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 Table of Contents  
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 151-152

EUS-guided fine-needle biopsy for gastric submucosal tumors: Does one size fit all?

1 Department of Medical and Surgical Sciences, University of Bologna Faculty of Medicine and Surgery, University of Bologna, Bologna, Italy
2 Department of Gastroenterology, Endoscopic Unit, IRCCS Humanitas Research Hospital, Milan, Italy
3 Gastrointestinal Unit, Hospital of Imola, University of Bologna, Bologna, Italy

Date of Submission11-Apr-2021
Date of Acceptance13-Jul-2021
Date of Web Publication08-Nov-2021

Correspondence Address:
Fabio Cortellini
University of Bologna, University of Bologna Faculty of Medicine and Surgery, Bologna
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00095

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How to cite this article:
Cortellini F, Carrara S, Fusaroli P. EUS-guided fine-needle biopsy for gastric submucosal tumors: Does one size fit all?. Endosc Ultrasound 2022;11:151-2

How to cite this URL:
Cortellini F, Carrara S, Fusaroli P. EUS-guided fine-needle biopsy for gastric submucosal tumors: Does one size fit all?. Endosc Ultrasound [serial online] 2022 [cited 2022 Jul 2];11:151-2. Available from: http://www.eusjournal.com/text.asp?2022/11/2/151/329905

Dear Editor,

We read with interest the article by Kamata et al.[1] on the usefulness of a 20G needle with a core trap for EUS-guided fine-needle biopsy (FNB) for gastric submucosal tumors (SMTs). This was a multicentre prospective study on (I) technical success rate, (II) adequacy for histologic evaluation, (III) rate of complications, (IV) accuracy for histological diagnosis of gastric SMTs, and (V) concordance between gastrointestinal stromal tumors (GISTs) mitotic index determined by EUS-FNB and after tumor resection. The results were good to excellent: (I) 100%, (II) 90.4%, (III) 0%, (IV) 81.6%, and (V) 89.7%.

The authors concluded that EUS-FNB using a 20G needle with a core trap is technically feasible and provides histological specimens of sufficient quality for the diagnosis of gastric SMTs.

Gastric SMTs detected by endoscopy can be either benign not requiring further interventions (leiomyomas, ectopic pancreas, schwannomas), or bear malignant potential (GISTs). While symptomatic GISTs should be resected, there is no consensus about asymptomatic ones. Based on the size and EUS features of the lesions, management includes either endoscopic/surgical resection or EUS surveillance to monitor for suspicious changes.[2]

Growth during follow-up and tumor ulceration is sufficient to refer the lesion to the surgeon without the need of a biopsy.[3] Heterogeneity of the internal echoes and/or irregular margins may be additional imaging features that suggest a malignant potential. According to the latest guidelines, in case of suspected GISTs that may need neoadjuvant therapy before surgery, histological diagnosis is always warranted.[3] Unfortunately, Kamata et al. did not mention whether some patients underwent neoadjuvant therapy before surgical resection.

Moreover, the authors underlined the importance of performing EUS-FNB even for gastric SMTs <2 cm. It appears that EUS features were not taken into account to gauge the decision whether to perform EUS-FNB or not. While this strategy could be beneficial in detecting those benign SMTs not requiring further follow-up, on the other hand, internal growth is observed in <5% of GISTs,[4] suggesting a malignant behavior only in rare cases. Therefore, EUS-FNB for small GISTs, irrespective of imaging features or performed outside clinical studies, could be interpreted as overtreatment.

Another study published in this journal by the same authors enrolling a larger number of patients (157 vs. 52 in the present study) showed that contrast-enhanced harmonic EUS could help in defining the SMTs nature. The hyper-enhanced pattern of the SMTs predicted GISTs with an 82.2% diagnostic accuracy,[5] which is comparable to the accuracy obtained by the histological assessment with EUS-FNB in the present study (81.6%).

In our opinion, the management of patients with SMTs should be as less invasive as possible and based on a cost/benefit ratio. Since EUS-FNB is more invasive and expensive compared to EUS with CH-EUS, imaging follow-up is still a valid option for gastric SMTs with benign features. Instead, it should always be pursued in those gastric SMTs showing either indeterminate features or suspicion of GISTs requiring neoadjuvant therapy. The authors should be commended in demonstrating that a 20 G EUS-FNB core trap needle is a useful tool to select the optimal management on an individual basis.

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Conflicts of interest

Pietro Fusaroli is a senior associate editor of the journal. The article was subject to the journal's standard procedures, with peer review handled independently of this editor and his research groups.

  References Top

Kamata K, Kurita A, Yasukawa S, et al. Utility of a 20G needle with a core trap in EUS-guided fine-needle biopsy for gastric submucosal tumors: A multicentric prospective trial. Endosc Ultrasound 2021;10:134-40.  Back to cited text no. 1
Standards of Practice Committee, Faulx AL, Kothari S, Acosta RD, et al. The role of endoscopy in subepithelial lesions of the GI tract. Gastrointest Endosc 2017;85:1117-32.  Back to cited text no. 2
Nishida T, Hirota S, Yanagisawa A, et al. Clinical practice guidelines for gastrointestinal stromal tumor (GIST) in Japan: English version. Int J Clin Oncol 2008;13:416-30.  Back to cited text no. 3
Catena F, Di Battista M, Ansaloni L, et al. Microscopic margins of resection influence primary gastrointestinal stromal tumor survival. Onkologie 2012;35:645-8.  Back to cited text no. 4
Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of submucosal tumors of the upper gastrointestinal tract. J Gastroenterol Hepatol 2017;32:1686-92.  Back to cited text no. 5


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