Treatment Of Gastric MALT Lymphoma Research Articles

胃MALTリンパ腫の診断と治療

胃MALTリンパ腫の診断と治療

An Unusual Presentation of HCV-Associated Gastric MALT Lymphoma

Extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT Lymphoma) is a form of non-Hodgkin's lymphoma(NHL), commonly found in the gastrointestinal tract. The average age of diagnosis is between fifth and seventh decade. MALT Lymphomas are well documented to be associated with chronic inflammation of either autoimmune or infectious etiology. Chronic Helicobacter Pylori (H. Pylori) is associated with approximately 90% of the affected gastric MALT Lymphoma. Treatment of H. Pylori with regimen of antibiotics and PPI associated gastric Maltomas has an approximately 70% cure rate. While there are no current guidelines for management of patient who are H. Pylori negative, recognition and resolution of the underlying inflammatory process is paramount. 34-year-old man with no medical history presented after a syncopal event with tachycardia, hypotension, and black stool on exam. Reported fatigue for several hours preceding the event. Labs were notable for Cr of 1.6, total protein 7.3, albumin 2.5, and Hgb of 3.1. TSH and free T4 were both within normal limits. CT revealed a gastric ulcer 1.2x1.0 cm. Once patient was stabilized, EGD revealed a 4cm non-bleeding necrotic gastric ulcer and a 1cm clean based gastric ulcer. Pathology results read as MALT lymphoma with negative H. Pylori on immunochemistry. Subsequent lab work revealed Hepatitis C viral load of 744,000 IU/ml. Unfortunately, patient left the hospital against medical advice prior to finalized pathology report. A year later he presented again after another syncopal episode. Repeat EGD revealed a 10cm Gastric H. Pylori Negative MALT Lymphoma. The patient left against medical advice again. Gastric MALT lymphomas present with non-specific symptoms including abdominal pain, loss of appetite, and weight loss. Occult blood loss is a reported symptom in less than 20% of cases. In our case, gastric MALT lymphoma is diagnosed on EGD as part evaluation of these non-specific complaints. Given negative histology for H. Pylori from two separate EGDs, gastric MALT lymphoma was likely secondary to chronic HCV.His age, HCV association, negative H.Pylori, and presenting complaint of syncope are all very atypical for gastric MALT Lymphoma. While antibiotics are curative in H. Pylori positive MALT Lymphoma, treatment of active HCV in our patient may not be curative treatment of gastric MALT lymphoma. Additional conventional approaches like surgery, chemotherapy and radiotherapy may be required.2611_A Figure 1. Necrotic Gastric Ulcer2611_B Figure 2. 10cm Gastric MALT Lymphoma

Treatment of Gastric MALT Lymphoma Utilizing a Magnetic Resonance Image Guided Radiation Therapy (MR-IGRT) System: Evaluation of Interfractional Target Motion

Treatment of Gastric MALT Lymphoma Utilizing a Magnetic Resonance Image Guided Radiation Therapy (MR-IGRT) System: Evaluation of Interfractional Target Motion

TU‐AB‐BRA‐10: Treatment of Gastric MALT Lymphoma Utilizing a Magnetic Resonance Image‐Guided Radiation Therapy (MR‐IGRT) System: Evaluation of Gating Feasibility

Purpose:To evaluate the feasibility of real‐time, real‐anatomy tracking and gating for gastric lymphoma patients treated with magnetic resonance image‐guided radiation therapy (MR‐IGRT)Methods:Over the last 2 years, 8 patients with gastric lymphoma were treated with 0.3‐T, Co‐60 MR‐IGRT. Post‐treatment analysis of real‐time cine imaging in the sagittal plane during each patient's treatment revealed significant motion of the stomach. While this motion was accounted for with generous PTV margins, the system's capability for real‐time, real‐anatomy tracking could be used to reduce treatment margins by gating. However, analysis was needed for the feasibility of gating using only the single available sagittal imaging plane. While any plane may be chosen, if the stomach moves differently where it is not being observed, there may potentially be a mistreatment. To that end, imaging with healthy volunteers was done to ascertain stomach motion over 2–4 min by analyzing multiple parallel sagittal and coronal planes 0.75 cm apart. The stomach was contoured on every slice, and the mean displacement between pairs of contour centroids was used to determine the amount of overall motion.Results:The mean displacement of the centroid in the image plane was 4.3 ± 0.7 mm. The greatest observed motion was more medial with respect to the patient, and less motion laterally, which implies that gating on a plane located closer to MRI isocenter will provide the more conservative scenario as it will turn the radiation delivery off when the stomach is observed to move outside a predetermined boundary.Conclusion:The stomach was observed to move relatively uniformly throughout, with maximum extent of motion closer to where most MRI systems have the best spatial integrity (near isocenter). Analysis of possible PTV margins from the healthy volunteer study (coupled with previous patient data on interfraction volumetric stomach deformation) is pending.

Intensity Modulated Radiation Therapy Using Frontal Technique With Active Breathing Control in the Treatment of Gastric MALT Lymphoma: Implications for Normal Tissue Sparing

Intensity Modulated Radiation Therapy Using Frontal Technique With Active Breathing Control in the Treatment of Gastric MALT Lymphoma: Implications for Normal Tissue Sparing

Tu1264 Could Target Controlled Infusion Technology (TCI) Facilitate Access to Propofol Sedation by Gastroenterologist? Preliminary Results of a Randomized Double Blind Controlled Trial

the author during January-April 2012. Peristaltic movement was judged by observation in the antrum of the stomach for 20 min (none, mild, and severe: severe indicates peristalsis involving the pylorus). Next, 20 mL of the l-menthol preparation was dispersed on the antrum, and observations were conducted again for 20 min to evaluate the inhibitory effect on peristalsis and the effect on tumor identification (whether tumors are found after dispersion of the l-menthol preparation). In addition, the efficacy in borderline determination was evaluated by dispersing the l-menthol preparation on tumors when borderline determination was difficult in cases where tumors had already been diagnosed. Results: Patients were 66.7 years of age on average (27-88), and the male:female ratio was 81:43. The background gastric mucosa consisted of 78.2% atrophic gastritis, 46.8% before/after the treatment of malignant gastric tumors (58/124; 39 after gastric cancer ESD/EMR, 9 before the treatment of gastric cancer, 9 after the treatment of gastric MALT lymphoma, and 1 during chemotherapy of gastric cancer). Peristaltic movement after the dispersion of the l-menthol preparation was: 37.1% none, 13.7% mild, and 49.2% severe. The inhibitory effect on peristalsis after dispersion was: total inhibition in 49.2%, partial inhibition in 6.5%, originally no peristalsis (none) in 37.1%, and no effect in 7.3%. The scope passed through the pyloric ring smoothly in 94.4%. In addition, peristalsis was inhibited completely after the dispersion of the l-menthol preparation in 77.0% of patients with severe peristalsis (47/61). Tumors were newly found in two cases in the antrum after dispersion (0-IIc tub1 and 0-IIa-like adenoma). Moreover, the author experienced three cases (2 corpus IIc and 1 antrum IIc) in which the borderline was clarified by dispersion of the preparation directly on the tumor when it was difficult to determine the borderline of tumors. Conclusion: The lmenthol preparation was effective not only for the inhibition of gastric peristalsis but also for identification and borderline determination of gastric tumors. Presumably, it is also superior because of its simplicity and convenience. It requires no highlighting of imaging such as those for NBI or magnification.

High Levels of FOXP3+ Regulatory T Cells in Gastric MALT Lymphoma Predict Responsiveness to Helicobacter pylori Eradication

Although Helicobacter pylori eradication is a first-line treatment of gastric MALT lymphoma, roughly 25% of patients do not respond to treatment. CD4⁺ FOXP3⁺ regulatory T (Treg) cells regulate immune responses in physiological conditions and various inflammatory conditions, including H. pylori-associated diseases. Our goal was to determine how Treg cells affect responsiveness to H. pylori eradication therapy. We performed dual immunohistochemistry for CD4 and FOXP3 to evaluate the prevalence of FOXP3⁺ Treg cells in the stomach of 63 patients with MALT lymphoma and 55 patients with chronic active gastritis. Receiver operating characteristic analysis was carried out to determine the best cut-off point in differentiating H. pylori eradication responders from nonresponders. Both the FOXP3⁺/CD4⁺ cell ratio and the absolute number of FOXP3⁺ cells per high-power field in MALT lymphoma were significantly greater in H. pylori eradication responders compared with nonresponders, suggesting that Treg cells function in regression mechanisms of MALT lymphomas. Cut-off points with good sensitivities and specificities were obtained to predict eradication outcome. A high number of Treg cells or a high ratio of Treg cells to the total number of CD4⁺ T cells in gastric MALT lymphoma could predict responsiveness to eradication therapy.

Remission of acquired von Willebrand syndrome after successful treatment of gastric MALT lymphoma

Remission of acquired von Willebrand syndrome after successful treatment of gastric MALT lymphoma

Chlamydia or Not Chlamydia , That Is the Question: Which Is the Microorganism Associated With MALT Lymphomas of the Ocular Adnexa?

In the mid-1990s, the demonstration that Helicobacter pylori infection is a risk factor for gastric marginal-zone B-cell lymphoma of MALT type (MALT lymphoma) and the fi nding that eradication of these bacteria can result in histological lymphoma regression in most patients made this tumor a popular model of antigen-driven lymphomagenesis ( 1 ) . The association of H. pylori with gastric MALT lymphoma led to the hypothesis that the microorganism provides an antigenic stimulus that sustains the growth of the lymphoma in the stomach, and today it is generally accepted that administration of antibiotics to eradicate H. pylori should be the sole initial treatment of gastric MALT lymphoma that is confi ned to the gastric wall. This approach has been validated in more than 20 reported studies ( 2 ) . These advances in the understanding and treatment of gastric MALT lymphoma pro mpted a search for microorganisms responsible for the growth of MALT lymphomas outside the stomach. Although Borrelia burgdorferi and Campylobacter jejuni have been associated with marginal-zone lymphomas arising in the skin and small intestine, respectively ( 3 , 4 ) , results implicating particular infectious microorganisms in nongastric lymphomas have often been elusive. In 2004, Ferreri et al. ( 5 ) reported in this journal that Chlamydia psittaci DNA was detected in 87% of lymphomas arising in the ocular adnexa (orbital soft tissue, lachrymal glands, and conjunctiva), and therefore, it has been proposed that C. psittaci infection may be a cause of these lymphomas. Furthermore, a very recent epidemiologic paper has shown a possible real increase in the incidence of ocular adnexal lymphomas, suggesting C. psittaci or another microorganism as possible causative agents ( 6 ) . However, subsequent to the report of Ferreri et al., other groups analyzed the prevalence of C. psittaci in these lymphomas, and overall, the reported data did not confi rm a strong link between C. psittaci infection and ocular adnexal MALT lymphomas ( Table 1 ). Thus, our understanding of the role of C. psittaci is far from complete. In this issue of the Journal, Ferreri et al. ( 7 ) report the results of a prospective trial in which patients affected by marginal-zone B-cell lymphoma of the ocular adnexa were treated for 3 weeks with the oral antibiotic doxycycline, with the intent of eradicating C. psittaci. The endpoints of the study were the rate of objective lymphoma response to antibiotic treatment and the presence or absence of C. psittaci DNA in peripheral blood mononuclear cells, the latter endpoint serving as a measure of C. psittaci eradication. Twenty-seven patients were enrolled and evaluated for response to treatment, 15 of them were newly diagnosed with ocular adnexal lymphoma and 12 had relapsed after previous therapies. Three patients had lymphoma involving regional lymph nodes and fi ve had bilateral MALT lymphomas. Preliminary results in the fi rst nine cases of the study have previously been published ( 8 ). C. psittaci was detected, using, as in the previous studies, a touchdown enzyme time release polymerase chain reaction ( 5 , 7 – 8 ) in 11 of 27 or 41% of lymphoma biopsies, a percentage lower than in the fi rst report from the same investigators

Diagnosis and treatment of gastric MALT lymphoma

Diagnosis and treatment of gastric MALT lymphoma

Early Cancer of the Stomach Arising after Successful Treatment of Gastric MALT Lymphoma in Patients with Autoimmune Disease

Background: Extranodal marginal zone B-cell lymphoma of the mucosa associated lymphoid tissue (MALT lymphoma) arises in lymphoid tissue acquired through chronic antigenic stimulation as exemplified by Helicobacter pylori. Secondary development of gastric cancer, however, is thought to be a rare event. The detection of a signet ring cell carcinoma during follow-up endoscopy after successful therapy of MALT lymphoma in a patient with Sjogren's syndrome prompted us to analyse the frequency of subsequent gastric cancer in patients with underlying autoimmune disease (AD). Methods: Patients with early stage MALT lymphoma and an underlying AD were evaluated for the occurrence of a secondary gastric cancer during the course of follow-up. Data analysed included the type of AD, stage of MALT lymphoma, H. pylori status, treatment for MALT lymphoma and response, follow-up, the presence of a secondary cancer, and time to development of cancer. In all patients, histologic samples were reassessed for the extent of gastritis, presence of intestinal metaplasia or focal atrophy at the time of lymphoma diagnosis. Results: A total of eight patients with overt AD at the time of diagnosis of MALT lymphoma were identified. All patients were women aged between 56 and 77 years; 5 had Sjogren's syndrome, 2 had autoimmune thyroiditis (1 along with psoriasis) and 1 suffered from polymyalgia rheumatica. All patients had early stage MALT lymphoma restricted to the mucosa and submucosa at the time of diagnosis, and the presence of H. pylori was found in all cases. Two of these patients achieved complete remission (CR) of the lymphoma following H. pylori eradication, while six were judged unresponsive and underwent chemotherapy, resulting in CR in all cases. One patient died from stroke while being in CR for 2 months following chemotherapy. Two patients (25%) developed early cancer limited to the gastric mucosa while being in CR from lymphoma for 9 and 27 months, respectively, and underwent partial gastrectomy. Final staging of gastric cancer revealed pTlpNOMO in both cases. Of the remaining 5 cases, 1 patient had a local lymphoma relapse 18 months after CR and was salvaged with radiotherapy. In the remaining 4 patients, no evidence of lymphoma recurrence or a second malignancy has been found so far by regular follow-up every 3 months for a time-span between 52 and 63 months after initial diagnosis. Conclusion: Patients with concurrent MALT lymphoma and an underlying autoimmune condition show not only an impaired response to H. pylori eradication but might also be at increased risk for the development of gastric cancer. In view of this, such patients should be followed closely by regular endoscopies after remission of MALT lymphoma.

Treatment of gastric MALT lymphoma by Helicobacter pylori eradication: a study controlled by endoscopic ultrasonography.

Previous studies have demonstrated a link between Helicobacter pylori infection and low grade B-cell gastric MALT lymphoma. The aim of this study was to evaluate the effect of Helicobacter pylori eradication in 17 patients with low grade B-cell gastric MALT lymphoma stage EI. For disease staging EUS and CT scan were systematically performed. Eight patients were excluded from the present series because stage EII disease was diagnosed. To demonstrate B-cell monoclonality, immunohistochemistry and polymerase chain reaction were used. H. pylori eradication was performed with triple therapy. H. pylori was eradicated in all patients after first (n = 15) or second line (n = 2) treatment. Histologic regression of lymphoma was observed in all patients after a median period of 2 mo. Disappearance of monoclonality according to polymerase chain reaction took significantly longer (7 mo). At the end of the study, four of 16 patients still exhibited persistent monoclonal bands. Relapse of lymphoma occurred in two patients associated with H. pylori reinfection/recrudescence. Eradication of H. pylori seems to be an effective therapy in patients with stage EI gastric MALT lymphoma, although long-term results are still uncertain. Endoscopic ultrasonography is useful for a more accurate staging of the disease. The clinical significance of detecting monoclonality by polymerase chain reaction remains to be determined.

Treatment of gastric MALT lymphoma by Helicobacter pylori eradication: a study controlled by endoscopic ultrasonography

Objective: Previous studies have demonstrated a link between Helicobacter pylori infection and low grade B-cell gastric MALT lymphoma. The aim of this study was to evaluate the effect of Helicobacter pylori eradication in 17 patients with low grade B-cell gastric MALT lymphoma stage EI. Methods: For disease staging EUS and CT scan were systematically performed. Eight patients were excluded from the present series because stage EII disease was diagnosed. To demonstrate B-cell monoclonality, immunohistochemistry and polymerase chain reaction were used. H. pylori eradication was performed with triple therapy. Results: H. pylori was eradicated in all patients after first (n = 15) or second line (n = 2) treatment. Histologic regression of lymphoma was observed in all patients after a median period of 2 mo. Disappearance of monoclonality according to polymerase chain reaction took significantly longer (7 mo). At the end of the study, four of 16 patients still exhibited persistent monoclonal bands. Relapse of lymphoma occurred in two patients associated with H. pylori reinfection/recrudescence. Conclusion: Eradication of H. pylori seems to be an effective therapy in patients with stage EI gastric MALT lymphoma, although long-term results are still uncertain. Endoscopic ultrasonography is useful for a more accurate staging of the disease. The clinical significance of detecting monoclonality by polymerase chain reaction remains to be determined.