CASE REPORT

The authors present the case of a 56-year-old female patient with a history of smoking, referred for upper endoscopy due to dyspepsia associated with vomits and weight loss (12Kg in 6 months). Laboratory study revealed no abnormalities. Upper endoscopy revealed erythema and thickening of the gastric folds, more apparent in the distal body, associated with atrophic gastropathy of the antrum (Figure 1). Biopsies of the body and antrum were performed.

Endoscopic ultrasound (EUS) was performed and revealed a diffuse and concentric wall thickening (10mm) of the gastric body, with loss of the pentalaminar structure, despite maintenance of cleavage plain with adjacent structures (Figure 2). The remaining gastric segments revealed no abnormalities in EUS. Neither abnormal peri gastric lymph nodes nor ascites were detected.

Histology revealed fragments of gastric mucosa with chorion expansion, infiltrated by a population of small lymphocyte cells with irregular nucleus (Figure 3). Helicobacter pylori was found in the specimen. Immunohistochemistry revealed strong expression of CD20 and CD79a without expression of CD5 or cycline D1.

WHAT IS THE MOST LIKELY DIAGNOSIS?

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DISCUSSION

These findings are compatible with gastric MALT lymphoma IE2 (Ann Arbor staging system). Gastric MALT lymphoma comprises about 50% of primary gastric lymphomas (PGL) and up to 90% of PGL are either MALT or DLBCL [1].

Endoscopy combined with multiple biopsies is considered the gold standard in the diagnosis of gastric MALT lymphoma [2]. However, EUS is considered the method of choice for locoregional staging, including the detection of affected peri gastric lymph nodes [3]. This is of great importance since locoregional staging is one of the major factors that can predict the response to treatment. EUS findings in gastric MALT lymphoma may vary from a thickening of the inner two or three layers to a diffuse wall thickening, with or without preservation of the typical 5-layer structure [3]. Furthermore, it has to be highlighted that EUS pattern may correlate with the histologic subtype of primary gastric lymphoma [4]. Indeed, superficial spreading or diffuse-infiltrating lesions on EUS were associated with MALT lymphoma, while mass-forming lesions were associated with gastric DLBCL.

Current evidence favors the use of Helicobacter pylori eradication regimens as the first-line treatment in Helicobacter pylori positive patients irrespective of tumor stage [5]. Additional therapeutic options with favorable efficacy may include radiotherapy, chemotherapy, or immunotherapy [5].

REFERENCES

1. Janssen J. The impact of EUS in primary gastric lymphoma. Best Practice & Research. Clinical Gastroenterology. 2009;23(5):671–678. doi: 10.1016/j.bpg.2009.05.008
2. Zucca E., Dreyling M., Group EGW Gastric marginal zone lymphoma of MALT type: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2010;21(Supplement 5):v175–v176
3. Vetro C., Chiarenza A., Romano A., et al. Prognostic assessment and treatment of primary gastric lymphomas: how endoscopic ultrasonography can help in tailoring patient management. Clinical Lymphoma, Myeloma & Leukemia. 2014;14(3):179–185. doi: 10.1016/j.clml.2013.10.010
4. Suekane H., Iida M., Yao T., Matsumoto T., Masuda Y., Fujishima M. Endoscopic ultrasonography in primary gastric lymphoma: correlation with endoscopic and histologic findings. Gastrointestinal Endoscopy. 1993;39(2):139–145
5. Zucca E., Copie-Bergman C., Ricardi U., et al. Gastric marginal zone lymphoma of MALT type: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Annals of Oncology. 2013;24(Supplement 6):vi144–vi148. doi: 10.1093/annonc/mdt343

AUTHORS

Ferreira-Silva J¹, Moutinho-Ribeiro P¹, Fonseca E², Macedo G¹.

1. Gastroenterology Department, Centro Hospitalar Universitário de São João, Portugal.
2. Pathology Department, Centro Hospitalar Universitário de São João, Portugal.