Diagnosis And Staging Of Gastric Malt Lymphoma

The stomach is the most common and best studied organ involved with MALT lymphoma and it will be helpful to discuss the clinical aspects of diagnosis, staging, and treatment of gastric MALT lymphoma separately from all other sites.

The most common presenting symptoms of gastric MALT lymphoma are dyspepsia, epigastric pain, nausea, and chronic manifestations of GI bleeding, such as anemia. The upper GI complaints often lead to an endoscopy that usually reveals nonspecific gastritis or peptic ulcer with mass lesions being unusual.41

The best staging system is still controversial.46 We use the modification of the Blackledge staging system recommended at an international workshop.4748

The initial staging procedures should include a gastro-duodenal endoscopy with multiple biopsies from each region of the stomach, duodenum, gastroesophageal (GE)

junction, and from any abnormal-appearing site. The presence of active H. pylori infection must be determined by histochemistry and breath test. Endoscopic ultrasound is recommended to evaluate the presence of peri-gastric lymph nodes and the depth of infiltration of the gastric wall. A deep infiltration is associated with a higher risk of lymph node involvement, and a lower response rate with antibiotic therapy alone.49-52 Presentation with multiple MALT localizations is more frequent in patients with non-GI lymphoma, in which about one-fourth of cases have been reported to present with involvement of multiple mucosal sites or nonmucosal sites such as bone marrow.53,54

Regardless of the presentation site, initial workup should include complete blood counts, basic biochemical studies (including LDH and ^-microglobulin), computed tomography of the chest, abdomen, and pelvis, and a bone marrow biopsy. Indeed, although the disease remains usually localized in the stomach, systemic dissemination and bone marrow involvement should be assessed at presentation, since prognosis is worse with advanced-stage disease or with unfavourable International Prognostic Index (IPI) score.41

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