Gastric Lymphoma. El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
This is the case of a 44 year-old male who previously had two endoscopies practiced with another college, the first one due to epigastric pain, that Endoscopy showed two ulcerated nodules at the antrum, biopsies displayed helicobacter pylori and a gastric lymphoma, after the eradication of H pylori the two nodules have been regressed. 3 months after the patient ask for second opinion, we performed this Endoscopy presented in this atlas.

Video Endoscopic Sequence 1 of 12.

 This is the case of a 44 year-old male who previously had
 two endoscopies practiced with another collegue, the first
 one due to epigastric pain, that endoscopy showed two
 ulcerated nodules at the antrum, biopsies displayed
 helicobacter pylori and a gastric lymphoma, after the
 eradication of H pylori the two nodules have been
 regressed. 3 months after the patient ask for second
 opinion, we performed this endoscopy presented in this
 atlas.

 
This image shows multiple irregular and large ulcers. Primary malignant lymphoma of the stomach are almost all non Hodgkin's type and of B-cell lineage. These lymphomas usually arise from MALT (mucosa associated lymphoid tissue)- also known as Marginal Zone B - cell lymphoma (Low and High grade). Diffuse large B-cell lymphoma include high grade lymphoma of MALT origin and non-MALT type and they are indistinguishable. Other types include mantle cell lymphoma (malignant lymphomatous polyposis) , follicular lymphoma, Burkitt's lymphoma and rare solitary plasmacytoma.

Video Endoscopic Sequence 2 of 12.

This image shows multiple irregular and large ulcers.

 Primary malignant lymphoma of the stomach are almost all
 non Hodgkin's type and of B-cell lineage.
 These lymphomas usually arise from MALT
 (mucosa associated lymphoid tissue)- also known as
 Marginal Zone B - cell lymphoma (Low and High grade).
 Diffuse large B-cell lymphoma include high grade
 lymphoma of MALT origin and non-MALT type and they
 are indistinguishable. Other types include mantle cell
 lymphoma (malignant lymphomatous polyposis) , follicular
 lymphoma, Burkitt's lymphoma and rare solitary
 plasmacytoma.

 
The gastrointestinal (GI) tract, particularly the stomach, is the most common primary site of extranodal lymphoma. However, primary gastric lymphoma is uncommon and constitutes only 2%–5% of malignant gastric lesions . Most gastric lymphomas are of B-cell lineage. Among them, most primary low-grade B-cell lymphomas of the stomach have long been known as "pseudolymphomas" or "lymphoreticular hyperplasia" because of the presence of reactive follicles and mixed inflammatory cell infiltration at histopathologic examination and because of the favorable prognosis. However, recent immunohistochemical studies have shown that most pseudolymphomas are monoclonal B-cell proliferations and that the majority of these B cells are considered to originate from mucosa-associated lymphoid tissue (MALT). These B cells have the same cytologic and immunophenotypic characteristics as the B cells that are normally found around the mantle zones of Peyer patches Therefore, these low-grade B-cell lymphomas, which have the morphologic features of MALT with the high-grade lesions that may evolve from them, are known as MALT lymphoma .

Video Endoscopic Sequence 3 of 12.

 The gastrointestinal (GI) tract, particularly the stomach, is
 the most common primary site of extranodal lymphoma.
 However, primary gastric lymphoma is uncommon and
 constitutes only 2%–5% of malignant gastric lesions.
 Most gastric lymphomas are of B-cell lineage. Among
 them, most primary low-grade B-cell lymphomas of the
 stomach have long been known as "pseudolymphomas"
 or "lymphoreticular hyperplasia" because of the presence
 of reactive follicles and mixed inflammatory cell infiltration
 at histopathologic examination and because of the
 favorable prognosis. However, recent
 immunohistochemical studies have shown that most
 pseudolymphomas are monoclonal B-cell proliferations
 and that the majority of these B cells are considered to
 originate from mucosa-associated lymphoid tissue
 (MALT). These B cells have the same cytologic and
 immunophenotypic characteristics as the B cells that are
 normally found around the mantle zones of Peyer patches
 Therefore, these low-grade B-cell lymphomas, which have
 the morphologic features of MALT with the high-grade
 lesions that may evolve from them, are known as MALT
 lymphoma .

Multiple irregular shallow ulcers. The paradox of lymphomas arising in the stomach has been explained by the observation of MALT in the stomach in response to infections by H pylori and by the presence of this organism in more than 90% of gastric MALT lymphomas . In some cases, low-grade MALT lymphomas have regressed with eradication of H pylori . I

Video Endoscopic Sequence 4 of 12.

Multiple irregular shallow ulcers.

 The paradox of lymphomas arising in the stomach has been
 explained by the observation of MALT in the stomach in
 response to infections by H pylori and by the presence of
 this organism in more than 90% of gastric MALT
 lymphomas. In some cases, low-grade MALT lymphomas
 have regressed with eradication of H pylori .

GastricLymphoma5

Video Endoscopic Sequence 5 of 12.

 MALT lymphoma is an indolent (commonly called low
 grade) type of B-cell non-Hodgkin lymphoma,
 first recognised as a specific type of lymphoma in 1983.
 It occurs at sites that are outside lymph nodes or the
 spleen. The organisation of the lymphoma cells,
 when viewed under the microscope, resembles the
 lymphoid tissue normally found in the gut, which is
 called ‘mucosa-associated lymphoid tissue (MALT).
 MALT lymphoma most frequently arises within this type
 of lymphoid tissue after it has accumulated as part of
 a reaction to an infection or inflammation.
Chromoendoscopy with indigo carmine stain. MALT lymphoma is an indolent (commonly called low grade) type of B-cell non-Hodgkin lymphoma, first recognised as a specific type of lymphoma in 1983. It occurs at sites that are outside lymph nodes or the spleen. The organisation of the lymphoma cells, when viewed under the microscope, resembles the lymphoid tissue normally found in the gut, which is called ‘mucosa-associated lymphoid tissue’ (MALT). MALT lymphoma most frequently arises within this type of lymphoid tissue after it has accumulated as part of a reaction to an infection or inflammation.

Video Endoscopic Sequence 6 of 12.

Chromoendoscopy with indigo carmine stain.

 MALT lymphoma is an indolent (commonly called low grade)
 type of B-cell non-Hodgkin lymphoma, first recognised as a
 specific type of lymphoma in 1983. It occurs at sites that are
 outside lymph nodes or the spleen. The organisation of the
 lymphoma cells, when viewed under the microscope, resembles
 the lymphoid tissue normally found in the gut, which is called
 ‘mucosa-associated lymphoid tissue’ (MALT). MALT lymphoma
 most frequently arises within this type of lymphoid tissue after it
 has accumulated as part of a reaction to an infection or
 inflammation.

 In the new World Health Organisation classification of lymphoid
 tumours, MALT lymphoma is more correctly called 'extra-nodal
 marginal zone B-cell lymphoma'. This is because there is now
 strong evidence to suggest that the type of cell from which the
 lymphoma develops is a specific B-cell which is founding a
 specific compartment of the lymphoid tissue called the marginal
 zone.

In the new World Health Organisation classification of lymphoid tumours, MALT lymphoma is more correctly called 'extra-nodal marginal zone B-cell lymphoma'. This is because there is now strong evidence to suggest that the type of cell from which the lymphoma develops is a specific B-cell which is founding a specific compartment of the lymphoid tissue called the marginal zone.

Video Endoscopic Sequence 7 of 12.

 In the new World Health Organisation classification of
 lymphoid tumours, MALT lymphoma is more correctly
 called 'extra-nodal marginal zone B-cell lymphoma'. This is
 because there is now strong evidence to suggest that the
 type of cell from which the lymphoma develops is a specific
 B-cell which is founding a specific compartment of the
 lymphoid tissue called the marginal zone.
MALT lymphoma is the third most common type of non-Hodgkin lymphoma, although it only accounts for about 7-8% of these tumours. MALT lymphomas have been described at almost all extra-nodal sites (sites other than lymph nodes), but are most commonly found in the gastrointestinal tract - the gut - (50% of all MALT lymphomas) within which the stomach is the most frequently involved area (34% overall; 50-70% of gastrointestinal MALT lymphomas). It appears to be a contradiction that MALT lymphomas are found least frequently in sites in which MALT is normally present, like the terminal part of the small intestine, and seem only to develop when the lymphoid tissue arises in response to infection or other cause of inflammation.

Video Endoscopic Sequence 8 of 12.

 MALT lymphoma is the third most common type of
 non-Hodgkin lymphoma, although it only accounts for
 about 7-8% of these tumours. MALT lymphomas
 have been described at almost all extra-nodal sites
 (sites other than lymph nodes), but are most commonly
 found in the gastrointestinal tract - the gut - (50% of
 all MALT lymphomas) within which the stomach is the
 most frequently involved area (34% overall; 50-70%
 of gastrointestinal MALT lymphomas). It appears to be
 a contradiction that MALT lymphomas are found
 least frequently in sites in which MALT is normally
 present, like the terminal part of the small intestine,
 and seem only to develop when the lymphoid tissue
 arises in response to infection or other cause
 of inflammation.

GastricLymphoma9

Video Endoscopic Sequence 9 of 12.

 Gastric MALT lymphomas account for up to 4% of
 all primary gastric tumours and 40-50% of all
 primary gastric lymphomas (the remaining being mostly
 the more aggressive (commonly called high grade)
 diffuse large B-cell lymphomas).

 MALT lymphomas are approximately equally
 distributed between men and women. This lymphoma
 is most frequent in late middle aged/elderly people
 although it may be found in any age-group.
MALT lymphomas arise at sites that have acquired some MALT-type lymphoid tissue due to some other disease/disorder or infection. For some MALT lymphomas this underlying condition remains a mystery, while for others more is known about predisposing factors. For example, in the thyroid and salivary glands, MALT lymphomas can develop due to autoimmune inflammatory conditions known respectively as Hashimoto’s thyroiditis and Sjogren’s syndrome. However, most is known about gastric MALT lymphoma, as this is the commonest site at which these lymphomas develop. In the stomach, the majority of these lymphomas are associated with infection by a bacterium called Helicobacter pylori (see below). This causes inflammation of the lining of the stomach which includes the development of MALT-type lymphoid tissue. Once the MALT-type tissue is acquired, there is continuous stimulation of the lymphocytes to replicate and increase in number as a result of the constant presence of bacteria (a normal immune reaction). However, in a small minority of people, this results in a mistake within the genetic material of a lymphoid cell and continuation of this faulty cell line leads to the development of a lymphoma.

Video Endoscopic Sequence 10 of 12.

 MALT lymphomas arise at sites that have acquired some
 MALT-type lymphoid tissue due to some other
 disease/disorder or infection. For some MALT lymphomas
 this underlying condition remains a mystery, while for
 others more is known about predisposing factors.
 For example, in the thyroid and salivary glands,
 MALT lymphomas can develop due to autoimmune
 inflammatory conditions known respectively
 as Hashimoto’s thyroiditis and Sjogren’s syndrome.

 However, most is known about gastric MALT lymphoma,
 as this is the commonest site at which these lymphomas
 develop. In the stomach, the majority of these lymphomas
 are associated with infection by a bacterium called
 Helicobacter pylori This causes inflammation of the
 lining of the stomach which includes the development
 of MALT-type lymphoid tissue. Once the MALT-type
 tissue is acquired, there is continuous stimulation of the
 lymphocytes to replicate and increase in number as a
 result of the constant presence of bacteria
 (a normal immune reaction). However, in a small minority
 of people, this results in a mistake within the
 genetic material of a lymphoid cell and continuation of
 this faulty cell line leads to the development of a lymphoma.
GastricLymphoma11

Video Endoscopic Sequence 11 of 12.

 Until the early 1990's surgery was probably the most
 commonly used treatment for gastric MALT lymphoma.
 However, with the recognition of the common association
 between gastric MALT lymphoma and Helicobacter
 infection and following some laboratory-based studies on
 cells derived from lymphomas, it was suggested that
 eradication of Helicobacter alone might have a therapeutic
 effect. Further studies some of which now have follow-up
 extending to over ten years, have shown that eradication of
 Helicobacter alone can induce tumour regression in 50-70%
 of cases. The cases that respond the best are those that
 have not extended very far through the gastric wall and
 have not spread to lymph nodes. An initial antibiotic-based
 regime for eradication is usually prescribed, followed by
 endoscopies to confirm eradication of the organism and to
 assess tumour response.

The interval between Helicobacter eradication and
 regression of the tumour is highly variable between
 patients. A proportion of patients will not respond to
 eradication therapy alone and will go on to more
 conventional anti-lymphoma therapies such as
 chemotherapy or radiotherapy. There is, at present, no
 clear agreement between doctors as to when eradication
 therapy can be assessed as having failed in an individual,
 but while there are sequential improvements in biopsies
 taken during endoscopies, it may be worth delaying the use
 of other therapies. Some cases have been reported where
 there has been regression of the lymphoma many years
 after eradication and in the absence of other therapies.

GastricLymphoma12

Video Endoscopic Sequence 12 of 12.

 When Helicobacter eradication has been deemed to have failed,
 more conventional therapies can be used. While surgery has,
 in the past, been the mainstay of treatment for gastric lymphoma,
 this is no longer the case. Several studies have shown that,
 although the lymphoma is usually concentrated in one part of the
 stomach, there are small deposits all over the stomach lining.

 Both radiotherapy and chemotherapy have been shown to
 be highly effective in the treatment of gastric MALT lymphoma.
 Single-agent chemotherapy with alkylating agents (substances
 which are used to treat some cancers by interfering with
 cell metabolism and growth) such as cyclophosphamide
 or chlorambucil or nucleoside analogues (other drugs used
 to check the growth of lymphoma cells) such as cladribine
 appear to have equal activity.

 
Gastric Adenocarcinoma with metastases to the duodenum. This 74 year-old male with weigh loss of 20 pounds and vomiting. The image and the video clip shows a large mass in the duodenal bulb.

Endoscopic Sequence 1 of 15.

Gastric lymphoma with metastases to the duodenum.

This 74 year-old male with weigh loss of 20 pounds and vomiting.

The image and the video clip shows a large mass in the duodenal bulb.

Post bulbar metastases. Nearly all cases of primary gastric lymphoma are of the non-Hodgkin's variety. Diagnoses in such cases are difficult due to considerable histological similarities between the 2 disease entities.

Endoscopic Sequence 2 of 15.

Post Bulbar Metastases.

 Nearly all cases of primary gastric lymphoma are of the
 non-Hodgkin's variety. Diagnoses in such cases are
 difficult due to considerable histological similarities
 between the 2 disease entities.

 
Ca MetastDuoden3

Endoscopic Sequence 3 of 15.

Another view of the mass in the duodenal bulb.
Retroflexed view in the duodenum showing the large mass in the bulb in the limit of the second part of the duodenum.

Endoscopic Sequence 4 of 15.

 Retroflexed view in the duodenum showing the large mass
 in the bulb in the limit of the second part of the duodenum.
Retroflexed view

Endoscopic Sequence 5 of 15.

Retroflexed view

 
The Pre-pyloric antrum is showed with infiltration with the neoplasia.

Endoscopic Sequence 6 of 15.

The Pre-pyloric antrum is showed with infiltration with the neoplasia.

 
The antrum with extensive malign infiltration.

Endoscopic Sequence 7 of 15.

The antrum with extensive malign infiltration.
Ca MetastDuoden8

Endoscopic Sequence 8 of 15.

The gastric angle is infiltrated.
Ca MetastDuoden9

Endoscopic Sequence 9 of 15.

Some rest of food is observed.
In this image shows the freshness of the banana in the middle of neoplasia is evident.

Endoscopic Sequence 10 of 15.

In this image shows the freshness of the banana in the middle of neoplasia is evident.
Again, post bulbar metastases.

Endoscopic Sequence 11 of 15.

Again, post bulbar metastases.
Ca MetastDuoden12

Endoscopic Sequence 12 of 15.
Ca MetastDuoden15

Endoscopic Sequence 13 of 15.

 
Ca MetastDuoden13

Endoscopic Sequence 14 of 15.

 
Ca MetastDuoden14

Endoscopic Sequence 15 of 15.

 
Gastric Lymphoma. B-Cell Lymphoma. Non-Hodgkin's Lymphomas caused by malignant (cancerous) B-Cell lymphocytes represent a largesubset (about 85% in the US) of the known types of lymphoma (the other 2 subsets being T-Cell lymphomas and lymphomas where the cell type is unknown). B-Cells undergo many changes in their life cycle dependent on complex signaling processes between cells and interaction with foreign substances in the body. Apparently various types of lymphoma or leukemia can occur in the B-Cell life cycle.

Gastric Lymphoma.

B-Cell Lymphoma.

 Non-Hodgkin's Lymphomas caused by malignant
 (cancerous) B-Cell lymphocytes represent a largesubset
 (about 85% in the US) of the known types of lymphoma
 (the other 2 subsets being T-Cell lymphomas and
 lymphomas where the cell type is unknown). B-Cells
 undergo many changes in their life cycle dependent on
 complex signaling processes between cells and interaction
 with foreign substances in the body. Apparently various
 types of lymphoma or leukemia can occur in the B-Cell life
 cycle.
Malt Lymphoma. Small cell lymphomas may resemble reactive lymphoid hyperplasia. Lymphomatous involvement of the stomach may have a variety of manifestations, including large infiltrated rouge, eroded nodules and exophytic and ulcerated masses, erosions and ulcers.

Malt Lymphoma.

 Small cell lymphomas may resemble reactive lymphoid
 hyperplasia.
 Lymphomatous involvement of the stomach may have
 a variety of manifestations, including large infiltrated
 rouge, eroded nodules and exophytic and ulcerated
 masses, erosions and ulcers.
 
Non-Hodking Lymphoma B Cells.

Video Endoscopic Sequence 1 of 7.

Non-Hodking Lymphoma B Cells. MALT
 (mucosa associated lymphoid tissue).
Non-Hodking Lymphoma.

Video Endoscopic Sequence 2 of 7.

Non-Hodking Lymphoma MALT
 (mucosa associated lymphoid tissue).
Lymphoid Neoplasia that substitutes the gastric mucosa.

Video Endoscopic Sequence 3 of 7.

Lymphoid Neoplasia that substitutes the gastric mucosa.
Cytokeratine negative by Inmunohistochemistry.

Video Endoscopic Sequence 4 of 7.

Cytokeratine negative by Inmunohistochemistry.
LCA positive.

Video Endoscopic Sequence 5 of 7.

LCA positive
CD20: Positive in cells tumor.

Video Endoscopic Sequence 6 of 7.

CD20: Positive in cells tumor.

CD3: Negative. Non-Hodking Lymphoma B Cells.

Video Endoscopic Sequence 7 of 7.

CD3: Negative.

Non-Hodking Lymphoma B Cells.
Systemic Lymphoma. There are several lesions in the stomach that histologically and proved to be systemic lymphoma.

 Systemic Lymphoma.

 There are several lesions in the stomach that histologically
 and proved to be systemic lymphoma.
Non-Hodking Lymphoma.

Video Endoscopic Sequence 1 of 3.

Non-Hodking Lymphoma
Non-Hodking Lymphoma.

Video Endoscopic Sequence 2 of 3.

Non-Hodking Lymphoma
Non-Hodking Lymphoma.

Video Endoscopic Sequence 3 of 3.

Non-Hodking Lymphoma
This 69 year-old woman, was referred to our unit for endoscopic evaluation of previous diagnostic of a gastric lymphoma. A large and ulcerated mass was found at on the greater curvature of the body and fundus.

Video Endoscopic Sequence 1 of 10.

 This 69 year-old woman, was referred to our unit for
 endoscopic evaluation of previous diagnostic of a gastric
 lymphoma.

 A large and ulcerated mass was found at on the greater
 curvature of the body and fundus.
Fungating, ulcerated mass extending from the distal foundus to the body.

Video Endoscopic Sequence 2 of 10.

 Fungating, ulcerated mass extending from the distal foundus to the body.

 
Helicobacter pylori infection is a risk factor for gastric lymphoma . Some MALT lymphomas have been reported in immunocompromised patients (in AIDS and following organ transplantation). High grade lymphoma following organ transplantation may be related to Epstein-Barr virus.

Video Endoscopic Sequence 3 of 10.

Helicobacter pylori infection is a risk factor for gastric lymphoma

 Some MALT lymphomas have been reported in
 immunocompromised patients (in AIDS and following
 organ transplantation). High grade lymphoma following
 organ transplantation may be related to Epstein-Barr virus.

 
An endoscopic view from the cardias and fundus.

Video Endoscopic Sequence 4 of 10.

An endoscopic view from the cardias and fundus

A close up showing multiple irregular ulcers.

Video Endoscopic Sequence 5 of 10.

A close up showing multiple irregular ulcers
Cytokeratin negative on lymphoid infiltrate.

Video Endoscopic Sequence 6 of 10.

Cytokeratin negative on lymphoid infiltrate

 
Giemsa stain show severe lymphoid infiltration.

Video Endoscopic Sequence 7 of 10.

Giemsa stain shows severe lymphoid infiltration

 
There are lymphocytic infiltration with lymphoepithelial lesion.

Video Endoscopic Sequence 8 of 10.

There are lymphocytic infiltration with lymphoepithelial lesion

 
Lymphocyte infiltrating the lamina propria.

Video Endoscopic Sequence 9 of 10.

Lymphocyte infiltrating the lamina propria

 
Leucocyte common antigen positive.

Video Endoscopic Sequence 10 of 10.

Leucocyte common antigen positive

Abstracts:

 Critical evaluation of Bcl-6 protein expression in diffuse large B
 cell lymphoma of the stomach and small intestine. Am J of Surg
 Pathol. 2003 ; 27 (6): 790-8.

 Regression of high grade mucosa associated lymphoid tissue
 (MALT) lymphoma after Helicobacter pylori eradication. Gut
 2001 ; 49 ( 4) : 584-7. (full text)

 Clinicopathological features of gastric-mucosa associated
 lymphoid tissue lymphoma : a comparison with diffuse large
 B-cell lymphoma without a mucosa associated lymphoid tissue
 lymphoma component . J Gastroenterol Hepatol. 2001; 16 (7):
 734-9.

 Histological grading with clinical relevance in gastric
 mucosa-associated lymphoid tissue (MALT) lymphoma. Recent
 Results Cancer Res. 2000 : 156: 27-32.

 Clinicopathological features of gastric mucosa associated
 lymphoid tissue (MALT) lymphomas: high grade transformation
 and comparison with diffuse large B cell lymphomas without
 MALT lymphoma features. J Clin Pathol 2000; 53: 187-190.

 Gastrointestinal lymphoma. Hum Pathol. 1994; 25; 1020-29.

 Relationship between high-grade lymphoma and B-cell
 mucosa-associated lymphoid tissue lymphoma (MALToma) of
 the stomach. Am J Pathol. 1990; 136;1153-1164

 Gastrointestinal lymphomas: an overview with emphasis on new
 findings and diagnostic problems.Seminars in Diagnostic
 Pathology 1996; 13 260-96