Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Pierre H. Deprez; Leon M.G. Moons; Dermot OʼToole; Rodica Gincul; Andrada Seicean; Pedro Pimentel-Nunes; Gloria Fernández-Esparrach; Marcin Polkowski; Michael Vieth; Ivan Borbath; Tom G. Moreels; Els Nieveen van Dijkum; Jean-Yves Blay; Jeanin E. van Hooft

doi:10.1055/a-1751-5742

Endoscopy, Table of Contents

Endoscopy 2022; 54(04): 412-429
DOI: 10.1055/a-1751-5742

Guideline

Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Authors

Pierre H. Deprez

¹Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
Leon M.G. Moons

²Divisie Interne Geneeskunde en Dermatologie, Maag-, Darm- en Leverziekten, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
Dermot OʼToole

³Neuroendocrine Tumor Service, ENETS Centre of Excellence, St. Vincent’s University Hospital and Department of Clinical Medicine, Trinity College Dublin, University of Dublin St. James’s Hospital, Dublin, Ireland
Rodica Gincul

⁴Service de Gastroentérologie et Endoscopie Digestive, Hôpital Privé Jean Mermoz, Lyon, France
Andrada Seicean

⁵Regional Institute of Gastroenterology and Hepatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
Pedro Pimentel-Nunes

⁶Department of Gastroenterology, Portuguese Oncology Institute of Porto; Department of Surgery and Physiology, Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Portugal
Gloria Fernández-Esparrach

⁷Endoscopy Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clínic, Barcelona, Spain
Marcin Polkowski

⁸Department of Gastroenterology, Hepatology and Clinical Oncology, Center for Postgraduate Medical Education, and Department of Oncological Gastroenterology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
Michael Vieth

⁹Institut of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
Ivan Borbath

¹Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
Tom G. Moreels

¹Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
Els Nieveen van Dijkum

¹⁰Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, The Netherlands
Jean-Yves Blay

¹¹Centre Léon Bérard, Université Claude Bernard Lyon 1, Lyon, France
Jeanin E. van Hooft

¹²Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands

Abstract

Main Recommendations

1 ESGE recommends endoscopic ultrasonography (EUS) as the best tool to characterize subepithelial lesion (SEL) features (size, location, originating layer, echogenicity, shape), but EUS alone is not able to distinguish among all types of SEL.

Strong recommendation, moderate quality evidence.

2 ESGE suggests providing tissue diagnosis for all SELs with features suggestive of gastrointestinal stromal tumor (GIST) if they are of size > 20 mm, or have high risk stigmata, or require surgical resection or oncological treatment.

Weak recommendation, very low quality evidence.

3 ESGE recommends EUS-guided fine-needle biopsy (EUS-FNB) or mucosal incision-assisted biopsy (MIAB) equally for tissue diagnosis of SELs ≥ 20 mm in size.

Strong recommendation, moderate quality evidence.

4 ESGE recommends against surveillance of asymptomatic gastrointestinal (GI) tract leiomyomas, lipomas, heterotopic pancreas, granular cell tumors, schwannomas, and glomus tumors, if the diagnosis is clear.

Strong recommendation, moderate quality evidence.

5 ESGE suggests surveillance of asymptomatic esophageal and gastric SELs without definite diagnosis, with esophagogastroduodenoscopy (EGD) at 3–6 months, and then at 2–3-year intervals for lesions < 10 mm in size, and at 1–2-year intervals for lesions 10–20 mm in size. For asymptomatic SELs > 20 mm in size that are not resected, ESGE suggests surveillance with EGD plus EUS at 6 months and then at 6–12-month intervals.

Weak recommendation, very low quality evidence.

6 ESGE recommends endoscopic resection for type 1 gastric neuroendocrine neoplasms (g-NENs) if they grow larger than 10 mm. The choice of resection technique should depend on size, depth of invasion, and location in the stomach.

Strong recommendation, low quality evidence.

7 ESGE suggests considering removal of histologically proven gastric GISTs smaller than 20 mm as an alternative to surveillance. The decision to resect should be discussed in a multidisciplinary meeting. The choice of technique should depend on size, location, and local expertise.

Weak recommendation, very low quality evidence.

8 ESGE suggests that, to avoid unnecessary follow-up, endoscopic resection is an option for gastric SELs smaller than 20 mm and of unknown histology after failure of attempts to obtain diagnosis.

Weak recommendation, very low quality evidence.

9 ESGE recommends basing the surveillance strategy on the type and completeness of resection. After curative resection of benign SELs no follow-up is advised, except for type 1 gastric NEN for which surveillance at 1–2 years is advised.

Strong recommendation, low quality evidence.

10 For lower or upper GI NEN with a positive or indeterminate margin at resection, ESGE recommends repeating endoscopy at 3–6 months and another attempt at endoscopic resection in the case of residual disease.

Strong recommendation, low quality evidence.

Full Text

References

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