Role of Endoscopy and EUS in the Staging of Superficial GI Neoplastic Lesions

Aims/Purpose: In case of superficial neoplastic GI lesions the depth of infiltration is associated with the risk of nodal metastasis and guides the choice between minimally invasive endoscopic treatments and resective surgery. The aim of the study was to compare the performance of the endoscopic evaluation and EUS in identifying early tumors fit for endoscopic resection. Methods: Retrospective study on patients affected by early-appearing neoplastic GI lesions. We compared the high-definition endoscopic assessment of the lesions according to the Paris classification (classifying them as fit or unfit for endoscopic resection, according to guidelines) and the EUS staging (classifying them as intramucosal or submucosal) to the histological staging after resection. Results: From 4/2022 to 6/2025 57 patients were included. Lesions were located in the esophagus (19), stomach (29), and rectum (9); they underwent EMR—endoscopic mucosal resection—(six), ESD—endoscopic submucosal dissection—(29), upfront surgical resection (18), or upfront TEM—transanal endoscopic microsurgery (four); thereafter, 11 patients underwent surgery or TEM after not-radical endoscopic treatment or complications. After endoscopic assessment 42 lesions were considered fit for endoscopic resection: nine (21.4%) yielded HGD, 19 (45.3%) T1a, and 14 (33.3%) T1b; 15 were considered unfit for endoscopic resection: one (6.7%) yielded T1a, 14 (93.3%) T1b. Endoscopic accuracy for identifying intramucosal lesions (HGD or T1a) thus fit for endoscopic resection was 73.7%. EUS staged 29 lesions as uT1a: eight (27.6%) yielded HGD, 8 (27.6%) T1a, and 13 (44.8%) T1b; EUS staged 28 lesions as uT1 b: one (3.6%) yielded HGD, 12 (42.8%) T1a, and 15 (53.6%) T1b. EUS accuracy for identifying intramucosal lesions (HGD or T1a) was 54.4%, but it showed a 91.7% PPV for the N0 status. Conclusions: The endoscopic evaluation was more accurate than EUS (73.7% vs. 54.4%, p < 0.05) in distinguishing GI intraepithelial or intramucosal lesions fit for endoscopic resection, with a markedly higher NPV. EUS could rather be considered as a complementary tool to exclude suspicious lymph nodes before endoscopic resection.