gleeson - eus evaluation of gi lumps and bumps - revised...
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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)
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Ferga C. Gleeson, MD, FACG, FASGE
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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Ferga C. Gleeson, MD, FACG, FASGE
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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Ferga C. Gleeson, MD, FACG, FASGE
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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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 Li1. Lipoma2. Carcinoid3. Cystic Pancreas Neuroendocrine Tumor4. Duplication cyst5. GIST
What do these images represent?What do these images represent?
1 Li1. Lipoma2. Carcinoid3. Cystic Pancreas Neuroendocrine Tumor4. Duplication cyst5.5. GISTGIST
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
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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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
What do these images represent?What do these images represent?
1 Li1. Lipoma2. Carcinoid3. Leiomyoma4. Duplication cyst5. GIST
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 Li1. Lipoma2. Carcinoid3.3. LeiomyomaLeiomyoma4. Duplication cyst5. GIST
What do these images represent?What do these images represent?
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Ferga C. Gleeson, MD, FACG, FASGE
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
What do these images represent?What do these images represent?
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 GIST1. GIST2. Carcinoid3. Hemorrhoids4. Endometriosis5. Pelvic abscess
What do these images represent?What do these images represent?
1 GIST1. GIST2. Carcinoid3. Hemorrhoids4.4. EndometriosisEndometriosis5. Pelvic abscess
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
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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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
What do these images represent?What do these images represent?
1 R t l C i id1.Rectal Carcinoid2.Submucosal Esophageal Cancer3.Gastric GIST4.Rectal Melanoma5.Gastric Polypyp
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 R t l C i id1.Rectal Carcinoid2.Submucosal Esophageal Cancer3.Gastric GIST4.Rectal Melanoma5.Gastric Polypyp
What do these images represent?What do these images represent?
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Ferga C. Gleeson, MD, FACG, FASGE
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
What do these images represent?What do these images represent?
Patient with neurofibromatosis type 1 and a 3rd duodenum or periduodenal lesion
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 N fib1.Neurofibroma2.GIST3. Lymphoma4.Phaeochromocytoma5.Sarcoma
What do these images represent?What do these images represent?
1 N fib1.Neurofibroma2.2.GISTGIST3.Lymphoma4.Phaeochromocytoma5.Sarcoma
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
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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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
What do these images represent?What do these images represent?
1 R t l C i id1.Rectal Carcinoid2.Rectal GIST3. Lymphoma4.Carcinoma5.Sarcoma
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 R t l C i id1.Rectal Carcinoid2.Rectal GIST3.3. LymphomaLymphoma4.Carcinoma5.Sarcoma
What do these images represent?What do these images represent?
High grade B-cell Burkitt’s lymphoma EBV +
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represenWhat do these images represent?t?
Rectal Rectal subepithelialsubepithelial lesionlesion
What do these images represent?What do these images represent?
1 Li1. Lipoma2. Carcinoid3. Hemorrhoids4. Duplication cyst5. Pelvic abscess
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 Li1. Lipoma2.2. CarcinoidCarcinoid3. Hemorrhoids4. Duplication cyst5. Pelvic abscess
What do these images represent?What do these images represent?
Rectal Rectal subepithelialsubepithelial lesionlesion
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Ferga C. Gleeson, MD, FACG, FASGE
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
What do these images represent?What do these images represent?
Gastric WallGastric Wall
8mm8mm
Gastric WallGastric Wall
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 L h1. Lymphoma2. Linitis Plastica3. Ménétrier's Disease4. T2 Gastric Cancer5. GIST
What do these images represent?What do these images represent?
1 L h1. Lymphoma2.2. Linitis PlasticaLinitis Plastica3. Ménétrier's Disease4. T2 Gastric Cancer5. GIST
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
Gastric WallGastric Wall
8mm8mm
Gastric WallGastric Wall
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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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
What do these images represent?What do these images represent?
1 R t l GIST1.Rectal GIST2.Rectal Lipoma3.Rectal Adenoma4.Rectal Carcinoid5.Rectal endometriosis depositp
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 R t l GIST1.Rectal GIST2.Rectal Lipoma3.Rectal Adenoma4.Rectal Carcinoid5.Rectal endometriosis depositp
What do these images represent?What do these images represent?
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Ferga C. Gleeson, MD, FACG, FASGE
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
What do these images represent?What do these images represent?
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
1 T t1. Teratoma2. Tailgut Cyst3. Dermoid Cyst4. Duplication cyst5. Pelvic abscess
What do these images represent?What do these images represent?
1 T t1. Teratoma2.2. Tailgut CystTailgut Cyst3. Dermoid Cyst4. Duplication cyst5. Pelvic abscess
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Ferga C. Gleeson, MD, FACG, FASGE
What do these images represent?What do these images represent?
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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Ferga C. Gleeson, MD, FACG, FASGE
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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