Helicobacter pylori & Gastric MALT Lymphoma Zine - Charaf AMIR–TIDADINI , Fatima ASSELAH Department of Histopathology CHU Mustapha Algiers, ALGERIA
IAP AD, Algiers 2008
Helicobacter pylori and Gastric MALT Lymphoma
Background
Most extra nodal lymphomas arise in Stomach Æ G’M’L
Isaacson 1983: Marginal zone B L ; Indolent localized at diagnosis
H pylori : the leading cause (Development, progression); 60-90% regression after Hp eradication
(Fischbach, 2004)
Gastric MALT Lymphoma : G’M’L
Epidemiology
Increasing GL incidence in Algerians - 67 % of GI lymphomas - 37 % of gastric cancers Vs 10 % *
Average mean age at 44 years in Algerian population / Æ 2 decades younger than in occident (61 y)* Æ 25% < 30 years old (serum immunoelectrophoresis careful endoscopy + duodeno-jejunal biopsies to exclude the extension to the stomach of an IPSID) No difference according to gender (M/F ratio : 1/1.2)* * OMS, 2008 *Anon, Blood 1997
G’M’L : PRECURSOR LESIONS Æ H pylori Chronic Gastritis
In Malt lymphoma the prevalence of H. pylori infection is 90% Vs 96% in our series
Giemsa
Helicobacter pylori – – –
gram-negative spiral microaerophilic bacterium campylobacterales order, Helicobacteracea family capable to colonize the hostile environment of the human stomach – Secreting urease to neutralize the local acid pH. – Since its successful isolation in 1983 by Warren and Marshall, H. pylori has been linked to various pathologies and a strong association with gastric carcinoma and GL’M’ (carcinogen class I : OMS 1994) – Over 50% of the world’s population carries this infection, in Algeria more than 90% of general population are Hp infected (Megraud, 1989)
NOBEL Price of Medecine 2005 Warren & Marshall
HELICOBACTER Pylori
Infection rates vary among the developed and developing countries of the world – decline in most of the western countries mainly due to the success of combination therapies and improved personal hygiene and community sanitation to prevent re-infection – However, the situation is not improving in many of the developing countries like in Algeria
HELICOBACTER Pylori
Hp infection -> acquired during childhood
Transmission occurs predominantly within families
Hp causes chronic active gastritis, only a small minority
(1 – 2%) develop a malignant disease (gastric carcinoma and GL’M’)
Distinct genotypes have been found to be associated with particular geographic regions The cag pathogenicity island (cag PAI) and the cagA gene are principle virulence factors within the Hp strains.
G ‘M’ L
Clinical features
Non specific symptoms – Abdominal pain : most common presenting symptom – Dyspepsia, nausea, vomiting… – Palpable epigastric mass, Weight Loss… At endoscopy : – Enlarged gastric folds, gastritis – Superficial erosions – Suspect antral ulceration (> 80% of cases)
G’M’L : Macroscopy apearance
Gastric Lymphoma Histological Classification (OMS 2008)
MALT L
(G ‘M’ L)
Diffuse large B cell L – Diffuse large B cell L + MALT L component
Others : rares / Mantle cell L (cycline D1) , FL (CD10, Bcl2), CLL (CD5), Burkitt L, T L (HTLV1), HDK …
Histological features G’M’L (1) • Closely simulate those of a Peyer’s plaque
Stereotypy – Neoplastic cells infiltrate around reactive B -cell follicles – Marginal zone cell distribution and spreading outwards Æ diffuse to lamina propria
Reactive non neoplastic follicles Æ Important component of MALT L. Æ Often colonized
Histological features : G’M’L (2)
Exhibit a variety of cytological appearances with – Lymphocytic cells : small to medium sized, small irregular nuclei characteristic of centrocyte- like cells (CLC) – monocytoid B-cells with abundant pale cytoplasm and well defined cell borders – Scattered large transformed centroblast or immunoblast-like cells usually dispersed – Variable numbers of plasma reactive cells are frequently present beneath the surface epithelium, a few of them may be proliferative monoclonal cells
Histological features : G’M’L (3)
Lymphoepithelial lesions (LEL) : Characteristic feature Æ Invasion of individual crypts by aggregates (≥ 3) of Centrocyt Like Cell (CLC) Æ Degenerative changes + disintegration of the crypt epithelium (oncocyte- like)
LEL
EMA
Histological features : G’M’L (4)
Foci of DLBCL may be seen suggesting that there has been transformation from one to the other (Isaacson:1 -10% of blastic cells in cluster of 20 cells or diffuse infiltrate of blastic cells = high grade component)
Progression to DLBCL
Giemsa
Islands or clusters of 20 blastic cells Diffuse infiltrate of large cells
Histological features : G’M’L (4)
In our serie, 2/3 (157/ 244: 65%) of gastric lymphoma are of MALT type Hp associated. The others (87/ 244 : 1/3) are DLBCL with G’M’ L component 96% of GL are associated to Hp gastritis
G‘M’L Histopathology : Summary Two components 1. Malignant Lymphocyt cells centrocytic - like Monocytoid cells Plasmacytoid cells Expanded\confluent marginal zones Scattered large transformed centroblast or immunoblast-like cells Lymphoepithelial lesions 2. Reactive Reactive germinal centers may be colonized by marginal zone cells
G ’M’ L Immunophenotype
No specific phenotype
They are typically CD20+ – and B marker like CD19, CD79a… – CD43+ sometimes, – BCL-2+ – CD5 and CD10 negative – express surface and cytoplasm immunoglobulin (IgM, few IgA or IgG) – Light chain restriction sometimes
G‘M’L : Immunophenotype
CD 20
G’M’L : Immunophenotype – CD21, CD23 or CD35 can be used to highlight colonized follicles – EMA can be used to highlight lymphoepithelial lesions – Bcl-10 over expression confers an increasing capacity of an autonomous development of GL, so no responding to tritherapy
Differential diagnosis
Difficulties of diagnosis specific to the G ‘M’ L
Diagnosis relatively easy on gastrectomy specimen, can be difficult on biopsies – especially if they are very few, of small size and crushed Æ research of histological criteria of GL’M’ – LEL ≠ lymphoepithelial images (chronic gastritis with severe intensity) Æ histological scoring of lymphoid infiltrations in the stomach according to Wotherspoon and colleagues (Gut, 2006) may be helpful
Histological scoring of lymphoid infiltrations in the stomach according to Wotherspoon (Gut, 2006) Score
Diagnosis
Histological features
Normal
Scattered plasma cells in lamina propria (LP). No lymphoid follicles
1
Chronic active gastritis
Small clusters of lymphocytes in LP. No lymphoid follicles. No LEL
2
Chronic active gastritis With florid lymphoid follicle formation
Prominent lymphoid follicle with surrounding mantle zone and plasma cells. No LEL (lymphoepithelial lesions)
Suspicious lymphoid infiltrate, probably reactive
lymphoid follicles surrounded by small lymphocytes that infiltrate diffusely in LP +/- into epithelium
0
3 4 5
Suspicious lymphoid lymphoid follicles surrounded by marginal infiltrate, probably lymphoma zone cells that infiltrate diffusely in LP and into epithelium in small groups MALT lymphoma
Dense infiltrate of marginal zone cells in LP with proeminent LEL
G‘M’L Differential diagnosis on Bx Malt type L Vs florid acquired Malt in CG - sometimes difficult Æ multiples specimen, better directed Æ morphological arguments / IHC
Floride acquired MALT
G ‘M’ L
IHC : monoclonality Kappa
Lambda
Difficulties of diagnosis specific to the G‘M’L
G ‘M’ L Vs another type of small B-cell lymphoma – Follicular lymphoma : CD 10, Bcl2, Bcl6 – Lymphocytic lymphoma : clinique, CD5, CD43, CD23 – Mantle cells lymphoma (lymphomatose polyposis) Æ cells with same cleaved feature (centrocyte - like) : Activated cells + respected germinatives centers + LEL exceptional Gastric localization is rare, characteristic endoscopic aspect, fast dissemination and fatal evolution may help for diagnosis IHC (cycline D1)
Difficulties of diagnosis – DLBCL with MALT type component Vs MALT lymphoma (on superficial specimen): 1 to 10% of blastic cells in cluster of 20 cells are in favor of high grade component (Isaacson) – DLBCL with cluster of 20 blastic cells Vs colonized residual follicle center : IHC using CD21 or CD23 may be help to differential diagnosis between cluster of blastic cells and colonized follicle – On undifferentiated zones :Alcian Blue highlighting mucins, a poor differentiated carcinoma with mucipares cells can be diagnosed ; IHC : EMA, CK
Differential diagnosis on Bx DLBCL Vs germinatif résiduel center Islands or clusters of 20 blastic cells Dc # : colonized germinatif résiduel center (cfd CD23+)
CD23 germinal center Organoid net work of Fol. dentr. cell
CD23 Malt L Disorganized net- work
Differential diagnosis on Bx DLBCL Vs indifferenciated carcinoma
DLBCL
Dc # : morphologic features / nuclei histochemestry stains / Giemsa, AB IHC / EMA, CD 20 CD 20
Histological evaluation after early G’M’L Hp eradication Wundisch Histological grading (J. Clin. Oncol, 2005)
H pylori and early Gastric MALT Lymphomas
Triple therapy for one week (OAM / OAC) - Omeprazole 20mg 2x/d - Amoxycillin 1000mg - Metronidazole 500mg or Clarythromycin 500mg Few cases required 3 to 4 cures for Hp eradication (45 d interval)
Follow up examination including endoscopy and histology 3 m intervals / two y, every 6 m then after Histological grading for evaluation
Evaluation of histological response of early G’M’L after Hp eradication : Wundisch Histological grading (J. Clin. Oncol, 2005)
Best method of post treatment follow up – Serial endoscopy with histological assessment of multiples biopsies (and ultrasound endoscopy)
Grading describes 5 levels of response using 3 factors :
– lymphoid infiltrate – LEL – and stromal changes
Results may be complete remission CR, histological residual disease hRD, partial remission PR and no change NO or progression of the disease PD
Evaluation of histological response of early G’M’L, after Hp eradication Wundisch Histological grading (J. Clin. Oncol, 2005)
In our serie 61 of 157 patients (39%) with early MALT lymphoma, had Hp eradication : – 57% CR (Vs 60 à 90 % : Fischbach study, 2004) that needs : 2 successives negatives biopsies with multiple specimens and a mapping to confirm the CR – 21% hRD (vs 18%, Fischbach) : No therapeutic nor prognostic signification, so a watch and wait strategy must applied – PR and NC Vs PD : 20% (vs 16%) show after sequential biopsies a blastic component; low and high grade component may be synchronous in GL so that needs a gastric mapping which minimizes sampling errors
CR
hR D
PR
N C vs PD
G ‘M’ L
Histological eradication therapy response depends of – Histological lymphoma grade – Stage (nodes infiltration and depth infiltration assessed by endoscopic ultrasonography) – Associated genetics abnormalities / t(11,18); t(1,14) IHC study using Bcl-10 : Nuclear +ve
G‘M’L
Eradication therapy : simple, efficient regression --> 56 à 100% Wotherspoon,1993 : 5/6 cases Bayerdorffler ; 1997 Isaacson,1999 : 6/6 cases Fischbach, 2002-2004 : 56/90 cases Wundisch, 2005 : 96/120 cases Amir et al., 2007 : 35/61 cases Shiho, 2008 : 66/74 cases SHIHO et al. Tohoku J. Exp. Med., 2008, 214, 79- 87
G‘ M’ L
CR : 2 series successive Bx (-) / multiples specimens generaly obtained between 6 -18 months after Therapy
No response ---> Foci of large cells ! t (11;18) / t(1,14)
hRD monoclonal persistance : no signification
Molecular pathology
G‘M’L : Molecular pathology A number of genetic and epigenetic abnormality have been described (Isaacson, 2005): • t(11,18)(q21;q21), t(1;14)(p22;q32), t(14;18)(q32;q21) Æ 3 chromosomal translocations are specifically associated with Malt Lymphoma Æ Role in diagnosis, prognosis • Trisomies 3 (60%) , 12 and 18 less frequent • p53 LOH/mutation, p15, p16 promoter methylation ... •PAX5/IGH
T(11;18) MLT and API2 genes – t (11;18) (q21; q21) in 30-40% MALT L caused not
reciprocal fusion of the API2 and MALT1 genes
been detected in MALT with DLBCL
This
kind of lymphoma gain autonomous growth ability
and resistant to Hp eradication
Other mutations – t(14;18) (genes IGH and MLT) cytogenetically similar but molecularly distinct from follicular lymphoma – t(1;14)(p22;q32) and t(1;2)(p22;p12) < 5% : exclusive Hp independent - GL ‘M’ and those may undergo high grade transformation; this translocation juxtaposes BCL-10 to an immunoglobulin gene locus thus deregulating its expression
Bcl-10 t (1;14) and t (1;2) involve the bcl-10 gene = Advance stage of lymphoma t(11;18) does not involve the bcl-10 gene
Nuclear bcl-10
immunohistochemistry detects both t(11;18) and t(1;14)
Pathogenesis of gastric MALT lymphoma
Pathogenesis of G’M’L
Normal gastric mucosa is devoid of lymphoid tissue Multistage process starting with Hp infection Æ stimulating Hp-specific T-cell clones Æ B cell follicles Æ promotes malignant transformation of reactive B-cells due to acquisition of genetics abnormalities Æ induces and sustains an active proliferating B-cell population that may develop genetic abnormalities Æ attracting and activating neutrophils, which release oxygen reactive species = genotoxic and causes genetic abnormalities
Chronic Hp infection
directe Ag stimulation
Acquired MALT
65%
30% Hp specific T cells
Trisomies 3, 12, 18
Early MALT Lymphoma
B cells proliferation
5%
Hp dependant advanced MALT Lymphoma
T(1;14) (p:22;p:32) MALT Lymphoma
inactivation p53, p16
Hp independant
c. myc ; BCL-6
MALT Lymphoma
t (11;18) (q:21; q21) MALT Lymphoma
Conclusion (1)
Helicobacter pylori play a crucial role in the development and progression of gastric lymphoma GL is a relatively prevalent gastric malignant tumor; GL’M’ is an indolent disease but may become locally aggressive, spread, or undergo high grade transformation True prolonged remissions are possible right by Hp eradication treatment
Conclusion (2)
Eradication therapy is efficient and simple; it permitted the regression of more than a half of early gastric MALT lymphomas in our Hp positive patients. Careful endoscopic evaluation with
multiple
biopsy
and
endoscopic
ultrasonography would help in staging and monitoring patients
Conclusion (3)
Histological diagnosis depends on – clinical data information, – MALT sites exploration with multiple directed and performed biopsy specimens (gastric mapping with more than 20 specimens in order to identify a high grade component) – best histological techniques with good HE and CD20 (IHC) Immunohistochemistry, molecular biology would allow a better comprehension of these GL for better treating and why not preventing them by vaccination.
XXVII International Congress of the IAP Athens, Greece 2008
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