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

Abstract

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.