Endosonographic Characteristics of Subepithelial Lesions of the Upper Digestive Tract: Experience of a Referral Center in Colombia

Introduction: Subepithelial lesions (SELs), described as bulges or masses covered by healthy-looking mucosa, are usually found incidentally during endoscopic studies. They are typically asymptomatic and are estimated to be identified in 1% of esophagogastroduodenoscopies performed. Materials and methods: A descriptive study was conducted with retrospective data collection. We included all patients treated at the Unión de Cirujanos, a referral gastroenterology unit of the Coffee Region in Manizales, between January 2020 and January 2022, who underwent endoscopic ultrasonography to study subepithelial-looking lesions located in the esophagus, stomach, and duodenum. Results: 152 endoscopic ultrasounds were performed, finding 108 SELs; 66.6% of the patients were women, and the average age was 58. Most SELs were located in the stomach (78.7%), the antrum being the most frequent location. The average diameter of the gastric SELs was 14.6 mm, and 47% of the lesions depended on the fourth echolayer; the most frequent presumptive diagnoses were gastrointestinal stromal tumor (GIST; 65.8%) and lipoma (11.7%). Conclusions: SELs of the GI tract originate in the muscularis mucosae, submucosa, or muscularis propria. They are most frequently located in the stomach, and their characterization usually requires endoscopic ultrasonography and histopathology. Treatment of these lesions remains controversial due to their low frequency, histological variety, and low malignant potential.

Introducción: las lesiones subepiteliales (LSE), descritas como abultamientos o masas cubiertas por mucosa de aspecto sano, se encuentran usualmente de manera incidental durante estudios endoscópicos; suelen ser asintomáticas y se estima que se identifican en el 1% de las esofagogastroduodenoscopias realizadas. Métodos: se realizó un estudio descriptivo con recolección retrospectiva de la información. Se incluyeron todos los pacientes atendidos en Unión de Cirujanos, unidad de gastroenterología de referencia del Eje Cafetero ubicada en la ciudad de Manizales, entre enero de 2020 y enero de 2022, a quienes se les realizó ultrasonografía endoscópica como parte del estudio de lesiones de aspecto subepitelial localizadas en el esófago, estómago y duodeno. Resultados: se realizaron 152 endosonografías y se encontraron 108 lesiones subepiteliales, 66,6% de los pacientes eran mujeres y el promedio de edad fue 58 años. La mayoría de las LSE se localizaron en el estómago (78,7%) y, de estas, la localización más frecuente fue el antro; el diámetro promedio de las LSE gástricas fue de 14,6 mm y el 47% de las lesiones eran dependientes de la cuarta ecocapa; los diagnósticos presuntivos más frecuentes fueron el tumor del estroma gastrointestinal (GIST; 65,8%) y lipoma (11,7%). Conclusiones: las LSE del tracto gastrointestinal se originan en la muscular de la mucosa, submucosa o muscular propia, de manera más frecuente se localizan en el estómago y su caracterización suele requerir la realización de ultrasonografía endoscópica y estudio histopatológico. El tratamiento de estas lesiones sigue siendo controversial debido a su baja frecuencia, variedad histológica y bajo potencial maligno.

Páncreas ectópico, diagnóstico diferencial de lesión gástrica subepitelial: reporte de caso y enfrentamiento inicial / Ectopic pancreas, differential diagnosis of subepithelial gastric lesion: case report and initial confrontation

Subepithelial lesions are generally an incidental diagnosis with an prevalence of 0.4%. These tumors represent a great diagnostic challenge, mainly when ruling out potentially malignant lesions, such as gastrointestinal stromal tumor (GIST), lymphomas and carcinomas. Among the many differential diagnosis, the ectopic pancreas arises with an prevalence of 1-2% in general population. The first diagnostic approach is performed using upper digestive endoscopy, computed tomography and endosonography. This last one has a diagnostic performance of less than 50%, which increases to 90% when it is associated with a histopathological examination. There is no current consensus regarding the management and monitoring of these lesions. Based on the imaging and histological characteristics, the possibilities range from observation to endoscopic or surgical resection. In this context, we will present a clinical case of ectopic pancreas as an incidental finding, and afterwards the diagnostic and therapeutic breakdown of subepithelial lesions.

Las lesiones subepiteliales son pesquisadas generalmente de manera incidental, con una prevalencia de 0,4%. Estos tumores suponen un gran desafío diagnóstico, principalmente al momento de descartar lesiones potencialmente malignas, como el tumor estromal gastrointestinal (GIST), linfomas y carcinomas. Dentro de los posibles diagnósticos, surge el páncreas ectópico, con una prevalencia de hasta 1-2% en la población general. La primera aproximación diagnóstica se realiza mediante endoscopia digestiva alta, tomografía computarizada y la endosonografía, ésta última con un rendimiento diagnóstico menor del 50%, que aumenta hasta el 90% al asociar el examen histopatológico. No existe consenso actual respecto al manejo y seguimiento de estas lesiones, que según sus características imagenológicas e histológicas, va desde la observación hasta la resección endoscópica o quirúrgica. En este contexto, se presenta un caso clínico de páncreas ectópico como hallazgo incidental y el desglose diagnóstico y terapéutico de las lesiones subepiteliales.

Clinical Significance of Extraluminal Compressions according to the Site of the Duodenum

BACKGROUND/AIMS: Differentiating extraluminal compressions from true subepithelial tumors in the duodenum by endoscopy alone is difficult. Endoscopic ultrasonography (EUS) is one of the most useful diagnostic modalities for this purpose. Extraluminal compression in the duodenum is occasionally observed, but its clinical significance has not been reported. Therefore, the aim of this study was to evaluate the clinical significance of extraluminal compression in the duodenum according to lesion location. MATERIALS AND METHODS: We retrospectively evaluated 22 patients diagnosed as having extraluminal compression in the duodenum based on EUS findings between January 2006 and December 2017. Some patients underwent abdominal computed tomography for accurate diagnosis. RESULTS: The location of the extraluminal compression was the duodenal bulb in 10 cases, the superior duodenal angle in 10 cases, and the second portion of the duodenum in 2 cases. Of the 22 cases, 12 were caused by normal structures, including vessels, the right kidney, the gallbladder, and the pancreas, and 10 were caused by pathological lesions, including the hepatic cyst, remnant cystic duct and dilated common bile duct after cholecystectomy; gallstones, gallbladder polyps, remnant cystic duct cancer, and pseudomyxoma peritoneii. The anterior wall of the duodenum was the most frequent location of extraluminal compression. However, the lesions in the anterior wall of the duodenal bulb and superior duodenal angle showed a high frequency of pathologic lesions, including malignancy. CONCLUSIONS: If the extraluminal compression is found in the anterior wall of the duodenum, EUS is needed because of the high frequency of pathological lesions.

Esophageal Basaloid Squamous Carcinoma Treated by Endoscopic Resection and Radiation / 대한소화기학회지

Esophageal basaloid squamous carcinoma (BSC) is a rare, aggressive variant of squamous cell carcinoma. BSC is usually diagnosed in advanced stage and its prognosis is relatively poor. A 59-year-old male with subepithelial lesion of the esophagus that was incidentally discovered during health promotion examination was referred to our hospital. Esophagogastroduodenoscopy showed a 10-mm bulging mucosa with an intact surface at 34 cm from incisor teeth. Endoscopic ultrasonography revealed a smooth margined homogenous hypoechoic lesion, measuring 11.3×3.9 mm with a submucosal layer of origin. The patient underwent endoscopic mucosal resection of the subepithelial lesion. Pathologic examination of the resected specimen revealed BSC with involvement of vertical margin by tumor. The patient then underwent radiotherapy, and is doing well without recurrence for 35 months. We report a case of esophageal BSC confined to submucosal layer successfully treated with endoscopic resection followed by radiation.

Colorectal Subepithelial Lesions

Most of subepithelial lesion (SEL) being identified was accidentally discovered as small bulging lesion covered with normal mucosa from endoscopic screening. The type of treatment and prognosis vary depending on the type of tumor, it would be crucial to perform an accurate differential diagnosis. Since the differentiation of SEL relied on the indirect findings observed from the mucosal surface using an endoscopy only in the past, it was able to confirm the presence of lesion only but difficult to identify complex detailed nature of the lesion. However, after the endoscopic ultrasonography (EUS) was introduced, it became possible to identify extrinsic compression, and size of intramural tumors, internal properties and contour so that it gets possible to have differential diagnosis of lesions and prediction on the lesion whether it is malignant or benign. In addition, the use of EUS-guided fine needle aspiration and EUS-guided core biopsy made it possible to make histological differential diagnosis. This study intended to investigate endoscopic and EUS findings, histological diagnosis, treatment regimen and impression of colorectal SELs.

Acurácia da ultrassonografia endoscópica no diagnóstico diferencial dos abaulamentos subepiteliais do trato gastrointestinal / Accuracy of endoscopic ultrasound in the differential diagnosis of subepithelial bulging of the gastrointestinal tract

Introdução: A ultrassonografia endoscópica é importante ferramenta para o diagnóstico diferencial dos abaulamentos subepiteliais do trato gastrointestinal por permitir delinear as diferentes camadas da parede do tubo digestivo. Neste estudo, analisamos o papel do método na avaliação das lesões intramurais subepiteliais e das compressões extrínsecas do trato gastrointestinal. Métodos: Uma análise retrospectiva do papel da ultrassonografia endoscópica para pacientes encaminhados com abaulamentos subepiteliais do esôfago, estômago, duodeno e retossigmoide foi conduzida em um centro de referência pelo mesmo examinador (CVL). Os achados ecográficos analisados foram a natureza da lesão, sua camada de origem, tamanho, bordos, ecogenicidade, homogeneidade e diagnóstico presuntivo. Resultados: De setembro/2009 a março/2013, 126 pacientes (63,5% mulheres; idade média: 51,6 anos) com 128 abaulamentos subepiteliais à endoscopia foram analisados. Das 128 lesões, 104 (81,2%) eram lesões intramurais. Outros 24 (18,8%) abaulamentos eram compressões extrínsecas, na maioria dos casos (n = 21), por órgãos e estruturas normais. Para a detecção de lesões intramurais pela imagem da ultrassonografia endoscópica, a sensibilidade, especificidade, valores preditivos positivo e negativo, e a acurácia do método foram de, respectivamente, 98,1%, 92%, 98,1%, 92% e 96,9%. Por sua vez, para a detecção de compressões extrínsecas pela ultrassonografia endoscópica, os mesmos parâmetros foram de, respectivamente, 92%, 100%, 100%, 98,1% e 98,5%. Quando da punção ecoguiada para lesões intramurais, agulhas calibrosas e lesões maiores de 2cm apresentaram melhores resultados quanto ao diagnóstico diferencial. Conclusões: A ultrassonografia endoscópica é método de grande acurácia para o diagnóstico diferencial entre lesões subepiteliais intramurais e compressões extrínsecas do trato gastrointestinal (AU)

Introduction: Endoscopic ultrasonography is an important tool for the differential diagnosis of gastrointestinal subepithelial bulges because it allows to outline the different layers of the wall of the digestive tract. In this study, we analyzed the role of the method in the evaluation of subepithelial intramural lesions and extrinsic compressions of the gastrointestinal tract. Methods: A retrospective analysis of the role of endoscopic ultrasound for patients with subepithelial bulges of the esophagus, stomach, duodenum and rectosigmoid was conducted in a reference center by the same examiner (CVL). The sonographic findings analyzed were the nature of the injury, its layer of origin, size, borders, echogenicity, homogeneity, and presumptive diagnosis. Results: From September 2009 to March 2013, 126 patients (63.5% women, mean age: 51.6 years) with 128 subepithelial bulges at endoscopy were analyzed. Of the 128 lesions, 104 (81.2%) were intramural lesions. Other 24 (18.8%) bulges were extrinsic compressions, in most cases (n = 21) by normal organs and structures. For the detection of intramural lesions by endoscopic ultrasound image, the sensitivity, specificity, positive and negative predictive values, and accuracy of the method were, respectively, 98.1%, 92%, 98.1%, 92% and 96.9%. In turn, for the detection of extrinsic compression by endoscopic ultrasound, the same parameters were, respectively, 92%, 100%, 100%, 98.1% and 98.5%. For ultrasonographic-guided puncture for intramural lesions, thicker needles and lesions larger than 2 cm showed better outcomes concerning differential diagnosis. Conclusions: Endoscopic ultrasound is a highly accurate method for the differential diagnosis between subepithelial intramural lesions and extrinsic compressions of the gastrointestinal tract (AU)

Acurácia da ultrassonografia endoscópica no diagnóstico diferencial dos abaulamentos subepiteliais do trato gastrointestinal / Accuracy of endoscopic ultrasound in the differential diagnosis of subepithelial bulging of the gastrointestinal tract

INTRODUÇÃO: A ultrassonografia endoscópica é importante ferramenta para o diagnóstico diferencial dos abaulamentos subepiteliais do trato gastrointestinal por permitir delinear as diferentes camadas da parede do tubo digestivo. Neste estudo, analisamos o papel do método na avaliação das lesões intramurais subepiteliais e das compressões extrínsecas do trato gastrointestinal. MÉTODOS: Uma análise retrospectiva do papel da ultrassonografia endoscópica para pacientes encaminhados com abaulamentos subepiteliais do esôfago, estômago, duodeno e retossigmoide foi conduzida em um centro de referência pelo mesmo examinador (CVL). Os achados ecográficos analisados foram a natureza da lesão, sua camada de origem, tamanho, bordos, ecogenicidade, homogeneidade e diagnóstico presuntivo. RESULTADOS: De setembro/2009 a março/2013, 126 pacientes (63,5% mulheres; idade média: 51,6 anos) com 128 abaulamentos subepiteliais à endoscopia foram analisados. Das 128 lesões, 104 (81,2%) eram lesões intramurais. Outros 24 (18,8%) abaulamentos eram compressões extrínsecas, na maioria dos casos (n = 21), por órgãos e estruturas normais. Para a detecção de lesões intramurais pela imagem da ultrassonografia endoscópica, a sensibilidade, especificidade, valores preditivos positivo e negativo, e a acurácia do método foram de, respectivamente, 98,1%, 92%, 98,1%, 92% e 96,9%. Por sua vez, para a detecção de compressões extrínsecas pela ultrassonografia endoscópica, os mesmos parâmetros foram de, respectivamente, 92%, 100%, 100%, 98,1% e 98,5%. Quando da punção ecoguiada para lesões intramurais, agulhas calibrosas e lesões maiores de 2cm apresentaram melhores resultados quanto ao diagnóstico diferencial. CONCLUSÕES: A ultrassonografia endoscópica é método de grande acurácia para o diagnóstico diferencial entre lesões subepiteliais intramurais e compressões extrínsecas do trato gastrointestinal

INTRODUCTION: Endoscopic ultrasonography is an important tool for the differential diagnosis of gastrointestinal subepithelial bulges because it allows to outline the different layers of the wall of the digestive tract. In this study, we analyzed the role of the method in the evaluation of subepithelial intramural lesions and extrinsic compressions of the gastrointestinal tract. METHODS: A retrospective analysis of the role of endoscopic ultrasound for patients with subepithelial bulges of the esophagus, stomach, duodenum and rectosigmoid was conducted in a reference center by the same examiner (CVL). The sonographic findings analyzed were the nature of the injury, its layer of origin, size, borders, echogenicity, homogeneity, and presumptive diagnosis. RESULTS: From September 2009 to March 2013, 126 patients (63.5% women, mean age: 51.6 years) with 128 subepithelial bulges at endoscopy were analyzed. Of the 128 lesions, 104 (81.2%) were intramural lesions. Other 24 (18.8%) bulges were extrinsic compressions, in most cases (n = 21) by normal organs and structures. For the detection of intramural lesions by endoscopic ultrasound image, the sensitivity, specificity, positive and negative predictive values, and accuracy of the method were, respectively, 98.1%, 92%, 98.1%, 92% and 96.9%. In turn, for the detection of extrinsic compression by endoscopic ultrasound, the same parameters were, respectively, 92%, 100%, 100%, 98.1% and 98.5%. For ultrasonographic-guided puncture for intramural lesions, thicker needles and lesions larger than 2 cm showed better outcomes concerning differential diagnosis. CONCLUSIONS: Endoscopic ultrasound is a highly accurate method for the differential diagnosis between subepithelial intramural lesions and extrinsic compressions of the gastrointestinal tract

Concordance of Endoscopic Ultrasonography-Guided Fine Needle Aspiration Diagnosis with the Final Diagnosis in Subepithelial Lesions

BACKGROUND/AIMS: In this study we aimed to determine the rate of concordance of endoscopic ultrasonography (EUS)-guided fine needle aspiration (FNA) diagnosis with the final diagnosis obtained by surgery or endoscopic resection and follow-up in upper gastrointestinal subepithelial lesions. METHODS: We retrospectively studied patients with subepithelial lesions who underwent EUS at our center from 2007 to 2011. RESULTS: We had a final diagnosis in 67 patients (mean age+/-SD, 51.23+/-12.48 years; 23 [34.3%] female, 44 [65.6%] male). EUS-FNA was performed in all of the patients. On-site pathology was not performed. In nine of the patients, the obtained material which was obtained was insufficient. The cytologic examination was benign in 31 and malignant in 27 of the patients. Based on the final diagnosis, the EUS-FNA had a sensitivity of 96%, a specificity of 100%, and a diagnostic yield of 85%. CONCLUSIONS: The diagnostic yield of EUS-FNA, in the absence of the on-site cytopathologist, is feasible for the diagnosis of subepithelial lesions of the upper gastrointestinal system.

Endoscopic Ultrasound, Where Are We Now in 2012?

Topics related with endoscopic ultrasound (EUS) made up considerable portion among many invited lectures presented in International Digestive Endoscopy Network 2012 meeting. While the scientific programs were divided into the fields of upper gastrointestinal (UGI), lower gastrointestinal, and pancreato-biliary (PB) categories, UGI and PB parts mainly dealt with EUS related issues. EUS diagnosis in subepithelial lesions, estimation of the invasion depth of early gastrointestinal cancers with EUS, and usefulness of EUS in esophageal varices were discussed in UGI sessions. In the PB part, pancreatic cystic lesions, EUS-guided biliopancreatic drainage, EUS-guided tissue acquisition, and improvement of diagnostic yield in indeterminate biliary lesions by using intraductal ultrasound were discussed. Advanced techniques such as contrast-enhanced EUS, EUS elastography and forward-viewing echoendoscopy were also discussed. In this paper, I focused mainly on topics of UGI and briefly mentioned about advanced EUS techniques since more EUS related papers by other invited speakers were presented afterwards.

A Case of Endoscopic Resection of a Colonic Semipedunculated Leiomyoma

During colonoscopic examination, epithelial lesions, such as adenomatous polyps, are frequently encountered, unlike subepithelial lesions, such as leiomyomas, which are uncommon. A colonic leiomyoma is a rare tumor, originating either from the mucularis mucosa or from the proper muscle, and accounts for only 3% of all gastrointestinal leiomyomas. Colonic leiomyomas are usually benign and asymptomatic. However, they can sometimes cause symptoms, ie, abdominal pain, intestinal obstruction, hemorrhage, and perforation. The traditional management option for a colonic leiomyoma is surgical resection. Recently, with the development of endoscopy devices and techniques, the endoscopic resection has been considered as an alternative treatment option. We experienced a patient with a leiomyoma that was diagnosed during colonoscopy. The leiomyoma was resected endoscopically without complication. We report this case with a review of the literature.

Diagnostic Use of Endoscopic Ultrasound-guided Trucut Biopsy in Various Diseases / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic ultrasound-guided trucut biopsy (EUS-TCB) is a relatively new method, which facilitates obtaining a core biopsy through the gut wall. We evaluated the diagnostic accuracy of EUS-TCB based on the types of lesions. METHODS: We retrospectively reviewed the database of 37 cases in 35 patients (mean age, 57.2+/-2.3 years; 23 men) with thoracic and abdominal masses who got EUS-TCB between January 2007 and June 2008. Final diagnoses were determined by malignant positive EUS specimens, surgical pathology, or the clinical course. RESULTS: Adequate samples were obtained by EUS-TCB in 78.4% (29/37) of the cases. The overall diagnostic accuracies of the EUS-TCB were 73.0%. The mean size of the masses was 3.7+/-2.6 cm. The diagnostic accuracies of EUS-TCB according to the lesions were as follows: lymph node, 85.7% (18/21); subepithelial lesion, 60.0% (6/10); and solid tumor, 50% (3/6). With respect to accuracy, lymph nodes were significantly superior to non-lymph node lesions (p=0.046). There was a minor bleeding controlled by hemoclipping (2.7%). CONCLUSIONS: EUS-TCB is a useful technique for the diagnosis of lymph nodes, subepithelial tumors, and solid tumors that were not able to be diagnosed by other methods. In addition, EUS-TCB is a safe and minimally invasive method.

Diagnostic Yield of Tissue Sampling Using a Bite-On-Bite Technique for Incidental Subepithelial Lesions

BACKGROUND/AIMS: Techniques for endoscopic evaluation of gastrointestinal subepithelial lesions include conventional endoscopy, jumbo biopsy, endoscopic ultrasonogrphy (EUS), EUS-guided fine needle aspiration, and endoscopic submucosal resection. However, these procedures have many limitations, such as low diagnostic yields and high complication rates. We therefore evaluated the diagnostic yield for tissue sampling of incidental subepithelial lesions using the bite-on-bite technique. METHODS: One hundred and forty subepithelial lesions were found in 129 patients during conventional diagnostic esophagogastroduodenoscopy by one examiner from October 2003 to November 2004. Bite-on-bite biopsies with conventional-sized forceps were taken from 36 patients having 37 lesions that did not appear to be hypervascular or to have a thick overlying epithelium. Two to eight bites were performed to obtain submucosal tissue for one lesion. RESULTS: The bite-on-bite technique was diagnostic in 14 of the 37 lesions (38%). Blood oozing for more than 30 seconds occurred in five cases, but was easily controlled by epinephrine injection (2 cases) or hemoclip (3 cases). The diagnostic yield tended to be higher in the esophagus than in the stomach and duodenum (54% vs. 28%, p=0.109). CONCLUSIONS: The bite-on-bite technique for subepithelial lesions is an effective and safe method in selected cases. This technique may be useful for incidental subepithelial lesions, especially those of the esophagus, except for ones with a high risk of bleeding or thick overlying epithelium.

Catheter Probe Endoscopic Ultrasonography Using the Jelly-Filled Method for Esophageal Subepithelial Lesions / 대한소화기내시경학회지

BACKGROUND/AIMS: The catheter probe endoscopic ultrasonography (EUS) system is widely used to evaluate upper gastrointestinal tract lesions. The depiction of the esophageal wall by probe EUS remains problematic due to the difficulty of the filling of water in the esophageal lumen. In addition, filling the esophagus with water can be associated with an increased risk of aspiration. To resolve such problems, we recently applied the use of probe EUS with the jelly-filled method for the evaluation of subepithelial lesions. The procedure is characterized by filling the esophageal lumen with jelly. In this study, we evaluated the efficacy of probe EUS by using the jelly-filled method for esophageal subepithelial lesions. METHODS: We analyzed the records of the patients with suspected subepithelial lesions at the time of endoscopy that was performed from November 2005 to June 2007. Esophageal subepithelial lesions with both EUS findings and pathological reports were retrospectively compared. RESULTS: The study included 181 patients (96 males, 85 females), with an average age of 55.5 years (age range, 29~78 years). Sixty-eight patients had lesions in the upper esophagus, 60 patients had lesions in the middle esophagus and 53 patients had lesions in the lower esophagus. Secondary layers of esophageal lesions were predominant (91/181) in the cases. Pathological findings were available for 34 patients. Compared with the pathological findings, the diagnostic accuracy of EUS was 91.1%. CONCLUSIONS: Probe EUS by using the jelly-filled method is convenient and safe to perform and provides clear and full-circumferential imaging of a lesion. It is an alternative method to use in place of previously used probe-EUS procedures for the assessment of esophageal subepithelial lesions.

Endoscopic Ultrasonography in Upper Gastrointestinal Subepithelial Lesions / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic ultrasonography (EUS) is known for its value to characterize incidentally found subepithelial lesions, and we so reviewed our data to validate the norm. METHODS: We analyzed the records of the patients with suspected subepithelial lesions at the time of endoscopy, which was performed from Aug. 2001 to Oct. 2004. RESULTS: The data includes 622 patients (248 males) with average age of 52 years (age range 15~83 years). Extraluminal compression was noted in 10.1% of the patients. Intraluminal lesions were dominant in the stomach and their average size was 14.8 mm. The inner three wall layers were the predominant layers of origin. Mesenchymal tumors were the most frequent EUS impression. Pathologic findings were available for 88 patients and 80.7% of them were benign. Compared with the pathology, the diagnostic accuracy of EUS was 78.4%. The differentiation of malignant and benign GISTs by the EUS findings was 56.3%. Among the 60 EUS cases that had follow up data available (at mean interval of 12.2 months) and who also had less than 3 cm benign lesions, growth was detected only in 10 cases (17%). Pathology confirmed that the lesions in 3 of them were benign. CONCLUSIONS: More than 10% of the subepithelial lesions found from endoscopy were extraluminal compression. The majority of intramural lesions were benign. The EUS impression was relatively accurate and helpful for the management of upper gastrointestinal submucosal lesions.