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Solitary primary extraosseous plasmacytoma is a rare disease in the gastrointestinal tract, recently classified as an "exceptional" tumor of the colon site. The real incidence (one case/population/year) is unknown but reasonably less than 1/10,000,000 cases/year with very few descriptions in the literature. The rare cases described in the literature are often diagnosed after surgery for perforation and with predominant localization of the left colon. The main endoscopic presentation mimics colon carcinoma with ulcerated mass and obstructing lumen. In this paper, we report a rare case of isolated mass mimicking a submucosal lesion of the ascending colon diagnosed in an older female patient by colonoscopy. The patient was almost asymptomatic; she reported only a history of hematochezia without anemia. This mass was successfully treated by surgery and followed by hematological investigations, including bone marrow biopsy, specific laboratory tests, and CT/PET scan, which confirmed primary isolated plasmacytoma of the colon.

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Gastritis cystica profunda (GCP) has been defined as a rare submucosal benign gastric lesion with cystic gland growth. Due to its unclear etiopathogenesis, this lesion is often misdiagnosed and mistaken for other gastric masses. Currently, a standardized treatment for GCP lesions is still missing. Here, we illustrate a case of a patient admitted to our general surgery department for melena and general discomfort. No history of peptic ulcer or gastric surgery was present. Upper GI endoscopy was performed, showing a distal gastric lesion with a small ulceration on the top. CT-scan and endoscopic ultrasound confirmed the presence of the lesion, compatible with a gastric stromal tumor, without showing any eventual metastasis. Surgical gastric resection was performed. Histological findings were diagnostic for GCP, with cistically ectasic submucosal glands, chronic inflammation, eosinophilic infiltration and foveal hyperplasia. GCP is a very exceptional cause of upper-GI bleeding with specific histological features. Its diagnosis as well as its therapy are challenging, resulting in several pitfalls. Even though it is a rare entity, GCP should always be considered in the differential diagnosis of gastric submucosal lesions.

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OBJECTIVE: To determine the accuracy of endoscopic ultrasonography (EUS) in the diagnosis of upper gastrointestinal submucosal lesions (SMLs). METHODS: This was a retrospective study involving patients diagnosed with SMLs using EUS and confirmed by histopathology from November 2014 to December 2020 at The Third Xiangya Hospital of Central South University. RESULTS: A total of 231 patients with SMLs were examined by EUS. Histologically, 107 lesions were stromal tumors, and 75 lesions were leiomyomas. Stromal tumors were mainly located in the stomach (89.7%), and leiomyomas were predominantly seen in the esophagus (69.3%). The diagnostic accuracy of EUS for stromal tumors and leiomyomas was 80.4% and 68.0%, respectively. The diagnostic accuracy was highest for lesions located in the muscularis mucosa. The mean diameter of stromal tumors measured using EUS was significantly larger than that of leiomyomas (21.89 mm vs. 12.35 mm, p < 0.001). Stromal tumors and leiomyomas originated mainly from the muscularis propria (94.4%) and the muscularis mucosa (56.0%), respectively. Compared with the very low-risk and low-risk groups of stromal tumors according to the National Institute of Health guidelines, the intermediate-risk and high-risk groups were more likely to have a lesion > 3 cm (p < 0.001) and a surface ulcer (p < 0.01) identified by EUS. CONCLUSIONS: EUS has good diagnostic value for the diagnosis of upper gastrointestinal SMLs based on the lesion size and the muscle layer of origin. The diagnostic accuracy of EUS lesions is related to the origin, and the diagnostic accuracy is greatest in the mucosal muscularis layer. Stromal tumors > 3 cm and a surface ulcer on EUS are likely to be intermediate or high risk for invasion.

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A 34-year-old man presented to our hospital with a 2-month history of repeated dull upper abdominal pain. Gastroscopy and endoscopic ultrasonography indicated a hemispherical mass at the junction of the greater curvature and the gastric fundus, with hypoechogenicity originating from the intrinsic muscular layer. He was diagnosed with a gastric body submucosal lesion and gastrointestinal stromal tumor, and underwent endoscopic full-thickness resection. However, postoperative pathological examination of the mass unexpectedly revealed heterotopic spleen tissue (accessory spleen). Intragastric ectopic spleen tissue originating from the intrinsic muscular layer of the stomach is a rare clinical condition, with no specific clinical symptoms. This finding is of great clinical significance for the identification of gastric submucosal tumors.

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BACKGROUND: Esophagectomy is still advised as an additional treatment for pathological T1b (pT1b) esophageal squamous cell carcinoma (ESCC) following attempted endoscopic resection (ER). ER followed with definitive chemoradiotherapy (dCRT) has shown increased quality of life as well as comparable oncological outcomes to esophagectomy. However, there is no well-designed phase III trial to compare the two treatments for patients with pT1b ESCC. METHODS: One hundred seventy-six patients with clinical stage N0 (cN0) and pT1b ESCC will be recruited at three centers and randomly assigned to the esophagectomy group or the dCRT group. The clinical lymph node status will be measured by image examination, including computer tomography and positron emission tomography-computed tomography. The pathological tumor status will be diagnosed after endoscopic submucosal dissection (ESD). All patients will be followed up for 60 months after randomization. The primary endpoint is 5-year overall survival. The secondary endpoints are quality of life, related adverse events, 3-year overall survival, and relapse-free survival rates. DISCUSSION: To the best of our knowledge, this is the first phase III randomized controlled trial to compare esophagectomy and dCRT for patients with cN0-pT1b ESCC after ESD. Based on the results of this study, we will show whether dCRT will benefit patients more than esophagectomy, which will contribute more high-quality evidence to the primary salvage treatment for these patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04135664 . Registered on Aug. 10, 2019.

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BACKGROUND: Gastric bronchogenic cysts (BCs) are extremely rare cystic masses caused by abnormal development of the respiratory system during the embryonic period. Gastric bronchial cysts are rare lesions first reported in 1956; as of 2019, only 37 cases are available in the MEDLINE/PubMed online databases. BCs usually have no clinical symptoms in the early stage, and their imaging findings also lack specificity. Therefore, they are difficult to diagnose before histopathological examination. CASE SUMMARY: A 55-year-old woman presented at our hospital with intermittent epigastric pain. She had a slightly high level of serum carbohydrate antigen 72-4 (CA 72-4). Endoscopic ultrasound found that a cystic mass originated from the submucosa of the posterior gastric wall near the cardia, indicating a diagnosis of cystic hygroma of the stomach. Furthermore, a computed tomography scan demonstrated a quasi-circular cystic mass closely related to the lesser curvature of the gastric fundus with a low density. Because the imaging examinations did not suggest a malignancy and the patient required complete resection, she underwent laparoscopic surgery. As an intraoperative finding, this cystic lesion was located in the posterior wall of the fundus and contained some yellow viscous liquid. Finally, the pathologists verified that the cyst in the fundus was a gastric BC. The patient recovered well with normal CA 72-4 levels, and her course was uneventful at 10 mo. CONCLUSION: This is a valuable report as it describes an extremely rare case of gastric BC. Moreover, this is the first case of BC to present with elevated CA 72-4 levels.

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Teaching Point: A submucosal bladder wall lesion with high signal on T2-weighted MRI warrants blood and urine analysis to rule out a paraganglioma.

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BACKGROUND: Oesophageal cancer is the fourth most common cause of cancer-related deaths in India. Esophageal squamous cell carcinomas (ESCCs) arise from the epithelial layer, and commonly present as polypoidal, ulcerative or ulceroproliferative growth in the oesophageal lumen. In contrast, oesophageal submucosal tumours are a distinct group of tumours arising from the mesenchyme (examples include leiomyoma, fibrovasculoma, lipoma, granular cell tumour or carcinoid), and mostly do not breach the mucosa. Oesophageal submucosal tumours are a distinct group of tumours arising from the mesenchyme, and mostly do not breach the mucosa. Complete intramural growth of an advanced primary ESCC is an exceedingly rare presentation, with only six cases reported in the literature thus far. We herein report a case of primary ESCC with complete intramural invasion that endoscopically mimics a submucosal lesion. CASE SUMMARY: A 50 year old male presented with a progressive mechanical type of dysphagia for one month. His history was significant, including squamous cell carcinoma of the tongue that was treated with surgery and chemoradiation 1 year prior. Upper gastrointestinal endoscopy revealed a large, hemispherical lesion with normal-appearing overlying mucosa about 4 cm × 5 cm in size extending from 30-34 cm from incisors. The patient underwent endoscopic ultrasound (EUS), and a fine­needle biopsy was performed, which was suggestive for squamous cell carcinoma. We herein report a case of primary ESCC with complete intramural invasion, endoscopically mimicking a submucosal lesion. The diagnosis could be established only by a EUS-guided biopsy. CONCLUSION: This case report highlights that intramural ESCC may look like a submucosal lesion in endoscopy, and EUS biopsy is needed for final diagnosis.

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INTRODUCTION: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are commonly used for the minimally invasive treatment of submucosal lesions of the gastrointestinal tract. AIM: To evaluate the safety, efficacy, outcome and recurrence rate of EMR and ESD for mucosal and submucosal lesions in the colon and rectum. MATERIAL AND METHODS: Records of 26 patients who underwent ESD and EMR for mucosal and submucosal lesions in the colon and rectum between January 2013 and March 2018 in our endoscopy unit were retrospectively reviewed. RESULTS: A total of 26 patients (6 female and 20 male) were evaluated. The mean age of the patients was 58.03 ±15.19 (21-80). Fifteen patients underwent ESD and EMR for rectal lesions. Tubular adenomas were found in 3 of these patients, tubulo-villous adenomas in 2, inflammatory polyps in 1, neuroendocrine tumors in 2 and carcinomas in 7 (intramucosal, in-situ and invasive). Eleven patients underwent ESD and EMR for colonic lesions. Villous adenomas were found in 2 of these patients, tubular adenoma showing dysplasia in 2, tubulo-villous adenomas showing dysplasia in 1 and carcinoma (in-situ, invasive and intramucosal) in 6. Two lesions were resected with secondary transanal local excision to obtain free margins. The follow-up period was 3 to 48 months and no recurrence was observed. CONCLUSIONS: The EMR and ESD are reliable minimally invasive techniques with a low rate of complications and short hospital stay in the treatment of colon and rectal lesions, including early stage carcinomas of different size and morphology.

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INTRODUCTION: The growing incidence of gastrointestinal diseases forces to improve imaging techniques. Identification of lesions located inside the wall of intestinal tract or in close proximity often was not possible using endoscopy or computed tomography. AIM: To assess the usefulness of endosonography (EUS) in the differentiation between compression from the outside and intramural lesions of the upper gastrointestinal tract. MATERIAL AND METHODS: For 4 years 20,012 patients with performed gastroscopies were enrolled in the study. One hundred and ninety-nine patients (96 females, 103 males; age 62.2 ±14.1 years) with pathology of the wall of the upper gastrointestinal tract qualified for further diagnosis. Endosonography and computed tomography (CT) were performed in each patient. A chest CT was performed in patients with a lesion in the oesophagus. An abdomen CT was performed in patients with pathology in the stomach or duodenum. Based on the results of EUS, histopathology, and imaging, each patient qualified for treatment, endoscopic observation, surgery, or cancer treatment. RESULTS: In EUS 129 (64.8%) intramural lesions were identified. Five (2.5%) diagnoses were false negative. In 62 (31.2%) patients no intramural changes were recognised and three (1.5%) results were false positive. The sensitivity and specificity of EUS was 96.3% and 95.4%, respectively, with positive predictive value 90.7%, negative predictive value 97.8%, and overall accuracy 95% (p < 0.05). Endoscopic therapy was performed in 31 (15.6%) patients, and 99 (49.8%) were classified for endoscopic observation. Surgery was performed in 50 (25.1%) patients, and 19 (9.5%) patients required oncologic treatment. CONCLUSIONS: Endosonography exceeds computed tomography in differentiating compression from the outside and intramural lesions of the upper gastrointestinal tract.

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Purpose of Review The study aimed to discuss novel endoscopic approaches to resection of submucosal lesions. Recent Findings Endoscopic resection by excavation, full-thickness resection, and submucosal tunneling are by now well-documented techniques for submucosal tumor resection. Combined approaches with laparoscopy such as several variations of laparoscopic endoscopic cooperation surgery (LECS) and non-exposed wall-inversion surgery (NEWS) are also possible now. Reports of these approaches show good results. However, lesion size is the main limitation to these approaches. Summary Endoscopic submucosal tumor resection can be effectively done endoscopically or by endoscopy combined with laparoscopy. These techniques allow localized resection of lesions at difficult locations such as in the gastroesophageal junction with limited influence on the normal anatomy. Variations in techniques are being practiced worldwide striving to achieve complete resection with minimal disturbance of function or contamination. The choice between approaches depends largely on the size and site of the lesion and expertise available.

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Objective To investigate the role of endoscopic ultrasonography (EUS) in diagnosis and treatment of colorectal submucosal lesions. Methods EUS were applied in 74 patients with suspected colorectal submucosal lesions. According to the origin of submucosal lesion, the patients had received biopsy, endoscopic ultrasonography-fine needle aspiration (EUS-FNA) and endoscopic treatment or surgery. The correlation between EUS and clinical pathology is analyzed retrospectively. Results In the diagnosis based on EUS, there were 28 cases of neuroendocrine tumors (occurred in the rectum), 15 lipomas (4 cases occurred in ileocecal, 1 in transverse colon, 8 in ascending colon, 2 in sigmoid colon), 2 rectal gastrointestinal stromal tumor (1 in muscularis propria and the other in muscularis mucosa), 14 external pressure changes (9 ovarian tumor, 2 lymph nodes, 3 pelvic tumor), 5 cyst (4 in transverse colon, 1 in ascending colon), 1 gas cyst, 3 sigmoid colon endometriosis, 4 rectum malignant tumor invasion, 2 intestinal lymphoma. All the patients had received biopsy, EUS-FNA, endoscopic treatment or surgery. Compared with pathology, a total coincidence rate of 91.9% (68/74) was achieved by EUS, and 2 cases were pathologically diagnosed as leiomyoma, which is considered as rectal carcinoma by EUS at first, 1 case of intestinal lymphoma instead of lipoma, 2 inflammatory mass instead of malignant tumor around the rectum, and 1 rectal carcinoma instead of endometriosis. Conclusion The digestive tract structure could be showed clearly with EUS, and the size of the colon and rectal submucosal lesions, the layer of origin and the structural relationship of adjacent tissues could also be detected. Then, the appropriate treatment against the colon and rectal submucosal lesions would be adopted after the accurate judgment of lesions with EUS.

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BACKGROUND AND AIM: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumor of the gastrointestinal tract. However, little is known about the clinical presentation of GIST, especially small lesions. The purpose of the present study was to clarify the efficacy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for the diagnosis of GIST and to determine its clinical course. METHODS: Pathological and clinical records of GIST extracted from our institutional database between 1996 and 2012 were reviewed. All GIST cases were diagnosed pathologically by surgical specimen or EUS-FNA. To examine the efficacy of EUS-FNA for the diagnosis of GIST, the pathological findings of EUS-FNA were compared with the surgical findings from resected cases. Next, to clarify the clinical presentation of GIST, imaging findings and changes in tumor size over time were evaluated in follow up. RESULTS: Of 84 cases of GIST, 67 were resected surgically after EUS-FNA; tumor size was <20 mm in 19 patients, and ≥20 mm in 48 patients. For the diagnosis of small GIST<20 mm, sensitivity and positive predictive value of EUS-FNA were 81.3% and 100%, respectively. A total of 27 patients with GIST was follow up for more than 1 year. Tumor size increased significantly during follow up. However, generalized linear analysis showed that there was no significant relationship between tumor size and follow up period. CONCLUSIONS: The present results showed that even small GIST can be correctly identified by EUS-FNA. Moreover, size of small GIST increased significantly during follow up.

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OBJECTIVES: The purpose of this study was to evaluate the clinical value of catheter-based miniprobe sonography for diagnosis of esophageal submucosal lesions. METHODS: A total of 199 patients with esophageal submucosal lesions underwent miniprobe sonography via gastroscopy. The sonograms were reviewed, and the sonographic findings were compared with pathologic findings from specimens obtained by endoscopic or surgical dissection. RESULTS: The diagnoses for the 199 patients were as follows: 54 cysts, 58 leiomyomas, 25 stromal tumors, 26 venous aneurysms, 15 lipomas, and 21 extramural compressions. A total of 145 lesions were verified by surgery and pathologic examinations. The results for 139 lesions were confirmed by miniprobe sonography; 6 lesions were misdiagnosed. The diagnostic accuracy rate for miniprobe sonography was 95.9%. CONCLUSIONS: Miniprobe sonography can provide precise information about the size, location, border, and echogenicity of esophageal submucosal lesions. It has high diagnostic accuracy. Preoperative miniprobe sonography via gastroscopy may play an important role in the choice of therapy for esophageal submucosal lesions.

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We describe a case of gastric aberrant pancreas with acute pancreatitis followed up with subsequent endoscopic ultrasound. A 20-year-old woman known to have aberrant pancreas in the stomach was admitted to our hospital because of severe epigastralgia. Laboratory tests showed slight C reactive protein elevation without hyperamylasemia. Esophagogastroduodenoscopy revealed a swollen submucosal lesion (SML) to a greater degree compared with the previous findings. Subsequent endoscopic ultrasonography (EUS) revealed a swollen lesion of 35 mm in diameter. The internal echo-pattern was more hypoechoic than in the previous EUS. The border between the fourth layer (muscularis propria) and the SML was unclear. The anechoic lumen in the mass, considered as the ductal lumen, was dilated. Based on these results, we diagnosed the patient as having acute inflammation, resembling pancreatitis, in the aberrant pancreas.