Guidelines: Diagnosis and Management of Gastrointestinal Subepithelial Lesions
Key findings
- Gastrointestinal subepithelial lesions (SEL) may be found incidentally or during an evaluation for signs and symptoms; either way, securing a diagnosis is typically necessary to determine appropriate management
- The American College of Gastroenterology has published its first formal recommendations about the diagnosis and management of SEL
- Endoscopic ultrasound (EUS) is preferred over endoscopy alone, CT or MRI for diagnosis; the choice of echoendoscope (forward viewing vs. oblique viewing) for any particular case is left to the discretion of the operator
- EUS with tissue acquisition is suggested for improved diagnostic accuracy in identifying solid non-lipomatous SEL; the expert panel suggests specific techniques according to the wall layer affected
- Patients with symptoms or blood loss should undergo resection; the panel provides guidance about the different approaches for each type of lesion. This may include resection or surveillance depending on the diagnosis
After the introduction of endoscopic ultrasound (EUS), incidental discovery of gastrointestinal subepithelial lesions (SEL) became commonplace. These are usually small and innocuous, but some SEL cause symptoms, bleeding, and chronic anemia. Simple mucosal biopsies may be inadequate for diagnosis.
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The American College of Gastroenterology (ACG) has published its first formal recommendations for the diagnosis and management of SEL. Brian Jacobson, MD, MPH, director of program development for the Division of Gastroenterology at Massachusetts General Hospital and Associate Professor of Medicine at Harvard Medical School, served as first author of the document, which appears in The American Journal of Gastroenterology.
Methods
Content experts on the ACG team developed 15 clinical questions with the help of research librarians. They investigated by searching EMBASE, PubMed, Cochrane Reviews, and the Cochrane Central Register of Controlled Clinical Trials for English-language papers published between 2000 and December 31, 2020.
This search yielded 444 papers, although few randomized controlled trials or systematic reviews. The panel developed a set of 11 recommendations. Two formally trained methodologists assessed the quality of evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process.
Diagnosis
The panel made only one strong recommendation, which concerns diagnosis:
- When evaluating SEL, the choice of echoendoscope (forward viewing vs. oblique viewing) for any particular case should be left to the operator's discretion
The guidelines include five conditional recommendations about diagnosis:
- EUS is preferential to endoscopy or contrast-enhanced cross-sectional imaging for diagnosing non-lipomatous SEL
- "Bite-on-bite" biopsies are not suggested to evaluate SEL before EUS. Bite-on-bite refers to removing the mucosa above the SEL with jumbo biopsy forceps, then performing repeat biopsies within the mucosal defect to attempt subepithelial sampling
- EUS with tissue acquisition is suggested for improved diagnostic accuracy in identifying solid non-lipomatous SEL
- For solid SEL, EUS with fine-needle biopsy (FNB) or EUS with fine-needle aspiration (FNA) and rapid on-site evaluation (ROSE) is preferable to EUS-FNA without ROSE
- An unroofing technique is suggested when a definitive diagnosis of an SEL is necessary and EUS-FNB or EUS-FNA is nondiagnostic
Therapy
The panelists settled on five conditional recommendations about therapy:
- When resection is necessary for managing SEL originating from the muscularis propria layer of the esophagus and gastroesophageal junction, perform submucosal tunneling endoscopic resection or surgical resection
- Gastric GI stromal tumors (GIST) >2 cm and all nongastric GIST should be resected because of their malignant potential; there is insufficient evidence to recommend surveillance vs. resection of GIST ≤2 cm
- Either endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) can be considered for the treatment of type 1 gastric neuroendocrine tumors
- ESD is recommended over EMR for resection of small type 3 gastric neuroendocrine tumors (those that are low-grade or without radiologic or EUS evidence of lymphadenopathy)
- Either EMR or ESD can be considered for the treatment of small (<1 cm), low-grade rectal neuroendocrine tumors
Other important features of the guidelines are a list of key clinical concepts and an algorithm that summarizes an evidence-based approach to diagnosing and managing SEL.
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