Early gastric mucosa-associated lymphoid tissue lymphoma treated by endoscopic submucosal dissection

A previously healthy 66-year-old woman was referred to our hospital for belching with a positive ¹³C-labeled urea breath test. A coarse nodular lesion was observed upon upper endoscopy ([Fig. 1 a]). She was treated with standard H. pylori quadruple therapy for 2 weeks.

Fig. 1 Examination reports before endoscopic submucosal dissection a A coarse nodular lesion was observed upon upper endoscopy before standard H. pylori quadruple therapy. b, c A follow-up endoscopy showed suspected lymphoma after standard H. pylori quadruple therapy. d Endoscopic ultrasound showed an inhomogeneous hypoechoic lesion involving the mucosal and submucosal layers, with the remaining structures being intact (red arrows). e Abdominal computed tomography presented localized thickening in the gastric antrum (red arrows). No regional lymph node enlargement or mass was found.

Six months after H. pylori eradication therapy, a follow-up endoscopy revealed no changes in the gastric lesion, which was a suspected lymphoma ([Fig. 1 b, c]). The ¹³C-labeled urea breath test remained negative for H. pylori. On further examination, endoscopic ultrasound showed an inhomogeneous hypoechoic lesion involving the mucosal and submucosal layers, with the remaining structures being intact ([Fig. 1 d]). Abdominal computed tomography presented only localized thickening in the gastric antrum ([Fig. 1 e]). To confirm the histological diagnosis and to achieve complete resection of the lesion, we performed endoscopic submucosal dissection (ESD) ([Video 1]). The resected specimen measured 50 × 70 mm ([Fig. 2 a]).

Video 1 Early gastric mucosa-associated lymphoid tissue lymphoma treated by endoscopic submucosal dissection in a 66-year-old woman.

Fig. 2 Examination reports after endoscopic submucosal dissection. a Surgical resection of gross specimens. b, c Postoperative histological examination showed that the lesion was infiltrated by dysmorphic lymphoid cells. d Positron emission tomography/computed tomography showed a slightly elevated distribution of the contrast agent in the antrum, considered to be due to postoperative changes. e A follow-up endoscopy after 2 years (black oval).

Postoperative histological examination showed that the lesion was infiltrated by dysmorphic lymphoid cells that were positive for CD20. The lateral and deep margins of the resected specimen did not show lymphocytic infiltration ([Fig. 2 b, c]). In addition, genetic testing revealed MALT1(+). Finally, she was diagnosed with gastric MALT lymphoma.

To clarify whether there were distant metastases, positron emission tomography/computed tomography (PET/CT) showed a slightly elevated distribution of the contrast agent in the antrum, considered to be due to postoperative changes ([Fig. 2 d]). Two years after ESD, there was only a scar at the site of resection in a follow-up endoscopy with no evidence of histological recurrence ([Fig. 2 e]).

Currently, MALT lymphoma has a low rate of positive identification upon endoscopic as well as pathological analysis, which poses great resistance to early identification [1]. Our case indicated that ESD may be a new strategy that allows not only accurate histological examination but also radical resection for early lymphoma.

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AB

Competing interests

The authors declare that they have no conflict of interest.

^* Contributed equally to this work

• Reference

• 1 Raderer M, Kiesewetter B, Ferreri AJ. Clinicopathologic characteristics and treatment of marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). CA Cancer J Clin 2016; 66: 153-171

Publication History

Article published online:
17 March 2023