A 42-year-old woman presents with progressive epigastric pain, early satiety, and unintentional weight loss over 6 months. Upper endoscopy reveals a rigid, non-distensible stomach with thickened folds and loss of normal rugae, but no discrete ulcerated mass. The structure marked **B** in the diagram is suspected. Initial superficial biopsies from the gastric mucosa are reported as "benign gastritis." Which of the following is the most appropriate next diagnostic step?
A. CT chest/abdomen/pelvis for staging and diagnostic laparoscopy to exclude peritoneal metastases
B. Endoscopic ultrasound (EUS) to assess depth of invasion and perigastric lymph nodes
C. Repeat endoscopy with deep biopsies using jumbo forceps or endoscopic mucosal resection
D. PET-CT imaging to evaluate for distant metastatic disease
Explanation
Why "Repeat endoscopy with deep biopsies using jumbo forceps or endoscopic mucosal resection" is right
Linitis plastica (the structure marked B) is a diffuse-type gastric adenocarcinoma characterized by signet-ring cell infiltration in the submucosa and muscularis propria, often with a deceptively normal-appearing mucosa. Superficial biopsies are falsely negative in up to 50% of cases because the malignant cells lie beneath the mucosa. The NCCN Gastric Cancer Guidelines 2024 and Sabiston Textbook of Surgery 21e emphasize that deep biopsies using jumbo forceps or endoscopic mucosal resection are mandatory when linitis plastica is clinically suspected but superficial samples are non-diagnostic. This is the critical diagnostic step before staging.
Why each distractor is wrong
CT chest/abdomen/pelvis for staging and diagnostic laparoscopy: While these are essential for staging once diagnosis is confirmed, they cannot be performed without histologic proof of malignancy. Staging comes after diagnosis, not before.
Endoscopic ultrasound (EUS) to assess depth of invasion and perigastric lymph nodes: EUS is valuable for T-staging and nodal assessment in confirmed gastric cancer, but it does not establish histologic diagnosis. It cannot replace tissue confirmation.
PET-CT imaging to evaluate for distant metastatic disease: Signet-ring cell adenocarcinomas are often FDG-negative on PET-CT, making this imaging modality unreliable for diffuse-type gastric cancer. Moreover, diagnosis must precede metastatic workup.
High-YieldNEET PG
Linitis plastica is a "great imitator"—superficial biopsies are frequently falsely negative; always obtain deep biopsies when clinical suspicion is high and initial samples are benign.
NCCN Gastric Cancer Guidelines 2024; Sabiston Textbook of Surgery 21e; Lauren classification and diagnostic approach to diffuse-type gastric adenocarcinoma
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