Submucosal tumors: Comprehensive guide for the diagnosis and therapy of gastrointestinal submucosal tumors

Abstract

Small submucosal tumors (SMT) without symptoms are frequently found by endoscopic and radiological examinations. To find proper diagnostic measures and therapeutic indications for histologically undiagnosed SMT, we reviewed published articles in PubMed between 1990 and March 2013 using the key words 'submucosal tumor' and the name of a specific disease. SMT is observed in a wide range of gastrointestinal (GI) diseases and conditions, including compression by extra-GI organs and lesions, congenital tumors, inflammation, and benign as well as malignant neoplastic lesions. In the diagnosis of diseases and decision-making for therapy, endoscopic ultrasonography (EUS) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) may play a key role. Symptomatic SMT and SMT histologically diagnosed as malignant or potentially malignant tumors such as gastrointestinal stromal tumor (GIST) should be treated by surgery. SMT >5 cm, SMT increasing in size and those with 'high-risk features' including irregular border, heterogeneous internal echo such as anechoic area, and heterogeneous enhancement by contrast media may also be removed by surgery. Laparoscopic approach is feasible for gastric GIST <5 cm and this is considered less invasive than the open approach. Emerging techniques using flexible endoscopes appear less invasive, but require further evidence and are still under clinical study. Correct diagnosis of SMT is challenging; however, EUS and EUS-FNA are useful in the histological diagnosis and clinical decisionmaking. In the future, minimally invasive approaches may be a mainstream of surgical treatment for small SMT.

Current status of submucosal tunneling endoscopic resection for gastrointestinal submucosal tumors originating from the muscularis propria layer (Review)

“…Following the identification of a gastrointestinal submucosal tumor (SMT), periodic surveillance using endoscopy and endoscopic ultrasonography (EUS) remains a major strategy, but the use of this strategy is associated with multiple concerns, including patient compliance and stress, cost-effectiveness, and the risks associated with repeated endoscopic procedures and delayed diagnosis of malignancy (1,2). Furthermore, certain tumors exhibit malignant potential, particularly those that originate from the muscularis propria (MP) layer or are large in diameter (1).…”

“…Furthermore, certain tumors exhibit malignant potential, particularly those that originate from the muscularis propria (MP) layer or are large in diameter (1). Therefore, removing these SMTs is crucial.…”

“…Current methods to remove SMTs include surgery and endoscopic resection, compared with the latter, surgical approaches are more invasive and associated with increased costs and a longer hospital stay. Endoscopic resection is a first-line treatment for SMTs ≤50 mm in diameter (1,2). Alternative methods include endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE) and endoscopic full-thickness resection, but these may be associated with unsatisfactory outcomes due to incomplete resection and/or the risk of perforation during the procedure (3)(4)(5).…”

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“…Endoscopic ultrasound (EUS), contrast-enhanced CT, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) have been recommended for subepithelial tumors between 2 to 5 cm [13]. We would also recommend preoperative histologic confirmation using EUS-FNA or incision biopsy.…”

Natural Course of Gastric Subepithelial Tumor

“…4 GIST; low risk (10) GIST; very low risk (2) Schwannoma (2) Leiomyoma (1) Heterotopic pancreas (1) Lipoma (1) GCP (1) Hata et al GIST; high risk (1) GIST; low risk (5) SETs, subepithelial tumors; EUS, endoscopic ultrasonography; GIST, gastrointestinal stromal tumor; GE, gastroesophageal; EGD, esophagogastroduodenoscopy; GCP, gastritis cystica profunda. …”