Endoscopic Removal of Submucosal Tumors: Preprocedure Diagnosis, Technical Options, and Results

Introduction

Submucosal tumors (SMTs) of the gastrointestinal tract are uncommon and are usually found incidentally at endoscopy. When an SMT is encountered on upper endoscopy, the difficulty in formulating a management plan lies in the uncertainty as to the histopathologic nature of the tumor. Many techniques have been used in attempts to obtain adequate samples for tissue diagnosis, including endoscopic boring biopsy, biopsy after mucosal incision to expose the tumor, endoscopic submucosal tumorectomy, and biopsy after resection of the mucosa [1] [2] [3] [4] [5]. Unfortunately, these methods pose significant risks of hemorrhage and perforation. Endoscopic ultrasonography (EUS) may be a useful adjunctive diagnostic technique. However, it does not always permit the differential diagnosis of various submucosal tumors to be made, and it cannot necessarily distinguish benign from malignant lesions.

Thus, until recently, management of SMT consisted of two relatively unsatisfactory options: (i) observation without a definitive tissue diagnosis, or (ii) surgical resection. Although most SMTs of less than 5 cm are not malignant, this cannot be presumed. Thus, follow-up examinations at regular intervals are recommended to monitor the tumor for changes in size and shape. However, this imposes a tremendous emotional burden on patients, who can become preoccupied with the possibility that the tumor is malignant. On the other hand, open surgical resection of SMTs, especially benign SMTs of the esophagus, is a fairly invasive approach to a benign disease. This is complicated by the fact that patients may feel worse after surgery, particularly those who had been asymptomatic or who had minimal symptoms beforehand [6]. Thus, less invasive techniques such as endoscopic resection are becoming the preferred method of treating SMTs. Recently technical advances in EUS as well as new devices designed for endoscopic mucosal resection have opened the field to many therapeutic possibilities [7] [8].

The decision to resect an SMT should take several factors into consideration, including the patient’s symptoms, the level of certainty of diagnosis, characteristics of the particular tumor, potential for bleeding or obstructive complications, and available therapeutic options. Therapeutic decisions are then tailored to the individual patient and their level of co-morbidity, the tumor in question, and the comfort level and expertise of the physician. This article will focus on the various endoscopic techniques that have been applied to SMTs, through a review of endoscopic resection techniques, the results reported for each technique, and a review the literature on this subject.

References

• 1 Yamashita Y, Bekki F, Kakegawa T. et al . Two laparoscopic techniques for resection of leiomyoma in the stomach.  Surg Laparosc Endosc. 1995;  5 38-42
• 2 Kawamoto K, Yamada Y, Furukawa N. et al . Endoscopic submucosal tumorectomy for gastrointestinal submucosal tumors restricted to the submucosa: a new form of endoscopic minimal surgery.  Gastrointest Endosc. 1997;  46 311-317
• 3 Asaki S, Ishii N, Nishimura T. et al . New biopsy method for submucosal tumor of the gastrointestinal tract.  Tohoku J Exp Med. 1986;  150 140-146
• 4 Eda Y, Asaki S, Yamagata L. et al . Endoscopic treatment for submucosal tumors of the esophagus; studies in 25 patients.  Gastroenterol Jpn. 1990;  25 411-416
• 5 Uno Y, Sasaki Y, Munakata A. A study of endoscopic resection of the colonic submucosal tumor by local methylene blue injection.  Gastroenterol Endosc. 1992;  34 1888-1892
• 6 Bonavina L, Segalin A, Rosati R. et al . Surgical therapy of esophageal leiomyoma.  J Am Coll Surg. 1995;  181 311-315
• 7 Muto M, Miyamoto S, Doi T. et al . Endoscopic mucosal resection in the stomach using the insulated-tip needle knife.  Endoscopy In press. 2005;  37 178-182
• 8 Shim C S. Endoscopic mucosal resection: an overview of the value of different techniques.  Endoscopy. 2001;  33 271-275
• 9 Yasuda K, Nakajima M, Kawai K. Endoscopic ultrasonographic imaging of submucosal lesions of the upper gastrointestinal tract.  Gastrointest Endosc Clin N Am. 1992;  2 615-624
• 10 Caletti G C, Fusaroli P, Bocus P. Endoscopic ultrasonography.  Endoscopy. 1998;  30 198-221
• 11 Tio T L, Tygat G N, den H artog. Endoscopic ultrasonography for the evaluation of smooth muscle tumors in the upper gastrointestinal tract: an experience with 42 cases.  Gastrointest Endosc. 1990;  36 342-350
• 12 Zhang Q L, Nian W D. Endoscopic ultrasonography diagnosis in submucosal tumors of stomach.  Endoscopy. 1998;  30 Suppl 1 A69-71
• 13 Matsushita M, Hajiro K, Okazaki K. et al . Gastric aberrant pancreas: EUS analysis in comparison with the histology.  Gastrointest Endosc. 1999;  49 493-497
• 14 Yasuda K, Nakajima M, Yoshida S. et al . The diagnosis of submucosal tumors of the stomach by endoscopic ultrasonography.  Gastrointest Endosc. 1989;  35 10-15
• 15 Kawamoto K, Yamada Y, Utsunomiya T. et al . Gastrointestinal submucosal tumors: evaluation with endoscopic US.  Radiology. 1997;  205 733-740
• 16 Jafri I H, Saltzman J R, Colby J M. et al . Evaluation of the clinical impact of endoscopic ultrasonography in gastrointestinal disease.  Gastrointest Endosc. 1996;  44 367-370
• 17 Knox T A. Endoscopic ultrasound: diagnostic and therapeutic uses.  Surg Endosc. 1998;  12 1088-1090
• 18 Shim C S. Role of endoscopic ultrasonography for gastric lesions.  Endoscopy. 1998;  30 Suppl 1 A55-59
• 19 Roesch T, Siess M, Kapfer B. et al . Influence of endoscopic ultrasonography on further management and cost-effectiveness in upper GI submucosal tumors: a prospective multicenter study of the German EUS-Club.  Endoscopy. 1999;  31 Suppl 1 E47
• 20 Waxman I, Saitoh Y. Clinical outcome of endoscopic mucosal resection for superficial GI lesions and the role of high-frequency US probe sonography in an American population.  Gastrointestinal Endosc. 2000;  52 322-327
• 21 Kojima T, Takahashi H, Parra-Blanco A. et al . Diagnosis of submucosal tumor of the upper GI tract by endoscopic resection.  Gastrointest Endosc. 1999;  50 516-522
• 22 Sakai P. Submucosal tumors of the esophagus and stomach: endoscopic/surgical resection.  Endoscopy. 1999;  31 Suppl 1 E26
• 23 Villmann P. Endoscopic ultrasound assisted and directed therapy.  Endoscopy. 2000;  32 Suppl 1 E13
• 24 Wei S C, Wong J M, Shieh M J. et al . Endoscopic resection of gastrointestinal submucosal tumors.  Hepatogastroenterology. 1998;  45 114-118
• 25 Hur B, Chun H, Park D. et al . Reassessment of usefulness of endoscopic ultrasonography in differentiation of benign and malignant gastric stromal tumors which were diagnosed according to pathologic guidelines of Ackermans Surgica.  Gastrointest Endosc. 2000;  51 AB215
• 26 Nickl N, Behling C, McClave S. et al . Specific EUS features can identify hypoechoic masses which are not benign stromal cell tumors.  Gastrointest Endosc. 1999;  49 AB211
• 27 Rosch T, Lorenz R, Dancygier H. et al . Endosonographic diagnosis of submucosal upper gastrointestinal tract tumors.  Scand J Gastroenterol. 1992;  27 1-8
• 28 Kusano C, Sane S, Yoshidome S. et al . Massive hemorrhage after biopsy of an esophageal polyp.  Dis Esophagus. 1998;  11 134-136
• 29 Sun S, Wang M, Sun S. Use of endoscopic ultrasound-guided injection in endoscopic resection of solid submucosal tumors.  Endoscopy. 2002;  34 82-85
• 30 Higashino K, Iishi H, Narahara H. et al . Endoscopic resection with a two-channel videoendoscope for gastric carcinoid tumors.  Hepatogastroenterology. 2004;  51 269-272
• 31 Yu J P, Luo H S, Wang X Z. Endoscopic treatment of submucosal lesions of the gastrointestinal tract.  Endoscopy. 1992;  24 190-193
• 32 Ghazi A, Ferstenberg H, Shinya H. Endoscopic gastroduodenal polypectomy.  Ann Surg. 1984;  200 175-180
• 33 Higaki S, Nishiaki M, Mitani N. et al . Effectiveness of local endoscopic resection of rectal carcinoid tumors.  Endoscopy. 1997;  29 171-175
• 34 Pfeil S A, Weaver M G, Abdul-Karim F W. et al . Colonic lipoma: outcome of endoscopic removal.  Gastrointest Endosc. 1990;  36 435-438
• 35 Cornish D, Feinstat T, Schneider P. et al . Esophageal granular cell tumor removed by endoscopic polypectomy.  Am J Gastroenterol. 1985;  80 950-953
• 36 Hyun J H, Jeen Y T, Chun H J. et al . Endoscopic resection of submucosal tumor of the esophagus: results in 62 patients.  Endoscopy. 1997;  29 165-170
• 37 Waxman I, Saitoh Y, Raju G S. et al . High-frequency probe EUS-assisted endoscopic mucosal resection: a therapeutic strategy for submucosal tumors of the GI tract.  Gastrointest Endosc. 2002;  55 44-49
• 38 Kajiyama T, Hajiro K, Sakai M. et al . Endoscopic resection of gastrointestinal submucosal lesions: a comparison between strip biopsy and aspiration lumpectomy.  Gastrointest Endosc. 1996;  44 404-410
• 39 Songur Y, Okai T, Fujii T. et al . Endoscopic ultrasonography as a guide to strip biopsy removal of esophageal submucosal tumors.  J Clin Gastroenterol. 1995;  20 77-79
• 40 Ono A, Fujii T, Saito Y. et al . Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device.  Gastrointest Endosc. 2003;  57 583-587
• 41 Berkelhammer C, Jasper I, Kirvaitis E. et al . ”Band-snare“ resection of small rectal carcinoid tumors.  Gastrointest Endosc. 1999;  50 582-585
• 42 Akahoshi K, Fujimaru T, Nakanishi K. et al . Endosonography probe-guided endoscopic resection of small flat rectal carcinoid tumor using band ligation technique.  Endoscopy. 2001;  33 471
• 43 Inoue H, Takeshita K, Hori H. et al . Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions.  Gastrointest Endosc. 1993;  39 58-62
• 44 Tada M, Inoue H, Yabata E. et al . Colonic mucosal resection using a transparent cap-fitted endoscope.  Gastrointest Endosc. 1996;  44 63-65
• 45 Matsuzaki K, Nagao S, A K, Miyazaki J. et al . Newly designed soft pre-looped cap for endoscopic mucosal resection of gastric lesions.  Gastrointest Endosc. 2003;  57 242-246
• 46 Oshitani N, Hamasaki N, Sawa Y. et al . Endoscopic resection of small rectal carcinoid tumors using an aspiration method with a transparent cap.  J Int Med Res. 2000;  28 241-246
• 47 Imada-Shirakata Y, Sakai M, Kajiyama T. et al . Endoscopic resection of rectal carcinoid tumors using aspiration lumpectomy.  Endoscopy. 1996;  28 34-38
• 48 Endo S, Hirasaki S, Doi T. et al . Granular cell tumor occurring in the sigmoid colon treated by endoscopic mucosal resection using a transparent cap (EMR-C).  J Gastroenterol. 2003;  38 385-389
• 49 Kajiyama T, Sakai M, Torii A. et al . Endoscopic aspiration lumpectomy of esophageal leiomyoma derived from the muscularis mucosa.  Am J Gastroenterol. 1995;  90 417-422
• 50 Ninh T N, Ninh T X. Cystic hygroma in children: a report of 126 cases.  J Pediatr Surg. 1974;  9 191-195
• 51 Berardi R S. Lymphangioma of the large intestine: report of a case and review of the literature.  Dis Colon Rectum. 1974;  17 265-272
• 52 Kubo S, Kudo T, Ogiwara Y. et al . A case of lymphangioma of the transverse colon with intussusception.  Jpn J Gastroenterol. 1988;  85 1686-1689
• 53 Lam A, Ternberg J L. Cystic lymphangioma of the cecum with ileocecal intussusception.  Am Surg. 1975;  41 648-649
• 54 Mimura T, Kumamoto S, Hachimoto M. et al . Unroofing for lymphangioma of the large intestine: a new approach to endoscopic treatment.  Gastrointest Endosc. 1997;  46 259-263
• 55 Hizawa K, Kawasaki M, Kouzuki T. et al . Unroofing technique for the endoscopic resection of a large duodenal lipoma.  Gastrointest Endosc. 1999;  49 391-392
• 56 Fukuda S, Yamagata R, Mikami T. et al . Gastric lipoma successfully treated by endoscopic unroofing.  Dig Endosc. 2003;  15 228-231
• 57 Hizawa K, Matsumoto T, Kouzuki T. et al . Cystic submucosal tumors in the gastrointestinal tract: endoscopic finding and endoscopic removal.  Endoscopy. 2003;  32 712-714
• 58 Oh Y S, Kwun K A, Kim E J. et al . Endoscopic unroofing therapy for colonic lymphangioma.  Korean J Gastrointest Endosc. 2000;  21 572-576
• 59 Kurahara K, Aoyagi K, Hizawa K. et al . Spontaneous disappearance of gastric lipoma after endoscopic biopsy.  Endoscopy. 1999;  31 S31
• 60 Kim H J, Kim B R, Kim S H. et al . Unroofing technique for endoscopic therapy of gastrointestinal lipoma [abstract].  Korean J Gastrointest Endosc. 2003;  27 362
• 61 Spinelli P, Cerrai F G, Cambareri A R. et al . Two-step endoscopic resection of gastric leiomyoma.  Surg Endosc. 1993;  7 90-92
• 62 Hyun J H, Cho W Y. Endoscopic incisional enucleation of esophageal submucosal tumor.  Korean J Gastroenterol. 1988;  8 5-10
• 63 Park Y S, Park S W, Kim T I. et al . Endoscopic enucleation of upper GI submucosal tumors by using an insulated-tip electrosurgical knife.  Gastrointest Endosc. 2004;  59 409-416