85 year old male was recently diagnosed with gastric adenocarcinoma. His past medical history included coronary artery disease; he underwent coronary bypass surgery, hypertension, benign prostate hyperplasia, and asthma. Family history was significant for gastric cancer in his nephew. He had history of smoking in the past.
Upper endoscopy showed diffusely prominent proximal gastric folds. The examination of the antrum and pylorus showed normal looking gastric mucosa. Again, on withdrawal distinct transition point was seen in antrum and proximal body. Similar changes were seen in the fundus of the stomach. These are the narrow band imaging of the prominent gastric folds in the proximal body. The narrow band imaging showed cobblestone pattern of the gastric mucosa with normal pit pattern. This is the retroflex view of the gastric cardia and the fundus showing the extent of the disease.
The radial endoscopic ultrasound (EUS) examination of the antrum showed the normal architecture of the gastric wall, showing normal looking mucosa, deep mucosa, submucosa and muscularis propria. Total thickness of the antral wall was 3 mm. These are again the views of the radial EUS examination performed in the normal looking gastric mucosa in the antrum. Normal architecture of the gastric wall is seen.
EUS examination of the proximal gastric body showed diffuse thickening of the gastric folds with some preservation of the wall architecture. Diffuse thickening of the deep mucosa and submucosa was seen with normal looking muscularis propria layer. Biopsy forceps of the deep mucosa confirmed the diagnosis of the gastric carcinoma. In this portion, the gastric wall thickening was about 9 mm, as compared to the normal looking antral mucosa where the gastric wall was only 3 mm in size.
Linitus plastica carcinomas are poorly differentiated tumors that diffusely infiltrate the stomach wall. Normal stomach wall is 3-4 mm in thickness. More than 4 mm thickness suggests infiltrating cancer. Two EUS patterns have been described. Type I: There is complete loss of five stomach layers. Type II: Preserved five layer pattern, but the muscularis propria and submucosal layers are thickened.
Manmeet Padda, MD, Yale University
Harry Aslanian, M.D., Yale University