MKSAP Quiz: Persistent dyspepsia despite treatment
A 65-year-old man is evaluated for persistent dyspepsia despite treatment with antacid therapy. He also has recent weight loss of 3 kg (6.6 lb) and development of epigastric abdominal pain. Following a physical exam, biopsy, and CT scan, what is the most appropriate management?
A 65-year-old man is evaluated for persistent dyspepsia despite treatment with antacid therapy. He also has recent weight loss of 3 kg (6.6 lb) and development of epigastric abdominal pain. He does not smoke or drink alcohol. He takes no medications other than antacids.
On physical examination, vital signs are normal. There is epigastric tenderness but no abdominal masses, no hepatosplenomegaly, and no lymphadenopathy.
The endoscopic biopsy specimen shows evidence of mucosa-associated lymphoid tissue (MALT) lymphoma involving the stomach. Immunohistochemical stains for Helicobacter pylori are positive.
A CT scan shows thickening of the gastric wall but no abdominal or other lymphadenopathy.
Which of the following is the most appropriate management?
A. Combination therapy with rituximab and chemotherapy
B. Gastrectomy
C. PET
D. Proton pump inhibitor and antibiotic therapy
E. Radiation therapy
MKSAP Answer and Critique
The correct answer is D. Proton pump inhibitor and antibiotic therapy. This content is available to MKSAP 18 subscribers as Question 87 in the Hematology and Oncology section. More information about MKSAP is available online.
The appropriate treatment for this patient with gastric mucosa-associated lymphoid tissue (MALT) lymphoma associated with Helicobacter pylori infection is proton pump inhibitor and dual antibiotic therapy, such as clarithromycin and amoxicillin, for 7 to 14 days. Chronic antigen stimulation can lead to clonal expansion of MALT and progress to malignant transformation manifesting as lymphoma. The lymphoma originates in B cells in the marginal zone of MALT and expresses the CD20 surface antigen. Eradication of H. pylori infection is associated with a high rate of response and long-term remission for these tumors and is the treatment of choice given its efficacy and ease of use. Regression of these lymphomas occurs slowly, and serial endoscopy will be needed to document this patient's response to therapy.
For MALT lymphoma that is not localized to the stomach or, rarely, that is localized to the stomach but does not respond to eradication of H. pylori infection, anti-CD20–directed therapy with rituximab may be effective. However, the initial treatment for this patient is eradication of H. pylori infection.
Although surgery can be used to treat localized gastrointestinal lymphomas, it is generally performed in the setting of a complication, such as hemorrhage or perforation, because other therapies are less invasive and may be as effective as or more effective than surgery.
Obtaining a PET scan to complete staging before making treatment recommendations is not needed for this patient. Marginal zone lymphomas are less likely to be detected by PET than follicular and aggressive lymphomas; therefore, the test is less sensitive and is unlikely to change management in the absence of other abnormal findings on CT scanning or clinical examination.
Radiation therapy is quite effective in the treatment of gastric marginal zone lymphoma, with high local control rates and relatively low toxicity. However, radiation would generally be reserved for patients for whom H. pylori eradication therapy has failed, those with residual or recurrent disease, or those who are H. pylori−negative and thus not likely to respond to antibiotic therapy.
Key Point
- The initial treatment for gastric mucosa-associated lymphoid tissue lymphoma associated with Helicobacter pylori infection is proton pump inhibitor and antibiotic therapy.