An 84 year old female presented to another facility two months earlier with anemia and melena. Initial EGD identified a large gastric body ulcer with biopsies revealing chronic inflammation, with no H.pylori or malignancy detected. Endoscopy now shows an irregular 5 cm area with a central depression, at the junction of the distal body and antrum, along the lesser curvature. The lesion appears raised and nodular with a smooth mucosal surface and some disruption of the mucosal vascular pattern. On retroflexion, a smaller 2 cm raised, nodular area is seen in the gastric cardia, a few centimeters below the GE junction. Narrow band imaging highlights the vascular irregularity.
Radial EUS imaging identifies normal gastric wall architecture adjacent to the lesion in the gastric body with thickening of the deep mucosal layer. No peri-gastric or celiac lymphadenopathy was seen. Mucosal biopsies from both gastric lesions revealed low-grade B-cell MALT lymphoma. The patient was H.pylori negative and is currently undergoing radiation therapy.
MALT (mucosa associated lymphoid tissue) lymphomas are comprised of a variety of small B-cells infiltrating the marginal zone of reactive B-cell follicles. MALT lymphomas represent 50% of all gastric lymphomas and 5% of all non-Hodgkins lymphomas. MALT lymphomas often develop in the elderly and have an indolent course. Patients may present with abdominal pain, weight loss, and gastrointestinal bleeding. MALT lymphomas are associated with H.pylori infection. Eradication of H.pylori may result in regression of up to 80% of cases with disease limited to the superficial mucosa. Recent studies suggest that more advanced MALT lymphomas may also benefit from H.pylori eradication, in addition to therapy with radiation or chemotherapy, with greater than 80% five-year survival.
Uzma Siddiqui, M.D., Yale University
V. Murali Dharan, M.D., Yale University
Harry Aslanian, M.D., Yale University