Accepted Article DR.

MITSUHIRO KIDA (Orcid ID : 0000-0003-2420-1176)

Received Date : 15-Dec-2016

Revised Date : 19-Feb-2017

Accepted Date : 27-Feb-2017

Article type : Review

EUS diagnosis of Subepithelial lesions

Dept. of Gastroenterology, Kitasato University

Mitsuhiro KIDA, Yusuke Kawaguchi, Eiji Miyata, Rikiya Hasegawa, Toru Kaneko,

Hiroshi Yamauchi, Shuko Koizumi, Kosuke Okuwaki, Shiro Miyazawa, Tomohisa

Iwai, Hidehiko Kikuchi, Maya, Watanabe, Hiroshi Imaizumi, Wasaburo Koizumi

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which
may lead to differences between this version and the Version of Record. Please cite this
article as doi: 10.1111/den.12854

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Accepted Article
Corresponding author: Mitsuhiro KIDA

Dept. of Gastroenterology, Kitasato University

1-15-1 Kitasato, Minami-ward, Sagamihara, Kanagawa,

252-0374, Japan

E-mail: m-kida@kitasato-u.ac.jp

Key words: Endoscopic ultrasonography

Subepithelial lesions

EUS-FNA

Abstract

Using EUS, it is practicable to diagnose Subepithelial lesions (SEL) with

originating layer, echo level, and internal echo pattern etc. Lipoma, lymphangioma,

and cyst have characteristic features, therefore they have no need for EUS-FNA.

Ectopic pancreases and glomus tumors, which are originated from 3rd and 4th layer,

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Accepted Article
are frequently seen in the antrum. Although ectopic pancreases located in the

fundus or body are large and originated from 3rd and 4th layer (thickening of 4th

layer). Each Subepithelial lesions has each characteristic finding. However,

imaging differentiation of tumors originated from 4th layer is very difficult, even if

contrast echo is employed. Therefore EUS-FNA should be done in those tumor, but

the diagnostic yield for small lesions is not enough for clinical demands. Generally,

those tumors including small ones should be firstly followed up in 6 months, then

yearly follow up in case of no significant change in size and features. When

those tumors become more than 1-2cm, EUS-FNA is recommended. Furthermore,

unusual SELs and SELs with malignant findings such as nodular, heterogeneous,

anechoic area, and ulceration should be indicated EUS-FNA. Cap attached

forward-viewing echoendoscope is very helpful for EUS-FNA of small SELs.

1, Introduction

Endoscopic ultrasonography (EUS) is the diagnostic examination based on cross

sectional imaging, which is different from conventional endoscopy. After Aibe et al

reported 5-layer structure of gastrointestinal wall corresponding to each layer in

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Accepted Article
1984 (1), it has become practicable to diagnose the gastrointestinal cancer invasion,

and Subepithelial lesions etc. Furthermore, Vilmann et al reported the first case of

EUS-guided fine needle aspiration cytology/ biopsy (EUS-FNA) in 1992 (2), EUS,

EUS-FNA have widened their applications and become an indispensable

examination in the clinical fields.

2, Imaging diagnosis of Subepithelial lesions by originating layer (Figure 1, 2)

Gastrointestinal wall is detected as a 5-layer structure with lower frequency

(7.5-12 MHz) and a 9-layer structure with higher frequency (12-20MHz) (Figure 1).

Then using EUS, it has become possible to diagnosis Subepithelial lesions by

evaluating its originating layer, its echo level, and its internal echo pattern etc.

Lipomas, Lymphangiomas, fibromas etc. are originated from 3rd layer and

gastrointestinal stromal tumors (GIST), leiomyomas, and schwannomas from 4th

layer (Figure 2). Ectopic pancreases are basically originated from 3rd layer, however

there are two types such as shallow type and deep type. Shallow type generally is

small and locates in the antrum, on the other hand deep type which is originated

from 3rd and 4th layer, is generally large, and locates in the middle and upper part of

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Accepted Article
the stomach. Furthermore, Glomus tumors are mainly originated from 4th layer and

sometimes 4th and 3rd layer, and granular cell tumors are mainly originated from 2nd

layer and sometimes 2nd and 3rd layer, especially in the stomach and colon.

Metastatic tumors are generally originated from 3rd layer and multiple lesions with

central depression or ulceration.

3, Imaging diagnosis of Subepithelial lesions by echo level (Figure 3)

Concerning about the echo level of SELs, Lipoma is revealed as a hyperechoic

tumor, and on the other hand lymphangioma and cyst is detected as an anechoic

tumor (Figure 3). Neuroendocrine tumor (NET, called Carcinoid tumor in former

era), and gastrinoma, malignant lymphoma is revealed as a hypoechoic tumor.

Brunnerioma, Ectopic pancreas, GIST, leiomyoma, and schwannoma etc. is detected

as a slightly hypoechoic – hypoechoic tumor.

4, Imaging diagnosis of Subepithelial lesions by internal echo pattern

Concerning about the internal echo pattern, most of SELs are revealed as solid

pattern tumors, however cyst and lymphangioma are revealed cystic pattern tumor.

Lymphangiomas have septum whereas cysts have generally no septum.

Furthermore, ectopic pancreases, brunneriomas, and hamartomas have sometimes

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cystic components, however these tumors have solid components even they are

small. Schirrhous type gastric cancer and amyloidosis is basically not Subepithelial

lesion and detected as the thickening of gastrointestinal wall with

unwell-demarcated contour.

5, Each Subepithelial lesion

A, GIST (Figure 4)

GISTs are the most commonly identified mesenchymal tumors in the stomach

and have malignant potential. GISTs arise from the interstitial cells of Cajal and

can be identified using immunohistochemical staining C-kit (CD117) and CD34 etc.

GISTs have occupied 70-90 % of SELs originated from 4th layer of the stomach (3,4).

GISTs located 46.4%-58% in the body, 21- 33.3% in the fundus, 13-18.9% in the

antrum, and 1.4-8% in the cardia (3,4). According to the NCCN (national

comprehensive cancer network) guideline, GISTs should be always indicated

surgical operation. We have proposed malignant findings for SELs originated from

4th layer of the stomach in 1992 (5), which are ①more than 3cm, ②Nodular, ③
heterogeneous, ④anechoic area, ⑤ulceration. If some tumor has 3 or more

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findings, it suspected to be malignant (GIST) (5). Calcification is rarely seen in

GISTs (0-3.5%) (3,5). However, it is difficult to differentiate GIST from leiomyoma

and schwannoma by imaging diagnosis, although some reports concluded that

GISTs have hypervascular pattern by contrast echo, compared to leiomyomas and

schwannomas (6). Therefore, EUS-FNA or surgical operation is necessary to

diagnose GIST. Concerning about EUS-FNA, sampling rate and diagnostic accuracy

for SELs less than 2cm is not satisfied clinically. Generally, EUS-FNA has a

diagnostic yield of 40% to 50 % for lesions measuring up to 10mm and 60 to 70% for

11 to 30mm, with a lower diagnostic yield for small lesion (7), although good

diagnostic yield of EUS-FNA such as 81.5-87.5% are reported recently with

forward-viewing echoendoscope (I will mention in the last part) (8,9). EUS-FNB

using 22-guage needle obtains a high yield (85.7% - 86%) for the diagnosis of gastric

SELs ≧2cm (10,11). On the diagnosing GISTs, it is necessary to obtain those

histological specimens by EUS-FNA or surgery. Then immunohistochemical

staining such as C-kit (+), DOG1(+), CD34 (+), PDGFRA-mutations etc. can be

performed. Furthermore, Miettinen et al reported the long-term prognosis of GISTs

(12). Tumors <2cm did not metastasize if the number of mitoses was less than 5/50

HPFs. However, GISTs with a mitotic count greater than 6/50 HPFs showed high

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level of metastasis in all gastrointestinal tracts tumors, except for the stomach,

although Aso et al reported a rare case of gastric GIST smaller than 20 mm with

liver metastasis. Size of GISTs increased significantly during follow up,

furthermore the doubling time of high grade GISTs is 4.6 months, whereas that of

moderate -low grade GISTs is 14 months (14). In order to detect high grade GISTs,

we recommend follow up schedule at 6 months later, even if SELs which originated

from 4th layer are small. If the size and feature is not significantly changed, then

yearly follow up is recommended. When those tumors become more than 1-2cm,

EUS-FNA is recommended.

B, Leiomyoma (Figure 5)

Leiomyomas are benign tumors that arise from either the muscularis mucosae or

the muscularis propria. As mentioned before, leiomyoma looks like GIST, therefore

it is difficult to differentiate leiomyoma from GIST and schwannoma by imaging

diagnosis. leiomyomas have occupied 60-80% of SMTs originated from 4th layer of

the esophagus. In the stomach leiomyomas are seen 63.6-80 % near the

esophago-cardiac junction, 1.5-14.2% in the body, 1.5-2.9% in the antrum, and 0- 2.9

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% in the fundus (3,4). Leiomyomas sometimes (6.5-18%) have calcification, whereas

GISTs and schwannoma is rare (0-3.5% and 0-3.7%) (3,5,16). In order to diagnose

leiomyoma, it is necessary to evaluate by histology with Desmin (+), C-kit (-), and

CD34 (-). Therefore, EUS-FNA are recommended for SELs originated from 4th layer

more than 1-2cm in size, whereas smaller SELs are followed up, except for SELs

with malignant sign such as nodular, heterogeneous, anechoic area, and ulceration.

C, Schwannoma (Figure 6)

Schwannomas are very low malignant potential tumors of spindle cells that

originate from any nerve having a Schwan cell sheath such as Auerbach’s plexus or

less frequently, from Meissner’s plexus. As mentioned before, schwannomas look

like GIST, therefore it is also difficult to differentiate schwannoma from GIST and

leiomyoma by imaging diagnosis. Schwannomas have occupied 2-8.3% of the

stomach SELs. In the stomach schwannomas are seen 57-81% in the body, 7.4-40%

in the antrum, and 0-29.6% in the fundus (3,4,15,16). Calcification is rarely seen in

schwannomas (0-3.7%) (3,16). In order to diagnose schwannomas, it is necessary to

evaluate by histology with S100 (+), C-kit (-), and CD34 (-). EUS-FNA is also

indicated SELs same as leiomyomas.

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D, Ectopic pancreas (Figure 7, 8)

Ectopic pancreases are defined as pancreatic tissue with no anatomic or vascular

connection to the pancreas. Generally ectopic pancreases have no symptom, but

sometimes introduces gastrointestinal bleeding (17). Using EUS, there are two

types of ectopic pancreases such as shallow type and deep type. Ectopic pancreatic

tissue limited to the 3rd layer in shallow type and extended to 3rd and 4th layer.

Generally shallow type is small and exists in antral area, on the other hand deep

type is large and exists in middle and upper part of the stomach. In 1909, Heinrich

classified ectopic pancreas into 3 types such as Ⅰ, Ⅱ, Ⅲ; Heinrich Ⅰcontains all

components includes acinar cell, ductal structure, and islets of Langerhans, and is

generally large and exists in the middle and upper part of the stomach. Heinrich Ⅱ
contains incomplete or lobular arrangement and lacks endocrine components. And

Heinrich Ⅲ comprises ectopic tissue of proliferating ducts, exhibiting neither

acinar cells nor endocrine components(18). Therefore, ductal structures are

sometimes seen in ectopic pancreas. And ectopic pancreases rarely have cystic

components (less than 10%), although main part is consisted of solid components

(19). The common site of ectopic pancreas locates in the gastrointestinal tract:

stomach (especially in the antrum) (38%-26%), duodenum (28%-36%), and jejunum

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(16%) (3,4,18). Lesions have also been reported in the colon, spleen, gall bladder,

liver, Meckel’s diverticulum, bile duct, or fallopian tubes (11,19). Using

conventional endoscopy, typical ectopic pancreas is detected round or oval

Subepithelial lesion in the antrum with central dimpling (or umbilication) which

caused by the opening of a duct may be observed. Characteristic EUS features of

ectopic pancreas reveal unwell-demarcated contour, heterogeneous echogenicity,

and sometimes ductal structure and cystic components. Concerning about deep type

of ectopic pancreas, which is generally located in the middle or upper part of the

stomach and large, is originated from 3rd and 4th layer. We call “thickening of 4th

layer”, this finding is mostly characteristic for ectopic pancreas (Figure 8).

D, Lipoma (Figure 9)

Lipomas are benign tumors composed of mature lipocytes and are frequently seen

in the antrum of stomach, duodenum, and body of the stomach. On endoscopy,

lipomas usually present soft, solitary, not so high Subepithelial lesions with

yellowish color and cushion sign when pressed with biopsy forceps. Using EUS,

lipomas are originated from 3rd layer and hyperechoic SELs which are most

characteristic pattern, therefore it is not necessary to perform EUS-FNA.

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E, Neuroendocrine tumor (NET, carcinoid tumor) (Figure 10)

Nowadays NETs are classified into G1 (so called “carcinoid tumor” in former age),

G2, and G3 (so called neuroendocrine carcinoma; NEC) (20). NET is frequently

occurred in 40-50 years old, and sex ratio (M: F) is 2:1 (21). NET is often seen in the rectum,

duodenum, and stomach. On endoscopy, NETs present as small, round, sessile,

sometimes polypoid lesion with dilated vessels and occasional central depression or

ulceration. Generally, NETs can be diagnosed by endoscopic biopsy, whereas the

yield of mucosal biopsies from other SELs are usually low. Using EUS, NETs are

originated from 3rd and deep 2nd layer, and hypoechoic SEL. Rendi classified gastric

NET(G-NET) into 3 type; Type Ⅰ (70-80%): none metastatic, arose in a background of

body-fundus atrophic gastritis and hypergastrinemia, type Ⅱ (5-10%): locally metastatic,
were associated with hypertrophic gastropathy and hypergastrinemia due to multiple

endocrine neoplasia/ Zollinger-Ellison syndrome; and Type Ⅲ (10-15%): deeply invasive,

metastatic, and histologically atypical. All deeply invasive and metastatic, were composed of

anaplastic, small- to intermediate-sized cells with high mitotic index and focal necrosis (22).

Ⅰ
For Type and Ⅱ, G-NETs, according to the national comprehensive cancer network
(NCCN) guideline, management of Type Ⅰand Ⅱ, G-NETs are simple surveillance or
endoscopic resection (ER) for tumors that are smaller than 20 mm in size, and without

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invasion of muscularis propria or metastasis, regardless of tumor number. Surgical

resection, or ER is recommended for tumor that are greater than 20 mm in size, whether

single or multiple. Type Ⅲ, G-NET are recommended to manage in the same manner of
gastric carcinomas, except for tumors < 2cm can be considered endoscopic or wedge resection.

For duodenal -NETs (D-NETs) ENETS (European Neuroendocrine Tumor Society)

guidelines recommend G1 D-NETs ( ≦1cm) in nonampullar locations and without metastasis

or functional hormonal syndromes can be resected by endoscopic technique. However, if the

D-NETs are present in the ampullary region, local surgical resection with lymphadenectomy

or picking is recommended. D-NETs (1-2cm) is controversial, endoscopic resection or surgery.

D-NETs (>2cm) D-NETs of any size with lymph node involvement, should be treated by

limited surgical resection. However, the NCCN guidelines recommend endoscopic resection

for well localized D-NETs, whenever possible. In Japan, D-NETs less than 1cm are generally

treated by endoscopic technique, whereas D-NETs more than 1 cm in size are removed by

surgery.

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F, Gastrinoma (Figure 11)

Gastrinomas are one of neuroendocrine tumor, hypoechoic tumor, and originated

from 3rd layer of the duodenum, however these tumors have tendency to invade

deeper layer and have lymph node metastasis, and become advanced, even if they

are small. Gastrinomas are generally small, therefore it is also recommended to

perform endoscopic mucosal biopsy, instead of EUS-FNA.

G, Glomus tumor (Figure 12)

Glomus tumors are mesenchymal tumors originating from modified smooth

muscle cells of glomus body and occur frequently at extremities as subcutaneous

tumor with pain, but rarely in the stomach. The median age of patients with

Glomus tumors was 45 years old and sex ratio (M: F) is 1: 1.6. Fang reported that 61%

of patients complained of upper abdominal pain or fullness, 25% had bloody stool

and 14% were asymptomatic, and most (85%) of Glomus tumors exist in the antrum

as Subepithelial lesions sometimes with ulceration (23). Using EUS, Glomus tumor

is basically originated from 4th layer and sometimes connects with 3rd layer, various

patterns of echo level. Because Masson classified Glomus tumor into 4 types ; ①

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anigomatous form, ②epitheloid form, ③neurofibromatous form, ④degenerative
form, therefore it is generally isoechoic (slightly echogenic than echo level of proper

muscle layer) and homogeneous, but sometimes hypoechoic and heterogeneous.

Histological diagnosis depends on immunohistochemical staining such as α-SMA

(+), Vimentin (+), Laminin (+), CD34 (rarely), c-kit (-) (24). Most characteristic

finding is hypervascular pattern by contrast echo or CT.

H, Lymphangioma (Figure 13)

Lymphangiomas are rare benign tumors. Most frequently occurring in children

and involving the neck or axilla, these tumors are much less common in adults and

very rarely involve the abdominal organs. On endoscopy, lymphangiomas usually

present soft, solitary, not so high SELs with cushion sign when pressed with biopsy

forceps. Lymphangioma is cystic tumor which originates from 3rd layer and anechoic

- hypoechoic tumor with septum. However, lymphangioma has no solid components,

whereas ectopic pancreas and hamartoma have solid components. Furthermore,

lymphangioma sometimes extends to extra-stomach area.

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I, Hamartoma (Figure 14)

Hamartomas are originated from 3rd layer, and consists of solid and cystic

components. Therefore, it is sometimes difficult to differentiate hamartoma from

ectopic pancreas with cystic components. Furthermore, it is very difficult to

diagnose hamartoma, even if employed EUS-FNA. Because hamartoma is the

tumor, in which gastric mucosa gastric gland migrates into the submucosa, and

normal gastric mucosa is sampled by EUS-FNA, then diagnosed contamination.

J, Granular cell tumor (Figure 15)

Granular cell tumors are often seen in the esophagus, rarely in the stomach and

colon and are considered benign, and only small number of cases are malignant,

especially in the stomach. Endoscopically, granular cell tumors are generally small

(less than 20 mm in diameter), sessile SELs with a yellowish-white color and “molar

teeth appearance” especially in the esophagus. On EUS, they are detected as

hypoechoic, homogeneous lesions with well-demarcated margins arising from

mainly 2nd layer, sometimes from 2nd and 3rd layer, especially in the stomach and

colon.

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J, Bruunerioma (Figure 16)

Brunneriomas are neoplasms of Brunner gland and are most frequent SELs in

the duodenum, originated from 3rd layer of the duodenum and basically a

hypoechoic tumor, however sometimes have cystic components.

6, EUS-FNA

A, Indications

Concerning about Subepithelial lesions, main target of EUS-FNA are differential

diagnosis GIST from leiomyoma and schwannoma, and diagnosis of rare SELs such

as NET (carcinoid tumor), Glomus tumor, granular cell tumor, etc. Then the

indication of EUS-FNA for SELs is tumors originated from 4th layer, SELs with

malignant sign such as heterogeneous, nodular, ulceration, anechoic area etc., and

unusual pattern of SELs.

As mentioned before, EUS-FNA has a not enough diagnostic yield for small lesion

(8). Although EUS-FNB using 22-guage needle obtains a high yield (85.7% - 86%)

for the diagnosis of gastric SELs ≧2cm (10,11). Therefore, SELs originated from 4th

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Accepted Article
layer are recommended to follow up until tumors becomes more than 1-2cm in size.

However, in order to prevent overlooking of high grade GIST, we have to make 1st

follow up at 6 months later (14). Of course, we should perform EUS-FNA in SELs

with malignant sign or unusual SELs even they are less than 1-2cm in size.

B, New technique

It is difficult to perform EUS-FNA in SELs, compared to other tumor such as

pancreas cancer etc. Because SELs are movable and hard. In this situation, cap

attached forward-viewing echoendoscope is very helpful (figure17) (8,9,25). That

is, target lesion is catched by cap and suction, puncture a needle, make stroke about

10-20 times, and remove a needle. It is practicable to perform EUS-FNA even in

small lesions because of fixation of the target.

7, Conclusions

Using EUS, it is practicable to diagnose SELs with originating layer, echo level

and internal echo pattern. However, it is sometimes necessary to diagnose SELs

histologically, especially GIST, NET, et. Then EUS-FNA is very helpful for

diagnosing SELs and management of SELs.

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Accepted Article
1)Aibe T: A Study on the structure of layers of the gastrointestinal wall visualized

by means of the ultrasonic endoscope. 1) the structure of layers of the gastric wall.

(in Japanese with English abstracts) Gastroenterol Endosc. 26;1447-1464,1984

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7) Hoda KM, Rodriguez SA, Faigel DO: EUS-guided sampling of suspected GI

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13) Aso A, Ihara E, Kubo H, et al: Gastric gastrointestinal stromal tumor smaller

than 20 mm with liver metastasis. Clin J Gastroenterol 6: 29-32, 2013

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Hrubasn RH, Theise ND, editors. WHO classification of tumors of the digestive

system. Lyon: IARC, 2010:13-14.

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Legends

Figure 1, Normal stomach wall by EUS

Using lower frequency, GI wall is detected 5-layer structure 1st & 2nd layer means

mucosa, 3rd layer submucosa 4th proper muscle layer and 5th subserosa and serosa.

Using high frequency, muscularis mucosae and border of inner and outer muscle

are separately detected.

Figure 2, Imaging diagnosis of submucosal tumor by originating layer

Figure 3, Imaging diagnosis of submucosal tumor by echo level

Figure 4, Case of GIST

Endoscopy reveals a slightly elevated lesion in the lesser curvature of the body.

EUS detects a round, hypoechoic tumor originating from 4th layer. Histology shows

spindle cells with c-kit positive by EUS-FNA

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Accepted Article
Figure 5, Case of Leiomyoma

Endoscopy reveals an elevated lesion in the lesser curvature of the upper body. EUS

detects a round, hypoechoic tumor originating from 4th layer. Histology shows

spindle cells with α-SMA positive by EUS-FNA

Figure 6, Case of Schwannoma

Endoscopy reveals a slightly elevated lesion in the posterior wall the body. EUS

detects a round, hypoechoic tumor originating from 4th layer and elastography as a

hard tumor. Histology shows spindle cells with S – 100 positive by EUS-FNA

Figure 7, Case of Ectopic pancreas (shallow type)

Endoscopy reveals an elevated lesion in the antrum. EUS detects an

unwell-defined, hypoechoic tumor originating from 3rd layer with cystic area.

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Accepted Article
Figure 8, Case of Ectopic pancreas (deep type)

Endoscopy reveals an elevated lesion in the greater curvature of body. EUS detects

an unwell-defined, hypoechoic tumor originating from 3rd – 4th layer. “Thickening of

4th layer” which is caused by pancreatic tissue existing are shown.

Figure 9, Case of Lipoma

Endoscopy reveals an elevated, soft lesion in the antrum, which is measured about

2.5 cm in size by means of measuring rubber ring (outer 1.0 cm, inner 0.5 cm in

diameter). EUS detects a hyperechoic, homogeneous tumor originating from 3rd

layer. This is typical finding of lipoma, then no need to perform EUS-FNA.

Figure 10, Case of neuroendocrine tumor

Endoscopy reveals an elevated lesion in the greater curvature of the upper body.

EUS detects a round, hypoechoic tumor originating from 3rd layer. Histology shows

rounded cells with synaptophysin and chromogranin positive by EUS-FNA

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Accepted Article
Figure 11, Case of gastrinoma

Endoscopy reveals an elevated lesion with central dimpling in the duodenum. EUS

detects a hypoechoic tumor originating from 3rd layer and lymph nodes swelling.

Figure 12, Case of Glomus tumor

Endoscopy reveals an elevated lesion in the antrum. EUS detects an isoechoic

tumor originating from 4th layer.

Figure 13, Case of Lymphangioma

Endoscopy reveals an elevated lesion in the antrum. EUS detects an anechoic tumor

originating from 3rd layer with septum.

Figure 14, Case of Hamartoma

Endoscopy reveals an elevated lesion in the greater curvature of body. EUS detects

a tumor originating from 3rd layer with septum and cystic area.

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Accepted Article
Figure 15, Case of Granular cell tumor

Endoscopy reveals a submucosal lesion with a yellowish-white color and “molar

teeth appearance. EUS detects a hypoechoic tumor originating from 2rd layer. And

endoscopic mucosal resection had been performed.

Figure 16, Case of Brunnerioma

Endoscopy reveals a polypoid lesion with stalk in the duodenal bulb. EUS detects a

hypoechoic tumor originating from 3rd layer at stalk. And endoscopic polypectomy

had been performed.

Figure 17, cap attached forward-viewing echoendoscope

In case of EUS-FNA of SMT especially small one, it is very useful to perform

EUS-FNA with cap attached forward-viewing echo endoscope

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Accepted Article
Figure 1, Normal stomach wall by EUS

7.5-12 MHz 12-20 MHz

Mucosa
{
First layer （border echo）

Second Layer
First layer （border echo）
Second Layer } Proper mucosa

Third layer（border e.）

Musclaris mucosae
Fourth layer

Submucosa Third Layer Fifth Layer Submucosa

Inner muscle
Sixth Layer
Proper Fourth Layer Seventh layer (border e.) Connective tissue
Muscle Eighth Layer Outer Muscle
Subserosa, Fifth Layer (border Ninth layer Subserosa,
Serosa echo) (border echo Serosa

Figure 2, Imaging diagnosis of submucosal tumor by originating layer

2-Layer 3-Layer 4-Layer
Leiomyoma
Granular Cell Tumor
Carcinoid tumor Invasion

Brunnerioma
Lympｈangioma
Lipoma
Fibroma
Cyst
Ectopic Pancreas
Glomus Tumor
GIST
Leiomyoma
Schwanoma

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Accepted Article
Figure3, Imaging diagnosis of submucosal tumor by echo level
Anechoic Hypoechoic Isoechoic Hyperechoic
(Fluid) (pm) (Liver & Spleen) (sm)
Cyst
Lymphangioma
Carcinoid tumor
GIST
Leiomyoma
Leiomyosarcoma
Schwanoma
Glomus Tumor
Fibroma
Ectopic Pancreas
Brunnerioma
Lipoma

Figure 4, Case 1 GIST

HE C-kit

Radial EUS EUS-FNA

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Accepted Article
Figure 5, Leiomyoma
Endoscopy EUS-FNA

HE α-SMA

Figure 6, Ｓｃｈｗａｎｎｏｍａ
EUS Elastography

Endoscopy HE S-100

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Accepted Article
Figure 7, Ectopic Pancreas
(shallow type)

Figure 8, Ectopic Pancreas

(deep type)

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Accepted Article
Figure 9, Lipoma

Radial EUS

Figure 10, Neuroendocrine tumor (carcinoid tumor)

内視鏡像

HE Synapt CromoG

Radial EUS EUS-FNA

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Accepted Article
Figure 11、Gastrinoma（sm invasion with lymph node swelling）

Figure 12, Glomus tumor

H.E. α-SMA

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Accepted Article
Figure 13, Lymphangioma

Figure 14, Hamartoma

Histology of FNA Histology of resectd specimen

HE
HE

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Accepted Article
Figure 15, Granular Cell Tumor

HE S-100

Figure 16, Bruunerioma

HE

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Accepted Article
Figure 17, Cap attached Forward-viewing
Echoendoscope for SMT

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