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I was interested to read the article by Alsolaiman and colleagues on the long term follow up of gastric diffuse large B cell lymphoma after eradication of Helicobacter pylori (
Gastric lymphomas represent approximately 5% of all gastric malignancies and are frequently due to mucosa associated lymphoid tissue (MALT) B cell gastric lymphomas. Acquired MALT due to H pylori infection provides the tissue of origin for the B cell lymphoma. Monoclonal proliferation of B cells in the germinal centres of lymphoid tissue with epithelial invasion—“lymphoepithelial lesions”—are the histological hallmark of MALT lymphoma. H pylori induced chronic gastritis through genetic mutation of trisomy 3 and 18 leads to the development of MALT lymphoma.
Eradication of H pylori with triple therapy (two antibiotics and double dose proton pump inhibitor) is curative for low grade gastric MALT lymphoma. There are reports of long term studies in the literature from the major centres around the world1–3 on the efficacy and safety of this modality of treatment for low grade MALT lymphoma.
District General Hospital (DGH) experience of treating MALT lymphoma is limited due to the rarity of the disorder. However, MALT lymphoma can be managed at a DGH with long term follow up.4 Regular endoscopic surveillance is required following eradication of H pylori.
Primary diffuse large B cell gastric lymphoma (previously known as high grade MALT lymphoma) is not considered treatable with antimicrobial agents alone. I agree with the authors that it is important to differentiate between patients who may benefit from H pylori eradication as a single modality of treatment and patients who require conventional chemotherapy in this group. The authors have cautioned that although some patients with diffuse large B cell gastric lymphoma might benefit from eradication treatment, this should not be considered standard therapy at present.
However, it was encouraging to note that high grade gastric MALT lymphoma can be treated with a single modality of antibiotic eradication of H pylori, provided the patient is willing to undergo close observation and endoscopic surveillance. This is particularly pertinent for a DGH to heed this message as in a rare situation of being faced with a high grade gastric MALT lymphoma, one would feel confident to try antibiotic eradication of H pylori alone with careful endoscopic surveillance, as often is employed in the case of low grade gastric MALT lymphoma.4