Diagnostic procedures for submucosal tumors in the gastrointestinal tract

Table 1 Macroscopic and endoscopic ultrasound features of the submucosal tumors

	Endo-scopical	Size	Distinctborders	Ulcer	Layer	Form	Echogenecity		Number	Consistency
Leiomyoma[3,21,22,29,32,63,101-105]	Umbilicated	< 5 cm	Yes	Central or normal mucosa	4th (2nd)	Smooth	Homo	Hypo	-	Firm
Granular cell tumor[4,22,28,60,62,63,106-108]	Yellow	< 2 cm	Mostly no	No	2nd, 3rd, 4th	Sessile polyps, nodules or plaques	Mosaic	Hypo	S (M)	Very firm
Ectopic pancreas[4,13,21,22,31,64,66]	Duct opening	1-4 cm	Yes (no)	No	3rd,4th (2nd, 5th)	Sessile, hemispherical	Perhaps hetero	Hyper	S	Firm
Schwannoma [19,22,28,58,95,109]	Spherical (multi- nodular)	3 cm (0.5-10 cm)	Yes (sometimes fibrous capsule)	No	4th (3rd)	Round/oval (multinodular)	(Homo)	Hypo, bull's eye5	S (M)	-
Lipoma[4,13,21,22,29,32,67,110,111]	Yellow	-	Yes, pseudocapsule	Most often intact mucosa, but ulcers do occur	3rd (4th, 5th)	Polypoid, discrete, round	Homo	Hyper	S	Soft, compressible
3Neurofibroma [28,50,68,74,112]	Some times long segments of nodular thickening	Few mm. up to a meter	Yes, often macroscopically	No	May involve all layers	Fusiform, diffuse, "ropelike" or "bag of worms"	Hetero	-	M	Rubbery or firm
Vascular[4,13,21,28,29,73,113]	Lymph- angiomas: yellow	Depending on type	Yes	No	2nd, 3rd; cavernous may involve all layers	Round/ oval/ wavy	Homo	An-/hyper1	M/S	Liquid/soft
Leiomyosarcoma [21,22,32,43,72,78]	Exophytic	> 3 cm	Irregular	Deep ulcer (> 5 mm)	2nd, 4th	Nodular, polypous	Hetero	An- areas2	S	Softer than leiomyomas
Kaposi’s sarcoma [4,43,63,85]	Red-purple	Varying (see text)	-	Often ulceration and bleeding	1st, 2nd, 3rd	Maculopapular/ nodular/ polypous	-	-	M/S	-
Metastases[6,22,86,114]	Endo-/ exophytic	-	No	Yes/No	All layers	Volcanolesions, nodules, polyps, linitis plastica	Depends on the primary tumor	-	M/S	-
GIST[4,13,19,22,50,93]	Varying	> 2 cm	Yes/no	Occasionally	4th (2nd, 3rd, 5th)	Elliptical, multilobular/ pedunculated; smooth/nodular	Homo/ hetero4	Hypo, bull's eye5	S3	Friable

¹Hyperechoic in lymphangiomas[13].

²The anechoic areas are histologically consistent with necrotic areas[21].

³Neurofibromatosis type 1 is associated with gastrointestinal stromal tumors (GIST). GIST are often multiple in neurofibromatosis type 1[50].

⁴Normally gastrointestinal stromal tumors are homogenic, but if the tumor is large, central necrosis (cystic spaces) can result in heterogeneity[19,44]. Furthermore, echogenic foci and calcifications may be seen[19].

⁵A hypoechoic, marginal halo resulting in a bull's eye appearance of the SMT[19]. Homo: homogeneous; Hetero: heterogeneous; Hypo: hypoechoic; Hyper: hyperechoic; An: anechoic. -: means that no date was found on the subject.

Table 2 Endoscopic ultrasonographic criteria for malignancy in different SMTs

Reference	Tumor type	Criteria fordetermining theSMT as malignantor borderline	Size	Irregularborders	Abnormalregionallymphnodes	Heterogeneouscho pattern		Shape notoval/round	Ulcer
						Cysticspaces	Echo-genicfoci
Ando et al 2002[30]	GIST	Size > 5 cm and at least 1 of the 2 other features:	> 5 cm	Yes	-	Yes	-	-	-
Nickl et al 2002[20]	Hypo- echoic SMTs	1 or more of the features:	> 3 cm	Yes	Yes	No	No	Yes	Yes
Brand et al 2002[24]	SMTs in general	2 or more of the features or 1 and clinical symptoms (pain, dysphagia, weight loss, hemorrhage)	> 3 cm	Yes	-	Heterogeneous echo pattern		-	-
Rösch et al 2002[12]	SMTs in general	2 or more of the features:	> 3 cm	Yes	Yes	Heterogeneous echo pattern		-	-
Palazzo et al 2000[23]	GIST	2 or more of the features:	-	Yes	Yes	Yes	-	-	-
Chak et al 1997[115]	GIST	2 or more of the features:	> 4 cm	Yes	-	> 4 mm	> 3 mm	-	-

Nickl and coworkers[20] had the highest sensitivity rate (100%) while Palazzo and coworkers[23] had the highest specificity rate (88%). -: means that this feature was not part of the criteria in the given study.