Gastrointestinal malignant lymphomas of the mucosa-associated lymphoid tissue: factors relevant to prognosis

Cross-talk between immune cells and tumor cells in non-Hodgkin lymphomas arising in common variable immunodeficiency

INTRODUCTION

CVID is the commonest and most symptomatic primary immune deficiency of adulthood. NHLs are the most prevalent malignancies in CVID. The cross-talk between tumor cells and immune cells may be an important risk factor in lymphomagenesis.

AREAS COVERED

The present review highlights immune cell, genetic and histopathological alterations in the CVID-associated NHLs.

EXPERT OPINION

CVID patients exhibit some notable immune defects that may predispose to lymphomas. T/NK cell defects including reduced T cells, naïve CD4+T cells, T regs, and Th17 cells, increased CD8+T cells with reduced T cell proliferative and cytokine responses and reduced iNKT and NK cell count and cytotoxicity. B cell defects include increased transitional and CD21low B cells, clonal IgH gene rearrangements, and increased BCMA levels. Increase in IL-9, sCD30 levels, and upregulation of BAFF-BAFFR signaling are associated with lymphomas in CVID. Increased expression of PFTK1, duplication of ORC4L, germline defects in TACI, NFKB1, and PIK3CD, and somatic mutations in NOTCH2 and MYD88 are reported in CVID-associated lymphomas. Upregulation of PD-L1-PD-1 pathway may also promote lymphomagenesis in CVID. These abnormalities need to be explored as prognostic or predictive markers of CVID-associated NHLs by large multicentric studies.

Clinical Management of Patients with Gastric MALT Lymphoma: A Gastroenterologist's Point of View

Gastric mucosa-associated lymphoid tissue (MALT) lymphomas (GML) are non-Hodgkin lymphomas arising from the marginal zone of the lymphoid tissue of the stomach. They are usually induced by chronic infection with Helicobacter pylori (H. pylori); however, H. pylori-negative GML is of increasing incidence. The diagnosis of GML is based on histological examination of gastric biopsies, but the role of upper endoscopy is crucial since it is the first step in the diagnostic process and, with currently available novel endoscopic techniques, may even allow an in vivo diagnosis of GML per se. The treatment of GML, which is usually localized, always includes the eradication of H. pylori, which should be performed even in H. pylori-negative GML. In the case of GML persistence after eradication of the bacteria, low-dose radiotherapy may be proposed, while systemic treatments (immunochemotherapy) should be reserved for very rare disseminated cases. In GML patients, at diagnosis but even after complete remission, special attention must be paid to an increased risk of gastric adenocarcinoma, especially in the presence of associated gastric precancerous lesions (gastric atrophy and gastric intestinal metaplasia), which requires adequate endoscopic surveillance of these patients.

Clinical and endoscopic features of primary small bowel lymphoma: a single-center experience from mainland China

Objective

The worldwide incidence of primary small intestinal lymphoma (PSIL) is increasing. However, little is known about the clinical and endoscopic characteristics of this disease. The aim of this study was to investigate the clinical and endoscopic data of patients with PSIL, with the goal of enhancing our understanding of the disease, improving diagnostic accuracy, and facilitating more accurate prognosis estimation.

Methods

Ninety-four patients diagnosed with PSIL were retrospectively studied at Qilu Hospital of Shandong University between 2012 and 2021. The clinical data, enteroscopy findings, treatment modalities, and survival times were collected and analyzed.

Results

Ninety-four patients (52 males) with PSIL were included in this study. The median age of onset was 58.5 years (range: 19-80 years). Diffuse large B-cell lymphoma (n=37) was the most common pathological type. Abdominal pain (n=59) was the most frequent clinical presentation. The ileocecal region (n=32) was the most commonly affected site, and 11.7% of patients had multiple lesions. At the time of diagnosis, the majority of patients (n=68) were in stages I-II. A new endoscopic classification of PSIL was developed, including hypertrophic type, exophytic type, follicular/polypoid type, ulcerative type, and diffusion type. Surgery did not show a significant increase in overall survival; chemotherapy was the most commonly administered treatment. T-cell lymphoma, stages III-IV, "B" symptoms, and ulcerative type were associated with poor prognosis.

Conclusion

This study provides a comprehensive analysis of the clinical and endoscopic features of PSIL in 94 patients. This highlights the importance of considering clinical and endoscopic characteristics for accurate diagnosis and prognosis estimation during small bowel enteroscopy. Early detection and treatment of PSIL is associated with a favorable prognosis. Our findings also suggest that certain risk factors, such as pathological type, "B" symptoms, and endoscopic type, may affect the survival of PSIL patients. These results underscore the need for careful consideration of these factors in the diagnosis and treatment of PSIL.

First-line antibiotic treatment in patients with localized extragastric mucosa-associated lymphoid tissue lymphoma

Between January 2010 and December 2015, we enrolled 28 patients with stage IEI/IIE1 extragastric mucosa-associated lymphoid tissue (MALT) lymphoma who received first-line antibiotic treatment, after informing them about the pros and cons of alternative therapies. In addition, during the same period, 64 patients with stage IE/IIE1 disease who received conventional treatment were selected as the control group. The most common primary sites were the ocular adnexal area (17 cases), followed by the salivary glands (four cases), pulmonary (three cases), and thyroid, trachea, larynx, and colon region (one case each). First-line antibiotic treatment resulted in an overall response rate of 57.1%: 12 patients achieved complete remission (CR), while four achieved partial remission (antibiotic-responsive tumors). Monoclonal gammopathy was significantly prevalent in antibiotic-unresponsive tumors than in antibiotic-responsive tumors (50.0% [6/12] vs. 12.5% [2/16], p = 0.044). After a median follow-up of 7 years, all patients with CR remained lymphoma-free, with 7-year event-free survival (EFS) and overall survival (OS) rates of 62.7% and 96.4%, respectively. The 7-year EFS and OS rates of patients who received conventional treatments were 73.1% and 91.1%, respectively. Compared with that noted in patients who received conventional treatment, antibiotic treatment was effective in some patients with localized extragastric MALT lymphoma.

Efficacy of Surgery in Patients with Stage I Primary Parotid Gland Lymphoma: A Population-Based Study

Background. Limited and controversial evidence is available on the efficacy of surgery for patients with stage I primary parotid gland lymphoma. Thus, we aimed to investigate whether surgery can enhance the prognosis of patients with stage I primary parotid gland lymphoma using large sample data. Methods. From 1998 to 2015, we searched the Surveillance, Epidemiology, and End Results (SEER) program database and extracted information regarding patients with stage I primary parotid gland lymphoma; we classified these patients into surgery and nonsurgery groups. We calculated overall survival (OS) and cancer-specific survival (CSS) using Kaplan–Meier curves and log-rank testing. Propensity score matching (PSM) analysis was also used to further account for confounding variables before comparing the OS and CSS again. We used the COX proportional hazard regression model in both multivariate and univariate analyses. Results. We enrolled 918 patients with stage I primary parotid gland lymphoma, among which 656 (71.5%) patients underwent surgery. Before PSM, the surgery group had better OS (hazard ratio (HR) = 0.673, 95% confidence interval (CI): 0.519–0.873, and $p=0.003$ ) and CSS (HR = 0.595, 95% CI: 0.403–0.879, and $p=0.008$ ) than the nonsurgery group. After PSM, surgery was still a beneficial factor for OS (HR = 0.569, 95% CI: 0.399–0.810, and $p=0.002$ ) and CSS (HR = 0.384, 95% CI: 0.220–0.669, and $p=0.001$ ). Furthermore, in univariate and multivariate analyses, total parotidectomy significantly increased OS ( $p=0.001$ and $p=0.021$ , respectively) and CSS ( $p=0.001$ and $p=0.037$ , respectively). Conclusions. In summary, the prognosis of patients with stage I primary parotid gland lymphoma can be significantly improved by surgery. Moreover, total parotidectomy was a protective factor for OS and CSS before and after PSM analysis, suggesting that surgery acts as a significant component in multimodal therapy for early primary parotid gland lymphoma.

Immunohistochemistry for IRTA1 and MNDA helps differentiate gastric MALT lymphoma from chronic gastritis/reactive lymphocyte hyperplasia

It is difficult to histologically differentiate extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) from chronic gastritis (CG)/ reactive lymphoid hyperplasia (RLH). To determine whether immunohistochemistry for IRTA1 and MNDA can differentiate gastric MALT lymphoma from CG/RLH, we investigated 81 stomach biopsy specimens [Wotherspoon grade (WG) 1, 11 cases; WG 2, 9 cases; WG 3, 20 cases; WG 4, 31 cases; and WG 5, 10 cases]. According to a previously reported algorithm involving PCR for immunoglobulin heavy (IgH) chain locus rearrangement, all 81 cases were divided into three groups: CG/RLH (55 cases), MALT lymphoma (19 cases) groups, and IgH undetectable group (7 cases). We analyzed the CG/RLH and MALT lymphoma groups. The median percentage of IRTA1-positive cells was 0% (range 0%-90.6%) in the CG/RLH group and 43.5% (range 0%-97.6%) in the MALT lymphoma group (p < 0.0001). The median percentage of MNDA-positive cells was 32.4% (range 0%-97.6%) in the CG/RLH group and 55.1% (range 0%-97.6%) in the MALT lymphoma group (p = 0.0044). These results indicate that immunohistochemistry for IRTA1 and MNDA can help differentiate gastric MALT lymphoma from CG/RLH.

[Gastric MALT lymphoma - from pathogenetic insights to consequent deescalation of therapy]

Gastric MALT- (mucosa-associated-lymphoid-tissue) lymphoma represents the most frequent gastrointestinal lymphoma. For decades, surgery and later on radiation and chemotherapy were regarded as established therapy. Some 30 years ago, the pathogenetic role of Helicobacter pylori infection for the development of gastric MALT-lymphoma became evident. During the following years, the pathogenetic insights were consequently implemented into clinical medicine. This lead to a radical change of the therapeutic approach to these lymphoma. Nowadays, Helicobacter pylori eradication is the internationally established therapy of first choice. It is followed by lymphoma regression in most cases. The long-term prognosis of patients after exclusive eradication therapy is excellent, even if endoscopic and/or histological residuals persist and a watch-and-wait strategy is favored.The pathogenetic insights und their clinical application implicated a consequent deescalation of therapy of gastric MALT-lymphoma. This review summarizes the single steps of this development and gives a recommendation for the actual management of patients with gastric MALT lymphoma.

Optimal Initial Workup in Patients With Superficial Primary Gastric MALT Lymphoma

BACKGROUND AND AIMS

The prognosis of gastric mucosa-associated lymphoid tissue (MALT) lymphoma is favorable, especially in the absence of lymph node metastasis (LNM). We investigated LNM incidence and location in superficial type gastric MALT lymphoma.

METHODS

We performed a retrospective analysis of 450 patients newly diagnosed with gastric MALT lymphoma with tumor infiltration confined to the mucosa or submucosa as evidenced by endoscopic ultrasonography. LNM incidence and location were evaluated.

RESULTS

Of the 450 patients, most patients (434, 96.4%) were initially LNM negative as confirmed by computed tomography (CT) scanning. Sixteen patients (3.6%) were LNM positive. There was no difference in clinical characteristics between the 2 groups except for the extent of lymphoma involvement and endoscopic findings. Among 41 patients undergoing abdominal/pelvic CT (APCT) only, LNM was detected in 1 (2.4%). There were 8 LNM cases among 238 patients undergoing both APCT and chest CT (3.4%). Among 171 patients undergoing APCT, chest CT, and neck CT, 7 cases of LNM were detected (4.1%). The detection rates for each CT were as follows: abdominal CT, 13/450 (2.9%); chest CT, 6/408 (1.5%); and neck CT, 1/171 (0.6%). Among 6 patients with chest CT-positive findings, 3 showed no evidence of LNM on APCT.

CONCLUSION

LNM was an infrequent finding in gastric MALT lymphoma patients with tumor infiltration confined to the mucosa or submucosa. Besides endoscopy and endoscopic ultrasonography, APCT and chest CT are considered as optimal initial workup modalities in patients with assumed primary superficial gastric MALT lymphoma.

Need to Inspect the Total Gastrointestinal Tract of Patients With Malignant Lymphomas

BACKGROUND/AIM

Malignant lymphoma (ML) cases with overlapping gastrointestinal (GI) lesions are often encountered. We aimed to elucidate the importance of examining the GI tract in patients with ML and assess the overlap rate.

PATIENTS AND METHODS

We analysed 190 patients diagnosed with GI MLs. We compared the overlap rates among the different histopathological types.

RESULTS

Twenty-five (13.2%) patients had overlapping GI lesions in more than two segments. The overlap rates were 100% in mantle cell lymphomas (MCL), 27.6% in follicular lymphomas (FL), and 16.3% in diffuse large B-cell lymphomas (DLBCL). MCL, FL, and DLBCL cases showed significantly higher overlap rates than mucosa-associated lymphoid tissue lymphoma cases (p<0.01). About 64.0% of cases of ML with overlapping lesions involved the small intestine.

CONCLUSION

In GI ML cases, it is ideal to examine the entire GI tract by esophagogastroduodenoscopy, colonoscopy, and capsule endoscopy and/or balloon-assisted endoscopy, especially in MCL, FL, and DLBCL.

Clinical course of duodenal mucosa-associated lymphoid tissue lymphoma: Comparison with gastric mucosa-associated lymphoid tissue lymphoma

BACKGROUND AND AIM

There are few cases of duodenal mucosa-associated lymphoid tissue (MALT) lymphoma reported in the literature, and little is known about the clinical course of this disease. Here, we aimed to characterize the clinical features of duodenal MALT lymphoma by comparison with gastric MALT lymphoma.

METHODS

Thirteen patients diagnosed with duodenal MALT lymphoma at Asan Medical Center from March 1997 to February 2017 were included in this retrospective study, along with patients with gastric MALT lymphoma, matched by age and sex at a 1:10 ratio.

RESULTS

Median age of patients with duodenal MALT lymphoma was 49 (range 20-72) years, and 53.8% (7/13) were male. Comparison of patient characteristics indicated that Helicobacter pylori infection (46.2% vs 90.8%, P < 0.001) and lymph node metastasis (23.1% vs 5.4%, P = 0.049) rates differed between patients with duodenal and gastric MALT lymphoma. Overall complete remission (61.5% vs 86.2%, P = 0.021) and complete remission after initial H. pylori eradication therapy (50% vs 87.7%, P = 0.037) were significantly lower in patients with duodenal than gastric MALT lymphoma. Complications including bleeding, stricture, and transformation to high-grade lymphoma occurred in a total of seven patients (4.9%), with a higher incidence in patients with duodenal than gastric MALT lymphoma (38.5% vs 1.5%, P < 0.001).

CONCLUSIONS

Duodenal MALT lymphoma is very rare, and treatment outcomes appear to be inferior to those of gastric MALT lymphoma.

Value of 18F-FDG PET/CT for prognostic stratification in patients with primary intestinal diffuse large B cell lymphoma treated with an R-CHOP-like regimen

PURPOSE

The prognostic value of ¹⁸F-FDG PET/CT for primary intestinal diffuse large B-cell lymphoma (PI-DLBCL) patients has not been determined. This prompted us to explore the value of ¹⁸F-FDG PET/CT for prognostic stratification in patients with PI-DLBCL treated with an R-CHOP-like regimen.

MATERIALS AND METHODS

Seventy-three PI-DLBCL patients who underwent baseline PET/CT between January 2010 and May 2019 were included in this retrospective study. Total metabolic tumor volume (TMTV) and total lesion glycolysis (TLG) were computed using the 41% SUV_max thresholding method. Progression-free survival (PFS) and overall survival (OS) were used as endpoints to evaluate prognosis.

RESULTS

During the follow-up period of 3-117 months (29.0 ± 25.5 months), high TLG, non-germinal center B-cell-like (non-GCB) and high National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI) were significantly associated with inferior PFS and OS. TLG, cell-of-origin and NCCN-IPI were independent predictors of PFS, and both TLG and NCCN-IPI were independent predictors of OS. The grading system was based on the number of risk factors (high TLG, non-GCB, high NCCN-IPI) and patients were divided into 4 risk groups (PFS: χ² = 33.858, P < 0.001; OS: χ² = 29.435, P < 0.001): low-risk group (none of the 3 risk factors, 18 patients); low-intermediate risk group (1 risk factor, 24 patients); high-intermediate risk group (2 risk factors, 16 patients); and high-risk group (all 3 risk factors, 15 patients).

CONCLUSIONS

High TLG, non-GCB and high NCCN-IPI can identify a subset of PI-DLBCL patients with inferior survival outcomes. Furthermore, the grading system can identify PI-DLBCL patient groups with markedly different prognoses, which might contribute to the adjustment of the therapeutic regime.

A Unique Case of Primary Extranodal Marginal Zone Lymphoma of the Anal Canal

Marginal zone lymphomas represent approximately 10-12% of all B-cell lymphomas. Extranodal marginal zone lymphomas (EMZL) or mucosa-associated lymphoid tissue (MALT) lymphomas are the most common subtype. Almost half of all MALT lymphomas arise in the gastrointestinal (GI) tract and, while the stomach is the most common site of GI involvement, the small and large intestines can also be involved. Rare cases of MALT lymphoma involving the rectum have been reported; however, to our knowledge, involvement of the anal canal has never been reported in the literature. Here, we describe a unique case of MALT lymphoma of the anal canal. Infectious agents have been implicated in the pathogenesis of MALT lymphomas, possibly through persistent antigenic stimulation of the area; however, in our case no such infection was documented.

Sequential H. pylori eradication and radiation therapy with reduced dose compared to standard dose for gastric MALT lymphoma stages IE & II1E: a prospective randomized trial

BACKGROUND

In Helicobacter pylori (H. pylori) positive stage I gastric low-grade MALT lymphoma, eradication is the accepted first-line therapy. The role of eradication therapy in lymphoma > stage IE is still unclear. However, about 20% of patients show persistent lymphoma following successful eradication or primary H. pylori-negative lymphoma. A prospective study for salvage radiation therapy with standard 36 Gy in comparison to a reduced dose of 25.2 Gy is still missing.

METHODS

A prospective, multicentre study investigated the efficacy of eradication in H. pylori-positive gastric low-grade MALT lymphoma stages IE and II1E (HELYX I). Refractory lymphoma or H. pylori-negative patients were treated in a prospective, randomised, multicentre, phase II study to receive either 25.2 Gy or 36 Gy radiotherapy (HELYX II).

RESULTS

102 patients (3 drop outs) were included in HELYX I: 75/99 (75.8%) showed complete remission after a median of 2.8 months. 18 (18.2%) had partial remission (PR) and 6 (6.0%) no change (NC). 29 patients (7 drop outs) were randomized in HELYX II (7 primarily H. pylori-negative, 15 patients from HELYX I with refractory disease after eradication). All patients achieved stable CR irrespective of radiation dose. Both presence of the t(11,18) translocation (OR 9.0, p = 0.01) and monoclonality of the tumour cells (OR 6.3, p = 0.006) were predictors for persistant lymphoma after eradication therapy.

CONCLUSIONS

Most H. pylori-positive low grade gastric MALT lymphoma stage IE and II1E respond with stable CR after eradication therapy. In patients with refractory disease or H. pylori negative low grade gastric MALT lymphoma a dosage-reduced radiation therapy with 25.2 Gy is an effective standard dose in stage IE and II1E.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00154440.

Transabdominal ultrasonographic features in the diagnosis of gastrointestinal lymphoma

Background

Gastrointestinal (GI) lymphoma is a challenging disease. We aimed to study and characterize the different endoscopic and transabdominal ultrasonography (TUS) features of gut lymphoma and to assess whether TUS has a complementary role to endoscopy in the diagnosis of GI lymphoma.

Methods

This study was conducted on 21 patients with GI lymphoma, attending the GI endoscopy and liver unit, Endemic Medicine Department and Oncology Department in Kasr El Aini Hospital, Cairo University. Patients were subjected to GI endoscopy (upper endoscopy & colonoscopy) and transabdominal ultrasonography. The diagnosis was finally based on histopathology of core biopsies (obtained either endoscopically or by ultrasonography) and immuno-histochemistry.

Results

In all 21 patients with GI lymphoma included in this study, TUS could accurately determine the site of disease affection compared to endoscopy which is considered the gold standard for site localization. The main TUS pathologic features detected were increased wall thickness of the affected bowel segment with a mean value of (15.6±5.9 mm) and loss of layering pattern in 16 patients (76%). While the most common endoscopic features were ulcers and mass lesions accounting for 38% of the patients for each. Diffuse large B-cell lymphoma was found in 19 patients (90%). Because of endoscopic biopsies were conclusive in 14 patients (67%), TUS guided biopsy was resorted to in 7 patients and was diagnostic in all of them.

Conclusions

Transabdominal ultrasonography is a useful tool in the diagnosis of GI lymphoma that is complementary to conventional diagnostic endoscopic procedures.

MALT Lymphoma as a Model of Chronic Inflammation-Induced Gastric Tumor Development

Mucosa-associated lymphoid tissue (MALT) lymphoma, or extranodal marginal zone lymphoma of MALT, is an indolent B-cell non-Hodgkin lymphoma linked with preexisting chronic inflammation. The stomach is the most commonly affected organ and the MALT lymphoma pathogenesis is clearly associated with Helicobacter pylori gastroduodenitis. Inflammation induces the lymphoid infiltrates in extranodal sites, where the lymphoma then subsequently develops. Genetic aberrations arise through the release of reactive oxygen species (ROS), H. pylori-induced endonucleases, and other effects. The involvement of nuclear factor kappa B (NF-κB) pathway activation, a critical regulator of pro-inflammatory responses, further highlights the role of inflammation in gastric MALT lymphoma. The NF-κB pathway regulates key elements of normal lymphocyte function, including the transcription of proliferation-promoting and anti-apoptotic genes. Aberrant constitutive activation of NF-κB signaling can lead to autoimmunity and malignancy. NF-κB pathway activation can happen through both the canonical and non-canonical pathways and can be caused by multiple genetic aberrations such as t(11;18)(q12;q21), t(1;14)(p22;q32), and t(14;18)(q32;q21) translocations, chronic inflammation and even directly by H. pylori-associated mechanisms. Gastric MALT lymphoma is considered one of the best models of how inflammation initiates genetic events that lead to oncogenesis, determines tumor biology, dictates clinical behavior and leads to viable therapeutic targets. The purpose of this review is to present gastric MALT lymphoma as an outstanding example of the close pathogenetic link between chronic inflammation and tumor development and to describe how this information can be integrated into daily clinical practice.

Prevalence and Implications of Bone Marrow Involvement in Patients with Gastric Mucosa-Associated Lymphoid Tissue Lymphoma

Background/Aims

Mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach is an uncommon disease. Bone marrow involvement is reported even in patients with only a mucosal lesion. We evaluated the prevalence and risk factors of marrow involvement and its implications for diagnosis and treatment.

Methods

In total, 132 patients who were diagnosed with gastric MALT lymphoma at the National Cancer Center in Korea between January 2001 and December 2016 were enrolled in the study. The patient data were collected and analyzed retrospectively.

Results

Of the 132 patients, 47 (35.6%) were male, with a median age of 52 years (range, 17 to 81 years). The median follow-up duration was 48.8 months (range, 0.5 to 169.9 months). Helicobacter pylori infection was detected in 82 patients (62.1%). Most patients (80.3%) had stage IE1 according to the modified Ann Arbor staging system. Ninety-two patients underwent bone marrow evaluation, and four patients (4.3%) had marrow involvement. Of these patients, one presented with abdominal lymph node involvement, while the other three had stage IE1 disease if marrow involvement was disregarded. All three patients had no significant symptoms and were monitored after local treatment without evidence of disease aggravation.

Conclusions

Bone marrow involvement was found in 4.3% of the patients with gastric MALT lymphoma. Bone marrow examination may be deferred because marrow involvement does not change the treatment options or outcome in gastric MALT lymphoma confined to the stomach wall.

Gastric follicular lymphoma: A report of 3 cases and a review of the literature

Follicular lymphoma (FL) occurs primarily in the gastrointestinal tract, with the stomach being one of the rarest sites. According to the literature, <20 cases of primary gastric FL have been reported, with the number of cases with detailed pathological descriptions being even less. The aim of the present study was to compare clinicopathological features of gastric FL with FL at alternative sites. A total of 3 cases of gastric FL were retrieved from among 3,216 cases in the databases of 4 university hospitals in South Korea: Seoul National University (SNU) Hospital, SNU Boramae Hospital, SNU Bundang Hospital (all Seoul, South Korea) and Dongtan Sacred Heart Hospital Hallym University (Dongtan, South Korea), including 2 primary cases and 1 case that was possibly secondary to nodal FL. The 2 primary gastric FL cases were incidentally detected in routine health check-ups. An endoscopy revealed a single polypoid submucosal mass and biopsies failed to confirm the diagnosis due to minimal mucosal involvement. Therefore, a partial gastrectomy was performed. The epicenters of the tumors were submucosal, with focal extension to the muscularis propria. However, 1 case exhibited an isolated FL nodule in the omentum. Histopathological examination revealed FL of grade 1–2 with a follicular pattern and with strong expression of germinal center markers and B-cell lymphoma 2 (BCL2). Rearrangement of BCL2 was not identified using fluorescence in situ hybridization studies in 2 cases. In contrast to these 2 cases, the remaining FL case was confirmed with an endoscopic biopsy. The endoscopy revealed multiple eroded polypoid lesions, and pathology revealed FL of grade 1–2 with a predominantly diffuse pattern, and with immunoglobulin heavy chain IGH/BCL2 translocation. In view of the extensive lymphadenopathy, the last case possibly presented as secondary involvement of nodal FL. It is challenging to diagnose FL in the stomach due to little mucosal involvement, as well as the unfamiliarity of the tumor due to its rarity. However, the results of the present study suggest that primary gastric FL may exhibit unique pathological features, including a predominantly follicular pattern and an absence of BCL2 rearrangement.

IVTH BRAZILIAN CONSENSUS CONFERENCE ON HELICOBACTER PYLORI INFECTION

ABSTRACT Significant progress has been obtained since the III Brazilian Consensus Conference on H. pylori infection held in 2012, in Bento Gonçalves, Brazil, and justify a fourth meeting to establish updated guidelines on the current management of H. pylori infection. Therefore, the Núcleo Brasileiro para Estudo do Helicobacter pylori e Microbiota (NBEHPM), association linked to Brazilian Federation of Gastroenterology (FBG) held its fourth meeting again in Bento Gonçalves, RS, Brazil, on August 25-27, 2017. Twenty-six delegates, including gastroenterologists, endoscopists, and pathologists from the five regions of Brazil as well as one international guest from the United States, participated in the meeting. The participants were invited based on their knowledge and contribution to the study of H. pylori infection. The meeting sought to review different aspects of treatment for infection; establish a correlation between infection, dyspepsia, intestinal microbiota changes, and other disorders with a special emphasis on gastric cancer; and reassess the epidemiological and diagnostic aspects of H. pylori infection. Participants were allocated into four groups as follows: 1) Epidemiology and Diagnosis, 2) Dyspepsia, intestinal microbiota and other afections, 3) Gastric Cancer, and, 4) Treatment. Before the consensus meeting, participants received a topic to be discussed and prepared a document containing a recent literature review and statements that should be discussed and eventually modified during the face-to-face meeting. All statements were evaluated in two rounds of voting. Initially, each participant discussed the document and statements with his group for possible modifications and voting. Subsequently, during a second voting in a plenary session in the presence of all participants, the statements were voted upon and eventually modified. The participants could vote using five alternatives: 1) strongly agree; 2) partially agree; 3) undecided; 4) disagree; and 5) strongly disagree. The adopted consensus index was that 80% of the participants responded that they strongly or partially agreed with each statement. The recommendations reported are intended to provide the most current and relevant evidences to management of H. pylori infection in adult population in Brazil.

Marginal Zone Lymphoma: Clinicopathologic Variations and Approaches to Therapy

PURPOSE OF REVIEW

The purpose of the study is to summarize the current conundrums in the management of marginal zone lymphomas (MZL).

RECENT FINDINGS

In 2017, the US Food and Drug Administration (FDA) approved ibrutinib, a first in class Bruton Tyrosine Kinase inhibitor, for the treatment of relapsed/refractory MZL based on pivotal open-label phase II trial demonstrating an overall response rates of 48%. Clinical trials design utilizing chemotherapy-free regimens for relapsed/refractory disease are gaining popularity. Recent studies have identified multiple genetic biomarkers that helped characterize and prognosticate different subtypes of MZL. MZLs are heterogeneous, mostly indolent, malignancies derived from B lymphocytes. Three disease subtypes are recognized, extranodal, nodal, and splenic. The disease characteristics, clinical picture, and treatment algorithms vary considerably based on subtype and site of involvement. Recent discoveries have enhanced our knowledge of the pathogenesis of MZLs leading to development of more accurate prognostic models as well as novel targeted systemic therapies.

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.

Marginal zone lymphoma in elderly and geriatric patients

Approximately 50% of patients with newly diagnosed marginal zone lymphoma (MZL) are of advanced age. For the three subtypes of MZL (extranodal MZL of mucosa-associated lymphoid tissue, splenic MZL, nodal MZL), the median age at diagnosis is around 65-70 years. Due to the lack of larger studies in MZL, little is known of the prevalence of comorbidity, polypharmacy, or geriatric syndromes in older patients with MZL. The impact of these concurrent conditions on the tolerability and feasibility of diagnostic or therapeutic procedures used in MZL has not been specifically investigated. However, some extrapolations can be made from other studies in cancer, thereby raising questions about potential benefits of geriatric assessment in older patients with MZL. Core of this article is a review of recommended diagnostic and therapeutic procedures in MZL in light of potential barriers and complications that might be encountered in elderly and geriatric patients with MZL.

Early, Isolated Duodenal Mucosa-Associated Lymphoid Tissue Lymphoma Presenting without Symptoms or Grossly Apparent Endoscopic Lesions and Diagnosed by Random Duodenal Biopsies

Clinical data regarding mucosa-associated lymphoid tissue lymphoma (MALToma) solely involving the duodenum are sparse because of the relative rarity of the disease. A comprehensive literature review revealed only 17 cases reported until 2004, and only a moderate number of cases have been reported since. MALToma can be asymptomatic in its very early stages but frequently produces localized or nonspecific symptoms, including early satiety, abdominal pain, vomiting, and involuntary weight loss in later stages. While gastric MALToma is strongly associated with gastric Helicobactor pylori infection, duodenal MALToma is often unassociated with H. pylori infection. A 74-year-old female presented with only dysphagia (without symptoms referable to a duodenal lesion), without systemic 'B' symptoms, and with no evident duodenal lesions at esophagogastroduodenoscopy; however, she was diagnosed with duodenal MALToma by pathologic examination of random duodenal biopsies performed to exclude celiac disease. An important clinical feature of this case is that duodenal MALToma was diagnosed by pathologic analysis of duodenal biopsies despite (1) no endoscopically apparent duodenal lesions; (2) duodenal involvement without gastric involvement; (3) lack of symptoms attributable to duodenal MALToma, and (4) absence of evident H. pylori infection. This work shows that early duodenal MALToma can be difficult to diagnose because of absent symptoms, absence of gastric involvement, absence of endoscopic abnormalities, and absence of H. pylori infection; it may require random duodenal biopsies for diagnosis.

Bone marrow involvement is not associated with the clinical outcomes of gastric mucosa-associated lymphoid tissue lymphoma

Objective Bone marrow (BM) examination is recommended as part of the initial staging work-up in patients with gastric mucosa-associated lymphoid tissue (MALT) lymphoma. However, the clinical significance of BM involvement in gastric MALT lymphoma patients has not been evaluated. Materials and methods From November 1995 to September 2014, 496 subjects who were diagnosed with gastric MALT lymphoma and underwent BM examination were eligible to be included in this study. BM involvement was found in 33 patients (6.7%) by retrospective review, and after exclusions, the clinical outcomes of 28 patients with BM involvement and 412 patients without BM involvement were evaluated. Results When comparing the characteristics of patients, age (median 60 vs. 53 years, p = 0.007) and Helicobacter pylori infection rate (71.0% vs. 85.5%, p = 0.040) were different between patients with and without BM involvement, while the location, macroscopic findings, and depth of invasion were similar. The overall complete remission (CR) rate was 85.2% during a median follow-up period of 42 months (interquartile range, 23-66 months) and did not differ between the two groups (78.6 and 85.7%, p = 0.280). Eradication therapy was performed as the first-line treatment in 18 of the 28 patients (64.3%) with BM involvement, and CR was achieved in 13 patients (72.2%). Logistic regression analysis showed that age and location in the upper part of the stomach were factors related to remission failure. Conclusion Gastric MALT lymphoma has a favorable outcome, and eradication therapy can be justified in selected cases even with BM involvement, when these patients are closely monitored.

Correlation of Endoscopic Findings of Gastric Mucosa-Associated Lymphoid Tissue Lymphoma with Recurrence after Complete Remission

Background/Aims

In gastric mucosa-associated lymphoid tissue (MALT) lymphoma, the clinical significance of various endoscopic findings has not yet been determined. This study aimed to compare the time to complete remission (CR) and relapse-free survival (RFS) in gastric MALT lymphoma based on endoscopic findings.

Methods

In this single-center retrospective cohort study, the medical records of 122 consecutive adult patients with gastric MALT lymphoma were collected over a period of 12 years. CR was defined by the absence of macroscopic or microscopic features of lymphoma on two subsequent follow-ups. Relapse was clinically defined by a positive endoscopic biopsy after CR.

Results

The median time to CR did not differ significantly between treatment methods. However, it was significantly longer in the group with polypoid endoscopic appearance than in the groups with diffuse infiltration or ulceration (7.83, 3.43, and 3.10 months, respectively; p=0.003). Six patients relapsed after CR. Kaplan-Meier analysis showed that RFS differed significantly between groups based on Ann Arbor staging, treatment methods, and initial endoscopic findings.

Conclusions

In gastric MALT lymphoma, the endoscopically defined polypoid type was characterized by a longer duration to CR, with a higher likelihood of recurrence, compared to the endoscopically defined diffuse infiltration or ulceration types.

Clinicopathologic characteristics and treatment of marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)

Extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT lymphoma) accounts for 7% to 8% of newly diagnosed lymphomas. Because of its association with infectious causes, such as Helicobacter pylori (HP) or Chlamydophila psittaci (CP), and autoimmune diseases, it has become the paradigm of an antigen-driven malignancy. MALT lymphoma usually displays an indolent course, and watch-and-wait strategies are justified initially in a certain percentage of patients. In patients with gastric MALT lymphoma or ocular adnexal MALT lymphoma, antibiotic therapy against HP or CP, respectively, is the first-line management of choice, resulting in lymphoma response rates from 75% to 80% after HP eradication and from 33% to 65% after antibiotic therapy for CP. In patients who have localized disease that is refractory to antibiotics, radiation is widely applied in various centers with excellent local control, whereas systemic therapies are increasingly being applied, at least in Europe, because of the potentially systemic nature of the disease. Therefore, the objective of this review is to briefly summarize the clinicopathologic characteristics of this distinct type of lymphoma along with current data on management strategies.

Evaluation of the clinical characteristics, management, and prognosis of 103 patients with gastric mucosa-associated lymphoid tissue lymphoma

The diagnosis of gastric mucosa-associated lymphoid tissue (MALT) lymphoma is difficult owing to its non-specific symptoms and various endoscopic findings. Treatments such as radiotherapy (RT) for localized and chemotherapy (CT) for advanced stages of the disease are employed. The aim of the present study was to examine the clinical characteristics and prognostic factors of Helicobacter pylori (H. pylori) eradication (HPE) in patients with gastric MALT lymphoma. The medical records of 103 patients with gastric MALT lymphoma for the period 2001–2013, were analyzed. The 103 median age of the patients was 53 years and the male to female ratio was 1:1. Serum lactate dehydrogenase and β2-microglobulin were within normal range. Macroscopically, the most commonly involved site was the antrum, followed by the corpus and fundus. A total of 97 patients (94%) tested positive for H. pylori. Forty patients (39%) had stage I, 35 patients (35%) had local or distant nodal involvement, 20 of 103 patients had stage IIIE (19%) and 8 of 103 patients had stage IV (7%) disease. Complete remission, after HPE, was achieved in 54 of the 69 patients (78%) that were H. pylori-positive and in 2 of the 4 patients (50%) that were H. pylori-negative. HPE had a superior trend in the H. pylori-positive patients although no significant difference was identified in the two groups (p=0.194). In patients with advanced disease, the 5-year progression-free survival (PFS) and overall survival (OS) estimates were significantly improoved for patients receiving HPE with CT or RT than those receiving CT or RT (p=0.046 and 0.035, respectively). The multivariate analysis revealed that, the advanced stages were independently associated with shorter PFS, and the modified-International Prognostic Index (m-IPI) (≥2) was associated with shorter OS. In conclusion, gastric MALT lymphoma had a favorable outcome with a high OS rate. HPE was an effective treatment for gastric MALT lymphoma. The patients with advanced stages and m-IPI (≥2) had a much worse prognosis.

Bone marrow involvement is rare in superficial gastric mucosa-associated lymphoid tissue lymphoma

BACKGROUND

The initial staging work-up of gastric mucosa-associated lymphoid tissue (MALT) lymphoma includes bone marrow examination. Since gastric MALT lymphoma is mostly detected in early stages with the national cancer screening programme in Korea, bone marrow is rarely involved.

AIMS

To investigate the incidence of bone marrow involvement in gastric MALT lymphomas and the role of bone marrow examination for an initial staging work-up.

METHODS

Patients diagnosed with gastric MALT lymphoma at Seoul National University Hospital from January 2005 to July 2014 were enrolled. Clinical databases of the patients were retrospectively reviewed.

RESULTS

Out of 105 patients, 91 (86.7%) were classified as stage IE1. Among these patients, 78 patients with Helicobacter pylori infection underwent eradication therapy, and complete remission was achieved in 74 cases (94.9%). Twelve out of 13 patients (92.3%) without H. pylori infection underwent radiotherapy or surgery and all achieved complete remission. Bone marrow involvement was proven in only one patient (1.0%).

CONCLUSION

Bone marrow involvement was rare in patients with only superficial gastric MALT lymphoma without extragastric invasion. Further studies are warranted to identify the risk factors of bone marrow involvement in gastric MALT lymphoma.

Radical surgery may be not an optimal treatment approach for pulmonary MALT lymphoma

Primary pulmonary MALT lymphoma is a rare disease, and no standard treatments have been defined yet. In this study, 38 consecutive patients from single center were reviewed. Among 25 patients with localized disease, radical surgery were performed in 12 patients, and the other 13 patients had chemotherapy combined with (7 patients) or without (6 patients) radiotherapy. No significant difference in overall survival (OS) was found between patients who received surgery or not; however, patients treated with chemotherapy had superior progression-free survival (PFS) than those treated with upfront surgery (P = 0.032). Among the 12 patients who received radical surgery, 7 were given adjuvant chemotherapy and 1 patient had consolidation radiotherapy. No significant differences in PFS and OS exist between those who received adjuvant treatment or not (P > 0.05). For patients who received chemotherapy, PFS and OS were significantly better for those treated with cyclophosphamide-based therapy than fludarabine-based therapy. At a median follow-up time of 61.1 months, 5- and 10-year PFS rate was 70.0 and 43.0 %, respectively, and 5- and 10-year OS rate was both 81.0 %. In conclusion, we confirmed the indolent behavior and favorable outcome of this disease. In order to preserve lung function and reduce the risks associated with surgery, radiotherapy or rituximab in combination with alkylating drug-based chemotherapy should be considered as first-line option for pulmonary MALT lymphoma.

Pathology of indolent B-cell neoplasms other than follicular lymphoma

Indolent B-cell lymphomas include follicular lymphoma (FL), chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and marginal zone lymphomas (MZLs). They are a diverse group of disorders with different clinical, morphological, immunophenotypic and genetic features. However, because of several histological similarities, such as in cell size and nodular structure, it may sometimes be difficult to differentiate them and to make a definitive diagnosis. In this review article, we summarize the histopathology of indolent B-cell neoplasms excluding FL and including hairy cell leukemia, and briefly mention recent genetic findings useful for their differential diagnosis. In addition, a provisional subtype of low-grade B-cell lymphoma, "prolymphocytic/paraimmunoblastic lymphoma", is described.

Gastric MALT lymphoma - update on diagnosis and treatment

Gastrointestinal lymphoma represent a heterogenous group with differences in pathogenesis, treatment and prognosis. Gastric MALT lymphoma is the most common entity. Helicobacter pylori has been identified as its decisive pathogenetic factor. Once a definitive diagnosis has been established a staging procedure is obligatory for defining the stage of disease. H. pylori eradication is the treatment of choice in all MALT lymphoma patients being infected by the bacterium. In some 70-80% of patients with stages I/II complete regression of the lymphoma will develop after successful eradication of H. pylori. Another 20% of patients will reveal minimal histological residuals after eradication. They can be successfully managed by a watch-and-wait strategy if initial endoscopic abnormalities disappear. At present, it is unclear if this strategy can be also offered to patients with persisting minimal endoscopic abnormalities. Why eradication therapy is effective in some patients with negative H. pylori status is highly speculative at present. Non-responders to H. pylori therapy are transferrred to radiotherapy in stages I/II or to immuno-chemotherapy in stages III/IV.

Refractory peptic ulceration following radiation therapy in primary gastric lymphoma: A report of two cases

The optimal prognosis for primary gastric lymphoma (PGL) is observed in those patients exhibiting PGL with minimal infiltration and who are eligible for radical resection. The initial treatment strategy for high-grade PGL (stages I/II) is chemotherapy followed by radiotherapy, however, subsequent to chemotherapy and/or radiotherapy for PGL, there is a risk of gastric bleeding and perforation. The present study reports two cases of PGL with refractory peptic ulcers that were negative for Helicobacter pylori following radiotherapy. Although the two patients received regular treatment for their ulcers and symptoms, the position and size of the ulcers remained unchanged for a number of years.

Clinicopathological analysis and prognostic factors of 11 patients with primary non-Hodgkin lymphoma of the small intestine in a single institute

The gastrointestinal (GI) tract is the most common extranodal site of involvement in non-Hodgkin lymphoma (NHL). Primary GI NHL is frequently discussed in survival analyses. Primary intestinal NHL is significantly different from primary gastric NHL with regard to its clinical features, pathological subtype, treatment and prognosis. The small intestine is involved in lymphoma less often than the large intestine. The present study aimed to analyze the clinical and pathological characteristics of primary NHL of the small intestine and its prognostic factors. A retrospective analysis was performed on clinical data from 313 cases of NHL that occurred between 1995 and 2008 in the Tri-Service General Hospital (National Defense Medical Center, Taipei, Taiwan). Among these cases, 11 cases of primary NHL of the small intestine were identified. A Cox model was used to perform the multivariate analysis. The Kaplan-Meier method was used for the survival analysis. From the 11 patients with primary NHL of the small intestine, seven patients were male (63.6%) and four patients were female (36.3%). Furthermore, nine patients (81.8%) were diagnosed with B-cell lymphoma, of which five (45.5%) were also diagnosed with diffuse large B-cell lymphoma (DLBL). Abdominal pain and/or distention were present in six (54.5%) of the patients and jejunum involvement was also observed in six (54.5%) of the 11 patients. The mean overall survival (OS) time of the 11 patients was 27.2 months and the four-year survival rate was 36.3%. The mean OS time in the patients with jejunum involvement was shorter than in those without jejunum involvement (16.9 vs. 39.6 months), although this difference was not significant (P=0.657). Surgical treatment was performed on four of the six patients with jejunum involvement due to an acute abdomen or perforation-related peritonitis. The results of the present study indicate that DLBL is the most common subtype of primary lymphoma of the small intestine, and that the site involved in NHL may affect the potential for surgery in patients with intestinal lymphoma. Furthermore, patients with primary lymphoma of the small intestine have been found to have a poor outcome compared with those with lymphoma in other regions of the GI tract. In the present study, a similar trend was observed, however, the sizes of the subgroups of primary lymphoma of the small intestine were too small for individual analysis.

HELICOBACTER PYLORI AND t(11;18)(q21;q21) TRANSLOCATION IN GASTRIC MALT LYMPHOMA

ContextGastric mucosa-associated lymphoid tissue (MALT) lymphoma is clearly associated with Helicobacter pylori gastritis and can be cured with anti- H pylori therapy alone. The presence of t(11;18)(q21;q21) translocation is thought to predict a lower response rate to anti- H pylori treatment.ObjectivesTo study the presence of t(11;18)(q21;q21) genetic translocation and its clinical impact in low-grade gastric MALT lymphoma Brazilian patients.MethodsA consecutive series of eight patients with gastric MALT lymphoma were submitted to gastroscopy, endoscopic ultrasound, histopathological examination, H pylori search and RT-PCR-based methodology. All patients received anti-H pylori treatment. Eradicated patients were followed-up every 3-6 months for 2 years.ResultsEight patients were studied. All patients had tumor involvement restricted to the mucosa or submucosa and seven patients had low-grade gastric MALT lymphoma. All infected patients achieved H pylori eradication. Histological tumor regression was observed in 5/7 (71%) of the low-grade gastric MALT lymphoma patients. The presence of t(11;18)(q21;q21) translocation was found in 4 (57%) of these patients; among them only two had histological tumor regression following H pylori eradication.ConclusionsRT-PCR is a feasible and efficient method to detect t(11;18)(q21;q21) translocation, being carried out in routine molecular biology laboratories. The early detection of such translocation can be very helpful for better targeting the therapy to be applied to gastric MALT lymphoma patients.

Perforation of bowel lymphoma: beware of atypical presentations

INTRODUCTION

Intestinal lymphomas can present as surgical complications such as perforation. There is little data regarding the risk factors, clinical features, management, and prognosis of bowel perforation in patients with intestinal lymphoma. The aims of this study were to analyze the risk factors for this complication and to describe the clinical picture.

PATIENTS AND METHODS

All patients undergoing surgery for lymphoma-related perforation between 2002 and 2012 in the University Hospital of Dijon were retrospectively analyzed. The clinical, histological, and imaging features were recorded.

RESULTS

Six patients underwent emergent laparotomy for this cause: in three patients, the perforation revealed the underlying disease, and in the other three patients, it occurred during chemotherapy treatment for known lymphoma. The clinical picture was a typical acute peritonitis in the first group, but was nonspecific and insidious in the chemotherapy-induced group. In all cases, aggressive lymphomas were present, and three patients had coexisting infection with the human immunodeficiency virus.

CONCLUSION

Lymphoma-related perforation presents as an acute peritonitis in previously untreated patients in which it reveals the disease. However, it may be induced by chemotherapy and present with nonspecific insidious symptoms. The prognosis is also different according to these characteristics. The particularities of this disease warrant its knowledge to ensure an optimal management.

MALT lymphoma of the small bowel with protein-losing enteropathy

Mucosa-associated lymphoid tissue (MALT) lymphoma usually arises from chronic inflammation. We herein report a case of small intestinal MALT lymphoma with protein-losing enteropathy (PLE). A 73-year-old woman presented with lower leg edema and severe hypoalbuminemia. She had a medical history of pylorus-preserving pancreaticoduodenectomy with Billroth II reconstruction. Oral and anal route double-balloon enteroscopies revealed irregular nodular mucosal lesions with erosion extending from the jejunum to terminal ileum. Histopathological evaluation of the biopsied mucosa showed proliferation of small-to-medium-sized lambda light chain-restricted B cells. Plasmacytic differentiation and lymphoepithelial lesions were present, leading to the diagnosis of MALT lymphoma. Tc-99m albumin scintigraphy indicated tracer exudation in the small bowel, suggesting the presence of PLE. Combination immunochemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) regimen improved both MALT lymphoma and PLE, whereas rituximab monotherapy was not successful. This case is considered to be common type of MALT lymphoma at an uncommon site and is distinct from immunoproliferative small intestinal disease (IPSID). To our knowledge, this is the first case of non-IPSID-type small intestinal MALT lymphoma complicated by PLE. Gastrointestinal reconstruction may be responsible for underlying chronic inflammation via small intestinal bacterial overgrowth.

Intestinal diffuse large B-cell lymphoma: an evaluation of different staging systems

The gastrointestinal tract is the most common primary extranodal site for diffuse large B-cell lymphoma (DLBCL). However, there is no consensus on the most appropriate staging system for intestinal DLBCL. We evaluated the utility of the modified Ann Arbor system, the Lugano system, and the Paris staging system (a modification of the Tumor, Node, Metastases [TNM] staging for epithelial tumors) in 66 cases of resected intestinal DLBCL. The cases were treated with surgery, plus either cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) chemotherapy alone (n=26) or with the addition of rituximab immunotherapy (n=40). Median follow-up time was 40.4 months (range, 2.1-171.6 months). Fifty-six patients (84.8%) achieved complete remission. The overall 5-yr survival rate was 86.4% (57/66). Of the stage categories defined for each staging system, only the T stage of the Paris classification showed prognostic significance for overall survival by univariate analysis. However, none of the stage parameters was significantly correlated with patient survival on multivariate analysis. In conclusion, the results suggest that the T stage of the Paris classification system may be a prognostic indicator in intestinal DLBCL. The results also imply that in surgically resected intestinal DLBCL, the addition of rituximab to the CHOP regimen does not confer significant survival advantage.

A case of ileal mucosa-associated lymphoid tissue lymphoma accompanied by luminal stricture and arterial spurting

Primary small intestinal lymphoma is relatively uncommon. Small bowel tumors are difficult to diagnose, because they are usually asymptomatic in the initial phase, and they are not easily detected by traditional methods of investigating the small intestine. This case shows a successfully detected and treated gastrointestinal bleeding from rare ileal mucosa-associated lymphoid tissue lymphoma, using double balloon endoscopy.

Treatment outcome for gastric mucosa-associated lymphoid tissue lymphoma according to Helicobacter pylori infection status: a single-center experience

Background/Aims

Helicobacter pylori eradication therapy has been used as a first-line treatment for H. pylori-positive gastric mucosa-associated lymphoid tissue (MALT) lymphoma. However, the management strategy for H. pylori-negative MALT lymphoma remains controversial. Therefore, the aim of this study was to examine the success rate of each treatment option for H. pylori-positive and H. pylori-negative gastric MALT lymphomas.

Methods

In total, 57 patients with gastric MALT lymphoma diagnosed between December 2000 and June 2012 were enrolled in the study. The treatment responses were compared between H. pylori-positive and H. pylori-negative gastric MALT lymphomas.

Results

Of the 57 patients, 43 (75%) had H. pylori infection. Forty-eight patients received H. pylori eradication as a first-line treatment, and complete remission was achieved in 31 of the 39 patients (80%) with H. pylori-positive MALT lymphoma and in five (56%) of the nine patients with H. pylori-negative MALT lymphoma; no significant difference was observed between the groups (p=0.135). The other treatment modalities, including radiation therapy, chemotherapy, and surgery, were effective irrespective of H. pylori infection status, with no significant difference in the treatment response between H. pylori-positive and H. pylori-negative MALT lymphomas.

Conclusions

H. pylori eradication therapy may be considered as a first-line treatment regardless of H. pylori infection status.

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

Endoscopic ultrasonography (EUS) has recently gained a pivotal role in the management of gastric lymphomas, especially in the diagnostic workup. Its accuracy and reliability have overcome those of other imaging techniques, such that it represents an invaluable tool for the management of gastric lymphomas. Although this technique is operator dependent, its application in large series has proved its reliability. Thus, it has generally been considered a useful tool for providing information crucial in deciding the treatment program, especially for mucosa-associated lymphoid tissue (MALT) lymphomas, for which EUS can provide an accurate evaluation of disease extension and treatment response probability. Limited-stage disease, confined to the submucosa, has a greater probability to respond to sole Helicobacter pylori eradication. In contrast, the value of EUS in response assessment and follow-up monitoring is still debated, with discordant opinions about its reliability and clinical advantages, because normalization of the EUS findings occurs with a considerable delay compared to the histologic evaluation. In the follow-up setting, preliminary data have indicated that persistently positive EUS findings in low-grade gastric lymphoma could represent a warning for a possible relapse. However, in high-grade gastric lymphoma, such findings do not have any clinical implications.