MALT Lymphoma in a H.Pylori-Negative Patient Ramesh Piyumal De Silva1*, Sukaina Jaffar2 and Michael Devadas2
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ISSN: 2378-3397 De Silva RP, et al. Int J Surg Res Pract 2017, 4:056 DOI: 10.23937/2378-3397/1410056 Volume 4 | Issue 2 International Journal of Open Access Surgery Research and Practice CASE REPORT Laparoscopic Sleeve Gastrectomy - An Unexpected Finding: MALT Lymphoma in a H.Pylori-Negative Patient Ramesh Piyumal De Silva1*, Sukaina Jaffar2 and Michael Devadas2 1Department of Surgery, Blacktown Hospital, Australia 2Department of Surgery, Westmead Hospital, Australia *Corresponding author: Ramesh Piyumal, Department of Surgery, Blacktown Hospital, B Sci (Med) Hons, B Med Studies/ MD Junior Medical Officer, 32 Chameleon Drive, Erskine Park NSW, 2759, Sydney, Australia, Tel: +61-43532-5072, E-mail: [email protected] at the posterior wall, involving the mucosa and muscu- Abstract laris propria of the fundus, and extending anteriorly by Overweight and Obesity have been associated with an in- 60 × 25 mm (Figure 1). The fundal lesion consisted of a creased risk of developing a variety of gastrointestinal can- cers [1]. The increasing implementation of bariatric surgery diffuse lymphoid infiltrate from the mucosa to the mus- to manage overweight and obesity would likely increase the cularis propria. Atypical small to intermediate cells were incidental diagnosis of malignancies in patients who were noted on microscopy with occasional lymphoepithelial previously asymptomatic or had nonspecific gastrointestinal lesions and residual reactive follicular centres. An area symptoms. We present the case of a MALT gastric lympho- ma incidentally diagnosed on histopathology following lapa- of necrosis within the tumour was also identified. Lym- roscopic sleeve resection for obesity. phoid immunoperoxidase staining demonstrated: Keywords CD20 and bcl2: positive CD5, CD10, CD23, bcl6 and Gastrectomy, Bariatric surgery, Obesity, Lymphoma, Gas- cyclin D1: negative Ki-67 proliferative index of 5% Heli- trointestinal tumour cobacter pylori (H. pylori) stain: negative. A diagnosis of extranodal marginal zone B cell lym- Case Report phoma of MALT (Mucosa Associated-Lymphoid Tissue) A 59-year-old female underwent standard laparo- type was confirmed. scopic gastric sleeve resection following failure of diet Post-operatively, the patient was reviewed by a and medical management for obesity (weight, 121.4 kg; hematologist who noted her to have been asymptom- BMI, 45 kg/m2). Comorbidities included hypertension, atic prior to the operation but for a single episode of hyper triglyceridaemia and insulin resistance. Routine non-specific dysphagia and upper abdominal pain. Clin- preoperative workup including upper gastrointestinal ical examination revealed no lymphadenopathy or hep- ultrasound, and barium swallow were unremarkable. atosplenomegaly. Lymphoma staging with computed Following routine 5 port optical entry, the greater tomography did not show clear evidence of local spread curvature vessels were divided. The sleeve resection or distal lymphadenopathy. Full blood panel was with- was performed using an Endo GIA Tristapler (Medtron- in normal limits. Peripheral blood smear did not show ic, Minneapolis). The staple line was reinforced with any evidence of lymphoproliferative disorders. Post-op- seamguard and imbricated proximally with 3.0 Prolene erative urea breath testing for H. pylori was negative. sutures. There were no intra-operative complications. Following multidisciplinary evaluation, she was placed Macroscopic evaluation of the resected gastric speci- onto a twice yearly endoscopic surveillance program, of men revealed an elevated mass measuring 180 × 30 mm which the two most recent surveillance results demon- Citation: De Silva RP, Jaffar S, Devadas M (2017) Laparoscopic Sleeve Gastrectomy - An Unexpected Finding: MALT Lymphoma in a H.Pylori-Negative Patient. Int J Surg Res Pract 4:056. doi. org/10.23937/2378-3397/1410056 Received: March 09, 2017: Accepted: June 21, 2017; Published: June 23, 2017 Copyright: © 2017 De Silva RP, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. De Silva RP, et al. Int J Surg Res Pract 2017, 4:056 • Page 1 of 4 • DOI: 10.23937/2378-3397/1410056 ISSN: 2378-3397 Figure 1: Macroscopic view of gastric fundus with MALT lymphoma ( ). strated no lymphoma or H. pylori in all biopsies tested. The prevalence of H. pylori in obese patients com- At one year post-operatively, the patient had lost 31.0 pared to the general population has been variably re- kg (BMI, 33.89 kg/m2) with no post-operative complica- ported with rates affected by geography and level of tions. economic development. A meta-analysis of 18 studies H. pylori Discussion failed to demonstrate an association between infection and BMI [10]. In contrast, a recent an ecologi- Extranodal marginal zone B-cell lymphoma of MALT cal review of 49 studies has demonstrated a significant type are the most prevalent of the heterogeneous gas- inverse relationship between H. pylori colonisation and trointestinal lymphoma group, accounting for approxi- prevalence of overweight and obesity in the developed mately 35% of primary gastric lymphomas [2]. world [11], highlighting disagreement in evidence. Gastric MALT lymphoma almost exclusively affects Routine surveillance of H. pylori is not a feature of adults. Clinical features are often nonspecific and in- pre-operative assessment in our bariatric practice. In- clude abdominal discomfort, vomiting and diarrhoea. deed, a lack of consensus on routine pre-operative Commonly, nonspecific upper gastrointestinal symp- screening for H. pylori in all bariatric patients exists in toms lead to incidental discovery of MALT lymphoma the literature. The American Association of Clinical En- on endoscopic biopsy [3]. Management is dependent docrinologists/The Obesity Society/American Society on sufficient biopsies being retrieved from the lesion for for Metabolic and Bariatric Surgery guidelines recom- histopathological diagnosis and to concurrently rule out mend routine preoperative H. pylori screening only in possibility of diffuse large B cell lymphomas. Once di- high prevalence areas [12]. In the setting of Roux-en-Y agnosed, recommended staging investigations include gastric bypass, no difference in complications such as esophagogastroduodenoscopy with multiple biopsies anastomotic ulcer rates between H. pylori tested and taken from each region of the stomach; endoscopic ul- non-tested patients has been reported [13]. Despite trasound to evaluate regional lymph nodes and gastric this, pre-operative eradication of H. pylori in bariatric wall infiltration; bone marrow aspirate and biopsy in patients has been advocated by various authors for rea- addition to routine biochemical and radiological inves- sons including the potential for gastric ulceration and tigations [4]. malignant transformation in the post-operative gastric remnant, which may be difficult to access postoper- Gastric MALT lymphomas are overwhelmingly linked atively during endoscopic evaluation, and therefore to concurrent gastroduodenal infection by H. pylori [5]. progress undetected, and the non-invasive and validat- Evidence for the pathogenic relationship include the ed cost-effective nature of the surveillance process [14]. identification H.of pylori in the gastric mucosa of 70-90% A recent prospective study by Abdullgaffar and col- of patients with MALT lymphoma, and in vitro studies leagues [15] calls into question the utility of routine which have demonstrated the stimulation of lymphoma microscopic examination of all laparoscopic sleeve gas- growth in culture when exposed to H. pylori strain specif- trectomy specimen. Based on < 1% incidence of benign ic T cells [6,7]. MALT lymphoma in our H. pylori negative lesions and no malignant lesions identified in 546 spec- patient is therefore an unusual finding. Pathogenesis of imens, they advocate special gross handling protocols H. pylori negative MALT lymphoma is unclear. Genetic and meticulous macroscopic evaluation with selective alterations in nuclear factor-kappa activation, and infec- microscopic examination only, for the benefit of cost tion by other bacteria have been implicated [8]. Where and time effectiveness whilst demonstrating no major the presence of active H. pylori is not demonstrated by compromise to patient safety. Further evidence on this immunohistochemistry, further investigations including position in gastrectomy procedures is however lacking. serology, urea breath test or stool antigen test must be Our institutional practice is for thorough histopatholog- performed to rule out infection [9]. ical evaluation of all resected specimen in sleeve gas- De Silva RP, et al. Int J Surg Res Pract 2017, 4:056 • Page 2 of 4 • DOI: 10.23937/2378-3397/1410056 ISSN: 2378-3397 trectomy, and the above case highlights the potential 2. Harris NL, Jaffe ES, Diebold J, Flandrin G, Muller Hermel- for missing incidental pathologies, despite their rarity, ink HK, et al. (1999) The World Health Organization clas- sification of neoplastic diseases of the hematopoietic and leading to adverse patient outcomes. lymphoid tissues. Report of the Clinical Advisory Commit- In H. pylori positive MALT lymphoma, detected prior tee meeting, Airlie House, Virginia, November, 1997. Ann to, or following bariatric surgery, a combination proton Oncol 10: 1419-1432. pump inhibitor and clarithromycin based triple therapy 3. Fischbach W