The Diagnosis Of Endoscopic Ultrasonography And Analysis Of Histopathology In Esophageal Submucosal Lesions

ObjectiveEvaluate the diagnosis of endoscopic ultrasonography(EUS)and analysis of histopathology in esophageal submucosal lesions(SMLs).MethodsDuring 2005-2016,2614 cases were diagnosed with esophageal submucosal lesions by EUS,we analyzed the clinical features,auxiliary examinations features,treatment outcomes and follow-up results of these patients.Besides,we conducted immunohistochemical staining and genetic test with some esophageal spindle cell tumors to make a definitive diagnosis.Results(1)Esophageal leiomyoma:the prevalence of leiomyoma is the most in all esophageal SMLs diagnosed by EUS,accounted for 90.40%,a homogeneous and hypoechoic tissue structure with clear margins was seen,most esophageal leiomyoma lesions were located within the middle and lower thirds of the esophagus(76.50%).Most lesions originated from the mucous layer or the muscularis propria(90.62%).The average size is 6.89±6.28mm.Those lesions with definitive diagnosis by pathological diagnosis have similar features with lesions primary diagnosed by EUS.17.24%(5/29)patients with abnormal serological features have other malignant diseases or diagnosed malignant diseases after surgeries.Computed tomography(44.54%,155/348)is not sensitive enough to show an esophageal leiomyoma compared with EUS.The successful rate has no significant difference between endoscopic therapy and surgical treatment(P>0.05),however,the incidence rate of complications is lower in endoscopic therapy than in surgical treatment(P=0.035).The preoperative diagnostic accuracy of EUS for esophageal leiomyoma is 83.16%(400/481).Most of the misdiagnosis patients are in the middle and lower thirds of the esophagus,patients are between 45 and 60 years,most of the pathological results are inflammation,cyst and squamous hyperplasia.Some patients without treatment receive endoscopy follow-up,and 2 lesions of them grew fast in short time,after EUS-FNA,1 lesion is squamous carcinoma,other patients with no significant growth during follow-up time.No relapse happened during follow-up time in treatment team.(2)Esophageal cyst:the prevalence of cyst is 3.48%in all esophageal SMLs diagnosed by EUS,an echoless and hypoechoic tissue structure with clear margins was seen,most lesions were located within the lower third of the esophagus(65.98%).Most lesions originated from the submucosal layer(88.54%).The average size is 6.01±4.68mm.All treatment patients successfully received endoscopy treartment,no complications happened.The preoperative diagnostic accuracy of EUS for esophageal cyst is 100.00%(3/3).Patients in non-treatment team with no significant growth during follow-up time.No relapse happened during follow-up time in treatment team.(3)Esophageal GISTs:the prevalence of GISTs is 2.49%in all esophageal SMLs diagnosed by EUS,a homogeneous and hypoechoic tissue structure with clear margins was seen,most lesions were located within the middle and lower thirds of the esophagus(89.55%).All pathologically confirmed lesions originated from the muscularis propria.The average size is 16.57±11.42mm.The successful rate and incidence rate of complications has no significant difference between endoscopic therapy and surgical treatment(P>0.05).The preoperative diagnostic accuracy of EUS for esophageal GISTs is 13.04%(3/23),most of the misdiagnosis patients are leiomyoma.Patients in non-treatment team with no significant growth during follow-up time.No relapse happened during follow-up time in treatment team.(4)Esophageal vascular related diseases:the prevalence of esophageal vascular related diseases is 1.80%in all esophageal SMLs diagnosed by EUS,a lowly or medially echoic tissue structure with clear margins was seen,most lesions were located within the middle and lower thirds of the esophagus(76.00%).Most lesions originated from the submucosal layer(96.00%).The average size is 8.41±6.61mm.The successful rate and incidence rate of complications has no significant difference between endoscopic therapy and surgical treatment(P>0.05).The preoperative diagnostic accuracy of EUS for esophageal vascular related diseases is 57.14%(4/7).Patients in non-treatment team with no significant growth during follow-up time.No relapse happened during follow-up time in treatment team.(5)Esophageal lipoma:the prevalence of esophageal lipoma is 1.53%in all esophageal SMLs diagnosed by EUS,a highly or medially echoic tissue structure with clear margins was seen,most lesions were located within the middle and lower thirds of the esophagus(87.50%).Most lesions originated from the submucosal layer(97.37%).The average size is 9.39±5.17mm.The successful rate and incidence rate of complications has no significant difference between endoscopic therapy and surgical treatment(P>0.05).The preoperative diagnostic accuracy of EUS for esophageal lipoma is 100%.Patients in non-treatment team with no significant growth during follow-up time.No relapse happened during follow-up time in treatment team.(6)Esophageal granulosa cell tumor:the prevalence of esophageal granulosa cell tumor is 0.31%in all esophageal SMLs diagnosed by EUS,a lowly or medially echoic tissue structure with clear margins was seen,most lesions were located within the middle third of the esophagus(75.00%).Most lesions originated from the mucous layer and submucosal layer.The average size is 6.90±4.69mm.All treatment patients successfully received endoscopy treartment.The preoperative diagnostic accuracy of EUS for esophageal granulosa cell tumor is 40.00%.No relapse happened during follow-up time in treatment team.(7)Histopathology analysis:the genetic test results showed that for those pathents with CD117 positive in immunohistochemical staining,2 patients may have C-KIT9 mutation(both were S476R),and these results were not common mutations from articles,and these errors may come from experiments.For those pathents with CD117 positive in immunohistochemical staining and no mutations in common C-KIT and PDGFRa mutations,maybe they were leiomyoma samples mixed with interstitial cells of Cajal or rare mutation of GISTs or wild type GISTs.ConclusionsIn all esophageal SMLs,leiomyoma is the most,other lesions are not familiar.Most leiomyoma originated from the mucous layer or the muscularis propria,most cyst originated from the submucosal layer,most GISTs originated from the muscularis propria,most vascular related diseases originated from the submucosal layer,most lipoma originated from the submucosal layer,most granulosa cell tumor originated from the mucous layer or submucosal layer.The majority of patients with esophageal SMLs remain asymptomatic.Preoperative diagnostic accuracy of EUS for esophageal SMLs was superior to conventional endoscopy and CT.EUS can guide proper treatment way for esophageal SMLs.preoperative diagnostic accuracy of EUS for esophageal cyst and lipoma were 100.00%,for leiomyoma is 83.16%,EUS has high value in diagnosis and differential diagnosis in these lesions.preoperative diagnostic accuracy of EUS for vascular related diseases is 57.14%,granulosa cell tumor is 40.00%,GISTs is 13.04%,suggested that these esophageal SMLs are not familiar.Follow-up research reminders that most esophageal SMLs are benign lesions.For esophageal spindle-shaped cell tumor,immunohistochemical staining is enough for most patients in diagnosis.Because of low occurrence of esophageal GISTs,it is unnecessary for patients to undergo genetic test,however,cause we cannot exclude the possibility of GISTs,patients should undergo endoscopy or EUS in time.