Prognostic assessment and treatment of primary gastric lymphomas: how endoscopic ultrasonography can help in tailoring patient management

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.

Discovery and Validation of a Novel Metastasis-Related lncRNA Prognostic Signature for Colorectal Cancer

Background: Cancer metastasis-related chemoresistance and tumour progression are the leading causes of death among CRC patients. Therefore, it is urgent to identify reliable novel biomarkers for predicting the metastasis of CRC.

Methods: The gene expression and corresponding clinical data of CRC patients were downloaded from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases. Univariate and multivariate analyses were performed to identify prognostic metastasis-related lncRNAs. Nomograms were constructed, and the predictive accuracy of the nomogram model was assessed by ROC curve analysis. Then, the R package “pRRophetic” was used to predict chemotherapeutic response in CRC patients. In addition, the CIBERSORT database was introduced to evaluate tumour infiltrating immune cells between the high—and low-risk groups. The potential roles of SNHG7 and ZEB1-AS1 in CRC cell lines were further confirmed by in vitro experiments.

Results: An 8-lncRNA (LINC00261, RP1-170O19.17, CAPN10-AS1, SNHG7, ZEB1-AS1, U47924.27, NIFK-AS1, and LINC00925) signature was constructed for CRC prognosis prediction, which stratified patients into two risk groups. Kaplan-Meier analysis revealed that patients in the higher-risk group had a lower survival probability than those in the lower-risk group [p < 0.001 (TCGA); P = 0.044 (GSE39582); and P = 0.0078 (GSE29621)] The AUCs of 1-, 3-, and 5-year survival were 0.678, 0.669, and 0.72 in TCGA; 0.58, 0.55, and 0.56 in GSE39582; and 0.75, 0.54, and 0.56 in GSE29621, respectively. In addition, the risk score was an independent risk factor for CRC patients. Nomograms were constructed, and the predictive accuracy was assessed by ROC curve analysis. This signature could effectively predict the immune status and chemotherapy response in CRC patients. Moreover, SNHG7 and ZEB1-AS1 depletion significantly suppressed the colony formation, migration, and invasion of CRC cells in vitro.

Conclusion: We constructed a signature that could predict the metastasis of CRC and provide certain theoretical guidance for novel therapeutic approaches for CRC.

The first description of a singular case of synchronous chronic myelomonocytic leukemia and diffuse large b-cell lymphoma

In CMML, neoplastic monocytes can be distinguished based on their immunophenotype. Supportive care myeloid growth factors in concomitant extranodal non-Hodgkin Lymphoma are safe.

Switching Fractioned R-CHOP Cycles to Standard R-CHOP Cycles Guided by Endoscopic Ultrasonography in Treating Patients with Primary Gastric Diffuse Large B-Cell Lymphoma

Background

Primary gastric diffuse large B-cell lymphoma (PG-DLBCL) is a common subtype of extranodal non-Hodgkin lymphoma (NHL), with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) as the commonly used treatment regimen. However, full cycles of standard R-CHOP present the risk of severe bleeding or perforation, even leading to emergency surgery, especially for those with deep lesions in their first 1-2 cycles of treatment. This study aims to explore the safety and efficacy of fractioned R-CHOP (rituximab d0, 50% dose of CHOP d1 and d5) followed by standard R-CHOP cycles in PG-DLBCL patients guided by endoscopic ultrasonography (EUS).

Patients and Methods

Thirty-one PG-DLBCL patients were analyzed in this retrospective study. All patients had lesions infiltrated to at least the 3rd layer of the stomach under EUS at baseline. Patients switched to standard R-CHOP if they showed the reduced infiltrated layers and restricted lesions after fractioned R-CHOP cycles.

Results

The overall response rate, 5-year progression-free survival (PFS) and overall survival (OS) of patients in our study were 93.5%, 75% and 84%, respectively. No treatment delay or dosage reduction from gastric adverse event was observed. None of the patients in our study suffered from severe bleeding or perforation during the treatment. Kaplan-Meier analyses showed that PG-DLBCL patients characterized by multiple localization, lesions ≥3cm, having B symptoms, lower serum albumin level, and elevated LDH level were associated with worse PFS and OS.

Conclusion

Our data indicate that it might be an effective approach in treating deeply infiltrated PG-DLBCL patients by switching fractioned R-CHOP to standard R-CHOP cycles guided by EUS.

Primary Gastric Small Cell Carcinoma (Presenting as Linitis Plastica) Diagnosed Using Endoscopic Ultrasound-Guided Biopsy: A Case Report

Small cell carcinomas are the most aggressive, highly malignant neuroendocrine tumors; among these, gastric small cell carcinoma (GSCC) is extremely rare. Here we report a case of a patient with primary GSCC, presenting as linitis plastic, who was diagnosed using endoscopic ultrasound (EUS)-guided biopsy. With undiagnosed linitis plastica, an 80-year-old woman was referred to our institution. Abdominal computed tomography revealed irregular wall thickening extending from the gastric body to the antrum. Endoscopy suspected to have Borrmann type IV advanced gastric cancer. EUS of the stomach showed diffuse submucosal thickening of the gastric wall, mainly the antrum. EUS-guided bite-on-bite biopsy confirmed the diagnosis of GSCC. In general, GSCC is difficult to diagnose and careful examination is necessary to determine the therapeutic strategy; however, EUS is particularly helpful in the differential diagnosis of a lesion presenting as linitis plastica.

The size and depth of lesions measured by endoscopic ultrasonography are novel prognostic factors of primary gastric diffuse large B-cell lymphoma

Diffuse large B cell lymphoma is one of the predominant histological subtypes of primary gastric lymphomas. Factors that contribute to precise stratification and guide the treatment of this disease are still not well understood. We analyzed 73 primary gastric diffuse large B cell lymphoma patients retrospectively, and found that patients characterized by late stage, multiple localization, B symptoms, lower serum albumin level and elevated LDH level had a shorter overall survival through Univariate Cox regression analysis. Multivariate Cox regression analysis demonstrated that ALB ≤ 35g/L, staging ≥ IIE and multiple sites localization were independent adverse prognostic factors. Significantly, in 35 patients who received endoscopy at diagnosis, Kaplan-Meier analyses indicated that patients with large (≥3 cm) and deep lesions (≥11 mm) had an inferior OS (p = .01 and .039). These findings implicated that tumor size and depth are two indicators of prognosis under ultrasonography. Further randomized studies with large number of cases are needed.

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

The value of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy in the gastric linitis plastica (GLP) with negative malignant endoscopy biopsies was investigated. Forty-six patients with linitis plastica who had undergone EUS-FNA were retrospectively studied, and their clinicopathological data were examined. Among the 46 eligible patients, 38 cases were diagnosed clearly by EUS-FNA. There were 24 cases with lymph node metastasis in the 38 patients. Both the lymph nodes and gastric lesions were punctured by EUS-FNA in the 24 cases. We compared the diagnostic accuracy in different sites, and the results showed that the diagnostic accuracy in lymph nodes was significantly higher than that in gastric lesions (P<0.05). Among them, 16 patients underwent surgical resection, and the accuracy of the pathological diagnosis by EUS-FNA was 87.5% (14/16). The preoperative diagnostic accuracy of T and N staging by endoscopic ultrasound (EUS) were both 75%. Neither severe hemorrhage nor perforation occurred in any patient. In conclusion, EUS-FNA is a safe and effective procedure for the diagnosis of indefinite linitis plastica, and puncturing metastatic lymph nodes can improve the diagnostic accuracy.

Endoscopic ultrasound-guided cutting of holes and deep biopsy for diagnosis of gastric infiltrative tumors and gastrointestinal submucosal tumors using a novel vertical diathermic loop

AIM

To report on a more accurate diagnostic possibility offered by endoscopic ultrasound-guided cutting of holes and deep biopsy (EUS-CHDB) for pathologic diagnosis of gastric infiltrative tumors and gastrointestinal submucosal tumors.

METHODS

Ten consecutive patients who were suspected of having gastric invasive tumors or gastrointestinal submucosal tumors underwent EUS-CHDB with a novel vertical diathermic loop. We reviewed their medical data and analysed the effectiveness and safety of this new method. The final diagnosis was based on the surgical pathology or clinical/imaging follow-up.

RESULTS

EUS-CHDB was performed successfully in all the ten patients. Neither severe haemorrhage nor perforation occurred in any patient. Among the ten patients, there were three cases of gastric linitis plastica, one case of gastric lymphoma, five cases of gastrointestinal stromal tumors (GISTs), and only one case of chronic non-atrophic gastritis. That is, nine (90%) of the cases treated by EUS-CHDB showed positive findings.

CONCLUSION

EUS-CHDB may be a technically feasible and safe option for patients with gastric infiltrative tumors or gastrointestinal submucosal tumors. EUS-CHDB may be used as a remedial or even preferred biopsy method for submucosal lesions.

The Role of Endoscopic Ultrasound in the Diagnosis and Management of Primary Gastric Lymphoma

Endoscopic ultrasound (EUS) is considered a valuable diagnostic tool during the workup of malignant gastric lesions, including primary gastric lymphomas (PGL). Although endoscopy combined with multiple biopsies remains essential in the establishment of PGL diagnosis, EUS utilization in locoregional disease staging has been well documented in the literature. Data also support the possible role of EUS in prediction of response to first-line treatment, that is, Helicobacter pylori eradication. However, its application in the posttreatment setting remains problematic, since concordance rates between endosonography and histology findings during follow-up seem to vary substantially. The aim of the present review is to summarize all available data regarding the role of EUS in the management of PGL.

The value of EUS in combination with cytological, flow cytometry, and gene rearrangement in the diagnosis of gastrointestinal lymphoma

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) have a great value in clinical practice of gastrointestinal lymphoma (GIL). Auxiliary methods such as flow cytometry (FCM) and gene rearrangement provide additional information for the diagnosis. Current study aims to explore the diagnostic value of EUS-FNA combined with FCM and gene rearrangement for GIL in our single institution. Suspected GIL cases, which were referred to EUS, FNA, FCM, or gene rearrangement examination, were retrospectively reviewed from January 2011 to May 2014. Definitive final diagnosis was included based on the pathological and immunostaining evidence. The gene scan analysis was applied for fragment detection in gene rearrangement. The sensitivity, specificity, and accuracy were considered and calculated. Fifty-three EUS cases were identified, including 38 GIL, 10 inflammations, 4 linitis plastica, and one multiple myeloma. EUS-FNA was successfully conducted in 39 out of 53 cases. After combined with FCM, the sensitivity, specificity, and accuracy were increased from 60.7% to 76.9%, 90.9% to 100%, and from 69.2% to 81.8% respectively. Among 33 cases for FCM, 11 of them gained positive B or T non-Hodgkin lymphoma diagnosis, and 28 out of 53 specimens were delivered for gene rearrangement. The sensitivity, specificity, and accuracy of gene rearrangement were 68.2%, 100%, and 75% respectively. EUS-FNA is a possible technique for the diagnosis of GIL, With additional FCM examination may further improve the diagnostic efficiency and facilitate subclassification. Moreover, gene rearrangement assay by gene scan is also a considerable method in the specimens from GIL. Copyright © 2016 John Wiley & Sons, Ltd.

Anatomic distribution, clinical features, and survival data of 87 cases primary gastrointestinal lymphoma

Background

The purpose of this study is to analyze the anatomic distribution, clinical features, therapeutic methods, and prognosis factors of primary gastrointestinal lymphoma (PGIL).

Methods

Clinical data of 87 cases PGIL in the First Affiliated Hospital of Dalian Medical University from January 1999 to December 2010 were collected. Follow-ups were made according to the clinical feature, pathological pattern, clinical stage, and therapeutic method. Kapan Meier method was used for the survival analysis. Log-rank test was used to perform univariate survival analysis. COX multivariate analysis was carried out to analyze factors of P < 0.05 in univariate survival analysis.

Results

The incidence of PGIL significantly increased in patients more than 40 years old (87.4 %). Clinical symptoms of PGIL were indistinguishable from other digestive system diseases, which included abdominal pain or discomfort (72.4 %), lack of appetite (16.3 %), gastrointestinal hemorrhage (14.9 %), and diarrhea (12.8 %). Some patients presented with systemic symptoms or complications, such as weight loss (35.6 %) and digestive tract obstruction (13.8 %). Primary gastric lymphoma (PGL) was the most common, followed by primary intestine lymphoma (PIL). The majority of PGIL were single lesion, which included 40 cases (87 %) PGL and 35 cases (94.5 %) PIL. The most frequent site of PGL was antrum of the stomach (43.5 %), as to PIL, the small intestine (90.2 %) was the most frequent site, especially within 100 cm far away from ileocecal valve. Most of PGIL were derived from B cell (93.1 %). The most common pathological type was mucosa-associated lymphoid tissue (MALT) (67.4 %) in the PGL group and diffuse large B cell lymphoma (DLBCL) (46.3 %) in the PIL group. Surgical treatment had been performed in most of PGIL, which included 32 cases in the PGL group and 38 cases in the PIL group. The 1-year overall survival (OS) and the 3-year OS were 82 and 77 %, respectively. Analysis of single factor affecting prognosis showed that lesion location, sources of cells, and clinical stage were associated with OS. PGL group had better OS than that of PIL group (1-year 89 vs 62 %, 3-year 84 vs 50 %, P = 0.03). B cell-originated group had better OS than that of T cell-originated group (1-year 89 vs 36 %, 3-year 85 vs 0 %, P = 0.008). Stage I + II group had better OS than that of stage III + IV group (1-year 89 vs 38 %, 3-year 87 vs 0 %, P = 0.007). Multivariate analysis showed that clinical stage and sources of cells were the significant independent prognostic factors.

Conclusions

It was more common to find location of PGIL in the stomach than that in the intestine. The most common pathological type was MALT in the PGL and DLBCL in the PIL. The treatment of PGL was focused on chemotherapy. It was noting that since PIL was not only difficult to make confirmed diagnosis but also likely to develop with complications, so it was usually needed surgical excision. Clinical stage and pathological pattern were related to prognosis of PGIL.

Rare gastrointestinal lymphomas: The endoscopic investigation

Gastrointestinal lymphomas represent up to 10% of gastrointestinal malignancies and about one third of non-Hodgkin lymphomas. The most prominent histologies are mucosa-associated lymphoid tissue lymphoma and diffuse large B-cell lymphoma. However, the gastrointestinal tract can be the site of rarer lymphoma subtypes as a primary or secondary localization. Due to their rarity and the multifaceted histology, an endoscopic classification has not been validated yet. This review aims to analyze the endoscopic presentation of rare gastrointestinal lymphomas from disease diagnosis to follow-up, according to the involved site and lymphoma subtype. Existing, new and emerging endoscopic technologies have been examined. In particular, we investigated the diagnostic, prognostic and follow-up endoscopic features of T-cell and natural killer lymphomas, lymphomatous polyposis and mantle cell lymphoma, follicular lymphoma, plasma cell related disease, gastrointestinal lymphomas in immunodeficiency and Hodgkin’s lymphoma of the gastrointestinal tract. Contrarily to more frequent gastrointestinal lymphomas, data about rare lymphomas are mostly extracted from case series and case reports. Due to the data paucity, a synergism between gastroenterologists and hematologists is required in order to better manage the disease. Indeed, clinical and prognostic features are different from nodal and extranodal or the bone marrow (in case of plasma cell disease) counterpart. Therefore, the approach should be based on the knowledge of the peculiar behavior and natural history of disease.

Endoscopic ultrasound-guided deep and large biopsy for diagnosis of gastric infiltrating tumors with negative malignant endoscopy biopsies

AIM: To assess the diagnostic yield and safety of a deep and large biopsy technique under the guidance of endoscopic ultrasound (EUS) for diagnosis of gastric infiltrating tumors with negative malignant endoscopy biopsies.

METHODS: From January 2009 to March 2014, 36 patients in whom gastric infiltrating tumors had been diagnosed by EUS received negative results for malignancy after endoscopic biopsies. The deep and large biopsy technique combined bite-on-bite technique with or without endoscopic mucosal resection (EMR) to obtain submucosal tissue from lesions. EUS was used to select the appropriate biopsy sites. If the lesion protruded into the cavity, EMR was performed for removal of the overlying mucosa and then bite-on-bite technique was conducted in the resected area to obtain submucosal tissue. If the lesion appeared to be flat or was difficult to lift by injection, the bite-on-bite technique was directly used.

RESULTS: Twenty-eight of the 36 patients were treated by EMR followed by bite-on-bite technique, while 8 patients only underwent bite-on-bite technique. Histological results showed 23 of the 36 lesions were poorly differentiated adenocarcinomas, 2 diffuse large B cell lymphomas, 4 mucosa-associated lymphoid tissue-type lymphomas, and 7 undiagnosed. The deep and large biopsy technique provided a definitive and conclusive diagnosis in 29 (80.6%) of the 36 patients. The 12 gastric linitis plastica and 6 lymphoma patients received chemotherapy and avoided surgery. Minor oozing of blood in 2 mucosal resection wounds was managed by argon plasma coagulation and in 5 cases after deep biopsies by epinephrine (0.001%). Neither severe hemorrhage nor perforation occurred in any patient.

CONCLUSION: The deep and large biopsy technique is superior to ordinary endoscopic biopsy for achieving an accurate diagnosis of gastric infiltrating tumors. This procedure guided by EUS is an effective and safe diagnostic method for gastric infiltrating tumors in which endoscopic biopsy results were negative for malignancy.

Endoscopic features of gastro-intestinal lymphomas: From diagnosis to follow-up

Many progresses have been done in the management of gastrointestinal (GI) lymphomas during last decades, especially after the discovery of Helicobacter pylori-dependent lymphoma development. The stepwise implementation of new endoscopic techniques, by means of echoendoscopy or double-balloon enteroscopy, enabled us to more precisely describe the endoscopic features of GI lymphomas with substantial contribution in patient management and in tailoring the treatment strategy with organ preserving approaches. In this review, we describe the recent progresses in GI lymphoma management from disease diagnosis to follow-up with a specific focus on the endoscopic presentation according to the involved site and the lymphoma subtype. Additionally, new or emerging endoscopic technologies that have an impact on the management of gastrointestinal lymphomas are reported. We here discuss the two most common subtypes of GI lymphomas: the mucosa-associated lymphoid tissue and the diffuse large B cell lymphoma. A general outline on the state-of-the-art of the disease and on the role of endoscopy in both diagnosis and follow-up will be performed.