Submucosal lesions

Most of the submucosal lesions encountered on endoscopy are benign; however, the fact that some of them may be malignant considerably influences the attitude toward the whole group. This article reviews the current status of endosonography in the management of submucosal lesions and focuses on determining the risk of malignancy. The predictive value of various endoscopic ultrasonography (EUS) features and their combinations and the capabilities and limitations of EUS-guided fine needle biopsy are discussed. Other issues addressed include differentiation between extraluminal compressions and true submucosal lesions, EUS-assisted endoscopic removal of submucosal lesions, and the potential role of catheter-based endosonography in the setting of submucosal lesions. Problems related to the surveillance of patients with submucosal lesions who are not candidates for surgical treatment are outlined. An overview of the recent changes in the pathologic classification of gastrointestinal mesenchymal tumors and their impact on the role of EUS in the management of submucosal lesions is given.     

内镜超声引导下经食管肺细针穿刺活检的诊断价值

目的 在内镜超声引导下经食管行肺部病变的细针穿刺活检来确定肺部病变的性质，并评价这种方法的对肺部病变的诊断价值。方法 选择经CT或内镜超声检查发现的肺部占位病变患者28例，所有肺部病变均邻近食管。对其进行内镜超声检查，以明确病变的大小、形态、位置，并观察有无淋巴结转移。在内镜超声导引下经食管对肺部病变行细针穿刺活检。结果 28例患者中，全部患者均得到了充足的组织碎片，25例最终确定为肿瘤的患者经组织细胞学检查23例为阳性结果(其中鳞状细胞癌，n=11；小细胞肺癌，n=6；大细胞癌，n=5；腺癌，n=1)，全部患者经手术治疗，得出经食管肺活检对肺癌诊断的敏感性为92％，特异性为100％。无1例患者出现不良反应。结论 内镜超声经食管肺活检是诊断肺部病变安全、有效的方法。     

Endoscopic ultrasonography in the evaluation of indeterminate biliary strictures

Biliary strictures may be due to a variety of benign and malignant processes. Imaging with endoscopic ultrasonography (EUS) often suggests the diagnosis, but is usually not definitive. EUS-guided fine needle aspiration (FNA) facilitates the diagnosis of extrahepatic biliary strictures, although peritioneal metastases due to needle tract seeding may occur after EUS-FNA of cholangiocarcinoma. In addition to diagnosis of strictures, EUS may play an important role in staging of cholangiocarcinoma.     

Endoscopic ultrasound-guided fine needle aspiration in submucosal lesion

A submucosal lesion, more appropriately a subepithelial lesion, is hard to diagnose. Endoscopic ultrasonography is good to differentiate the nature of submucosal lesion. For definite diagnosis, tissue acquisition from submucosal lesion is necessary, and many methods have been introduced for this purpose mainly by endoscopic ultrasonography, such as endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), EUS-guided Trucut Biopsy (TCB), and EUS-guided fine needle biopsy (FNB). For EUS-FNA, adequate processing of specimen is important, and for proper diagnosis of EUS-FNA specimen, both cytologic and histologic examinations, including immunohistochemical stains, are important. All gastrointestinal stromal tumors have some degree of malignant potential, so there have been a lot of efforts and methods to increase diagnostic yields of submucosal lesion. We herein review the current hot topics on EUS-FNA for submucosal tumor, such as needles, on-site cytopathologists, immunohistochemical stains, EUS-TCB, EUS-FNB, Ki-67 labelling index, DOG1, and combining EUS-FNA and EUS-TCB.     

经软腭超声引导细针穿刺诊断咽旁间隙肿瘤

目的探讨经软腭彩色多普勒超声(CDFI)诊断咽旁间隙肿瘤的应用价值.方法应用7.0 MHz腔内彩色多普勒超声探头对CT或MRI发现的40例(43个)咽旁间隙内可疑病变行软腭CDFI扫查.观察病变形态、大小、内部回声及血流情况,并行超声引导下细针穿刺(FNA)病理细胞学诊断.结果40例经CDFI扫查显示病变43个,FNA细胞学诊断良性病变6个,恶性病变32个,5个病变内未见癌细胞,其中2个病变CDFI检查高度怀疑为恶性病变,经鼻咽活检病理确诊为鼻咽癌.结论经软腭超声引导细针穿刺细胞学诊断是一种诊断鼻咽部肿瘤的新方法.当病变局限于咽旁间隙内时,FNA是对常规鼻咽活检一种有益的补充,可以提高鼻咽癌的早期诊断率.     

Sonographically guided core needle biopsy of soft tissue neoplasms

PURPOSE: This study was conducted to evaluate the usefulness of sonography (US)-guided needle biopsy in the diagnosis of soft tissue masses. PATIENTS AND METHODS: Thirty-seven patients with a mean age of 49 years were enrolled in the study. The size of the biopsy needle was selected according to the kind of tumor suspected (ie, primary or metastatic). In patients with suspected metastases, smaller biopsy needles were used; in patients with suspected primary tumors, larger needles were used so that larger specimens could be obtained. Prebiopsy color Doppler sonography (CDUS) was routinely used to guide the cutting needle to areas of the lesion showing sufficient vascularity. From 3 to 6 cores were obtained, depending on their quality. We compared the diagnoses yielded by the core biopsy and the final histopathologic analysis of the resected tumor by classifying the results as "concordant" or "discordant." RESULTS: A total of 37 tumors were examined. Final diagnoses were 24 malignant tumors (6 metastases and 18 primary tumors) and 13 benign tumors. The lesions were diagnosed correctly as either benign or malignant in 35 of the 36 cases for which needle biopsy specimens were adequate, with only 1 misdiagnosis. The diagnoses were concordant in 33 cases (17 primary malignant tumors, 6 metastatic tumors, and 10 benign tumors) and were discordant diagnosis in the other 4 cases (1 primary malignant tumor and 3 benign tumors). No complications were attributable to the needle biopsy. CONCLUSIONS: US-guided percutaneous core needle biopsy of soft tissue neoplasms is an easy, safe, and useful procedure. It can be considered a first-line procedure for the acquisition of tissue specimens adequate for histopathologic diagnosis.     

Role of endoscopic ultrasound in the diagnosis and staging of pancreatic cancer

Early diagnosis of pancreatic cancer remains a difficult task, and multiple imaging tests have been proposed over the years. The aim of this review is to describe the current role of endoscopic ultrasound (EUS) for the diagnosis and staging of patients with pancreatic cancer. A detailed search of MEDLINE between 1980 and 2007 was performed using the following keywords: pancreatic cancer, endoscopic ultrasound, diagnosis, and staging. References of the selected articles were also browsed and consulted. Despite progress made with other imaging methods, EUS is still considered to be superior for the detection of clinically suspected lesions, especially if the results of other cross-sectional imaging modalities are equivocal. The major advantage of EUS is the high negative predictive value that approaches 100%, indicating that the absence of a focal mass reliably excludes pancreatic cancer. The introduction of EUS-guided fine needle aspiration allows a preoperative diagnosis in patients with resectable cancer, as well as a confirmation of diagnosis before chemoradiotherapy for those that are not. This comprehensive review highlighted the diagnostic capabilities of EUS including the newest refinements such as contrast-enhanced EUS, EUS elastography, and 3-dimensional EUS. The place of EUS-guided biopsy is also emphasized, including the addition of molecular marker techniques.     

乳房肿块的超声诊断价值

本文报告２５０例共３１７只乳房肿块的超声检查资料，所有病例均经手术和病理证实。乳腺癌诊断符合率为８１．４１％，腺瘤为８７．２５％。发现的最小良性病灶４×５ｍｍ，最小癌６×６ｍｍ。本文就乳癌的早期发现、良恶性病灶的鉴别及部分病例误诊原因分析等几方面作了讨论。作者认为高分辨率、高频探头的应用为乳腺内小病灶的发现提供了基础。肿块的边界、包膜及形态是鉴别良恶性病灶的首要标准。而彩色多普勒信号仅能在此基础上起辅助作用。对发现的不能明确其性质的病灶可在超声引导下穿刺活检。     

Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB), of submucosal tumors, diffuse esophageal/gastric wall thickening, pancreatic solid masses and cystic-appearing lesions, mediastinal lesions unrelated to lung or esophageal cancer, cancer of the esophagus, stomach, and rectum, lymph nodes of unknown origin, adrenal gland masses, and focal liver lesions. False-positive cytopathological results and needle tract seeding are also discussed. The present Clinical Guideline describes the results of EUS-guided sampling in the different clinical settings, considers the role of this technique in patient management, and makes recommendations on circumstances that warrant its use. A two-page executive summary of evidence statements and recommendations is provided. A separate Technical Guideline describes the general technique of EUS-guided sampling, particular techniques to maximize the diagnostic yield depending on the nature of the target lesion, and sample processing. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling.     

Diagnosis and fine needle aspiration of intraductal papillary mucinous tumor by endoscopic ultrasound

A recently established clinical entity, intraductal papillary mucinous tumor (IPMT) of the pancreas embraces a spectrum of pathology ranging from benign to malignant disease. IPMT must be differentiated from other cystic neoplasms of the pancreas, as well as inflammatory cystic lesions. As the pancreas lies in close proximity to the gastric and duodenal walls, endoscopic ultrasonography (EUS) is ideally suited for imaging the pancreas. Additionally, EUS facilitates fine needle aspiration of pancreatic cysts and/or a dilated pancreatic duct for cytologic and tumor marker analysis. This article presents a brief history of IPMT, differential diagnosis, current imaging modalities, findings of cytologic and tumor marker analysis, prognosis, and treatment strategy. Special emphasis is dedicated to the role of EUS, as well as EUS with fine needle aspiration.     

Guillotine needle biopsy as a supplement to endosonography in the diagnosis of gastric submucosal tumors.

The presumptive diagnosis of gastric submucosal tumors can be made by endoscopic ultrasonography (EUS) but histological confirmation is still required. A special guillotine biopsy device (Flexi-Temno) which enables collection of adequate submucosal samples by the endoscopic approach was therefore evaluated. After visualization by EUS the guillotine needle biopsy was performed in 21 patients with submucosal tumors of the stomach. There were 2 failures in 2 patients with leiomyomas. The diagnosis suggested by EUS was confirmed by guillotine biopsy in 17 cases. Guillotine biopsy detected 2 cases of unsuspected leiomyosarcoma which were confirmed surgically. In cases of solid submucosal tumors confirmed on EUS, the guillotine needle biopsy enables a definitive histologic diagnosis. Thus malignancies can be detected when EUS findings are not significant.     

超声引导下乳腺小病变的活检

目的评估实时超声引导下穿刺活检对乳腺小病变良恶性的鉴别诊断价值。方法21例乳腺小病变均经高频超声与彩色多普勒超声检查,并根据二维声像特征按Stasrov分类法将乳腺小病变分成恶性组(5例)、性质未定组(13例)及良性组(3例)。所有病例均在实时超声引导下行乳腺活检取得病理诊断。结果高频彩超诊断为恶性可能组的5例中,3例活检病理证实为恶性肿瘤,2例活检病理为良性,误诊率为40%;高频彩超诊断为性质未定组13例中除1例活检病理证实为恶性外,其余12例活检病理均为良性。高频彩超诊断为良性组3例,活检病理均为良性。21例中有7例乳腺病变作手术切除,术后病理与穿刺病理相一致。结论实时超声引导下行乳腺小病变穿刺活检,可以进一步提高早期乳腺癌的确诊率,是一种理想的术前诊断方法之一。     

Learning, techniques, and complications of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Guideline

This article is the second of a two-part publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided Trucut biopsy. The first part (the Clinical Guideline) focused on the results obtained with EUS-guided sampling, and the role of this technique in patient management, and made recommendations on circumstances that warrant its use. The current Technical Guideline discusses issues related to learning, techniques, and complications of EUS-guided sampling, and to processing of specimens. Technical issues related to maximizing the diagnostic yield (e.g., rapid on-site cytopathological evaluation, needle diameter, microcore isolation for histopathological examination, and adequate number of needle passes) are discussed and recommendations are made for various settings, including solid and cystic pancreatic lesions, submucosal tumors, and lymph nodes. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling. A two-page executive summary of evidence statements and recommendations is provided.     

88例胃肠间质瘤临床诊断分析

目的探讨胃肠道间质瘤（GIST）的临床诊断方法。方法回顾性分析88例GIST患者的临床表现、影像学资料、胃肠镜、超声内镜（EUS）的结果,并进行分析、总结。结果 GIST缺乏特异性症状或体征;88例行腹部彩超发现16例病变,腹部彩超仅能发现腔外、转移病灶和少部分腔内病灶,价值不大;46例行腹部CT发现32例病变,腹部螺旋CT检查可发现较大病灶并且有助于判断胃肠间质瘤的危险性,对有无转移也有明确的诊断价值,但对于微小病灶的检出有一定困难;53例胃或结直肠病变的患者胃肠镜检查发现率为100%,但难以对病变进行定性;53例胃或结直肠病变的患者EUS误诊为其他疾病的有6例,对GIST的定性和定位有较好的辅助价值,但与病理结果之间仍有一定的出入。结论结合多种检查手段对明确GIST的诊断有重要价值,但确诊仍需病理检查。     

经软腭超声引导细针穿刺活检在鼻咽部及咽旁间隙占位诊断中的应用

目的 经口腔软腭超声检查咽旁间隙部占位,在超声引导下细针穿刺取得细胞学诊断结果,以期提高对鼻咽癌的早期病理诊断的准确率. 方法 应用7.0 MHz腔内超声探头经口腔软腭对CT或MRI发现的212例鼻咽部及咽旁间隙占位(222处病灶)行超声探测,并在超声引导下行细针穿刺,取得细胞病理学诊断结果. 结果 212例患者通过经口腔咽旁间隙彩色多普勒血流成像探测,发现病灶222处,10例为双侧咽旁间隙占位.与CT及MRI相比,肿块的显示率为100％.以细胞学病理为标准,本组病例超声提示恶性占位诊断的灵敏度为97.5％ (159/163),特异度为79.7％ (47/59). 结论 经软腭超声引导细针穿刺细胞病理学诊断是一种新的诊断鼻咽部肿瘤的方法,是对常规活检的有效补充,可提高鼻咽癌的早期诊断率.     

Endoscopic ultrasound: contrast enhancement

The development of ultrasound contrast agents has allowed for the evaluation of vascularity in digestive organs by contrast-enhanced endoscopic ultrasonography (EUS). Contrast-enhanced Doppler EUS and contrast-enhanced?harmonic EUS (CH-EUS) have improved characterization of pancreatic tumors, lymph nodes, and gastrointestinal submucosal tumors and compliment EUS fine-needle aspiration (FNA) in identifying malignant tumors. Moreover, CH-EUS can be used to identify the target for EUS-guided FNA by clearly depicting the outline of the lesions.     

Distant lymph node metastases in esophageal cancer: impact of endoscopic ultrasound-guided biopsy.

BACKGROUND AND STUDY AIMS: The aim of this retrospective study was to evaluate the impact of endoscopic ultrasound (EUS)-guided biopsy in patients with esophageal carcinoma where distant lymph nodes which were possibly metastatic were visualized using EUS. PATIENTS AND METHODS: Out of 198 patients (150 men, mean age 66 years) examined over a 4-year period by EUS for local staging of esophageal cancer (121 squamous cell carcinomas and 77 adenocarcinomas), there was EUS visualization of distant lymph nodes in 40 (20%). EUS-guided biopsy was carried out in the latter patients, of cervical nodes with mediastinal tumors (n = 19), of celiac nodes with cervical tumors (n = 2) or superior mediastinal tumors (n = 9), and upper mediastinal lymph nodes in the case of distal adenocarcinomas (n = 10). RESULTS: On EUS-guided biopsy, results were positive in 31 patients, eight were correctly negative (as confirmed by surgery), and in one patient there was a technical failure, with positive findings on subsequent surgery. The sensitivity and specificity of the diagnosis of malignant lymph nodes were therefore 97% and 100% respectively. The positive results of EUS-guided biopsy modified the tumor staging in 31 of these cases (77.5%), proving distant lymph node metastasis which is classified as stage M1. With regard to actual clinical management, surgery was withheld from 24 patients (60% of 40 cases) who were then treated with concomitant radiotherapy and chemotherapy. CONCLUSION: EUS-guided biopsy of distant lymph nodes was indicated in 20% of patients with esophageal cancers, and the biopsy results led to upgrading of the tumor stage in about 80% of cases and influenced the treatment decision in about 60%.     

Indirect percutaneous core needle biopsy of solid pancreatic or peripancreatic lesions

Solid pancreatic or peripancreatic lesions comprise a heterogeneous group of diseases that rely on a multimodality imaging approach for subsequent tissue procurement. Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA)/biopsy is an effective and safe method for tissue diagnosis in this region. The failure to obtain adequate tissue for diagnosis under EUS guidance is still a rare but important issue. Percutaneous core needle biopsy (CNB) provides an alternative pathway for adequate specimen acquisition. Because of the deep retroperitoneal location, the percutaneous biopsy of pancreatic or peripancreatic lesions may inevitably pass through visceral organs. The procedure is relatively risky and difficult for general radiologists, particularly beginners, and an adequate knowledge of the abdominal anatomy and biopsy technique is indispensable. In this review, various aspects of percutaneous CNB for solid pancreatic or peripancreatic lesions using different trans-organ approaches are reviewed to increase the chance of successful biopsy.

     

高频超声在浅表器官病变中的应用价值

目的　探讨对比运用 2 0 .0MHz和 7.5MHz高频超声对眼、甲状腺、乳腺、男性生殖器、浅表淋巴结及皮肤等组织器官病变进行诊断的临床应用价值。方法　运用 2 0 .0MHz与 7.5MHz的探头分别检查 92例浅表器官病变的形态、大小及血流状况。结果　 2 0 .0MHz超高频超声对乳腺、甲状腺肿块内沙粒状钙化灶的检出率明显高于 7.5MHz高频超声 (P <0 .0 5 ) ,明显提高了恶性病变的诊断率 ;2 0 .0MHz超高频超声可以明确显示小的病灶及细小管状结构的病变 ,如晶状体浑浊、乳腺导管内乳头状瘤及乳头状癌伴乳腺导管扩张、输精管扩张、腮腺导管结石伴导管扩张、阴茎硬结病变以及皮肤弥漫性或结节性病灶。结论　 2 0 .0MHz超高频超声对于浅表器官及皮肤等组织病变的检查具有重要价值。     

超声引导下穿刺活检对获得性免疫缺陷综合征患者合并淋巴结肿大的病因诊断价值

目的： 经超声引导下穿刺活检分析获得性免疫缺陷综合征（acquired immunodeficiency syndrome，AIDS）患者合并淋巴结肿大的病因。方法： 对2017年4月至2020年12月在上海市公共卫生临床中心行超声引导下穿刺活检的130例AIDS合并淋巴结肿大患者的病理诊断及实验室指标等进行回顾性分析，进而分析超声引导下穿刺活检对该类患者淋巴结肿大病因的诊断价值。结果： 130例患者中，最终诊断良性病变82例（63.1%），包括淋巴结核56例，非结核分枝杆菌感染7例，马尔尼菲篮状菌感染6例，坏死性淋巴结炎5例，隐球菌感染2例，巨细胞病毒感染2例，金黄色葡萄球菌感染、淋巴组织增生、淋巴囊肿、EB病毒感染各1例；恶性肿瘤36例（27.7%），包括淋巴瘤17例（其中弥漫大B细胞淋巴瘤、Burkitt淋巴瘤各5例，浆母细胞淋巴瘤、小淋巴细胞性淋巴瘤及间变大细胞淋巴瘤各1例，另4例未分型），转移性肿瘤17例，卡波西肉瘤2例；病因类型不明确12例，其中病理检查提示11例为良性病变、1例为肿瘤性坏死。130例患者淋巴结肿大病因总诊断率达90.8%。所有患者无并发症。结论： 超声引导下穿刺活检对AIDS合并淋巴结肿大患者淋巴结肿大病因诊断率高，且微创安全，对于该类患者淋巴结肿大临床早期诊断及精准治疗具有较高价值，值得临床推广应用。