Gastric Linitis Plastica Research Articles

Endoscopic ultrasound-guided bite-on-bite biopsy and endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of gastric tumors with negative malignant endoscopy biopsies: a retrospective cohort study

Background Specific types of gastric tumors, including gastric linitis plastica and lymphoma, may cause extensive deep-layer infiltration, impeding an accurate diagnosis with endoscopic biopsy. This study aims to evaluate the efficacy of endoscopic ultrasound (EUS)-guided bite-on-bite biopsy and EUS-guided fine-needle aspiration (EUS-FNA) in diagnosing gastric malignancies with negative endoscopic biopsies. Methods We retrospectively analyzed suspicious malignant gastric lesion cases in our hospital from October 2017 to August 2023. Clinical manifestations, radiographical examinations, endoscopic examinations, histopathological results, and therapeutic strategies were recorded and analyzed. Results Forty malignant gastric tumor cases with negative endoscopic biopsies were incorporated into our study. EUS-guided bite-on-bite biopsy was performed in 16 cases exclusively, whereas 17 patients received EUS-FNA exclusively, and seven patients underwent both simultaneously. Among the 23 patients who received the EUS-guided bite-on-bite biopsy, 22 (95.7%) were diagnosed with malignancies. Among the 24 patients who received EUS-FNA, a total of 19 cases with malignancies (79.2%) were confirmed by EUS-FNA (p = 0.11): 13 gastric adenocarcinomas, five metastatic malignancies, and one malignant stromal tumor. No adverse events were observed in any of the cases. Conclusions EUS-guided bite-on-bite biopsy and EUS-FNA possess their advantages and disadvantages. EUS-guided bite-on-bite biopsy could serve as a reliable diagnostic method for shallow lesions with negative malignant endoscopic biopsies.

A Rare Presentation of AKI Due to Retroperitoneal Fibross as A Result of Gastric Linitis Plastica: A Case-Based Review

Short bowel syndrome (SBS) refers to a condition resulting from loss of bowel or loss of small bowel absorptive surface area due to surgical resection or bypass leading to maldigestion, malabsorption and malnutrition.

Gastric Linitis Plastica: Clinical Characteristics and Outcomes from the National Cancer Database.

Gastric linitis plastica (LP) is a rare type of gastric tumor with limited data. We sought to investigate the clinical characteristics, treatment modalities, and outcomes utilizing a national database. The National Cancer Database (NCDB) was reviewed for LP of the stomach from 2004 to 2017. Kaplan-Meier analysis and Cox proportional hazards model were utilized to evaluate overall survival and predictors of survival. Out of 222,488 gastric cancer cases, 896 patients with histologically confirmed primary gastric LP were included. Patients were predominantly white (78.5%), female (51.9%) and presented at advanced stage disease (stage 4=69%). A total of 369 (41.2%) patients underwent surgical resection, 520 (58.0%) received chemotherapy and 158 (17.6%) received radiation therapy. The mean OS (overall survival) of the entire cohort was 16.9 months with 1-year and 5-year OS rates of 33% and 5%, respectively. Mean OS for the patients receiving surgery with chemotherapy and/or radiation, surgery alone, chemotherapy and/or radiotherapy alone, and no treatment was 28.4, 17.1, 12.3, and, 8.1 months, respectively (p<0.001). On multivariate cox-regression analysis, advanced-stage disease (stage IV) (p<0.001), no surgical resection (p<0.001), and no receipt of chemotherapy (p<0.001) were associated with increased hazards of death. Over time, the proportion of patients receiving surgical resection (30.7% from 48.3%) and radiation therapy decreased (13.8% from 20.6%) and the use of chemotherapy increased (63.9% from 54.8%). Gastric LP is associated with a poor prognosis. Multimodal therapy including surgical resection and systemic therapy in the neoadjuvant setting seems to provide the best long-term outcomes.

Analysis of genomic and immune intratumor heterogeneity in linitis plastica via multiregional exome and T-cell receptor sequencing.

The molecular landscape and the intratumor heterogeneity (ITH) architecture of gastric linitis plastica (LP) are poorly understood. We performed whole-exome sequencing (WES) and T-cell receptor (TCR) sequencing on 40 tumor regions from four LP patients. The landscape and ITH at the genomic and immunological levels in LP tumors were compared with multiple cancers that have previously been reported. The lymphocyte infiltration was further assessed by immunohistochemistry (IHC) in LP tumors. In total, we identified 6339 non-silent mutations from multi-samples, with a median tumor mutation burden (TMB) of 3.30 mutations per Mb, comparable to gastric adenocarcinoma from the Cancer Genome Atlas (TCGA) cohort (P = 0.53). An extremely high level of genomic ITH was observed, with only 12.42%, 5.37%, 5.35%, and 30.67% of mutations detectable across 10 regions within the same tumors of each patient, respectively. TCR sequencing revealed that TCR clonality was substantially lower in LP than in multi-cancers. IHC using antibodies against CD4, CD8, and PD-L1 demonstrated scant T-cell infiltration in the four LP tumors. Furthermore, profound TCR ITH was observed in all LP tumors, with no T-cell clones shared across tumor regions in any of the patients, while over 94% of T-cell clones were restricted to individual tumor regions. The Morisita overlap index (MOI) ranged from 0.21 to 0.66 among multi-regions within the same tumors, significantly lower than that of lung cancer (P = 0.002). Our results show that LP harbored extremely high genomic and TCR ITH and suppressed T-cell infiltration, suggesting a potential contribution to the frequent recurrence and poor therapeutic response of this adenocarcinoma.

Comprehensive transcriptomic profiling and mutational landscape of primary gastric linitis plastica

BackgroundPrimary gastric linitis plastica (GLP) is a distinct phenotype of gastric cancer with poor survival. Comprehensive molecular profiles and putative therapeutic targets of GLP remain undetermined.MethodsWe subjected 10 tumor-normal tissue pairs to whole exome sequencing (WES) and whole transcriptome sequencing (WTS). 10 tumor samples were all GLP which involves 100% of the gastric wall macroscopically. TCGA data were compared to generate the top mutated genes and the overexpressed genes in GLP.ResultsOur results reveal that GLP has distinctive genomic and transcriptomic features, dysfunction in the Hippo pathway is likely to be a key step during GLP development. 6 genes were identified as significantly highly mutated genes in GLP, including AOX1, ANKRD36C, CPXM1, PTPN14, RPAP1, and DCDC1). MUC6, as a previously identified gastric cancer driver gene, has a high mutation rate (20%) in GLP. 20% of patients in our GLP cohort had CDH1 mutations, while none had RHOA mutations. GLP exhibits high immunodeficiency and low AMPK pathway activity. Our WTS results showed that 3 PI3K-AKT pathway-related genes (PIK3R2, AKT3, and IGF1) were significantly up-regulated in GLP. Two genes were identified using immunohistochemistry (IHC), IGF2BP3 and MUC16, which specifically expressed in diffuse-type-related gastric cancer cell lines, and its knockdown inhibits PI3K-AKT pathway activity.ConclusionsWe provide the first integrative genomic and transcriptomic profiles of GLP, which may facilitate its diagnosis, prognosis, and treatment.

S3614 Gastric Linitis Plastica - An Easily Missed Diagnosis

Introduction: Gastric cancer remains one of the most common malignancies worldwide, with large variations based on genetic, ethnic, geographic, and socioeconomic factors. Patients can present with nonspecific abdominal pain, weight loss, early satiety, or anemia from occult gastrointestinal bleeding. Gastric linitis plastica, a diffuse type of gastric adenocarcinoma, results in proliferation of fibrous tissue in the submucosa and muscle layers of the stomach wall. Biopsy will show classic signet ring cells or poorly differentiated tumor cells. Case Description/Methods: A 54-year-old Caucasian male with a past medical history of end stage renal disease, hypertension, type II diabetes mellitus presented to the hospital for fatigue and melena. His hemoglobin was 7.3 g/dL, which was approximately 3g lower than his most recent hospitalization two weeks prior. He underwent upper endoscopy, which revealed a well-demarcated region of severely congested, erythematous, and friable mucosa with a reticular appearance localized to the gastric cardia, fundus, and body (Figure A and B). Histopathology revealed intramucosal adenocarcinoma with high-grade signet ring features (Figure C), consistent with gastric linitis plastica. Staining for Helicobacter pylori was negative. He was treated with acid suppression. The patient had a prolonged hospital course complicated by hypoxic respiratory failure and eventual cardiac arrest resulting in his death. Discussion: We present here a case of gastric linitis plastica. This is a diffuse type of gastric adenocarcinoma that involves the deeper layers of the stomach wall, making the stomach firm and non-distensible. It is not associated with Helicobacter pylori infection. Diagnostic upper endoscopy remains the gold standard for evaluation, however such malignancies that spare the mucosa can be easily missed on endoscopy or histopathology. The lack of mucosal involvement decreases the yield of endoscopy and biopsy, and findings on computed tomography imaging of the abdomen lack specificity. Early diagnosis remains challenging, as endoscopic findings are less sensitive. Clinicians should maintain a high index of suspicion for this condition with findings of localized congested-appearing gastric mucosa, especially with distinct demarcation and regional non-distensibility of the gastric lumen. Deeper biopsies using “bite-on-bite” technique or endoscopic ultrasound guided fine needle biopsy should be considered.Figure 1.: A and B. Reticular appearance of gastric mucosa in linitis plastica. Figure C. Pathology of gastric biopsy demonstrating the classic appearance of signet ring cells in linitis plastica.

Stomach metastasis from breast cancer-mimicking linitis plastica—A case report

We report a rare case of metastatic gastric cancer from invasive carcinoma of the breast (BC) as the firstsymptom of disease-mimicking primary gastric linitis plastica.

Circumferential Gastric Wall Thickening With Lymphadenopathy

Question: A 78-year-old Japanese man with a history of hypertension and abdominal aortic aneurysm visited our hospital for epigastric discomfort lasting more than a week. Blood examination revealed mildly elevated white blood cell counts (9900/μL) and normal red blood cell and platelet counts. Biochemical analyses indicated no specific abnormalities except mildly elevated C-reactive protein levels (1.89 mg/dL, normal range <0.14 mg/dL). Serum tumor marker levels, including carcinoembryonic antigen and carbohydrate antigen 19-9, were within the normal ranges. Although Helicobacter pylori infection was detected via serum antibody test, he had not received eradication therapy previously. Contrast-enhanced computed tomography (CT) showed circumferential gastric wall thickening with hyperenhancement on the mucosal surface, accompanied by infrapyloric lymphadenopathies (Figure A). Minimal ascites was found around the liver and in the pelvis. On fluorodeoxyglucose (FDG) positron emission tomography–CT, the thickened gastric wall and swollen lymph nodes showed intense accumulation of FDG with a maximum standardized uptake value of 5.23 and 4.33, respectively (Figure B). Moreover, minor mucosal erosions and ulcerations on the gastric body and the antrum were observed during esophagogastroduodenoscopy (EGD) (Figure C). The distensibility of the gastric wall by CO2 insufflation was not impaired on EGD. Endoscopic mucosal biopsies were performed on the thickened gastric wall with ulcerations. What is the most likely diagnosis here, and how should these lesions be treated? Look on page 339 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Gastric linitis plastica (GLP), a distinct subtype of gastric cancer characterized by thickening and rigidity of the gastric wall,1Vivier-Chicoteau J. Lambert J. Coriat R. et al.Development and internal validation of a diagnostic score for gastric linitis plastica.Gastric Cancer. 2020; 23: 639-647Crossref PubMed Scopus (10) Google Scholar was primarily suspected from the imaging findings. Perigastric lymphadenopathies and ascites suggested lymph node metastases and peritoneal dissemination, reflecting the aggressive behavior of GLP.1Vivier-Chicoteau J. Lambert J. Coriat R. et al.Development and internal validation of a diagnostic score for gastric linitis plastica.Gastric Cancer. 2020; 23: 639-647Crossref PubMed Scopus (10) Google Scholar However, the biopsy obtained from the margins of the ulceration did not reveal any malignant cells suggestive of GLP. Hematoxylin and eosin (HE) staining showed infiltration of numerous histiocytes and noncaseating granuloma formation (Figure D). Because the superficial biopsy often results in inconclusive diagnosis of GLP, laparoscopic resection of the swollen infrapyloric lymph nodes was performed to obtain a more substantial amount of tissue. HE staining of the surgically resected lymph nodes showed the formation of multiple small-size epithelioid granulomas (Figure E). To determine the etiology of granuloma formation, various kinds of immunohistochemical studies were performed. Accumulation of H pylori was observed inside the granuloma of both gastric mucosa (Figure F) and lymph nodes (Figure G) with the use of H pylori–specific antibody (B0471; Dako, Denmark) whereas Epstein-Barr virus or tuberculosis was not detected by in situ hybridization or Ziehl-Neelsen staining. In addition, the possibility of gastric sarcoidosis was low because the serum angiotensin-converting enzyme level was not elevated and gastric granuloma was negative for immunostaining of monoclonal antibody against Propionibacterium acnes (D371-3; MBL, Japan).2Yamaguchi T. Costabel U. McDowell A. et al.Immunohistochemical detection of potential microbial antigens in granulomas in the diagnosis of sarcoidosis.J Clin Med. 2021; 10: 983Crossref PubMed Scopus (17) Google Scholar,3Inomata M. Ikushima S. Awano N. et al.Upper gastrointestinal sarcoidosis: report of three cases.Intern Med. 2012; 51: 1689-1694Crossref PubMed Scopus (16) Google Scholar Therefore, the diagnosis of granulomatous gastritis associated with H pylori infection was made. Successful H pylori eradication therapy with vonoprazan, amoxicillin, and clarithromycin improved his symptoms. Furthermore, gastric wall thickening on CT as well as gastric mucosal ulcerations on EGD disappeared entirely 6 months after the H pylori eradication (Figures H and I), which further verified the diagnosis. This case highlights that granulomatous gastritis associated with H pylori infection needs to be considered in the differential diagnosis when encountering H pylori–positive cases exhibiting circumferential gastric wall thickening with lymphadenopathy.

A rare presentation of acute kidney failure due to retroperitoneal fibrosis as a result of gastric linitis plastica: a case-based review

This case study details the experience of a 52-year-old Dutch man, with a 4-month history of epigastric pain and weight loss, who was presented to a urology team and found to have rapidly deteriorating renal function with bilateral hydronephrosis. This prompted his admission to hospital for insertion of bilateral JJ ureteral stents. However, the patient's kidney function continued to worsen despite relief of the obstruction. He became increasingly oliguric and was referred to the renal service. Retroperitoneal fibrosis with acute kidney injury resulting from both obstruction and compression of the urinary system was suspected. Treatment with high-dose steroid was initiated. Shortly after, the patient's urine volume began to increase and his kidney function improved drastically. This avoided the need for dialysis. A month after discharge, the patient was diagnosed with poorly differentiated adenocarcinoma cells of the stomach, a diagnosis consistent with linitis plastica.

Endoscopic ultrasound guided fine needle biopsy in patients with suspected gastric linitis plastica

BackgroundGastric linitis plastica (GLP) is a diffuse infiltrating type of gastric adenocarcinoma. It is associated with a poor prognosis and a five-year survival of 3–10%. The infiltrating profile of this tumor explains the low yield of the superficial mucosal biospies. The objective of this study was to investigate the role of endoscopic ultrasound-fine needle biopsy (EUS-FNB) in the diagnosis of GLP. MethodsWe performed a retrospective analysis including all patients who had an EUS-FNB, at a tertiary referral center, over the last 3 years. The primary outcome was the sensitivity of EUS-FNB in patients with suspected GLP. ResultsBetween January 2017 and December 2020, 34 patients had an EUS-FNB for suspected GLP. Ten patients had a diagnostic of GLP. This diagnosis was obtained by EUS-FNB in 90% (9/10) of the cases. Eight patients had at least one previous esophagogastroduodenoscopy (EGD) with negative mucosal biopsies. Gastric EUS-FNB helped diagnose other serious conditions in 47% (16/34) of cases with inconclusive mucosal biopsies. ConclusionGastric EUS-FNB in patients with suspected GLP and normal endoscopic mucosal biopsies may lead to a positive diagnosis of GLP in 90% of cases without notable adverse events. This technique should be considered as a second step in the setting of suspicion of GLP after inconclusive mucosal biopsies.

S3188 A Rare Case of Gastric Linitis Plastica Presenting as Crohn’s Disease

S3188 A Rare Case of Gastric Linitis Plastica Presenting as Crohn’s Disease

Cold snare mucosectomy after suction priming for tissue diagnosis in biopsy‐negative gastric linitis plastica

Cold snare mucosectomy after suction priming for tissue diagnosis in biopsy‐negative gastric linitis plastica

Diagnostic Value of EUS-Guided Fine-Needle Aspiration Biopsy for Gastric Linitis Plastica with Negative Endoscopic Biopsy.

Due to the tendency of gastric linitis plastica (GLP) to cause extensive submucosal infiltration, a superficial endoscopic biopsy sometimes yields no evidence of malignancy, hindering definite diagnosis. The present study was a single-center retrospective analysis of 54 consecutive patients diagnosed with GLP between 2016 and 2020 to evaluate EUS-guided fine-needle aspiration (EUS-FNA) biopsy outcomes in patients with negative endoscopic biopsy findings. A pathological GLP diagnosis was achieved by endoscopic biopsy in 40 patients (74.1%). EUS-FNA biopsy with a 22-gauge needle was performed in 13 of the remaining 14 patients, and GLP diagnosis was confirmed in 10 patients, with a median of three needle passes. The remaining four patients were laparoscopically diagnosed with GLP. The diagnostic ability of EUS-FNA biopsy for GLP was 76.9%, and EUS-FNA biopsy contributed to GLP diagnosis in 18.5% (10/54) of all cases. None of the 13 patients exhibited EUS-FNA biopsy-related adverse events. Univariable and multivariable analyses revealed an absence of superficial ulcerations as a predictor of false-negative endoscopic biopsy findings in patients with GLP. These results suggest EUS-FNA biopsy as a minimally invasive and safe alternative diagnostic modality for GLP in cases where conventional endoscopic biopsy fails to verify malignancy, although prospective studies with larger cohorts are warranted to confirm these findings.

Development of a Quantitative Diagnostic Criterion for Gastric Linitis Plastica: Findings From a Large Single-Institutional Study.

Gastric linitis plastica (GLP) is a descriptive term but lacks a quantitative definition. Several relatively quantitative criteria had been proposed, such as tumor involving a limit of one-third or two-thirds of the gastric surface. However, these criteria needed doctors to subjectively judge tumor infiltration area, which made diagnosis difficult to be objective and reproducible. This study aimed to propose a quantitative diagnostic criterion for distinguishing GLP. We performed a retrospective cohort study of 2,907 patients with Borrmann III and IV gastric cancer (GC) who underwent gastrectomy between 2011 and 2018 in our center. The Kaplan–Meier curves showed that patients with an observed tumor size more than 8 cm had obviously lower overall survival (OS) and disease-free survival (DFS) rates than those with a size less than 8 cm(p < 0.001; p < 0.001). However, there was no significantly different prognosis of patients with tumor sizes between more than 8 cm and more than 10 cm (p = 0.248; p = 0.534). Moreover, patients with tumor sizes greater than 8 cm more presented with advanced stage and had extremely poor 3-year OS and DFS (31.4%; 29.3%), with a stronger propensity toward peritoneal metastasis. Therefore, we considered patients’ observed tumor size more than 8 cm as a critical value for distinguishing the prognosis of Borrmann III and IV GC. Furthermore, we proposed an observed tumor size more than 8 cm as a quantitative diagnostic criterion for GLP on the premise of satisfying the originally descriptive and pathological definition regardless of Borrmann type.

Prognosis prediction model for a special entity of gastric cancer, linitis plastica.

Gastric linitis plastica (GLP) is characteristic by its poor prognosis and highly aggressive characteristics compared with other types of gastric cancer (GC). However, the guidelines have not yet been distinguished between GLP and non-GLP. A total of 342 eligible patients with GLP identified in the Surveillance, Epidemiology, and End Results (SEER) dataset were randomly divided into training set (n=298) and validation set (n=153). A nomogram would be developed with the constructed predicting model based on the training cohort's data, and the validation cohort would be used to validate the model. Principal component analysis (PCA) was used to evaluate the differences between groups. Cox regression and LASSO (least absolute shrinkage and selection operator) were used to construct the models. Calibration curve, time-dependent receiver operating characteristic (ROC) curve, concordance index (C-index) and decision curve analysis (DCA) were used to evaluate the predicting performance. Restricted mean survival time (RMST) was used to analyze the curative effect of adjuvant therapy. For patients in training cohort, univariable and multivariable Cox analyses showed that age, examined lymph nodes (LN.E), positive lymph nodes (LN.P), lesion size, combined resection, and radiotherapy are independent prognostic factors for overall survival (OS), while chemotherapy can not meet the proportional hazards (PHs) assumption; age, race, lesion size, LN.E, LN.P, combined resection and marital status are independent prognostic factors for cancer-specific survival (CSS). The C-index of the nomogram was 0.678 [95% confidence interval (CI), 0.660-0.696] and 0.673 (95% CI, 0.630-0.716) in the training and validation cohort, respectively. Meanwhile, the C-index of the CSS nomogram was 0.671 (95% CI, 0.653-0.699) and 0.650 (95% CI, 0.601-0.691) in the training and validation cohort for CSS, respectively. Furthermore, the nomogram was well calibrated with satisfactory consistency. RMST analysis further determined that chemotherapy and radiotherapy might be beneficial for improving 1- and 3-year OS and CSS, but not the 5-year CSS. We developed nomograms to help predict individualized prognosis for GLP patients. The new model might help guide treatment strategies for patients with GLP.

Gastric linitis plastica due to signet-ring cell carcinoma with Krukenberg tumors diagnosed by endoscopic ultrasound-guided fine-needle aspiration.

Gastric linitis plastica is a rare condition characterized by the stiffening and thickening of the gastric wall, presenting a "leather bottle" appearance. It is generally associated with infiltration of poorly differentiated gastric cancer cells, but similar findings can arise due to metastases from other cancers and benign inflammatory processes. Despite advances in imaging modalities, pathological evaluation is required for diagnosis. As endoscopic mucosal biopsies may not be diagnostic, endoscopic ultrasound-guided fine-needle aspiration of the thickened stomach wall presents a potential diagnostic option. We report a case which presented with bilateral ovarian tumors and was ultimately diagnosed as gastric signet-ring cell carcinoma with Krukenberg tumors by endoscopic ultrasound-guided fine-needle aspiration of the stomach wall. The preoperative diagnosis allowed the patient to avoid surgery and to start chemotherapy for gastric cancer. We also review the existing literature on endoscopic ultrasound-guided fine-needle aspiration in the context of gastric linitis plastica.

Endoscopic ultrasound efficacy in staging gastric linitis plastica lesion: a retrospective multicentric French study.

BackgroundEndoscopic ultrasound (EUS) is a key imaging technique in gastric cancer (GC). The aim of this study was to evaluate the performance of EUS in the staging of parietal and lymph node involvement in linitis plastica (LP) compared to “classical” GC.MethodsA retrospective multicentric French study was conducted on patients with no metastatic LP and operated by gastrectomy. A 2/1 matching based on pTNM stage and center was performed with GC.ResultsForty-three patients were included, sixteen patients in the LP group and 27 in the control group. Sensitivity and specificity of EUS for diagnosis of T3-T4 parietal invasion were 77% and 100% respectively in the LP group and 89% and 56% respectively in the control group. Sensitivity and specificity of EUS for diagnosis of lymph node involvement were 73% and 80%, respectively in the LP group and 88% and 50%, respectively in the control group. Patients from LP group had significantly more advanced histological lesion, and frequent undiagnosed peritoneal carcinomatosis.ConclusionsThis study evaluated for the first time in a European population, the preoperative EUS performance in LP. Our study identified a similar sensitivity and specificity of the EUS in LP compared to “classical” GC paving for a broader use of EUS in preoperative settings.

An unusual case of limited gastric linitis plastica in a Nigerian: A review of clinical, endoscopic and radiologic diagnostic aspects

Linitis plastica is considered to be one of the rarer types of gastric cancers. The involvement of only the fundus is the least common of the morphologic variants. This limited type is hardly ever documented among sub-Saharan African patients in scientific literatures. This case report presents one such unique case. Using unique attributes of this case's presentation, this article reviews clinical, endoscopic and radiologic aspects of the diagnosis of this unusual malignant entity.

Gastrointestinal: Franseen-tip transmural fine-needle biopsy for localized gastric linitis plastica.

A 59-year-old male patient presented with refractory nausea and vomiting. Esophagogastroduodenoscopy revealed a concentric, malignant-appearing stricture in the distal antrum (Fig. 1a). Of note, despite the clinical picture of functional outlet obstruction, endoscopic passage into the duodenum was maintained. However, two extensive rounds of conventional mucosal biopsies (each > 12) did not yield a malignant histology. While a thoracoabdominal computed tomography scan excluded distant metastases, endoscopic ultrasound (EUS) revealed marked, diffusely hypoechogenic wall thickening up to 30 mm with irregular margins and fusion of layers, highly suggestive of gastric linitis plastica (GLP) (Fig. 1b, linear probe: Pentax, EG38J10UT). Final locoregional staging was determined uT3N0, and transmural EUS fine-needle biopsy (FNB) using a novel FNB-dedicated 22G Franseen-tip needle was performed (Acquire, Boston Scientific) (Fig. 1c). Relative to more established EUS-FNB needle, such as the Procore needle, the specific design of the needle with its stabilizing three-point tip allows for improved tissue capture and reduced fragmentation. EUS-FNB was performed in the slow pull technique with extensive fanning through the lesion, resulting in a macroscopically excellent yield (Fig. 1d). Pathology assessment indicated atypical epithelial cells with a prominent desmoplastic stroma within the muscularis propria (Fig. 1e, top). There was faint granular positivity in the periodic acid-Schiff staining, albeit a clear-cut signet ring morphology was absent. Ancillary immunohistochemistries were positive for CK-20 (Fig. 1e, lower left), CDX-2 (Fig. 1e, lower right), and (not shown) carcinoembryonic antigen, while p53 remained negative. In conjunction with clinical characteristics, a final diagnosis of poorly differentiated adenocarcinoma underlying linitis plastica was entertained. After an unremarkable ileocolonoscopy, the patient underwent diagnostic laparoscopy, excluding peritoneal carcinomatosis and providing an enteral nutrition access, and perioperative chemotherapy using FLOT4 (fluorouracil plus leucovorin, oxaliplatin, and docetaxel) was recommended prior to surgical gastrectomy. EUS-based tissue acquisition of either the gastric wall and/or suspicious lymph nodes is instrumental in confirming the malignant nature of gastric wall thickening, albeit the distinct benefit of newer FNB-dedicated needles, such as with a Franseen-tip design, considered to translate into improved maintenance of tissue architecture, is yet to be better determined in systematic, GLP-exclusive analyses.

The efficacy of treating patients with non-metastatic gastric linitis plastica using surgery with chemotherapy and/or radiotherapy.

BackgroundTo explore the efficacy of treatment strategies for non-metastatic gastric linitis plastica (GLP).MethodsPatients with non-metastatic GLP from 2004 to 2014 were identified from the National Cancer Database (NCDB). We compared overall survival (OS) of those patients who received different treatments, including surgery alone, a combination of surgery with chemotherapy and/or radiotherapy (S + C/R), chemotherapy and/or radiotherapy (C/R), and no treatment.ResultsThe cohort included 474 patients with non-metastatic GLP. Overall, the median survival was significantly different among four groups (13.90 months in S + C/R, 8.38 months in surgery alone, 8.94 months in C/R and 2.50 months in no treatment). Then, we compared the efficacy of surgery alone and surgery with postoperative chemotherapy and/or radiotherapy (S + post C/R). When the tumor size was greater than 8 cm in stage III patients, S + post C/R was associated with a better survival benefit than surgery alone. S + post C/R also conferred an obvious survival advantage compared to surgery alone for R0 patients with positive lymph nodes and patients with positive margins.ConclusionsSurgery plays the fundamental role in improving the OS of patients with non-metastatic GLP. S + post C/R would benefit patients in stage III with large-sized tumors (>8 cm), patients with negative margins and positive lymph nodes, and/or patients with positive margins.