(Radiographics. 2001;21:1491-1502.)
© RSNA, 2001
Gastric Mucosa-associated Lymphoid Tissue Lymphoma: Spectrum of Findings at Double-Contrast Gastrointestinal Examination with Pathologic Correlation1
Su Kyung An, MD,
Joon Koo Han, MD,
Young Hoon Kim, MD,
Ah Young Kim, MD,
Byung Ihn Choi, MD,
Young A Kim, MD and
Chul Woo Kim, MD
1 From the Departments of Radiology (S.K.A., J.K.H., Y.H.K., A.Y.K., B.I.C.) and Pathology (Y.A.K., C.W.K.), Seoul National University College of Medicine, 28 Yongon-dong, Chongno-Gu, Seoul 110-744, Korea; and the Institute of Radiation Medicine, Seoul National University Medical Research Center, Korea (S.K.A., J.K.H., Y.H.K., A.Y.K., B.I.C.). Presented as an education exhibit at the 2000 RSNA scientific assembly. Received March 23, 2001; revision requested May 3; final revision received July 30; accepted August 2. Address correspondence to J.K.H. (e-mail: hanjk@radcom.snu.ac.kr).
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Abstract
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Mucosa-associated lymphoid tissue (MALT) is found in the surface epithelium of the stomach. MALT lymphoma is extranodal lymphoma originating from MALT. In the stomach, a strong association with Helicobacter pylori infection has been demonstrated. Low-grade gastric MALT lymphoma has been reported to have variable features at upper gastrointestinal (UGI) examination. Twenty-two patients with low-grade MALT lymphoma had ulcers (n = 11), fold thickening (n = 7), mucosal nodularity (n = 7), masses (n = 6), or prominent areae gastricae (n = 4) at UGI examination. Six patients with high-grade MALT lymphoma had masses (n = 4), fold thickening (n = 3), ulcers (n = 1), or mucosal nodularity (n = 1) at UGI examination. These findings were similar to those in gastric carcinoma or gastritis. Differentiation of low-grade MALT lymphoma from gastritis or gastric carcinoma was more difficult than differentiation of high-grade MALT lymphoma. Lesions of MALT lymphoma associated with H pylori gastritis were diffuse or multiple in 65% of cases; however, lesions of MALT lymphoma without proved H pylori gastritis were focal or solitary in 80% of cases. Therefore, multiplicity of lesions in MALT lymphoma was closely associated with H pylori infection.
Index Terms: Lymphoma, 72.349 • Lymphoma, diagnosis, 72.123 • Mucosa associated lymphoid tissue (MALT), 72.349 • Stomach, neoplasms, 72.349
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LEARNING OBJECTIVES FOR TEST 5
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After reading this article and taking the test, the reader will be able to:
- Recognize the findings of gastric MALT lymphoma at double-contrast UGI examination.
- Describe the distinguishing feature of gastric MALT lymphoma associated with H pylori infection.
- Discuss differential diagnosis of gastric MALT lymphoma from other gastric lesions such as gastritis and gastric carcinoma.
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Introduction
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The stomach is the most common site of extranodal lymphoma. However, there is normally no lymphoid tissue in the gastric mucosa. This paradox can be explained by the fact that chronic Helicobacter pylori gastritis is associated with the development of lymphoid tissue in the lamina propria (1,2). Most low-grade primary gastric lymphomas arise from this mucosa-associated lymphoid tissue (MALT) and are therefore classified as MALT lymphomas (3–5). As a result, it has been postulated that chronic infection of the stomach by H pylori causes lymphoid proliferation in the gastric mucosa, with subsequent development of gastric MALT lymphoma (6).
At histologic analysis, gastric MALT lymphoma can be classified into two types: low grade and high grade (7). Recently, low-grade MALT lymphoma has been reported to account for as many as 50%–72% of all primary gastric lymphomas (8,9). Most lesions that were previously considered to be gastric pseudolymphomas are considered low-grade MALT lymphomas according to current criteria (10). In addition, it has been suggested that high-grade MALT lymphoma results from transformation of the low-grade tumor (9). These statements suggest that MALT lymphoma is a more common tumor than was previously recognized.
Low-grade MALT lymphoma and high-grade MALT lymphoma show striking clinical and prognostic differences (11). Low-grade MALT lymphoma diagnosed at an early stage has a good prognosis (12–14). In some cases, eradication of H pylori with antibiotic therapy has resulted in regression of early-stage tumors (15). These facts strongly suggest a need for early diagnosis (16). However, detection of early-stage gastric lymphoma is not easy because it is often confused with gastritis and gastric carcinoma.
Computed tomography (CT) is indispensable for evaluation of higher-stage tumors and extragastric involvement. However, CT is of limited value in diagnosing low-grade MALT lymphoma featuring minimal gastric wall thickening or a shallow lesion (17). As a result, double-contrast upper gastrointestinal (UGI) examination is the most effective tool for detecting lesions at the earliest and curable stage. The appearance of gastric MALT lymphoma at UGI examination was first reported as innumerable tiny nodules throughout the stomach (6). Later, several studies demonstrated mucosal nodularity, a shallow or deep ulcer, single or multiple masses, rugal thickening, and enlarged areae gastricae (18,19).
In this article, we review the common manifestations of gastric MALT lymphoma at double-contrast UGI examination and correlate them with histopathologic manifestations. This article overlaps in terms of patient population and topic with the 1999 report by Kim et al (18). However, our patient population was more homogeneous and included high-grade MALT lymphoma as well as low-grade MALT lymphoma. In addition, we reached somewhat different conclusions than those reached by Kim et al (18).
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Materials and Methods
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Between July 1992 and July 2000, gastric MALT lymphoma was diagnosed with endoscopic biopsy or surgery in 50 patients at our institution. Twenty-eight of these patients underwent double-contrast UGI examination. We used 20 mg of intramuscularly injected scopolamine butylbromide (Buscopan; Boehringer Ingelheim Korea, Seoul, Korea) as a hypotonic agent and orally administered 200–250 mL of a 140% wt/vol barium suspension (Solotop-HD; Taejoon Pharm, Kyungkido, Korea). The effervescent agents were swallowed for adequate air distention. Under fluoroscopic observation, multiple spot radiographs were obtained after adequate mucosal coating. We retrospectively reviewed the UGI examination findings in 22 patients with low-grade MALT lymphoma and six patients with high-grade MALT lymphoma. (Fifteen of these patients were also included in the study of Kim et al [18].) We determined the most probable diagnosis on the basis of the radiologic findings and correlated them with endoscopic and pathologic findings. In two patients, the lesion could not be demonstrated at UGI examination.
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Results
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Clinical Findings
Sixteen of the 28 patients were women and 12 were men. The average patient age was 52 years and the age range was 31–80 years at diagnosis. The clinical symptoms were epigastric pain or discomfort in 22 patients (79%), anorexia in two (7%), no symptoms in two (7%), indigestion in one (4%), and gastrointestinal bleeding in one (4%).
Pathologic Findings
The lesions were seen at endoscopic examination (all 28 patients) or surgery (24 patients). Nineteen patients (68%) had lesions in the gastric body, 16 (57%) had lesions in the antrum, and two (7%) had lesions in the fundus. Biopsy specimens demonstrated low-grade MALT lymphoma in 22 patients (79%) and high-grade MALT lymphoma in six patients (21%). The high-grade MALT lymphomas included a background of low-grade MALT lymphoma at pathologic examination.
Findings at Double-Contrast UGI Examination
As in some preceding reports, our study showed variable UGI examination findings of MALT lymphoma (14,15). These are summarized in Table 1.
Ulcer.—
Single or multiple ulcers, found in 12 patients (43%), were the most common finding, especially in low-grade MALT lymphoma (50%). The ulcers were of varying size and were shallow or deep. Of the 11 patients with low-grade MALT lymphoma and ulcers, seven (64%) had multiple erosions or shallow ulcers (Fig 1) and four (36%) had deep ulcers. In the one patient with high-grade MALT lymphoma and an ulcer, the ulcer was deep (Fig 2). The most probable diagnoses in cases of low-grade MALT lymphoma with single or multiple deep ulcers were advanced gastric carcinoma and lymphoma. When the ulcers manifested as shallow lesions, the most probable diagnoses were gastritis, early gastric carcinoma, and advanced gastric carcinoma. The probable diagnoses are summarized in Table 2. The ulcers were usually located in the antrum or body. Six patients (50%) had mucosal convergence around the ulcer.
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Figure 1a. Low-grade gastric MALT lymphoma with multiple shallow ulcers in a 31-year-old woman. The probable diagnosis in this patient was gastritis. (a) Spot radiograph of the gastric antrum shows multiple erosions (open arrows) with diffuse enlargement of the areae gastricae (solid arrows). (b) Photograph of the resected specimen shows multiple shallow ulcers (arrows) in the gastric body and antrum. (c) Low-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows lymphoma cells (blue stain) diffusely infiltrating the mucosa (m) and submucosa (sm).
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Figure 1b. Low-grade gastric MALT lymphoma with multiple shallow ulcers in a 31-year-old woman. The probable diagnosis in this patient was gastritis. (a) Spot radiograph of the gastric antrum shows multiple erosions (open arrows) with diffuse enlargement of the areae gastricae (solid arrows). (b) Photograph of the resected specimen shows multiple shallow ulcers (arrows) in the gastric body and antrum. (c) Low-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows lymphoma cells (blue stain) diffusely infiltrating the mucosa (m) and submucosa (sm).
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Figure 1c. Low-grade gastric MALT lymphoma with multiple shallow ulcers in a 31-year-old woman. The probable diagnosis in this patient was gastritis. (a) Spot radiograph of the gastric antrum shows multiple erosions (open arrows) with diffuse enlargement of the areae gastricae (solid arrows). (b) Photograph of the resected specimen shows multiple shallow ulcers (arrows) in the gastric body and antrum. (c) Low-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows lymphoma cells (blue stain) diffusely infiltrating the mucosa (m) and submucosa (sm).
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Figure 2a. High-grade gastric MALT lymphoma with a background of low-grade MALT lymphoma in a 78-year-old woman. The probable diagnosis was advanced gastric carcinoma. (a) Compression spot radiograph shows a large, deep ulcer (solid arrows) in the posterior wall of the antrum. The convergence of thickened folds (open arrows) is disorganized. (b) Photograph of the resected specimen shows the ulcer (solid arrows) and the disorganized convergent rugae (open arrows).
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Figure 2b. High-grade gastric MALT lymphoma with a background of low-grade MALT lymphoma in a 78-year-old woman. The probable diagnosis was advanced gastric carcinoma. (a) Compression spot radiograph shows a large, deep ulcer (solid arrows) in the posterior wall of the antrum. The convergence of thickened folds (open arrows) is disorganized. (b) Photograph of the resected specimen shows the ulcer (solid arrows) and the disorganized convergent rugae (open arrows).
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Mass.—
Single or multiple masses were seen in 10 patients (36%). A mass with or without an ulcer was the second most common finding, along with thickened folds. In cases of high-grade MALT lymphoma, a mass was the most common UGI examination finding (67%). However, a mass was seen in only 27% of patients with low-grade MALT lymphoma. The diameter of the masses was larger in cases of high-grade lymphoma (5–10 cm) than in cases of low-grade lymphoma (1–5 cm). Six patients had multiple masses (Fig 3), whereas four patients had a single mass. All patients with a single mass and three patients with multiple masses had an accompanying ulcer in the mass (70%) (Fig 4). Three patients had mucosal convergence around the mass. The lesions were located in the antrum (n = 3), gastric body (n = 3), and antrum and gastric body (n = 4). Among the 10 patients, the probable diagnosis was lymphoma in six and advanced gastric carcinoma in four.
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Figure 3a. Low-grade gastric MALT lymphoma with masses in a 71-year-old woman. The probable diagnosis was lymphoma. (a) Spot radiograph from a UGI examination shows a large, well-circumscribed, lobulated mass in the gastric fundus (arrows). (b) Compression spot radiograph shows a small, polypoid mass in the greater curvature of the gastric body (arrow). (c) Photograph from endoscopy shows the large mass protruding from the fundus (solid arrows) and the small polyp in the gastric body (open arrow).
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Figure 3b. Low-grade gastric MALT lymphoma with masses in a 71-year-old woman. The probable diagnosis was lymphoma. (a) Spot radiograph from a UGI examination shows a large, well-circumscribed, lobulated mass in the gastric fundus (arrows). (b) Compression spot radiograph shows a small, polypoid mass in the greater curvature of the gastric body (arrow). (c) Photograph from endoscopy shows the large mass protruding from the fundus (solid arrows) and the small polyp in the gastric body (open arrow).
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Figure 3c. Low-grade gastric MALT lymphoma with masses in a 71-year-old woman. The probable diagnosis was lymphoma. (a) Spot radiograph from a UGI examination shows a large, well-circumscribed, lobulated mass in the gastric fundus (arrows). (b) Compression spot radiograph shows a small, polypoid mass in the greater curvature of the gastric body (arrow). (c) Photograph from endoscopy shows the large mass protruding from the fundus (solid arrows) and the small polyp in the gastric body (open arrow).
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Figure 4a. Low-grade gastric MALT lymphoma with a mass, an associated central ulcer, and another ulcer in an 80-year-old man. The probable diagnosis was advanced gastric carcinoma. (a) Compression spot radiograph shows a well-demarcated mass (solid arrows) with a central ulcer (u) and an adjacent filling defect (open arrow) with converging folds in the antrum. (Reprinted, with permission, from reference 18.) (b) Photograph of the resected specimen shows the mass (solid arrow) and the central ulcer (u) (the so-called bull’s-eye appearance) in the antrum. Another ulcer (open arrow) is accompanied by a small mass, which caused the filling defect seen in a. (c) Low-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows extension of tumor cells (blue stain) to the muscle layer. m = mucosa, pm = proper muscle, sm = submucosa. (d) Higher-power photomicrograph (x40) of the area in the top left corner of c shows normal gastric mucosa on the left and replacement by lymphoma cells on the right.
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Figure 4b. Low-grade gastric MALT lymphoma with a mass, an associated central ulcer, and another ulcer in an 80-year-old man. The probable diagnosis was advanced gastric carcinoma. (a) Compression spot radiograph shows a well-demarcated mass (solid arrows) with a central ulcer (u) and an adjacent filling defect (open arrow) with converging folds in the antrum. (Reprinted, with permission, from reference 18.) (b) Photograph of the resected specimen shows the mass (solid arrow) and the central ulcer (u) (the so-called bull’s-eye appearance) in the antrum. Another ulcer (open arrow) is accompanied by a small mass, which caused the filling defect seen in a. (c) Low-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows extension of tumor cells (blue stain) to the muscle layer. m = mucosa, pm = proper muscle, sm = submucosa. (d) Higher-power photomicrograph (x40) of the area in the top left corner of c shows normal gastric mucosa on the left and replacement by lymphoma cells on the right.
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Figure 4c. Low-grade gastric MALT lymphoma with a mass, an associated central ulcer, and another ulcer in an 80-year-old man. The probable diagnosis was advanced gastric carcinoma. (a) Compression spot radiograph shows a well-demarcated mass (solid arrows) with a central ulcer (u) and an adjacent filling defect (open arrow) with converging folds in the antrum. (Reprinted, with permission, from reference 18.) (b) Photograph of the resected specimen shows the mass (solid arrow) and the central ulcer (u) (the so-called bull’s-eye appearance) in the antrum. Another ulcer (open arrow) is accompanied by a small mass, which caused the filling defect seen in a. (c) Low-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows extension of tumor cells (blue stain) to the muscle layer. m = mucosa, pm = proper muscle, sm = submucosa. (d) Higher-power photomicrograph (x40) of the area in the top left corner of c shows normal gastric mucosa on the left and replacement by lymphoma cells on the right.
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Figure 4d. Low-grade gastric MALT lymphoma with a mass, an associated central ulcer, and another ulcer in an 80-year-old man. The probable diagnosis was advanced gastric carcinoma. (a) Compression spot radiograph shows a well-demarcated mass (solid arrows) with a central ulcer (u) and an adjacent filling defect (open arrow) with converging folds in the antrum. (Reprinted, with permission, from reference 18.) (b) Photograph of the resected specimen shows the mass (solid arrow) and the central ulcer (u) (the so-called bull’s-eye appearance) in the antrum. Another ulcer (open arrow) is accompanied by a small mass, which caused the filling defect seen in a. (c) Low-power photomicrograph (original magnification, x10; hematoxylin-eosin stain) shows extension of tumor cells (blue stain) to the muscle layer. m = mucosa, pm = proper muscle, sm = submucosa. (d) Higher-power photomicrograph (x40) of the area in the top left corner of c shows normal gastric mucosa on the left and replacement by lymphoma cells on the right.
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Fold Thickening.—
Rugal thickening was found in 10 patients (36%). In nine patients, the thickened folds converged to an ulcer (n = 6) or mass (n = 3) (Fig 5). One patient with high-grade MALT lymphoma had rugal thickening without an ulcer or mass (Fig 6). Thickened folds were an accompanying finding to other lesions, such as masses, ulcers, or mucosal nodularity, rather than a unique finding (18,19). The probable diagnoses in the patients with fold change were advanced gastric carcinoma (n = 5), lymphoma (n = 4), and early gastric carcinoma (n = 1).
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Figure 5a. High-grade gastric MALT lymphoma with a mass and rugal thickening in a 64-year-old man. The probable diagnosis was lymphoma. (a) Spot radiograph shows a well-demarcated mass (solid arrows) in the antrum and disorganized thickened folds (open arrows) that are primarily proximal to the mass. (b) Photograph of the resected specimen shows disorganization of the thickened rugae (black arrows) proximal to the mass (white arrows). (c) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows severe destruction of gastric glands by high-grade lymphoma cells.
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Figure 5b. High-grade gastric MALT lymphoma with a mass and rugal thickening in a 64-year-old man. The probable diagnosis was lymphoma. (a) Spot radiograph shows a well-demarcated mass (solid arrows) in the antrum and disorganized thickened folds (open arrows) that are primarily proximal to the mass. (b) Photograph of the resected specimen shows disorganization of the thickened rugae (black arrows) proximal to the mass (white arrows). (c) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows severe destruction of gastric glands by high-grade lymphoma cells.
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Figure 5c. High-grade gastric MALT lymphoma with a mass and rugal thickening in a 64-year-old man. The probable diagnosis was lymphoma. (a) Spot radiograph shows a well-demarcated mass (solid arrows) in the antrum and disorganized thickened folds (open arrows) that are primarily proximal to the mass. (b) Photograph of the resected specimen shows disorganization of the thickened rugae (black arrows) proximal to the mass (white arrows). (c) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows severe destruction of gastric glands by high-grade lymphoma cells.
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Figure 6a. High-grade gastric MALT lymphoma with rugal thickening in a 45-year-old man. The probable diagnosis was lymphoma. (a) Spot radiograph shows thickened nodular folds (arrows) in the greater curvature of the gastric body. No abnormal finding besides rugal thickening was observed in the resected specimen. (b) Low-power photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows the characteristic lymphoepithelial lesions formed by invasion of individual glands (arrows) or surface epithelium (arrowheads) by high-grade lymphoma cells that displace or destroy the glandular epithelium.
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Figure 6b. High-grade gastric MALT lymphoma with rugal thickening in a 45-year-old man. The probable diagnosis was lymphoma. (a) Spot radiograph shows thickened nodular folds (arrows) in the greater curvature of the gastric body. No abnormal finding besides rugal thickening was observed in the resected specimen. (b) Low-power photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows the characteristic lymphoepithelial lesions formed by invasion of individual glands (arrows) or surface epithelium (arrowheads) by high-grade lymphoma cells that displace or destroy the glandular epithelium.
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Mucosal Nodularity.—
Focal (n = 3) or diffuse (n = 5) mucosal nodularity was found in eight patients (29%). Seven of these patients had low-grade MALT lymphoma. The nodules were round or oval and of variable size (Fig 7). Diffuse nodular lesions were usually located in the antrum. Focal nodularity was located in the fundus, gastric body, and antrum. In six patients, an ulcer or mass was an accompanying finding; in two patients, mucosal nodularity was the only abnormal radiologic finding. The probable diagnoses were gastritis (n = 1), early gastric carcinoma (n = 2), advanced gastric carcinoma (n = 3), and lymphoma (n = 2).
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Figure 7a. Low-grade gastric MALT lymphoma with diffuse nodularity in a 54-year-old woman. The probable diagnosis was lymphoma. (a) Spot radiograph shows numerous nodules of varying size in the gastric body and antrum. (b) Photograph of the resected specimen shows diffuse nodules with distinct margins and variable sizes. (c) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows diffuse tumor cells and lymphoepithelial lesions (arrows) formed by invasion of individual glands by low-grade lymphoma cells.
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Figure 7b. Low-grade gastric MALT lymphoma with diffuse nodularity in a 54-year-old woman. The probable diagnosis was lymphoma. (a) Spot radiograph shows numerous nodules of varying size in the gastric body and antrum. (b) Photograph of the resected specimen shows diffuse nodules with distinct margins and variable sizes. (c) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows diffuse tumor cells and lymphoepithelial lesions (arrows) formed by invasion of individual glands by low-grade lymphoma cells.
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Figure 7c. Low-grade gastric MALT lymphoma with diffuse nodularity in a 54-year-old woman. The probable diagnosis was lymphoma. (a) Spot radiograph shows numerous nodules of varying size in the gastric body and antrum. (b) Photograph of the resected specimen shows diffuse nodules with distinct margins and variable sizes. (c) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows diffuse tumor cells and lymphoepithelial lesions (arrows) formed by invasion of individual glands by low-grade lymphoma cells.
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Coarse Areae Gastricae.—
Prominent areae gastricae were a unique finding (n = 1) or were accompanied by diffuse nodularity or multiple erosions (n = 3). The lesions were diffuse in the antrum and gastric body (Fig 8). The probable diagnoses were gastritis in three patients and lymphoma in one. In some cases, mucosal nodularity was difficult to differentiate from enlarged areae gastricae. The nodules had distinct margins and were round or oval and variable in size, whereas areae gastricae tended to be more uniform in size, producing a sharply marginated reticular network.
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Figure 8a. Low-grade gastric MALT lymphoma with enlarged areae gastricae and subsequent diffuse mucosal nodularity in a 48-year-old man. The probable diagnosis was gastritis. (a) Spot radiograph shows diffuse prominent areae gastricae in the gastric body and antrum. (b) Photograph from endoscopy shows diffuse enlarged areae gastricae. (c) Photograph of the resected specimen shows distinct nodularity of the gastric mucosa. (Fig 8c reprinted, with permission, from reference 20.)
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Figure 8b. Low-grade gastric MALT lymphoma with enlarged areae gastricae and subsequent diffuse mucosal nodularity in a 48-year-old man. The probable diagnosis was gastritis. (a) Spot radiograph shows diffuse prominent areae gastricae in the gastric body and antrum. (b) Photograph from endoscopy shows diffuse enlarged areae gastricae. (c) Photograph of the resected specimen shows distinct nodularity of the gastric mucosa. (Fig 8c reprinted, with permission, from reference 20.)
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Figure 8c. Low-grade gastric MALT lymphoma with enlarged areae gastricae and subsequent diffuse mucosal nodularity in a 48-year-old man. The probable diagnosis was gastritis. (a) Spot radiograph shows diffuse prominent areae gastricae in the gastric body and antrum. (b) Photograph from endoscopy shows diffuse enlarged areae gastricae. (c) Photograph of the resected specimen shows distinct nodularity of the gastric mucosa. (Fig 8c reprinted, with permission, from reference 20.)
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Probable Diagnoses.—
The probable diagnoses are summarized in Table 3. The proportion of correct diagnoses at UGI examination was 25% in cases of low-grade MALT lymphoma and 67% in cases of high-grade MALT lymphoma. It was more difficult to differentiate low-grade MALT lymphoma from gastritis or gastric carcinoma than it was to differentiate high-grade MALT lymphoma.
H pylori Gastritis.—
Twenty (77%) of 26 patients who underwent evaluation for H pylori had histopathologic evidence of infection. We compared the UGI examination findings in cases of MALT lymphoma and associated H pylori gastritis with the findings in cases of MALT lymphoma without proved H pylori gastritis. The lesions were multiple in 65% of cases with H pylori gastritis (13 of 20) and in 20% of cases without H pylori gastritis (one of five). (The lesion in one of the 26 patients could not be seen at UGI examination.) Therefore, multiplicity of lesions in MALT lymphoma was closely associated with H pylori infection.
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Discussion
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Gastric MALT lymphoma showed variable radiologic features at UGI examination. In particular, low-grade MALT lymphoma had a wider spectrum of appearances than high-grade MALT lymphoma. The most common finding in low-grade MALT lymphoma was ulcer (50% of cases), which was the second most common finding in the report by Kim et al (18). The distinctive finding in high-grade MALT lymphoma was a mass, which was present in most cases (67%). These findings are summarized in Table 1.
The most common finding in gastric MALT lymphoma (both low and high grade) was ulcers of variable size, depth, and number (43% of cases). In patients with low-grade MALT lymphoma, the ulcers manifested as multiple erosions or shallow ulcers in 63% of cases and as deep ulcers in 37%. Multiple shallow lesions tended to occur in low-grade rather than high-grade MALT lymphoma. The study by Kim et al (18) revealed thickened mucosal folds converging on the ulcer in 75% of patients with low-grade MALT lymphoma. In our study, six patients (50%) had mucosal convergence around the ulcer. It was difficult to differentiate gastric MALT lymphoma manifesting as an ulcer from other stomach diseases, especially gastric adenocarcinoma (Table 2).
A mass with or without an ulcer was the second most common finding in gastric MALT lymphoma (36% of cases). A mass was the most common finding in cases of high-grade MALT lymphoma (67%); however, among patients with low-grade MALT lymphoma, masses were seen in only 27% in our study and in 16% in the study of Kim et al (18). The masses were larger in high-grade than in low-grade MALT lymphoma. Masses in gastric MALT lymphoma were accompanied by an internal ulcer in 70% of cases. In particular, high-grade MALT lymphomas manifesting as masses demonstrated central ulcers in all four patients.
Rugal thickening was the second most common finding, along with masses. However, rugal thickening was an accompanying finding to other lesions, such as ulcers or masses, rather than a unique finding (18,19). Mucosal nodularity, which was the most common finding in the study of Kim et al (18), was the third most common finding in our study. Seven of eight patients with mucosal nodularity had low-grade MALT lymphoma. Prominent areae gastricae were a unique finding or were accompanied by diffuse nodularity or multiple erosions. In some cases, mucosal nodularity was difficult to differentiate from enlarged areae gastricae.
The paradox of lymphoma arising in the stomach has been explained by the observation of MALT in the stomach in response to infection with H pylori and by the presence of this organism in more than 90% of gastric MALT lymphomas (1–3,18). In our study, 77% of patients had histopathologic evidence of infection. In addition, MALT lymphomas with associated H pylori gastritis tended to manifest as multiple lesions more often than MALT lymphomas without H pylori gastritis. This result suggests that multiplicity of the lesions in MALT lymphoma may be closely associated with infection with H pylori.
In summary, gastric MALT lymphoma has variable UGI examination findings, the most common of which is shallow or deep ulcers. The lesions in high-grade MALT lymphoma tend to be more aggressive than those in low-grade MALT lymphoma. Differentiation of gastric MALT lymphoma from gastritis or gastric carcinoma is extremely difficult, especially in cases of low-grade lymphoma.
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Footnotes
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See the commentary by Levine
following this article.
Abbreviations: MALT = mucosa-associated lymphoid tissue,
UGI = upper gastrointestinal
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References
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Abstract
LEARNING OBJECTIVES FOR TEST...
