Gastric Lymphoma. EL SALVADOR ATLAS of Gastrointestinal VideoEndoscopy

This is the case of a 44 year-old male who previously had two endoscopies practiced with another college, the first one due to epigastric pain, that Endoscopy showed two ulcerated nodules at the antrum, biopsies displayed helicobacter pylori and a gastric lymphoma, after the eradication of H pylori the two nodules have been regressed. 3 months after the patient ask for second opinion, we performed this Endoscopy presented in this atlas.

Video Endoscopic Sequence 1 of 12.

This is the case of a 44 year-old male who previously had
two endoscopies practiced with another collegue, the first
one due to epigastric pain, that endoscopy showed two
ulcerated nodules at the antrum, biopsies displayed
helicobacter pylori and a gastric lymphoma, after the
eradication of H pylori the two nodules have been
regressed. 3 months after the patient ask for second
opinion, we performed this endoscopy presented in this
atlas.

Video Endoscopic Sequence 2 of 12.

This image shows multiple irregular and large ulcers.

Video Endoscopic Sequence 3 of 12.

The gastrointestinal (GI) tract, particularly the stomach, is
the most common primary site of extranodal lymphoma.
However,primary gastric lymphoma is uncommon and
constitutes only 2%–5%of malignant gastric lesions.
Most gastric lymphomas areof B-cell lineage. Among
them, most primary low-grade B-celllymphomas of the
stomach have long been known as "pseudolymphomas"
or "lymphoreticular hyperplasia" because of the presence
ofreactive follicles and mixed inflammatory cell infiltration
at histopathologic examination and because of the
favorableprognosis. However, recent
immunohistochemical studies have shown that most
pseudolymphomas are monoclonal B-cellproliferations
and that the majority of these B cells are consideredto
originate from mucosa-associated lymphoid tissue
(MALT).These B cells have the same cytologic and
immunophenotypic characteristicsas the B cells that are
normally found around the mantle zonesof Peyer patches
Therefore, these low-grade B-celllymphomas, which have
the morphologic features of MALT withthe high-grade
lesions that may evolve from them, are knownas MALT
lymphoma .

Video Endoscopic Sequence 4 of 12.

Multiple irregular shallow ulcers.

The paradox of lymphomas arising in the stomach has been
explainedby the observation of MALT in the stomach in
response to infectionsby H pylori and by the presence of
this organism in more than90% of gastric MALT
lymphomas. In some cases,low-grade MALT lymphomas
have regressed with eradication ofH pylori .

Video Endoscopic Sequence 5 of 12.

MALT lymphoma is an indolent (commonly called low
grade) type of B-cell non-Hodgkin lymphoma,
first recognised as a specific type of lymphoma in 1983.
It occurs at sites that are outside lymph nodes or the
spleen. The organisation of the lymphoma cells,
when viewed under the microscope, resembles the
lymphoid tissue normally found in the gut, which is
called ‘mucosa-associated lymphoid tissue (MALT).
MALT lymphoma most frequently arises within this type
of lymphoid tissue after it has accumulated as part of
a reaction to an infection or inflammation.

Video Endoscopic Sequence 6 of 12.

Chromoendoscopy with indigo carmine stain.

Video Endoscopic Sequence 7 of 12.

In the new World Health Organisation classification of
lymphoid tumours, MALT lymphoma is more correctly
called 'extra-nodal marginal zone B-cell lymphoma'. This is
because there is now strong evidence to suggest that the
type of cell from which the lymphoma develops is a specific
B-cell which is founding a specific compartment of the
lymphoid tissue called the marginal zone.

Video Endoscopic Sequence 8 of 12.

MALT lymphoma is the third most common type of
non-Hodgkin lymphoma, although it only accounts for
about 7-8% of these tumours. MALT lymphomas
have been described at almost all extra-nodal sites
(sites other than lymph nodes), but are most commonly
found in the gastrointestinal tract - the gut - (50% of
all MALT lymphomas) within which the stomach is the
most frequently involved area (34% overall; 50-70%
of gastrointestinal MALT lymphomas). It appears to be
a contradiction that MALT lymphomas are found
least frequently in sites in which MALT is normally
present, like the terminal part of the small intestine,
and seem only to develop when the lymphoid tissue
arises in response to infection or other cause
of inflammation.

Video Endoscopic Sequence 9 of 12.

Gastric MALT lymphomas account for up to 4% of
all primary gastric tumours and 40-50% of all
primary gastric lymphomas (the remaining being mostly
the more aggressive (commonly called high grade)
diffuse large B-cell lymphomas).

MALT lymphomas are approximately equally
distributed between men and women. This lymphoma
is most frequent in late middle aged/elderly people
although it may be found in any age-group.

Video Endoscopic Sequence 10 of 12.

MALT lymphomas arise at sites that have acquired some
MALT-type lymphoid tissue due to some other
disease/disorder or infection. For some MALT lymphomas
this underlying condition remains a mystery, while for
others more is known about predisposing factors.
For example, in the thyroid and salivary glands,
MALT lymphomas can develop due to autoimmune
inflammatory conditions known respectively
as Hashimoto’s thyroiditis and Sjogren’s syndrome.

However, most is known about gastric MALT lymphoma,
as this is the commonest site at which these lymphomas
develop. In the stomach, the majority of these lymphomas
are associated with infection by a bacterium called
Helicobacter pylori This causes inflammation of the
lining of the stomach which includes the development
of MALT-type lymphoid tissue. Once the MALT-type
tissue is acquired, there is continuous stimulation of the
lymphocytes to replicate and increase in number as a
result of the constant presence of bacteria
(a normal immune reaction). However, in a small minority
of people, this results in a mistake within the
genetic material of a lymphoid cell and continuation of
this faulty cell line leads to the development of a lymphoma.

Video Endoscopic Sequence 11 of 12.

Until the early 1990's surgery was probably the most
commonly used treatment for gastric MALT lymphoma.
However, with the recognition of the common association
between gastric MALT lymphoma and Helicobacter
infection and following some laboratory-based studies on
cells derived from lymphomas, it was suggested that
eradication of Helicobacter alone might have a therapeutic
effect. Further studies some of which now have follow-up
extending to over ten years, have shown that eradication of
Helicobacter alone can induce tumour regression in 50-70%
of cases. The cases that respond the best are those that
have not extended very far through the gastric wall and
have not spread to lymph nodes. An initial antibiotic-based
regime for eradication is usually prescribed, followed by
endoscopies to confirm eradication of the organism and to
assess tumour response.

The interval between Helicobacter eradication and
regression of the tumour is highly variable between
patients. A proportion of patients will not respond to
eradication therapy alone and will go on to more
conventional anti-lymphoma therapies such as
chemotherapy or radiotherapy. There is, at present, no
clear agreement between doctors as to when eradication
therapy can be assessed as having failed in an individual,
but while there are sequential improvements in biopsies
taken during endoscopies, it may be worth delaying the use
of other therapies. Some cases have been reported where
there has been regression of the lymphoma many years
after eradication and in the absence of other therapies.

Video Endoscopic Sequence 12 of 12.

When Helicobacter eradication has been deemed to have failed,
more conventional therapies can be used. While surgery has,
in the past, been the mainstay of treatment for gastric lymphoma,
this is no longer the case. Several studies have shown that,
although the lymphoma is usually concentrated in one part of the
stomach, there are small deposits all over the stomach lining.

Both radiotherapy and chemotherapy have been shown to
be highly effective in the treatment of gastric MALT lymphoma.
Single-agent chemotherapy with alkylating agents (substances
which are used to treat some cancers by interfering with
cell metabolism and growth) such as cyclophosphamide
or chlorambucil or nucleoside analogues (other drugs used
to check the growth of lymphoma cells) such as cladribine
appear to have equal activity.

Gastric Adenocarcinoma with metastases to the duodenum. This 74 year-old male with weigh loss of 20 pounds and vomiting. The image and the video clip shows a large mass in the duodenal bulb.

Endoscopic Sequence 1 of 15.

Gastric lymphoma with metastases to the duodenum.

This 74 year-old male with weigh loss of 20 pounds and vomiting.

The image and the video clip shows a large mass in the duodenal bulb.

Endoscopic Sequence 2 of 15.

Post bulbar metastases.

Endoscopic Sequence 3 of 15.

Another view of the mass in the duodenal bulb.

Endoscopic Sequence 4 of 15.

Retroflexed view in the duodenum showing the large mass
in the bulb in the limit of the second part of the duodenum.

Endoscopic Sequence 5 of 15.

Retroflexed view from a little more far.

Endoscopic Sequence 6 of 15.

The Pre-pyloric antrum is showed with infiltration with the neoplasia.

Endoscopic Sequence 7 of 15.

The antrum with extensive malign infiltration.

Endoscopic Sequence 8 of 15.

The gastric angle is infiltrated.

Endoscopic Sequence 9 of 15.

Some rest of food is observed.

Endoscopic Sequence 10 of 15.

In this image shows the freshness of the banana in the middle of neoplasia is evident.

Endoscopic Sequence 11 of 15.

Again, post bulbar metastases.

Endoscopic Sequence 12 of 15.

Endoscopic Sequence 13 of 15.

Endoscopic Sequence 14 of 15.

Endoscopic Sequence 15 of 15.

Gastric Lymphoma.

B-Cell Lymphoma.

Non-Hodgkin's Lymphomas caused by malignant
(cancerous) B-Cell lymphocytes represent a largesubset
(about 85% in the US) of the known types of lymphoma
(the other 2 subsets being T-Cell lymphomas and
lymphomas where the cell type is unknown). B-Cells
undergo many changes in their life cycle dependent on
complex signaling processes between cells and interaction
with foreign substances in the body. Apparently various
types of lymphoma or leukemia can occur in the B-Cell life
cycle.

Malt Lymphoma.

Small cell lymphomas may resemble reactive lymphoid
hyperplasia.
Lymphomatous involvement of the stomach may have
a variety of manifestations, including large infiltrated
rouge, eroded nodules and exophytic and ulcerated
masses, erosions and ulcers.