Intestinal subepithelial lesions are often encountered during endoscopy. Etiologies can include lesions intrinsic or extrinsic to the gastrointestinal wall. They can present a diagnostic dilemma as simple mucosal biopsies are often nondiagnostic. The combination of characteristic radiographic, endoscopic, and endosonographic features can aid in a definitive diagnosis precluding the need for unnecessary tissue sampling of extrinsic compressive etiologies. The location of the space of Retzius which is the traditional site of penile prosthetic pump reservoir insertion can predispose to cecal compression. We present a rare case of a penile prosthetic pump reservoir presenting as a cecal subepithelial mass on endoscopy.

UNASSIGNED: For gastric subepithelial lesions (GSELs) showing a hypoechoic mass (HM) on endoscopic ultrasonography (EUS) imaging, the utility of EUS-guided tissue acquisition using conventional fine-needle aspiration needles (EUS-TA-CFNAN) and the frequency of histological types remain unclear. This study aimed to examine this issue.
UNASSIGNED: This prospective observational study enrolled 291 consecutive patients who underwent EUS-TA-CFNAN for GSELs showing an HM (GSELHM) on EUS imaging. Immunohistochemical analysis was performed for all EUS-TA-CFNAN and surgically resected specimens. The main outcome measures were the technical results of EUS-TA-CFNAN and the frequency of histological types in GSELHM.
UNASSIGNED: The endoscopic ultrasound-guided tissue acquisition using conventional fine-needle aspiration needle diagnosis rate for GSELHM was 80.1% (95% confidence interval [CI]: 75.0-84.5, 233/291). It was significantly lower for antrum (P = 0.004) and lesions smaller than 2 cm (P = 0.003). There were no adverse events. The immunohistochemical diagnoses of EUS-TA-CFNAN included 149 cases of gastrointestinal stromal tumour (GIST) (51.2%), 48 cases of leiomyoma (16.5%), 11 cases of schwannoma (3.8%), 8 cases of the ectopic pancreas (2.7%), 5 cases of subepithelial lesion like cancer (1.7%), 12 cases of other lesions (4.1%), and 58 cases of undiagnosable lesions (19.9%). The frequency of malignant or potentially malignant tumour in GSELHM was 55.0% (95% CI: 49.1-60.8, 160/291). Surgery was performed in 149 patients according to the conclusive EUS-TA-CFNAN results, in which the diagnostic accuracy of EUS-TA-CFNAN was 97.3% (95% CI: 94.7-99.9, 145/149).
UNASSIGNED: The use of EUS-TA-CFNAN for GSELHMs is safe and accurate. Gastric subepithelial lesions showing a hypoechoic mass have a reasonably high possibility of containing malignant or potentially malignant tumours, including GISTs.

An 81-year-old woman who underwent laparoscopic-assisted low anterior resection with instrumented anastomosis using the double stapling technique for rectal cancer 5 years ago was found to have an enlarged anastomotic mass on computed tomography. On colonoscopy, the anastomotic mass was observed as a 30-mm-sized subepithelial lesion, which was presumed to be the submucosa on endoscopic ultrasonography (EUS). EUS-guided fine-needle aspiration was performed; however, no cellular components were collected. Therefore, endoscopic submucosal dissection (ESD) was performed to remove the entire anastomotic mass. However, any lesion in the submucosa was not detected during ESD, and the lesion was suspected to be located deeper than the submucosa. Therefore, EUS was performed from the muscule layer just below the dissected submucosa, and the mass was detected outside the muscle layer in contact with the rectal wall. Upon endoscopic incision of the muscle layer, milky white mucus was excreted into the rectal lumen. Subsequently, the scope was advanced to an area outside the muscle layer where the mass was located, which was a closed lumen with mucus retention. Surface biopsy of the closed lumen revealed normal colonic mucosa. Therefore, the subepithelial lesion was diagnosed as an implantation cyst arising outside the rectal wall.

UNASSIGNED: This pilot study aimed to evaluate safety and tissue sampling from subepithelial lesions (SEL) in the upper gastrointestinal tract with a novel electric motor driven endoscopic ultrasonography (EUS)-guided 17-gauge (G) size core needle biopsy (CNB) instrument.
UNASSIGNED: An investigator-led prospective open label, performance and safety control study, including seven patients (female n = 4, median 71 y, range 28-75) with a determined SEL (median size 30 mm, range 17-150 mm) in the upper digestive tract (stomach n = 6, duodenum n = 1) were eligible and later followed up 14 days after index procedure. All investigations were completed according to protocol with three FNB 22-G passes with four fanning strokes and two EndoDrill® 17-G passes with three fanning strokes.
UNASSIGNED: Quality of samples as \'visible pieces\' (>5 mm): FNB (n = 5/7) (fragmented/blood imbibed n = 1, poor tissue quantity n = 1) compared with 17-G CNB (n = 7/7). Histological result which led to final diagnosis (leiomyoma n = 2, adenocarcinoma n = 1, schwannoma n = 1, neuroendocrine tumour n = 1, desmoid tumour n = 1 and gastrointestinal stromal tumour (GIST) n = 1) could be obtained with the 17-G CNB instrument in all seven patients. FNB technique reached correct diagnosis in six patients. No serious adverse event were recorded.
UNASSIGNED: By using an electric driven 17-G biopsy device, a true cylinder of core tissue can be obtained in one single puncture from the area of interest reducing the need for a second sampling. The absolute benefit of EUS-guided CNB is that the sample can be handled and histologically prepared in the same manner as standard percutaneous core needle sample, e.g., breast and prostate cancer.

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Endoscopic ultrasound is a minimally invasive modality that combines endoscopy with ultrasound, providing a possibility to visualize the wall of the gastrointestinal tract and adjacent tissues and organs. Since the development of the modality in the 1980s, advancements in endoscopic ultrasound technology have led to increasingly broadening indications: besides diagnostic indications, therapeutic indications have also expanded greatly. According to recent guidelines regarding rectal cancer staging, rectal ultrasonography is mainly considered to be a secondary imaging modality compared to magnetic resonance imaging. With the use of forward-viewing echoendoscopes and ultrasound miniprobes that can be inserted through the working channel of the endoscope, endoscopic ultrasound technology can be expanded to proximal, colonic areas as well. Rectal ultrasonography can also play an important role in the differential diagnosis of subepithelial lesions, in the detection of rectal varices, in the diagnosis of inflammatory bowel diseases as well as perianal complications. Diagnostic accuracy can further be improved with the addition of ultrasound-guided sampling in certain cases. Currently, therapeutic indications are more like promising possibilities, than part of everyday clinical practice, but this might change in the near future. The purpose of this review is to summarize the current indications of rectal ultrasound in the clinical practice, including diagnostic and therapeutic ones as well. Orv Hetil. 2023; 164(30): 1176-1186.
Az endoszkópiát és az ultrahangtechnikát ötvöző, a tápcsatorna falának és a környező szerveknek és szöveteknek a vizualizálására minimálisan invazív módon alkalmas endoszkópos ultrahangvizsgálat az 1980-as évekbeli kifejlesztése óta jelentős technikai fejlesztéseken esett át. Ezáltal a vizsgálat indikációs köre folyamatosan bővül, így a diagnosztikus indikációk mellett már terápiás beavatkozásokra is lehetőséget biztosíthat. A rectumtumorok stádiummeghatározásában a legfrissebb ajánlások alapján a rectalis ultrahangvizsgálat – néhány speciális esettől eltekintve – elsősorban másodvonalbeli, kiegészítő modalitásként jön szóba a mágneses rezonanciás képalkotás mellett. Előretekintő echoendoszkópok és a munkacsatornán bevezethető ultrahangos miniszondák alkalmazásával a proximálisabb vastagbél területére is kiterjeszthető az endoszkópos ultrahangvizsgálat alkalmazása. A rectalis vizsgálat emellett a subepithelialis laesiók differenciáldiagnosztikájában, a rectalis varixok azonosításában, valamint a gyulladásos bélbetegségek és a perianalis szövődmények diagnosztikájában is fontos szerepet játszhat. Az eljárás diagnosztikus pontossága bizonyos esetekben ultrahangvezérelt mintavétellel növelhető. A rectalis ultrahangvizsgálat terápiás alkalmazási területei egyelőre inkább ígéretes lehetőségek, mintsem a bevett klinikai gyakorlat részei, a jövőben azonban várhatóan egyre nagyobb teret nyerhetnek. A jelen összefoglaló célja az alsó tápcsatornai ultrahangvizsgálattal kapcsolatos általános ismeretek bemutatása mellett a vizsgálat indikációs körének áttekintése, beleértve a diagnosztikus és a terápiás indikációkat is. Orv Hetil. 2023; 164(30): 1176–1186.

Duodenal neuroendocrine tumors (NETs) are rare subepithelial tumors that arise from the neuroendocrine cells beneath the epithelial layer. However, an accurate histopathological diagnosis is difficult when tissue samples are obtained using conventional endoscopic forceps biopsy alone. This study aimed to evaluate the magnifying endoscopy with narrow-band imaging (ME-NBI) findings of duodenal NETs. We retrospectively analyzed a database of 22 duodenal NETs from 21 patients who underwent ME-NBI between January 2011 and June 2022. The ME-NBI, endosonographic, and histopathologic findings of duodenal NETs were analyzed. Nineteen lesions were located in the bulb, two were located in the superior duodenal angle, and one was located in the second portion of the duodenum. Eighteen lesions (82%) had IIa morphology, and nine (41%) had central depression on the surface. On endoscopic ultrasonography, almost all lesions (20/22, 91%) were located in the second and/or third layers, and the median tumor size was 6 mm. During ME-NBI, the microsurface pattern was regular in 18 lesions (82%) and absent in 4 (18%). The microvascular pattern was regular in 17 lesions (77%), irregular in 4 (18%), and absent in 1 (5%). Thickened subepithelial vessels were observed in 15 (68%) lesions. There was no difference in tumor size according to the presence or absence of thickened subepithelial vessels (6.1 ± 1.8 mm vs. 5.9 ± 3.8 mm, p = 0.860). In conclusion, the characteristic ME-NBI findings of duodenal NETs were regular microsurface and microvascular patterns and the presence of thickened subepithelial vessels. These ME-NBI features may be useful for differentiating duodenal NETs from other duodenal subepithelial lesions.

BACKGROUND: Endoscopic ultrasonography (EUS) is recommended as the best tool for evaluating gastric subepithelial lesions (SELs); nonetheless, it has difficulty distinguishing gastrointestinal stromal tumors (GISTs) from leiomyomas and schwannomas. GISTs have malignant potential, whereas leiomyomas and schwannomas are considered benign.
OBJECTIVE: This study aimed to establish a combined radiomic model based on EUS images for distinguishing GISTs from leiomyomas and schwannomas in the stomach.
METHODS: EUS images of pathologically confirmed GISTs, leiomyomas, and schwannomas were collected from five centers. Gastric SELs were divided into training and testing datasets based on random split-sample method (7:3). Radiomic features were extracted from the tumor and muscularis propria regions. Principal component analysis, least absolute shrinkage, and selection operator were used for feature selection. Support vector machine was used to construct radiomic models. Two radiomic models were built: the conventional radiomic model included tumor features alone, whereas the combined radiomic model incorporated features from the tumor and muscularis propria regions.
RESULTS: A total of 3933 EUS images from 485 cases were included. For the differential diagnosis of GISTs from leiomyomas and schwannomas, the accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve were 74.5%, 72.2%, 78.7%, and 0.754, respectively, for the EUS experts; 76.8%, 74.4%, 81.0%, and 0.830, respectively, for the conventional radiomic model; and 90.9%, 91.0%, 90.6%, and 0.953, respectively, for the combined radiomic model. For gastric SELs <20 mm, the accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve of the combined radiomic model were 91.4%, 91.6%, 91.1%, and 0.960, respectively.
CONCLUSIONS: We developed and validated a combined radiomic model to distinguish gastric GISTs from leiomyomas and schwannomas. The combined radiomic model showed better diagnostic performance than the conventional radiomic model and could assist EUS experts in non-invasively diagnosing gastric SELs, particularly gastric SELs <20 mm.