Endoscopic resection of submucosal tumors

Abstract

Submucosal gastrointestinal tumors represent a unique, diverse and challenging group of lesions found in modern medical practice. While management has traditionally been surgical, the development of advanced endoscopic techniques is challenging this approach. This review aims to investigate the role of endotherapy in treatment pathways, with a focus on carcinoid and gastrointestinal stromal tumors. In particular, we will discuss which lesions can be safely treated endoscopically, the evidence base behind such approaches and the limitations of the current evidence. The review will consider how these techniques may change the management of submucosal tumors in the future.

Keywords:

• carcinoid
• EMR
• ESD
• gastroscopy
• GIST
• NET
• submucosal tumor

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Submucosal tumors are lesions originating beneath the epithelium, from the submucosa, muscularis mucosa or muscularis propria.

• They represent a wide variety of cell types, including mesenchymal tumors, lipomas, leiomyomas, carcinoids and gastrointestinal stromal tumors, and sarcomas can arise in this area. Malignant potential ranges from completely benign to malignant depending on histology.

• They are an increasingly common finding at endoscopy, with many lesions found as incidental findings.

• Obtaining biopsy samples can be challenging due to supepithelial location.

• Endoscopic ultrasound can predict from which layer the tumor originates, but is not particularly effective in predicting histology. It can be used to obtain a targeted biopsy. A positive endoscopic ultrasound is useful but a negative endoscopic ultrasound may be understaging the lesion.

• Resection may be the only reliable method to obtain histology in many lesions.

• Type I and Type II carcinoids <2 cm in size can be effectively treated endoscopically.

• Gastrointestinal stromal tumors <2 cm in size with <5 mitoses/hpf can be effectively treated endoscopically.

• Success rates of 90–100% have been found in most reported series, with perforation rates of 0–20% and bleeding rates of 0–5% reported.

• Recurrence rates were reported as very low in all of the published series, although follow-up was often short and long term follow-up data is needed.

Notes