An Unusual Duodenal Subepithelial Lesion: A Challenging Case

Abstract

The diagnostic journey in gastrointestinal lesions, particularly when presenting with atypical features, often poses formidable challenges in clinical practice. This challenge is vividly illustrated in the case of an 88-year-old man with severe acute-on-chronic gangrenous cholecystitis. Imaging studies prior to surgery unveiled an unexpected 30 × 26 mm nodular formation nestled between the pancreas and duodenum suspected for neoplasia. Endoscopic ultrasound allows obtaining an atypical benign diagnosis of a benign subepithelial lesion. This intriguing case highlights the intricate nature of differential diagnosis in such lesions, especially when they attain substantial dimensions. The nuanced imaging features and integration of advanced techniques like endoscopic ultrasound with DWI and elastography emerge as pivotal tools in achieving precise diagnosis and guiding tailored treatment strategies.

 

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Keywords

endoscopic ultrasound - EUS - leiomyoma - subepithelial lesion

An 88-year-old man with multiple comorbidities underwent urgent cholecystectomy for acute-on-chronic gangrenous cholecystitis. A preoperative contrast-enhanced abdominal computed tomography scan identified a 30 × 26 mm hypodense solid nodular lesion between the descending part of the duodenum and the pancreatic head, which showed both a hyper- and a hypovascular component, suspected to be neoplastic ([Fig. 1]). Esophagogastroduodenoscopy ruled out mucosal duodenal lesions or infiltrative neoplasia. Endoscopic ultrasound (EUS) revealed an oval hypoechoic lesion with slightly heterogeneous pattern and mild “fat stranding” originating from the muscularis propria ([Fig. 2A]). The evaluation of microvasculature and parenchymal perfusion with EUS detective flow imaging (EUS-DFI) confirmed the mixed vascularity patterns ([Fig. 2B]), while elastography did not show increased stiffness. Based on US findings and lesion location, the main hypothesized diagnosis was a type IV gastrointestinal stromal tumor (GIST). A EUS fine-needle biopsy (EUS-FNB) was performed using a 22-gauge needle (Acquire, Boston Scientific, Marlborough, MA, United States) with a fanning technique (2 passes) to sample the hypo- and hypervascular components.

Fig. 1 Contrast-enhanced abdominal computed tomography revealed a nodular lesion between the descending part of the duodenum and the pancreatic head. (A) Arterial phase. (B) Portal phase.

Fig. 2 (A) An endoscopic ultrasound showed a slightly inhomogeneous hypoechoic lesion with mild “fat stranding” originating from the muscularis propria. (B) The evaluation of microvasculature and parenchymal perfusion with detective flow imaging demonstrated mixed vascularity patterns (a hypo- and a hypervascular region). (C) Elastography revealed an average texture.

The histopathological examination revealed a benign spindle cell tumor with smooth muscle differentiation with no evidence of atypia or necrosis compatible with a diagnosis of leiomyoma (α-smooth muscle actin + , desmin + , S100-, CD34-, DOG1-, CD117, Ki-67 < 1%). Therefore, no treatment or follow-up was needed.

As demonstrated in our case, the differential diagnosis of subepithelial lesions (SELs), especially those with atypical features, represents a challenge in clinical practice.[1] [2] Advanced techniques such as EUS-DFI, elastography, and EUS-FNB are essential to achieve an accurate diagnosis by delineating the morphological features, originating wall layers, and histological characteristics (when needed).[3]

Gastrointestinal leiomyomas are benign tumors originating from smooth muscle cells, mainly occurring in the esophagus.[4] Duodenal leiomyomas are rare (<5% of all gastrointestinal leiomyomas). While the exact pathogenesis remains uncertain, a possible chronic inflammatory pathway has been described and may be considered for atypical sites as in this case.[5]

Leiomyomas are typically asymptomatic and incidentally discovered during imaging. They can mimic pancreatic or duodenal malignancies, when large, ulcerated, or with necrosis. EUS is essential for histopathological diagnosis.

In summary, our case supported the pivotal role of EUS-FNB in the differential diagnosis of SELs with atypical sites and findings, preventing unnecessary surgical procedures in high-risk patients.

 

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Conflict of Interest

None declared.

Authors' Contributions

All the authors were involved in writing and editing the manuscript.

• References

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• 2 Sharzehi K, Sethi A, Savides T. AGA clinical practice update on management of subepithelial lesions encountered during routine endoscopy: expert review. Clin Gastroenterol Hepatol 2022; 20 (11) 2435-2443.e4
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• 5 Latos W, Kawczyk-Krupka A, Strzelczyk N, Sieroń A, Cieślar G. Benign and non-neoplastic tumours of the duodenum. Prz Gastroenterol 2019; 14 (04) 233-241

Publication History

Article published online:
21 November 2024