A prospective study on endoscopic ultrasonography criteria to guide management in upper GI submucosal tumors.
A prospective study on endoscopic ultrasonography criteria to guide management in upper GI submucosal tumors.
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DOI：
10.2478/v10035-011-0010-z
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发表时间：
2011-02-01
期刊：
影响因子：
--
通讯作者：
Meyer, Frank
中科院分区：
文献类型：
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作者：
Will, Uwe;Fueldner, Frank;Meyer, Frank
未标记：超声内窥镜(EUS)可以区分印迹和粘膜下肿瘤(SMT)，但目前尚不清楚EUS标准是否能可靠地指导治疗。这项前瞻性研究的目的是评估一种基于临床和EUS标准的建议切除和后续调查的方法，关于识别恶性病变和良性病变的预测价值。材料和方法：在7年的时间段内，所有接受上消化道黏膜下病变EUS评估的患者都是前瞻性入选的。诊断为EUS的腔外印迹没有进一步考虑。如果EUS所见的粘膜下肿瘤有明显的症状，或发现其中一个参数(肿瘤大小<3厘米，边缘不规则，回声结构不均匀和/或淋巴结增大)，建议切除。结果：241例粘膜下病变中65例有印迹，176例有真性粘膜下病变。后者中29例为非肿瘤性病变(囊肿、静脉曲张)。在59例患者中，由于临床症状和常规内窥镜检查可疑发现，认为有必要切除。这些受试者接受了手术(起始层，固有肌层)或内窥镜切除(粘膜下起源)：35.6%是恶性的，外科手术组更常见(41.6%比20%)。然而，在59例没有严重症状和真正的SMT的患者中，52.5%(n=31)的患者因为他们的额外标准而建议切除。18名患者(12.2%)拒绝摘除SMT，甚至拒绝定期EUS随访。家庭医生的临床随访调查没有显示这些病例有明显的恶性(再移植未登记)。EUS随访70例(平均5年，范围1~7年)。67/70例保持不变，3例有改变的患者中有2例接受了良性肌瘤手术(1例患者拒绝接受手术，1例随访1年MRI未见改变)。结论：基于明确特征的EUS策略去除了在常规内窥镜下无严重症状和可疑发现的SMT，符合推荐的方法，对恶性病变有合理的阳性预测值(88%)。单纯的临床症状或有内窥镜发现的症状往往太模糊，不能决定合理的SMT切除。所选择的EUS标准对以下方面有价值：1)实现所有潜在恶性SMT的一期切除；2)避免因随访结果显示没有发现恶性病变而忽视它们。
UNLABELLED: Endoscopic ultrasonography (EUS) can differentiate between impression and submucosal tumor (SMT) but it is not known whether EUS criteria can reliably guide management. The aim of this prospective study was to assess an approach to recommend removal versus follow-up investigation based on clinical and EUS criteria, with respect to the predictive values to recognize malignancy versus benign lesions.MATERIAL AND METHODS: Over a 7-years time period, all patients referred for the EUS assessment of submucosal upper GI lesions were prospectively enrolled. Extraluminal impressions diagnosed with EUS were not further considered. If submucosal tumors seen with EUS were clearly symptomatic or one of several parameters (tumor size >3 cm, irregular margins, inhomogeneous echotexture and/or enlarged lymph nodes) were found, resection was recommended. The remaining cases were subjected to EUS follow-up.RESULTS: Of cases with 241 submucosal lesions, 65 had impressions and 176 had true submucosal lesions. Of the latter, 29 cases had non-neoplastic lesions (cysts, varices). In 59 cases, removal was deemed necessary due to clinical symptoms and suspicious findings in conventional endoscopy. These subjects underwent either surgical (originating layer, muscularis propria) or endoscopic resection (submucosal origin): 35.6% were malignant, more frequently in the surgical group (41.6% vs 20%). However, in 52.5% (n=31) of the 59 cases with no severe symptoms and true SMT, EUS suggested removal because of their additional criteria. Eighteen patients (12.2%) refused SMT removal and even regular EUS-based follow-up investigation. Clinical follow-up investigation by the family practitioner did not show frank malignancy in these cases (retransferal not registered). Follow-up investigation with EUS was recommended in 70 cases (mean follow-up period, 5 years; range, 1-7 years). The pattern remained unchanged in 67/70, and 2 of the 3 cases with changes underwent surgery for benign leiomyoma (patient refusal, n=1 with no change in the one-year follow-up MRI).CONCLUSIONS: An EUS strategy based on defined characteristics to remove SMT with no severe symptoms and suspicious finding in the conventional endoscopy shows a good adherence to the recommended approach and has a reasonable positive predictive value for malignancy (88%). Clinical symptoms alone or with endoscopic finding are frequently too vague to decide for a reasonable SMT resection. The chosen EUS criteria are valuable to: 1) achieve the primary resection of all potentially malignant SMT and 2) avoid to overlook them as shown by the results of the follow-up investigations with no detected malignant lesion.