Endoscopic ultrasound-guided fine-needle aspiration biopsy for diagnosis of gastric linitis plastica with negative malignant endoscopy biopsies

Role of endoscopic ultrasound-guided tissue acquisition for the diagnosis of gastric wall thickening: a retrospective study with meta-analysis

Background

Tissue acquisition from a thickened gastric wall using biopsy forceps may not always lead to diagnosis, given the submucosal location of the pathology. Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) may serve as a minimally invasive diagnostic tool in such cases. Hence, we aimed to assess the diagnostic outcome and safety of EUS-TA from thickened gastric walls.

Methods

Data from patients with gastric wall thickening undergoing EUS-TA at 5 tertiary care centers from August 2020 to August 2022 were retrospectively analyzed. These data were pooled with studies obtained from a comprehensive search of Medline, Embase and Scopus from January 2000 to November 2022 and a meta-analysis was performed. Pooled event rates were calculated using an inverse variance model.

Results

The search strategy yielded 13 studies that were combined with data from 30 patients from our centers; a total of 399 patients were included in the analysis. The pooled rate of sample adequacy was 94.1% (95% confidence interval [CI] 90.0-98.2), while the pooled rate of diagnostic accuracy was 91.3% (95%CI 87.0-95.5). The pooled sensitivity and specificity for diagnosing malignant lesions with EUS-TA from gastric wall thickening were 94.8% (95%CI 91.3-97.2) and 100% (95%CI 93.6-100), respectively. There were no reported adverse events in any of the studies.

Conclusions

EUS-TA offers a safe and accurate diagnostic modality for the etiological diagnosis of thickened gastric walls. Further research is required to identify the needle type and optimal technique for improving outcomes.

Thrombotic microangiopathy and disseminated intravascular coagulation in a patient with carcinomatosis of the bone marrow due to gastric adenocarcinoma: Case report

Carcinomatosis of the bone marrow is a rare clinical condition characterized by diffuse tumor infiltration of the bone marrow accompanied by hematological abnormalities, including thrombotic microangiopathy (TMA) and disseminated intravascular coagulation (DIC). In patients with gastric carcinoma, this association is infrequent. Below we present a case of a 19-year-old female patient with no known pathological history who presented with upper digestive tract bleeding. Upon examination, anemia and thrombocytopenia were documented, with schistocytes in the peripheral blood smear and prolonged coagulation times. Endoscopic studies indicated a lesion in the Borrmann IV gastric body, and the bone marrow biopsy showed the presence of signet ring cells. Because there was no possibility of systemic therapy, the patient died during hospitalization. This case contributes to the medical literature by describing an unusual presentation of a very frequent pathology.

Interventional gastroenterology in oncology

Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.

Gastric linitis plastica with autoimmune pancreatitis diagnosed by an endoscopic ultrasonography-guided fine-needle biopsy: A case report

BACKGROUND

Gastric linitis plastica (GLP) is a subset of gastric cancer with a poor prognosis. It is difficult to obtain a definitive diagnosis by endoscopic mucosal biopsies, and the usefulness of an endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) for GLP has been recently reported. Meanwhile, autoimmune diseases are occasionally known to coexist with malignant tumors as paraneoplastic syndrome. We herein report the usefulness of an EUS-FNB for detecting GLP and the possibility of paraneoplastic syndrome coexisting with GLP.

CASE SUMMARY

An 81-year-old man was admitted to our hospital for a 1-mo history of epigastric pain that increased after eating. His laboratory data revealed high levels of serum carbohydrate antigen 19-9 and immunoglobulin-G4. Endoscopic examinations showed giant gastric folds and reddish mucosa; however, no epithelial changes were observed. The gastric lumen was not distensible by air inflation, suggesting GLP. Computed tomography showed the thickened gastric wall, the diffuse enlargement of the pancreas, and the peripancreatic rim, which suggested autoimmune pancreatitis (AIP) coexisting with GLP. Because the pathological findings of the endoscopic biopsy showed no malignancy, he underwent an EUS-FNB and was diagnosed with GLP. He received chemotherapy for unresectable gastric cancer due to peritoneal metastasis, after which both the gastric wall thickening and diffuse enlargement of the pancreas were improved.

CONCLUSION

An EUS-FNB for GLP with a negative endoscopic biopsy is useful, and AIP may develop as a paraneoplastic syndrome.

EUS-guided fine needle aspiration provides an open view for duodenal obstruction caused by urothelial carcinoma: a case report

Background

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a good alternative and diagnostic tool for gastrointestinal wall thickening with prior negative endoscopic biopsies.

Case presentation

Here we reported a case of a 60-years-old woman admitted with atrophic right kidney and hydronephrosis and intermittent postprandial bloating. Esophagogastroduodenoscopy and small bowel endoscopy revealed wall thickening and stenosis at the junction of the descending and inferior duodenum. Biopsies from endoscopy showed no specific findings. EUS-FNA of the thickened duodenal wall was performed and histopathological examinations revealed poorly differentiated carcinoma. Immunohistochemically staining was positive for pan-cytokeratin, CK7, CK20, and weakly positive for GATA-3 and P63. These results were highly suggestive of metastatic urothelial cancer.

Conclusions

EUS-FNA played an important role in the diagnosis of unexplained gastrointestinal wall thickening and rare metastases to the gastrointestinal wall.

Endoscopic ultrasound-guided fine-needle biopsy for the diagnosis of gastric linitis plastica

We report two cases of patients with gastric linitis plastica (GLP), in which the histopathological diagnosis was made by endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) using a Franseen-tip needle. Esophagogastroduodenoscopy findings showed mucosal swelling and poor distensibility of the gastric antrum. Abdominal computed tomography findings showed significant thickening of the gastric wall at the antrum. Conventional endoscopic and bite-on-bite biopsy were attempted but resulted in failure to diagnose the lesions. We performed EUS-FNB to obtain histopathological samples from a deeper site, which confirmed the diagnosis. We considered this method safe and effective for the diagnosis of GLP.

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.

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-guided Fine Needle Aspiration for the Diagnosis of Duodenal Stenosis Due to Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) initially presents with hematuria and hydronephrosis. We report a case of UTUC presenting with initial findings of duodenal stenosis before the appearance of hydronephrosis. A 59-year-old man presented with upper abdominal symptoms on his initial visit. Esophagogastroduodenoscopy (EGD) revealed circumferential stenosis at the descending part of the duodenum. However, the underlying cause of duodenal stenosis was unknown as repeated histopathological examinations of endoscopic biopsy specimens showed no specific findings. We then performed endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of the thickened duodenal wall, and successfully diagnosed duodenal metastasis of UTUC. EUS-FNA is an effective diagnostic method in cases in which the cause of duodenal stenosis is unknown.

Multiple metabolic parameters and visual assessment of 18F-FDG uptake heterogeneity of PET/CT in advanced gastric cancer and primary gastric lymphoma

PURPOSE

Advanced gastric cancer (AGC) and primary gastric lymphoma (PGL) are the two most common malignant tumors of the stomach. Conventional imaging examinations have difficulty distinguishing the two. This study explored the values of multiple parameters and visual assessment of ¹⁸F-fluorodeoxyglucose(¹⁸F-FDG) uptake heterogeneity of positron emission tomography/computed tomography(PET/CT) for differentiating between AGC and PGL.

METHODS

This retrospective study included 70 AGC and 26 PGL patients, all of whom had undergone ¹⁸F-FDG PET/CT before treatment. We analyzed the differences between AGC and PGL in the distribution of metastatic lesions and multiple metabolic parameters, including the maximum standardized uptake value (SUVmax), SUVmax/maximal thickness(THKmax), metabolic tumor volume and total lesion glycolysis (TLG). In addition, ¹⁸F-FDG uptake heterogeneity was visually assessed using a visual scoring method and a method of measuring SUVmax differences (SUVmax-d).

RESULTS

The most common metastasis of AGC patients were liver, bone, peritoneal and proximal lymph nodes; PGL patients had fewer peritoneal metastases and lymph node metastasis could appeared to be "skip metastasis." The metabolic parameters-SUVmax, SUVmax/THKmax and TLG-were higher in patients who had PGL, especially in diffuse large B-cell lymphoma (DLBCL). In the visual assessment of ¹⁸F-FDG uptake heterogeneity, the measurements of SUVmax-d in PGL were significantly higher than in AGC. Receiver operating characteristics curve analysis suggested that SUVmax has the highest comprehensive diagnostic efficiency due to having the highest value of area under the curve and the highest accuracy (77.2%).

CONCLUSION

¹⁸F-FDG PET/CT had a high diagnostic efficiency for discrimination of AGC and PGL, especially between DLBCL and other pathological subtypes. Visual assessment used to evaluate ¹⁸F-FDG uptake heterogeneity could help to distinguish the two types of tumors. In addition, our innovative method of measuring the heterogeneity of ¹⁸F-FDG uptake-namely, SUVmax-d-could contribute to identification of the two tumor types and should have its significance clarified by future studies.