MALT – LYMPHOMAS ASSOCIATED WITH HELICOBACTER PYLORI. A COMPARISON OF TWO CLINICAL CASES

СРАВНЕНИЕ ДВУХ КЛИНИЧЕСКИХ СЛУЧАЕВ MALT ЛИМФОМ, AССОЦИИРОВАННЫХ С H. PYLORI

Бацевичюте Елизавета Гинтарасовна

студент, Медицинский институт, Российский университет дружбы народов (РУДН) им. Патриса Лумумбы,

РФ г. Москва

Белова Дарья Дмитриевна

студент, Медицинский институт, Российский университет дружбы народов (РУДН) им. Патриса Лумумбы,

РФ г. Москва

Эмаимо Алисе Джон

научный руководитель, ассистент КИЯ Медицинского института, Российского университета дружбы народов (РУДН) им. Патриса Лумумбы,

РФ, г. Москва

ABSTRACT

This paper presents two clinical cases of MALT lymphoma associated with Helicobacter pylori infection. Each case is analyzed in detail, including clinical presentation, diagnostic approaches (gastroscopy, histology, molecular methods), eradication therapy regimens, and disease dynamics following treatment. Based on the findings, a comparative analysis of the two cases is performed across key parameters: patient age and sex, lymphoma stage, degree of H. pylori colonization, response to antibiotic therapy, and clinical outcome. The comparison aims to clarify prognostic factors and optimize management strategies for patients with this condition.

АННОТАЦИЯ

В данной статье представлены два клинических случая MALT-лимфомы, ассоциированной с инфекцией Helicobacter pylori. Каждый случай подробно проанализирован, включая клиническую картину, диагностические подходы (гастроскопия, гистология, молекулярные методы), схемы эрадикационной терапии и динамику заболевания после лечения. На основании полученных результатов проводится сравнительный анализ двух случаев по ключевым параметрам: возрасту и полу пациента, стадии лимфомы, степени колонизации H. pylori, реакции на антибиотикотерапию и клиническим результатам. Цель сравнения - уточнить прогностические факторы и оптимизировать стратегии ведения пациентов с этим заболеванием.

Keywords: Lymphoma, gastric lymphoma, MALT lymphoma, stomach cancer, H. Pylori, Non-Hodgkin’s lymphoma.

Ключевые слова: лимфома, лимфома желудка, MALT лимфома, рак желудка, H. Pylori, неходжкинская лимфома.

Aim

To perform a comparative analysis of two clinical cases of MALT lymphoma associated with Helicobacter pylori in order to clarify prognostic factors and optimize patient management strategies.

Objectives

1. Characterize the clinical presentation of each case.

2. Evaluate the diagnostic approaches used (gastroscopy, histology, molecular methods).

3. Compare the eradication therapy regimens and disease dynamics following treatment.

4. Compare both cases across key parameters (age, sex, lymphoma stage, degree of H. Pylori colonization, response to therapy, outcome).

5. Formulate recommendations for optimizing patient management based on the findings obtained

Analysis

Two female patients with gastric MALT lymphoma were compared based on clinical presentation, H. Pylori status, treatment approach, and outcomes.

Patient A (68 years) presented with epigastric discomfort and had a history of chronic H. Pylori-associated gastritis since 2016, with documented resistance to eradication therapy after two lines (triple and quadruple therapy). Despite negative stool PCR and breath test, a weakly positive urease test indicated persistent infection. Diagnostic workup revealed extensive gastric involvement (subcardial region to antrum, fundus, both curvatures), lymph node involvement (paragastric, epigastric, hepatic portal, portocaval), and extranodal foci (right liver lobe, lung fibrosis). She received no pre-treatment H. Pylori eradication but underwent six cycles of R-B (rituximab + bendamustine), achieving complete remission.

Patient B (61 years) had diabetes type 2 and a history of duodenal ulcer. She had no evidence of H. Pylori-associated chronic gastritis, no resistance, and no prior eradication therapy. Gastric MALT lymphoma was detected incidentally during preventive screening, localized to the pyloric part, with no lymph node involvement but diffuse fatty infiltration of the liver. She received no immunochemotherapy or surgery; H. Pylori eradication (esomeprazole, amoxicillin, clarithromycin, de-nol) was not performed before antitumor treatment. Despite this, complete remission was achieved.

Key differences: Patient A had aggressive, disseminated disease requiring immunochemotherapy; Patient B had localized disease that regressed without specific antitumor treatment. Both achieved complete remission.

Method

A qualitative case-based method was employed to analyze the two patient cases. This approach was chosen to explore the heterogeneity of clinical presentations, treatment decisions, and outcomes in gastric MALT lymphoma without relying on statistical generalization.

The work was conducted according to the following steps:

Case selection: Two representative cases (Patient A and Patient B) were purposively selected based on contrasting clinical features, including differences in disease extent, H. Pylori status, and treatment pathways.

Data extraction: Clinical data were systematically extracted from patient documents using a predefined template covering demographics, comorbidities, diagnostic methods, H. Pylori status, treatment history, and outcomes.

Thematic comparison: A cross-case thematic analysis was performed to identify key similarities and differences between the two patients, focusing on disease localization, lymph node involvement, treatment rationale, and remission status.

Interpretation: Findings were interpreted in the context of current clinical guidelines and existing literature, with attention to atypical patterns (e.g., remission without H. Pylori eradication in Patient B).

Synthesis

A narrative synthesis was developed to highlight implications for individualized treatment and to generate hypotheses for future research.

Study Design

Comparative case analysis of two patients diagnosed with gastric MALT lymphoma.

Data Collection

Clinical, endoscopic, histological, and imaging data were extracted from patient records. Parameters included demographics, comorbidities, H. Pylori status, eradication history, diagnostic modalities, treatment regimens, and outcomes.

 Diagnostic Methods

Endoscopy with biopsy (EGD) for tissue sampling.

Histology and immunohistochemistry for MALT lymphoma confirmation.

Cytology for cellular analysis.

PET/CT and MSCT (Patient A only) for staging and extranodal involvement.

H. Pylori detection: Urease test, stool PCR, isotopic breath test (Patient A); stool PCR only (Patient B).

Treatment Protocols

Patient A: Six cycles of immunochemotherapy with rituximab + bendamustine (R-B). No prior H. Pylori eradication.

Patient B: No immunochemotherapy or surgery. H. Pylori eradication regimen (esomeprazole, amoxicillin, clarithromycin, de-nol) was not administered before lymphoma treatment.

Outcome Assessment

Complete remission was defined as absence of detectable gastric MALT lymphoma and lymph node involvement on follow-up imaging and endoscopy with biopsy.

Discussion

These two cases illustrate the heterogeneous clinical course and treatment strategies in gastric MALT lymphoma. Patient A presented with advanced disease including lymph node and extranodal involvement, despite negative stool PCR and breath test. The weakly positive urease test suggested low-level persistent H. Pylori infection, but the decision was made to proceed directly with immunochemotherapy (R-B) rather than further eradication attempts. This approach aligns with current guidelines for H. Pylori-negative or refractory cases with disseminated disease. The complete remission achieved after six cycles confirms the efficacy of R-B in advanced-stage MALT lymphoma.

In contrast, Patient B had localized disease (pyloric part) without lymph node involvement and no histological evidence of H. Pylori-associated gastritis. Surprisingly, she received no H. Pylori eradication therapy before lymphoma treatment and no immunochemotherapy, yet still achieved complete remission. This raises important questions: Was remission spontaneous? Could the prior use of de-nol (bismuth) in an unspecified context have had an anti-lymphoma effect? Or was the initial diagnosis an indolent lesion that regressed without intervention? Spontaneous regression of gastric MALT lymphoma, though rare, has been reported, particularly in localized, asymptomatic cases.

The presence of diffuse fatty liver in Patient B and fibrotic lung foci in Patient A were likely incidental findings unrelated to lymphoma, though liver involvement in MALT lymphoma should be ruled out by biopsy if clinically indicated.

A key limitation is the absence of follow-up duration and specific remission confirmation methods in the original data. Additionally, the lack of H. Pylori eradication in Patient B before remission challenges the conventional paradigm that H. Pylori eradication is necessary for remission in HP-positive or even HP-negative localized MALT lymphoma.

Conclusion

Gastric MALT lymphoma exhibits variable clinical behavior. In localized, indolent cases without risk factors, complete remission may occur even without H. Pylori eradication or immunochemotherapy, suggesting a potential for watchful waiting in selected patients. In contrast, disseminated disease with lymph node involvement requires systemic immunochemotherapy, such as R-B, which can achieve complete remission even in the presence of prior H. Pylori resistance. These cases highlight the need for individualized treatment decisions based on disease stage, H. Pylori status, and patient characteristics. Further studies are warranted to explore predictors of spontaneous regression and the role of bismuth-containing compounds in MALT lymphoma.

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