Editorial
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Dec 10, 2015; 7(18): 1262-1267
Published online Dec 10, 2015. doi: 10.4253/wjge.v7.i18.1262
Opinion: How to manage subepithelial lesions of the upper gastrointestinal tract?
Matheus Cavalcante Franco, Ricardo Teles Schulz, Fauze Maluf-Filho
Matheus Cavalcante Franco, Ricardo Teles Schulz, Fauze Maluf-Filho, Digestive Endoscopy Unit, Cancer Institute of São Paulo University, São Paulo 05612-000, Brazil
Author contributions: Franco MC, Schulz RT and Maluf-Filho F performed the research, wrote the article, and did a critical revision of the article for important intellectual content.
Conflict-of-interest statement: The authors have no conflict of interests.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Fauze Maluf-Filho, MD, PhD, Director, Digestive Endoscopy Unit, Cancer Institute of São Paulo University, R. Olegario Mariano, 488, São Paulo 05612-000, Brazil. fauze.maluf@terra.com.br
Telephone: +55-11-38847599 Fax: +55-11-38932296
Received: May 28, 2015
Peer-review started: May 28, 2015
First decision: August 25, 2015
Revised: September 28, 2015
Accepted: November 10, 2015
Article in press: November 11, 2015
Published online: December 10, 2015
Processing time: 193 Days and 0.6 Hours
Abstract

Subepithelial lesions (SELs) in the upper gastrointestinal (GI) tract are relatively frequent findings in patients undergoing an upper GI endoscopy. These tumors, which are located below the epithelium and out of reach of conventional biopsy forceps, may pose a diagnostic challenge for the gastroenterologist, especially when SELs are indeterminate after endoscopy and endoscopic ultrasound (EUS). The decision to proceed with further investigation should take into consideration the size, location in the GI tract, and EUS features of SELs. Gastrointestinal stromal tumor (GIST) is an example of an SEL that has a well-recognized malignant potential. Unfortunately, EUS is not able to absolutely differentiate GISTs from other benign hypoechoic lesions from the fourth layer, such as leiomyomas. Therefore, EUS-guided fine needle aspiration (EUS-FNA) is an important tool for correct diagnosis of SELs. However, small lesions (size < 2 cm) have a poor diagnostic yield with EUS-FNA. Moreover, studies with EUS-core biopsy needles did not report higher rates of histologic and diagnostic yields when compared with EUS-FNA. The limited diagnostic yield of EUS-FNA and EUS-core biopsies of SELs has led to the development of more invasive endoscopic techniques for tissue acquisition. There are initial studies showing good results for tissue biopsy or resection of SELs with endoscopic submucosal dissection, suck-ligate-unroof-biopsy, and submucosal tunneling endoscopic resection.

Keywords: Gastrointestinal neoplasm; Gastrointestinal endoscopy; Endoscopic ultrasound-guided fine needle aspiration; Endosonography; Gastrointestinal stromal tumors

Core tip: Subepithelial lesions (SELs) of the upper gastrointestinal tract include a broader differential diagnosis, which can range from non-malignant tumors to lesions with malignant potential such as gastrointestinal stromal tumors. The possibility of having a potentially malignant lesion may bring anxiety and discomfort to patients and doctors. Further investigation should be carried out for patients with high-risk lesions after risk stratification. This editorial presents the current evidence about the diagnostic management of SELs.