AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review

Best Practice Advice Statements:: Best Practice Advice 1: Forceps bite-on-bite or deep-well biopsies or tunnel biopsies can sometimes establish a pathologic diagnosis of SEL. Best Practice Advice 2: EUS is the modality of choice to evaluate indeterminate SEL of the GI track and/or if non-diagnostic tissue by forceps biopsies. Best Practice Advice 3: SEL arising from the submucosa can be sampled using tunnel biopsies (or deep-well biopsies), EUS guided fine-needle aspiration (FNA), EUS guided fine-needle biopsy (FNB), or advanced endoscopic techniques (unroofing or endoscopic submucosal resection). Best Practice Advice 4: SEL arising from muscularis propria should be sampled (preferably using FNB or FNA) to determine whether the lesion is a GIST or leiomyoma. Structural assessment and staining will allow differentiation of mesenchymal tumors and assessing their malignant potential. Best Practice Advice 5: Endoscopic resection techniques have been described for removal of SEL and should be limited to endoscopists skilled in advanced tissue resection techniques. Best Practice Advice 6: Management of each SEL depends on the size of the lesion, histopathology, their malignant potential, and presence of symptoms. Best Practice Advice 7: SEL that have an endoscopic appearance consistent with a lipoma or pancreatic rest and normal mucosal biopsies do not need further evaluation or surveillance. Best Practice Advice 8: For SEL arising from muscularis propria that are less than 2 cm in size, surveillance using EUS should be considered. Best Practice Advice 9: Gastric GIST larger than 2 cm should be considered for resection. Best Practice Advice 10: Subepithelial lesions that are ulcerated, bleeding, or causing symptoms should be considered for resection.