How I treat MALT lymphoma: 'a subjective interpretation of the gospel according to Isaacson….'

A survey of practice patterns and adherence to national and international guidelines on the management of Helicobacter pylori infection among gastroenterologists and gastroenterology fellows in India

BACKGROUND

Patients and primary care providers alike benefit greatly from the expertise of gastroenterologists when it comes to managing Helicobacter pylori (H. pylori) infection. However, information on gastroenterologists' practices in the management of H. pylori infection is scarce in this part of the world. This study aimed at evaluating the practice patterns of gastroenterologists and gastroenterology fellows in India.

METHOD

This was a cross-sectional questionnaire-based survey of gastroenterologists and gastroenterology fellows working in India.

RESULTS

Total 207 gastroenterologists and 53 fellows filled out the questionnaire. Responses were received from all around India. Approximately 70% of respondents perceive H. pylori to be a gastric pathogen, while 20% regard it as a commensal bacterium. While the proportion of respondents who chose a test and treat method (34.6%) for uninvestigated dyspepsia without alarm symptoms was comparable to empirical proton pump inhibitor (PPI) therapy (38.8%), about one-fifth chose a scope and treat strategy in this setting. Even in the absence of alarm signs, more than half of respondents (61.5%) preferred endoscopic biopsy to detect H. pylori. While rapid urease testing (RUT) was the preferred modality (80%) for detecting H. pylori, about one-third preferred single-site RUT (from the antrum). Only 40% followed the Updated Sydney protocol, while performing biopsies and a majority (78.8%) are unable to discontinue PPIs before testing for H. pylori. PPI-clarithromycin-based triple treatment was the preferred regimen (67%) for first-line eradication, while nearly a quarter of respondents did not utilize bismuth due to concerns about adverse effects.

CONCLUSION

The survey reveals a lack of adherence to the current H. pylori guidelines for diagnosis, testing and treatment among gastroenterologists and gastroenterology fellows in India. It is vital that scientific societies simplify guidelines, investigate challenges to their effective implementation and execute targeted interventions to increase adherence.

Guiding function of positron emission tomography-computed tomography examination in the diagnosis and treatment of ocular adnexal mucosa associated lymphoid tissue lymphoma

AIM

To explore the role of positron emission tomography-computed tomography (PET-CT) examination in the diagnosis and treatment of ocular adnexal mucosa associated lymphoid tissue lymphoma (OAML).

METHODS

The general clinical data, postoperative PET-CT results, treatment regimens, and the prognosis of 21 histopathologically confirmed OAML patients between October 2017 and September 2021 were collected. Among the 21 patients, five patients underwent surgical treatment alone, 13 patients underwent surgical treatment combined with radiotherapy, and three patients underwent surgical treatment combined with chemotherapy.

RESULTS

The follow-up period ranged from 8 to 79mo, with four cases of recurrence and no deaths. Through PET-CT examination, two patients exhibited both local ocular metabolic elevation and systemic metastasis, and one of these patients had cervical lymph node metastasis, while the other had submandibular and parotid gland metastasis. Nine patients showed only local ocular metabolic elevation, while 10 patients had no abnormal metabolic activity locally.

CONCLUSION

PET-CT examination plays a crucial role in detecting residual lesions and recurrence following tumor resection, aiding in precise disease staging, and facilitating the development of personalized treatment plans, ultimately improving patient prognosis.

Antibiotic resistance characteristics and risk factors analysis of Helicobacter pylori strains isolated from patients in Liaoning Province, an area in North China

Background

The prevalence of Helicobacter pylori (H. pylori) keeps rising while the eradication rate continues to decline due to the increasing antibiotic resistance. Regional variations of antimicrobial resistance to H. pylori have been recommended by guidelines in recent years. This study aims to investigate the antibiotic resistance rate of H. pylori and its association with infected subjects' characteristics in Liaoning Province, an area in north China.

Methods

Gastric tissues from 178 H. pylori positive participants without previous antibiotic use within four weeks were collected for H. pylori culture. Antibiotic susceptibility to furazolidone (AOZ), tetracycline (TC), levofloxacin (LFX), metronidazole (MET), clarithromycin (CLA), and amoxicillin (AMX) were examined with the agar dilution method. Associations between H. pylori resistance and patient characteristics were further analysed.

Results

No resistance was observed in AOZ or TC. For LFX, MET, CLA, and AMX, the overall resistance rates were 41.10%, 79.14%, 71.78%, and 22.09% respectively. There were significant differences between resistance to CLA and MALToma (P = 0.021), and between resistance to MET and age (P < 0.001).

Conclusions

The primary resistant rates of LEX, MET, CLA, and AMX were relatively high in Liaoning. Treatment effectiveness improvement could be achieved by prior antimicrobial susceptibility tests before antibiotic prescription.

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.

Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report

Helicobacter pyloriInfection is formally recognised as an infectious disease, an entity that is now included in the International Classification of Diseases 11th Revision. This in principle leads to the recommendation that all infected patients should receive treatment. In the context of the wide clinical spectrum associated with Helicobacter pylori gastritis, specific issues persist and require regular updates for optimised management.The identification of distinct clinical scenarios, proper testing and adoption of effective strategies for prevention of gastric cancer and other complications are addressed. H. pylori treatment is challenged by the continuously rising antibiotic resistance and demands for susceptibility testing with consideration of novel molecular technologies and careful selection of first line and rescue therapies. The role of H. pylori and antibiotic therapies and their impact on the gut microbiota are also considered.Progress made in the management of H. pylori infection is covered in the present sixth edition of the Maastricht/Florence 2021 Consensus Report, key aspects related to the clinical role of H. pylori infection were re-evaluated and updated. Forty-one experts from 29 countries representing a global community, examined the new data related to H. pylori infection in five working groups: (1) indications/associations, (2) diagnosis, (3) treatment, (4) prevention/gastric cancer and (5) H. pylori and the gut microbiota. The results of the individual working groups were presented for a final consensus voting that included all participants. Recommendations are provided on the basis of the best available evidence and relevance to the management of H. pylori infection in various clinical fields.

[Treatment and prognosis of primary ocular adnexal extranodal marginal zone mucosa-associated lymphoid tissue lymphoma: a report from a single center]

Objective: This study aimed to see how different initial treatment regimens affected the long-term prognosis of patients with extranodal marginal zone mucosa-associated lymphoid tissue lymphoma confining to the ocular adnexal (OAML) . Methods: Between April 2008 and April 2019, 109 patients with initial mucosa-associated lymphoid tissue confining to ocular adnexal were evaluated and followed-up, and the prognosis of various initial treatment regimens were examined. Results: A total of 36 patients underwent complete surgical resection of the lesions, and 73 patients had residual lesions after surgery, of which 37 patients chose watchful waiting, and 36 patients chose treatment. The treatment regimen included local radiotherapy and systemic treatment (chemotherapy, immunochemotherapy, the combination of radiotherapy and chemotherapy, etc.) , and no serious toxic and side effects were observed in patients receiving systemic treatment. The median follow-up time was 61 (10-142) months. The 5-year and 10-year progression-free survival (PFS) of monocular involvement patients were 78.2% and 76.0% . The 5-year and 10-year PFS rates of patients with binocular involvement were 64.4% and 23.5%. There was significant diference in PFS between patients with monocular and binocular involvement (P=0.010) . Patients who received additional treatment had higher PFS than those patients in the watchful waiting group (P=0.046) . The 5-year PFS was 71.4% and 90.1% among patients in the watchful waiting group and those who received additional treatment, whereas the 10-year PFS was 63.5% and 75.1% , respectively. Patients with OAML were still a risk of disease progression after 5 years. Conclusions: Patients with binocular involvement OAML at the start of the disease had a poor prognosis, but treatment could reduce the risk of recurrence/progression. Systemic therapy is one of the first-line treatment options for patients with OAML, who require long-term monitoring.

Current Status of the Spectrum and Therapeutics of Helicobacter pylori-Negative Mucosa-Associated Lymphoid Tissue Lymphoma

Simple Summary

The prevalence of Helicobacter pylori (HP)-negative gastric mucosa-associated lymphoid tissue (MALT) lymphoma has increased over the last two decades, whereas that of HP-positive gastric MALT lymphoma has decreased. Although the role of first-line antibiotics in the treatment of HP-negative gastric MALT lymphomas remains ambiguous, several case series have reported that a first-line HP eradication therapy (HPE)-like regimen could result in complete remission in a proportion of patients with localized HP-negative gastric MALT lymphoma. Previous sporadic reports have indicated that certain patients with extragastric MALT lymphoma can respond to first-line antibiotic treatment as well. These findings suggest that, in contrast to antibiotic-unresponsive tumors, antibiotic-responsive tumors may be recognized within the spectrum of HP-negative MALT lymphoma. In addition to conventional chemotherapy and immunochemotherapy, macrolide antibiotics and immunomodulatory drugs have been previously used and demonstrated to be efficacious. This article provides the spectrum and therapeutics for HP-negative MALT lymphoma.

Abstract

Helicobacter pylori (HP)-unrelated mucosa-associated lymphoid tissue (MALT) lymphoma includes the majority of extragastric MALT lymphomas and a small proportion of gastric MALT lymphomas. Although the role of first-line antibiotics in treating HP-negative gastric MALT lymphomas remains controversial, HP eradication therapy (HPE)-like regimens may result in approximately 20–30% complete remission (CR) for patients with localized HP-negative gastric MALT lymphoma. In these patients, H. heilmannii, H. bizzozeronii, and H. suis were detected in sporadic gastric biopsy specimens. Extragastric MALT lymphoma is conventionally treated with radiotherapy for localized disease and systemic chemotherapy for advanced and metastatic diseases. However, a proportion of extragastric MALT lymphomas, such as ocular adnexal lesions and small intestinal lesions, were reported to be controlled by antibiotics for Chlamydophila psittaci and Campylobacter jejuni, respectively. Some extragastric MALT lymphomas may even respond to first-line HPE. These findings suggest that some antibiotic-responsive tumors may exist in the family of HP-negative MALT lymphomas. Two mechanisms underlying the antibiotic responsiveness of HP-negative MALT lymphoma have been proposed. First, an HPE-like regimen may eradicate the antigens of unknown bacteria. Second, clarithromycin (the main component of HPE) may have direct or indirect antineoplastic effects, thus contributing to the CR of these tumors. For antibiotic-unresponsive HP-negative MALT lymphoma, high-dose macrolides and immunomodulatory drugs, such as thalidomide and lenalidomide, have reported sporadic success. Further investigation of new treatment regimens is warranted.

Two rare cases of bronchus-associated lymphoid tissue lymphoma successfully treated with rituximab-bendamustine

BALT lymphoma is a rare B-NHL with a favorable prognosis. We here report on two patients with nonspecific symptoms: one showed as major symptom severe thrombocytopenia and the other dyspnea and dry cough, thereby suggesting an inflammatory focus in the lungs. There is no standard of care established yet. Both patients were successfully treated with rituximab and bendamustine. Thus, combined immunochemotherapy should be considered as first-line therapy as in other MALT lymphomas, if the treatment/eradication of an underlying chronic inflammatory disorder/trigger factor can be excluded.

How can we assess and measure prognosis for MALT lymphoma? A review of current findings and strategies

INTRODUCTION

: MALT (mucosa associated lymphoid tissue) lymphoma is a distinct type of B-cell lymphoma characterized by extranodal manifestation and an indolent clinical course with 10-year survival rates up to 90%. However, transformation to aggressive lymphoma may occur and treatment is indicated in case of symptomatic or progressive disease.

AREAS COVERED

: This review covers clinical and biological features potentially related to prognosis and outcome of MALT lymphoma patients, as well as available prognostic tools and risk stratification systems with a focus on the MALT-IPI (international prognostic index) and the POD24 (progression of disease at 24 months) cohort. In addition, we address the role of watch-and-wait, the importance of defining the optimal time point for treatment initiation and the relevance of depth of remission, which appear to be some of the central questions for physicians involved in the care of MALT lymphoma patients. A computerized database search using PubMed® was performed to identify available publications on prognostic factors and risk stratification tools in MALT lymphoma.

EXPERT OPINION

: Despite the development of disease-specific risk stratification systems, there is no clear concept how to measure prognosis and tailor treatment. Careful observation of the individual clinical course is essential to assess the optimal time point of treatment initiation and avoid overtreatment, particularly in patients with disseminated disease. In addition, early detection of patients with histological transformation is necessary, as these patients face a poor prognosis.

Primary Hepatic Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue in a Patient with Chronic Hepatitis B Virus Infection: Case Report and Summary of the Literature

Background: The incidence of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is low, at 7–8% of all non-Hodgkin lymphoma cases. The most common site of MALT lymphoma occurrence is the stomach. Primary hepatic extranodal marginal zone lymphoma of MALT is classified as a type of non-gastric MALT lymphoma and is considered extremely rare, with no consensus on imaging study findings or treatment due to a limited number of reports. We herein describe a rare case of primary hepatic extranodal marginal zone lymphoma of MALT with underlying hepatitis B infection (HBV) and present useful diagnostic findings of various imaging modalities, including contrast-enhanced ultrasonography (CEUS) with Sonazoid. Case presentation: A 66-year-old woman was diagnosed as being a non-active carrier of HBV at 51 years of age at the time of total hysterectomy and bilateral adnexectomy for uterine cervical cancer. She was admitted to our hospital following the incidental detection of two focal liver lesions on computed tomography. The lesions were considered malignant based on clinical and other radiologic imaging findings. Her CEUS results of hypo-enhancement in the portal and late phases were consistent with those of previously reported cases of hepatic extranodal marginal zone lymphoma of MALT, and histological liver biopsy findings were compatible with the diagnosis. Conclusions: Primary hepatic extranodal marginal zone lymphoma of MALT is a rare condition that can appear in HBV carriers. Characteristic CEUS findings may help in disease diagnosis. Clinicians should bear primary hepatic extranodal marginal zone lymphoma of MALT in mind when encountering patients with focal liver lesions which exhibit image findings different from those of typical hepatocellular carcinoma.