Download PDF
Ultraschall Med 2012; 33(7): E210-E217
DOI: 10.1055/s-0032-1313135
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic Ultrasound for Differential Diagnosis of Duodenal Lesions

Endoskopischer Ultraschall für die Differenzialdiagnose von Läsionen des Zwölffingerdarms
A. Pavlovic Markovic
1   Faculty of Medicine, University of Belgrade, Belgrade, Serbia
2   Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
,
T. Rösch
3   Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf
,
T. Alempijevic
1   Faculty of Medicine, University of Belgrade, Belgrade, Serbia
2   Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
,
M. Krstic
1   Faculty of Medicine, University of Belgrade, Belgrade, Serbia
2   Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
,
D. Tomic
1   Faculty of Medicine, University of Belgrade, Belgrade, Serbia
2   Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
,
P. Dugalic
4   Department of Internal Medicine, Zemun Clinical Hospital, Belgrade, Serbia
,
A. Sokic Milutinovic
1   Faculty of Medicine, University of Belgrade, Belgrade, Serbia
2   Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
,
M. Bulajic
1   Faculty of Medicine, University of Belgrade, Belgrade, Serbia
5   Department of Gastroenterology, Clinical Centre, Dr. Dragisa Misovic, Belgrade, Serbia
› Author Affiliations
Further Information

Publication History

29 December 2011

02 July 2012

Publication Date:
05 November 2012 (online)

Also available at
    Permissions and Reprints

Abstract

Purpose: Duodenal tumors are rare and require a different management from that of esophagogastric neoplasia. The present study retrospectively analyses the endoscopic ultrasound (EUS) features of duodenal tumors of both epithelial and subepithelial origin.

Materials and Methods: During a 12 year period, all duodenal tumors with histologic confirmation by surgery or biopsy were collected including endoscopic and endosonographic images. EUS images were analyzed for specific features (echogenicity, wall layer structure and relation, outer margins) to possibly distinguish epithelial (polyps and carcinoma versus lymphoma) and subepithelial (tumor type) tumors.

Results: 53/80 cases had histologic confirmation (mean age 53.1 ± 11.4 years, m:f = 33:20), 31 were epithelial (13 adenomas, 12 carcinomas, 6 lymphomas) and 22 subepithelial (11 GISTs, 7 Brunneromas, 1 lipoma, 3 NETs). EUS did not recognize carcinomas in 2/13 adenomas. EUS features suggesting carcinoma were loss of wall layers and irregular margins. 5/6 lymphomas showed inhomogeneous thickening with layers partially recognizable. Tumor type of subepithelial lesions correlated with echogenicity: GIST tumors were mostly (62.5 %) hypocheoic with the 3 malignant cases being characterized by heterogeneous echopattern with irregular outer margins. Of the hyperechoic lesions, lipomas had a homogeneous whitish appearance, while NET and Brunneromas were less hyperechoic. In the latter, the endoscopic aspect was also helpful for differential diagnosis. Accuracy of combined endoscopic/EUS imaging for all duodenal lesions was 84.9 % (45/53). No procedural complications occurred among all patients that received EUS examinations.

Conclusion: EUS contributes to the differential diagnosis of epithelial lesions known to be malignant; in subepithelial tumors, tissue confirmation is still required.

Zusammenfassung

Ziel: Tumore des Zwölffingerdarms sind selten und erfordern eine andere Vorgehensweise als ösophagogastrische Neoplasien. Die vorliegende Studie analysiert retrospektiv die Merkmale von duodenalen Tumoren sowohl epithelialen als auch subepithelialen Ursprungs im endoskopischen Ultraschall (EUS).

Material und Methoden: Über einen Zeitraum von 12 Jahren wurden alle nach Operation oder Biopsie histologisch bestätigten Tumore des Duodenums einschließlich der Bilder aus Endoskopie und endoskopischem Ultraschall gesammelt. EUS-Bilder wurden im Hinblick auf spezifische Merkmale (Echogenität, Struktur der Wandschichten und deren Beziehung, äußere Ränder) analysiert, um epitheliale (Polypen und Karzinome im Gegensatz zu Lymphomen) und subepitheliale (tumorartige) Tumore zu unterscheiden zu können.

Ergebnisse: Eine histologische Bestätigung (Durchschnittsalter 53,1 ± 11,4 Jahre, M:F = 33:20) lag in 53/80 Fälle vor, davon waren 31 epithelial (13 Adenome, 12 Karzinome, 6 Lymphome) und 22 subepithelial (11 GISTs, 7 Brunneromas, 1 Lipom, 3 NETs). EUS konnte bei 2/13 Adenomen kein Karzinom erkennen. Die EUS-Zeichen, die für ein Karzinom sprechen, waren der Verlust der Wandschichten und unregelmäßige Ränder. 5/6 Lymphome zeigten eine inhomogene Verdickung der Schichten mit teilweise erkennbaren Schichten. Der Tumortypus bei subepithelialen Läsionen korrelierte mit der Echogenität. GIST-Tumore waren größtenteils (62,5 %) echoarm, wobei die 3 malignen Fälle durch ein heterogenes Echomuster mit irregulären Außenrändern charakterisiert wurden. Bei den echoreichen Läsionen zeigten die Lipome ein homogenes weißliches Erscheinungsbild, während NET und Brunneromas weniger echoreich waren. Bei Letzteren war für die Differenzialdiagnose das endoskopische Erscheinungsbild hilfreich. Die Genauigkeit der kombinierten endoskopischen/EUS-Bilder bei allen duodenalen Läsionen betrug 84,9 % (45/53). Bei keinem der Patienten mit EUS-Untersuchungen traten eingriffsbedingte Komplikationen auf.

Schlussfolgerung: EUS leistet einen Beitrag zur Differenzialdiagnostik von epithelialen Läsionen mit malignem Hintergrund; bei subepithelialen Tumoren ist eine Bestätigung im Gewebe immer noch notwendig.

Key words

abdomen - duodenum - endoscopic ultrasonography - duodenal lesion
 

  • References

  • 1 Caletti G, Fusaroli P, Bocus P. Endoscopic Ultrasonography. Digestion 1998; 59: 509-529
    CrossrefPubMedGoogle Scholar
  • 2 Chak A. Endoscopic Ultrasonography. Endoscopy 2000; 32: 146-152
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Darles Y, Clouard R. Physical principles: endosonographic apperance of the normal gastrointestinal tract wall. In: Dancygier H, Lightdale J. Endosonography in gastroenterology. 1st ed. Stuttgart-New York: Thieme-Verlag; 1999: 1-12
    Google Scholar
  • 4 Yasuda K, Cho E, Nakajima M et al. The diagnosis of submucosal lesions of the upper gastrointestinal tract by endoscopic ultrasonography. Gastrointest Endosc 1990; 36: S17-S20
    CrossrefPubMedGoogle Scholar
  • 5 Buscarini E, Stasi MD, Rossi S et al. Endosonographic diagnosis of submucosal upper gastrointestinal tract lesions and large fold gastropathies by catheter ultrasound probe. Gastrointest Endosc 1999; 49: 184-191
    CrossrefPubMedGoogle Scholar
  • 6 Hizawa K, Kawasaki M, Kouzuki T et al. Endosonographic classifications of gastrointestinal submucosal tumors. Digestive Endoscopy 2000; 12: 120-125
    CrossrefPubMedGoogle Scholar
  • 7 Jenssen C, Dietrich CF. Endoscopic ultrasound of gastrointestinal subepithelial lesions. Ultraschall in Med 2008; 29: 236-264
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Xu GQ, Wu YQ, Wang LJ et al. Values of endoscopic ultrasonography for diagnosis and treatment of duodenal protruding lesions. J Zhejiang Univ Sci B 2008; 9: 329-334
    CrossrefPubMedGoogle Scholar
  • 9 Kimmey MB, Martin RW, Haggitt RC et al. Histological correlates of gastrointestinal endoscopic ultrasound images. Gastroenterology 1989; 96: 433-441
    CrossrefPubMedGoogle Scholar
  • 10 Lok KH, Lai L, Yiu HL et al. Endosonographic Surveillance of Small Gastrointestinal Tumors Originating from Muscularis Propria. J Gastrointestin Liver Dis 2009; 18: 177-180
    PubMedGoogle Scholar
  • 11 Kawamoto K, Yamada Y, Utsunomiya T et al. Gastrointestinal submucosal tumors: evaluation with endoscopic US. Radiology 1997; 205: 733-740
    PubMedGoogle Scholar
  • 12 Chen HT, Xu GQ, Wang LJ et al. Sonographic features of duodenal lipomas in eight clinicopathologically diagnosed patients. World J Gastroenterol 2011; 17: 2855-2859
    PubMedGoogle Scholar
  • 13 Inai M, Sakai M, Kajiyama T et al. Endosonographic characterization of duodenal elevated lesions. Gastroinest Endosc 1996; 44: 714-719
    CrossrefPubMedGoogle Scholar
  • 14 Rösch T, Lorenz R, Dancygier H et al. Endosonographic diagnosis of submucosal upper gastrointestinal tract tumors. Scand J Gastroenterol 1992; 27: 1-8
    PubMedGoogle Scholar
  • 15 Rose DM, Hochwald SN, Klimstra DS et al. Primary duodenal adenocarcinoma: a ten-year experience with 79 patients. J Am Coll Surg 1996; 183: 89-96
    PubMedGoogle Scholar
  • 16 Kojima Y, Kobayashi T, Note M et al. A case of duodenal carcinoma presenting as a submucosal tumor. Surg Today 1992; 22: 357-362
    CrossrefPubMedGoogle Scholar
  • 17 Kohno S, Ohshima K, Yoneda S et al. Clinicopathological analysis of 143 primary malignant lymphomas in the small and large intestines based on the new WHO classification. Histopathology 2003; 43: 135-143
    CrossrefPubMedGoogle Scholar
  • 18 Caletti G, Fusaroli P, Togliani T. EUS in MALT Lymphoma. Gastrointest Endosc 2002; 56: 21-26
    CrossrefPubMedGoogle Scholar
  • 19 Nakamura S, Matsumoto T, Suekane H et al. Predictive value of endoscopic ultrasonography for regression of gastric low grade and high grade MALT lymphomas after eradication of Helicobacter pylori. Gut 2001; 48: 454-460
    CrossrefPubMedGoogle Scholar
  • 20 Hwang JH, Rulyak SD, Kimmey MB et al. American Gastroenterological Association Institute Technical Review on the Management of Gastric Subepithelial masses. Gastroenterology 2006; 130: 2217-2228
    CrossrefPubMedGoogle Scholar
  • 21 Fletcher CD, Berman JJ, Corless C et al. Diagnosis of gastrointestinal stromal tumors: a consensus approach. Hum Pathol 2002; 33: 459-465
    Google Scholar
  • 22 Miettinen M, El-Rifai W, Sobin L et al. Evaluation of malignancy and prognosis of gastrointestinal stromal tumors: a review. Hum Pathol 2002; 33: 478-483
    CrossrefPubMedGoogle Scholar
  • 23 Calabuig-Farinas S, Lopez-Guerrero JA, Llombart-Bosch A. The GIST paradigm: how to establish diagnostic and prognostic criteria. Arkh Patol 2011; 73: 13-21
    PubMedGoogle Scholar
  • 24 Miettinen M, Lasota J. Gastrointestinal stromal tumors: pathology and prognosis at different sites. Semin Diagn Pathol 2006; 23: 70-83
    CrossrefPubMedGoogle Scholar
  • 25 Palazzo L, Landi B, Cellier C et al. Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours. Gut 2000; 46: 88-92
    CrossrefPubMedGoogle Scholar
  • 26 Crosby J, Catton C, Davis A et al. Malignant Gastrointestinal Stromal Tumors of the Small Intestine: A Review of 50 Cases From a Prospective Database. Ann Surg Oncol 2001; 8: 50-59
    CrossrefPubMedGoogle Scholar
  • 27 Miettinen M, Kopczynski J, Makhlouf HR et al. Gastrointestinal stromal tumors, intramural leiomyomas, and leiomyosarcomas in the duodenum: a clinicopathologic, immunohistochemical, and molecular genetic study of 167 cases. Am J Surg Pathol 2003; 27: 625-641
    CrossrefPubMedGoogle Scholar
  • 28 Yasuda K. Gastrointestinal lesions. In: Yasuda K. The handbook of endoscopic ultrasonography in digestive tract. 1st ed. Tokio: Blackwell Science Japan; 2000: 45-63
    Google Scholar
  • 29 Trupiano JK, Stewart RE, Misick C et al. Gastric stromal tumors: a clinicopathologic study of 77 cases with correlation of features with nonaggressive and aggressive clinical behaviors. Am J Surg Pathol 2002; 26: 705-714
    CrossrefPubMedGoogle Scholar
  • 30 Giovannini M, Seitz JF, Monges G et al. Fine- needle aspiration biopsy guided by endoscopic ultrasonography: results in 141 patients. Endoscopy 1995; 27: 171-177
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Gress FG, Hawes RH, Savides TJ et al. Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography. Gastintest Endosc 1997; 45: 243-250
    PubMedGoogle Scholar
  • 32 Hoda KM, Rodriguez SA, Faigel DO. EUS-guided sampling of suspected GI stromal tumors. Gastrointest Endosc 2009; 69: 1218-1223
    CrossrefPubMedGoogle Scholar
  • 33 Sepe PS, Moparty B, Pitman MB et al. EUS-guided FNA for the diagnosis of GI stromal cell tumors: sensitivity and cytologic yield. Gastrointest Endosc 2009; 70: 254-261
    CrossrefPubMedGoogle Scholar
  • 34 Miki Y, Kurokawa Y, Hirao M et al. Survival analysis of patients with duodenal gastrointestinal stromal tumors. J Clin Gastroenterol 2010; 44: 97-101
    CrossrefPubMedGoogle Scholar
  • 35 Miettinen M, Sobin LH, Lasota J. True smooth muscle tumors of the small inestine: a clinicopathologic, immunohistochemical, and molecular genetic study of 25 cases. Am J Surg Pathol 2009; 33: 430-436
    CrossrefPubMedGoogle Scholar
  • 36 Sou S, Nomura H, Takaki Y et al. Hemorrhagic duodenal lipoma managed by endoscopic resection. J Gastroenterol Hepatol 2006; 21: 479-481
    CrossrefPubMedGoogle Scholar
  • 37 Blanchet MC, Arnal E, Paparel P et al. Obstructive duodenal lipoma successfully treated by endoscopic polypectomy. Gastrointest Endosc 2003; 58: 938-939
    CrossrefPubMedGoogle Scholar
  • 38 Dalenbäck J, Havel G. Local endoscopic removal of duodenal carcinoid tumors. Endoscopy 2004; 36: 651-655
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer 2003; 97: 934-959
    CrossrefPubMedGoogle Scholar
  • 40 Yoshikane H, Goto H, Niwa Y et al. Endoscopic resection of small duodenal carcinoid tumors with strip biopsy technique. Gastrointest Endosc 1998; 47: 466-470
    CrossrefPubMedGoogle Scholar
  • 41 Yokoyama S, Takifuji K, Tani M et al. Endoscopic resection of duodenal bulb neuroendocrine tumor larger than 10 mm in diameter. BMC Gastroenterol 2011; 11: 67
    CrossrefPubMedGoogle Scholar
  • 42 Rocco A, Borriello P, Compare D et al. Large Brunner's gland adenoma: case report and literature review. World J Gastroenterol 2006; 12: 1966-1968
    CrossrefPubMedGoogle Scholar