ACG guides diagnosis, management of subepithelial GI lesions with new recommendations
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The ACG has developed a clinical guideline to aid physicians in the diagnosis and management of patients with gastrointestinal subepithelial lesions, which recently was published in The American Journal of Gastroenterology.
“The term subepithelial lesion (SEL) is used to describe a mass or mass-like structure that typically projects into the gastrointestinal lumen and arises from a non-mucosal layer within the GI tract wall,” Brian C. Jacobson, MD, MPH, FACG, director of program development for gastroenterology at Massachusetts General Hospital, and colleagues wrote. “SEL may be non-neoplastic, neoplastic but benign, neoplastic with malignant potential or malignant. When small, SEL rarely cause signs or symptoms and are typically incidental findings. However, depending on their location and size, some may cause symptoms such as dysphagia, overt or occult GI bleeding and chronic anemia.
“Because the location of SEL typically precludes making a diagnosis through simple mucosal biopsies, they often present a diagnostic challenge.”
Although the diagnosis and management of SEL previously have been examined, specific diagnostic and treatment recommendations have not been formally evaluated.
Using the Grading of Recommendations Assessment, Development and Evaluation process, the ACG developed 11 “preferable approaches” to a typical patient with SEL based on currently published literature and expert review. Highlights include:
- Compared with endoscopy or contrast-enhanced cross-sectional imaging, researchers suggest the use of endoscopic ultrasound for the diagnosis of nonlipomatous SEL.
- Researchers do not recommend one specific type of echoendoscope (ie, forward viewing vs. oblique viewing) for evaluation.
- EUS with tissue acquisition may improve diagnostic accuracy for the identification of solid nonlipomatous SEL.
- Although there is insufficient evidence to recommend surveillance vs. resection of gastric gastrointestinal stromal tumors (GIST) smaller than 2 cm, GIST larger than 2 cm and all non-gastric GIST should undergo resection.
- Researchers recommend endoscopic submucosal dissection over endoscopic mucosal resection for low-grade, small type 3 gastric neuroendocrine tumors without radiologic or EUS evidence of lymphadenopathy.
- Researchers do not suggest one type of endoscopic therapy for the resection of small (< 1 cm), low-grade rectal neuroendocrine tumors.
“Future studies should clarify the role of primary resection vs. pre-resection diagnosis, whether there is a diagnostic role for artificial intelligence and directly compare endoscopic resection methods,” Jacobson and colleagues wrote. “Head-to-head comparisons of endoscopic vs. surgical resection techniques would better clarify their respective strengths and limitations and improve patient selection criteria.”
They continued, “As new endoscopic tools and devices become available, a standardized lexicon of terminology should be developed, and attention should be paid to their potential application in the management of SEL.”
Perspective
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Amit Bhatt, MD
SELs are not uncommon and can be seen in approximately one in 300 endoscopies. The ACG recognized the need for a guideline that presented a practical approach to dealing with these lesions when found on endoscopy and developed recommendations for the diagnosis and treatment of SELs using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.
For SELs that do not have typical features of a lipoma, an endoscopic ultrasound is recommended for evaluation, which has been shown to be superior to both regular endoscopy and radiologic imaging in the evaluation of SELs. EUS can differentiate external compression of the gastrointestinal lumen from a true SEL that arises from within the GI luminal wall. EUS-guided fine needle biopsy or fine needle aspiration with rapid on-site evaluation is recommended for tissue diagnosis of SELs.
The new guidelines recognize and acknowledge the advances made in endoscopic resection. Submucosal tunneling endoscopic resection can be considered in the management of SELs originating from the muscularis propria layer, while endoscopic submucosal dissection and endoscopic mucosal resection can be considered in the management of neuroendocrine tumors.
This ACG guideline offers a very practical approach to the diagnosis and treatment of SELs.
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