Association of Helicobacter pylori (H. Pylori) infection with gastric \u27Mucosa Associated Lymphoid Tissue\u27 (MALT) lymphomas (MALTomas) is well established. In this study the frequency and characteristics of gastric MALToma over a period of 18 years was evaluated. During this period 24 patients with gastric MALToma were diagnosed; out of them, 13 (54.2%) had active H. Pylori infection. The mean and median age was 49.7 and 53.5 years. The male: female ratio was 17:7. The common presenting complaints were epigastric pain (n=10) and dyspepsia (n=9). Endoscopic findings revealed mild gastric hyperemia (n=16), superficial erosions (n=4) and superficial ulcers (n=4). It was concluded that the prevalence of gastric MALToma was very low in contrast to a high H. pylori gastritis in the Pakistani population

Aaqil, Hina

Akhtar, Nake

Ali, Naureen

Mumtaz, Khalid

Pervez, Shahid

Siddiq Ullah, Syed

Association of Helicobacter pylori (H. Pylori) infection with gastric ‘Mucosa Associated Lymphoid Tissue’ (MALT) lymphomas (MALTomas) is well established. In this study the frequency and characteristics of gastric MALToma over a period of 18 years was evaluated. During this period 24 patients with gastric MALToma were diagnosed; out of them, 13 (54.2%) had active H. Pylori infection. The mean and median age was 49.7 and 53.5 years. The male: female ratio was 17:7. The common presenting complaints were epigastric pain (n=10) and dyspepsia (n=9). Endoscopic findings revealed mild gastric hyperemia (n=16), superficial erosions (n=4) and superficial ulcers (n=4). It was concluded that the prevalence of gastric MALToma was very low in contrast to a high H. pylori gastritis in the Pakistani population

Ullah, Syed Siddiq

eCommons@AKU

eCommons@AKUDepartment of Pathology and Laboratory Medicine Medical College, PakistanJanuary 2011Gastric MALT lymphoma: a rarityShahid PervezSection of Histopathology, Dept of Pathology & Laboratory Medicine, Aga Khan University Hospital, Karachi,shahid.pervez@aku.eduNaureen AliAga Khan UniversityHina AaqilAga Khan UniversityKhalid MumtazSyed Siddiq UllahAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiolPart of the Microbiology Commons, and the Pathology CommonsRecommended CitationPervez, S., Ali, N., Aaqil, H., Mumtaz, K., Ullah, S. (2011). Gastric MALT lymphoma: a rarity. JCPSP: Journal of the College ofPhysicians and Surgeons Pakistan., 21(3), 171-172.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiol/481Journal of the College of Physicians and Surgeons Pakistan  2011, Vol. 21 (3): 171-172 171MALT lymphomas were first described in 1983 by PeterIsaacson and Dennis Wright. They noted that primarylow grade gastric B-cell lymphomas recapitulate thehistology of Mucosa Associated Lymphoid Tissue(MALT) exemplified by the Peyer’s patches and coinedthe term ‘MALT lymphoma’. These lymphomas arecurrently recognized as ‘Extranodal marginal zone B-celllymphomas of MALT type’ according to the ‘WHOClassification for tumours of hematopoietic andlymphoid tissues’.1 The stomach is the most reportedand best studied site of MALT lymphomas. An intimaterelationship has been reported between the presenceof Helicobacter pylori (H. pylori) in the stomach and thedevelopment of MALT lymphoma. In fact the patho-genesis of gastric MALT lymphoma is believed to becaused by repeated antigenic stimulation of the immunesystem in the stomach by H. pylori. The role of H. pylori inthe pathogenesis of gastric MALTomas can be illustratedby the fact that 75% of the patients who have gastricMALToma undergo remission if treated with antibiotics toeradicate H. pylori.2 About half the people in the worldhave H. pylori colonized in their gastrointestinal tract. Ofthese most remain asymptomatic. Despite the fact that,a high prevalence of H. pylori is reported from Pakistan,3,4the prevalence of gastric MALToma is very low in ourexperience. Therefore, this study was carried out withthe objective of studying the frequency of MALTomasin a population with a high prevalence of H. pyloriassociated gastritis. Medical records of all the patients diagnosed to havegastric MALToma over an 18 years period (January 1991to December 2008) according to ICS-9 coding systemwere retrieved. A total of approximately, 4000 ± 500gastroscopies are performed in the institution’s endo-scopy unit annually. The medical records of all caseswith diagnosis of gastric MALToma (extra nodal marginalB-cell lymphomas of the MALT) were reviewed forrelevant clinical information along with retrieval andreview of histopathological slides and blocks. Relevantimmunohistochemical workup was done in all cases.Twenty four confirmed cases of gastric MALTomas overa period of 18 years were retrieved. The mean and median ages of patients with gastricMALToma were 49.7 years and 53.5 (ranging from 18-80years). The male: female ratio was 17:7. Thirteenpatients (54.2%) were found to have active H. pyloriinfection at the time of diagnosis. Two of these caseshad a past diagnosis of active H. pylori associatedgastritis on endoscopic biopsies which was not treated. The presenting symptoms of the cohort includedepigastric pain (n=10), dyspepsia (n=9), chronicdiarrhoea (n=2), weight loss (n=2) and nausea (n=1).The endoscopic examination findings included gastricantral hyperemia, gastric antral erosion, small gastricantral superficial ulcer etc. The typical histopathologicfeatures included extensive mucosal infiltration bycentrocyte-like B-cells and lymphoepithelial lesions(Figure 1). Neoplastic cells were positive for LCA, CD20and CD79a with low mib-1 (ki-67). The reactivepopulation contained abundant CD3 positiveT cells andin many cases well developed lymphoid follicles withgerminal centers (Figure 1).This study is the first report of its kind from Pakistan. Itwas found that despite the high seroprevalence ofH. pylori infection in the Pakistani population (58.3%),3,4cases with MALT lymphomas were few. This correlateswith the ‘Asian enigma’ described by various authorswhere less developed Asian countries like Pakistan,India, Bangladesh and Thailand have lower rates ofABSTRACTAssociation of Helicobacter pylori (H. Pylori) infection with gastric ‘Mucosa Associated Lymphoid Tissue’ (MALT) lymphomas(MALTomas) is well established. In this study the frequency and characteristics of gastric MALToma over a period of 18years was evaluated. During this period  24 patients with gastric MALToma were diagnosed; out of them, 13 (54.2%) hadactive H. Pylori infection. The mean and median age was 49.7 and 53.5 years. The male: female ratio was 17:7. The commonpresenting complaints were epigastric pain (n=10) and dyspepsia (n=9). Endoscopic findings revealed mild gastrichyperemia (n=16), superficial erosions (n=4) and superficial ulcers (n=4). It was concluded that the prevalence of gastricMALToma was very low in contrast to a high H. pylori gastritis in the Pakistani population.Key words: Helicobacter pylori. MALToma.   Lymphoma.   Stomach.Department of Pathology1/Medicine2, The Aga Khan UniversityHosptial, Karachi.Correspondence: Dr. Shahid Pervez, House No. 639, DOHS-1,Malir Cantt, Karachi.E-mail: shahid.pervez@aku.eduReceived  January 12, 2010;  accepted  January 07, 2011.Gastric MALT Lymphoma: A Rarity Shahid Pervez1, Naureen Ali1, Hina Aaqil1, Khalid Mumtaz2, Syed Siddiq Ullah1 and Nake Akhtar1SHORT COMMUNICATIONgastric carcinoma compared to well developed countrieslike Japan and China, despite a higher prevalence ofH. pylori infection in the former population. H. pyloriinfection has been established to have a role in theetiology of gastric carcinoma and its paradoxical highprevalence in areas with few cases of gastric carcinomahas long puzzled researchers. Available evidence doesnot support difference in H. pylori strains as the soleexplanation for this enigma. It has also been observedthat patients with duodenal ulcer caused by H. pylori, donot develop gastric tumours, in contrast to other H. pylori-associated pathology, such as gastric ulcer. Thisillustrates variation in host responses despite infectionwith the same organism, and so suggests the role ofgenetic factors in different ethnic groups.Thus, precisely, who will develop a neoplastic lesionassociated with H. pylori, like MALToma, probablydepends on 3 factors: the virulence of the H. pylori strain,types and extent of the host immune response and co-factors like diet and smoking.In 1993 Wotherspoon and colleagues described remarkableobservation of regression of  MALTomas, by eradicationof H. pylori with use of antibiotics.5 Response range wasreported to be between 60-90%. Transformation intolarge B-Cell lymphoma is also possible. Most of thelesions appeared to pursue an indolent clinical course.In some cases (45.8%), no evidence of H. pylori infectionwas found. In such cases it is not clear whether theinfection has been present previously and resolved at astage after the lymphoma has attained autonomousgrowth or whether there is yet another unrecognizedcausative agent. A more detailed investigation into theepidemiologic and etiological factors in this part of theworld would be invaluable in the search for the exactcause of gastric MALT lymphoma and its link to H. pylori.REFERENCES1. Issaacson PG, Chott A, Nakamura S, Hermelink M, Harris NL,Swerdlow SH, editors. WHO classification of tumours ofhaematopoietic and lymphoid tissues. Extranodal marginal zonelymphoma of mucosa-associated lymphoid tissue (MALTlymphoma), 4th ed. France: IARC; 2008. p. 214-9.2. Ono S, Kato M, Ono Y, Itoh T, Kubota K, Nakagawa M, et al.Characteristics of magnified endoscopic images of gastricextranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue, including changes after treatment.Gastrointest Endosc 2008; 68:624-31. Epub 2008 Jun 5. Commentin: p. 632-4.3. Abbas Z, Jafri W, Khan AH, Shah MA. Prevalence of Helicobacterpylori antibodies in endoscopy personnel and non-medicalvolunteers of Karachi. J Pak Med Assoc 1998; 48:201-3 4. Ahmad T, Rakhshanda B, Azra K. Prevalence of Helicobacter pyloriinfection in asymptomatic children of Islamabad suburbs(Pakistan). Int J Agriculture Biol 2008; 10:685-8.5. Fischbach W, Goebeler-Kolve ME, Dragosics B, Greiner A,Stolte M. Long-term outcome of patients with gastric marginalzone B cell lymphoma of mucosa associated lymphoidtissue (MALT) following exclusive Helicobacter pylori eradicationtherapy: experience from a large prospective series. Gut 2004;53:34-7.172 Journal of the College of Physicians and Surgeons Pakistan  2011, Vol. 21 (3): 171-172Shahid Pervez, Naureen Ali, Hina Aaqil, Khalid Mumtaz, Syed Siddiq Ullah and Nake AkhtarFigure 1: Microphotographs of a case of gastric MALToma (A, B & C)showing a lymphoid follicle with sheets of monomorphic small and irregularcentrocyte like tumour cells emanating from inconspicuous marginal zone ofthe follicle ( H & E , Mag: 4X, 10X & 20X). (D) Lympho-epithelial lesion showing extensive infiltration of the glandularepithelium by small neoplastic cells , H & E: Mag 20Xl l l l lOl l l l l

English

Gastric MALT lymphoma: a rarity

eCommons@AKUDepartment of Pathology and Laboratory Medicine Medical College, PakistanMarch 2011Gastric MALT lymphoma: a rarityShahid PervezAga Khan UniversityNaureen AliAga Khan UniversityHina AaqilAga Khan UniversityKhalid MumtazAga Khan UniversitySyed Siddiq UllahAga Khan UniversitySee next page for additional authorsFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiolPart of the Pathology CommonsRecommended CitationPervez, S., Ali, N., Aaqil, H., Mumtaz, K., Siddiq Ullah, S., Akhtar, N. (2011). Gastric MALT lymphoma: a rarity. Journal of the Collegeof Physicians and Surgeons Pakistan, 21(3), 171-2.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiol/8AuthorsShahid Pervez, Naureen Ali, Hina Aaqil, Khalid Mumtaz, Syed Siddiq Ullah, and Nake AkhtarThis article is available at eCommons@AKU: http://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiol/8Journal of the College of Physicians and Surgeons Pakistan  2011, Vol. 21 (3): 171-172 171MALT lymphomas were first described in 1983 by PeterIsaacson and Dennis Wright. They noted that primarylow grade gastric B-cell lymphomas recapitulate thehistology of Mucosa Associated Lymphoid Tissue(MALT) exemplified by the Peyer’s patches and coinedthe term ‘MALT lymphoma’. These lymphomas arecurrently recognized as ‘Extranodal marginal zone B-celllymphomas of MALT type’ according to the ‘WHOClassification for tumours of hematopoietic andlymphoid tissues’.1 The stomach is the most reportedand best studied site of MALT lymphomas. An intimaterelationship has been reported between the presenceof Helicobacter pylori (H. pylori) in the stomach and thedevelopment of MALT lymphoma. In fact the patho-genesis of gastric MALT lymphoma is believed to becaused by repeated antigenic stimulation of the immunesystem in the stomach by H. pylori. The role of H. pylori inthe pathogenesis of gastric MALTomas can be illustratedby the fact that 75% of the patients who have gastricMALToma undergo remission if treated with antibiotics toeradicate H. pylori.2 About half the people in the worldhave H. pylori colonized in their gastrointestinal tract. Ofthese most remain asymptomatic. Despite the fact that,a high prevalence of H. pylori is reported from Pakistan,3,4the prevalence of gastric MALToma is very low in ourexperience. Therefore, this study was carried out withthe objective of studying the frequency of MALTomasin a population with a high prevalence of H. pyloriassociated gastritis. Medical records of all the patients diagnosed to havegastric MALToma over an 18 years period (January 1991to December 2008) according to ICS-9 coding systemwere retrieved. A total of approximately, 4000 ± 500gastroscopies are performed in the institution’s endo-scopy unit annually. The medical records of all caseswith diagnosis of gastric MALToma (extra nodal marginalB-cell lymphomas of the MALT) were reviewed forrelevant clinical information along with retrieval andreview of histopathological slides and blocks. Relevantimmunohistochemical workup was done in all cases.Twenty four confirmed cases of gastric MALTomas overa period of 18 years were retrieved. The mean and median ages of patients with gastricMALToma were 49.7 years and 53.5 (ranging from 18-80years). The male: female ratio was 17:7. Thirteenpatients (54.2%) were found to have active H. pyloriinfection at the time of diagnosis. Two of these caseshad a past diagnosis of active H. pylori associatedgastritis on endoscopic biopsies which was not treated. The presenting symptoms of the cohort includedepigastric pain (n=10), dyspepsia (n=9), chronicdiarrhoea (n=2), weight loss (n=2) and nausea (n=1).The endoscopic examination findings included gastricantral hyperemia, gastric antral erosion, small gastricantral superficial ulcer etc. The typical histopathologicfeatures included extensive mucosal infiltration bycentrocyte-like B-cells and lymphoepithelial lesions(Figure 1). Neoplastic cells were positive for LCA, CD20and CD79a with low mib-1 (ki-67). The reactivepopulation contained abundant CD3 positiveT cells andin many cases well developed lymphoid follicles withgerminal centers (Figure 1).This study is the first report of its kind from Pakistan. Itwas found that despite the high seroprevalence ofH. pylori infection in the Pakistani population (58.3%),3,4cases with MALT lymphomas were few. This correlateswith the ‘Asian enigma’ described by various authorswhere less developed Asian countries like Pakistan,India, Bangladesh and Thailand have lower rates ofABSTRACTAssociation of Helicobacter pylori (H. Pylori) infection with gastric ‘Mucosa Associated Lymphoid Tissue’ (MALT) lymphomas(MALTomas) is well established. In this study the frequency and characteristics of gastric MALToma over a period of 18years was evaluated. During this period  24 patients with gastric MALToma were diagnosed; out of them, 13 (54.2%) hadactive H. Pylori infection. The mean and median age was 49.7 and 53.5 years. The male: female ratio was 17:7. The commonpresenting complaints were epigastric pain (n=10) and dyspepsia (n=9). Endoscopic findings revealed mild gastrichyperemia (n=16), superficial erosions (n=4) and superficial ulcers (n=4). It was concluded that the prevalence of gastricMALToma was very low in contrast to a high H. pylori gastritis in the Pakistani population.Key words: Helicobacter pylori. MALToma.   Lymphoma.   Stomach.Department of Pathology1/Medicine2, The Aga Khan UniversityHosptial, Karachi.Correspondence: Dr. Shahid Pervez, House No. 639, DOHS-1,Malir Cantt, Karachi.E-mail: shahid.pervez@aku.eduReceived  January 12, 2010;  accepted  January 07, 2011.Gastric MALT Lymphoma: A Rarity Shahid Pervez1, Naureen Ali1, Hina Aaqil1, Khalid Mumtaz2, Syed Siddiq Ullah1 and Nake Akhtar1SHORT COMMUNICATIONgastric carcinoma compared to well developed countrieslike Japan and China, despite a higher prevalence ofH. pylori infection in the former population. H. pyloriinfection has been established to have a role in theetiology of gastric carcinoma and its paradoxical highprevalence in areas with few cases of gastric carcinomahas long puzzled researchers. Available evidence doesnot support difference in H. pylori strains as the soleexplanation for this enigma. It has also been observedthat patients with duodenal ulcer caused by H. pylori, donot develop gastric tumours, in contrast to other H. pylori-associated pathology, such as gastric ulcer. Thisillustrates variation in host responses despite infectionwith the same organism, and so suggests the role ofgenetic factors in different ethnic groups.Thus, precisely, who will develop a neoplastic lesionassociated with H. pylori, like MALToma, probablydepends on 3 factors: the virulence of the H. pylori strain,types and extent of the host immune response and co-factors like diet and smoking.In 1993 Wotherspoon and colleagues described remarkableobservation of regression of  MALTomas, by eradicationof H. pylori with use of antibiotics.5 Response range wasreported to be between 60-90%. Transformation intolarge B-Cell lymphoma is also possible. Most of thelesions appeared to pursue an indolent clinical course.In some cases (45.8%), no evidence of H. pylori infectionwas found. In such cases it is not clear whether theinfection has been present previously and resolved at astage after the lymphoma has attained autonomousgrowth or whether there is yet another unrecognizedcausative agent. A more detailed investigation into theepidemiologic and etiological factors in this part of theworld would be invaluable in the search for the exactcause of gastric MALT lymphoma and its link to H. pylori.REFERENCES1. Issaacson PG, Chott A, Nakamura S, Hermelink M, Harris NL,Swerdlow SH, editors. WHO classification of tumours ofhaematopoietic and lymphoid tissues. Extranodal marginal zonelymphoma of mucosa-associated lymphoid tissue (MALTlymphoma), 4th ed. France: IARC; 2008. p. 214-9.2. Ono S, Kato M, Ono Y, Itoh T, Kubota K, Nakagawa M, et al.Characteristics of magnified endoscopic images of gastricextranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue, including changes after treatment.Gastrointest Endosc 2008; 68:624-31. Epub 2008 Jun 5. Commentin: p. 632-4.3. Abbas Z, Jafri W, Khan AH, Shah MA. Prevalence of Helicobacterpylori antibodies in endoscopy personnel and non-medicalvolunteers of Karachi. J Pak Med Assoc 1998; 48:201-3 4. Ahmad T, Rakhshanda B, Azra K. Prevalence of Helicobacter pyloriinfection in asymptomatic children of Islamabad suburbs(Pakistan). Int J Agriculture Biol 2008; 10:685-8.5. Fischbach W, Goebeler-Kolve ME, Dragosics B, Greiner A,Stolte M. Long-term outcome of patients with gastric marginalzone B cell lymphoma of mucosa associated lymphoidtissue (MALT) following exclusive Helicobacter pylori eradicationtherapy: experience from a large prospective series. Gut 2004;53:34-7.172 Journal of the College of Physicians and Surgeons Pakistan  2011, Vol. 21 (3): 171-172Shahid Pervez, Naureen Ali, Hina Aaqil, Khalid Mumtaz, Syed Siddiq Ullah and Nake AkhtarFigure 1: Microphotographs of a case of gastric MALToma (A, B & C)showing a lymphoid follicle with sheets of monomorphic small and irregularcentrocyte like tumour cells emanating from inconspicuous marginal zone ofthe follicle ( H & E , Mag: 4X, 10X & 20X). (D) Lympho-epithelial lesion showing extensive infiltration of the glandularepithelium by small neoplastic cells , H & E: Mag 20Xl l l l lOl l l l l

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Gastric MALT lymphoma: a rarity

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