Endoscopic Ultrasound and Endoscopic Ultrasound-Guided Fine-Needle Biopsy for the Diagnosis of Malignant Submucosal Tumors

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Abstract
Epidemiological data are scant and imprecise, but approximately one in every 300 routine endoscopies reveals a bulging of the gastrointestinal wall covered by smooth mucosa of normal appearance [ 1 ] (Figure [ 1 ]). Such a finding, though usually incidental, raises questions of clinical significance: Does the bulging represent a pathology that is real or only a figment of the endoscopist’s imagination? Does it result from pressure on the wall from the outside, and if so, what is the compressing structure? Or is there a tumor deep in the wall, under the smooth surface of the overlying mucosa, a so-called submucosal tumor (SMT)? Finally, and most importantly, what is the risk that the lesion in question is malignant and requires treatment? Figure 1 a Endoscopic appearance of a small gastric submucosal tumor (SMT) and extraluminal compression (EC) caused by an adjacent bowel loop or the gallbladder. b There was little doubt in this case that the larger bulge was caused by an extraluminal structure because after a while it started moving and finally disappeared; however, endoscopic differentiation between SMTs and extraluminal compression is usually not that easy. False-positive diagnosis of a tumor in a patient with extraluminal compression is the most common error. Endoscopic ultrasound (EUS) has been used for more than two decades to answer these questions in everyday clinical practice; over the same period many studies have provided numerous data on the capabilities and limitations of this method. This review focuses on the endosonographic diagnosis of malignant SMTs and the role that EUS-guided needle biopsy plays in this setting.

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