• Users Online:169
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 
IMAGES AND VIDEOS
Ahead of print publication  

Epstein–Barr virus-associated gastric carcinoma diagnosed by EUS-guided fine needle biopsy (with video)


1 Faculty of Laboratory Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
2 Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan
3 Department of Clinical Science of Surgery, Yamaguchi University Graduate School of Medicine, Ube, Japan

Date of Submission13-Jan-2021
Date of Acceptance06-May-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Jun Nishikawa,
Faculty of Laboratory Science, Yamaguchi University Graduate School of Medicine, Minamikogushi 1-1-1, Ube, Yamaguchi 755-8505
Japan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00026

PMID: 34494584



How to cite this URL:
Nishikawa J, Kaino S, Goto A, Harada E, Sakaida I. Epstein–Barr virus-associated gastric carcinoma diagnosed by EUS-guided fine needle biopsy (with video). Endosc Ultrasound [Epub ahead of print] [cited 2021 Oct 16]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=325246

A 64-year-old woman with a gastric tumor was referred to us for pathologic diagnosis and further treatment. Esophagogastroduodenoscopy revealed a 20-mm subepithelial lesion in the gastric body [Figure 1]. Forceps biopsy from the top of the lesion showed no evidence of malignancy. EUS showed a hypoechoic mass mainly in the submucosal layer [Figure 2]a. Immediately after injection of the contrast agent, Sonazoid (Perflubutane, Daiichi-Sankyo Pharmaceuticals, Tokyo, Japan), the lesion was heterogeneously enhanced [Video 1 [Additional file 1]] and [Figure 2]b]. An EUS-guided fine needle biopsy (EUS-FNB) with an Acquire 22-G needle (Boston Scientific Japan, Tokyo, Japan) was conducted using a convex-type ultrasonic endoscope GF-UCT260 (Olympus Medical System Corp., Tokyo, Japan) with the observation device, ProSound alpha-10 (Aloka Co. Ltd., Tokyo, Japan) [Figure 2]c. The pathologic specimen revealed poorly differentiated adenocarcinoma with prominent lymphocytic infiltration that was diagnosed as carcinoma with lymphoid stroma (CLS) [Figure 3]a. We obtained enough tissue for immunohistochemistry and Epstein–Barr virus-encoded small RNA 1 (EBER1) in situ hybridization. The tumor cells were positive for a pan epithelial marker, cytokeratin AE1/AE3 [Figure 3]b, and EBER1 signals were observed in the nuclei of tumor cells [Figure 3]c. The infiltrating lymphocytes were positive for pan T-cell marker, CD3 [Figure 3]d. Distal gastrectomy with lymph node dissection was performed, and the final pathological diagnosis was Epstein–Barr virus (EBV)-positive CLS limited to the submucosal layer. Lymphovascular invasion was positive but without lymph node metastasis.
Figure 1: Endoscopic image revealed a 20-mm subepithelial lesion in the gastric body

Click here to view
Figure 2: Endoscopic ultrasound image revealed a hypoechoic mass mainly in the submucosal layer (a). Contrast-enhanced endoscopic ultrasound revealed that the lesion was heterogeneously enhanced (b). An endoscopic ultrasound-guided fine-needle aspiration with a 22-G needle was conducted (c)

Click here to view
Figure 3: The pathologic specimen revealed poorly differentiated adenocarcinoma with prominent lymphocytic infiltration (a). The tumor cells were positive for pan epithelial marker, cytokeratin AE1/AE3, by immunohistochemistry (b). Epstein–Barr virus-encoded small RNA 1 in situ hybridization showed that signals of Epstein–Barr virus-encoded small RNA 1 were observed in the nuclei of tumor cells (c). The infiltrating lymphocytes were positive for pan T-cell marker, CD3 (d). (orig. mag. ×20)

Click here to view


The rate of lymph node metastasis is low in EBV-associated gastric carcinoma. Thus, endoscopic resection and minimally invasive surgery might be suitable for this subtype. Since the presence of EBV affects treatment strategies for gastric cancer, the importance of detecting EBV in gastric carcinoma is increasing.[1] Subepithelial lesion-like morphology is considered to be one of the features of CLS as CLS is comprised a poorly differentiated tumor mass that accompanies infiltrating lymphocytes in a submucosal or deeper layer.[2] EUS revealed a hypoechoic mass in the submucosal layer reflecting CLS histology.[3],[4],[5] Since >90% of gastric CLS cases are associated with EBV infection,[6] these findings might be helpful in the diagnosis of EBV-associated gastric carcinoma. EUS-FNB was useful for pathologic diagnosis for CLS and its association with EBV.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her names and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nishikawa J, Iizasa H, Yoshiyama H, et al. Clinical importance of epstein − barr virus-associated gastric cancer. Cancers (Basel) 2018;10:167.  Back to cited text no. 1
    
2.
Yanai H, Nishikawa J, Mizugaki Y, et al. Endoscopic and pathologic features of Epstein-Barr virus-associated gastric carcinoma. Gastrointest Endosc 1997;45:236-42.  Back to cited text no. 2
    
3.
Nishikawa J, Yanai H, Mizugaki Y, et al. Case report: Hypoechoic submucosal nodules: A sign of Epstein-Barr virus-associated early gastric cancer. J Gastroenterol Hepatol 1998;13:585-90.  Back to cited text no. 3
    
4.
Tanabe H, Ando K, Sutoh D, et al. A case of gastric carcinoma with lymphoid stroma diagnosed by an endoscopic ultrasound-guided fine-needle biopsy. J Clin Ultrasound 2019;47:419-22.  Back to cited text no. 4
    
5.
Yanagita T, Hikichi T, Nakamura J, et al. Gastric carcinoma with lymphoid stroma diagnosed by endoscopic ultrasound-guided fine-needle aspiration. Clin J Gastroenterol 2021;14:471-7.  Back to cited text no. 5
    
6.
Murphy G, Pfeiffer R, Camargo MC, et al. Meta-analysis shows that prevalence of Epstein-Barr virus-positive gastric cancer differs based on sex and anatomic location. Gastroenterology 2009;137:824-33.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

 
Top
 
 
  Search
 
     Search Pubmed for
 
    -  Nishikawa J
    -  Kaino S
    -  Goto A
    -  Harada E
    -  Sakaida I
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   References
   Article Figures

 Article Access Statistics
    Viewed211    
    PDF Downloaded2    

Recommend this journal