{"id":58933,"date":"2024-06-25T10:32:32","date_gmt":"2024-06-25T10:32:32","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=58933"},"modified":"2024-07-03T17:47:41","modified_gmt":"2024-07-03T17:47:41","slug":"role-of-endoscopic-ultrasound-in-diagnosis-of-submucosal-lesions-of-gastrointestinal-tract","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol17no2\/role-of-endoscopic-ultrasound-in-diagnosis-of-submucosal-lesions-of-gastrointestinal-tract\/","title":{"rendered":"Role of Endoscopic Ultrasound in Diagnosis of Submucosal Lesions of Gastrointestinal Tract"},"content":{"rendered":"\n

Introduction<\/strong><\/p>\n\n\n\n

Submucosal lesions are Lesions that appear as\nprotuberance in GI tract with normal overlying mucosa they are a frequent\nsource of Referral EUS evaluation1<\/sup>. Those lesions are most often\nfound incidentally during endoscopy and colonoscopy. The majority are\nasymptomatic. Others, may found with hemorrhage obstruction, or dysphagia. Women\nand men were equally affected, and most patients were more than 50 years old at\nthe time of diagnosis2<\/sup>. Some of these lesions can be benign, premalignant\nor malignant, they most commonly occur within the stomach, but are also\nregularly noted in the duodenum and esophagus. Furthermore, during colonoscopy,\nsubmucosal lesions were often detected in the cecum and rectum, but familiar\nlesions such as lipomas may be seen in any part of the colon3<\/sup>.<\/p>\n\n\n\n

They might arise from any layer of the gastrointestinal tract wall\n(intramural) or outside of the wall (extramural). Intramural lesions originate\nfrom the submucosal layer are usually lipomas, carcinoid tumors, granular cell\ntumors pancreatic rests, fibromas and duplication cysts. Lesions arising from\nthe muscularis propria usually represent GI stromal tumors (G I S T),\nleiomyomas4,5<\/sup>.<\/p>\n\n\n\n

There are conventional methods of diagnosis of\nsubmucosal lesions as computed tomography C T Barium studies, Endoscopic\nstudies with biopsies and MRI6<\/sup>.<\/p>\n\n\n\n

EUS is now considered to be superior to\nconventional studies as it provides an understanding of whether the lesion\narises from the bowel wall (intramural) or from a structure outside the bowel\nwall (extramural) It also determine the layer of origin of intramural lesions\ne.g.; stromal cell tumors, can be seen as evolving from the muscularis mucosa,\nwhereas lipomas evolve from the submucosal7<\/sup>. <\/p>\n\n\n\n

Furthermore, EUS can determine the\nechogenicity, size of the lesion, margins, vascularity and absence or presence\nof adjacent lymph nodes. Lastly, it is helpful in confirming diagnosis by EUS\n-guided fine needle aspiration (FNA) and sometimes in appropriate management of\nthe diagnosed lesions8<\/sup>.<\/p>\n\n\n\n

Aim of the work<\/strong><\/p>\n\n\n\n

The study aimed to understand the magnitude of submucosal\nlesions as part of the referral to the EUS unit in one year and know the\npercent of the different types and sites of submucosal lesions of GIT in TBRI\nas tertiary referral center draining Egyptian community.<\/p>\n\n\n\n

Subjects and Methods<\/strong><\/p>\n\n\n\n

Research\ndesign<\/strong><\/p>\n\n\n\n

This cross-sectional hospital-based study, was\nconducted through one year on all cases referred to the EUS unit at TBRI for\nassessment, whom were analyzed to assess the percent of cases of submucosal\nlesions as part of the total referral and to know the different types seen and\ntheir common sites as compared to the international literature.<\/p>\n\n\n\n

Cases were subjected to; thorough history\ntalking, physical examination, laboratory investigations (CBC, liver function\ntests, renal function tests), finally,\nEUS was done using\na linear echo-endoscope (PENTAX EG- 3870 UTK) and processor (<\/strong>HITACHI-HI\nVision Avius)<\/p>\n\n\n\n

A preliminary upper endoscopy was performed to\nidentify the lesions and characterize the overlying mucosa. After intubation of\nthe esophagus, stomach, duodenum, rectum and colon the linear echo-endoscope\nwas advanced under direct endoscopic guidance. Then, the ultrasound transducer was placed against the\nlesion under direct visualization whenever possible. <\/p>\n\n\n\n

Lesions requiring more characterization were\nsubjected to EUS\u2013guided fine\u2013needle aspiration (FNA) using needles of different\ncalibers (25, 22 or 19) (ECHO 3-22 Cook Echotip ultra, ECHO \u2013 HD- 22-c Cook Echotip procore, ECHO 19\nCook Echotip ultra and Boston 22ga (0.72\nmm)<\/p>\n\n\n\n

Statistical\nanalysis<\/strong><\/p>\n\n\n\n

Collected data were subjected to statistical\nanalysis by SPSS. Ver. 22. Descriptive statistics and analytical statistics\nwere treated according to data type.<\/p>\n\n\n\n

Aspirated specimens were candidate for\nhistopathological examination, after being stained using the two complementary\ntypes of slide-preparation techniques; air-dried and alcohol-fixed slides, the\ntwo preparations were\ncomplementary and were\nused to demonstrate different cytological features of lesions. Cases of GISTs\nand leiomyomas, further differentiation is needed using immune-histochemical\nstaining by CD 117 and desmin to show spindle cells.<\/p>\n\n\n\n

Results <\/strong><\/p>\n\n\n\n

The present study included 36 patients; 16\nfemales and 20 males. As shown in Table (1); ranging in ages from 21 to 75\nyears. All patients had preliminary upper endoscopy or colonoscopy and\naccording to the indication of upper preliminary endoscopy or colonoscopy, 12\n(33.3%) complained of melena, 5 (13.8%) hematemesis,1(2.7%) bleeding per\nrectum, 7 (19.4%) upper abdominal pain, 2(5.5%) dysphagia, 8 (22.2%) vomiting\nand 1(2.7%) hepatic focal lesion on normal liver, upper endoscopy was done screening\nfor the primary lesions.<\/p>\n\n\n\n

Table 1: Demographic data and indication of upper preliminary endoscopy or colonoscopy<\/strong>.<\/p>\n\n\n\n\n\n\n\n\n
\n

Variable<\/strong><\/p>\n<\/td>\n

\n

Data<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Age<\/strong><\/p>\n

-Range<\/p>\n

-Mean +SD<\/p>\n<\/td>\n

\n

 <\/p>\n

21-75<\/p>\n

52.4+12.8<\/p>\n<\/td>\n<\/tr>\n

\n

Sex: N (%)<\/strong><\/p>\n

-Males<\/p>\n

-Females<\/p>\n<\/td>\n

\n

 <\/p>\n

20(55.6%)<\/p>\n

16(44.4%)<\/p>\n<\/td>\n<\/tr>\n

\n

Indication of upper preliminary endoscopy or olonoscopy N (%):<\/strong><\/p>\n

-Melena<\/p>\n

-Hematemesis<\/p>\n

-Bleeding per-rectum<\/p>\n

-Upper abdominal pain<\/p>\n

-Dysphagia<\/p>\n

-Vomiting<\/p>\n

-Hepatic focal lesion on normal liver (screening for the primary lesion)<\/p>\n<\/td>\n

\n

 <\/p>\n

 <\/p>\n

12(33.3%)<\/p>\n

5(13.8%)<\/p>\n

1(2.7%)<\/p>\n

7(19.4%)<\/p>\n

2(5.5%)<\/p>\n

8(22.2%)<\/p>\n

1(2.7%)<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

As shown in table (2), the laboratory findings\nof submucosal lesions were evaluated revealing Haemoglobin level (11.7\u00b11.5),\nplatelet count (243.9\u00b178.2), INR (1.1\u00b10.2), ALT and AST respectively (28.3\u00b114.5)\nand (36.8\u00b114.4), TLC (6500\u00b1154.2), urea (38.3\u00b111.6) and creatinine (0.9\u00b10.13).<\/p>\n\n\n\n

Table 2: Laboratory data of submucosal lesions. <\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Range<\/strong><\/p>\n<\/td>\n

\n

Mean+SD<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Haemoglobin Level<\/p>\n<\/td>\n

\n

10-14<\/p>\n<\/td>\n

\n

11.7\u00b11.5<\/p>\n<\/td>\n<\/tr>\n

\n

Platelets count 10<\/p>\n<\/td>\n

\n

60-420<\/p>\n<\/td>\n

\n

243.9\u00b178.2<\/p>\n<\/td>\n<\/tr>\n

\n

INR<\/p>\n<\/td>\n

\n

1-2<\/p>\n<\/td>\n

\n

1.1\u00b10.2<\/p>\n<\/td>\n<\/tr>\n

\n

ALT (U\/L)<\/p>\n<\/td>\n

\n

5-65<\/p>\n<\/td>\n

\n

28.3\u00b114.5<\/p>\n<\/td>\n<\/tr>\n

\n

AST(U\/L)<\/p>\n<\/td>\n

\n

14-75<\/p>\n<\/td>\n

\n

36.8\u00b114.4<\/p>\n<\/td>\n<\/tr>\n

\n

TLC<\/p>\n<\/td>\n

\n

4800-9900<\/p>\n<\/td>\n

\n

6500\u00b1154.2<\/p>\n<\/td>\n<\/tr>\n

\n

Urea (mg %)<\/p>\n<\/td>\n

\n

13-58<\/p>\n<\/td>\n

\n

38.3\u00b111.6<\/p>\n<\/td>\n<\/tr>\n

\n

Creatinine (mg %)<\/p>\n<\/td>\n

\n

0.5-1.3<\/p>\n<\/td>\n

\n

0.9\u00b10.13<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

As shown by Table (3), the site of the\nsubmucosal lesion varied, 24 (66.67%) were gastric, 6 (16.67%) esophageal, 4\n(11.1%) duodenal, one gastro- esophageal (2.8%), and one (2.8%) rectal.<\/p>\n\n\n\n

Table 3: Site of submucosal lesion <\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Number<\/strong><\/p>\n<\/td>\n

\n

%<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Submucosal oesophageal mass<\/p>\n<\/td>\n

\n

6<\/p>\n<\/td>\n

\n

16.67<\/p>\n<\/td>\n<\/tr>\n

\n

Submucosal Gastro oesophageal mass<\/p>\n<\/td>\n

\n

1<\/p>\n<\/td>\n

\n

2.8<\/p>\n<\/td>\n<\/tr>\n

\n

Submucosal gastric mass<\/p>\n<\/td>\n

\n

24<\/p>\n<\/td>\n

\n

66.67<\/p>\n<\/td>\n<\/tr>\n

\n

Submucosal duodenal mass<\/p>\n<\/td>\n

\n

4<\/p>\n<\/td>\n

\n

11.1<\/p>\n<\/td>\n<\/tr>\n

\n

Submucosal rectal mass<\/p>\n<\/td>\n

\n

1<\/p>\n<\/td>\n

\n

2.8<\/p>\n<\/td>\n<\/tr>\n

\n

Total<\/p>\n<\/td>\n

\n

36<\/p>\n<\/td>\n

\n

100%<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

As shown in Table (4), Gastric lesions were the\ncommonest diagnosed submucosal lesions (66.67%), taking different locations; ten\nwere fundal (41.67%), 6 at the greater curvature (25%), 4 at the antrum (16.67%),\none at the lessor curvature (4.16%), one subcardial (4.16%), one at the\njunction between gastric body and antrum (4.16%), and one at the body of the\nstomach (4.16%). <\/p>\n\n\n\n

Table 4: Different locations of submucosal stomach lesions.<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Number<\/strong><\/p>\n<\/td>\n

\n

%<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Fundal<\/p>\n<\/td>\n

\n

10<\/p>\n<\/td>\n

\n

41.67<\/p>\n<\/td>\n<\/tr>\n

\n

At grater curvature<\/p>\n<\/td>\n

\n

6<\/p>\n<\/td>\n

\n

25<\/p>\n<\/td>\n<\/tr>\n

\n

At lesser curvature<\/p>\n<\/td>\n

\n

1<\/p>\n<\/td>\n

\n

4.16<\/p>\n<\/td>\n<\/tr>\n

\n

At the antrum<\/p>\n<\/td>\n

\n

4<\/p>\n<\/td>\n

\n

16.67<\/p>\n<\/td>\n<\/tr>\n

\n

Subcardial<\/p>\n<\/td>\n

\n

1<\/p>\n<\/td>\n

\n

4.16<\/p>\n<\/td>\n<\/tr>\n

\n

At the junction between gastric body and the antraum<\/p>\n<\/td>\n

\n

1<\/p>\n<\/td>\n

\n

4.16<\/p>\n<\/td>\n<\/tr>\n

\n

At the body of the stomach<\/p>\n<\/td>\n

\n

1<\/p>\n<\/td>\n

\n

4.16<\/p>\n<\/td>\n<\/tr>\n

\n

Total<\/p>\n<\/td>\n

\n

24<\/p>\n<\/td>\n

\n

100<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

 As shown\nin Table (5), it was noticed that 34 cases (94%) were covered by normal overlying\nmucosa while 2 cases (6%) had some superficial ulcerations.<\/p>\n\n\n\n

 Table 5: Overlying mucosa of submucosal lesions<\/strong><\/p>\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Number<\/strong><\/p>\n<\/td>\n

\n

%<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

1.     Normal mucosa<\/p>\n<\/td>\n

\n

34<\/p>\n<\/td>\n

\n

94.4<\/p>\n<\/td>\n<\/tr>\n

\n

2.     Normal mucosa and some superficial ulceration:<\/p>\n<\/td>\n

\n

2<\/p>\n<\/td>\n

\n

5.6<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

As shown in Table (6) and figure (1), it was\nfound that 31 lesions (86.1%) were intramural, while 5 lesions (13.9%) were\nextra mural (3 of them from gall bladder and 2 from the liver).<\/p>\n\n\n\n

Table 6: Intramural and extramural submucosal lesions<\/strong>.<\/p>\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Number<\/strong><\/p>\n<\/td>\n

\n

%<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

1-     Intramural<\/p>\n<\/td>\n

\n

31<\/p>\n<\/td>\n

\n

86.1<\/p>\n<\/td>\n<\/tr>\n

\n

2-     Extramural<\/p>\n<\/td>\n

\n

5<\/p>\n<\/td>\n

\n

13.9<\/p>\n<\/td>\n<\/tr>\n

\n

–        From gall bladder<\/p>\n

–        From liver<\/p>\n<\/td>\n

\n

3<\/p>\n

2<\/p>\n<\/td>\n

\n

60<\/p>\n

40<\/p>\n<\/td>\n<\/tr>\n

\n

Total<\/p>\n<\/td>\n

\n

36<\/p>\n<\/td>\n

\n

100<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

As shown in Table (7) EUS examination of the\noutline of the intramural lesions, 93.22% were circumscribed while 6.45% were\nill defined. <\/p>\n\n\n\n

Regarding the echogenicity, 71% of the lesions\nwere hypoechoic, 9.7% hyperechoic, 16.1% anechoic and 3.2% isoechoic. <\/p>\n\n\n\n

Regarding the pattern, 77.4% of the lesions\nwere homogenous, while 22.6% were heterogeneous.<\/p>\n\n\n\n

The majority of the submucosal lesions were\nwell circumscribed, hypoechoic and homogenous. <\/p>\n\n\n\n

Regarding the size of the lesions, the mean\nsize was 3.9 x 3.4 cm. <\/p>\n\n\n\n

As regards the layer of origin, 32.3% of the\nlesions originate from the muscularis mucosa (2nd layer), 35.2% from the\nsubmucosa (3rd layer), 25.8% from muscularis propria (4th layer) and in 3.2% of\nlesions the layer of origin could not be defined. <\/p>\n\n\n\n

As regards the regional lymph node enlargement,\n16.1% of lesions had enlarged regional LN, while 83.9% had not. <\/p>\n\n\n\n

Regarding areas of breakdown, 32.26% of the\nlesions showed areas of breakdown, while the remaining 67.74% did not. <\/p>\n\n\n\n

Table 7: Outline, echogenicity, homogenicity, size, layer of origin, regional lymph node and areas of breakdown of intramural submucosal lesions diagnosed by EUS <\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Number<\/strong><\/p>\n<\/td>\n

\n

%<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Out Line<\/strong><\/p>\n

–        Well circumscribed<\/p>\n

–        Ill \u2013 defined<\/p>\n<\/td>\n

\n

 <\/p>\n

29<\/p>\n

2<\/p>\n<\/td>\n

\n

 <\/p>\n

93.55<\/p>\n

6.45<\/p>\n<\/td>\n<\/tr>\n

\n

Echogenicity<\/strong><\/p>\n

–        Hypoechoic<\/p>\n

–        Hyperechoic<\/p>\n

–        Isoechoic<\/p>\n

–        Anechoic<\/p>\n<\/td>\n

\n

 <\/p>\n

22<\/p>\n

3<\/p>\n

1<\/p>\n

5<\/p>\n<\/td>\n

\n

 <\/p>\n

71<\/p>\n

9.7<\/p>\n

3.2<\/p>\n

16.1<\/p>\n<\/td>\n<\/tr>\n

\n

Homogeneity<\/strong><\/p>\n

–        Homogenous<\/p>\n

–        Heterogonous<\/p>\n<\/td>\n

\n

 <\/p>\n

24<\/p>\n

7<\/p>\n<\/td>\n

\n

 <\/p>\n

77.4<\/p>\n

22.6<\/p>\n<\/td>\n<\/tr>\n

\n

Size (mean in Cm)<\/p>\n<\/td>\n

\n

3.9X3.4<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

Layer of origin<\/strong><\/p>\n

–        Muscularis mucosa (2nd<\/sup> layer)<\/p>\n

–        Submucosa (3rd<\/sup> layer)<\/p>\n

–        Muscularis propria (4th<\/sup> layer)<\/p>\n

–        Infiltration all layers except serosa<\/p>\n<\/td>\n

\n

 <\/p>\n

10<\/p>\n

11<\/p>\n

8<\/p>\n

2<\/p>\n<\/td>\n

\n

 <\/p>\n

32.3<\/p>\n

35.5<\/p>\n

25.8<\/p>\n

6.4<\/p>\n<\/td>\n<\/tr>\n

\n

Regional lymph node<\/strong><\/p>\n

–        No<\/p>\n

–        Present:<\/p>\n<\/td>\n

\n

 <\/p>\n

26<\/p>\n

5<\/p>\n<\/td>\n

\n

 <\/p>\n

83.9<\/p>\n

16.1<\/p>\n<\/td>\n<\/tr>\n

\n

Areas of breakdown<\/strong><\/p>\n

–        Present<\/p>\n

–        Not present<\/p>\n<\/td>\n

\n

10<\/p>\n

 <\/p>\n

21<\/p>\n<\/td>\n

\n

32.26<\/p>\n

 <\/p>\n

67.74<\/p>\n<\/td>\n<\/tr>\n

\n

Total<\/p>\n<\/td>\n

\n

31<\/p>\n<\/td>\n

\n

100<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

As shown in Table (8), figure (2), (3) and (4)\ntwenty-five cases of submucosal lesions indicated for FNA and histopathology;\n15 (60%) were GIST, 4 (16%) leiomyoma, 2 (8%) duplications cyst, 1 (4%)\nsubmucosal polyp, 1 (4%) infiltrating Adenocarcinoma and 2 (8%)\nnon-infiltrative Adenocarcinoma.<\/p>\n\n\n\n

Table 8: Submucosal lesions indicated for FNA and histopathology<\/strong>.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Number<\/strong><\/p>\n<\/td>\n

\n

%<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

GIST<\/p>\n<\/td>\n

\n

15<\/p>\n<\/td>\n

\n

60<\/p>\n<\/td>\n<\/tr>\n

\n

Leiomyoma<\/p>\n<\/td>\n

\n

4<\/p>\n<\/td>\n

\n

16<\/p>\n<\/td>\n<\/tr>\n

\n

Duplication cyst<\/p>\n<\/td>\n

\n

2<\/p>\n<\/td>\n

\n

8<\/p>\n<\/td>\n<\/tr>\n

\n

Submucosal polyp<\/p>\n<\/td>\n

\n

1<\/p>\n<\/td>\n

\n

4<\/p>\n<\/td>\n<\/tr>\n

\n

Adenocarcinoma<\/p>\n

Infiltrating pancreas<\/p>\n

Non infiltrating<\/p>\n<\/td>\n

\n

1<\/p>\n

2<\/p>\n<\/td>\n

\n

4<\/p>\n

8<\/p>\n<\/td>\n<\/tr>\n

\n

Total<\/p>\n<\/td>\n

\n

25<\/p>\n<\/td>\n

\n

100<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

As shown in Table (9) and figure (5), six cases\nof submucosal lesions were not indicated for FNA, of them, 3 were anechoic\nlesions.<\/p>\n\n\n\n

Colored Doppler EUS was used to differentiate\nbetween them, 2 lesions showed color flow therefore, were diagnosed as varices\nin gastric body and duodenum, while one lesion showed no evidence of flow and\naccording to its anatomical site in biliary area, MRCP was done and aspiration\nof the fluid showed bile hence a diagnosis of choledocal cyst was suggested. <\/p>\n\n\n\n

The other 3 lesions, because of high accuracy\nof EUS in diagnosing lipomas, FNA and histopathology were not required.<\/p>\n\n\n\n

Table 9: Submucosal lesions not indicated for FNA (N= 6)<\/strong>.<\/p>\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Number<\/p>\n<\/td>\n

\n

%<\/p>\n<\/td>\n<\/tr>\n

\n

Lipoma (without FNA and histology)<\/p>\n<\/td>\n

\n

3<\/p>\n<\/td>\n

\n

50<\/p>\n<\/td>\n<\/tr>\n

\n

Colored Doppler:<\/strong><\/p>\n

–        Body varix<\/p>\n

–        Duodinal varix<\/p>\n<\/td>\n

\n

 <\/p>\n

1<\/p>\n

1<\/p>\n<\/td>\n

\n

 <\/p>\n

16.7<\/p>\n

16.7<\/p>\n<\/td>\n<\/tr>\n

\n

Choledocal cyst (MRCP, aspiration chemistry)<\/p>\n<\/td>\n

\n

1<\/p>\n<\/td>\n

\n

16.7<\/p>\n<\/td>\n<\/tr>\n

\n

Total<\/p>\n<\/td>\n

\n

6<\/p>\n<\/td>\n

\n

100<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

As shown in Table (10), the results of\nhistopathology, 22 lesions were benign, while 3 were malignant. The age of\npatients with benign lesions ranged from 21-75 years, while the ages of patients\nwith malignant lesions range from 52 \u2013 62 years. Benign lesions were more\ncommon in males (63.6%) while malignant lesions more common in females (66.7%)<\/p>\n\n\n\n

According to upper endoscopy results, 95.5% of\nbenign lesions were covered by normal mucosa, while 4.5% the mucosa showed some\nsuperficial ulceration. All benign lesions covered by mucosa showed some\nsuperficial ulceration proved to be GIST on histopathology. FNA and histopathology\nof malignant lesions showed early adenocarcinoma (non-infiltrative) covered by\nnormal mucosa in (66.7%) and infiltrating adenocarcinoma covered by mucosa\nhaving some superficial ulceration in (33.3%).<\/p>\n\n\n\n

EUS can differentiate between benign and\nmalignant lesions. Regarding the lesions\u2019 outline, all benign lesions (100%)\nwere well circumscribed, while 33.3% of malignant lesions were well\ncircumscribed and 66.7% of malignant lesions were ill defined.<\/p>\n\n\n\n

Regarding the echogenicity of lesions, 86.4% of\nbenign lesions were hypoechoic, 9.1% were anechoic and 4.5% were isoechoic. No\nbenign lesions were hyperechoic.<\/p>\n\n\n\n

Regarding the pattern of lesions: 81.8% of\nbenign lesions were homogenous and 18.2% were heterogenous while all malignant\nlesions (100%) were heterogenous.<\/p>\n\n\n\n

Regarding the size of lesions: Mean size of\nbenign lesions was 3.7 x 3.4 cm (<4 cm.), while mean size of malignant\nlesions was 6.2 x 4.6 (>4.5 cm.).<\/p>\n\n\n\n

Regarding the layer of origin of the lesion, it\nwas found that any submucosal lesion infiltrating all layers is a malignant\nlesion.<\/p>\n\n\n\n

Regarding the presence of regional lymph node\n90.9% of benign lesions showed no reginal lymph node enlargement, and 9.1% of\nbenign lesions showed benign looking regional lymph node enlargement. All\nmalignant lesions showed malignant looking regional lymph node enlargement.<\/p>\n\n\n\n

Regarding the areas of breakdown, all malignant\nlesions (100%) showed areas of break down, while only 31.8% of benign lesions\nshowed areas of breakdown. The rest of benign lesions (68.2%) did not show any\nbreakdown<\/p>\n\n\n\n

It was noticed that all submucosal lesions\nwithout areas of breakdown were benign lesions, while 70% of submucosal lesions\nwith areas of breakdown were malignant lesions while 30% of submucosal lesions\nwith areas of breakdown were benign lesions.<\/p>\n\n\n\n

Histopathological examination of benign lesions\nrevealed that 68.2% were GIST, 18.2% were leiomyoma, 9.1% were duplication\ncysts and 4.2% were submucosal polyps. Histopathologic examination of malignant\nlesions revealed that 66.7 were early adenocarcinoma (non-infiltrative) while\n33.3% were infiltrating Adenocarcinoma.  <\/p>\n\n\n\n

Table 10: showing benign and malignant lesions according to the results of histopathology.<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Benign(n=22)<\/strong><\/p>\n<\/td>\n

\n

Malignant(n=3)<\/strong><\/p>\n<\/td>\n

\n

P- value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Age<\/strong><\/p>\n

Range<\/p>\n

Mean + SD<\/p>\n<\/td>\n

\n

 <\/p>\n

28-75<\/p>\n

55.8 12.16<\/p>\n<\/td>\n

\n

 <\/p>\n

52-62<\/p>\n

58 5.3<\/p>\n<\/td>\n

\n

 <\/p>\n

0.432<\/p>\n<\/td>\n<\/tr>\n

\n

Sex<\/strong><\/p>\n

Males<\/p>\n

Females<\/p>\n<\/td>\n

\n

 <\/p>\n

14(63.6%)<\/p>\n

8(36.4%)<\/p>\n<\/td>\n

\n

 <\/p>\n

1(33.3%)<\/p>\n

2(66.7%)<\/p>\n<\/td>\n

\n

 <\/p>\n

0.838<\/p>\n<\/td>\n<\/tr>\n

\n

Overlying mucosa<\/strong><\/p>\n

-Normal<\/p>\n

-Intact mucosa and superficial ulceration<\/p>\n<\/td>\n

\n

 <\/p>\n

21(95.5%)<\/p>\n

1(4.5%)<\/p>\n<\/td>\n

\n

 <\/p>\n

2(66.7 %)<\/p>\n

1(33.3%)<\/p>\n<\/td>\n

\n

 <\/p>\n

0.451<\/p>\n<\/td>\n<\/tr>\n

\n

EUS Finding<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Outline:<\/p>\n

–         Well circumscribed<\/p>\n

–         Ill-defined<\/p>\n

Echogenicity:<\/p>\n

–         Hypoechoic<\/p>\n

–         Hyperechoic<\/p>\n

–         Isoechoic<\/p>\n

–         Anechoic<\/p>\n

Homogeneity:<\/p>\n

–         Homogenous<\/p>\n

–         Heterogenous<\/p>\n

Size (mean in Cm)<\/p>\n

Layer of origin:<\/p>\n

–         Muscularis mucosa (2nd<\/sup> layer) with intact seraosa in some areas and loss gastric wall in others<\/p>\n

–         Muscularis mucosa (2nd<\/sup> layer)<\/p>\n

–         Submucosa (3rd<\/sup> layer)<\/p>\n

–         Muscularis propria (4th<\/sup> layer)<\/p>\n

Infiltration all layer except serosa<\/p>\n<\/td>\n

\n

22(100%)<\/p>\n

0(0%)<\/p>\n

19(86.4%)<\/p>\n

0)0%)<\/p>\n

1(4.5%)<\/p>\n

2(9.1%)<\/p>\n

18(81.8%)<\/p>\n

4(18.2%)<\/p>\n

3.7×3.4<\/p>\n

0(0%)<\/p>\n

9(40.9%)<\/p>\n

5(22.7%)<\/p>\n

8(36.4%)<\/p>\n

0(0%)<\/p>\n<\/td>\n

\n

1(33.3%)<\/p>\n

2(66.7%)<\/p>\n

3(100%)<\/p>\n

0(0%)<\/p>\n

0(0%)<\/p>\n

0(0%)<\/p>\n

0%)<\/p>\n

3(100%)<\/p>\n

6.2×4.6<\/p>\n

1(33.3%)<\/p>\n

0(0%)<\/p>\n

1(33.3%)<\/p>\n

0(0%)<\/p>\n

1(33.3%)<\/p>\n<\/td>\n

\n

0.001<\/p>\n

 <\/p>\n

 <\/p>\n

0.620<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

0.368<\/p>\n<\/td>\n<\/tr>\n

\n

Regional lymph node<\/p>\n

–         No<\/p>\n

–         Present:<\/p>\n

–         Benign<\/p>\n

–         Malignant<\/p>\n

–         Reactive<\/p>\n

Areas of break down<\/p>\n

–         Present<\/p>\n

–         Not present<\/p>\n

FNA<\/p>\n

–         Histopathology of benign lesion:<\/p>\n

–         GIST<\/p>\n

–         Leiomyoma<\/p>\n

–         Duplication cyst<\/p>\n

–         Submucosal polyp<\/p>\n

Histopathology of Malignant<\/p>\n

      lesion:<\/p>\n

–         Infiltration pancreas<\/p>\n

–         Non infiltration pancreas<\/p>\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

7(31.8%)<\/p>\n

15(68.2%)<\/p>\n

 <\/p>\n

 <\/p>\n

15(68.2%)<\/p>\n

4(18.2)<\/p>\n

2(9.1%)<\/p>\n

1(4.5%)<\/p>\n

 <\/p>\n

0(0%)<\/p>\n

0(0%)<\/p>\n

0(0%)<\/p>\n<\/td>\n

\n

 <\/p>\n

0(0%)<\/p>\n

3(100%)<\/p>\n

0(0%)<\/p>\n

1(33.3%)<\/p>\n

2(66.7%)<\/p>\n

 <\/p>\n

3(100%)<\/p>\n

0(0%)<\/p>\n

 <\/p>\n

 <\/p>\n

0(0%)<\/p>\n

0(0%)<\/p>\n

0(0%)<\/p>\n

0(0%)<\/p>\n

 <\/p>\n

3(100%)<\/p>\n

1(33.3%)<\/p>\n

2(66.7%)<\/p>\n

 <\/p>\n<\/td>\n

\n

0.0<\/p>\n

 <\/p>\n

 <\/p>\n

0.001<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

As shown in Table (11): Immune-histochemical\nstaining of GIST and leiomyoma, to confirm diagnosis after FNA and\nhistopathological examination, because of difficulty in distinguishing between both\nlesions, being composed of spindle cells.<\/p>\n\n\n\n

Spindle cells of GIST have shown positive\nimmunostaining for CD 117 in 100% of cases and positive immunostaining for\ndesmin in 6.7% and have shown negative immunostaining for desmin by in 93.3 of\npatients.<\/p>\n\n\n\n

Spindle cells of leiomyoma have shown positive\nimmunostaining for desmin in 100% of cases and negative immunostaining for\nCD117 in 100% of cases.<\/p>\n\n\n\n

Table 11: Immune-histochemical staining of GIST and Leiomyoma<\/strong>.<\/p>\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

GIST<\/strong><\/p>\n

N=15<\/strong><\/p>\n<\/td>\n

\n

Leiomyoma<\/strong><\/p>\n

N=4<\/strong><\/p>\n<\/td>\n

\n

P-value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

CD117<\/p>\n

+ve<\/p>\n<\/td>\n

\n

15(100%)<\/p>\n<\/td>\n

\n

–<\/p>\n<\/td>\n

\n

0.002<\/p>\n<\/td>\n<\/tr>\n

\n

-ve<\/p>\n<\/td>\n

\n

–<\/p>\n<\/td>\n

\n

4(100%)<\/p>\n<\/td>\n

\n

–<\/p>\n<\/td>\n<\/tr>\n

\n

Desmin<\/p>\n

+ve<\/p>\n<\/td>\n

\n

1(6.7%)<\/p>\n<\/td>\n

\n

4(100%)<\/p>\n<\/td>\n

\n

0.001<\/p>\n<\/td>\n<\/tr>\n

\n

-ve<\/p>\n<\/td>\n

\n

14(93.3%)<\/p>\n<\/td>\n

\n

–<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

The most common submucosal lesions in this study; GISTs, leiomyoma, duplication cyst and lipoma. The mean age of GIST is 70.8 years (old age), leiomyoma 44.5 years, duplication cyst is 39 years and lipoma is 46.6 years.<\/p>\n\n\n\n

Also, it was found that GIST presents in males\nslightly more than females, leiomyoma presents in males more than females,\nduplication cyst presents in males and females equally and lipoma presents in\nfemales more than in males.<\/p>\n\n\n\n

In this study, it was found that the commonest\nsite for GIST is the stomach especially at the fundus and the greater\ncurvature. Leiomyomas were present in the esophagus in 100% of cases.\nDuplication cysts and lipomas were more common in the stomach. oesphogus.<\/p>\n\n\n\n

In this study, it was found that 46.6% of GISTs\narise from muscularis mucosa (2nd layer) and 46.6% arise from muscularis\npropria (4th layer). Only 6.7% of GISTs came from submucosa (3rd layer). <\/p>\n\n\n\n

Also, it was observed that 50% of leiomyomas arise\nfrom muscularis mucosa (2nd layer), 25% arise from submucosa (3rd layer) and 25%\narise from musclaris propria (4th layer). <\/p>\n\n\n\n

It was found that 100% of duplication cysts\narise from submucosa (3rd layer) <\/p>\n\n\n\n

As shown in Table (12), it was found that 66.7%\nof lipomas arise from submucosa (3rd layer) and 33.3% arise from muscularis\nmucosa (2nd layer). <\/p>\n\n\n\n

Table 12: commonest submucosal lesions.  <\/strong><\/p>\n\n\n\n\n\n\n
\n

Subcardial<\/p>\n

At the junction<\/p>\n

Between gastric body and the antrum<\/p>\n

At the body of the stomach<\/p>\n

–         Submucosal   duodenal mass<\/p>\n

–         Submucosal rectal mass<\/p>\n<\/td>\n

\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

1(7.1%)<\/p>\n

1(6.7%)<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

1(50%)<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n

\n

     Outline:<\/p>\n

–         Well circumscribed<\/p>\n

–         Ill-defined<\/p>\n

Echogenicity:<\/p>\n

–         Hypechoic<\/p>\n

–         Hyperechoic<\/p>\n

–         Isoechoic<\/p>\n

–         Anechoic<\/p>\n

Homgenicity:<\/p>\n

–         Homogenous<\/p>\n

–         Heterogenous<\/p>\n

 <\/p>\n

Size(mean in Cm)<\/p>\n

Layer of origin:<\/p>\n

–         Muscularis mucosa(2nd<\/sup> layer)<\/p>\n

–         Submucosa(3rd<\/sup> layer)<\/p>\n

–         Muscularis propria(4th<\/sup> layer)<\/p>\n<\/td>\n

\n

 <\/p>\n

 <\/p>\n

15(100%)<\/p>\n

 <\/p>\n

 <\/p>\n

15(100%)<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

12(80%)<\/p>\n

3(20%)<\/p>\n

 <\/p>\n

3.65×3.3<\/p>\n

 <\/p>\n

 <\/p>\n

7(46.65%)<\/p>\n

 <\/p>\n

1(6.7%)<\/p>\n

 <\/p>\n

7(46.65%)<\/p>\n<\/td>\n

\n

 <\/p>\n

 <\/p>\n

4(100%)<\/p>\n

 <\/p>\n

 <\/p>\n

3(75%)<\/p>\n

 <\/p>\n

1(25%)<\/p>\n

 <\/p>\n

 <\/p>\n

3(75%)<\/p>\n

1(25%)<\/p>\n

 <\/p>\n

3.2×2.8<\/p>\n

 <\/p>\n

 <\/p>\n

2(50%)<\/p>\n

 <\/p>\n

1(25%)<\/p>\n

 <\/p>\n

1(25%)<\/p>\n<\/td>\n

\n

 <\/p>\n

 <\/p>\n

2(100%)<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

2(100%)<\/p>\n

 <\/p>\n

2(100%)<\/p>\n

 <\/p>\n

 <\/p>\n

1.9×2,1<\/p>\n

 <\/p>\n

 <\/p>\n

2(100%)<\/p>\n<\/td>\n

\n

 <\/p>\n

 <\/p>\n

3(100%)<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

3(100%)<\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

3(100%)<\/p>\n

 <\/p>\n

 <\/p>\n

1.06×1.06<\/p>\n

 <\/p>\n

 <\/p>\n

1(33.3%)<\/p>\n

 <\/p>\n

2(66.7%)<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

As shown in table (13) the sensitivity of\nunaided EUS, in diagnosing of submucosal lesions, versus EUS \u2013 guided fine\nneedle aspiration (FNA) and histopathology (gold standard) was 72%; submucosal\nlesions indicated for FNA and histopathology were 25 patients; 18 of them\ndiagnosed by unaided EUS whereas the other 7 patients were diagnosed by EUS \u2013\nguided fine needle aspiration (FNA) and histopathology (gold standard). <\/p>\n\n\n\n

Table 13: sensitivity of unaided EUS, in diagnosing of submucosal lesions, versus EUS \u2013 guided fine needle aspiration (FNA) and histopathology (gold standard). <\/strong><\/p>\n\n\n\n\n\n\n
\n<\/td>\n\n

AUC<\/strong><\/p>\n<\/td>\n

\n

Sensitivity<\/strong><\/p>\n<\/td>\n

\n

P-value<\/strong><\/p>\n<\/td>\n

\n

95% Confidence interval<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

   EUS          <\/p>\n<\/td>\n

\n

0.860<\/p>\n<\/td>\n

\n

75%<\/p>\n<\/td>\n

\n

0.001<\/p>\n<\/td>\n

\n

0.733-0.942<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 1: EUS image showing extramural compression by enlarged gall bladder<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 2: EUS image showing FNA from submucosal mass (infiltrative Adenocarcinoma)<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 3: EUS image showing submucosal mass (non-infiltrative Adenocarcinoma).<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 4: EUS image showing submucosal mass (non-infiltrative Adenocarcinoma).<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 5: EUS image showing Lipoma<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 6: EUS image showing malignant LN.<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 7: EUS image showing malignant LN.<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 8: EUS image showing duplication CYST.<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 9: EUS image showing duplication CYST<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 10: EUS image showing GIST<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 11: EUS image showing cystic degeneration.<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
\"\"<\/td>\n\n

Figure 12: EUS image showing leiomyoma.<\/strong><\/p>\n

<\/p>\n

Click here to view Figure<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

Discussion<\/strong><\/p>\n\n\n\n

Three\npatients, not having FNA and histopathology were in\naccordance to Nakamuras who reported in 2022that biopsies or FNA were generally not needed\nbecause of high accuracy of EUS in diagnosing lipomas9<\/sup>.<\/p>\n\n\n\n

The other 25 patients of intramural lesions\nunderwent FNA and histopathological examination was done to reach a definite\ndiagnosis.<\/p>\n\n\n\n

Lesions were classified according to the\nresults of histopathology as a benign and malignant.<\/p>\n\n\n\n

The number of benign lesions were 22, while the\nmalignant lesions were 3. The age of patients with benign lesions ranged from\n21-75years, while the ages of patients with malignant lesions range from 52 \u2013\n62 years. Benign lesions were more common in males (63.6%) while malignant\nlesions were more\ncommon in females (66.7%)<\/p>\n\n\n\n

According to upper endoscopy results, 95.5% of\nbenign lesions were covered by normal mucosa, while 4.5% the mucosa showed some\nsuperficial ulceration. All benign lesions covered by mucosa showing some\nsuperficial ulceration proved to be GIST on histopathology in accordance to\nSouquet and Bobichon who reported in 2015 that in some cases of GIST, the\noverlying mucosa may be slightly ulcerated10<\/sup>.<\/p>\n\n\n\n

FNA and histopathology of malignant lesions\nshowed early adenocarcinoma (non-infiltrative) covered by normal mucosa in\n(66.7%) and infiltrating adenocarcinoma covered by mucosa having some\nsuperficial ulceration in (33.3%). This is in accordance with Akira Dobashi who\nreported in 2021 in a case report that a case of early duodenal adenocarcinoma\nresembling a submucosal tumor cured with endoscopic resection11<\/sup>.<\/p>\n\n\n\n

And in accordance with Nobusuke who reported in\n1997 that a case of advanced gastric cancer was seen resembling submucosal\ntumor of the stomach12<\/sup>. <\/p>\n\n\n\n

In this study, we report 3 cases of submucosal\nmasses as a case report that they proved to be malignant lesions when FNA and histopathology\nwere done, 2 of them were early Adenocarcinoma (non-infiltrative) and the other\nwas infiltrating adenocarcinoma (Advanced cancer). <\/p>\n\n\n\n

EUS can differentiate between benign and\nmalignant lesions. Regarding the outline of lesions, all benign lesions (100%)\nare well circumscribed, while 33.3% of malignant lesions were well circumscribed\nand 66.7% of malignant lesions were ill defined in accordance to Chak and others who reported in 2016that\nsubepithelial tumors with a smooth margin are likely to be benign, while\nsubepithelial tumors with irregular outer borders are suggestive of malignancy13<\/sup>.\n<\/p>\n\n\n\n

Regarding the echogenicity of lesions, 86.4% of\nbenign lesions were\nhypoechoic, 9.1% are anechoic and 4.5% are isoechoic. No benign lesions were\nhyperechoic. <\/p>\n\n\n\n

All malignant lesions in this study (100%) were\nhypoechoic, but the number of malignant lesions in this study (n=3) was insufficient and\nstatistically insignificant. <\/p>\n\n\n\n

So, we need a larger number of malignant\nlesions to know the different echo patterns of malignant lesions and exact role\nof echogenicity in diagnosing malignant lesions. <\/p>\n\n\n\n

In this study 5 lesions were anechoic. Colored Doppler EUS was used\nto differentiate between them. Two of them showed evidence of flow in colored\nDoppler   suggestive of varices of\ngastric body and duodenum. The other 3 lesions had no flow in colored Doppler,\none of them proved to be a choledocal cyst according to its anatomical site,\naspiration and chemistry (Bile) and confirmation by MRCP. The other 2 lesions\nrevealed thick mucinous materials or debris by using FNA of the fluid\nsuggestive of duplication cyst. <\/p>\n\n\n\n

Regarding the pattern of lesions:  81.8% of benign lesions were homogenous and\n18.2% were heterogenous while all malignant lesions (100%) were heterogenous.\nThis means that homogenous lesions were benign in accordance with Chak and colleagues who reported in 2016 that\nBenign GISTs are typically hypoechoic and homogenous lesions14<\/sup>.<\/p>\n\n\n\n

Regarding the size of lesions: Mean size of\nbenign lesions was 3.7 x 3.4 cm (<4 cm.), while mean size of malignant\nlesions was 6.2 x 4.6 (>4.5 cm.). We can take the size of   4.5 cm as a cut off where > 4.5 cm were considered malignant\nlesions while < 4.5 cm were\nbenign lesions. This is in accordance with Chak and others who reported in 2016 that features\npredictive of malignant subepithelial tumors were diameter > 4 cm and\nfeatures predictive of benign subepithelial tumors were diameter < 3 cm13<\/sup>.<\/p>\n\n\n\n

Regarding the layer of origin of the lesion, it\nwas found that any submucosal lesion infiltrating all layers is a malignant\nlesion.<\/p>\n\n\n\n

 Regarding the presence of regional lymph node\n90.9% of benign lesions showed no regional lymph node enlargement, and 9.1% of benign lesions\nshowed benign looking regional lymph node enlargement. All malignant lesions\nshowed malignant looking regional lymph node enlargement. <\/p>\n\n\n\n

Regarding the areas of breakdown, all malignant\nlesions (100%) showed areas of break down, while only 31.8% of benign lesions\nshowed areas of breakdown. The rest of benign lesions (68.2%) did not show any\nbreakdown in accordance to Chak  who\nreported in 2016 that EUS features of GIST including irregularity of\nextraluminal border, presence of cystic spaces, echogenic foci, heterogeneity\nand large size are associated with an invasive tumor14. It was noticed that all\nsubmucosal lesions without areas of breakdown were benign lesions, while 70% of\nsubmucosal lesions with areas of breakdown are malignant lesions while 30% of\nsubmucosal lesions with areas of breakdown were benign lesions. This means that all\nsubmucosal lesions with areas of breakdown must be biopsied for histopathologic\nexamination to exclude malignant lesions. <\/p>\n\n\n\n

Histopathological examination of benign lesions\nrevealed that 68.2% were GIST, 18.2% were leiomyoma, 9.1% were duplication\ncysts and 4.2% were submucosal polyps. Histopathologic examination of malignant\nlesions revealed that 66.7 were early adenocarcinoma (non-infiltrative) while\n33.3% were infiltrating adenocarcinoma. <\/p>\n\n\n\n

After FNA and histopathological examination\nthere was a difficulty in differentiating between GIST and leiomyoma as they\nare composed of spindle cells, so they needed confirmation by\nimmunohistochemical staining. <\/p>\n\n\n\n

Spindle cells of GIST have shown positive\nimmunostaining for CD 117 in 100% of cases and positive immunostaining for\ndesmin in 6.7% and have shown negative immunostaining for desmin by in 93.3 of\npatients, in accordance to Abraham who reported in 2021 that GIST is positive\nfor kit CD117 and < 5% are positive for desmin. Spindle cells of leiomyoma\nhave shown positive immunostaining for desmin in 100% of cases and negative\nimmunostaining for CD117 in 100% of cases15<\/sup>. This is in accordance\nwith ZHU who reported in 2019 that esophageal leiomyoma typically shows strong\npositivity for desmin while proves negative for CD11716<\/sup>. <\/p>\n\n\n\n

The most common submucosal lesions in this\nstudy were GISTs,\nleiomyoma, duplication cyst and lipoma. The mean age of GIST is 70.8 years (old\nage), the mean age of leiomyoma is 44.5 years, the mean age of duplication cyst\nis 39 years and the mean age of lipoma is 46.6 years. This is in accordance\nwith Nilsson who reported in 2012 that median age of GIST at diagnosis is 66-69\nyears in population-based studies, mean age of leiomyoma is 45-50 years, mean\nage of duplication cyst is 30-40 years, and mean age of lipoma is 40 to 45years17<\/sup>.  <\/p>\n\n\n\n

Also, it was found that GIST presents in males\nslightly more than females, leiomyoma presents in males more than females,\nduplication cyst presents in males and females equally and lipoma presents in\nfemales more than in males.<\/p>\n\n\n\n

 This is\nin accordance with Miettinen who reported in 2022 that there is a slight male\npredominance in adult GIST, with no difference between males and females in\nleiomyoma and duplication cysts, while lipoma is more common in females 18<\/sup>.\n<\/p>\n\n\n\n

In this study, it was found that the most\ncommon site for GIST is the stomach especially at the fundus and the greater\ncurvature. This is in accordance with S\u0103ftoiu who reported in 2020 that\nsubepithelial tumors are mostly gastric GISTs. Leiomyomas were present in the\nesophagus in 100% of cases. Duplication cysts and lipomas were more common in\nthe stomach19<\/sup>. This is in accordance with Yamashita who reported in\n2015 that approximately two thirds of all GISTs occur in the stomach20<\/sup>.\nPunpale who reported in 2021 that leiomyoma is predominantly found in the\nesophagus21<\/sup>. Maderal F et al who reported in 2016 that gastric\nlipoma accounts for about 5% of all gastrointestinal lipomas and 75% are\nlocated in the antrum22<\/sup>. Wieczorek who reported in 2019 that\napproximately 50% of duplication cysts are found in the small intestine, with\nthe remainder in the esophagus, stomach and colon23<\/sup>.<\/p>\n\n\n\n

In this study, it was found that 46.6% of GISTs\narise from muscularis mucosa (2nd layer) and 46.6% arise from muscularis\npropria (4th layer). Only 6.7% of GISTs came from submucosa (3rd layer)., This\nis in accordance with Ando who reported in 2012 that most GISTs arise from the\n2nd or the 4th layer of gastrointestinal tract, corresponding to muscularis\nmucosa and the muscularis propria24<\/sup>. <\/p>\n\n\n\n

Also, it was observed that 50% of leiomyomas\narise from muscularis mucosa (2nd layer), 25% arise from submucosa (3rd layer)\nand 25% arise from muscularis propria (4th<\/sup> layer). This is in\naccordance with Shim who reported in 2015 that part of esophageal leiomyomas is\nderived from muscularis propria (4th layer) and others arise from muscularis\nmucosa (2nd layer)25<\/sup>.  <\/p>\n\n\n\n

It was found that 100% of duplication cysts\narise from submucosa (3rd layer) in accordance with Yasuda who reported in 2017\nthat EUS of duplication cysts usually appears as an anechoic lesion in the\nthird hypoechoic layer (submucosa)26<\/sup>.<\/p>\n\n\n\n

Also, it was found that 66.7% of lipomas arise\nfrom submucosa (3rd layer) and 33.3% arise from muscularis mucosa (2nd layer)\nin accordance to Kim who reported in 2020 that lipoma usually originates from\nthe third echo \u2013 Rich layer (submucosa), though sometimes from other layers as\nwell27<\/sup>. <\/p>\n\n\n\n

Finally, in this study, we compare the ability\nof EUS alone in diagnosing of submucosal lesions versus EUS \u2013 guided fine\nneedle aspiration (FNA) and histopathology (gold standard) <\/p>\n\n\n\n

It was found that number of submucosal lesions\nindicated for FNA and histopathology were 25 patients, 18 of them diagnosed by\nEUS alone and the other 7 patients not diagnosed by EUS alone and FNA and\nhistopathology were\nneeded for diagnosis this means that sensitivity of EUS alone in diagnosing of\nsubmucosal lesions versus EUS \u2013 guided fine needle aspiration (FNA) and\nhistopathology (gold standard ) was 72% in accordance with Kwon who reported in\n2015 in a similar study that shows the accuracy of endoscopic ultrasonographic\nimpression compared with pathologic diagnosis in gastrointestinal submucosal\ntumors, in which 58 cases of gastrointestinal SMTs with both EUS findings and\npathologic reports were compared retrospectively. It was found that EUS and\npathologic diagnosis coincided in 46\/58 with sensitivity (79.3%) of the cases. <\/p>\n\n\n\n

Conclusion<\/strong><\/p>\n\n\n\n

EUS guided fine needle aspiration (FNA) and\nhistopathological examination should be done for some submucosal masses to put\na definite diagnosis. EUS with colored Doppler is necessary in differentiating\ncystic from vascular lesions.<\/p>\n\n\n\n

Acknowledgment<\/strong><\/p>\n\n\n\n

We\nthanks all the participants<\/p>\n\n\n\n

Funding\nsource<\/strong><\/p>\n\n\n\n

None<\/p>\n\n\n\n

Conflict\nof interest<\/strong><\/p>\n\n\n\n

None<\/p>\n\n\n\n

References <\/strong><\/p>\n\n\n\n

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