Benign lymphoid hyperplasia of the stomach and duodenum

Low-grade gastric mucosa-associated lymphoid tissue lymphoma: correlation of radiographic and pathologic findings

PURPOSE

To describe upper gastrointestinal (Gl) examination findings of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma and to correlate them with pathologic examination findings.

MATERIALS AND METHODS

A retrospective review of upper Gl examinations was performed in 25 patients with proved low-grade gastric MALT lymphomas. Upper Gl examinations were reviewed for common findings and most probable diagnosis, and these findings were correlated with pathologic findings in resected specimens in 15 patients.

RESULTS

The common findings at upper Gl examination included mucosal nodularity (n = 13), ulcer (n = 12), rugal thickening (n = 6), mass (n = 4), and enlarged areae gastricae (n = 2). The most probable diagnoses were early gastric carcinoma (n = 7), advanced gastric carcinoma (n = 6), gastritis (n = 9), and lymphoma (n = 3). Of 17 lesions found on resected specimens, six ulcers and two masses were not depicted at barium study. Disorganized convergent rugae projecting to multiple points and vague ulcer margins were present in four and seven lesions, respectively. Multiple ulcers were seen in two patients.

CONCLUSION

Although the common radiographic and pathologic findings observed in low-grade gastric MALT lymphomas were similar to those of gastric carcinomas or gastritis, disorganized convergent rugae, vague ulcer margins, and multiplicity of lesions may be helpful in differentiating them from gastric carcinomas or gastritis.

A case of pseudolymphoma of the liver with chronic hepatitis C

A case of pseudolymphoma (reactive lymphoid hyperplasia) of the liver in a 72-year-old male with chronic hepatitis C is presented. Imaging studies, comprising ultrasonography, computed tomography, incremental computed tomography, and magnetic resonance imaging, suggested hepatocellular carcinoma. A tumor-like lesion was therefore resected. Grossly, the lesion was relatively poorly defined and measured 15 x 17 mm; microscopically, it consisted of lymphocytic proliferations forming follicles comprising numerous germinal centers that were mainly composed of L-26 positive B-cell lymphocytes. The lymphocytes surrounding germinal centers were mainly UCHL-1 positive T lymphocytes. The B cells in the lymphoid follicles stained positive for both kappa and lambda light chains at sequential frequencies, indicating polyclonal and benign features. These findings suggest that the diagnosis of pseudolymphoma of the liver is tenable from imaging studies supplemented, when necessary, with biopsy. Further studies may provide insights into diagnostic strategies and the mechanism of stimulation in HCV infections.

Histopathological and immunohistochemical study of atypical lymphoid hyperplasia and benign lymphoid hyperplasia of the stomach

We propose dividing histologically reactive lymphoid hyperplasia (RLH) of the stomach into two categories: atypical lymphoid hyperplasia (ALH), characterized by abnormal follicular architecture and infiltration of atypical lymphoid cells, and benign lymphoid hyperplasia (BLH), where normal follicular patterns are preserved and no atypical cells are found. Using twenty RLH cases (10 ALHs and 10 BLHs), both categories were compared from histopathological and immunohistochemical aspects. Macroscopic division into superficial, thick-walled and nodular types revealed most ALH (80%) to be superficial in character whereas in BLH superficial and thick-walled types were almost equally represented. Lesion size tended to be larger in ALH (greater than 6.1 cm) than in BLH (6.0 cm greater than) cases. As for prognosis after gastrectomy, both categories were favorable. On immunohistochemistry, ALH tended to be strongly labeled by B lymphocyte markers as compared to BLH, where only a weakly positive reaction was expressed. Infiltration of cells labeled by T lymphocyte markers was less conspicuous in ALH than in BLH. From these data, we concluded that ALH and BLH are two distinctive categories of lesion and that ALH has characteristics similar to these demonstrated by malignant lymphoma.

Pseudolymphoma of the stomach. A clinicopathologic study of 15 cases

Fifteen cases of gastric pseudolymphoma (GPL) were studied and classified into three subtypes: The nodular type, which is elevated, representing a submucosal tumor. Histologically, the tumor is composed of lymphoid hyperplasia with no associated ulcer. The lesion is well demarcated with no sinusoidal structure. Those findings indicate a nonreactive state. The ulcerative type, which usually is accompanied by deep ulceration with extensive fibrosis. The erosive type, which is infiltrated by extensive lymphoid hyperplasia in the propria mucosa and submucosa. The latter two types represent the reactive state in response to chronic gastric ulcer or inflammation. One of four ulcerative GPLs, however, was associated with focal malignant lymphoma which accounted for one of the fifteen GPL studied. Although there is a low incidence of malignant lymphoma among GPL patients, pseudolymphoma should be considered as a precursor lesion with malignant potential.

Gastric pseudolymphoma. A challenging clinical problem

Gastric pseudolymphoma is a benign inflammatory condition that is usually associated with chronic gastric ulcer and often mimics gastric carcinoma or malignant lymphoma. Our experience with 12 histologically documented gastric pseudolymphomas at the Medical College of Virginia is presented with an emphasis on the approach to both diagnosis and surgical management. Preoperative diagnoses in this series ranged from benign gastric ulcer to gastric cancer. Treatment was by gastric resection in all cases and it included, as a minimum, antrectomy and excision of the lesion with an adequate gross margin. Of 11 cases with adequate follow-up, there are eight asymptomatic patients without recurrence and one patient who died of other causes without recurrence 5 years after gastrectomy. One patient developed recurrent pseudolymphoma in the proximal gastric remnant 39 months after a distal subtotal gastrectomy for pseudolymphoma. Another patient subsequently developed Hodgkin's disease of the gastric remnant, with regional lymph node and liver involvement, and died 35 months after the earlier subtotal gastrectomy for pseudolymphoma. Our clinical experience with this confusing and uncommon entity is compared with that previously reported in the medical literature.

Lymphomas and pseudolymphomas of the alimentary tract. An immunohistochemical study with clinicopathologic correlations

One hundred one lymphoproliferative lesions of the gastrointestinal tract (66 malignant lymphomas, 20 pseudolymphomas, and 5 borderline lesions) were reviewed. The pathologic features were compared to the clinical findings, with reference to differential diagnosis and prognosis. Special attention was paid to immunohistochemical features. The gross appearance was diagnostic in only a limited number of cases. Endoscopic biopsy alone was also of limited value because only a diagnosis of probability could be made in several cases. In most of them the definitive diagnosis had to be based on histologic examination of the resected specimen. Immunohistochemical examination was found to be very useful as an ancillary diagnostic technique. Malignant lymphomas displayed either cytoplasmic immunoglobulins with a monoclonal pattern (47.1 per cent) or a negative reaction, whereas the pseudolymphomas were generally characterized by polyclonal immunoglobulins. Ninety per cent of malignant lymphomas with cytoplasmic immunoglobulins contained lambda chains. The survival probability was found to be related to the size of the lesion, the depth of infiltration, and the immunohistochemical characteristics of the tumors. The histologic type of the lymphomas was of limited value as a predictor of prognosis in the present series.

Reactive lymphoid hyperplasia of the stomach. An immunohistochemical study

The surgically excised stomachs were re-examined histopathologically, and eighteen cases were placed in the category of reactive lymphoid hyperplasia (RLH). The distribution and the classes of infiltrating immunoglobulin (Ig) bearing cells were examined on lesions of RLH cases together with ten histopathologically determined malignant lymphomas (ML) of the stomach and the control stomachs. It was found that in eleven cases of RLH and one case of ML, many lymphoid cells bearing different classes of Ig were present in those lesions in an intermingled way (polyspecific group). Meanwhile, lymphoid cells in three RLH cases and two ML cases bore only a single monospecific Ig (monospecific group). In other cases, the number of Ig bearing cells were not sufficient to reach any clear conclusions (undetermined group). It was speculated that regardless of the histopathological diagnosis, the monospecific group might belong to the category of neoplasm of B cell type and the polyspecific group in the category of true reactive process. The possible histopathological criteria for differentiation of the reactive process and lymphoid neoplasm of the stomach were re-checked, and the importance of immunohistochemical study on these cases were stressed.

Gastric pseudolymphoma

Six histologically proved cases of gastric pseudolymphoma are described. This uncommon benign condition often simulates ulcerated gastric carcinoma radiologically, and pathologically it may cause considerable confusion with malignant lymphoma. Recognition of this condition is important to prevent unnecessary and often hazardous treatment whether by surgery or radiotherapy and to prevent inclusion in series of malignant gastric lymphoma, so that falsely high survival rates are not recorded.

Lymphomas of the gastrointestinal tract: a study of 117 cases presenting with gastrointestinal disease

A study was made of 117 patients who presented with gastrointestinal lymphoma. The occurrence was 48 in the stomach, 37 in the small intestine, 13 in the ileocecal region, two in the appendix and 11 in the large intestine. In six cases, multiple sites in the gastrointestinal tract were involved, but in five cases this appeared to be secondary to massive mesenteric or retroperitoneal lymph node disease. Using Rappaport's classification, diffuse histiocytic lymphoma was the most frequent histologic type and constituted 60% of the cases. Nodular lymphomas comprised 10% of the total, nodular poorly differentiated lymphocytic lymphoma forming the majority of this group. Ten of the lymphomas were undifferentiated, 5 of Burkitt's type and 5 non-Burkitt's type. Five were Mediterranean-type lymphomas associated with plasma cell infiltration of the adjacent mucosa, and only two cases of primary Hodgkin's disease were encountered. Two lymphomas could not be classified. Eight percent of the cases showed plasmacytoid changes and were classified as a distinct subgroup of the parent lymphoma rather than as examples of extramedullary plasmacytoma. Gastrointestinally lymphomas occurred most frequently during the fourth to seventh decades. However, nine lymphomas occurred in children younger than 16 years of age. In comparison to adults, the childhood lymphomas showed a number of notable differences with respect to sex distribution, site of involvement and histologic type. Information concerning the extent of the disease at the time of diagnosis was available in 75 cases. Of these, 49% of the lymphomas were confined to the affected viscus and 33% had associated regional lymph node involvement; the remaining 18% had mode widespread disease. In 44 patients information on the spread of disease was available and in 48% there was extra abdominal spread. Prognosis appeared to correlate best with the stage of the disease rather than the histologic type.

Untreated gastric pseudolymphoma

Gastric pseudolymphoma is an inflammatory process that may simulate malignancy. In most reported cases, the initial diagnosis has been malignant lymphoma and treatment has been applied accordingly. We report a case of gastric pseudolymphoma wherein the diagnosis was made from multiple surgical biopsies, and follow-up now exceeds 11 years. To our knowledge no other case of untreated gastric pseudolymphoma has been reported. This case may more closely represent the biologic nature of this presumably benign condition.

Benign lymphoid hyperplasia of the gastric antrum - another cause of "etat mammelonne"

The radiological and endoscopic appearance of "etat mammelonne" has been attributed to hypertrophic gastritis or prominence of the areae gastricae. An additional cause for this appearance is described in two patients with benign lymphoid hyperplasia of the gastric antrum. The significance of these lesions is discussed.

Benign lymphoid hyperplasia of the duodenal bulb

Four cases of benign lymphoid hyperplasia (BLH) of the duodenal bulb are reported. The roentgen findings of this entity are presented and the literature on BLH of the gastrointestinal tract is briefly reviewed.