Gastric Subepithelial Tumors Research Articles

Endoscopic full-thickness resection with defect closure using clips and an endoloop for gastric subepithelial tumors arising from the muscularis propria

This retrospective study evaluated the safety and efficacy of endoscopic full-thickness resection (eFTR) with defect closure using clips and an endoloop for the treatment of gastric subepithelial tumors (SETs) arising from the muscularis propria (MP). From January 2009 to December 2012, 51 patients with gastric SETs arising from the MP underwent eFTR with defect closure using clips and an endoloop. The key steps were (1) several milliliters of mixture solution was injected into the submucosa after dots were marked around the tumor; (2) a cross incision was made in the mucosa to reveal the tumor; (3) subsequently, circumferential excavation was performed as deep as the muscularis propria, and full-thickness resection of the tumor was performed with an insulated-tip knife, including its underlying MP and serosa; (4) the gastric wall defect was closed with clips and an endoloop was then placed to fix and tighten all of the clips together. Successful complete resection by eFTR was achieved in 50 cases (98.0%). One case failed and was converted into a laparoscopic resection due to the tumor falling into the peritoneal cavity during the procedure. The mean procedure time was 52 min. No patients had severe complications, such as massive bleeding, delayed bleeding, peritonitis, or gastrointestinal tract leakage. The mean tumor length was 2.4 cm. Pathological diagnoses of the tumors were leiomyomas (21/51) and gastrointestinal stromal tumors (30/51). The median follow-up period after the procedure was 22.4 months (range 1-48 months), and no residual tumor or tumor recurrence was detected during the follow-up period. eFTR with defect closure with clips and an endoloop appears to be a safe and effective technique for the treatment of patients with gastric SETs originating from the MP, especially for those with extraluminal growth or adhesions to the MP.

Intramural gastric abscess caused by a toothpick presenting as a subepithelial tumor.

In the present report, we describe an unusual case of an intramural gastric abscess caused by a foreign body, detected in the form of a subepithelial tumor. A 64-year-old woman was referred to our gastroenterology clinic for further evaluation of a gastric subepithelial tumor. The patient presented with a 1-month history of sustained dull epigastric pain. Esophagogastroduodenoscopy revealed an ill-demarcated, round, smooth, protruding lesion with a small central erosion on the great curvature of the proximal antrum. Endoscopic ultrasonography indicated the presence of an ovoid, heterogeneous, hypoechoic lesion with small echogenic foci located in the submucosa and muscularis propria layers. An abdominal computed tomography scan showed focal gastric wall thickening and regional lymph node enlargement. Endoscopic submucosal dissection was performed for definite diagnosis and management. Thus, we detected a toothpick and removed it using grasping forceps. The final diagnosis was an intramural gastric abscess caused by a toothpick.

Endoscopic ultrasound-guided sampling of a metastatic mucinous adenocarcinoma mimicking a gastric subepithelial tumor.

Metastatic mucinous adenocarcinoma of appendix origin and mimicking a gastric subepithelial tumor (SET) is very rare. Endoscopic ultrasound (EUS)-guided sampling is a useful diagnostic method for SETs. However, the cytologic findings of metastatic mucinous adenocarcinoma are unfamiliar to many pathologists and gastroenterologists. These findings present a diagnostic challenge because the introduction of gastric epithelium and mucin into the specimen during the procedure can be misleading. This is the first reported experience of an EUS-guided sampling of a gastric SET in a patient with suspected appendiceal tumor, to make the diagnosis of a mucinous adenocarcinoma.

Accuracy of a scoring system for the differential diagnosis of common gastric subepithelial tumors based on endoscopic ultrasonography

We aimed to validate a new scoring system for the differential diagnosis of gastric subepithelial tumors (SET) based on endoscopic ultrasonography (EUS) findings, and to determine its diagnostic yield for different gastric SET. Data of patients with gastric SET treated with endoscopic mucosal resection, endoscopic submucosal dissection or surgical resection from April 2001 to October 2012 at the Soonchunhyang University Hospital (Bucheon, Korea) were retrospectively reviewed. Four variables, including location, shape, layer of origin and echogenicity of the tumor on EUS were used to validate the new scoring system. Among the 226 patients with gastric SET, 69 (30.5%) had gastrointestinal stromal tumors (GIST), 68 (30.1%) had ectopic pancreas and 35 (15.5%) had leiomyoma. Most GIST were located at the fundus and body (79.7%), whereas most leiomyomas were found at the cardia (80.0%). Ectopic pancreas was mostly found at the antrum (88.2%). GIST were mainly irregular and round in shape, while ectopic pancreas and lipoma were oval and leiomyomas were irregularly shaped on EUS. With a score range of 0-1 for leiomyoma, 2-3 for GIST, 4-6 for ectopic pancreas and 7-8 for lipoma, the sensitivity and specificity of the scoring system were 75.8% and 85.4% for GIST, 84.6% and 73.1% for ectopic pancreas, 75.9% and 99.5% for leiomyoma and 91.7% and 96.7% for lipoma, respectively. The new scoring system was simple and relatively useful for predicting the histology of gastric SET without acquiring tissues. Prospective studies with large sample sizes are needed in the future.

Efficacy and safety of endoscopic submucosal dissection in treating gastric subepithelial tumors originating in the muscularis propria layer: a single-center study of 144 cases

Objective. Subepithelial tumors (SETs) in the stomach are usually considered benign. However, some do have potential for malignant transformation, especially when originating in the muscularis propria (MP). Our study aimed to evaluate the clinical efficacy and safety of endoscopic submucosal dissection (ESD) for gastric SETs originating in MP. Material and methods. A total of 145 gastric MP SETs in 144 patients were treated by ESD between September 2008 and December 2012. Characteristics of patients and SETs, therapeutic outcomes, pathologic characteristics, complications and follow-up outcomes were evaluated. Results. Among the 144 patients, 104 were female (72.22%) and 40 were male (27.78%), and the mean age was 55.75 ± 11.29 years (range 18–78 years). The mean size of the tumors determined by endoscopic ultrasound (EUS) was 15.14 ± 9.70 mm (range 3–50 mm). En bloc complete resection was achieved in 134 of 145 tumors, giving a complete resection rate of 92.41%. The final histopathologic diagnoses included 52 leiomyomas, 89 gastrointestinal stromal tumors, 3 neurogenic tumors and 1 lipoma. Perforations occurred in 21 patients (14.48%) and were endoscopically repaired with clips or nylon bands. Intraoperative bleeding occurred in seven patients (4.83%) and was corrected with argon plasma coagulation (APC) or hot biopsy forceps. No local recurrence or distant metastasis was detected during a mean follow-up of 19.14 ± 10.29 months (range 3–51 months). Conclusions. ESD appears to be an effective and safe treatment for gastric SETs originating in MP.

EUS-guided Full-thickness Resection of a Gastric Subepithelial Tumor and Endoscopic Suture Closure of Post-resection Defect

EUS-guided Full-thickness Resection of a Gastric Subepithelial Tumor and Endoscopic Suture Closure of Post-resection Defect

Endoscopic Resection of Gastric Subepithelial Tumors and Closure of Muscularis Propria Layer by Double Peroral Endoscopy

Endoscopic Resection of Gastric Subepithelial Tumors and Closure of Muscularis Propria Layer by Double Peroral Endoscopy

Safety and Efficacy of Endoscopic Excavation for Gastric Subepithelial Tumors Originating From the Muscularis Propria Layer

In this retrospective study, we investigated the safety and efficacy of endoscopic excavation of gastric subepithelial tumors (SETs) originating from the muscularis propria (MP) layer. Between November 2007 and June 2012, 212 patients with gastric SETs originating from the MP layer were treated via endoscopic excavation. The key procedures were: (1) injecting a mixture solution (100 mL saline+2 mL indigo carmine+1 mL epinephrine) into the submucosa around the tumor; (2) making a cross-incision of the mucosa and then excavating the tumor by the technique of endoscopic excavation. After the tumor was completely excavated from the MP layer, it was removed using a snare; (3) closing the artificial ulcer with clips. The mean diameter of the 212 tumors was 16.5 mm. Complete resection by endoscopic excavation was achieved in 204 cases (96.2%). The rate of complete resection was significantly higher for tumors <2 cm (98.0%) than for tumors >2 cm (91.9%) (P=0.035). Perforation occurred in 32 cases (15.1%), and massive bleeding occurred in 9 cases (4.2%) during the procedure. The rate of perforation was significantly higher for the fundus and the body than for antrum (21.5%, 11.5%, 0%, respectively; P=0.036), and also differed significantly in relation to histologic diagnosis (23.7% for gastrointestinal stromal tumors vs. 7.8% for leiomyoma; P=0.001). Histologic diagnosis showed that the density of gastrointestinal stromal tumors located in the fundus and the body of the stomach was significantly higher than in the antrum (44.1%, 51.9%, 13.3%, respectively; P=0.036). Endoscopic excavation is a safe and efficient method for resecting small (>3.5 cm) gastric SETs originating from the MP layer.

Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria

Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation, particularly for tumors located at the gastric fundus and originating from the muscularis propria. Based on our experience with endoscopic submucosal dissection (ESD) and a novel endoscopic device, namely the ‘Resolution clip’ for the endoscopic closure of iatrogenic upper gastrointestinal (upper GI) perforations, we evaluated the clinical feasibility and safety of ESD for gastric fundus subepithelial tumors originating from the muscularis propria. In this prospective study, 11 consecutive patients who presented with gastric SETs ≤3 cm in diameter were enrolled. Regardless of whether perforation occurred, the gastric wall defect was closed with clips. The patients were followed up after the surgery. Endoscopic resection was successfully performed in 10 patients; however, in one patient a pure endoscopic approach was impossible as the lesion was severely adhered to surrounding tissue, and a switch to laparoscopic wedge resection was necessary. The mean resected tumor size was 18.8×17.2 mm and the mean surgery time of the 10 patients with ESD was 81 min (range 45–130 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in eight lesions [very low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in three lesions. Perforation occurred in 3/10 patients. Gastric closure with the Resolution clips was performed successfully in all cases. Early post-ESD bleeding (EPEB) occurred in one patient. Basic ferric sulfate solution was sprayed during the upper GI endoscopy examination and the bleeding stopped. No complications occurred and the follow-up was unremarkable. In this early study, ESD using the Resolution clip was demonstrated to be a feasible and minimally invasive treatment for gastric fundus subepithelial tumors originating from the muscularis propria.

Su1980 How to Refine Treatment Strategy in Patients With Gastric Subepithelial Tumor

Background: Lymphoepithelioma-like gastric carcinoma (LELC), which is characterized by a dense infiltration of lymphocytes in the tumor stroma, is associated with EBV infection in more than 80% of cases. There have been few studies on the clinicopathologic characteristics and prognosis of EBV-negative LELC compared to EBV-positive LELC. In addition, it remains controversial whether EBV infection itself plays a role in determining the prognosis of LELC. Methods: From 1994 to 2011, 124 EBV-positive and 21 EBV-negative curatively resected LELCs were identified. Their clinicopathologic characteristics and prognosis were compared. To identify independent risk factors for survival, multivariate analyses were performed. Results: Patients with EBV-positive LELC were more frequently associated with young age, male gender, lower T stage, and lower AJCC stage than those of EBV-negative LELC. In Kaplan-Meier curves, patients with EBV-positive LELC showed more favorable overall and recurrence free survival than those of EBV-negative LELC (p=0.011, p=0.004, respectively). In Cox proportional hazard model, older age (Hazard ratio (HR) 1.102, 97.5% CI 1.010-1.202), EBV-negative status (HR 15.958, 97.5% CI 2.412-105.582) and stage IIIIV (HR 8.1, 97.5% CI 1.119-58.634) were identified as independent predictors of overall survival in patients with LELC. Conclusion: EBV-negative LELC showed distinct features compared to their EBV-positive counterpart. EBV Infection might serves as an independent predictor of survival in patients with LELC. Further studies are required to confirm our results and to identify underlying mechanism of this finding.

Su1549 EUS-Guided Needle Sampling for Gastric Subepithelial Tumors: Factors Associated With Higher Diagnostic Yield

EUS-guided sampling is an indispensible procedure for tissue diagnosis of gastric subepithelial tumors (SETs). Studies evaluating the factors associated with higher diagnostic yield of gastric SETs are limited.

Endoscopic submucosal dissection as a treatment for gastric subepithelial tumors that originate from the muscularis propria layer: a preliminary analysis of appropriate indications

BackgroundEndoscopic submucosal dissection (ESD) is a well-established method for the treatment of gastrointestinal epithelial tumors. However, the treatment of gastric subepithelial tumors (SETs) that originate from the muscularis propria layer still depends primarily on surgical techniques. We evaluated the appropriate indications for ESD in the treatment of SETs that originate from the muscularis propria layer.MethodsThirty-five patients with gastric SETs that originate from the muscularis propria layer who underwent ESD were enrolled, and the charts were retrospectively reviewed to investigate the parameters predictive complete resection and complications.ResultsThe mean age of the patients was 54.15 ± 9.3 years, and the male/female ratio was 2:3. Twenty-eight of the 35 SETs (85.7 %) were movable, and 15 (45.7 %) had a positive rolling sign. The most frequent location of the SETs was high body (n = 14). The most common pathological diagnoses were leiomyoma (60 %) and gastrointestinal stromal tumor (28.6 %). The complete resection rate was 74.3 %. A positive rolling sign (p = 0.022) and small tumor size (≤20 mm; p = 0.038) were significantly associated with complete resection. Two patients (6.1 %) developed perforations that required surgical treatment; their SMTs were neurogenic tumors with fixed lesion. Tumor mobility was significantly associated with perforation (p = 0.017).ConclusionsThe ESD method appears to be relatively safe for use in the complete resection of SETs that originate from the muscularis propria layer. Small tumor size (≤20 mm) and a positive rolling sign are appropriate indications for ESD.

Human applications of submucosal endoscopy under conscious sedation for pure natural orifice transluminal endoscopic surgery

The submucosal endoscopy provide not only a reliable methods of access and closure for peritoneoscopy, but also an endoscopic working space for full-thickness resection. The aim of this study was to report the clinical outcome of submucosal endoscopy for pure natural orifice transluminal endoscopic surgery. We prospectively evaluated 10 patients who received submucosal endoscopies. The indications of submucosal endoscopy were transgastric peritoneoscopy (TGP) and endoscopic full-thickness resection (EFTR) of a gastric subepithelial tumor. All procedures were performed with a standard gastroscope under conscious sedation with the balanced propofol method in the endoscopic unit. After a 40 mm submucosal tunnel was created using an endoscopic submucosal dissection technique, (1) in TGP, balloon dilation of a serosal puncture and intraperitoneal exploration was performed; (2) in EFTR, a full-thickness incision and snaring resection was performed. Closure of the mucosal incision was performed by endoclips. All cases were technically feasible. The mean times for creating the submucosal tunnel, main procedure (peritoneal exploration or resection), and closure were acceptable (10.44 ± 2.42 minutes, 18.80 ± 9.41 minutes, and 5.63 ± 2.17 minutes, respectively). The mean hospital stay was 3.8 ± 1.48 days. All TGPs were diagnostic (4 peritoneal carcinomatosis and 1 tuberculosis). En bloc and complete resections were possible in all EFTRs (3 gastrointestinal stromal tumors and 2 schwannomas; mean tumor size, 20.8 ± 3.27 mm). There were no procedure-related complications, such as significant bleeding or peritonitis. Human applications of submucosal endoscopy under conscious sedation for pure NOTES were feasible and safe.

A Case of Gastric Calcifying Fibrous Tumor Presenting as a Subepithelial Tumor

Gastric subepithelial tumor is a common finding of upper gastric endoscopy. Differential diagnosis is needed, sometimes a rare disease can be found. Calcifying fibrous tumor is a rare benign fibrous tumor, and mostly affects children and young adults. It can involve all over the body, and shows predilection for abdominal cavity and peritoneum. Stomach lesions are quite rare. We report a case of a 43-year-old woman with a calcifying fibrous tumor presenting as gastric subepithelial tumor. Initially, a subepithelial lesion measuring 8 cm in diameter was incidentally found on her gastric endoscopy, and she had no symptoms. Computed tomography showed an exophytic mass originating from the gastric wall. Laparoscopic wedge resection was performed on the suspicion of gastrointestinal stromal tumor. Pathologically, the tumor showed hypocellular and densely hyaline collagen. Psammomatous calcifications and fibroblastic spindle cells were also found. On the basis of pathological findings, calcifying fibrous tumor was diagnosed. (Korean J Helicobacter Up Gastrointest Res 2013;13:248-251)

Prevalence and Predictive Factors of Malignant Potential in Resected Gastric Subepithelial Tumors

Background/Aims: EUS is a useful method to differentiate malignant from benign gastric subepithelial tumors (SETs) and to determine resection. However, this results in unnecessary resections of benign gastric SETs. The aim of our study is 1. to investigate clinical factors that may predict malignancy in gastric SET and 2. to determine how many of them have malignant potential in resected gastric SETs. Materials and Methods: We retrospectively identified 111 patients who underwent pathologic confirmation for gastric SETs by surgical (104/111, 93.6%) and endoscopic resection between February 2003 and April 2012 and analyzed the clinical, EUS findings and final pathologic diagnosis for these patients. Results: The diagnostic accuracy of EUS for SETs was 58.6% (51/87) and the rate of resection for benign SETs was 31.5% (35/111). In multivariate analysis, old age (≥65), as well as tumor size (≥2 cm) and location (upper or middle) were significant predictive factors for malignant potential of gastric SETs. Conclusions: One-third of endoscopic and surgical resections are performed for benign SETs. Patient’s age, tumor size, and location should be considered before resection of gastric SETs. In addition, more accurate tools for histologic confirmation should be developed in order to avoid unnecessary resection. (Korean J Helicobacter Up Gastrointest Res 2013;13:104-108)

Hybrid natural orifice transluminal endoscopic surgery in gastric subepithelial tumors

Diagnosis of gastric subepithelial tumor (SET) has shown a rapid increase worldwide. Although, until now, endoscopic ultrasound guided procedures such as fine needle aspiration have shown relatively high accuracy in diagnosis of SET, the most important modality for diagnosis and treatment of SETs is complete resection such as endoscopic or surgical resection. However, endoscopic resection or laparoscopic wedge resection alone also has some limitations. Endoscopic resection is difficult to perform in cases of gastric SET located within deep portion of the gastric layer or a relatively large (larger than 25 mm diameter). On the other hand, gastric SET in a difficult location, such as the gastroesophageal junction or pyloric ring is challenging for laparoscopic surgical resection. The hybrid natural orifice transluminal endoscopic surgery (NOTES) technique is a combined method, including the advantages of both laparoscopic resection and endoscopic resection for gastric SETs. This method may be performed safely with reasonable operation times, less bleeding, and adequate resection margin and regardless of tumor size. In particular, in the case of a difficult location for resection, such as the esophagogastric junction or pyloric ring, hybrid NOTES is currently believed to be an ideal treatment method.

Clinical Features and Risk Factors of Gastric Subepithelial Tumor Needed Surgery in Clinical Practice: A Single-center Retrospective Study

Background/Aims: Gastric subepithelial tumor (SET) is often noted incidentally during esophagogastroduodenoscopy (EGD). The prevalence of SET is increasing in accordance with the increase of EGD and endosonographies. SET can range from benign lesions to tumors with malignant behavior or potential such as gastrointestinal stromal tumor (GIST) and carcinoid tumor. The aim of this study was to evaluate clinical features and risk factors of gastric SET that needed surgery in a single center. Materials and Methods: We retrospectively analyzed medical records of 90 patients who underwent operations due to SET during the period from January 2006 to December 2010. Results: Of the 90 patients, those who were diagnosed with GIST, ectopic pancreas, leiomyoma, schwannoma, carcinoid tumor, and inflammatory fibroid polyp after surgery were 43 (47.8%), 14 (15.6%), 13 (14.4%), 8 (8.9%), 3 (3.3%), and 2 (2.2%), respectively. Most patients who received operation due to SET were asymptomatic (52.2%). Patients were divided into non-GIST and GIST groups, non-malignant and malignant groups, respectively. Baseline characteristics between both groups were significantly different in age, and size (P＜0.05). Age was an independent risk factor of malignant gastric SET (OR, 1.045; 95% CI, 1.008∼1.084; P=0.016). In addition, age and size were independent risk factors of gastric SET with potential of GIST (OR, 1.049; 95% CI, 1.011∼ 1.089; P=0.011, OR, 1.026; 95% CI, 1.002∼1.050; P=0.031). Conclusions: We demonstrated that an independent risk factor of malignant gastric SET that needed surgery was age, and independent risk factors of GIST were age and size of the tumor. (Korean J Helicobacter Up Gastrointest Res 2013;13:44-49)

A feasible modified biopsy method for tissue diagnosis of gastric subepithelial tumors

To evaluate the diagnostic yield and safety of a modified technique for the histological diagnosis of subepithelial tumors (SETs). A retrospective review of patients who underwent a modified technique for the histological diagnosis of gastric SETs, consisting of a mucosal incision with a fixed flexible snare (MIF) and deep-tissue biopsy under conventional endoscopic view, from January 2012 to January 2013 was performed. Eleven patients with gastric SETs 10-30 mm in diameter and originating from the third or fourth layer on endoscopic ultrasonography were included. The mean age was 59.8 (range, 45-76) years, and 5 patients were male. The mean size of the SETs was 21.8 (range, 11-30) mm. The number of biopsy specimens was 6.3 (range 5-8). The mean procedure time was 9.0 min (range, 4-17 min). The diagnostic yield of MIF biopsies was 90.9% (10/11). The histological diagnoses were leiomyoma (4/11, 36.4%), aberrant pancreas (3/11, 27.3%), gastrointestinal stromal tumors (2/11, 18.2%), an inflammatory fibrinoid tumor (1/11, 9.1%); one result was non-diagnostic (1/11, 9.1%). There were six mesenchymal tumors; the specimens obtained in each case were sufficient for an immunohistochemical diagnosis. There was no major bleeding, but one perforation occurred that was successfully controlled by endoscopic clipping. The MIF biopsy was simple to perform, safe, and required a shorter procedure time, with a high diagnostic yield for small SETs.

EndoResect study: endoscopic full-thickness resection of gastric subepithelial tumors

Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation. New techniques such as use of the over-the-scope clip (OTSC) may enable secure endoscopic closure of perforations. We aimed to evaluate the feasibility of endoscopic resection of small gastric SETs using a grasp-and-snare technique followed by OTSC closure of the gastric wall if necessary. In this prospective study 20 consecutive patients who presented with gastric SETs ≤ 3 cm were enrolled. Endoscopic resection was performed using a double-channel endoscope, a tissue anchor and a monofilament snare. If perforation occurred, the aim was to achieve complete closure with a tissue twin grasper and the OTSC. Procedures were performed under laparoscopic control using a 5-mm optic, which was introduced via a single 5-mm trocar through the umbilicus. All patients were followed up for 3 months after the procedure. In 6 /20 patients a pure endoscopic approach was impossible and a switch to laparoscopic wedge resection was necessary (large tumor size in 2 /6 patients; mainly extraluminal growth in 4 /6 patients). Solely endoscopic resection was successfully performed in the remaining 14 patients. Amongst these, laparoscopic control was impossible in two cases. Perforation occurred in 6 /14 patients but gastric closure with the OTSC was performed successfully in all these cases. No complications occurred and follow-up was unremarkable. Endoscopic snare resection enables safe treatment of small gastric SETs (diameter ≤ 3 cm) and seems faster and easier to perform than other endoscopic resection techniques, such as endoscopic submucosal dissection (ESD) or submucosal tunneling. Perforations occurring after full-thickness resection can be adequately managed by OTSC closure. Solely endoscopic resection without laparoscopic control seems possible in selected patients with tumors known to have purely intraluminal growth.

Bloc biopsy by using submucosal endoscopy with a mucosal flap method for gastric subepithelial tumor tissue sampling (with video)

Subepithelial tumors (SETs) include widely malignant tumors such as GI stromal tumors, malignant lymphomas, carcinoid tumors, gastric cancers similar to SETs, and benign tumors such as leiomyomas, aberrant pancreas, and lipomas. Currently, minimally invasive local resection techniques such as hybrid natural orifice transluminal endoscopic surgery (NOTES), which consists of endoscopic full-thickness gastric resection, have been developed for the treatment of GI stromal tumors. 1 However, there is no consensus regarding the optimal strategy for the tissue diagnosis of SETs before determining the plans for further management such as surgical resection or observation. SET differentiation is essentially important, because different types of lesions may need different management, prognoses, and therapeutic options. EUS morphologic features alone have limited specificity for the diverse subtypes of SETs, and EUS cannot differentiate between a benign or malignant origin. Recently, several diagnostic methods have been proposed for the tissue diagnosis of SETs. EUS-guided FNA (EUS-FNA) biopsy has been introduced as an easy, safe, and valuable method for obtaining tissue samples for the accurate diagnosis of GI SETs. 2-7 In