J Korean Med Sci.  2016 Nov;31(11):1768-1774. 10.3346/jkms.2016.31.11.1768.

Using Forceps Biopsy after Small Submucosal Dissection in the Diagnosis of Gastric Subepithelial Tumors

• Jung YS
• Lee H
• Kim K
• Sohn JH
• Kim HJ
• Park JH

• KMID: 2470273
• DOI: http://doi.org/10.3346/jkms.2016.31.11.1768

Abstract

The current tissue sampling techniques for subepithelial tumors (SETs) of the gastrointestinal (GI) tract have limited diagnostic efficacy. We evaluated the diagnostic yield and safety of forceps biopsies after small endoscopic submucosal dissection (SESD biopsies) in the diagnosis of gastric SETs. A total of 42 patients with gastric SETs > 10 mm were prospectively enrolled between May 2013 and October 2014. A dual knife was used to incise the mucosa and submucosa and forceps biopsies were then introduced deep into the lesion. To compare SESD biopsies with EUS-FNA, we used the retrospective data of 30 EUS-FNA cases. The diagnostic yield of SESD biopsies was comparable to that of EUS-FNA (35/42, 83.3% vs. 24/30, 80.0%, P = 0.717). The mean procedure time of SESD biopsies was shorter than that of EUS-FNA (10 vs. 37 minutes, P < 0.001). There were no procedure-related adverse events in the both group. The pathological diagnoses in SESD biopsies group included 15 leiomyomas, 7 GISTs, 10 heterotopic pancreases, 2 lipomas, and one other lesion. SESD biopsies are an easy, effective and safe technique for the diagnosis of gastric SETs and its diagnostic yield is comparable to that of EUS-FNA. This technique may be a reliable alternative to conventional EUS-FNA (Clinical trial registration No. KCT0000730).

Keyword

Subepithelial Tumor; Submucosal Dissection; Forceps Biopsy

MeSH Terms

Adult
Aged
Endoscopic Mucosal Resection/*methods
Endoscopic Ultrasound-Guided Fine Needle Aspiration/*methods
Female
Gastric Mucosa/*pathology
Humans
Male
Middle Aged
Platelet Count
Stomach Neoplasms/*diagnosis/pathology

Figure

• 

  Fig. 1 Forceps biopsy technique after small submucosal dissection. (A) Endoscopic view of a gastric subepithelial tumor (SET). (B) Endoscopic ultrasonography image of a gastric SET. (C) Submucosal saline injection. (D) Cross-shaped dissection of the mucosa and submucosa with a dual knife. (E) Confirming the exposure of the underlying tumor. (F) Biopsy forceps were introduced through the hole, taking multiple tissue samples from inside. (G) Prophylactic or hemostatic clipping.

Reference

1. Akahoshi K, Sumida Y, Matsui N, Oya M, Akinaga R, Kubokawa M, Motomura Y, Honda K, Watanabe M, Nagaie T. Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration. World J Gastroenterol. 2007; 13:2077–2082.

2. Williams DB, Sahai AV, Aabakken L, Penman ID, van Velse A, Webb J, Wilson M, Hoffman BJ, Hawes RH. Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience. Gut. 1999; 44:720–726.

3. Philipper M, Hollerbach S, Gabbert HE, Heikaus S, Böcking A, Pomjanski N, Neuhaus H, Frieling T, Schumacher B. Prospective comparison of endoscopic ultrasound-guided fine-needle aspiration and surgical histology in upper gastrointestinal submucosal tumors. Endoscopy. 2010; 42:300–305.

4. Fernández-Esparrach G, Sendino O, Solé M, Pellisé M, Colomo L, Pardo A, Martínez-Pallí G, Argüello L, Bordas JM, Llach J, et al. Endoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover study. Endoscopy. 2010; 42:292–299.

5. Polkowski M, Gerke W, Jarosz D, Nasierowska-Guttmejer A, Rutkowski P, Nowecki ZI, Ruka W, Regula J, Butruk E. Diagnostic yield and safety of endoscopic ultrasound-guided trucut [corrected] biopsy in patients with gastric submucosal tumors: a prospective study. Endoscopy. 2009; 41:329–334.

6. Cantor MJ, Davila RE, Faigel DO. Yield of tissue sampling for subepithelial lesions evaluated by EUS: a comparison between forceps biopsies and endoscopic submucosal resection. Gastrointest Endosc. 2006; 64:29–34.

7. Ji JS, Lee BI, Choi KY, Kim BW, Choi H, Huh M, Chung WC, Chae HS, Chung IS. Diagnostic yield of tissue sampling using a bite-on-bite technique for incidental subepithelial lesions. Korean J Intern Med. 2009; 24:101–105.

8. Białek A, Wiechowska-Kozłowska A, Pertkiewicz J, Polkowski M, Milkiewicz P, Karpińska K, Ławniczak M, Starzyńska T. Endoscopic submucosal dissection for treatment of gastric subepithelial tumors (with video). Gastrointest Endosc. 2012; 75:276–286.

9. Li QL, Yao LQ, Zhou PH, Xu MD, Chen SY, Zhong YS, Zhang YQ, Chen WF, Ma LL, Qin WZ. Submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a large study of endoscopic submucosal dissection (with video). Gastrointest Endosc. 2012; 75:1153–1158.

10. Hwang JC, Kim JH, Kim JH, Shin SJ, Cheong JY, Lee KM, Yoo BM, Lee KJ, Cho SW. Endoscopic resection for the treatment of gastric subepithelial tumors originated from the muscularis propria layer. Hepatogastroenterology. 2009; 56:1281–1286.

11. Waterman AL, Grobmyer SR, Cance WG, Hochwald SN. Is endoscopic resection of gastric gastrointestinal stromal tumors safe? Am Surg. 2008; 74:1186–1189.

12. von Renteln D, Riecken B, Walz B, Muehleisen H, Caca K. Endoscopic GIST resection using FlushKnife ESD and subsequent perforation closure by means of endoscopic full-thickness suturing. Endoscopy. 2008; 40:Suppl 2. E224–5.

13. Park YS, Park SW, Kim TI, Song SY, Choi EH, Chung JB, Kang JK. Endoscopic enucleation of upper-GI submucosal tumors by using an insulated-tip electrosurgical knife. Gastrointest Endosc. 2004; 59:409–415.

14. Huang WH, Feng CL, Lai HC, Yu CJ, Chou JW, Peng CY, Yang MD, Chiang IP. Endoscopic ligation and resection for the treatment of small EUS-suspected gastric GI stromal tumors. Gastrointest Endosc. 2010; 71:1076–1081.

15. Lee SH, Park JH, Park DH, Chung IK, Kim HS, Park SH, Kim SJ, Cho HD. Endoloop ligation of large pedunculated submucosal tumors (with videos). Gastrointest Endosc. 2008; 67:556–560.

16. Sun S, Ge N, Wang C, Wang M, Lü Q. Endoscopic band ligation of small gastric stromal tumors and follow-up by endoscopic ultrasonography. Surg Endosc. 2007; 21:574–578.

17. Binmoeller KF, Shah JN, Bhat YM, Kane SD. Retract-ligate-unroof-biopsy: a novel approach to the diagnosis and therapy of large nonpedunculated stromal tumors (with video). Gastrointest Endosc. 2013; 77:803–808.

18. Binmoeller KF, Shah JN, Bhat YM, Kane SD. Suck-ligate-unroof-biopsy by using a detachable 20-mm loop for the diagnosis and therapy of small subepithelial tumors (with video). Gastrointest Endosc. 2014; 79:750–755.

19. Palazzo L, Landi B, Cellier C, Cuillerier E, Roseau G, Barbier JP. Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours. Gut. 2000; 46:88–92.

20. Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, Miettinen M, O’Leary TJ, Remotti H, Rubin BP, et al. Diagnosis of gastrointestinal stromal tumors: A consensus approach. Hum Pathol. 2002; 33:459–465.

21. Demetri GD, Benjamin RS, Blanke CD, Blay JY, Casali P, Choi H, Corless CL, Debiec-Rychter M, DeMatteo RP, Ettinger DS, et al. NCCN Task Force report: management of patients with gastrointestinal stromal tumor (GIST)--update of the NCCN clinical practice guidelines. J Natl Compr Canc Netw. 2007; 5:Suppl 2. S1–29.

22. Huang HY, Li CF, Huang WW, Hu TH, Lin CN, Uen YH, Hsiung CY, Lu D. A modification of NIH consensus criteria to better distinguish the highly lethal subset of primary localized gastrointestinal stromal tumors: a subdivision of the original high-risk group on the basis of outcome. Surgery. 2007; 141:748–756.

23. Hoda KM, Rodriguez SA, Faigel DO. EUS-guided sampling of suspected GI stromal tumors. Gastrointest Endosc. 2009; 69:1218–1223.

24. Ginès A, Wiersema MJ, Clain JE, Pochron NL, Rajan E, Levy MJ. Prospective study of a Trucut needle for performing EUS-guided biopsy with EUS-guided FNA rescue. Gastrointest Endosc. 2005; 62:597–601.

25. de la Serna-Higuera C, Pérez-Miranda M, Díez-Redondo P, Gil-Simón P, Herranz T, Pérez-Martín E, Ochoa C, Caro-Patón A. EUS-guided single-incision needle-knife biopsy: description and results of a new method for tissue sampling of subepithelial GI tumors (with video). Gastrointest Endosc. 2011; 74:672–676.

26. Lee HL, Kwon OW, Lee KN, Jun DW, Eun CS, Lee OY, Jeon YC, Han DS, Yoon BC, Choi HS, et al. Endoscopic histologic diagnosis of gastric GI submucosal tumors via the endoscopic submucosal dissection technique. Gastrointest Endosc. 2011; 74:693–695.

27. Lee CK, Chung IK, Lee SH, Lee SH, Lee TH, Park SH, Kim HS, Kim SJ, Cho HD. Endoscopic partial resection with the unroofing technique for reliable tissue diagnosis of upper GI subepithelial tumors originating from the muscularis propria on EUS (with video). Gastrointest Endosc. 2010; 71:188–194.

28. Nishida T, Kawai N, Yamaguchi S, Nishida Y. Submucosal tumors: comprehensive guide for the diagnosis and therapy of gastrointestinal submucosal tumors. Dig Endosc. 2013; 25:479–489.