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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 33  |  Issue : 1  |  Page : 38-42

Study on the evaluation of sonographic characteristics of gastric submucosal tumors


Department of Diagnostic Imaging, Clinical Faculty No.1, Pyongyang Medical College, Kim Il Sung University, Pyongyang, Democratic People's Republic of Korea

Date of Web Publication14-Oct-2019

Correspondence Address:
Gwang-Il Kim
Pyongyang Medical College, Kim Il Sung University, Pyongyang
Democratic People's Republic of Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_64_18

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  Abstract 


Aims: The purpose of the present study is to evaluate some characteristics of gastric submucosal tumors on the ultrasound image that can be used for the diagnosis and differential diagnosis of gastric submucosal tumors.
Subjects and Methods: Subjects – 24 patients with gastric submucosal tumors diagnosed by physical examination, gastrointestinal endoscopy, ultrasonography, radiography, and pathological examination after the operation at Pyongyang Medical College Hospital of Kim Il Sung University from February 2009 to 2015. Methods – The ultrasonic diagnostic unit used was HD-6 type, and the probes with the frequencies of 3.5 and 7.5 MHz of convex and linear types were used. The patient was examined after drinking of 1–1.5 L of degassed water to evaluate the submucosa of the stomach correctly. The ultrasonographic evaluating indices were location, size, internal echo pattern, and homogeneity, and they were compared by disease.
Results: We have identified some sonographic characteristics of gastric submucosal tumors. The incidence of gastric submucosal tumors by location was the highest at the body of the stomach as 20 (83.3%) patients. The number of patients with gastric submucosal tumors <3 cm was the highest. The numbers of anechoic and hypoechoic tumors were, respectively, 9 (37.5%) and 7 (29.2%), were more than others. Most of tumors (75.0%) were homogeneous.
Conclusions: We think transabdominal ultrasound can be used as an alternative method for the diagnosis of submucosal tumors of the stomach.

Keywords: Leiomyoma, leiomyosarcoma, lipoma, submucosal tumor, ultrasound


How to cite this article:
Kim GI, Yo CH, Ri UB, Ju HC. Study on the evaluation of sonographic characteristics of gastric submucosal tumors. J Med Soc 2019;33:38-42

How to cite this URL:
Kim GI, Yo CH, Ri UB, Ju HC. Study on the evaluation of sonographic characteristics of gastric submucosal tumors. J Med Soc [serial online] 2019 [cited 2019 Nov 18];33:38-42. Available from: http://www.jmedsoc.org/text.asp?2019/33/1/38/269112




  Introduction Top


A gastric submucosal tumor means the one locating in the submucosa of the stomach. They include leiomyoma, lipoma, cyst, ectopic pancreas, leiomyosarcoma, lymphoma, and so on. They may be benign or malignant.

A submucosal mass or a bulge encountered during an endoscopy can arise from within any layer of the gastrointestinal (GI) tract wall (intramural) or outside of the wall (extramural). They are usually found incidentally during routine imaging with barium contrast radiography or endoscopy.[1]

The diagnosis of submucosal tumors by endoscopy or barium contrast studies is not easy since these tumors are usually covered with a normal mucosal layer. To determine the main portion of the wall stratification in the GI wall in which the tumors lie is the most important part of diagnostic imaging of submucosal tumors. For this purpose, endoscopic ultrasound (EUS), including the use of an EUS-guided fine-needle aspiration biopsy, is the best choice;[2],[3] however, not all institutions have the equipment or experienced staff to easily perform EUS in all cases with submucosal tumors. Transabdominal ultrasound, with the remarkable improvement of equipment, can be used as an alternative method.[4],[5],[6] There have been several reports on transabdominal ultrasound as an acceptable alternative for the diagnosis of submucosal tumors. Hence, we designed to identify some characteristics of gastric submucosal tumors using transabdominal ultrasound.


  Subjects and Methods Top


Subjects

Twenty-four patients with gastric submucosal tumors diagnosed by physical examination, GI endoscopy, ultrasonography, radiography, and pathological examination after the operation at Pyongyang Medical College Hospital of Kim Il Sung University from February 2009 to 2015.

The composition by sexuality and age of the patients is shown in [Table 1].
Table 1: The composition by sexuality and age of the patients (%)

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As shown in [Table 1], according to sexuality the number of men was 17 (70.8%), higher than the one of women, and according to age, the number of patients aged forties was 11 (45.8%), the highest.

Methods

The ultrasonic diagnostic unit used was HD-6 type, and the probes with the frequencies of 3.5 and 7.5 MHz of convex and linear types were used.

The patient was examined after drinking of 1–1.5 L of degassed water to evaluate the submucosa of the stomach correctly.

The ultrasonographic evaluating indices were location, size, internal echo pattern, and homogeneity, and they were compared by disease.


  Results Top


Rates of gastric submucosal tumors by disease

As shown in [Table 2], leiomyoma was most as eight patients (33.3%) in benign tumors and leiomyosarcoma was most as six patients (25.0%) in malignant tumors.
Table 2: Rates of gastric submucosal tumors by disease (%)

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Characteristics of gastric submucosal tumors on the ultrasound

As shown in [Table 3], the incidence of gastric submucosal tumors by location was the highest at the body of the stomach as 20 (83.3%) patients.
Table 3: Incidence of gastric submucosal tumors by location (%)

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As shown in [Table 4], the number of patients with gastric submucosal tumors <3 cm was the highest.
Table 4: Composition of gastric submucosal tumors by size (%)

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As shown in [Table 5], the numbers of anechoic and hypoechoic tumors were, respectively, 9 (37.5%) and 7 (29.2%), were more than others.
Table 5: Composition of gastric submucosal tumors by internal echo pattern (%)

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As shown in [Table 6], most of the tumors (75.0%) were homogeneous.
Table 6: Composition of gastric submucosal tumors by homogeneity (%)

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  Discussion Top


Lipomas are benign intramucosal tumors of mature lipocytes that are commonly incidental findings on colonoscopy and endoscopy. They can be seen in any part of the GI tract, although they are most common in the lower GI tract.[7] On the ultrasound, lipomas are hyperechoic, homogeneous lesions with regular margins arising from the submucosa (third layer of the GI tract).[1] In our study, lipoma was hyperechoic, homogeneous, and the size of lipomas were <2 cm [Figure 1].
Figure 1: Lipoma of the body of the stomach. It was hyperechoic, homogeneous, and the size was <2 cm

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The classic or usual GI tract leiomyoma has a similar morphologic appearance to leiomyomas in other organs. In the gut, they are usually small and well circumscribed. The tumors typically arise from the muscularis propria; growth may be intraluminal, extraluminal, or a combination with a dumb-bell shape. Leiomyomas can range in size from <0.5 cm (microleiomyomas) to as large as 30 cm. In our study, leiomyoma was hypoechoic and its size ranged 1–5 cm [Figure 2].
Figure 2: Leiomyoma of the body of the stomach. It was well visualized without drinking of boiled water and hypoechoic on the ultrasound

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In our study, most of the leiomyosarcomas were mixed echoic on the ultrasound and their size was larger than 5 cm. Most of the leiomyosarcomas are histologically high grade, and by immunohistochemistry, they express smooth muscle actin, desmin, or both.[8] EUS is the most accurate method for distinguishing leiomyomas from other submucosal lesions.[9],[10] Leiomyomas arise from the fourth hypoechoic layer (the muscularis propria), distinguishing them from more superficial lesions. Specific sonographic features may also distinguish a leiomyoma from other submucosal lesions, such as a lipoma or esophagogastric varices, and from other neoplasms such as lymphomas, carcinoids, cysts, pancreatic rests, and polyps. In one series, EUS correctly diagnosed 48 of 50 submucosal mass lesions confirmed by pathology or angiography.[9] EUS also may be helpful for distinguishing a leiomyoma from a leiomyosarcoma. Benign tumors are more likely to have regular margins, a tumor size <30 mm, and a homogeneous echo pattern.[11] However, sonographic characteristics alone are usually insufficient proof that a tumor is benign. Serial examinations may be helpful in such cases.[9]

A pancreatic rest (also known as ectopic pancreas, aberrant pancreas, and heterotopic pancreas) refers to ectopic pancreatic tissue. These rare submucosal tumors most commonly consist of cystically dilated exocrine cells.[12] Pancreatic rests are most frequently found in the distal stomach, duodenum, or proximal jejunum but have also been reported within a Meckel's diverticulum, the gall bladder, bile ducts, and the minor and major papillae.[13] They are typically discovered incidentally during endoscopy, surgery, or autopsy. Sonographically pancreatic rests are hypoechoic or intermediate echogenic heterogeneous lesions with indistinct margins. They most commonly arise from the third or fourth layer or a combination of the two layers of the GI tract. Anechoic areas within the lesion correlate with ductal structures.[12] In our study, pancreatic rests were hypoechoic and homogeneous.

In high-grade lymphoma, ultrasound most often showed large-nodular lesions, whereas low-grade lymphomas showed a tendency toward small-nodular or diffuse lesions.[14] Gastric lymphoma is most commonly found in the antrum. But in our study, malignant lymphoma was mostly found in the body. Low-grade lymphoma is a superficial, infiltrating lesion that produces a nodular gastric mucosa [Figure 3].
Figure 3: Transverse view (a) and sagittal view (b) of gastric lymphoma located in the body of the stomach. The concaved surface (arrow) of the tumor means ulcer-like feature of lymphoma. TU: Tumor, ST: Stomach

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Histologically, the neoplastic cells of lymphoma infiltrate between preexisting lymphoid follicles and may be difficult to differentiate from a florid gastritis.[15] High-grade gastric lymphomas are infiltrative, polypoid, ulcerative, or nodular masses.[16] It may difficult to differentiate gastric lymphoma from gastric adenocarcinoma on imaging studies alone because they have similar morphologic features.[17]

Moreover, we have found cysts in the gastric submucosa. They were anechoic and homogeneous. Their size was <3 cm.


  Conclusions Top


We have identified some sonographic characteristics of gastric submucosal tumors using transabdominal ultrasound. In this study, we evaluated the indices such as location, size, internal echo pattern, homogeneity of gastric submucosal tumors, and compared them on abdominal ultrasound. The sonographic characteristics were useful information in the diagnosis and differentiation of gastric submucosal tumors. Thus, we think transabdominal ultrasound can be used as an alternative method to EUS in the evaluation of gastric submucosal tumors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hwang JH, Saunders MD, Rulyak SJ, Shaw S, Nietsch H, Kimmey MB, et al. A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses. Gastrointest Endosc 2005;62:202-8.  Back to cited text no. 1
    
2.
Arantes V, Logroño R, Faruqi S, Ahmed I, Waxman I, Bhutani MS, et al. Endoscopic sonographically guided fine-needle aspiration yield in submucosal tumors of the gastrointestinal tract. J Ultrasound Med 2004;23:1141-50.  Back to cited text no. 2
    
3.
Vander Noot MR 3rd, Eloubeidi MA, Chen VK, Eltoum I, Jhala D, Jhala N, et al. Diagnosis of gastrointestinal tract lesions by endoscopic ultrasound-guided fine-needle aspiration biopsy. Cancer 2004;102:157-63.  Back to cited text no. 3
    
4.
Futagami K, Hata J, Haruma K, Yamashita N, Yoshida S, Tanaka S, et al. Extracorporeal ultrasound is an effective diagnostic alternative to endoscopic ultrasound for gastric submucosal tumours. Scand J Gastroenterol 2001;36:1222-6.  Back to cited text no. 4
    
5.
Polkowski M, Palucki J, Butruk E. Transabdominal ultrasound for visualizing gastric submucosal tumors diagnosed by endosonography: Can surveillance be simplified? Endoscopy 2002;34:979-83.  Back to cited text no. 5
    
6.
Tsai TL, Changchien CS, Hu TH, Hsiaw CM. Demonstration of gastric submucosal lesions by high-resolution transabdominal sonography. J Clin Ultrasound 2000;28:125-32.  Back to cited text no. 6
    
7.
Maderal F, Hunter F, Fuselier G, Gonzales-Rogue P, Torres O. Gastric lipomas – An update of clinical presentation, diagnosis, and treatment. Am J Gastroenterol 1984;79:964-7.  Back to cited text no. 7
    
8.
Miettinen M, Sarlomo-Rikala M, Sobin LH, Lasota J. Gastrointestinal stromal tumors and leiomyosarcomas in the colon: A clinicopathologic, immunohistochemical, and molecular genetic study of 44 cases. Am J Surg Pathol 2000;24:1339-52.  Back to cited text no. 8
    
9.
Boyce GA, Sivak MV Jr., Rösch T, Classen M, Fleischer DE, Boyce HW Jr., et al. Evaluation of submucosal upper gastrointestinal tract lesions by endoscopic ultrasound. Gastrointest Endosc 1991;37:449-54.  Back to cited text no. 9
    
10.
Yasuda K, Cho E, Nakajima M, Kawai K. Diagnosis of submucosal lesions of the upper gastrointestinal tract by endoscopic ultrasonography. Gastrointest Endosc 1990;36:S17-20.  Back to cited text no. 10
    
11.
Palazzo L, Landi B, Cellier C, Cuillerier E, Roseau G, Barbier JP, et al. Endosonographic features predictive of benign and malignant gastrointestinal stromal cell tumours. Gut 2000;46:88-92.  Back to cited text no. 11
    
12.
Matsushita M, Hajiro K, Okazaki K, Takakuwa H. Gastric aberrant pancreas: EUS analysis in comparison with the histology. Gastrointest Endosc 1999;49:493-7.  Back to cited text no. 12
    
13.
Lucena JF, Alvarez OA, Gross GW. Endoscopic resection of heterotopic pancreas of the minor duodenal papilla: Case report and review of the literature. Gastrointest Endosc 1997;46:69-72.  Back to cited text no. 13
    
14.
Görg C, Weide R, Schwerk WB. Sonographic patterns in extranodal abdominal lymphomas. Eur Radiol 1996;6:855-64.  Back to cited text no. 14
    
15.
Wotherspoon A, Chott A, Gascoyne RD, Muller-Hermelink HK. Lymphoma of the stomach. In: Aaltonen LA, editor. World Health Organization Classification of Tumors: Pathology and Genetics of Tumors of the Digestive System. Lyon: IARC Press; 2000. p. 57-61.  Back to cited text no. 15
    
16.
Levine MS, Rubesin SE, Pantongrag-Brown L, Buck JL, Herlinger H. Non-Hodgkin's lymphoma of the gastrointestinal tract: Radiographic findings. AJR Am J Roentgenol 1997;168:165-72.  Back to cited text no. 16
    
17.
Buy JN, Moss AA. Computed tomography of gastric lymphoma. AJR Am J Roentgenol 1982;138:859-65.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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