Low-grade MALT Lymphoma Research Articles

Helicobacter pylori a karcinom žaludku

Helicobacter pylori belongs to the most common bacterial infections worldwide; despite its decreasing prevalence during the past four decades (currently ~ 40–50%), it is more prevalent in developing countries compared to developed ones. Intensive research of chronic Helicobacter pylori infection clarified the pathogenesis of several gastric and extragastric diseases, including different cancers. This review pointed out the role of Helicobacter pylori in different gastric malignancies. Chronic Helicobacter pylori infection is an etiological factor in non-cardia gastric cancer and most cases of low-grade MALT lymphoma of the stomach. However, there is an inverse association of Helicobacter pylori infection with other gastric malignancies, like cardia gastric cancer or rare hereditary Gastric Adenocarcinoma and Proximal Polyposis of the Stomach syndrome (GAPPS). A crucial issue has not been definitely solved yet: whether early eradication of Helicobacter pylori could prevent sporadic gastric cancer in the future? There is moderate evidence that searching for and eradicating Helicobacter pylori reduces the incidence of gastric cancer and death from gastric cancer in healthy asymptomatic infected Asian individuals, although data cannot necessarily be extrapolated to European or US populations so far. Indication for the eradication of Helicobacter pylori must now be considered with caution, on an individual basis of personalized medicine.

Low-grade malt lymphoma of the nasopharynx in young adults: Successful treatment of a rare diagnosis at a rare site by radiotherapy.

Mucosa Associated Lymphoid Tissue (MALT) lymphoma is the third most common subgroup of Non-Hodgkin's lymphoma and is the most common type of primary extranodal lymphoma. They are rarely found in the nasopharyngeal region and their mean age at presentation is the sixth decade of life. We present the clinical, pathological, treatment and 5-year follow-up data of 5 cases of nasopharyngeal MALT lymphoma treated with definitive radiotherapy at our hospital, between 2009 and 2011. The average age of diagnosis was 27 years which is more than a decade earlier than what has been reported previously. Clinical symptoms included nasal obstruction, tinnitus and hearing loss. All five patients had locoregional disease. They were treated by definitive radiotherapy to a dose between 30 to 40 Gy. At 5 years of follow-up, 4 patients were in complete remission while one had disease relapse. The younger age of presentation compared to older reports in this rare subsite was an interesting finding in our study. The authors speculate that rising levels of particulate air pollution may have played a part in the etiology in this younger population. Our series shows that despite the younger age, the disease displays an indolent course and responds well to radiotherapy alone as the primary treatment. Recurrence or disseminated disease is also highly treatable with systemic chemotherapy.

Antibiotic Resistance and Therapy for H. pylori Infection in Immigrant Patients Treated in Italy.

Background: Helicobacter pylori (H. pylori) infection is the leading cause of both peptic ulcers and gastric tumors, including low-grade MALT-lymphoma and adenocarcinoma. Although it is decreasing in developed countries, H. pylori prevalence remains high in developing areas, mainly due to low socio-economic levels, and the potential consumption of contaminated water. Moreover, a different pattern of primary antibiotic resistance is expected in their H. pylori isolates, potentially affecting the efficacy of standard eradication therapies. Indeed, a previous study showed the eradication rate following triple therapy was distinctly lower in dyspeptic H. pylori infected immigrants living in Italy as compared to Italian patients. Aims: to evaluate the resistance pattern in H. pylori isolates from immigrant patients in Italy, and the success rate of first-line therapy in these patients. Materials and Methods: This retrospective study evaluated data of consecutive immigrant patients, diagnosed with H. pylori infection in a single center (Bologna, Italy) between January 2009 and January 2019. Patients underwent first-line therapy with either sequential or Pylera® (Allergan USA, Inc. Madison, NJ, USA) therapy. Results: A total of 609 immigrants were diagnosed with H. pylori infection during the study period, but 264 previously received an eradication therapy. Therefore, the study was focused on 294 out of 345 naïve patients with a successful bacterial culture with antibiogram. Latin America immigrants had the highest overall resistance rate. Levofloxacin resistance rate was significantly higher in Latin Americans and Asians as compared with Europeans. Based on resistance patterns, sequential therapy showed a clear decreasing trend in eradication rates. Conclusions: while antibiotic resistance rates are generally increasing worldwide, Pylera® seems to achieve a good performance as first-line treatment in all naïve foreigner patients, except for Africans.

1212 H. pylori Breath Testing in an Academic Medical Center: Utilization and Treatment Outcomes

INTRODUCTION: Helicobacter pylori is a major cause of stomach and duodenal ulcers According to the 2017 American College of Gastroenterology (ACG) Clinical Guidelines, only patients with active or past Peptic Ulcer Disease (PUD), low-grade MALT lymphoma, or history of endoscopically resected early gastric cancer should be tested for H. pyloriinfection. The breath test should be performed at least 4 weeks after stopping antibiotics and at least 2 weeks after stopping PPIs. The objective of this study was to determine whether the guidelines for the use of the breath test in an internal medicine physician practice were being followed. METHODS: We evaluated all 2016 patients in an academic Internal Medicine practice who had a BreathTek® Urea Breath Test for H. pylori in 2016. Patient files were reviewed through 2018 with respect to treatment and outcomes. RESULTS: An H. pylori breath test was performed in 257 patients (191 African-American (AA); 74%) and 66 non-AA). It was most likely used for diagnostic purposes (217/257 = 84%) and more likely to be ordered by a non-gastroenterologist (non-GI) (94% vs 69%; P < 0.001). Only 2 tests were for PUD; the majority were for Acid Reflux/Dyspepsia/GERD (48%), Abdominal Discomfort (33%), or Nausea/Vomiting/Recurrence of symptoms (12%). Of the 68 patients on a PPI, the gastroenterologists (GI) were more likely to comply with the guidelines of waiting to perform the test 2 weeks later as compared to the non-GI (48% vs 23%; P < 0.05). Of the 84 patients who were positive for H. pylori and were treated, 55 were cured with treatment, 22 were lost to follow up, and 7 were not cured with treatment (89% cure per protocol). The primary treatment was triple therapy (n = 77) with Clarithromycin/Amoxicillin (Metronidazole)/PPI. Seven patients were treated with quadruple therapy (triple plus bismuth). The percent of cured patients was similar between AA (87%) and non-AA (95%). Retreatment was successful in the 3 patients who received it. CONCLUSION: The majority of breath tests were for gastric/esophageal discomfort and did not meet the recommended criteria for the test. Significant numbers of providers in this study did not wait the recommended 2 weeks following PPI usage when ordering a breath test for H. pylori. Patients responded well to treatment with antibiotic and PPI therapy regardless of race. Thus, these studies suggest that educational interventions might be useful to increase compliance with the guidelines.

Sequential H. pylori eradication and radiation therapy with reduced dose compared to standard dose for gastric MALT lymphoma stages IE & II1E: a prospective randomized trial

In Helicobacter pylori (H. pylori) positive stage I gastric low-grade MALT lymphoma, eradication is the accepted first-line therapy. The role of eradication therapy in lymphoma > stage IE is still unclear. However, about 20% of patients show persistent lymphoma following successful eradication or primary H. pylori-negative lymphoma. A prospective study for salvage radiation therapy with standard 36Gy in comparison to a reduced dose of 25.2Gy is still missing. A prospective, multicentre study investigated the efficacy of eradication in H. pylori-positive gastric low-grade MALT lymphoma stages IE and II1E (HELYX I). Refractory lymphoma or H. pylori-negative patients were treated in a prospective, randomised, multicentre, phase II study to receive either 25.2Gy or 36Gy radiotherapy (HELYX II). 102 patients (3 drop outs) were included in HELYX I: 75/99 (75.8%) showed complete remission after a median of 2.8months. 18 (18.2%) had partial remission (PR) and 6 (6.0%) no change (NC). 29 patients (7 drop outs) were randomized in HELYX II (7 primarily H. pylori-negative, 15 patients from HELYX I with refractory disease after eradication). All patients achieved stable CR irrespective of radiation dose. Both presence of the t(11,18) translocation (OR 9.0, p = 0.01) and monoclonality of the tumour cells (OR 6.3, p = 0.006) were predictors for persistant lymphoma after eradication therapy. Most H. pylori-positive low grade gastric MALT lymphoma stage IE and II1E respond with stable CR after eradication therapy. In patients with refractory disease or H. pylori negative low grade gastric MALT lymphoma a dosage-reduced radiation therapy with 25.2Gy is an effective standard dose in stage IE and II1E. ClinicalTrials.gov: NCT00154440.

Clinicopathological profile of gastrointestinal lymphomas in Kashmir.

Background:The histological categorization of lymphoma has been a source of controversy for many years for both clinicians and pathologists. Clinicopathologic information of gastrointestinal lymphomas in Indian subcontinent is lacking. We studied histopathological spectrum of Primary Gastrointestinal Lymphomas (PGIL) and attempted to classify the G.I. lymphomas based on the recent WHO classification in to major histological types and immunological categories.Material and Methods:This study was done to evaluate the clinicopathological pattern of 100 cases with a histopathological diagnosis of primary gastrointestinal lymphoma at a tertiary care hospital. All patients of primary gastrointestinal lymphomas were included with the help of medical records over a 11-years period that is, January 2005 to December 2015.Results:The study included 100 cases (60 males, 40 females; mean age 51.43 years; age range 4.5-90 years). The disease involved stomach in 82 (82%), small intestine in 8 (8%), large bowel and rectum in 8 (8%), gall bladder in 1 (1%) and oesophagus in 1 (1%). 82 (82%) of the 100 cases were Diffuse Large B cell lymphomas; 12 (12%) were Extra Nodal Marginal Zone Lymphomas (ENMZL of MALT type) 2 (2%) IPSID 2 (2%) of Mantle cell lymphoma morphology, 1 (1%) Burkitt's and 1(1%) enteropathy associated T cell lymphoma. The commonest presenting symptom was abdominal pain. 99 (99%) of 100 tumours were classified as B-cell lymphomas immunohistochemically and majority exhibited monoclonal light chain restriction on kappa/lambda staining. In addition; Burkitt's lymphoma showed positivity for CD 10. One tumour (1%) showed positivity for T-cell markers. The data demonstrated that primary GI NHL is more common among males, mainly in their fifth decade. Abdominal pain is the most common presenting symptom, with stomach being the most commonly involved site. Diffuse large cell lymphoma is the most frequent histologic subtype, followed by extranodal marginal-zone B cell lymphoma (MALT type). H. Pylori infection was observed in cases with low grade MALT lymphomas. Striking was the observation of two cases of IPSID (a disease commonly found in Mediterranean countries) and one case of enteropathy associated T cell lymphoma.Conclusion:EGD, imaging, light microscopic examination and immunohistochemical workup for B and T cell markers and staining for light chains to assist documentation of monoclonality are of precise diagnostic value in gastrointestinal lymphomas and form a part of the diagnostic workup.

Primary Gastric Low-Grade Malt Lymphoma: Evaluation of Clinical and Laboratorial Factors for Achieving Complete Remission

Introduction: Gastric mucosa associated lymphoid tissue (MALT) lymphoma, is an indolent cancer that occurs in the presence of pre-existing prolonged lymphoid proliferation in mucosal sites. In that instance, the most well established trigger is the gastric Helicobacter pylori (Hp) infection. Aim: Evaluation of clinical and laboratorial factors and the effect of therapy in achieving Complete Remission (CR) in patients with gastric MALT lymphoma. Methods: Multi centric study from a geographic area (Southern Portugal), in which clinical and pathological features of patients with gastric MALT lymphoma, according to Dawson criteria for primary gastrointestinal lymphoma, were evaluated retrospectively with a follow-up ≥ 12 months. Lugano system was used for staging. Statistical analysis was performed using Kaplan-Meyer curves and bivariate analysis with Mann-Whitney test. A p-value of ≤ 0.05 was considered statistically significant. Results: A total of 34 cases were identified, 23 men, and 11 women, with an average age of 59 years. The most common symptom was epigastric pain (74%); 6 patients presented gastrointestinal bleeding and 3 patients had type B symptoms. The most prevalent localization was gastric body; 18 patients had an ulcerative pattern at endoscopy. At diagnosis, 91% and 94% were classified as limited disease (Lugano I-II and Ann Arbor IE-IIE respectively) and 94% had an International Prognostic Index (IPI) 0.05). Conclusion: The results confirm the good prognosis and the indolence of MALT lymphoma. The variables studied couldn't predict CR in 1 year, but enhance the idea that patients with early stage Hp-negative MALT lymphoma and with advanced disease, might still benefit from antibiotic treatment.

Treatment of low-grade gastric MALT lymphoma using Helicobacter pylori eradication.

Lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of the stomach usually occurs as a consequence of Helicobacter pylori (H. pylori) infection. The aim of this study was to investigate the long-term effect of treatment of low-grade gastric MALT lymphoma with the H. pylori eradication method. In the period 2002-2012 in 20 patients with dyspepsia, mean age 55.1 years, the endoscopic and histologic diagnosis of gastric MALT lymphoma in the early stages were made. Histological preparations of endoscopic biopsy specimens were stained with hematoxyllineosin (HE), histochemical and immunohistochemical methods. Endoscopic findings of gastritis were documented in 25% of the patients, and 75% of the patients had hypertrophic folds, severe mucosal hyperemia, fragility, nodularity, exulcerations and rigidity. Histopathologically, pathognomonic diagnostic criterion were infiltration and destruction of glandular epithelium with neoplastic lymphoid cells, the so-called lymphoepithelial lesions. In all 20 patients H. pylori was verified by rapid urease test and Giemsa stain. After the triple eradication therapy complete remission of MALT lymphoma was achieved in 85% of the patients, with no recurrence of lymphoma and H. pyloi infection in the average follow-up period of 48 months. In 3 (15%) of the patients, there was no remission of MALT lymphoma 12 months after the eradication therapy. Of these 3 patients 2 had progression of MALT lymphoma to diffuse large-cell lymphoma. Durable complete remission of low-grade gastric MALT lymphoma is achieved in a high percentage after eradication of H. pylori infection, thus preventing the formation of diffuse large-cell lymphoma and gastric adenocarcinoma.

A case of Helicobactor pylori negative low-grade gastric MALT lymphoma in an elderly female, successfully treated with rituximab

Patient: Female, 91Final Diagnosis: Low-grade gastric MALT lymphomaSymptoms: Recurrent epigastric and right upper quadrant dyscomfortMedication: RituximabClinical Procedure: esophagogastroduodenoscopy • gastric biopsySpecialty: GastroenterologyObjective:Unusual or unexpected effect of treatmentBackground:Mucosa associated lymphoid tissue (MALT) lymphoma can occur in any extranodal organ or tissue, stomach being the common site. Most of the gastric MALT lymphomas are related to chronic H. pylori infection. H. pylori negative gastric MALT lymphoma is relatively uncommon and usually treated with a short course of chemotherapy, radiotherapy or surgery.Case Report:Herein, we present a case of an elderly female with H. pylori negative, low-grade gastric MALT lymphoma that was successfully treated with a short course of rituximab.Conclusions:This case report emphasizes that rituximab monotherapy can be an effective treatment for H. pylori negative low grade gastric MALT lymphoma especially in an elderly patient where surgery or radiotherapy may not be appropriate.

Dose Response to Radiation Therapy for Primary Ocular Lymphomas

Lympho proliferative lesions are the most common primary orbital malignancies. Primary lymphoma of the orbit and ocular adnexa accounts for 59 years [4]. Orbital Lymphoma (OL) commonly presents with proptosis and is typically a painless, progressive orbital lesion; however, the conjunctival lesions appear clinically as fleshy salmon patch lesions [5,6]. The treatment options are surgical excision, chemotherapy, Radiation Therapy (RT), or combination of chemoradiation. Radiation therapy alone is the most effective treatment modality for the orbital lymphoma with excellent local tumor control [7-12]. The local and systemic relapse rate was reported to be less after treatment of OL by RT due to the indolent nature of the MALT variants. Different radiation techniques and doses (with or without adjuvant chemotherapy) were used by the several authors depending on the extent of the disease and severity. Kennerdell et al. reported 100% complete response of the lymphoid lesions of the orbit and ocular adnexa with low-dose RT (24-25.5 Gy) with very few acute and chronic side effects [8]. Several authors advocated 30-40 Gy for low to intermediate grade lymphomas with good local control and better 5 year survival. In a retrospective chart review of 31 cases of orbital MALT lymphoma, Le et al. observed a complete local control of the tumor with an overall 10 year survival of 73%. However, they did not find a significant difference in the outcomes among patients treated with RT dose of ≤ 30 Gy versus the >30 Gy and recommended that RT dose of 30-30.6 Gy provides excellent local control of tumor with minimal long-term side effects [9]. Galieni et al. observed complete response to the radiotherapy in seven patients of low-grade MALT lymphoma treated with RT dose of 36-40 Gy over a median follow-up of 51 months. However, among the patients treated with chemotherapy, local relapse was observed in 3/15, which resolved completely to the local irradiation [13]. In a multi-institutional, retrospective study by Uno et al. complete tumor response was seen in 26 patients (mean RT dose 36 Gy) and partial response in 20 others (mean RT dose 37.5 Gy) [11]. The local tumor recurrence was noted in 6 of the patients with partial or no response. They concluded that the age ( 60 years), gender, location (conjunctiva versus others), laterality (unilateral versus bilateral) or the dose of radiation therapy (≤ 30 Gy versus >30 Gy) did not contribute to the local tumor recurrence and felt the initial tumor response to RT influenced the probability of local recurrence. The overall 5-year survival rate for all the patients was 91% with a median follow-up of 46 months. Fung et al. noted 4 cases with local recurrence of the 98 cases of MALT lymphoma. Three of the 4 had stage I disease (primary orbital tumor treated with RT dose of 30 Gy) [7]. The systemic relapse-free survival rate among the stage I MALT lymphoma patients which comprise major group in their study was 75% at 5 years and the overall 5-year survival rate was 95%. However for the stage III-IV MALT lymphoma in the same study the 5 year disease specific survival rate was 49% and the overall survival rate was 39%. To summarize, excellent local tumor control rates were observed with radiation therapy with doses 2430 Gy in most studies.

Helicobacter pylori in immigrants: a “foreign” bacterium?

Helicobacter pylori infection is a worldwide spread disease with a definite morbidity and mortality. Indeed, the bacterium is the leading cause of both peptic ulcers and gastric tumors, including low-grade MALT-lymphoma and adenocarcinoma [1]. Although H. pylori prevalence is decreasing in developed countries, it remains very high in developing countries. Low socio-economic and educational levels, living in a family with a high number of siblings, and use of external water have been identified as risk factors for infection onset [2]. Moreover, in some countries, such as Chile and Peru, H. pylori has been isolated from municipal water, while it is absent in the developed countries [3]. Since the infection persists long-life, if not opportunely treated, infected patients who move from a developing country retain the infection also in the developed countries. There is evidence that H. pylori acquisition in developing countries occurs early in childhood, and, therefore, subjects in these geographic areas are at increased risk of developing gastroduodenal lesions despite young age. The recent study by Gatta et al. [4] shows that immigrant patients from East Europe who undergo upper endoscopy for dyspeptic symptoms have a significantly higher prevalence of peptic ulcer as compared to Italian patients (54 vs. 29%), despite a lower median age (39 vs. 55 years). How can we interpret such a finding? As above mentioned, this could depend on the early acquisition of infection in these patients. Alternatively, immigrants may be infected with more virulent—i.e. cagA-positive [5]— H. pylori strains more frequently than Italian patients. However, a potential selection bias in patients enrollment in this study cannot be excluded. For example, due to cost for both endoscopy and histology, it is possible that immigrants will be convinced on the necessity for endoscopy only when either dyspeptic symptoms become more intense or persistent, or alarm symptoms occur, such as bleeding or persistent vomiting due to an ulcer complication. Unfortunately, the prevalence rate of alarm symptoms in neither immigrants nor Italians is not reported in the manuscript. Unexpectedly, peptic ulcer prevalence in this study would appear very high (29%), even in the Italian dyspeptic patients. Indeed, in previous studies performed in the same geographic area, peptic ulcer prevalence is cited as 6.3–17% [6, 7]. Moreover, a prevalence rate as low as 2.7% on 11,148 consecutive upper endoscopy procedures is reported in a recent study performed in Rome [8]. In addition, in the study by Gatta et al. [4], a very similar prevalence of either duodenal (DU) or gastric ulcer (GU) is observed both in Italian (15.2 vs. 13.4%) and in immigrant (29.3 vs. 25%) patients. This would be in contrast with the higher prevalence of DU as compared to GU widely reported in literature (DU vs. GU = 3:1) [6]. As the Authors point out, the significance of all these findings remains unclear. Another relevant finding in the study by Gatta et al. [4] is that H. pylori eradication rate following standard, 7-day triple therapy is disappointingly low. In detail, 1 of every 3 Italian, and 1 of every 2 immigrant patients remain infected despite therapy. As the authors suggest, the lower efficacy of eradication therapy in immigrants may depend on a higher antibiotic resistance. However, a recent study performed in Bulgaria shows a 15.4% primary clarithromycin resistance rate [9], a value very similar to the 16.9% quoted in Italy [10]. Moreover, the therapeutic regimen chosen by Gatta et al. [4] did not include metronidazole for which A. Zullo (&) F. Cristofari M. C. Bragazzi C. Hassan Gastroenterology and Digestive Endoscopy, ‘‘Nuovo Regina Margherita’’ Hospital, Via E. Morosini, 30, 00153 Rome, Italy e-mail: zullo66@yahoo.it

Proteomic Helicobacter pylori biomarkers discriminative of low‐grade gastric MALT lymphoma and duodenal ulcer

To date no reliable diagnostic method exists to predict, among the very large and clinically heterogeneous group of Helicobacter pylori-infected patients, the extremely small group at risk for developing low-grade gastric MALT lymphoma (LG-MALT). Search of proteomic biomarkers holds promise for the classification of the H. pylori strains with regard to this severe clinical outcome. In the present study 69 H. pylori strains isolated from patients with two different H. pylori-associated diseases, duodenal ulcer (DU, n=29) and LG-MALT (n=40) were used. Protein expression patterns of the strains were analyzed by using the high-throughput methodology SELDI. Selected proteins were purified by means of chromatographic and electrophoretic methods in view of further sequencing by LC-MS/MS. Univariate analysis (Mann-Whitney test) of the protein expression patterns generated nine significant biomarkers that can discriminate between H. pylori strains from patients with DU and LG-MALT. These biomarkers are of low molecular weight, ranging from 6 to 26.6 kDa. Among them, two are overexpressed in LG-MALT strains and seven - in DU strains. Two biomarker proteins, one overexpressed in LG-MALT strains (13.2 kDa) and another one - overexpressed in DU strains (26.6 kDa), were purified to homogeneity and identified by using LC-MS/MS as a 50S ribosomal protein L7/L12 and a urease subunit, respectively. These biomarkers can be included in novel protein arrays for the differential diagnosis of H. pylori-associated clinical outcomes.

781 Effect of Celecoxib On the Suppression of Gastric Low-Grade MALT Lymphoma Induced By Helicobacter heilmannii Infection

781 Effect of Celecoxib On the Suppression of Gastric Low-Grade MALT Lymphoma Induced By Helicobacter heilmannii Infection

Clinicopathologic Study of Chromosomal Aberrations in Gastric Lymphomas of Korean Patients

Background : The incidence and clinical correlation of MALT1 translocation and numerical aberrations in Korean gastric MALT lymphoma patients have been rarely reported. We studied the incidence and clinicopathologic relationship of these chromosomal aberrations in Korean gastric lymphomas. Methods : Seventy-six gastric lymphomas, which consisted of 40 low grade MALT lymphoma, 4 high grade MALT lymphoma and 32 diffuse large B-cell lymphoma (DLBCL) cases, were analyzed for the detection of t(11;18) API2-MALT1, t(14;18) IgH-MALT1 and aneuploidies of chromosomes 3 or 18 using fluorescence in situ hybridization. Results : The t(11;18) was demonstrated in 3 low grade MALT lymphomas (7.5%) and one DLBCL, which was associated with advanced stage, deeper invasion, and disease progression or relapse. The t(14;18) was demonstrated in none of these cases. Trisomy 3 and 18 were detected in 8 (11%) and 11 of 76 cases (12.5%) respectively, and found only in translocation-negative cases. Two of 4 high grade MALT lymphomas showed trisomy 18. All patients survived with successful second treatment after progression or relapse. Conclusions : The t(11;18) API2-MALT1 was not quite frequent in Korean low grade gastric MALT lymphomas and was associated with advanced clinical situations. Overall prognosis was good for long-term follow-up regardless of progression or relapse.

Clinical, histopathological and immunohistological study of lymphoid disorders in the parotid gland of patients with Sjögren's syndrome

Sjögren's syndrome is a chronic autoimmune systemic disease characterized by polyglandular tissue destruction, leading to keratoconjunctivitis sicca and xerostomia. These patients have 44-fold increased risk of developing salivary gland lymphoma, of which 80% are marginal zone (MALT) type. Having in mind that criteria for distinguishing benign lymphoepithelial lesions from MALT lymphoma are obscure, the aim of this study was to provide practical information that could be integrated into diagnostic practice. Among 32 parotidectomies, 27 cases were identified as having benign lymphoepithelial disorders and 5 cases low grade MALT lymphoma. Histological sections were stained routinely with hematoxylin and eosin (H&E and special stains. Immunohistochemical study was performed by LSAB2 method, by using primary antibodies for CD20, CD3, Kappa and Lambda light chains and Cytokeratin (Dako Denmark). The 27 patients with Sjögren's sialoadenitis (22 women and 5 men), and 5 patients with MALT lymphoma (only women) were included in this analysis. According to the Ann Harbor Classification, all patients with MALT lymphoma had stage IE. Both groups of patients had an indolent clinical course, except permanent, rapid parotid enlargement in the patients with MALT lymphoma. Histologically, the periductal lymphoid infiltrate, gradually extended to the acini, completely replacing them by a sea of polyclonal lymphocytes, immunoblasts, germinal centers and plasma cells (confirmed immunohistochemically), but sparing the ducts and preserving lobular appearance. The histological feature of salivary gland MALT lymphoma included heterogeneous B-cell infiltrate that totally or subtotally had effaced the normal glandular structure. Malign lymphoepithelial lesions, representing infiltration of the ductal and epithelial structures by monoclonal neoplastic B-cells, positive for CD20, were highlighted by antibody to cytokeratin. The optimal diagnosis of salivary gland MALT lymphoma requires careful integration of clinical, morphological and immunohistochemical results.

Management and long-term follow-up of early stage H. pylori-associated gastric MALT-lymphoma in clinical practice: An Italian, multicentre study

Data on management and long-term follow-up of Helicobacter pylori-associated MALT-lymphoma in clinical practice are scanty. We evaluate the long-term efficacy of H. pylori eradication on low-grade MALT-lymphoma, and the efficacy of further therapies in refractory patients. This study enrolled patients with stages I-II(1) MALT-lymphoma and H. pylori infection. H. pylori eradication was attempted in all patients. Patients with lymphoma persistence or progression following H. pylori treatments received further lymphoma treatments. Both 5-year and disease-free survivals were calculated. Sixty patients (stage I/II(1): 50/10) were followed up for a median time of 65 months (range 7-156). H. pylori infection was successfully eradicated in 53 (88.3%) patients following three consecutive therapeutic attempts, and lymphoma regressed in 42 (79.2%) of these patients. Sixteen patients received anti-neoplastic treatments due to either lymphoma persistence or progression, and lymphoma was cured in 14 (87.5%) cases. At follow-up, lymphoma relapsed in 13/42 (30.9%) patients within a median time of 19 months (range 3-41), and all but 1 patient were cured with further therapies. Overall, lymphoma regression was achieved in 56 patients (93.3%). The 5-year and disease-free survivals were 94.7% and 74.6%, respectively. In clinical practice, a conservative approach with antibiotic eradication seems to be appropriate management for early-stage MALT-lymphoma, with oncologic therapy being reserved for those patients who fail to respond to H. pylori therapy.

Weekly clinico-pathological meetings: Utility or futile exercise?

17518 Background: The histopathological diagnosis is the backbone of oncology diagnosis. Errors in these reports can critically affect patient care. At our institute, weekly clinico-pathological meetings are held and attended by faculty and residents of pathology and medical oncology. We analyzed consecutive cases of lymphoma which were discussed in these meetings over a period of 16 months from September 2005 to December 2006 to assess the impact of these meetings in improving diagnostic accuracy. Methods: We retrieved the medical case records of those lymphoma cases discussed in these meetings over the specified time period. Primary pathological diagnosis was compared with diagnosis after discussion. Change in diagnosis was categorized as major if it caused change in treatment plan and as minor if it caused no change in treatment plan. Results: We analyzed fifty cases of lymphoma out of which thirty five cases were of Non- Hodgkin lymphoma and fifteen cases were of Hodgkin disease. Reason for listing for discussion in thirty two cases was for confirmation of pathological diagnosis, for sub typing or grading in fourteen cases and four cases were discussed as no diagnosis was given in primary pathological report. In thirty three (66%) cases, there was no change in diagnosis after discussion, eight (16%) cases had minor changes regarding sub typing or grading not leading to any change in treatment plan and nine (18%) cases had major changes. Among nine major changes we could establish diagnosis in four cases (three Hodgkin disease and one Non Hodgkin lymphoma) for which no diagnosis was available in primary pathology report. Five diagnosis were changed, one from Hodgkin disease to Anaplastic large cell lymphoma, one from T cell non Hodgkin lymphoma to Hodgkin disease, two from diffuse large B cell lymphoma to low grade follicular lymphoma and one diagnosis was amended from B cell NHL to low grade MALT lymphoma. Conclusions: Weekly clinico-pathological meetings allow early revision and refinement of patient diagnosis and management. The process facilitates interaction between clinicians and pathologists and also provides a valuable educational forum. No significant financial relationships to disclose.

Helicobacter pylori eradication therapy: indications, efficacy and safety

Background: Helicobacter pylori infects up to half of the world's population. It remains the major cause of peptic ulcer disease and is recognised as a carcinogen for its role in gastric carcinogenesis. Successful eradication of the bacteria is associated with improved health outcomes including fewer dyspeptic symptoms, reduced peptic ulcer recurrence and rebleeding, reduced peptic ulcer risk with NSAIDs and as a cure for low-grade gastric MALT lymphoma. The risk of gastric cancer is reduced in those without premalignant mucosal abnormalities at the time of eradication. Objective: This review outlines the current indications and options for therapy of H. pylori with particular reference to drug-induced adverse events associated with treatment. Methods: The indications for H. pylori eradication are evidence-based and in accordance with recent consensus statements and recommendations. The eradication treatment is based on numerous clinical trials and meta-analyses. Results/conclusion: Eradication therapy, in general, is safe and well tolerated. Antibiotic therapy may be associated with significant drug adverse reactions, especially gastrointestinal symptoms.

426 Overexpression of MicroRNA-142 and −155 in API2-MALT1-Positive Gastric Low-Grade MALT Lymphoma

426 Overexpression of MicroRNA-142 and −155 in API2-MALT1-Positive Gastric Low-Grade MALT Lymphoma

MALT Lymphoma of the Duodenum: A Rare Cause for Upper Gastrointestinal Bleeding and Pancreatitis

Purpose: Mucosa associated lymphoid tissue lymphoma of the duodenum represents a rare neoplasm. A review by Xiang et al[i] in 2004 highlighted only 17 previous cases of duodenal MALT lymphoma in the English literature. We report another rare case of duodenal MALT lymphoma. A 56 y.o. female presented with upper GI bleeding and acute pancreatitis. Upper endoscopy demonstrated an irregular ulceration in the second portion of the duodenum (Fig. 1). Endoscopic biopsies revealed acute and chronic inflammation. An abdominal CT scan demonstrated significant circumferential mural thickening involving the second portion of the duodenum and evidence of pancreatitis. Despite unremarkable endoscopic biopsies, the irregular appearance of the ulcer and CT findings raised suspicion of underlying malignancy. The surgical service performed an exploratory laparatomy. A nodular mass in the second portion of the duodenum extending into the pancreas was noted. Biopsy of the mass revealed a low grade MALT lymphoma. The patient recovered from her episode of pancreatitis and started radiation therapy. Patel et al.[ii] have previously reported a patient with duodenal MALT lymphoma with pancreatic infiltration. However, this is the first report of pancreatitis from the extension of a duodenal MALT lymphoma. This case hopes to expand the current knowledge of the possible presentations of this rare entity. [i] Xiang Z, Onoda N, Ohira M et al. Mucosa-associated lymphoid tissue lymphoma of the duodenum: a report of a case resistant to Helicobacter pylori eradication. Hepatogastroenterology 2004; 51(57): 732–5. [ii] Patel VG, Eltayeb OM, Henderson VJ et al. Primary duodenal low-grade mucosa-associated lymphoid tissue lymphoma presenting with outlet obstruction. American Surgery. 2004; 70(7): 613–6.[figure1]Figure