MALT Lymphomas

Primary cutaneous blastic marginal zone lymphoma: A comprehensive clinical, light microscopic, phenotypic and cytogenetic appraisal

BACKGROUND

Primary cutaneous marginal zone lymphoma (PCMZL) is a form of indolent lymphoproliferative disease where the disease is largely a cutaneous confined process. It is typically a neoplasm composed of post germinal small B-cells and light chain restricted plasma cells in a background of reactive T-cell hyperplasia and benign germinal centers. Rarely a significant degree of large cell infiltration occurs warranting the categorization as blastic marginal zone lymphoma.

MATERIALS AND METHODS

We reviewed our data base over a time period of 2016 to 2022 for cases diagnosed as blastic MZL. Twelve cases were identified. The clinical records and pathological data were reviewed.

RESULTS

Nine of the cases represented de novo forms of blastic MZL while in three cases there was a prior history of MZL. Multifocal cutaneous disease was not uncommon and one quarter of the cases had evidence of extracutaneous dissemination. All patients except three achieved remission with varied therapeutic interventions depending on the extent of the disease ranging from conservative re-excision to chemotherapy. No patient died from lymphoma. Light microscopically, there was evidence of a background of conventional MZL in the majority of cases. The large cell component was typically characterized by multiple micronodular aggregates throughout the dermis although in three cases there was a striking diffuse large cell component as the dominant infiltrate. Phenotypically, a third of the cases showed either CD5 or CD23 positivity amidst neoplastic B cells. Significant staining for BCL-2 was noted in the majority of cases tested while extensive MUM-1 positivity was observed in half of the cases tested. Kappa or lambda light chain restriction was seen in most. The Ki67 proliferation index exceeded 30 % in all cases. There was C-MYC positivity in two cases. While most cases did not detect cytogenetic abnormalities, one case had multiple cytogenetic hits that are associated with diffuse large B cell lymphoma. Next generation sequencing showed a Ten-eleven translocation 2 mutation in the earlier biopsy prior to transformation and in the later biopsy after transformation along with an additional B2M mutation in the transformed biopsy. Both types of mutations are very uncommon but held to contribute to tumor progression in the setting of diffuse large B cell lymphoma.

CONCLUSION

Blastic MZL is associated with a more aggressive clinical course. Even when there is disseminated disease patients while not always cured did not have a fatal course in this series. The light microscopic findings are reproducible. The background of MZL, identification of larger cells in significant numbers without a follicle center phenotype, at times expressing CD5 or CD23 with variable positivity for MUM1, BCL-2 and C-MYC and a high proliferation index define the pathology in most. Certain cytogenetic abnormalities and genetic mutations implicated in large cell transformation into a diffuse large B cell lymphoma are seen in blastic MZL with earlier biopsies prior to transformation potentially harboring at risk genetic mutations.

Primary mucosa-associated lymphoid tissue lymphoma in fallopian tubes: A case report and literature review

RATIONALE

Mucosa-associated lymphoid tissue (MALT) lymphoma accounts for 7%-8% of newly diagnosed lymphomas. The stomach is the most common organ of origin (nearly 50% of MALT lymphomas). Only 2% of MALT lymphomas arise from the female genital tract, and most originated from uterus. We described a rare case of MALT lymphoma primarily arising from the fallopian tube.

PATIENT CONCERNS

A 26-year-old woman was brought into our gynecological clinic because of a history of irregular menstruation. The transvaginal ultrasonography revealed cystic masses in bilateral adnexa and both of them showed rich vasculature. Laboratory tests showed a high level (455.3 U/mL) of cancer antigen-125 (CA-125).

INTERVENTIONS

A laparoscopy was performed.

OUTCOMES

Frozen section of the removed specimen revealed acute and chronic inflammation with abundant inflammatory cells infiltrating the mesenchyme. The right fallopian tube was removed. However, the final histological results showed inflammation accompanied by hyperplasia of lymphoid tissue. Immunohistochemistry staining were consistent with MALT lymphoma. The patient received the second surgery to remove the left fallopian tube and also confirmed the same pathology.

LESSONS

Gynecologists should be aware of cystic masses which showed rich vasculature and high level of CA-125.

Effects of Helicobacter pylori infection in gastrointestinal tract malignant diseases: From the oral cavity to rectum

Helicobacter pylori (H. pylori) has infected approximately fifty percent of humans for a long period of time. However, improvements in the public health environment have led to a decreased chance of H. pylori infection. However, a high infection rate is noted in populations with a high incidence rate of gastric cancer (GC). The worldwide fraction of GC attributable to H. pylori is greater than 85%, and a high H. pylori prevalence is noted in gastric mucosa-associated lymphoid tissue lymphoma patients. These results indicate that the majority of GC cases can be prevented if H. pylori infection is eliminated. Because H. pylori exhibits oral-oral or fecal-oral transmission, the relationship between this microorganism and other digestive tract malignant diseases has also attracted attention. This review article provides an overview of H. pylori and the condition of the whole gastrointestinal tract environment to further understand the correlation between the pathogen and the host, thus allowing improved realization of disease presentation.

Helicobacter pylori-negative extra-nodal marginal zone B-cell lymphoma of Mucosa-Associated Lymphoid Tissue (MALT) type following Roux-en-Y Gastric Bypass (RYGB)

Gastric MALT lymphoma is a common type of non-Hodgkin's lymphoma that has the potential for cure in patients found to have concomitant Helicobacter pylori (H. pylori) infection. This case report explores the evaluation, diagnosis, and treatment of H. pylori-negative MALT lymphoma in a patient with a history of a RYGB.

The Bacterial Microbiota of Gastrointestinal Cancers: Role in Cancer Pathogenesis and Therapeutic Perspectives

The microbiota has an essential role in the pathogenesis of many gastrointestinal diseases including cancer. This effect is mediated through different mechanisms such as damaging DNA, activation of oncogenic pathways, production of carcinogenic metabolites, stimulation of chronic inflammation, and inhibition of antitumor immunity. Recently, the concept of "pharmacomicrobiomics" has emerged as a new field concerned with exploring the interplay between drugs and microbes. Mounting evidence indicates that the microbiota and their metabolites have a major impact on the pharmacodynamics and therapeutic responses toward anticancer drugs including conventional chemotherapy and molecular-targeted therapeutics. In addition, microbiota appears as an attractive target for cancer prevention and treatment. In this review, we discuss the role of bacterial microbiota in the pathogenesis of different cancer types affecting the gastrointestinal tract system. We also scrutinize the evidence regarding the role of microbiota in anticancer drug responses. Further, we discuss the use of probiotics, fecal microbiota transplantation, and antibiotics, either alone or in combination with anticancer drugs for prevention and treatment of gastrointestinal tract cancers.

Epidemiological characterization, genetic alterations of Helicobacter pylori infection in chronic gastric disorder and prognostic values of heterozygosity loss in chromosome 3p

From the literature review, there seem to be no studies conducted on infection caused by Helicobacter pylori in patients with gastric MALT lymphoma in the KSA region. The present research is an attempt to understand the prevalence of patients infected with H. pylori in the selected region and the role of allelic imbalance of chromosome 3p regions to understand the clinical manifestations and features associated with MALT lymphomagenesis. The researcher analyzed the frequency of infection in patients from the region of Saudi Arabia by examining the data collected from hospitals and biopsy tissue samples as per the recommended protocol. The endoscopic diagnosis was performed to collect biopsy samples. Histology and AP-PCR DNA fingerprinting analyses were performed from the endoscopic gastric mucosal biopsies collected from patients with associated gastric MALT lymphoma. The existence of H. pylori was examined based on the results of gastric mucosal biopsies stained with hematoxylin-eosin (H&E) and Steiner's silver stains. MALT, MALT lymphoma tissue samples and H. pylori-positive chronic gastritis were examined for LOH at chromosome 3p24 using standard procedures and techniques. The findings of the paper revealed the H. pylori was found to be positive in 17% of the cases significantly high among the age group of 31-50 years. Patients with MALT, MALT lymphoma, and H. pylori-associated gastritis presented features such as lymphocyte accumulation, vacuolation, Peyer's patch appearance, and lymphatic follicles. H. pylori were found to appear as a dense colored accumulated mass in the gastric epithelial layer. The findings from AP-PCR generated DNA fingerprints revealed intense band including two prominent bands in MALT lymphoma. Among other loci, 3p24 was the only one locus that showed high percentages of LOH as reported earlier in all cancer-related cases. The findings of this research paper empower the fact that allelic imbalances play a vital role in the development of MALT lymphoma. However, future researches should be conducted to identify the chromosome regions of the AP-PCR generated DNA fingerprints of human gastric MALT lymphoma in order to confirm this proposition.

Endoscopic features and clinical outcomes of colorectal mucosa-associated lymphoid tissue lymphoma

BACKGROUND AND AIMS

Colorectal mucosa-associated lymphoid tissue (MALT) lymphoma is a rare disease. The purpose of this study was to investigate the clinical and endoscopic features of colorectal MALT lymphoma.

METHODS

Patients diagnosed with colorectal MALT lymphoma at Asan Medical Center from 2002 to 2016 were eligible. Medical records were reviewed to investigate clinical features and treatment outcomes. Endoscopic pictures were assessed to characterize the endoscopic features of colorectal MALT lymphoma.

RESULTS

A total of 51 patients were enrolled. The median age was 60 years (interquartile range, 55-71), and 21 (41%) were men. Twenty-six patients (51%) were asymptomatic. Forty-four patients (86%) were in early disease stages, namely Lugano stages I, II, and II_E. Endoscopic appearances were classified as 4 distinct types: subepithelial tumor type (26 patients, 51%), polyposis type (10 patients, 20%), epithelial mass type (7 patients, 14%), and ileitis type (8 patients, 16%). The rectum (20 patients, 39%) was the most common location, followed by the ileocecal area (15 patients, 30%). An initial endoscopic impression of lymphoma was made in only 7 patients. Forceps biopsy sampling as the initial tissue acquisition method could histologically diagnose MALT lymphoma in 28 of 35 patients (80%). Polypectomy as the initial histologic diagnosis could diagnose MALT lymphoma in 16 of 16 patients. Progression-free and overall survival rates at 5 years were 92% and 94%, respectively.

CONCLUSIONS

Colorectal MALT lymphomas show various endoscopic appearances, complicating the endoscopic suspicion of colorectal MALT lymphoma. The prognosis of colorectal MALT lymphoma was excellent.

Uptake Patterns of Untreated Primary Gastrointestinal Extranodal Lymphomas on Initial Staging 18F-FDG PET/CT and Metabolic Tumor Parameters

Objective:

Non-Hodgkin’s lymphomas arising from tissues other than primary lymphatic sites are classified as primary extranodal lymphomas (PEL). PELs of the gastrointestinal system (PGISL) originate from the lymphatic tissues within the gastrointestinal tract. The prognostic value of ¹⁸F-FDG PET/CT in lymphomas is high in terms of both overall survival (OS) and disease-free survival (DFS). Our aim was to investigate the uptake patterns and properties of low-grade and high-grade PGISL on primary staging ¹⁸F-FDG PET/CT, as well as the prognostic significance of metabolic tumor parameters in high grade PGISL.

Methods:

Thirty-nine patients with PGISL were enrolled in this retrospective cohort study between 2004-2015. Primary staging ¹⁸F-FDG PET/CT have been performed and quantitative parameters of SUV_max, SUV_mean, metabolic tumor volume (MTV), total lesion glycolysis (TLG) have been calculated for all patients prior to treatment. Low-grade and high-grade PGISL were compared in terms of metabolic tumor parameters. Cox regression models were performed to determine factors that correlate with DFS in high-grade PGISL.

Results:

There were statistically significant differences between high-grade and low-grade PGISL in terms of SUV_max, SUV_mean, MTV, TLG, recurrence, mortality, DFS and OS. None of the potential risk factors (sex, age, site, SUV_max, SUV_mean, MTV, TLG) for recurrence and metastasis in high grade PGISL was identified as a risk factor on univariate and multivariate Cox regression analysis.

Conclusion:

Metabolic tumor parameters are not predictive markers in high-grade PGISL, especially in diffuse large B cell variant and primary gastric lymphoma. The first implications suggest they will not play a role in patient management.

Prognosis estimation under the light of metabolic tumor parameters on initial FDG-PET/CT in patients with primary extranodal lymphoma

Background

Non-Hodgkin’s lymphomas arising from the tissues other than primary lymphatic organs are named primary extranodal lymphoma. Most of the studies evaluated metabolic tumor parameters in different organs and histopathologic variants of this disease generally for treatment response. We aimed to evaluate the prognostic value of metabolic tumor parameters derived from initial FDG-PET/CT in patients with a medley of primary extranodal lymphoma in this study.

Patients and methods

There were 67 patients with primary extranodal lymphoma for whom FDG-PET/CT was requested for primary staging. Quantitative PET/CT parameters: maximum standardized uptake value (SUVmax), average standardized uptake value (SUVmean), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were used to estimate disease-free survival and overall survival.

Results

SUVmean, MTV and TLG were found statistically significant after multivariate analysis. SUVmean remained significant after ROC curve analysis. Sensitivity and specificity were calculated as 88% and 64%, respectively, when the cut-off value of SUVmean was chosen as 5.15. After the investigation of primary presentation sites and histo-pathological variants according to recurrence, there is no difference amongst the variants. Primary site of extranodal lymphomas however, is statistically important (p = 0.014). Testis and central nervous system lymphomas have higher recurrence rate (62.5%, 73%, respectively).

Conclusions

High SUVmean, MTV and TLG values obtained from primary staging FDG-PET/CT are potential risk factors for both disease-free survival and overall survival in primary extranodal lymphoma. SUVmean is the most significant one amongst them for estimating recurrence/metastasis.

MALT lymphoma of the left biceps muscle: a rare case with an interesting presentation

Background

Extranodal marginal zone lymphoma (MZL), also called mucosa-associated lymphoid tissue (MALT) lymphoma accounts for 7–8 % of non-Hodgkin lymphomas (NHLs) and most commonly involves the stomach. However, muscle involvement is very rare.

Case description

A 57-year-old woman was referred to our orthopaedics and traumatology clinic with a painful lump in the left arm. Physical examination revealed a red-colored mass on the left arm and an enlarged lymph node measuring almost 5 cm in the left axillary region and 3 cm in the right axillary region. Tru-cut biopsy of the mass in the left arm was consistent with MZL. The diagnosis was MALT lymphoma infiltrating the skeletal muscle (stage IIEA). R-CHOP was started. Two additional infusions of rituximab were administered after the sixth cycle of R-CHOP. Then, the patient received radiotherapy to the left arm at a dose of 30 Gy. After 1 year of follow-up, the patient had no evidence of disease.

Discussion and evaluation

MALT lymphoma arises in a number of epithelial tissues. The clinical presentation of MALT lymphoma varies depending upon the tissue involved. To our knowledge, rare cases of MALT lymphoma of the skeletal muscle have been reported. Although the available literature suggests that primary skeletal muscle NHL with advanced stage is associated with poor prognosis, the case presented here suggests that rituximab based combination therapy followed by radiotherapy can be an effective treatment for primary skeletal MALT lymphoma.

Conclusion

There is limited data regarding the prognosis and treatment of MALT lymphoma of the skeletal muscle. This case implies that rituximab based combination therapy followed by radiotherapy should be considered for the treatment of primary skeletal MALT lymphoma.

Mucosa-associated lymphoid tissue (MALT) lymphoma as an unusual cause of malignant hilar biliary stricture: a case report with literature review

Background

Biliary strictures at the hilum of the liver arise from heterogeneous etiologies. The majority is malignant entities, but some may have benign etiologies. It is difficult to distinguish between malignant and benign biliary strictures preoperatively. It has been reported that 5~15 % of preoperative diagnoses of hilar cholangiocarcinoma turn out to be benign lesions or even other types of malignancies. Primary non-Hodgkin’s lymphoma of the extrahepatic bile duct is very rare, with only a few cases reported as mucosa-associated lymphoid tissue (MALT) lymphoma arising from the hepatic duct bifurcation. We herein report a case of a female patient presenting with perihilar bile ducts obstructed by primary MALT lymphoma resembling hilar cholangiocarcinoma, along with a review of the literature.

Case presentation

An 86-year-old female was referred to our hospital manifesting obstructive jaundice and abdominal pain. The reported imaging studies revealed distended intrahepatic bile duct with the stricture of common hepatic duct including bifurcation, which was suspicious of cholangiocarcinoma of the bile duct. The initial laboratory-confirmed cholestasis with a total bilirubin of 8.6 mg/dL, aspartate amino transferase (AST) 178 U/L, alanine transferase (ALT) 105 U/L, and the tumor marker CA 19-9 was elevated with a value of 167 U/mL. Viral markers for hepatitis B and C viruses were negative. She underwent extrahepatic bile duct resection and hepaticojejunostomy. Histological examination of the resected specimen revealed MALT lymphoma. Postoperative follow-up of 1 year has been completely uneventful, without any symptoms or disease recurrence.

Conclusions

In exceptional cases, in which radiologic and clinical features point to cholangiocarcinoma, the actual reason for obstructive jaundice and abdominal pain can be a non-Hodgkin’s lymphoma. In the case of a MALT lymphoma, it can be cured with complete resection.

Rituximab monotherapy as a first-line treatment for pulmonary mucosa-associated lymphoid tissue lymphoma

Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma is a rare extranodal lymphoma with a 5-year survival rate of 80-95 %. There is no standard treatment strategy for pulmonary MALT lymphoma. In the present study, we performed a retrospective evaluation of systemic rituximab monotherapy (375 mg m(-2) day(-1), 4-8 cycles) as first-line treatment in patients with pulmonary MALT lymphoma. Of the eight patients enrolled, five achieved complete response, one achieved partial response, and two showed stable disease. Median progression-free survival was 66.0 months (range 9.7-87.2 months). Treatment was well tolerated and all patients were alive during the median follow-up period of 64.0 months. Rituximab monotherapy was efficacious in patients with pulmonary MALT lymphoma, demonstrating long-term disease stabilization and symptom reduction. Larger prospective studies are warranted to further assess the efficacy of rituximab monotherapy. In conclusion, rituximab monotherapy may be considered for first-line therapy in patients with pulmonary MALT lymphoma.

Non-Hodgkin lymphoma and hepatitis C: where we are and what next?

The association between hepatitis C virus and certain B-cell non-Hodgkin lymphomas, such as marginal zone lymphomas, is supported by epidemiological studies. The exact pathogenetic mechanism is still unknown but both chronic antigenic stimulation and viral lymphotropism may contribute to the evolution of the malignant clone. Furthermore, the hematologic response following hepatitis C antiviral treatment suggests that the virus may have an etiologic role. Interferon and ribavirin based treatment proved to be successful in small case series of hepatitis C virus associated splenic lymphoma with villous lymphocytes, therefore, it is suggested that antiviral treatment could be an alternative to chemo-immunotherapy. In the near future new more potent direct acting antivirals will make interferon free treatments possible. It is still an open question whether these new short-course regimens are also effective in the treatment of associated lymphomas and what is the importance of the lymphoid reservoir in eliminating HCV.

Immunoglobulin gene repertoire diversification and selection in the stomach - from gastritis to gastric lymphomas

Chronic gastritis is characterized by gastric mucosal inflammation due to autoimmune responses or infection, frequently with Helicobacter pylori. Gastritis with H. pylori background can cause gastric mucosa-associated lymphoid tissue lymphoma (MALT-L), which sometimes further transforms into diffuse large B-cell lymphoma (DLBCL). However, gastric DLBCL can also be initiated de novo. The mechanisms underlying transformation into DLBCL are not completely understood. We analyzed immunoglobulin repertoires and clonal trees to investigate whether and how immunoglobulin gene repertoires, clonal diversification, and selection in gastritis, gastric MALT-L, and DLBCL differ from each other and from normal responses. The two gastritis types (positive or negative for H. pylori) had similarly diverse repertoires. MALT-L dominant clones (defined as the largest clones in each sample) presented higher diversification and longer mutational histories compared with all other conditions. DLBCL dominant clones displayed lower clonal diversification, suggesting the transforming events are triggered by similar responses in different patients. These results are surprising, as we expected to find similarities between the dominant clones of gastritis and MALT-L and between those of MALT-L and DLBCL.

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.

The t(14;18)(q32;q21)/IGH-MALT1 translocation in gastrointestinal extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)

AIMS

Studies have indicated that the t(14;18)(q32;q21)/IGH-MALT1 translocation is present in extranodal marginal zone lymphomas of mucosa-associated lymphoid tissue (MALT lymphoma). However, only a few studies have investigated the incidence of t(14;18)/IGH-MALT1 in primary gastrointestinal MALT lymphomas or in diffuse large B-cell lymphomas (DLBCL). The overall significance of t(14;18)/IGH-MALT1 in gastrointestinal MALT lymphomas is not clear. We examined 41 gastrointestinal MALT lymphoma and 23 DLBCL cases, with the aim of further understanding the role of t(14;18)/IGH-MALT1 in these diseases.

METHODS AND RESULTS

Fluorescence in-situ hybridization (FISH) assays for the detection of t(14;18)/IGH-MALT1 and t(11;18)(q21;q21)/API2-MALT1, along with immunostaining and histological evaluations, were performed on selected cases. Of the 64 analysed cases, one gastric MALT lymphoma and one colonic MALT lymphoma were positive for t(14;18)/IGH-MALT1.

CONCLUSIONS

We describe what are, to our knowledge, the first reported primary colonic MALT lymphoma carrying t(14;18)(q32;q21)/IGH-MALT1, and one of the few reported cases of gastric MALT lymphoma with this translocation. As this translocation is seen in only a few gastrointestinal MALT lymphomas, it is not useful as a diagnostic marker for routine clinical services. Although these findings suggest that t(14;18)/IGH-MALT1 is a rare molecular event in gastrointestinal MALT lymphomas and DLBCLs, further studies to elucidate the role of this genetic alteration in these diseases are indicated.

Primary malt lymphoma of the common bile duct

Primary mucosa-associated lymphoid tissue (MALT) lymphoma arising in the common bile duct (CBD) is extremely rare. In our case of MALT lymphoma, CT and MRI showed long, segmental, irregular wall thickening of the CBD and minimal dilatation of the upstream bile duct. A preoperative diagnosis of cholangiocarcinoma was made, but histologic evaluation confirmed MALT lymphoma of the CBD. We herein present a rare case of MALT lymphoma of the CBD with CT and MRI findings.

Lymphomas of the Gastrointestinal Tract: An Update

The gastrointestinal tract is the most common extranodal site of non-Hodgkin lymphoma. Certain lymphomas have a predilection for the gastrointestinal tract, including extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, mantle cell lymphoma, natural killer/T-cell lymphoma, and enteropathy-associated T-cell lymphoma. Follicular lymphoma may also be primary to the gastrointestinal tract. In addition to diagnosing neoplastic conditions, it is important to differentiate lymphomas from atypical reactive proliferations. Recent research relevant to non-Hodgkin lymphomas involving this location is reviewed with an emphasis on novel and evolving areas of classification.

Primary spinal marginal zone lymphoma: case report and review of the literature

BACKGROUND AND IMPORTANCE

Marginal zone lymphoma (MZL) describes a heterogeneous group of indolent B-cell lymphomas. The World Health Organization recognizes 3 types of MZLs: splenic MZL, nodal MZL, and extranodal MZL of mucosa-associated lymphoid tissue. There is no consensus on the optimal adjuvant treatment modalities for intracranial primary MZLs. To date, no case of spinal primary MZL has been reported.

CLINICAL PRESENTATION

We present the first case of spinal MZL diagnosed in a 65-year-old man with progressive paraparesis. He underwent surgical removal of the main spinal tumor mass, which extended epidurally from vertebral body T3 to T7. Surgery was followed by 10 sessions of local irradiation for a total dose of 31 Gy. On long-term follow-up in 2010, the patient was in good health without any signs of residual or recurrent disease. Twenty-seven publications reporting on 61 cases of intracranial primary MZL were identified and reviewed. In the majority of cases of marginal zone B-cell lymphoma, adjuvant radiotherapy was used, with some combining radiotherapy and chemotherapy after surgical removal of the bulk of the main tumor. Long-term follow-up in most patients showed no evidence of disease and clinical well-being years after the initial diagnosis.

CONCLUSION

Chemotherapy and/or radiation have been used in larger case series. Although there is no defined treatment guideline for this rare disease entity, our review of the literature suggests a favorable prognosis when combining surgical and adjuvant radiotherapy approaches.

Study of regulatory T-cells in patients with gastric malt lymphoma: influence on treatment response and outcome

Purpose

FOXP3+ regulatory T cells (Treg) play an essential role in modulating host responses to tumors and infections. The role of these cells in the pathogenesis of MALT lymphomas remains unknown. The aims of the study were to quantify the number of infiltrating FOXP3+ and CD3+ cells in patients with gastric MALT lymphoma at diagnosis and to study kinetics of these cells and CD20+ tumor cells after treatment and during long-term follow-up.

Methods

FOXP3+, CD3+ and CD20+ cells were analyzed by immunohistochemistry and the number of cells was quantified using a micrometric ocular. Samples of 35 patients with gastric MALT lymphoma at diagnosis and after treatment were included. Diagnostic samples were compared to 19 cases of chronic gastritis and diffuse large B-cell lymphoma (DLBCL) of the stomach.

Results

The median number of FOXP3+ infiltrating cells was higher (27 cells/cm²) in gastric MALT patients than in DLBCL (10 cells; p = 0.162) but similar to chronic gastritis (20 cells; p = 0.605). No characteristic or specific distribution pattern of infiltrating FOXP3+ cells was found. Gastric MALT lymphoma patients responding to bacterial eradication therapy had higher number of FOXP3+ cells at study entry. Kinetics of both infiltrating FOXP3+ cells and tumor CD20+ cells were strongly dependent on the treatment administered.

Discussion

Gastric MALT lymphomas have a number of Treg cells more similar to chronic gastritis than to DLBCL. Patients with higher number of tumor infiltrating FOXP3+ cells at study entry seem to have better response to antibiotics. Kinetics of Treg and tumor cells are influenced by type of treatment.

Colorectal lymphoma

Extranodal lymphomas account for a third of all cases of non-Hodgkin lymphoma with the gastrointestinal tract being the most common extranodal site. The most common location is the stomach followed by the small intestine, colon and rectum. Colorectal lymphomas are rare and comprise 10-20% of all gastrointestinal lymphomas and only 1% of all colorectal malignancies. Presenting symptoms include abdominal pain, weight loss, and anorexia. Diagnosis depends on the clinical setting with elective cases being diagnosed with colonoscopy and emergent cases being diagnosed in the operating room. Colonic lymphomas are frequently located proximal to the hepatic flexure. Management depends on the aggressiveness of the lymphoma subtype. Indolent tumors, which are resistant to standard chemotherapeutic regimens, are treated with surgical resection. Aggressive lymphoma subtypes are managed with chemotherapy and surgery with late-stage disease patients being referred to clinical trials.

CD5-positive mucosa-associated lymphoid tissue (MALT) lymphoma: a clinicopathologic study of 14 cases

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) is a B-cell neoplasm that is typically CD5 negative. We describe the clinicopathologic, immunophenotypic, and cytogenetic features of 14 cases of CD5+ MALT lymphoma. There were 9 men and 5 women (median age, 68 years; range, 34-87 years). MALT lymphoma was initially diagnosed in salivary glands (n = 4), nasopharynx (n = 2), and 1 case each in conjunctiva, thyroid, stomach, colon, skin, lung, kidney, and retroperitoneum. Two patients had localized disease; 9 had disseminated disease with generalized lymphadenopathy (n = 8), multifocal lymphoma (n = 6), or bone marrow involvement (n = 5). No staging information was available for the remaining patients. None presented with B symptoms, splenomegaly, cytopenias, lymphocytosis, monoclonal gammopathy, or elevated serum lactate dehyrogenase. Serum β2-microglobulin was elevated in 6. Morphologically, the neoplasms had features typical of MALT lymphoma being composed of small- to medium-sized cells with round to slightly irregular nuclear contours and moderate amount of cytoplasm. Lymphoepithelial lesions were noted in 4 cases. CD5 was positive in all cases by immunohistochemistry (n = 12) and/or flow cytometry (n = 11). All cases assessed were negative for cyclin D1 (13/13) and CD10 (11/11). Conventional cytogenetics in 7 cases showed trisomy 3 in 3 and diploid in 4. With a median follow-up of 71 months (range, 2-131 months), overall survival at 5 years was 100%, although 5 patients required chemotherapy. Our results show that CD5 expression is rare in MALT lymphoma, and is often associated with nongastric disease and an increased tendency to present with disseminated disease. Overall survival is excellent with appropriate therapy.

Indolent B-cell lymphomas associated with HCV infection: clinical and virological features and role of antiviral therapy

The association between hepatitis C virus (HCV) infection and B-cell non-Hodgkin's lymphomas (NHL) has been demonstrated by epidemiological studies, in particular in highly endemic geographical areas such as Italy, Japan, and southern parts of United States. In these countries, together with diffuse large B-cell lymphomas, marginal zone lymphomas are the histotypes most frequently associated with HCV infection; in Italy around 20–30% cases of marginal zone lymphomas are HCV positive. Recently, antiviral treatment with interferon with or without ribavirin has been proved to be effective in the treatment of HCV-positive patients affected by indolent lymphoma, prevalently of marginal zone origin. An increasing number of experiences confirmed the validity of this approach in marginal zone lymphomas and in other indolent NHL subtypes like lymphoplasmacytic lymphoma. Across different studies, overall response rate was approximately 75%. Hematological responses resulted significantly associated with the eradication of the virus. This is the strongest evidence of a causative link between HCV and lymphomas. The aim of this paper is to illustrate the relationship between HCV infection and different subtypes of indolent B-cell lymphomas and to systematically summarize the data from the therapeutic studies that reported the use of antiviral treatment as hematological therapy in patients with HCV-associated indolent lymphomas.

Lymphomas of the gastro-intestinal tract - pathophysiology, pathology, and differential diagnosis

The gastrointestinal tract (GIT) is the most commonly involved site of extranodal lymphomas. The close association between chronic inflammation and specific GIT lymphomas not only provide interesting insights into the pathobiology of lymphomas but also poses unique diagnostic challenges. A clear understanding of marginal zone and mucosa associated lymphoid tissue (MALT) in health and disease is helpful to place GIT lymphomas in proper context. A wide variety of lymphomas besides MALT lymphomas occur in various parts of the GIT. The characteristic pathological, immunophenotypic, and genetic features of different GIT lymphomas categorized according to World Health Organization (WHO) classification are presented. The epidemiological, clinical, and pathological features of lymphomas occurring in each part of the GIT are summarized and the key points regarding lymphomas at each site are emphasized. A tabular summary of the important differential diagnostic considerations at each site is given and suggestions for a minimal diagnostic work up are provided.

BCL10 down-regulation in peripheral T-cell lymphomas

The BCL10 gene encodes for a T-cell receptor signaling downstream protein involved in nuclear factor κB activation. It is expressed in normal lymphoid tissues and in several B-non Hodgkin lymphomas, its aberrant function being related to the pathogenesis of certain subtypes. Conversely, conflicting data are available concerning BCL10 expression in peripheral T cell lymphomas. We analyzed BCL10 expression in peripheral T cell lymphomas and correlated it with NFκB activation, proliferation, phenotypic aberration, and survival. First, gene expression analysis of 40 peripheral T cell lymphomas (28 peripheral T cell lymphomas/not otherwise specified, 6 anaplastic large cell lymphomas, and 6 angioimmunoblastic lymphomas), 4 reactive lymph nodes, and 20 samples of normal T-lymphocytes, showed significantly lower BCL10 gene expression in all tumors in comparison to normal samples, the lowest values being detected in anaplastic large cell lymphoma. Secondly, we studied the immunohistochemical expression of BCL10 in 52 peripheral T cell lymphomas/not otherwise specified on tissue microarrays. BCL10 was expressed in 10/52 cases (19%), not showing any significant correlation with either expression of Ki-67 and the T-cell markers or NFκB activation. Furthermore, BCL10 expression was not associated with peculiar gene expression profiles. Finally, we did not find significant correlations with progression free survival and overall survival, although a favorable trend was recorded in BCL10(+) cases. In conclusion, BCL10 was commonly down-regulated in peripheral T cell lymphomas, suggest the T-cell receptor signaling cascade for future characterization.

Marginal zone lymphoma of mucosa-associated lymphoid tissue with prominent plasma cell differentiation affecting the palatine tonsil: histopathological and immunohistochemical analysis

Non-Hodgkin lymphomas (NHLs) of the oral cavity and oropharynx constitute 13% of all primary extranodal NHLs. Marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT lymphoma) in the palatine tonsil is rare, corresponding to 6% of the NHLs of the Waldeyer ring. Some cases of MALT lymphoma can present prominent plasma cell differentiation, and less commonly, monoclonal gammopathy. The differential diagnosis of these cases from other NHLs with plasmacytic differentiation or plasma cell neoplasms is very difficult. In this article, we describe a rare case of MALT lymphoma in a 34-year-old man presenting as a swelling of the palatine tonsil. The tumor mass was diagnosed as MALT lymphoma with prominent plasma cell differentiation. Systemic evaluation was noncontributory. This is the first report of MALT lymphoma showing extensive plasmacytic differentiation of the palatine tonsil, and reinforces a possible relationship between extramedullary plasmacytoma and MALT lymphoma.

Gastric marginal zone B cell lymphoma of the duodenum

Small bowel lymphomas of the extranodal type occur in the young and are characteristically associated with malabsorption syndrome. We present the case of an elderly in whom there was no malabsorption and the duodenal tumor was a gastric type marginal zone B cell lymphoma also known as gastric mucosa-associated lymphoid tissue (MALT) lymphoma. A 73-year-old woman presented to the emergency room with 2 weeks of general weakness, recurrent vomiting containing food particles and abdominal distension. She had been diagnosed with diabetic gastroparesis 4 years prior. CT of the abdomen and pelvis was suggestive of gastric outlet obstruction but no evidence of pancreatic or duodenal mass. Endoscopy and biopsy of the tumor obstructing the distal first part of the duodenum confirmed a gastric marginal MALT lymphoma. The patient's symptoms improved with radiotherapy. Gastric MALT lymphoma, an extranodal lymphoma primarily described in the stomach, can also present in the small bowel and is not associated with malabsorption.

Treatment of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue with fludarabine: effect on tumor microenvironment

Gastric Helicobacter pylori (HP) positive extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) develops during chronic antigenic stimulation with specific T-cell help. Chemotherapy that acts both on the malignant B-cells and on T-cells in the microenvironment, i.e. nucleoside analogs, might therefore be an attractive treatment. In 14 patients with gastric MALT lymphoma treated with fludarabine, alterations in T-cell subsets were studied in subsequent peripheral blood samples and in gastric biopsies. Treatment with fludarabine resulted in a steep decrease in T-cell subsets in peripheral blood samples. By contrast no decrease in T-cell populations was observed in subsequent gastric biopsy samples and a moderate increase was observed in relative infiltration with CD3 +, CD4 + and CD8 + cells. In addition an increase in density of FOXP3 + cells (i.e. Tregs) was seen (p = 0.047). These alterations in different T-cell subsets were not observed in gastric biopsy samples of patients treated with HP-eradication only.

Treatment of mucosa-associated lymphoid tissue lymphoma in Sjogren's syndrome: a retrospective clinical study

OBJECTIVE

To retrospectively analyze the clinical course of patients with mucosa-associated lymphoid tissue (MALT)-type lymphoma of the parotid gland and associated Sjögren's syndrome (SS).

METHODS

All consecutive patients with SS and MALT lymphoma (MALT-SS) diagnosed in the University Medical Center Groningen between January 1997 and January 2009 were analyzed. Clinical course and treatment outcome of SS and MALT lymphoma were evaluated.

RESULTS

From a total of 329 patients with SS, 35 MALT-SS patients were identified, with a median followup of 76 months (range 16-153 mo). MALT lymphoma was localized in the parotid gland in all cases. Treatment consisted of "watchful waiting" (n = 10), surgery (n = 3), radiotherapy (n = 1), surgery combined with radiotherapy (n = 2), rituximab only (n = 13), or rituximab combined with chemotherapy (n = 6). Complete response was observed in 14 patients, partial response in 1 patient, and stable disease in 20 patients. In 6 of 7 patients with initially high SS disease activity (M-protein, cryoglobulins, IgM rheumatoid factor > 100 KIU/l, severe extraglandular manifestations), MALT lymphoma progressed and/or SS disease activity increased after a median followup of 39 months (range 4-98 mo), necessitating retreatment. Only 1 patient with MALT who had low SS disease activity showed progression of lymphoma when left untreated.

CONCLUSION

An initially high SS disease activity likely constitutes an adverse prognostic factor for progression of lymphoma and/or SS. Such patients may require treatment for both MALT lymphoma and SS. In SS patients with localized asymptomatic MALT lymphoma and low SS disease activity, a "watchful waiting" strategy seems justified.

Cerebral localized marginal zone lymphoma presenting as hypothalamic-pituitary region disorder

Introduction

Marginal zone B-cell lymphoma is a rare disease which can be considerably difficult to recognize and diagnose when signs of systemic involvement are absent.

Case Presentation

We report the case of a 57-year-old woman with initial olfactory disturbance, followed by psychosis, diabetes insipidus and hypothalamic eating disorder as an uncommon clinical presentation of marginal zone B-cell lymphoma.

Conclusion

Marginal zone B-cell lymphoma should be considered as a potential differential diagnosis in patients with hypothalamic disturbances.

Expression of PIK3CA and FOXP1 in gastric and intestinal non-Hodgkin's lymphoma of mucosa-associated lymphoid tissue type

Non-Hodgkin's lymphoma of mucosa-associated lymphoid tissue (MALT) type arises from a wide variety of extranodal sites, most frequently from the gastrointestinal tract. Recently, it has been demonstrated that karyotypic alterations involving the PIK3CA and FOXP1 genes of chromosome 3 occur in MALT lymphoma. However, their associated protein expression has not been extensively studied. Tumor tissues from 27 gastric and 23 intestinal MALT lymphomas were analyzed for PIK3CA and FOXP1 protein expression using immunohistochemistry and correlated with histological features and treatment outcomes. Expression of PIK3CA, a novel indicator, was found in 40% of gastrointestinal cases and indicated an inferior progression-free survival in both gastric and intestinal MALT lymphomas (P = 0.001 and P = 0.015). Tumor staining of nuclear FOXP1 (46.0%) was more common in gastric than intestinal MALT lymphomas (P = 0.042) and was significantly associated with polymorphic histology (P = 0.007). FOXP1 expression was identified as an adverse prognostic factor for overall survival in gastric MALT lymphomas (P = 0.035). We further combined these two markers and observed that patients that are positive for both PIK3CA and FOXP1 had a worse overall and progression-free survival. Considering the small sample size of this study, these results should be confirmed in a large prospective study.

Extranodal MALT Lymphoma of the Right Triceps Muscle following Influenza Vaccine Injection: A Rare Case with an Interesting Presentation

The study describes a case of a 67-year-old female who developed a Stage I E marginal zone lymphoma of the right triceps muscle 1 month after influenza vaccination at the same site. She was treated with single modality, involved field radiation therapy (IFRT) to 4000 cGy in 20 fractions with excellent response and no evidence of disease after one year followup.

The role of abdominal CT scan as follow-up after complete remission with successful Helicobacter pylori eradication in patients with H. pylori-positive stage I(E1) gastric MALT lymphoma

BACKGROUND

Eradication of Helicobacter pylori with antibiotics is the established initial treatment of patients with localized gastric mucosa-associated lymphoid tissue (MALT) lymphoma. However, there are few reports on follow-up modalities to identify sustained remission in patients who achieve complete remission (CR). We therefore investigated the role of abdominal computed tomography (CT) as follow-up after CR with H. pylori eradication.

PATIENTS AND METHODS

We retrospectively analyzed 122 patients with H. pylori-positive stage I(E1) gastric MALT lymphoma who achieved CR with successful H. pylori eradication.

RESULTS

The median follow-up after CR was 35 months (range 3-140 months). At a median of 17 months (range 12-21 months) after CR, 7 of 122 patients (5.7%) experienced lymphoma recurrence, all cases of which were confined to the gastric mucosa and were detectable only by endoscopy with multiple biopsies. At the time of recurrence, four of seven patients showed re-infection by H. pylori. Eradication therapy was successful in these patients, resulting in both bacterial eradication and tumor regression. Three patients who experienced histologic recurrence without H. pylori re-infection were observed by a watch and wait strategy and again achieved CR.

CONCLUSIONS

None of the patients with H. pylori-positive stage I(E1) gastric MALT lymphoma who experienced tumor recurrence after CR with successful H. pylori eradication showed recurrence at extragastric sites, including lymph nodes without gastric mucosal lesion. These findings indicate that endoscopic biopsies without abdominal CT scans are sufficient to detect recurrence in these patients.

Mucosa-associated lymphoid tissue lymphoma: multimodality imaging and histopathologic correlation

OBJECTIVE

We will illustrate the imaging features of gastrointestinal and nongastrointestinal mucosa-associated lymphoid tissue (MALT) lymphoma and their correlation with histopathologic findings. The radiologic features to distinguish gastrointestinal MALT lymphoma from other types of lymphomas will also be described.

CONCLUSION

Differences in clinical behavior and management make it exceedingly important to differentiate MALT lymphoma from other types of lymphomas. Radiologic and histopathologic findings need to be taken into account before making a diagnosis and treatment plan.

Treatment outcome of localized Helicobacter pylori-negative low-grade gastric MALT lymphoma

AIM: To investigate treatment outcome of Helicobacter pylori (H. pylori)-negative low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma.

METHODS: In this study, we retrospectively reviewed the clinical outcome and clinicopathologic factors of stage IE H. pylori-negative low-grade gastric MALT lymphoma cases from August 1998 to June 2009.

RESULTS: A total of eleven patients with H. pylori-negative low-grade gastric MALT lymphoma were enrolled in the study and received anti-H. pylori eradication treatment and/or radiotherapy or excisional therapy. Complete remission (CR) of gastric MALT lymphoma was achieved in all patients. The time to CR was 1-66 mo (median, 1 mo).

CONCLUSION: Eradication therapy may be offered as an initial treatment option even in cases of localized H. pylori-negative gastric MALT lymphoma.

The role of toll-like receptors in chronic B-cell malignancies

Toll-like receptors (TLR) are key players in host defence from infection. They recognize a specific set of molecular patterns of microbial origin, immediately trigger an innate immune response, and bridge innate and adaptive immunity. TLR have also been shown to play a role in tumor development. In this context, chronic B-cell malignancies are an interesting example as clonal B lymphocytes remain responsive to and dependent on stimuli originating from the microenvironment which then become crucial for maintaining and propagating the disease. Emerging evidences suggest that, among other microenvironmental elements, TLR ligands may play a role in the pathogenesis of chronic B-cell lymphoid malignancies. Conceivably, their manipulation may find a place in specific settings of treatment of these tumors.

Mucosa-associated lymphoid tissue lymphoma of the duodenum together with multiple intra-abdominal thromboses and hepatitis C virus infection: a case report

Mucosa associated lymphoid tissue MALT lymphoma is a low grade malignancy that arises most commonly from the gastric mucosa. Small intestinal involvement is very rare. The causative relationship between Helicobacter pylori and the gastric MALT lymphoma is a well known issue, but recently there are several data suggesting the role of hepatitis C virus (HCV) infection in the pathogenesis of lymphoma including MALT lymphoma. Herein we present a rare case of duodenal MALT lymphoma with multiple intra-abdominal thromboses together with HCV infection that was confirmed by real-time polymerase chain reaction detecting HCV-RNA within the peripheral blood mononuclear cells.

The Evolution in the Management of Gastric Lymphoma

The management of gastric lymphoma is a rapidly changing field. The classification and staging of lymphomas have been revised in the past two decades, reflecting diagnostic advances that include the use of immunohistochemical stains and cell-surface markers. Furthermore, the use of CT scanning and endoscopic ultrasound has revolutionized the non-operative diagnostic modalities available. Despite these advances, the future of gastric lymphoma research lies in the development of therapeutic regimens.

A minute focus of extranodal marginal zone B-cell lymphoma arising in Hashimoto thyroiditis diagnosed with PCR after laser capture microdissection: a case report

Background

Primary thyroid gland lymphomas are uncommon tumours that occur in the setting of lymphocytic thyroiditis or Hashimoto's disease in almost all cases. In this condition a distinction between an inflammatory lymphoid infiltrate and a low grade lymphoma may be extremely difficult and precise criteria are necessary for a correct diagnosis.

Patient and methods

We report a case of a minute focus of primary extranodal marginal zone B-cell lymphoma (EMZBCL), incidentally discovered in a 63-year-old man with Hashimoto thyroiditis (HT) and diagnosed by means of polymerase chain reaction (PCR) after laser capture microdissection.

The histological examination of surgical specimen confirmed the diagnosis of HT and showed a minute focus of dense lymphoid infiltrate (less than 4 mm in diameter), composed by centrocyte-like cells forming MALT balls. Immunoistochemistry was not useful. A microscopic focus of EMZBCL was suspected on the basis of morphological features. PCR assays revealed the rearrangement of the heavy chain of immunoglobulins only in the microdissected suspicious area, confirming the diagnosis of EMZBCL.

Conclusion

Our finding suggests that in cases of autoimmune thyroiditis a careful examination of the thyroid specimen is warranted, in order to disclose areas or small foci of lymphomatous transformation. Furthermore, in difficult cases with doubtful immunohistological findings, ancillary techniques, such as molecular studies, are necessary for a conclusive diagnosis.