Advances and challenges of endoscopic ultrasound in the diagnosis and treatment of esophageal submucosal lesions_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LI Jing , YANG Wenjuan , ZHAO Yuting , CHEN Liuxiang ,  HU Bing

Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding?author：

HU Bing, Email: hubingnj@163.com

Keywords：

Endoscopic ultrasound; esophageal submucosal lesions; treatment; diagnosis; review

DOI：

10.7507/1007-4848.202506041

Video：

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Abstract Full text Figures/Tables Video References Cited by

Subepithelial esophageal lesions (SELs) constitute approximately 30% of upper gastrointestinal submucosal lesions, with a rising incidence in recent years. Prognostic heterogeneity among SELs directly dictates clinical decision-making regarding therapeutic strategies and surveillance protocols. The absence of pathognomonic symptoms and standardized diagnostic-therapeutic algorithms continues to challenge the clinical management of SELs. Innovations in endoscopic ultrasound (EUS) technology have driven transformative advances in the diagnosis and treatment of SELs. Novel modalities including quantitative elastography and contrast-enhanced harmonic EUS (CH-EUS) have enhanced noninvasive differentiation, while US capsule endoscopy (USCE) and EUS-AI may facilitate primary healthcare and standardized diagnostic-therapeutic practices. This review synthesizes the recent progress in these domains.

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2.	Jacobson BC, Bhatt A, Greer KB, et al. ACG clinical guideline: diagnosis and management of gastrointestinal subepithelial lesions. Am J Gastroenterol, 2023, 118(1): 46-58.
3.	Ko WJ, Song GW, Cho JY. Evaluation and endoscopic management of esophageal submucosal tumor. Clin Endosc, 2017, 50(3): 250-253.
4.	中國醫師協會外科醫師分會胃腸間質瘤診療專家工作組. 胃腸間質瘤規范化外科治療中國專家共識 (2025版). 中國實用外科雜志, 2025, 45(1): 11-24.GIST Expert Group, Surgeon Branch, Chinese Medical Doctor Association. Standardized surgical management of gastrointestinal stromal tumors: Chinese expert consensus (2025 Edition). Chin J Pract Surg, 2025, 45(1): 11-24.
5.	Pesenti C, Bories E, Caillol F, et al. Characterization of subepithelial lesions of the stomach and esophagus by contrast-enhanced EUS: a retrospective study. Endosc Ultrasound, 2019, 8(1): 43-49.
6.	Cazacu IM, Saftoiu A, Bhutani MS. Advanced EUS imaging techniques. Dig Dis Sci, 2022, 67(5): 1588-1598.
7.	Khalaf K, Terrin M, Jovani M, et al. A comprehensive guide to artificial intelligence in endoscopic ultrasound. J Clin Med, 2023, 12(11): 3757.
8.	Nishida T, Hirota S. Biological and clinical review of stromal tumors in the gastrointestinal tract. Histol Histopathol, 2000, 15(4): 1293-1301.
9.	Philipper M, Hollerbach S, Gabbert HE, et al. Prospective comparison of endoscopic ultrasound-guided fine-needle aspiration and surgical histology in upper gastrointestinal submucosal tumors. Endoscopy, 2010, 42(4): 300-305.
10.	Dietrich CF, Burmeister S, Hollerbach S, et al. Do we need elastography for EUS? Endosc Ultrasound, 2020, 9(5): 284-290.
11.	Bamber J, Cosgrove D, Dietrich CF, et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: basic principles and technology. Ultraschall Med, 2013, 34(2): 169-184.
12.	S?ftoiu A, Gilja OH, Sidhu PS, et al. The EFSUMB guidelines and recommendations for the clinical practice of elastography in non-hepatic applications: update 2018. Ultraschall Med, 2019, 40(4): 425-453.
13.	Costache MI, Dumitrescu D, S?ftoiu A. Technique of qualitative and semiquantitative EUS elastography in pancreatic examination. Endosc Ultrasound, 2017, 6(Suppl 3): S111-S114.
14.	Dietrich CF, Barr RG, Farrokh A, et al. Strain elastography: how to do it? Ultrasound Int Open, 2017, 3(4): E137-E149.
15.	Kim SH, Yoo IK, Kwon CI, et al. Utility of EUS elastography in the diagnosis of gastric subepithelial tumors: a pilot study (with video). Gastrointest Endosc, 2020, 91(1): 172-177.
16.	Ignee A, Jenssen C, Hocke M, et al. Contrast-enhanced (endoscopic) ultrasound and endoscopic ultrasound elastography in gastrointestinal stromal tumors. Endosc Ultrasound, 2017, 6(1): 55-60.
17.	Choi JH, Seo DW. The expanding role of contrast-enhanced endoscopic ultrasound in pancreatobiliary disease. Gut Liver, 2015, 9(6): 707-713.
18.	Gheorghiu MI, Seicean A, Pojoga C, et al. Contrast-enhanced guided endoscopic ultrasound procedures. World J Gastroenterol, 2024, 30(17): 2311-2320.
19.	Yokoyama K, Kanno A, Miwata T, et al. Efficacy of contrast-enhanced endoscopic ultrasonography for the diagnosis of pancreatic tumors. Diagnostics (Basel), 2022, 12(6): 1311.
20.	Hocke M, Menges M, Topalidis T, et al. Contrast-enhanced endoscopic ultrasound in discrimination between benign and malignant mediastinal and abdominal lymph nodes. J Cancer Res Clin Oncol, 2008, 134(4): 473-480.
21.	戴麗, 寧波. 諧波造影增強超聲內鏡在鑒別良惡性消化道黏膜下腫瘤和評估胃腸間質瘤侵襲危險度中的價值. 現代消化及介入診療, 2023, 28(1): 99-103.Dai L, Ning B. Diagnostic value of contrast-enhanced harmonic endoscopic ultrasound in differentiating benign from malignant gastrointestinal submucosal tumors and assessing invasive risk stratification of gastrointestinal stromal tumors. Mod Interv Diagn Ther Gastroenterol, 2023, 28(1): 99-103.
22.	Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of submucosal tumors of the upper gastrointestinal tract. J Gastroenterol Hepatol, 2017, 32(10): 1686-1692.
23.	Mekky MA, Abbas WA. Endoscopic ultrasound in gastroenterology: from diagnosis to therapeutic implications. World J Gastroenterol, 2014, 20(24): 7801-7807.
24.	Gounella R, Granado TC, Hideo Ando Junior O, et al. Endoscope capsules: the present situation and future outlooks. Bioengineering (Basel), 2023, 10(12): 1347.
25.	Lay HS, Cummins G, Cox BF, et al. In-vivo evaluation of microultrasound and thermometric capsule endoscopes. IEEE Trans Biomed Eng, 2019, 66(3): 632-639.
26.	Wang X, Seetohul V, Chen R, et al. Development of a mechanical scanning device with high-frequency ultrasound transducer for ultrasonic capsule endoscopy. IEEE Trans Med Imaging, 2017, 36(9): 1922-1929.
27.	Lee JH, Traverso G, Ibarra-Zarate D, et al. Ex vivo and in vivo imaging study of ultrasound capsule endoscopy. J Med Device, 2020, 14(2): 021005.
28.	Qiu Y, Huang Y, Zhang Z, et al. Ultrasound capsule endoscopy with a mechanically scanning micro-ultrasound: a porcine study. Ultrasound Med Biol, 2020, 46(3): 796-804.
29.	Lay HS, Cox BF, Seetohul V, et al. Design and simulation of a ring-shaped linear array for microultrasound capsule endoscopy. IEEE Trans Ultrason Ferroelectr Freq Control, 2018, 65(4): 589-599.
30.	Norton JC, Slawinski PR, Lay HS, et al. Intelligent magnetic manipulation for gastrointestinal ultrasound. Sci Robot, 2019, 4(31): eaav7725.
31.	Qiu XO, Jiang X, Chen YZ, et al. New US capsule endoscopy for superficial and submucosal imaging of the esophagus: the first-in-human study. Gastrointest Endosc, 2023, 98(4): 642-652.
32.	Zhang AM, Jiang DM, Wang SP, et al. Artificial intelligence-assisted endoscopic ultrasound diagnosis of esophageal subepithelial lesions. Surg Endosc, 2025, 39(6): 3821-3831.
33.	Minoda Y, Ihara E, Komori K, et al. Efficacy of endoscopic ultrasound with artificial intelligence for the diagnosis of gastrointestinal stromal tumors. J Gastroenterol, 2020, 55(12): 1119-1126.
34.	Ye XH, Zhao LL, Wang L. Diagnostic accuracy of endoscopic ultrasound with artificial intelligence for gastrointestinal stromal tumors: a meta-analysis. J Dig Dis, 2022, 23(5-6): 253-261.
35.	Dong Z, Zhao X, Zheng H, et al. Efficacy of real-time artificial intelligence-aid endoscopic ultrasonography diagnostic system in discriminating gastrointestinal stromal tumors and leiomyomas: a multicenter diagnostic study. EClinicalMedicine, 2024, 73: 102656.
36.	Minoda Y, Ihara E, Fujimori N, et al. Efficacy of ultrasound endoscopy with artificial intelligence for the differential diagnosis of non-gastric gastrointestinal stromal tumors. Sci Rep, 2022, 12(1): 16640.

1. Schneider MA, Vetter D, Gutschow CA. Management of subepithelial esophageal tumors. Innov Surg Sci, 2024, 10(1): 21-30.
2. Jacobson BC, Bhatt A, Greer KB, et al. ACG clinical guideline: diagnosis and management of gastrointestinal subepithelial lesions. Am J Gastroenterol, 2023, 118(1): 46-58.
3. Ko WJ, Song GW, Cho JY. Evaluation and endoscopic management of esophageal submucosal tumor. Clin Endosc, 2017, 50(3): 250-253.
4. 中國醫師協會外科醫師分會胃腸間質瘤診療專家工作組. 胃腸間質瘤規范化外科治療中國專家共識 (2025版). 中國實用外科雜志, 2025, 45(1): 11-24.GIST Expert Group, Surgeon Branch, Chinese Medical Doctor Association. Standardized surgical management of gastrointestinal stromal tumors: Chinese expert consensus (2025 Edition). Chin J Pract Surg, 2025, 45(1): 11-24.
5. Pesenti C, Bories E, Caillol F, et al. Characterization of subepithelial lesions of the stomach and esophagus by contrast-enhanced EUS: a retrospective study. Endosc Ultrasound, 2019, 8(1): 43-49.
6. Cazacu IM, Saftoiu A, Bhutani MS. Advanced EUS imaging techniques. Dig Dis Sci, 2022, 67(5): 1588-1598.
7. Khalaf K, Terrin M, Jovani M, et al. A comprehensive guide to artificial intelligence in endoscopic ultrasound. J Clin Med, 2023, 12(11): 3757.
8. Nishida T, Hirota S. Biological and clinical review of stromal tumors in the gastrointestinal tract. Histol Histopathol, 2000, 15(4): 1293-1301.
9. Philipper M, Hollerbach S, Gabbert HE, et al. Prospective comparison of endoscopic ultrasound-guided fine-needle aspiration and surgical histology in upper gastrointestinal submucosal tumors. Endoscopy, 2010, 42(4): 300-305.
10. Dietrich CF, Burmeister S, Hollerbach S, et al. Do we need elastography for EUS? Endosc Ultrasound, 2020, 9(5): 284-290.
11. Bamber J, Cosgrove D, Dietrich CF, et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastography. Part 1: basic principles and technology. Ultraschall Med, 2013, 34(2): 169-184.
12. S?ftoiu A, Gilja OH, Sidhu PS, et al. The EFSUMB guidelines and recommendations for the clinical practice of elastography in non-hepatic applications: update 2018. Ultraschall Med, 2019, 40(4): 425-453.
13. Costache MI, Dumitrescu D, S?ftoiu A. Technique of qualitative and semiquantitative EUS elastography in pancreatic examination. Endosc Ultrasound, 2017, 6(Suppl 3): S111-S114.
14. Dietrich CF, Barr RG, Farrokh A, et al. Strain elastography: how to do it? Ultrasound Int Open, 2017, 3(4): E137-E149.
15. Kim SH, Yoo IK, Kwon CI, et al. Utility of EUS elastography in the diagnosis of gastric subepithelial tumors: a pilot study (with video). Gastrointest Endosc, 2020, 91(1): 172-177.
16. Ignee A, Jenssen C, Hocke M, et al. Contrast-enhanced (endoscopic) ultrasound and endoscopic ultrasound elastography in gastrointestinal stromal tumors. Endosc Ultrasound, 2017, 6(1): 55-60.
17. Choi JH, Seo DW. The expanding role of contrast-enhanced endoscopic ultrasound in pancreatobiliary disease. Gut Liver, 2015, 9(6): 707-713.
18. Gheorghiu MI, Seicean A, Pojoga C, et al. Contrast-enhanced guided endoscopic ultrasound procedures. World J Gastroenterol, 2024, 30(17): 2311-2320.
19. Yokoyama K, Kanno A, Miwata T, et al. Efficacy of contrast-enhanced endoscopic ultrasonography for the diagnosis of pancreatic tumors. Diagnostics (Basel), 2022, 12(6): 1311.
20. Hocke M, Menges M, Topalidis T, et al. Contrast-enhanced endoscopic ultrasound in discrimination between benign and malignant mediastinal and abdominal lymph nodes. J Cancer Res Clin Oncol, 2008, 134(4): 473-480.
21. 戴麗, 寧波. 諧波造影增強超聲內鏡在鑒別良惡性消化道黏膜下腫瘤和評估胃腸間質瘤侵襲危險度中的價值. 現代消化及介入診療, 2023, 28(1): 99-103.Dai L, Ning B. Diagnostic value of contrast-enhanced harmonic endoscopic ultrasound in differentiating benign from malignant gastrointestinal submucosal tumors and assessing invasive risk stratification of gastrointestinal stromal tumors. Mod Interv Diagn Ther Gastroenterol, 2023, 28(1): 99-103.
22. Kamata K, Takenaka M, Kitano M, et al. Contrast-enhanced harmonic endoscopic ultrasonography for differential diagnosis of submucosal tumors of the upper gastrointestinal tract. J Gastroenterol Hepatol, 2017, 32(10): 1686-1692.
23. Mekky MA, Abbas WA. Endoscopic ultrasound in gastroenterology: from diagnosis to therapeutic implications. World J Gastroenterol, 2014, 20(24): 7801-7807.
24. Gounella R, Granado TC, Hideo Ando Junior O, et al. Endoscope capsules: the present situation and future outlooks. Bioengineering (Basel), 2023, 10(12): 1347.
25. Lay HS, Cummins G, Cox BF, et al. In-vivo evaluation of microultrasound and thermometric capsule endoscopes. IEEE Trans Biomed Eng, 2019, 66(3): 632-639.
26. Wang X, Seetohul V, Chen R, et al. Development of a mechanical scanning device with high-frequency ultrasound transducer for ultrasonic capsule endoscopy. IEEE Trans Med Imaging, 2017, 36(9): 1922-1929.
27. Lee JH, Traverso G, Ibarra-Zarate D, et al. Ex vivo and in vivo imaging study of ultrasound capsule endoscopy. J Med Device, 2020, 14(2): 021005.
28. Qiu Y, Huang Y, Zhang Z, et al. Ultrasound capsule endoscopy with a mechanically scanning micro-ultrasound: a porcine study. Ultrasound Med Biol, 2020, 46(3): 796-804.
29. Lay HS, Cox BF, Seetohul V, et al. Design and simulation of a ring-shaped linear array for microultrasound capsule endoscopy. IEEE Trans Ultrason Ferroelectr Freq Control, 2018, 65(4): 589-599.
30. Norton JC, Slawinski PR, Lay HS, et al. Intelligent magnetic manipulation for gastrointestinal ultrasound. Sci Robot, 2019, 4(31): eaav7725.
31. Qiu XO, Jiang X, Chen YZ, et al. New US capsule endoscopy for superficial and submucosal imaging of the esophagus: the first-in-human study. Gastrointest Endosc, 2023, 98(4): 642-652.
32. Zhang AM, Jiang DM, Wang SP, et al. Artificial intelligence-assisted endoscopic ultrasound diagnosis of esophageal subepithelial lesions. Surg Endosc, 2025, 39(6): 3821-3831.
33. Minoda Y, Ihara E, Komori K, et al. Efficacy of endoscopic ultrasound with artificial intelligence for the diagnosis of gastrointestinal stromal tumors. J Gastroenterol, 2020, 55(12): 1119-1126.
34. Ye XH, Zhao LL, Wang L. Diagnostic accuracy of endoscopic ultrasound with artificial intelligence for gastrointestinal stromal tumors: a meta-analysis. J Dig Dis, 2022, 23(5-6): 253-261.
35. Dong Z, Zhao X, Zheng H, et al. Efficacy of real-time artificial intelligence-aid endoscopic ultrasonography diagnostic system in discriminating gastrointestinal stromal tumors and leiomyomas: a multicenter diagnostic study. EClinicalMedicine, 2024, 73: 102656.
36. Minoda Y, Ihara E, Fujimori N, et al. Efficacy of ultrasound endoscopy with artificial intelligence for the differential diagnosis of non-gastric gastrointestinal stromal tumors. Sci Rep, 2022, 12(1): 16640.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesAdvances and challenges of endoscopic ultrasound in the diagnosis and treatment of esophageal submucosal lesions

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