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Editor,—Taal et al showed recently (Gut 1996; 39: 556–61) that both clinical parameters and endoscopic findings differ significantly between low and high grade gastric mucosa associated lymphoid tissue (MALT) lymphoma . In fact, low grade MALT lymphoma has often been interpreted endoscopically as a benign condition, whereas high grade MALT lymphoma often has neoplastic-like features. Weight loss and older age are more frequent in high grade MALT lymphoma.
In our experience the endoscopic findings and clinical parameters differ from the data reported by Taal et al.
Between 1993 and 1996 we diagnosed one high grade and three low grade MALT lymphomas. In the low grade MALT lymphomas (one 70 year old man and two women, one 65 and the other 56 years old), the endoscopic findings were a gastric ulcer in the male patient, and a large antral mass with multiple ulcerations in the first and a large polypoid mass with pyloric obstruction in the second female patient. All of them had lost weight (6–10 kg). The male patient and the female patient with multiple antral ulcerations were Helicobacter pyloripositive. These patients were treated with an H pylorieradication regimen, and the H pylori negative patient was treated with polichemotherapy. In all cases the tumour regressed and the endoscopic pattern resolved. In the 67 year old woman with high grade MALT lymphoma the endoscopy showed a pin-point stenosis of the pilorus, with a large mass ulcerated at the angulus and weight loss (6 kg in two months). Although H pylori was present, the patient was treated successfully with surgery (gastrectomy), followed by polichemotherapy. These data show that the clinical and endoscopic patterns are very similar in low and high grade MALT lymphoma, and that is very difficult to determine the grade of the MALT lymphoma on the basis of the endoscopic or clinical, or both, patterns.
At the initial gastroscopy the male patient with the low grade MALT lymphoma had two adjacent ulcers on the posterior wall of the gastric corpus, was H pylori positive, and had histological and immunohistochemical evidence of low grade MALT lymphoma only in gastric mucosal specimens obtained from the ulcer margins. Anti-H pylori treatment resulted both in the eradication of the bacterium and regression of the neoplasia, with resolution of the ulcers.1 After 18 months, the patient was reinfected byH pylori and endoscopy showed a diffuse thickening of gastric mucosal folds in all gastric sites, mimicking linitis plastica. Histological and immunohistochemical analyses showed a low grade MALT lymphoma.1 After the failure of two consecutive courses of anti-H pylori treatment, the patient was treated surgically due to progressive weight loss. Histological examination of the surgical specimens confirmed the diagnosis of low grade MALT lymphoma, stage EI1.2
This case shows clearly that the endoscopic pattern of low grade MALT lymphoma can change greatly even in a single patient, making it impossible to use the endoscopic or clinical pattern to distinguish between low and high grade MALT lymphoma.
Editor,—The endoscopic pattern of gastric non-Hodgkin’s lymphoma (NHL) has been described by several authors.1-1 1-2 There are three main patterns: a tumour-like appearance with a polypoid mass (exophytic type); ulceration or multiple small erosions (infiltrative type); or thickened, giant folds such as those seem in linitis plastica. Unfortunately, these descriptions are not specific for gastric NHL. As gastric lymphoma is a rather uncommon disease, one might imagine that the endoscopist is not always aware of the possibility of a lymphoma rather than a carcinoma or even the more frequently present gastritis.
In our series of 114 patients with primary gastric lymphoma we evaluated the initial endoscopic diagnosis in relation to clinical findings and grade of malignancy: the endoscopic appearance was interpreted as benign disease in 52% of 51 patients with low grade MALT lymphoma. In most patients (71% of 63) the high grade lymphomas were classified as malignant and in only 13% a correct diagnosis of NHL was made by the endoscopist. The pathologist, however, was able to give an accurate diagnosis at initial biopsy in 77% and in 91% after repeat endoscopy with multiple biopsies, when the diagnosis was not conclusive.1-3
So, we are not at all surprised by the findings reported by Dr Tursi and colleagues. They describe four cases: three of them with a low grade gastric NHL associated with a polypoid tumour mass in two (compared with 13 of 51 patients with low grade lymphoma in our series) and the third with an ulcer. The fourth case with high grade lymphoma suffered from significant weight loss and a tumour mass as is often found in this group. Thus, in summary the findings were consistent with the general pattern in two of the four cases. This supports our conclusion that the endoscopic recognition of gastric NHL is difficult; a high index of suspicion may help, but we feel that it is of utmost importance to take routine biopsy specimens in as many patients as possible, preferrably all patients seen in the GI endoscopy unit. So we do not agree with Tursi et al who reject our conclusions (based on the experience in 114 patients) with their report of four cases only, which cannot be considered as an impressive number of cases or even a series of patients.
The issue of treatment of gastric NHL by eradication of H pylori was not the subject of our study. Information on this topic is increasing and eradication treatment may induce complete regression in non-bulky, low grade MALT lymphoma stage I in approximately 70% of cases.1-2 1-4 The value of H pylori eradication in bulky disease as mentioned by Tursiet al is still a matter of much debate.
In general, it is important to detect gastric lymphoma at an early stage when treatment might be less toxic and most effective. Therefore, we would like to stress that a diagnosis of low grade gastric NHL should be kept in mind when encountering benign gastritis, and that high grade NHL expresses more carcinoma-like features. Multiple biopsy specimens are an absolute requirement for an optimal diagnosis and treatment choice.
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