorrhoids4. Endometriosis5. Pelvic abscess


1 GIST1. GIST2. Carcinoid3. Hemorrhoids4.4. EndometriosisEndometriosis5. Pelvic abscess


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Endometriosis FactoidsEndometriosis Factoids

The GI tract is the most common site for extra pelvic The GI tract is the most common site for extra pelvic endometriosis infiltration.

The endometriotic implants are hypoechoic or heterogeneous crescent shaped lesions, involving the serosa and the muscularis propria layers of the rectal wall, sparing the mucosal layers.

Th h t EUS f th i l t i The heterogeneous EUS appearance of the implants is caused by the presence of “chocolate cysts” that result from hemorrhage within the implant.


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1 R t l C i id1.Rectal Carcinoid2.Submucosal Esophageal Cancer3.Gastric GIST4.Rectal Melanoma5.Gastric Polypyp


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1 R t l C i id1.Rectal Carcinoid2.Submucosal Esophageal Cancer3.Gastric GIST4.Rectal Melanoma5.Gastric Polypyp



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Melanoma FactoidsMelanoma Factoids Extremely rare malignancy (0.05%

malignant colorectal neoplasia)

Distant primary cancers rarely Distant primary cancers rarely metastasize to the GI wall

- 1/ 3,847 upper GI- 1/ 1,871 colonoscopies

Circumferential wall thickening affecting predominantly the submucosal and muscularis propria layer which is in contrast to rectal endometriotic implants that are described as either hypoechoic or heterogeneous deposits involving the 4th and 5th layers with intact mucosal layersintact mucosal layers

EUS FNA ± Trucut biopsy: primary cancer origin: bladder, breast, stomach and cutaneous melanoma


Patient with neurofibromatosis type 1 and a 3rd duodenum or periduodenal lesion


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1 N fib1.Neurofibroma2.GIST3. Lymphoma4.Phaeochromocytoma5.Sarcoma


1 N fib1.Neurofibroma2.2.GISTGIST3.Lymphoma4.Phaeochromocytoma5.Sarcoma


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Patient with neurofibromatosis type 1 and a 3rd duodenum or periduodenal lesion

More GIST FactoidsMore GIST Factoids

DOG1 & C Kit iti DOG1 & C-Kit positive

NF1-associated GIST’s mainly small bowel Prevalence 4-25%

Usually GI bleeding & obstruction

National Comprehensive Cancer Network (NCCN) p ( )treatment guidelines recommend R0 resection with an intact pseudocapsule and negative microscopic margins for patients with tumors ≥2 cm


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1 R t l C i id1.Rectal Carcinoid2.Rectal GIST3. Lymphoma4.Carcinoma5.Sarcoma


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1 R t l C i id1.Rectal Carcinoid2.Rectal GIST3.3. LymphomaLymphoma4.Carcinoma5.Sarcoma


High grade B-cell Burkitt’s lymphoma EBV +


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What do these images represenWhat do these images represent?t?

Rectal Rectal subepithelialsubepithelial lesionlesion


1 Li1. Lipoma2. Carcinoid3. Hemorrhoids4. Duplication cyst5. Pelvic abscess


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1 Li1. Lipoma2.2. CarcinoidCarcinoid3. Hemorrhoids4. Duplication cyst5. Pelvic abscess


Rectal Rectal subepithelialsubepithelial lesionlesion


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Rectal Carcinoid FactoidsRectal Carcinoid Factoids

Carcinoids are rare intramucosal tumors ofintramucosal tumors of endocrine cell origin with malignant potential and are commonly asymptomatic

Gastric and ileal carcinoids are commonly multiple while thosemultiple, while those arising elsewhere are typically solitary


Gastric WallGastric Wall

8mm8mm



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1 L h1. Lymphoma2. Linitis Plastica3. Ménétrier's Disease4. T2 Gastric Cancer5. GIST


1 L h1. Lymphoma2.2. Linitis PlasticaLinitis Plastica3. Ménétrier's Disease4. T2 Gastric Cancer5. GIST


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8mm8mm


Gastric Linitis Plastica FactoidsGastric Linitis Plastica Factoids The routine use of staging EUS

can sometimes alter the therapeutic plan because of the finding of otherwise occultfinding of otherwise occult distant metastases - left lobe liver lesions - peritoneal deposits- ascites

5 sonographic layers disappear and replaced by a hypoechogenic thickening of the wall with the 4th layer significantly thickened

Max full thickness of the wall8-27mm

Perigastric ascites - 25%

Perigastric lymph nodes - 41%


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1 R t l GIST1.Rectal GIST2.Rectal Lipoma3.Rectal Adenoma4.Rectal Carcinoid5.Rectal endometriosis depositp


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1 R t l GIST1.Rectal GIST2.Rectal Lipoma3.Rectal Adenoma4.Rectal Carcinoid5.Rectal endometriosis depositp



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Lipoma FactoidsLipoma Factoids Have no malignant potential

Typically present as solitary lesionsYellow hue, often exhibit a “pillow sign” and some mobility, p g y“Pillow sign” : 98% specificity and 40% sensitivity

Homogeneous, hyperechoic, well-defined lesion, originating from the 3rd layer of the GI tract (submucosa) at EUS suggests a benign tumor, generally a lipoma.

However the following, although rare are in the differential for the upper GI tract:

i.Brunner’s gland hamartomaii.Hamartomatous polypiii.Gangliocytic paraganglioma iv.Renal cell carcinoma metastasis



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1 T t1. Teratoma2. Tailgut Cyst3. Dermoid Cyst4. Duplication cyst5. Pelvic abscess


1 T t1. Teratoma2.2. Tailgut CystTailgut Cyst3. Dermoid Cyst4. Duplication cyst5. Pelvic abscess


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3.4 x 3.3cm multi3.4 x 3.3cm multi--loculatedloculated cystic cystic extrinsic rectal wall mass*extrinsic rectal wall mass*


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Tailgut Cyst FactoidsTailgut Cyst Factoids Cystic hamartoma

Cystic loculi are lined by squamous epithelium transitional type Cystic loculi are lined by squamous epithelium, transitional type epithelium, and columnar epithelium with focal goblet cells

Malignant potential

Current recommendation is to avoid FNA of perirectal cysts due to concerns regarding abscess formation even with prophylactic antibiotic use, as highlighted in one patient who subsequently required percutaneous drainage [1].

Complete intact surgical excision is advised to avoid the potential risk of needle-tract seeding, infection, and fistula formation [2].

1. Mohamadnejad M, Al-Haddad MA, Sherman S et al. Utility of EUS-guided biopsy of extramural pelvic masses. Gastrointest Endosc 2012; 75: 146-151 2. Mathis KL, Dozois EJ, Grewal MS et al. Malignant risk and surgical outcomes of presacral tailgut cysts. Br J Surg 2010; 97: 575-579

EUS Evaluation of EUS Evaluation of GI GI Lumps and BumpsLumps and Bumps

The The differential diagnosis of GI differential diagnosis of GI subepithelialsubepitheliallesions from the esophagus to lesions from the esophagus to rectum with rectum with the aid the aid

of of EUS FNAEUS FNA

FergaFerga C. Gleeson, MD, FACG, FASGEC. Gleeson, MD, FACG, FASGE


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Documents

Gleeson - EUS Evaluation of GI Lumps and Bumps - revised ...s3.gi.org/meetings/bp2014/14ACG_Best_Practices_0030.pdf · The The differential diagnosis of GI differential diagnosis