A 66-year-old female presented with a 1-month history of dyspepsia. An initial upper GI endoscopy showed a shallow ulcerative lesion in the gastric high body and a hyperemic lesion in the low body (). A rapid urease test was positive for H. pylori. Histologic sections of the high and low bodies showed patchy infiltration of small lymphocytes into the lamina propria and lymphoepithelial lesions; the lymphocytes were focally aggressive toward the gland (). Phenotypic analysis showed that the lesion was positive for CD20, but negative for CD3, CD5, CD10, and Bcl-6, and that its proliferation rate was <2%, as shown by MIB1 (Ki-67) antibody analysis. Based on these histopathological and phenotypic features, the patient was diagnosed with low-grade MALT lymphoma. Staging procedures were performed. Endoscopic ultrasound (EUS) revealed hypoechoic disruption of the mucosal and submucosal layers; moreover, the fourth layer was preserved and there was no evidence of locoregional lymphadenopathy (u-T1smN0) (). A computed tomography (CT) scan showed a huge LN, about 30×15 mm in size, in the subcarinal area (). Fusion whole body positron emission tomography (PET) showed a hypermetabolic lesion, suggestive of a malignant lesion, on the subcarinal area. (). Bone marrow biopsy findings were normal. EUS of the subcarinal lesion showed 32×12 mm LN. Histopathological and phenotypic analysis of a biopsy sample obtained by EUS-guided fine needle aspiration () showed that the lesion was a MALT lymphoma (). The patient was diagnosed with a stage 4E gastric MALT lymphoma. For H. pylori eradication, the patient was treated with a 14-day course of amoxicillin 2,000 mg a day, clarithromycin 1,000 mg a day and pantoprazole 80 mg a day.
Fig. 1 Initial diagnostic tests. (A) Initial upper gastrointestinal endoscopy displaying a shallow ulcerative lesion in the gastric high body and a hyperemic lesion in the gastric low body. (B) Histopathologic examination of a gastric biopsy specimen displaying (more ...)
An endoscopy performed 2 months after treatment showed that the gastric high and low bodies were pale and flat, with no evidence of lymphoma infiltration (). EUS of the subcarinal area and CT showed that the LN had decreased markedly in size, to 12×11 mm (). Follow-up PET showed no significantly abnormal hypermetabolic lesions ().
Fig. 2 Follow-up evaluations 2 months (A, C, E, G, I) and 1 year (B, D, F, H, J) after Helicobacter pylori eradication. (A, C) Upper gastrointestinal endoscopy, displaying pale, flat gastric high and low bodies without lymphoma infiltration (H&E stain, (more ...)
One year after treatment, all assessments, including endoscopy with biopsy, CT, PET, and EUS, showed normal results (). At present, 14 months later, the patient remains in complete remission.