Endoscopic submucosal dissection for the treatment of intraluminal gastric subepithelial tumors originating from the muscularis propria layer

Background and study aims: Subepithelial tumors of the stomach used to be considered as benign, but they do have malignant potential, especially when they originate from the muscularis propria layer. The aims of this study were to determine the feasibility of endoscopic submucosal dissection (ESD) for the removal of subepithelial tumors from the muscularis propria layer and to evaluate the efficacy and safety of ESD for this indication.
Patients and methods: A total of 12 lesions in 11 patients were eligible for inclusion in the study during the period between December 2004 and February 2006. ESD using an insulated-tip knife was used to remove gastric subepithelial tumors from the muscularis propria where this was possible. Endoscopic mucosal resection using a suction and cap method (”EMR-c”) was used to obtain a sufficiently large specimen for tissue diagnosis if complete resection by ESD was not possible.
Results: Nine tumors were resected completely by ESD (success rate 75 %). The mean tumor size as determined by endoscopic ultrasound as 20.7 mm (range 6 - 40 mm). The histological diagnosis was gastrointestinal stromal tumor for eight lesions and leiomyoma for four tumors. The mean operation time was 60.9 minutes (range 20 - 170 minutes), and the average blood loss was 30 ml. No patient developed perforation or massive hemorrhage requiring surgical treatment, and there were no other immediate postprocedure complications.
Conclusions: ESD can be used for the resection of intraluminal gastric subepithelial tumors and could replace treatment by surgical resection in some cases. EMR-c is an alternative method that can be used to obtain sufficient tumor tissue for histological diagnosis if complete resection by ESD fails.

References

• 1 Hedenbro J L, Eklund M, Wetterberg P. et al . Endoscopic diagnosis of submucosal gastric lesions.  Surg Endosc. 1991;  5 20-23
• 2 Connolly E M, Gaffney E, Reynolds J V. Gastrointestinal stromal tumours.  Br J Surg. 2003;  90 1178-1186
• 3 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 52-58
• 4 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
• 5 Ono H. Endoscopic submucosal dissection for early gastric cancer.  Chin J Dig Dis. 2005;  6 119-121
• 6 Davila R E, Faigel D O. GI stromal tumors.  Gastrointest Endosc. 2003;  58 80-88
• 7 Palazzo L, Landi B, Cellier C. et al . Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours.  Gut. 2000;  46 88-92
• 8 Giovannini M, Seitz J F, Monges G. et al . Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients.  Endoscopy. 1995;  27 171-177
• 9 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
• 10 Hwang J H, Kimmey M B. The incidental upper gastrointestinal subepithelial mass.  Gastroenterology. 2004;  126 301-307
• 11 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;  59 409-415
• 12 Miettinen M, Lasota J. Gastrointestinal stromal tumors - definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis.  Virchows Arch. 2001;  486 1-12
• 13 Graadt van Roggen J F, van Velthuysen M L, Hogendoorn P C. The histolopathological differential diagnosis of gastrointestinal stromal tumours.  J Clin Pathol. 2001;  54 96-102
• 14 Emory T S, Sobin L H, Lukes L. et al . Prognosis of gastrointestinal smooth-muscle (stromal) tumors: dependence on anatomic site.  Am J Surg Pathol. 1999;  23 82-87