Clinicopathological profile of primary gastric lymphoma: A single-center experience of 45 patients in Benghazi, Libya

Abdelhakim M Elbarsha; Muftah I Elsahati; Abdelhadi O Hawil

doi:10.4103/LJMS.LJMS_13_20

ORIGINAL ARTICLE

Year : 2020 | Volume : 4 | Issue : 2 | Page : 76-79

Clinicopathological profile of primary gastric lymphoma: A single-center experience of 45 patients in Benghazi, Libya

Abdelhakim M Elbarsha¹, Muftah I Elsahati², Abdelhadi O Hawil²
¹ Benghazi Medical Centre, Gastroenterology and Hepatology Unit, Benghazi, Libya
² Department of Hematology/Oncology, Benghazi Medical Centre, Benghazi, Libya

Date of Submission	22-Feb-2020
Date of Acceptance	25-Apr-2020
Date of Web Publication	22-May-2020

Correspondence Address:
Dr. Abdelhakim M Elbarsha
Benghazi Medical Centre, Gastroenterology and Hepatology Unit, Second Ring Road, Benghazi
Libya

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_13_20

Abstract

Background/Aim: Gastric lymphoma can be primary or secondary, and it comprises <5% of all patients with gastric primary neoplasms. The presenting symptoms of primary gastric lymphoma (PGL) are usually nonspecific and are similar to common upper gastrointestinal disease symptoms. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype, followed by marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT). The present study aims to describe the clinicopathological characteristics of PGL. Patients and Methods: This was a cross-sectional and retrospective study of patients with PGL who were diagnosed in the Department of Oncology/Haematology, Benghazi Medical Centre, from January 2010 to December 2017. Results: A total of 45 cases of PGL were diagnosed. The mean age was 54 years, ranging from 17 to 83 years. The number of male and female patients was 26 (57.5%) and 19 (42.5%), respectively. Abdominal pain was the most common presenting symptom. The gastric antrum was the most common anatomical site of involvement (28 [62%]). DLBCL was the predominant histological subtype (28 [62%]). Serum Helicobacter pylori immunoglobulin G antibodies were raised in 19 (42.2%) patients. Half of the patients were in stage II1 at presentation (according to Lugano staging system). Conclusions: DLBCL and MALT lymphoma were the most common subtypes, and H. pylori infection was found in most of the patients with MALT lymphoma. Despite the clinical presentation being usually nonspecific, most of our patients were diagnosed with stage I or II disease.

Keywords: Diffuse B-cell lymphoma, gastric neoplasm, marginal zone B-cell lymphoma, primary gastric lymphoma

How to cite this article:
Elbarsha AM, Elsahati MI, Hawil AO. Clinicopathological profile of primary gastric lymphoma: A single-center experience of 45 patients in Benghazi, Libya. Libyan J Med Sci 2020;4:76-9

How to cite this URL:
Elbarsha AM, Elsahati MI, Hawil AO. Clinicopathological profile of primary gastric lymphoma: A single-center experience of 45 patients in Benghazi, Libya. Libyan J Med Sci [serial online] 2020 [cited 2023 Mar 30];4:76-9. Available from: https://www.ljmsonline.com/text.asp?2020/4/2/76/284684

Introduction

Non-Hodgkin lymphoma (NHL) is a heterogeneous group of lymphoproliferative disorders originating from B-lymphocytes, T-lymphocytes, and natural killer cells. Extranodal NHL affects mostly the gastrointestinal tract (GIT), with the stomach being the most common site of involvement (30%–40% of all extranodal lymphomas).^[1] Gastric lymphoma can be primary or secondary, and it comprises a small number of all patients with gastric neoplasms (≤5%) and 1% of all GIT neoplasms.^[2],[3],[4]

Primary gastric lymphoma (PGL) denotes those in which the involvement of the GIT is predominant, or the presentation is mainly with symptoms related to GIT involvement. Secondary gastric lymphomas are those in which gastric involvement is only a part of a more widespread systemic disease.^[5],[6] PGL occurs more likely in patients older than 50 years,^[7],[8] with males being two to three times more commonly affected than females.^[9] The presenting symptoms of PGL are usually nonspecific and are similar to common upper GIT conditions such as gastritis, peptic ulcer disease, pancreatic disorders, gallbladder stones, or functional disorders, which results in delay in the diagnosis.^[10] The most common symptoms are abdominal pain/fullness, weight loss, nausea, and vomiting. Less frequent symptoms include fatigue, fever, night sweats, jaundice, dysphagia, and gastrointestinal bleeding.^[11],[12] Physical examination is normal in 55% to 60% of patients.^[13]

An accurate pathological diagnosis of the subtype is the most important first step in the management, and immunohistochemistry is essential for the differentiation of various subtypes of NHL to establish the proper diagnosis. Almost 90% of PGL are of B-cell lineage with only very uncommon T-cell lymphomas and Hodgkin lymphoma. Diffuse large B-cell lymphoma (DLBCL) occurs in 59% of cases, while the marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) occurs in 38%.^[9] The prevalence of Helicobacter pylori in patients with MALT lymphoma is significantly higher than that in patients with DLBCL. H. pylori is considered the etiological factor in those patients and its eradication is associated with resolution of the disease.^{[3],[12],[14],[15]}

Each lymphoma subtype shows distinct immunotype with immunohistochemical staining. The typical immunohistochemical staining panel for DLBCL is CD20+, CD45+, and CD3−; for MALT lymphoma is CD10−, CD5−, CD20+, cyclin D1, and BCL2−; and for follicular lymphoma is CD10+, BCL2+, CD23±, CD43−, CD5−, CD20+, and BCL6+.^[16] Management and prognosis depend on staging of the disease. There are several staging systems used for the staging of PGL. Lugano system is a modified Ann Arbor staging system, which is now widely accepted.^[17] The present study aimed to describe the clinicopathological characteristics of PGL.

Patients and Methods

This was a retrospective study of the clinical, endoscopic, and pathological data of patients with PGL who were diagnosed in the Department of Oncology/Haematology, Benghazi Medical Centre, from January 2010 to December 2017. Clinical data included age, sex, and presenting symptoms. H. pylori serum antibodies and stool antigen tests results were collected. All patients were evaluated for disease extension by computed tomography (CT) of the chest and abdomen. Diagnosis was based on endoscopy and histopathological examination findings, and patients were staged according to the Lugano staging system for NHL. The immunohistochemical panel included CD20, CD10, CD3, CD45, CK, BCL2, BCL6, Ki67, and LCA.

Results

During the study period from January 2010 to December 2017, a total of 45 cases of PGL were diagnosed. The mean age was 54 years (range, 17–83). Twenty-five (55.5%) patients were above the age of 50 years, and the number of male and female patients was 26 (57.5%) and 19 (42.5%), respectively. Abdominal pain was the most common presenting symptom, followed by loss of weight [Table 1].

Table 1: Symptoms at presentation

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The anatomical sites of involvement were as follows: antrum (28 [62%]), corpus (7 [15%]), fundus (7 [15%]), and diffuse (3 [7%]). The most common endoscopic appearance was ulcerated lesion [Table 2]. DLBCL was the predominant histological subtype, followed by MALT lymphoma [Table 3]. H. pylori stool antigen test was positive in 8 (17.7%) patients, while serum H. pylori immunoglobulin (Ig) G antibodies were raised in 19 (42.2%) patients. Among the 15 patients with MALT lymphoma, positive H. pylori stool antigen test was seen in 4 (26.6%) patients, while 13 (88.9%) patients had positive serology, and two patients had both tests positive.

Table 2: Endoscopic appearance

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Table 3: Histological subtypes

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Regarding the stage of lymphoma at the time of presentation, patients had various disease stages, according to the Lugano staging system. Half of the patients were in stage II1 at presentation [Table 4]. The immunotype marker CD20 was positive in 27 (96.4%) patients with DLBCL and all patients with MALT lymphoma. The two patients with Burkitt's lymphoma and follicular lymphoma were also positive for CD20.

Table 4: Stage of lymphoma at presentation (Lugano staging system)

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Discussion

In this series of 45 patients with PGL, the mean age at the time of diagnosis was 54 years, with slight male predominance (57.7%; 1.4:1). Male predominance was also observed in other case series.^[18],[19] The number of patients aged 50 years or below was 20 (43.5%), indicating that PGL affects younger age groups as well. Four patients were even below the age of 30 years.

All cases were diagnosed by endoscopy and histopathological examination of endoscopic biopsy specimens, during workup for nonspecific upper GIT and constitutional symptoms. The majority of patients (86.6%) presented with abdominal pain as a chief symptom, while less commonly, patients reported weight loss, vomiting, anorexia, and melena. Abdominal pain was the predominant symptom reported in many observations worldwide.^{[19],[20],[21],[22],[23]} Endoscopic findings in PGL are indistinguishable from that of adenocarcinoma, and it appears sometimes as mild mucosal changes in the form of nodularity or erythema, rather than a discrete mass or ulcer. We found that gastric ulcerated lesion is the most common type of lesions detected by endoscopy, and the gastric antrum is the most frequent site of involvement. These findings are concordant to most of other observations, although some reports showed mixed findings regarding the site of involvement, as the gastric corpus was the most common site of involvement in some reports.^{[16],[19],[21],[23]}

In this case series, DLBCL was the most common histological subtype, followed by MALT lymphoma. Only two patients had rare subtypes (follicular lymphoma and Burkitt's lymphoma). These histological findings and their order of frequency are comparable to the findings reported in other studies.^{[16],[19],[20],[22],[24]}

Serum H. pylori IgG antibodies were raised in 19 patients. Most of them (68.4%) had MALT lymphoma. The other six patients with positive H. pylori serology had DLBCL. The majority of MALT lymphoma patients had raised serum H. pylori IgG antibodies (86.6%). Stool testing for H. pylori antigen was positive in only eight patients, probably because of previous exposure to antibiotics or acid suppression therapy in patients who had negative stool test. The high prevalence of H. pylori infection in patients with MALT lymphoma is an expected finding since it is the recognized etiology for this subtype of gastric lymphoma. The significantly higher prevalence of H. pylori infection in patients with MALT lymphoma was demonstrated in many studies.^{[19],[21],[22],[25]}

Staging of PGL depends on the anatomical site of involvement and the presence or absence of constitutional symptoms. Cross-sectional imaging with CT scan or magnetic resonance imaging is essential to assess disease location and spread and for staging. Our patients were staged using Lugano staging system, and most of them were in either stage II1 (22 [49%]) or stage I (14 [31%]); this finding is in consistent with previous published reports.^{[21],[22],[23]}

Conclusions

PGL, although considered an uncommon clinicopathological type of NHL, is still being diagnosed in different age groups. Gastroscopy with histopathology and immunohistochemistry are required to confirm the diagnosis and to determine the histopathological subtype. DLBCL and MALT lymphoma was the most common subtype, and H. pylori infection was found in most of the patients with MALT lymphoma. Despite the clinical presentation being usually nonspecific, most of our patients were diagnosed with stage I or II disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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