Endoscopic diagnosis and staging of mucosa-associated lymphoid tissue lymphoma

Mucosa-Associated Lymphoid Tissue Lymphoma Masked as Gastric Varices With Acute Upper Gastrointestinal Bleeding: A Case Report

Extra-nodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) is uncommon and difficult to diagnose due to varied clinical presentations and endoscopic appearances masquerading as other pathology. Rarely, it has been associated with acute upper gastrointestinal (GI) bleeding. We report on a 60-year-old male who presented with an acute upper GI bleed and endoscopic findings suggestive of isolated gastric varices (GV), ultimately determined to be MALT lymphoma. Complete remission was achieved with radiation therapy, with no recurrence at a 12-month follow-up. This case highlights a unique clinical and endoscopic presentation of MALT lymphoma which providers should be aware of. We emphasize the use of endoscopic ultrasound (EUS) evaluation for accurate diagnosis.

Recent advances upper gastrointestinal lymphomas: molecular updates and diagnostic implications

Approximately one-third of extranodal non-Hodgkin lymphomas involve the gastrointestinal (GI) tract, with the vast majority being diagnosed in the stomach, duodenum, or proximal small intestine. A few entities, especially diffuse large B-cell lymphoma and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, represent the majority of cases. In addition, there are diseases specific to or characteristic of the GI tract, and any type of systemic lymphoma can present in or disseminate to these organs. The recent advances in the genetic and molecular characterisation of lymphoid neoplasms have translated into notable changes in the classification of primary GI T-cell neoplasms and the recommended diagnostic approach to aggressive B-cell tumours. In many instances, diagnoses rely on morphology and immunophenotype, but there is an increasing need to incorporate molecular genetic markers. Moreover, it is also important to take into consideration the endoscopic and clinical presentations. This review gives an update on the most recent developments in the pathology and molecular pathology of upper GI lymphoproliferative diseases.

Hematologic malignancies of the gastrointestinal luminal tract

Hematologic malignancies include several lymphoproliferative and myeloproliferative disorders, many of which are frequently encountered in current health care settings. These malignancies frequently affect the gastrointestinal (GI) tract, either by secondary extranodal or extramedullary extension to the GI tract, or as a primary process arising in the GI tract. In fact, the GI tract may represent the most common extranodal site of involvement in many of them, such as lymphoma. Furthermore, in the current era of improved cancer treatment and advanced transplant procedures with increased survival, it has been quite common to encounter GI involvement by these malignancies through the disease course. Post-transplant lymphoproliferative disorder following kidney transplantation, for example, very commonly involves the GI tract. Other conditions that can involve the GI tract include multiple myeloma, plasmacytoma, myeloid sarcoma, mastocytosis, and Castleman disease. Imaging diagnosis of these malignancies can be challenging, since they are much less common than primary GI cancers and both share many common imaging features as well. However, certain imaging features, particularly in combination with a matching clinical scenario, play a pivotal role in diagnosing these conditions and directing further evaluation. In this article, we review common and rare hematologic malignancies of the GI tract and discuss their pathophysiologic, clinical, and imaging features.

Endoscopic features aiding the diagnosis of gastric mucosa-associated lymphoid tissue lymphoma

The incidence of gastric mucosa-associated lymphoid tissue (MALT) lymphoma is increasing worldwide, but the diagnosis is difficult. Most patients are asymptomatic or complain of nonspecific gastrointestinal symptoms. As the endoscopic features of gastric MALT lymphoma are variable and nonspecific, the possibility of this condition may be overlooked during esophagogastroduodenoscopy, and it remain undiagnosed. Therefore, this condition needs to be considered when an abnormal mucosa is observed during this procedure. Biopsy performed during endoscopy is the primary diagnostic test, but false negative results are possible; large numbers of samples should be collected from both normal and abnormal mucosae. Endoscopic ultrasonography is useful to assess the depth of invasion and to predict the treatment response. After treatment, follow-up tests are required every 3 months until complete remission is achieved, and annually thereafter. Early diagnosis of gastric MALT lymphoma is difficult, and its diagnosis and follow-up require wide experience and competent endoscopic technique.

The value of EUS in combination with cytological, flow cytometry, and gene rearrangement in the diagnosis of gastrointestinal lymphoma

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) have a great value in clinical practice of gastrointestinal lymphoma (GIL). Auxiliary methods such as flow cytometry (FCM) and gene rearrangement provide additional information for the diagnosis. Current study aims to explore the diagnostic value of EUS-FNA combined with FCM and gene rearrangement for GIL in our single institution. Suspected GIL cases, which were referred to EUS, FNA, FCM, or gene rearrangement examination, were retrospectively reviewed from January 2011 to May 2014. Definitive final diagnosis was included based on the pathological and immunostaining evidence. The gene scan analysis was applied for fragment detection in gene rearrangement. The sensitivity, specificity, and accuracy were considered and calculated. Fifty-three EUS cases were identified, including 38 GIL, 10 inflammations, 4 linitis plastica, and one multiple myeloma. EUS-FNA was successfully conducted in 39 out of 53 cases. After combined with FCM, the sensitivity, specificity, and accuracy were increased from 60.7% to 76.9%, 90.9% to 100%, and from 69.2% to 81.8% respectively. Among 33 cases for FCM, 11 of them gained positive B or T non-Hodgkin lymphoma diagnosis, and 28 out of 53 specimens were delivered for gene rearrangement. The sensitivity, specificity, and accuracy of gene rearrangement were 68.2%, 100%, and 75% respectively. EUS-FNA is a possible technique for the diagnosis of GIL, With additional FCM examination may further improve the diagnostic efficiency and facilitate subclassification. Moreover, gene rearrangement assay by gene scan is also a considerable method in the specimens from GIL. Copyright © 2016 John Wiley & Sons, Ltd.

Helicobacter pylori infection in gastric mucosa-associated lymphoid tissue lymphoma

Gastrointestinal lymphoma is the most common type of extranodal lymphoma, and most commonly affects the stomach. Marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) and diffuse large B-cell lymphoma are the most common histologic types of gastric lymphoma. Despite its increasing incidence, diagnosis of gastric lymphoma is difficult at an earlier stage due to its nonspecific symptoms and endoscopic findings, and, thus, a high index of suspicion, and multiple, deep, repeated biopsies at abnormally and normally appearing sites in the stomach are needed. In addition, testing for Helicobacter pylori (H. pylori) infection and endoscopic ultrasonography to determine the depth of tumor invasion and involvement of regional lymph nodes is essential for predicting response to H. pylori eradication and for assessment of disease progression. In addition, H. pylori infection and MALT lymphoma development are associated, and complete regression of low-grade MALT lymphomas after H. pylori eradication has been demonstrated. Radiotherapy and/or chemotherapy can be used in cases that show poor response to H. pylori eradication, negativity for H. pylori infection, or high-grade lymphoma.

Duodenal mucosa-associated lymphoid tissue lymphomas: two cases and the evaluation of endoscopic ultrasonography

Mucosa-associated lymphoid tissue lymphoma mainly arises in the stomach, with fewer than 30% arising in the small intestine. We describe here two cases of primary duodenal mucosa-associated lymphoid tissue lymphoma which were evaluated by endoscopic ultrasonography. A 52-year-old man underwent endoscopy due to abdominal pain, which demonstrated a depressed lesion on duodenal bulb. Endoscopic ultrasonographic finding was hypoechoic lesion invading the submucosa. The other case was a previously healthy 51-year-old man. Endoscopy showed a whitish granular lesion on duodenum third portion. Endoscopic ultrasonography image was similar to the first case, whereas abdominal computed tomography revealed enlargement of multiple lymph nodes. The first case was treated with eradication of Helicobacter pylori, after which the mucosal change and endoscopic ultrasound finding were normalized in 7 months. The second case was treated with cyclophosphamide, vincristine, prednisolone, and rituximab every 3 weeks. After 6 courses of chemotherapy, the patient achieved complete remission.

Treatment outcome of gastric extra-nodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type in the Hong Kong Chinese population: a single centre experience

OBJECTIVE

To analyze the clinical characteristics, treatment outcome of patients with gastric extra-nodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type (EMZBL-MALT).

METHODS

Data of 30 patients with gastric EMZBL-MALT diagnosed in Caritas Medical Center between July 1997 and June 2009 were analyzed retrospectively.

RESULTS

The median follow-up time was 6.4 years [interquartile range (IQR) 3.9 to 8.9 years] and the median age at time of diagnosis was 71.5 years (IQR 64 to 81 years). All subjects, with investigations done for disease staging, suffered from localized disease (stage I or II1). Helicobacter infection was identified in 67% of subjects. Twenty Helicobacter-positive subjects received Helicobacter eradication treatment and seven Helicobacter-negative subjects received single-agent chemotherapy (cyclophosphamide), with disease remission rates at 85% and 71% respectively. Only one subject died apparently from disease progression. The 5-year and 10-year overall survival rates were 75% and 62.5% respectively.

CONCLUSIONS

Helicobacter eradication and single-agent chemotherapy were effective treatment modalities for early stage gastric EMZBL-MALT with and without Helicobacter infection respectively. Survival was favorable.

Gastrointestinal lymphomas: Morphology, immunophenotype and molecular features

Primary gastrointestinal lymphoma comprises 10-15% of all non-Hodgkin lymphomas and encompasses 30-40% of the total extranodal lymphomas. Approximately 60-75% of cases occur in the stomach, and then the small bowel, ileum, cecum, colon and rectum. Lymphoid neoplasms may consist of mature B, T and less commonly extranodal NK/T cells. Of these, the two most frequently encountered histologic subtypes are extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), where Helicobacter pylori infection is implicated in a number of cases, and diffuse large B cell lymphoma. Several B cell lymphomas are associated with chromosomal aberrations. Enteropathy-associated T cell lymphoma, type I in particular, usually arises in a background of celiac disease. T cell gene rearrangement confirms clonality. NK/T cell neoplasms are invariably associated with Epstein-Barr virus infection and are often aggressive; thus, differentiation from a benign NK-cell enteropathy is paramount. Although incidence of other hematopoietic malignancies in the gastrointestinal tract such as plasma cell myeloma associated with amyloidosis, plasmablastic lymphoma, Hodgkin disease, histiocytic sarcoma and mast cell sarcoma is extremely rare, these entities have been documented, with the latter two demonstrating aggressive clinical behavior. Endoscopic ultrasonography is an important adjunct in disease staging and follow-up. Conservative antibiotic treatment of stage I MALT lymphomas with associated Helicobacter pylori infection achieves good clinical outcome with high remission rate. Chemotherapy, radiation and rarely surgery are reserved for advanced diseases or cases resistant to conservative therapy and those not associated with Helicobacter pylori infection.

Gastrointestinal lymphomas: Morphology, immunophenotype and molecular features

Primary gastrointestinal lymphoma comprises 10-15% of all non-Hodgkin lymphomas and encompasses 30-40% of the total extranodal lymphomas. Approximately 60-75% of cases occur in the stomach, and then the small bowel, ileum, cecum, colon and rectum. Lymphoid neoplasms may consist of mature B, T and less commonly extranodal NK/T cells. Of these, the two most frequently encountered histologic subtypes are extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), where Helicobacter pylori infection is implicated in a number of cases, and diffuse large B cell lymphoma. Several B cell lymphomas are associated with chromosomal aberrations. Enteropathy-associated T cell lymphoma, type I in particular, usually arises in a background of celiac disease. T cell gene rearrangement confirms clonality. NK/T cell neoplasms are invariably associated with Epstein-Barr virus infection and are often aggressive; thus, differentiation from a benign NK-cell enteropathy is paramount. Although incidence of other hematopoietic malignancies in the gastrointestinal tract such as plasma cell myeloma associated with amyloidosis, plasmablastic lymphoma, Hodgkin disease, histiocytic sarcoma and mast cell sarcoma is extremely rare, these entities have been documented, with the latter two demonstrating aggressive clinical behavior. Endoscopic ultrasonography is an important adjunct in disease staging and follow-up. Conservative antibiotic treatment of stage I MALT lymphomas with associated Helicobacter pylori infection achieves good clinical outcome with high remission rate. Chemotherapy, radiation and rarely surgery are reserved for advanced diseases or cases resistant to conservative therapy and those not associated with Helicobacter pylori infection.

[2 cases of gastric mucosa-associated lymphoid tissue lymphoma presenting as a submucosal tumor-like lesion]

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is the most common form of primary extranodal lymphomas. In most cases, it is developed as multifocal and mucosal lesions, and its initial diagnosis is made by biopsy of suspicious lesions on endoscopy. However, when gastric MALT lymphoma afflict submucosal site without typical mucosal lesion, further procedures are necessary for diagnosis, such as endoscopic mucosal resection and endoscopic ultrasonography. We recently experienced two cases of submucosal tumor-like gastric MALT lymphoma. Both cases were without any mucosal lesion. One case was confirmed by endoscopic mucosal resection, and the latter was by wedge resection. Treatment modalities included endoscopic mucosal resection, surgery, H. pylori eradication, and/or chemotherapy. Both cases achieved complete remission until our 18 months' and 16 months' follow up.

Diagnosis and staging in gastrointestinal lymphoma

The diagnosis gastrointestinal lymphoma can be made on endoscopic biopsies in the vast majority of cases. Definitive subtyping of the lymphoma according to the WHO classification with the use of additional immunological and molecular markers is the cornerstone for further decision making. Several lymphomas may occur multifocally or show both small cell and large cell components. Therefore, a second endoscopy with an extensive biopsy protocol (mapping) may be mandatory. Staging procedures are required for therapeutic decision making and should include CT-scan, laboratory studies and bone marrow examination as required in other lymphomas. Additional studies must be performed depending subtype and localisation of the lymphoma. In gastric lymphoma endosonography reveals prognostic information. In marginal zone lymphoma of MALT-type attention to other MALT-sites and autoimmune diseases is necessary. In enteropathy-associated T-cell lymphoma screening for coeliac disease and enteroscopy are required. In several lymphomas (diffuse large B-cell lymphoma and mantle cell lymphoma) a PET-scan is considered as standard of care. The value of staging procedures after treatment is less well defined. At least in gastric lymphomas, histology is the gold standard after treatment and during follow-up.