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

Abstract

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.

Keywords: biopsy; endoscopic ultrasound; fine-needle aspiration; gastric cancer; gastric linitis plastica; linitis plastica.

Figure 1

Flow chart of modalities used for histological diagnosis of gastric linitis plastica and specific diagnoses in 54 patients included in the study.

Figure 2

Case presentation of a patient with gastric linitis plastica in whom EUS-guided fine-needle biopsy (EUS-FNB) was useful for histological tissue sampling. A female patient in her 40s with abdominal pain and weight loss was referred to our hospital. (a) Contrast-enhanced computed tomography shows circumferential thickening of the gastric wall. (b) Upper endoscopy shows diffuse gastric wall thickening and large gastric folds. No ulceration is observed. Evaluation of multiple biopsies collected from the thickened gastric wall did not reveal evidence of malignancy. (c) On EUS, the thickened gastric wall is visualized as a 20-mm-thick, diffusely hypoechoic area with loss of normal layer definition. EUS-FNB of the thickened gastric wall was performed using a 22-gauge Franseen-tip core biopsy needle. (d,e) Histological diagnosis of the specimen collected by EUS-FNB showing a cluster of poorly differentiated adenocarcinoma within the muscularis propria of the gastric wall (hematoxylin/eosin staining). (f) Additional immunohistochemical analyses reveal that the tumor cells are positive for keratin AE1/AE3.