Discovery on cross-sectional imaging of jejunal masses should prompt referral for EUS-guided biopsy: Findings and outcomes in two cases

Dear Editor, The jejunum is often incidentally seen when scanning the abdomen for standard echoendoscopic landmarks. However, there has been virtually no discussion of targeted tissue acquisition of proximal jejunal masses in the literature or in textbooks,[1] and this may limit any referrals for this indication. We present the first two cases of known proximal jejunal masses referred for EUS-guided fine-needle aspiration/biopsy (EUS-FNA/B), regardless of location and appearance on cross-sectional imaging. A 75-year-old male presented with recurrent episodes of hematochezia and melena. He underwent a gastroscopy and colonoscopy, which did not find the source of bleeding. A computed tomography (CT) angiogram revealed a 2.6 cm × 2.8 cm × 3.1 cm enhancing jejunal lesion [Figure 1], suggesting a small bowel bleeding source.Figure 1: 3 cm mass in the mesentery abutting the small bowel loop (circled in white)EUS was performed, which showed a 2.8 cm well-circumscribed, hypoechoic mass seen easily from a stable position in the distal gastric body, arising from a small bowel loop [Figure 2]. Transgastric FNB was performed using a 25G reverse-bevel needle (Echotip Ultra™, ECHO-25, Cook Medical, Limerick, Ireland) and histopathology and immunocytochemical analysis confirmed the presence of a gastrointestinal stromal tumor (GIST).Figure 2: 2.8 cm well-circumscribed, hypoechoic mass arising from a small bowel loopA 66-year-old female presented with acute nausea and vomiting. An abdominal CT scan revealed partial small bowel obstruction, with a transition point in the proximal jejunum described as a 3 cm length of thickened small bowel [Figure 3]. Push enteroscopy demonstrated proximal jejunal stricturing and ulceration, with endoscopic biopsies containing chronic active inflammation with reactive features. EUS was performed but could not be advanced far enough into the duodenum to visualize the mass. However, imaging from the gastric body revealed a 3 cm segment of the jejunum with a surrounding solid component [Figure 4]. Transgastric FNB was undertaken using a 22G fork-tip FNB needle (Sharkcore™, Medtronic, Mississauga, Ontario, Canada), and histopathology confirmed low-grade follicular lymphoma.Figure 3: 3 cm segment of jejunum with surrounding solid component causing partial bowel obstruction (circled in white)Figure 4: 3 cm segment of jejunum with a surrounding solid componentJejunal masses are not routinely referred for EUS-FNB. While high-quality cross-sectional imaging can locate intra-abdominal masses, the images are static and cross-sectional imaging can be misleading in terms of predicting the ease of access for EUS-guided biopsy, particularly since CT scanning is performed in the supine position, whereas EUS is performed in the left lateral decubitus position, which may be associated with lesion displacement. In addition, when EUS is performed, inflation and deflation of the GI tract lumen occur, along with torque and pressure put against the lumen wall, distorting its shape and relationship to nearby organs. In our cases, in contrast to what was expected from the CT imaging, a standard, straight, and stable position from the gastric body provided unobstructed access to jejunal masses. Of note, both lesions were slightly distal to the ligament of Treitz. Our patients greatly benefited from a minimally invasive procedure that provided rapid diagnosis and allowed oral chemotherapy (imatinib) to be offered with the intention to treat a bleeding GIST (case 1) and chemotherapy for an obstructing follicular lymphoma (case 2). These are the first reported cases to our knowledge of known jejunal masses targeted successfully by EUS-FNB. We recommend proximal jejunal masses be referred for EUS-FNB as a first-choice modality. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest Anand V. Sahai is an Honoary Editor-in-Chief of the journal, and Jonathan M. Wyse is an Editorial Board Member. This article was subject to the journal’s standard procedures, with peer review handled independently of the editors and their research groups.

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