An Unusual Duodenal Subepithelial Lesion: A Challenging Case

An 88-year-old man with multiple comorbidities underwent a computed tomography scan that incidentally identified a 30 × 26 mm hypodense inhomogeneous solid nodular lesion between the duodenum and the pancreatic head, suspected for neoplasia ([Fig. 1]). Esophagogastroduodenoscopy ruled out mucosal duodenal alterations. Endoscopic ultrasound (EUS) revealed an oval hypoechoic lesion with slightly heterogeneous pattern and mild “fat stranding” originating from the muscularis propria ([Fig. 2A]). An evaluation of the microvasculature and parenchymal perfusion with EUS detective flow imaging (EUS-DFI) showed a mixed vascularity pattern ([Fig. 2B]), without “increased stiffness” at elastography. Based on ultrasound findings and lesion location, the main hypothesized diagnosis was a type IV gastrointestinal stromal tumor. A EUS with fine-needle biopsy (EUS-FNB) was performed using a 22-gauge needle (Acquire; Boston Scientific) 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) An evaluation of the 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 without 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 were needed.[1] [2]

Our case supported the pivotal role of EUS with advanced techniques, such as EUS-DFI, elastography, and EUS-FNB, in the differential diagnosis of gastrointestinal subepithelial lesions (SELs) with atypical sites and findings, preventing unnecessary surgical procedures in high-risk patients.[1] [2] [3]

Practical Implications for Endoscopists

1. EUS guided tissue sampling can help confirm the diagnosis and distinguish between GISTs and leiomyomas.

2. It is crucial to combine the EUS findings with other factors, such as clinical data, imaging, and potentially tissue sampling, to accurately diagnose and manage these SELs.

 

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Conflict of Interest

None declared.

Authors' Contributions

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

• References

• 1 Deprez PH, Moons LMG, OʼToole D. et al. Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2022; 54 (04) 412-429
• 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
• 3 Brand B, Oesterhelweg L, Binmoeller KF. et al. Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract. Dig Liver Dis 2002; 34 (04) 290-297

Publikationsverlauf

Artikel online veröffentlicht:
25. November 2024