Endoscopic Ultrasound for Differential Diagnosis of Duodenal Lesions

Abstract

Purpose: Duodenal tumors are rare and require a different management from that of esophagogastric neoplasia. The present study retrospectively analyses the endoscopic ultrasound (EUS) features of duodenal tumors of both epithelial and subepithelial origin.

Materials and Methods: During a 12 year period, all duodenal tumors with histologic confirmation by surgery or biopsy were collected including endoscopic and endosonographic images. EUS images were analyzed for specific features (echogenicity, wall layer structure and relation, outer margins) to possibly distinguish epithelial (polyps and carcinoma versus lymphoma) and subepithelial (tumor type) tumors.

Results: 53/80 cases had histologic confirmation (mean age 53.1 ± 11.4 years, m:f = 33:20), 31 were epithelial (13 adenomas, 12 carcinomas, 6 lymphomas) and 22 subepithelial (11 GISTs, 7 Brunneromas, 1 lipoma, 3 NETs). EUS did not recognize carcinomas in 2/13 adenomas. EUS features suggesting carcinoma were loss of wall layers and irregular margins. 5/6 lymphomas showed inhomogeneous thickening with layers partially recognizable. Tumor type of subepithelial lesions correlated with echogenicity: GIST tumors were mostly (62.5 %) hypocheoic with the 3 malignant cases being characterized by heterogeneous echopattern with irregular outer margins. Of the hyperechoic lesions, lipomas had a homogeneous whitish appearance, while NET and Brunneromas were less hyperechoic. In the latter, the endoscopic aspect was also helpful for differential diagnosis. Accuracy of combined endoscopic/EUS imaging for all duodenal lesions was 84.9 % (45/53). No procedural complications occurred among all patients that received EUS examinations.

Conclusion: EUS contributes to the differential diagnosis of epithelial lesions known to be malignant; in subepithelial tumors, tissue confirmation is still required.

Zusammenfassung

Ziel: Tumore des Zwölffingerdarms sind selten und erfordern eine andere Vorgehensweise als ösophagogastrische Neoplasien. Die vorliegende Studie analysiert retrospektiv die Merkmale von duodenalen Tumoren sowohl epithelialen als auch subepithelialen Ursprungs im endoskopischen Ultraschall (EUS).

Material und Methoden: Über einen Zeitraum von 12 Jahren wurden alle nach Operation oder Biopsie histologisch bestätigten Tumore des Duodenums einschließlich der Bilder aus Endoskopie und endoskopischem Ultraschall gesammelt. EUS-Bilder wurden im Hinblick auf spezifische Merkmale (Echogenität, Struktur der Wandschichten und deren Beziehung, äußere Ränder) analysiert, um epitheliale (Polypen und Karzinome im Gegensatz zu Lymphomen) und subepitheliale (tumorartige) Tumore zu unterscheiden zu können.

Ergebnisse: Eine histologische Bestätigung (Durchschnittsalter 53,1 ± 11,4 Jahre, M:F = 33:20) lag in 53/80 Fälle vor, davon waren 31 epithelial (13 Adenome, 12 Karzinome, 6 Lymphome) und 22 subepithelial (11 GISTs, 7 Brunneromas, 1 Lipom, 3 NETs). EUS konnte bei 2/13 Adenomen kein Karzinom erkennen. Die EUS-Zeichen, die für ein Karzinom sprechen, waren der Verlust der Wandschichten und unregelmäßige Ränder. 5/6 Lymphome zeigten eine inhomogene Verdickung der Schichten mit teilweise erkennbaren Schichten. Der Tumortypus bei subepithelialen Läsionen korrelierte mit der Echogenität. GIST-Tumore waren größtenteils (62,5 %) echoarm, wobei die 3 malignen Fälle durch ein heterogenes Echomuster mit irregulären Außenrändern charakterisiert wurden. Bei den echoreichen Läsionen zeigten die Lipome ein homogenes weißliches Erscheinungsbild, während NET und Brunneromas weniger echoreich waren. Bei Letzteren war für die Differenzialdiagnose das endoskopische Erscheinungsbild hilfreich. Die Genauigkeit der kombinierten endoskopischen/EUS-Bilder bei allen duodenalen Läsionen betrug 84,9 % (45/53). Bei keinem der Patienten mit EUS-Untersuchungen traten eingriffsbedingte Komplikationen auf.

Schlussfolgerung: EUS leistet einen Beitrag zur Differenzialdiagnostik von epithelialen Läsionen mit malignem Hintergrund; bei subepithelialen Tumoren ist eine Bestätigung im Gewebe immer noch notwendig.

Key words

abdomen - duodenum - endoscopic ultrasonography - duodenal lesion

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