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Endoscopic Biopsy by Mucosal Incision for Upper Gastrointestinal Submucosal Tumors
Video Journal and Encyclopedia of GI Endoscopy (2014) 1, 644–646
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/vjgien
INNOVATION FORUM AND EXPERIMENTAL ENDOSCOPY
Endoscopic Biopsy by Mucosal Incision for Upper Gastrointestinal Submucosal Tumors$, $$ Toru Okuzonon, Toshiyuki Mishima, Adel Badran, Hiroyuki Mizuno, Yusuke Miyashita, Hidetaka Hamamoto, Shun Sato, Naoto Miyake, Masato Nakahori, Akimichi Chonan Digestive Endoscopic Center, Sendai Kosei Hospital, Hirosemachi 4-15, Aoba Ward, Sendai City, Miyagi Prefecture, Japan Received 24 May 2013; received in revised form 18 July 2013; accepted 10 August 2013
KEYWORDS
Abstract
Submucosal tumor (SMT); Gastrointestinal stromal tumor (GIST); Leiomyoma; Schwannoma; Endoscopic biopsy by mucosal incision (EBM); EUS-FNA; Video
Histological diagnosis of upper gastrointestinal submucosal tumors (SMT) is a prerequisite for selecting the proper therapeutic approach. EUS-FNA has improved the evaluation of SMT. Endoscopic biopsy by mucosal incision (EBM) is a diagnostic procedure developed by Yokohata et al. The principal aim of this study was to examine the potential of EBM, as an alternative to the more expensive and technically-demanding EUS-FNA, in diagnosing SMT. This retrospective study included a consecutive series of 27 patients (15 males and 12 females, mean age 60.1 years) undergoing EBM and 11 patients (7 males and 4 females, mean age 65.7 years) undergoing EUS-FNA. The tumors had diameters of 15 mm or more, and were suspicious for continuity with the fourth layer as determined by EUS. We compared the diagnostic accuracy and the operating time of EBM with those of EUS-FNA. Results: The diagnostic accuracies of EBM and EUS-FNA were 85.2% (23/27) and 90.0% (9/10) respectively. The average operating time of EBM and EUS-FNA was 20 min and 41.0 min respectively. During our investigation no major complications were encountered in either group. Conclusion: EBM matches EUS-FNA in diagnostic accuracy of SMT and is more time and costefficient. & 2013 The Authors. Published by Elsevier GmbH. All rights reserved.
☆ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. ☆☆ The terms of this license also apply to the corresponding video. n Corresponding author. Tel.: +81 22 222 6181. E-mail address: [email protected] (T. Okuzono).
2212-0971/$ - see front matter & 2013 The Authors. Published by Elsevier GmbH. All rights reserved. http://dx.doi.org/10.1016/j.vjgien.2013.08.002
Endoscopic Biopsy by Mucosal Incision
Video related to this article Video related to this article can be found online at http:// dx.doi.org/10.1016/j.vjgien.2013.08.002.
1.
2. Strengths and limitations of standard procedure/device EUS-FNA allows for a safe and precise pre-operative diagnosis of SMT. However, EUS-FNA approach is expensive and technically-demanding. The factors restrict the application to a limited number of medical centers.
3. Potential benefit of the proposed procedure/device
Direct-observation biopsy with mucosal cutting (EBM)
4.
was developed to obtain specimens from gastrointestinal submucosal tumors with ordinary biopsy forceps. EBM does not require convex or linear EUS devices, only ESD devices are employed rendering EBM a practical and cost-efficient choice. The time required for EBM is much shorter compared to EUS-FNAB. Furthermore, the diagnostic accuracy of EBM matches that of EUS-FNA.
Materials
Endoscope; GIF-2TQ260M (Olympus) for gastrointestinal ESD.
Tip knife; Needle Knife (KD-1L-1; Olympus), Flash Knife (DK2618JN20; Fujifilm).
Biopsy forceps; EndJaw (FB-220K; Olympus). Hemostatic forceps; Coagulaspar (FD-410LR; Olympus).
5.
Endoscopic procedure
The mucosa is incised using a tip knife without saline
We usually obtain 3 or more tissue samples in the same
Background
The development of several endoscopic techniques, including EUS-FNA, has improved the evaluation of submucosal tumor (SMT) and led to reach a more precise preoperative diagnosis of SMT. However, EUS-FNA approach is expensive and technically-demanding. To this end, a more feasible, yet reliable, alternative is desired.
645
injection. (In the original method, direct-observation biopsy by mucosal cutting developed by Yokohata et al. [1], the mucosa is incised after infusing saline into the top of SMT.). We continue to incise the submucosa until we reach the SMT. We obtain the tissue specimens using needle fenestrated biopsy forceps with alligator cup (EndJaw; Olympus). This technique allows enough tissue to be sampled.
6.
session since the initial specimens are usually denatured by cauterization during the incision process. In the process, be careful with possible bleeding! If bleeding occurs, try to stop it with tip knife coagulation or hemostatic forceps (Coagulaspar; Olympus). Occasionally, it could be difficult to control the bleeding by coagulation, in which case we finally resort to clipping forceps.
Discussion
In this study we compared the duration and diagnostic accuracy of EBM and EUS-FNA in evaluating SMT. The average number of biopsy specimens obtained from EBM and EUS-FNA were 6.0 and 4.2 respectively. The accuracies of post-procedural histological examinations for EBM and EUS-FNA were 85.2% (23/27) and 90.0% (9/10) respectively. The average operating time of EBM and EUS-FNA was 20.0 min and 35.0 min respectively. The biopsy results were as follows; EBM: GIST, 18 patients; leiomyoma, 5 patients; lymphocytic infiltration, 1 patient; and unspecified tissue, 3 patients. EUS-FNA: GIST, 9 patients; unobtainable, 1 patient. Postoperative diagnoses of 18 patients who underwent EBM were as follows: GIST, 17 patients; and Shwannoma, one patient. In 14 patients who were diagnosed as GIST before and after the operation, the concordance of Fletcher Risk Table [2] was 100%. For EBM, intra-procedural bleeding was encountered in 7 patients (25.9%); while in EUS group no bleeding occurred (0%). The bleeding of EBM was stopped by coagulation or clipping forceps. No patients had secondary hemorrhage or perforation in both EBM and EUS-FNA. EBM requires neither convex nor linear EUS, and only ESD devices are being employed in the process. While many medical centers in Japan are equipped with ESD devices, the use of interventional EUS is still limited to a few numbers of medical centers owing to the aforementioned reasons. Therefore, EBM can prove convenient as a practical, time and cost-efficient alternative to EUS-FNA in terms of SMT diagnosis and evaluation. In implementing EUS-FNA there are limitations concerning the anatomical location of SMT. It is difficult to obtain adequate tissue samples from SMT located at the lower body of stomach by EUS-FNA [3]. On the other hand, almost all gastric SMT, regardless of their anatomical site, can be accessed with EBM giving another advantage for EBM over EUS-FNA. Nevertheless, EBM should only be avoided in case of outward-growing SMT for fear of possible perforation. During our investigation no major complications were encountered in either group. However, for EBM care should be taken in case bleeding occurred. Since the source of bleeding is a tumor, it is rather difficult to identify the bleeder and consequently controlling the bleeding could be time-consuming. In our hands, the diagnostic accuracy of EBM was comparable to that of EUS-FNA. The risk of dissemination has not been tackled in this study. However, it should be comparable to that of ordinary upper gastrointestinal biopsy.
646
T. Okuzono et al.
The reasons why diagnoses by EBM could not be made in some patients were as follows: (1) In case of Schwannoma, despite almost complete exposure of the tumor, only capsular specimens could be obtained while subcapsular tissue could not be reached. (2) The identity of some of the specimens could not be determined because of thermal denaturation during ablation. (3) In few cases, sufficient quantities of tissue could not be obtained due to intraoperative bleeding.
Based on the findings of our study we consider EBM to be a feasible and reliable alternative to EUS-FNA being rapid, safe and accurate with only few limitations.
7.
Take-home messages
Endoscopic biopsy by mucosal incision (EBM) is an
accurate, time and cost-efficient procedure for diagnosing upper gastrointestinal submucosal tumors. EBM matches EUS-FNA in diagnostic accuracy of SMT, and has an edge over EUS-FNA in terms of time and cost benefits. The only potential complication of EBM is intraprocedural bleeding that may occasionally interfere with proper sampling of SMT lesions.
Voiceover Text Endoscopic biopsy by mucosal incision for upper gastrointestinal submucosal tumors. The mucosa is incised using a needle knife without saline injection. We continue to incise the submucosa until we reach the SMT. We obtain the tissues using needle fenestrated biopsy forceps with alligator cup. In the process, be careful with possible bleeding! If bleeding occurs, try to stop it with tip knife coagulation or hemostatic forceps. Occasionally, it could be difficult to control the bleeding by coagulation. In which case we finally resort to clipping forceps. Endoscopic biopsy by mucosal incision (EBM) is an accurate, time and cost-efficient procedure for diagnosing upper gastrointestinal submucosal tumors. EBM matches EUSFNA in diagnostic accuracy of SMTs, and has an edge over EUS-FNA in terms of time and cost benefits. The only potential complication of EBM is intra-procedural bleeding that may occasionally interfere with proper sampling of SMT lesions.
Conflict of interest Authors declare no potential conflicts of interest.
8.
Scripted voiceover
Voiceover Text The development of several endoscopic techniques, including EUS-FNA, has improved the evaluation of Submucosal tumor and led to reach a more precise preoperative diagnosis of SMT. However, EUS-FNA approach is expensive and technically-demanding. To this end, a more feasible, yet reliable, alternative is desired. Endoscopic biopsy by mucosal incision is a time and costefficient candidate for accurate diagnosis of SMT. We propose Endoscopic biopsy by mucosal incision (EBM)for diagnosing upper gastrointestinal submucosal tumors.
References [1] Yokohata Norisuke, Tamegai Yoshihiro, Tokuhara Makoto, et al. 3 Cases of gastric SMT(submucosal tumor) which was diagnoced before operation -open biopsy with ESD (endoscopic submucosal dissection) for interstind SMT. Prog Dig Endosc 2007;70:82–3. [2] Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol 2002;33:459–65. [3] Suzuki T, Arai M, Matsumura T, et al. Factors associated with inadequate tissue yield in EUS-FNA for gastric SMT. ISRN Gastroenterol 2011.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/vjgien
INNOVATION FORUM AND EXPERIMENTAL ENDOSCOPY
Endoscopic Biopsy by Mucosal Incision for Upper Gastrointestinal Submucosal Tumors$, $$ Toru Okuzonon, Toshiyuki Mishima, Adel Badran, Hiroyuki Mizuno, Yusuke Miyashita, Hidetaka Hamamoto, Shun Sato, Naoto Miyake, Masato Nakahori, Akimichi Chonan Digestive Endoscopic Center, Sendai Kosei Hospital, Hirosemachi 4-15, Aoba Ward, Sendai City, Miyagi Prefecture, Japan Received 24 May 2013; received in revised form 18 July 2013; accepted 10 August 2013
KEYWORDS
Abstract
Submucosal tumor (SMT); Gastrointestinal stromal tumor (GIST); Leiomyoma; Schwannoma; Endoscopic biopsy by mucosal incision (EBM); EUS-FNA; Video
Histological diagnosis of upper gastrointestinal submucosal tumors (SMT) is a prerequisite for selecting the proper therapeutic approach. EUS-FNA has improved the evaluation of SMT. Endoscopic biopsy by mucosal incision (EBM) is a diagnostic procedure developed by Yokohata et al. The principal aim of this study was to examine the potential of EBM, as an alternative to the more expensive and technically-demanding EUS-FNA, in diagnosing SMT. This retrospective study included a consecutive series of 27 patients (15 males and 12 females, mean age 60.1 years) undergoing EBM and 11 patients (7 males and 4 females, mean age 65.7 years) undergoing EUS-FNA. The tumors had diameters of 15 mm or more, and were suspicious for continuity with the fourth layer as determined by EUS. We compared the diagnostic accuracy and the operating time of EBM with those of EUS-FNA. Results: The diagnostic accuracies of EBM and EUS-FNA were 85.2% (23/27) and 90.0% (9/10) respectively. The average operating time of EBM and EUS-FNA was 20 min and 41.0 min respectively. During our investigation no major complications were encountered in either group. Conclusion: EBM matches EUS-FNA in diagnostic accuracy of SMT and is more time and costefficient. & 2013 The Authors. Published by Elsevier GmbH. All rights reserved.
☆ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. ☆☆ The terms of this license also apply to the corresponding video. n Corresponding author. Tel.: +81 22 222 6181. E-mail address: [email protected] (T. Okuzono).
2212-0971/$ - see front matter & 2013 The Authors. Published by Elsevier GmbH. All rights reserved. http://dx.doi.org/10.1016/j.vjgien.2013.08.002
Endoscopic Biopsy by Mucosal Incision
Video related to this article Video related to this article can be found online at http:// dx.doi.org/10.1016/j.vjgien.2013.08.002.
1.
2. Strengths and limitations of standard procedure/device EUS-FNA allows for a safe and precise pre-operative diagnosis of SMT. However, EUS-FNA approach is expensive and technically-demanding. The factors restrict the application to a limited number of medical centers.
3. Potential benefit of the proposed procedure/device
Direct-observation biopsy with mucosal cutting (EBM)
4.
was developed to obtain specimens from gastrointestinal submucosal tumors with ordinary biopsy forceps. EBM does not require convex or linear EUS devices, only ESD devices are employed rendering EBM a practical and cost-efficient choice. The time required for EBM is much shorter compared to EUS-FNAB. Furthermore, the diagnostic accuracy of EBM matches that of EUS-FNA.
Materials
Endoscope; GIF-2TQ260M (Olympus) for gastrointestinal ESD.
Tip knife; Needle Knife (KD-1L-1; Olympus), Flash Knife (DK2618JN20; Fujifilm).
Biopsy forceps; EndJaw (FB-220K; Olympus). Hemostatic forceps; Coagulaspar (FD-410LR; Olympus).
5.
Endoscopic procedure
The mucosa is incised using a tip knife without saline
We usually obtain 3 or more tissue samples in the same
Background
The development of several endoscopic techniques, including EUS-FNA, has improved the evaluation of submucosal tumor (SMT) and led to reach a more precise preoperative diagnosis of SMT. However, EUS-FNA approach is expensive and technically-demanding. To this end, a more feasible, yet reliable, alternative is desired.
645
injection. (In the original method, direct-observation biopsy by mucosal cutting developed by Yokohata et al. [1], the mucosa is incised after infusing saline into the top of SMT.). We continue to incise the submucosa until we reach the SMT. We obtain the tissue specimens using needle fenestrated biopsy forceps with alligator cup (EndJaw; Olympus). This technique allows enough tissue to be sampled.
6.
session since the initial specimens are usually denatured by cauterization during the incision process. In the process, be careful with possible bleeding! If bleeding occurs, try to stop it with tip knife coagulation or hemostatic forceps (Coagulaspar; Olympus). Occasionally, it could be difficult to control the bleeding by coagulation, in which case we finally resort to clipping forceps.
Discussion
In this study we compared the duration and diagnostic accuracy of EBM and EUS-FNA in evaluating SMT. The average number of biopsy specimens obtained from EBM and EUS-FNA were 6.0 and 4.2 respectively. The accuracies of post-procedural histological examinations for EBM and EUS-FNA were 85.2% (23/27) and 90.0% (9/10) respectively. The average operating time of EBM and EUS-FNA was 20.0 min and 35.0 min respectively. The biopsy results were as follows; EBM: GIST, 18 patients; leiomyoma, 5 patients; lymphocytic infiltration, 1 patient; and unspecified tissue, 3 patients. EUS-FNA: GIST, 9 patients; unobtainable, 1 patient. Postoperative diagnoses of 18 patients who underwent EBM were as follows: GIST, 17 patients; and Shwannoma, one patient. In 14 patients who were diagnosed as GIST before and after the operation, the concordance of Fletcher Risk Table [2] was 100%. For EBM, intra-procedural bleeding was encountered in 7 patients (25.9%); while in EUS group no bleeding occurred (0%). The bleeding of EBM was stopped by coagulation or clipping forceps. No patients had secondary hemorrhage or perforation in both EBM and EUS-FNA. EBM requires neither convex nor linear EUS, and only ESD devices are being employed in the process. While many medical centers in Japan are equipped with ESD devices, the use of interventional EUS is still limited to a few numbers of medical centers owing to the aforementioned reasons. Therefore, EBM can prove convenient as a practical, time and cost-efficient alternative to EUS-FNA in terms of SMT diagnosis and evaluation. In implementing EUS-FNA there are limitations concerning the anatomical location of SMT. It is difficult to obtain adequate tissue samples from SMT located at the lower body of stomach by EUS-FNA [3]. On the other hand, almost all gastric SMT, regardless of their anatomical site, can be accessed with EBM giving another advantage for EBM over EUS-FNA. Nevertheless, EBM should only be avoided in case of outward-growing SMT for fear of possible perforation. During our investigation no major complications were encountered in either group. However, for EBM care should be taken in case bleeding occurred. Since the source of bleeding is a tumor, it is rather difficult to identify the bleeder and consequently controlling the bleeding could be time-consuming. In our hands, the diagnostic accuracy of EBM was comparable to that of EUS-FNA. The risk of dissemination has not been tackled in this study. However, it should be comparable to that of ordinary upper gastrointestinal biopsy.
646
T. Okuzono et al.
The reasons why diagnoses by EBM could not be made in some patients were as follows: (1) In case of Schwannoma, despite almost complete exposure of the tumor, only capsular specimens could be obtained while subcapsular tissue could not be reached. (2) The identity of some of the specimens could not be determined because of thermal denaturation during ablation. (3) In few cases, sufficient quantities of tissue could not be obtained due to intraoperative bleeding.
Based on the findings of our study we consider EBM to be a feasible and reliable alternative to EUS-FNA being rapid, safe and accurate with only few limitations.
7.
Take-home messages
Endoscopic biopsy by mucosal incision (EBM) is an
accurate, time and cost-efficient procedure for diagnosing upper gastrointestinal submucosal tumors. EBM matches EUS-FNA in diagnostic accuracy of SMT, and has an edge over EUS-FNA in terms of time and cost benefits. The only potential complication of EBM is intraprocedural bleeding that may occasionally interfere with proper sampling of SMT lesions.
Voiceover Text Endoscopic biopsy by mucosal incision for upper gastrointestinal submucosal tumors. The mucosa is incised using a needle knife without saline injection. We continue to incise the submucosa until we reach the SMT. We obtain the tissues using needle fenestrated biopsy forceps with alligator cup. In the process, be careful with possible bleeding! If bleeding occurs, try to stop it with tip knife coagulation or hemostatic forceps. Occasionally, it could be difficult to control the bleeding by coagulation. In which case we finally resort to clipping forceps. Endoscopic biopsy by mucosal incision (EBM) is an accurate, time and cost-efficient procedure for diagnosing upper gastrointestinal submucosal tumors. EBM matches EUSFNA in diagnostic accuracy of SMTs, and has an edge over EUS-FNA in terms of time and cost benefits. The only potential complication of EBM is intra-procedural bleeding that may occasionally interfere with proper sampling of SMT lesions.
Conflict of interest Authors declare no potential conflicts of interest.
8.
Scripted voiceover
Voiceover Text The development of several endoscopic techniques, including EUS-FNA, has improved the evaluation of Submucosal tumor and led to reach a more precise preoperative diagnosis of SMT. However, EUS-FNA approach is expensive and technically-demanding. To this end, a more feasible, yet reliable, alternative is desired. Endoscopic biopsy by mucosal incision is a time and costefficient candidate for accurate diagnosis of SMT. We propose Endoscopic biopsy by mucosal incision (EBM)for diagnosing upper gastrointestinal submucosal tumors.
References [1] Yokohata Norisuke, Tamegai Yoshihiro, Tokuhara Makoto, et al. 3 Cases of gastric SMT(submucosal tumor) which was diagnoced before operation -open biopsy with ESD (endoscopic submucosal dissection) for interstind SMT. Prog Dig Endosc 2007;70:82–3. [2] Fletcher CD, Berman JJ, Corless C, Gorstein F, Lasota J, Longley BJ, et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol 2002;33:459–65. [3] Suzuki T, Arai M, Matsumura T, et al. Factors associated with inadequate tissue yield in EUS-FNA for gastric SMT. ISRN Gastroenterol 2011.