Regression of primary high-grade gastric B-cell lymphoma following Helicobacter pylori eradication

Abstract

The causative association between Helicobacter pylori and gastric mucosal inflammation is well established. The inflammatory process leads to the acquisition of mucosa-associated lymphoid tissue (MALT) by the stomach. Evidence links H. pylori gastritis with the development of low-grade primary gastric lymphoma with a phenotype specific for lymphoma of MALT type. It is now accepted that primary low-grade MALT lymphomas regress with H. pylori eradication therapy. However, the response of primary, diffuse, large-cell gastric lymphoma to H. pylori eradication therapy is still not established. We report a case of a primary high-grade gastric lymphoma regressing after H. pylori eradication therapy.

Case Details

Disease Location

Gastric

Personal Characteristics

73 -year-old female no significant past medical history and no medication

Clinical Characteristics

Referred with a 4-week history of epigastric discomfort, abdominal pain and dyspepsia baseline hematological and biochemical tests were normal serological test for h. Pylori was positive upper-gi endoscopy showed a raised lesion with central necrosis in the distal greater curvature near the antrum of the stomach multiple biopsies from all quadrants of this lesion showed a high-grade diffuse large-cell b-cell nhl. CT of the abdomen didn't reveal any evidence of tumor spread or gastric wall thickening. Endoscopic ultrasound was normal with no features of gastric wall invasion by the tumor she was reluctant to do chemo or surgery, however h. Pylori eradication was undertaken for 10 days after 6 weeks of treatment, repeat upper-gi endoscopy showed a 1cm ulcer with no evidence of lymphoma on histology after 1 month, she complained of recurrent abdominal pain. Upper-gi endoscopy showed a smaller ulcer (0.5cm) on the anal greater curve. Biopsy showed chronic inflammation, and further h. Pylori eradication was initiated surveillance endoscopies at 2, 4, 6, 9, 12, 18, 24, and 30 months showed a mucosal scar deformity with intact mucosa. Follow-up endoscopic ultrasound exam was suggested but the she felt completely well and the declined the test pathology biospy material diagnostic of lymphoma showed superficially ulcerated fragments of gastric antral-type mucosa. A proportion of which were overrun by a pleomorphic, mitotically active b-cell lymphocytic infiltrate that effaced and destroyed native gastric glands a chronic lymphoplasmacytic inflammatory infiltrate was seen elsewhere in the fragments the neoplastic lymphoid cells were seen focallly to infiltrate the glandular epithelium. Typical features of a low-grade mucosa-associated lymphoma with an organized architectural arrangement to include lymphoid follicles, centrocyte-like cells and classical lympho-epithelial lesions were not seen. The tumor was described as a diffuse large b-cell lymphoma with a high proliferation fraction but showing no accompanying areas of typical low-grade b-cell lymphoma of malt type.

Remission Characteristics

After 6 weeks of treatment, symptoms improved and repeat upper-gi endoscopy showed a 1cm ulcer with no evidence of lymphoma at 30 months, biopsies from all quadrants of the stomach showed features of chronic inflammation with no evidence of lymphoma. Endoscopic appearances and biospies showed no evidence or h. Pylori or recurrence of the original lesion follow-up CT of the abdomen at 30 months post-eradication showed no evidence of any recurrence she remains aympatientomatic without any treatment at 30 months and is under regular surveillance

Treatment & Mechanisms

Proposed Remission Mechanisms

H. Pylori eradication

Clinical Treatment

H. Pylori eradication included lansoprazole, amoxicillin, and clarithromycin second h. Pylori eradication was followed with lansoprazole for symptomatic relief

Non-Clinical Treatment

None reported