Mines

The New England Journal of Medicine

CASE REPORTS

Brief Report

Patient 1 Patient 1 was a 36-year-old man with a six-month history of epigastric pain for which he underwent upper gastrointestinal endoscopy, with random biopsy specimens obtained, in 1981 (Table 1). Benign gastric peptic ulcer with chronic gastritis of the antrum and the body was diagnosed. The patient was treated withantacids and remained well until 1985, when the gastric symptoms recurred. Further endoscopic gastric biopsy confirmed the diagnosis of chronic gastritis associated with H. pylori infection. Treatment with ranitidine was given, with good relief of symptoms. Followup endoscopy in March 1990 revealed lymphoepithelial lesions and plasma-cell infiltrates in both the gastric body and the duodenum. Ahistologic diagnosis of low-grade MALT lymphoma was made. Routine staging procedures12 revealed stage I disease (lymphoma confined to the gastric mucosa). The symptoms resolved with the resumption of ranitidine treatment, and the patient declined to undergo gastrectomy. His condition was monitored with regular endoscopy and gastric biopsy, which showed no changes in histologic findings. In September1993, he received a 10-day course of amoxicillin (750 mg three times daily), metronidazole (500 mg three times daily), and omeprazole (40 mg daily) to eradicate H. pylori. Repeated gastric biopsies from 1994 to 1996 documented the eradication of H. pylori but the persistence of multifocal lesions of low-grade MALT lymphoma. In October 1996 endoscopy revealed a clear progression of the low-gradelymphoma in the stomach, with diffuse and deep infiltration of the gastric wall and duodenal invasion with stenosis of the duodenal bulb. A computed tomographic scan showed abdominal adenopathy; the results of a bone marrow biopsy were normal. He was treated with six cycles of a regimen consisting of doxorubicin, cyclophosphamide, vincristine, prednisone, and methotrexate. Complete remission wasdocumented in June 1997. The patient was still in remission at the most recent follow-up visit in December 1997. Patient 2 Patient 2 underwent selective proximal vagotomy in 1976, at the age of 40, followed eight years later by partial gastrectomy with a Billroth II anastomosis (Table 2). She had had severe peptic ulcer disease since the early 1970s. Pathological examination of the stomach specimensobtained at resection showed diffuse gastritis and peptic ulcer, without neoplastic tissue. In June 1988 a diffuse, mixed, predominantly large cell lymphoma (group F, according to the working formulation for the classification of lymphoma) in the gastric stump was diagnosed by endoscopic biopsy, and the patient was referred for staging and treatment. She reported increasing dysphagia, back pain,regurgitation, fever, night sweats, and a substantial weight loss in the preceding six months. Her H. pylori status was not known. Abdominal ultrasonography and computed tomographic scanning showed a large mass in the remnant gastric wall; multiple paragastric, mesenteric, and retroperitoneal lymphadenopathies; a focal liver lesion; and splenomegaly. Radiographs and computed tomographic scans of thechest showed no abnormalities. Analysis of a bone marrow aspirate and trephine biopsy showed infiltration from a large-cell lymphoma. The patient was treated with six courses of a regimen consisting of doxorubicin, cyclophosphamide, vincristine, prednisone, and high-dose methotrexate with leucovorin rescue, alternating every 22 days with etoposide, bleomycin, procarbazine, and cytarabine.13 She hada complete remission, but she had a relapse identified in bone marrow in January 1990 (the results of a gastricstump biopsy were suggestive of relapse but not conclusive). She had a second complete remission after two cycles of salvage treatment14 with a regimen consisting of etoposide, methylprednisolone, high-dose cytarabine, and cisplatin and subsequently underwent autologous bone marrow...