Diagnostic yield and safety of endoscopic-ultrasound guided trucut biopsy in patients with gastric submucosal tumors: a prospective study

Background and study aims: Endoscopic-ultrasound-guided trucut needle biopsy (EUS-TCB) has not been adequately evaluated in patients with submucosal tumors (SMTs).

Patients and methods: This prospective, uncontrolled study involving 49 consecutive patients with hypoechoic gastric SMTs (≥ 20 mm) evaluated diagnostic yield and 30-day morbidity of EUS-TCB, factors related to the success of EUS-TCB, and agreement between EUS-TCB and the surgical pathology diagnosis. Seventy-three percent of tumors were gastrointestinal stromal tumors (GIST).

Results: Tumor tissue adequate for diagnosis was obtained by EUS-TCB in 31 patients (63 %; 95 %CI 49 % to 75 %). In the remaining cases, EUS-TCB provided no tissue (n = 11) or an insufficient amount (n = 7). Logistic regression analysis showed that tumor location on the lesser curvature of the stomach was the only independent predictor of obtaining diagnostic material [odds ratio (OR) 7.4; 95 %CI 1.9 to 28; P = 0.004]. The experience of the endosonographer, the size of the tumor, and the location of the tumor relative to the long axis of the stomach were not related to the success of the biopsy. Agreement between EUS-TCB and surgical pathology specimens in respect of the diagnosis and CD117 status was high (0.9, standard error 0.31; and 0.95, standard error 0.16, respectively); however, there was no correlation between the mitotic index as determined on EUS-TCB and that determined on the surgical pathology specimen (correlation coefficient, 0.08). There were two severe septic complications in 52 procedures (3.9 %; 95 %CI 0.3 % to 14 %).

Conclusions: The diagnostic yield of EUS-TCB in patients with gastric SMTs was moderate. Tissue samples were too small to reliably determine the mitotic index. Antibiotic prophylaxis should be considered because of possible septic complications.

References

• 1 Hedenbro J L, Ekelund M, Wetterberg P. Endoscopic diagnosis of submucosal gastric lesions. The results after routine endoscopy.  Surg Endosc. 1991;  5 20-23
• 2 Sun S, Ge N, Wang C. et al . Endoscopic band ligation of small gastric stromal tumors and follow-up by endoscopic ultrasonography.  Surg Endosc. 2007;  21 574-578
• 3 Polkowski M, Palucki J, Butruk E. Transabdominal ultrasound for visualizing gastric submucosal tumors diagnosed by endosonography: can surveillance be simplified?.  Endoscopy. 2002;  34 979-983
• 4 Polkowski M. Endoscopic ultrasound and endoscopic ultrasound-guided fine-needle biopsy for the diagnosis of malignant submucosal tumors.  Endoscopy. 2005;  37 635-645
• 5 Hunt G C, Smith P P, Faigel D O. Yield of tissue sampling for submucosal lesions evaluated by EUS.  Gastrointest Endosc. 2003;  57 68-72
• 6 Cantor M J, Davila R E, Faigel D O. 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 Hwang J H, Saunders M D, Rulyak S J. et al . A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses.  Gastrointest Endosc. 2005;  62 202-208
• 8 Ando N, Goto H, Niwa Y. et al . The diagnosis of GI stromal tumors with EUS-guided fine needle aspiration with immunohistochemical analysis.  Gastrointest Endosc. 2002;  55 37-43
• 9 Hunt G C, Rader A E, Faigel D O. A comparison of EUS features between CD-117 positive GI stromal tumors and CD-117 negative GI spindle cell tumors.  Gastrointest Endosc. 2003;  57 469-474
• 10 Okubo K, Yamao K, Nakamura T. et al . Endoscopic ultrasound-guided fine-needle aspiration biopsy for the diagnosis of gastrointestinal stromal tumors in the stomach.  J Gastroenterol. 2004;  39 747-753
• 11 Chen V K, Eloubeidi M A. Endoscopic ultrasound-guided fine-needle aspiration of intramural and extraintestinal mass lesions: diagnostic accuracy, complication assessment, and impact on management.  Endoscopy. 2005;  37 984-989
• 12 Akahoshi K, Sumida Y, Matsui N. et al . Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration.  World J Gastroenterol. 2007;  13 2077-2082
• 13 Hoda K M, Rodriquez S A, Faigel D O. EUS-guided sampling of suspected GI stromal tumors [abstract].  Gastrointest Endosc. 2007;  65 AB204
• 14 Shah R, Early D S, Edmundowicz S A. et al . The spectrum of subepithelial gastric lesions in a tertiary referral EUS practice [abstract].  Gastrointest Endosc. 2007;  65 AB204
• 15 Hamerski C M, Shergill A K, De Lusong M AA. et al . Yield of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) in diagnosing submucosal lesions of the upper GI tract [abstract].  Gastrointest Endosc. 2008;  67 AB222
• 16 Li S Q, O’Leary T J, Buchner S B. et al . Fine needle aspiration of gastrointestinal stromal tumors.  Acta Cytol. 2001;  45 9-17
• 17 Wiersema M J, Levy M J, Harewood G C. et al . Initial experience with EUS-guided trucut needle biopsies of perigastric organs.  Gastrointest Endosc. 2002;  56 275-278
• 18 Levy M J, Jondal M L, Clain J. et al . Preliminary experience with an EUS-guided trucut biopsy needle compared with EUS-guided FNA.  Gastrointest Endosc. 2003;  57 101-106
• 19 Stelow E B, Bardales R H, Stanley M W. Pitfalls in endoscopic ultrasound-guided fine-needle aspiration and how to avoid them.  Adv Anat Pathol. 2005;  12 62-73
• 20 Ribeiro A, Vernon S, Quintela P. EUS-guided trucut biopsy with immunohistochemical analysis of a gastric stromal tumor.  Gastrointest Endosc. 2004;  60 645-648
• 21 Yadav D, Levy M J, Schwartz D. et al . EUS-guided trucut biopsy for diagnosis of an esophageal stromal tumor: case report.  Gastrointest Endosc. 2003;  58 457-460
• 22 Inoue H, Mizuno N, Sawaki A. et al . Life-threatening delayed-onset bleeding after endoscopic ultrasound-guided 19-gauge Trucut needle biopsy of a gastric stromal tumor.  Endoscopy. 2006;  38 Suppl 2 E38
• 23 Varadarajulu S, Fraig M, Schmulewitz N. et al . Comparison of EUS-guided 19-gauge trucut needle biopsy with EUS-guided fine-needle aspiration.  Endoscopy. 2004;  36 397-401
• 24 Cotton P B. Outcomes of endoscopy procedures: struggling towards definitions.  Gastrointest Endosc. 1994;  40 514-518
• 25 Larghi A, Verna E C, Stavropoulos S N. et al . EUS-guided trucut needle biopsies in patients with solid pancreatic masses: a prospective study.  Gastrointest Endosc. 2004;  59 185-190
• 26 Levy M J, Smyrk T C, Reddy R P. et al . Endoscopic ultrasound-guided trucut biopsy of the cyst wall for diagnosing cystic pancreatic tumors.  Clin Gastroenterol Hepatol. 2005;  3 974-979
• 27 Aithal G P, Anagnostopoulos G K, Kaye P. EUS-guided Trucut mural biopsies in the investigation of unexplained thickening of the esophagogastric wall.  Gastrointest Endosc. 2005;  62 624-629
• 28 Gines A, Wiersema M J, Clain J E. et al . Prospective study of a Trucut needle for performing EUS-guided biopsy with EUS-guided FNA rescue.  Gastrointest Endosc. 2005;  62 597-601
• 29 DeWitt J, McGreevy K, LeBlanc J. et al . EUS-guided Trucut biopsy of suspected nonfocal chronic pancreatitis.  Gastrointest Endosc. 2005;  62 76-84
• 30 Itoi T, Itokawa F, Sofuni A. et al . Puncture of solid pancreatic tumors guided by endoscopic ultrasonography: a pilot study series comparing Trucut and 19-gauge and 22-gauge aspiration needles.  Endoscopy. 2005;  37 362-366
• 31 Levy M J, Reddy R P, Wiersema M J. et al . EUS-guided trucut biopsy in establishing autoimmune pancreatitis as the cause of obstructive jaundice.  Gastrointest Endosc. 2005;  61 467-472
• 32 Kien-Fong V C, Chang F, Doig L. et al . A prospective control study of the safety and cellular yield of EUS-guided FNA or Trucut biopsy in patients taking aspirin, nonsteroidal anti-inflammatory drugs, or prophylactic low molecular weight heparin.  Gastrointest Endosc. 2006;  63 808-813
• 33 Wittmann J, Kocjan G, Sgouros S N. et al . Endoscopic ultrasound-guided tissue sampling by combined fine needle aspiration and trucut needle biopsy: a prospective study.  Cytopathology. 2006;  17 27-33
• 34 Storch I, Jorda M, Thurer R. et al . Advantage of EUS Trucut biopsy combined with fine-needle aspiration without immediate on-site cytopathologic examination.  Gastrointest Endosc. 2006;  64 505-511
• 35 Aithal G P, Anagnostopoulos G K, Tam W. et al . EUS-guided tissue sampling: comparison of ”dual sampling“ (Trucut biopsy plus FNA) with ”sequential sampling“ (Trucut biopsy and then FNA as required).  Endoscopy. 2007;  39 725-730
• 36 Saftoiu A, Vilmann P, Guldhammer S B. et al . Endoscopic ultrasound (EUS)-guided Trucut biopsy adds significant information to EUS-guided fine-needle aspiration in selected patients: a prospective study.  Scand J Gastroenterol. 2007;  42 117-125
• 37 Storch I, Shah M, Thurer R. et al . Endoscopic ultrasound-guided fine-needle aspiration and Trucut biopsy in thoracic lesions: when tissue is the issue.  Surg Endosc. 2008;  22 86-90
• 38 Vanderheyden A D, Proctor K A, Rizk M K. et al . The value of touch imprint cytology in EUS-guided Trucut biopsy.  Gastrointest Endosc. 2008;  68 44-50
• 39 Yun S S, Remotti H, Vazquez M F. et al . Endoscopic ultrasound-guided biopsies of pancreatic masses: comparison between fine needle aspirations and needle core biopsies.  Diagn Cytopathol. 2007;  35 276-282
• 40 Caletti G C, Brocchi E, Ferrari A. et al . Guillotine needle biopsy as a supplement to endosonography in the diagnosis of gastric submucosal tumors.  Endoscopy. 1991;  23 251-254
• 41 Miettinen M, Sobin L H, Lasota J. Gastrointestinal stromal tumors of the stomach: a clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up.  Am J Surg Pathol. 2005;  29 52-68
• 42 Demetri G D, Benjamin R S, Blanke C D. 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 1-29
• 43 Zhou X D, Lv N H, Chen H X. et al . Endoscopic management of gastrointestinal smooth muscle tumor.  World J Gastroenterol. 2007;  13 4897-4902
• 44 Gines A, Fernandez-Esparrach G, Pellise M. et al . Comparison of EUS-guided trucut with EUS-guided FNA in subepithelial tumors: preliminary results of a prospective study [abstract].  Gastrointest Endosc. 2007;  65 AB204