Download PDF
CC BY 4.0 · Journal of Digestive Endoscopy 2025; 16(02): 102-103
DOI: 10.1055/s-0044-1795110
Learning Images

An Unusual Duodenal Subepithelial Lesion: A Challenging Case

Cristina Lucidi 
1   Emergency Department, Gastroenterology and Urgency Digestive Endoscopy Unit, S. Eugenio Hospital, Rome, Italy
,
Laura Conti
2   Gastroenterology and Urgency Digestive Endoscopy Unit, S. Eugenio Hospital, Rome, Italy
,
Francesca Biancaniello
3   Department of Translational and Precision Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
,
Daniele Lisi
2   Gastroenterology and Urgency Digestive Endoscopy Unit, S. Eugenio Hospital, Rome, Italy
,
Anthony Vignone 
3   Department of Translational and Precision Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
,
Valeria D'Ovidio
2   Gastroenterology and Urgency Digestive Endoscopy Unit, S. Eugenio Hospital, Rome, Italy
› Author Affiliations
Funding None.
› Further Information
Also available at
  Permissions and Reprints

An 88-year-old man with multiple comorbidities underwent a computed tomography scan that incidentally identified a 30 × 26 mm hypodense inhomogeneous solid nodular lesion between the duodenum and the pancreatic head, suspected for neoplasia ([Fig. 1]). Esophagogastroduodenoscopy ruled out mucosal duodenal alterations. Endoscopic ultrasound (EUS) revealed an oval hypoechoic lesion with slightly heterogeneous pattern and mild “fat stranding” originating from the muscularis propria ([Fig. 2A]). An evaluation of the microvasculature and parenchymal perfusion with EUS detective flow imaging (EUS-DFI) showed a mixed vascularity pattern ([Fig. 2B]), without “increased stiffness” at elastography. Based on ultrasound findings and lesion location, the main hypothesized diagnosis was a type IV gastrointestinal stromal tumor. A EUS with fine-needle biopsy (EUS-FNB) was performed using a 22-gauge needle (Acquire; Boston Scientific) with a fanning technique (2 passes) to sample the hypo- and hypervascular components.

Zoom Image
Fig. 1 Contrast-enhanced abdominal computed tomography revealed a nodular lesion between the descending part of the duodenum and the pancreatic head. (A) Arterial phase. (B) Portal phase.
Zoom Image
Fig. 2 (A) An endoscopic ultrasound showed a slightly inhomogeneous hypoechoic lesion with mild “fat stranding” originating from the muscularis propria. (B) An evaluation of the microvasculature and parenchymal perfusion with detective flow imaging demonstrated mixed vascularity patterns (a hypo- and a hypervascular region). (C) Elastography revealed an average texture.

The histopathological examination revealed a benign spindle cell tumor with smooth muscle differentiation without evidence of atypia or necrosis compatible with a diagnosis of leiomyoma (α-smooth muscle actin+, desmin+, S100−, CD34−, DOG1−, CD117−, Ki-67 < 1%). Therefore, no treatment or follow up were needed.[1] [2]

Our case supported the pivotal role of EUS with advanced techniques, such as EUS-DFI, elastography, and EUS-FNB, in the differential diagnosis of gastrointestinal subepithelial lesions (SELs) with atypical sites and findings, preventing unnecessary surgical procedures in high-risk patients.[1] [2] [3]

Authors' Contributions

All the authors were involved in the writing and editing of the manuscript.




Publication History

Article published online:
25 November 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Deprez PH, Moons LMG, OʼToole D. et al. Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2022; 54 (04) 412-429
    Thieme ConnectPubMedSearch in Google Scholar
  • 2 Sharzehi K, Sethi A, Savides T. AGA clinical practice update on management of subepithelial lesions encountered during routine endoscopy: expert review. Clin Gastroenterol Hepatol 2022; 20 (11) 2435-2443.e4
    CrossrefPubMedSearch in Google Scholar
  • 3 Brand B, Oesterhelweg L, Binmoeller KF. et al. Impact of endoscopic ultrasound for evaluation of submucosal lesions in gastrointestinal tract. Dig Liver Dis 2002; 34 (04) 290-297
    CrossrefPubMedSearch in Google Scholar