A 57-year-old woman comes to clinic with a 9-month history of persistent upper-abdominal discomfort, intermittent fevers, and drenching night sweats. She reports an unintentional 6-kg weight loss. She takes no regular medication and has been previously healthy. She works as a taxi driver and her only recent travel was a short holiday to Spain.
Endoscopy shows an ulcerated mass in the distal stomach (antrum).
Which underlying factor most likely contributed to the development of this tumour?
A. Chronic Helicobacter pylori infection
B. Epstein–Barr virus infection
C. Untreated coeliac disease
D. Schistosoma japonicum infestation
E. Human T-lymphotropic virus type 1 (HTLV-1)
Detailed ExplanationÂ
A tumour in the antrum that presents with fever, night sweats, dyspepsia, and weight loss strongly suggests gastric MALT lymphoma, a low-grade B-cell lymphoma.
The single most important cause of gastric MALT lymphoma is chronic Helicobacter pylori infection.
Why H. pylori causes MALT lymphoma
- Long-standing H. pylori infection leads to chronic gastritis.
- Chronic inflammation stimulates the formation of mucosa-associated lymphoid tissue (MALT) in the stomach.
- Over time, constant antigenic stimulation may trigger monoclonal B-cell proliferation → lymphoma.
Many MALT lymphomas regress when H. pylori is eradicated, confirming its causative role.
Why the other options are wrong
- EBV → Burkitt lymphoma, Hodgkin lymphoma, nasopharyngeal carcinoma (not gastric MALT).
- Coeliac disease → enteropathy-associated T-cell lymphoma in the small intestine, not the stomach.
- Schistosoma japonicum → liver and colorectal cancer; S. haematobium → bladder cancer.
- HTLV-1 → adult T-cell leukaemia/lymphoma (systemic, not gastric).
Correct answer: A. Chronic H. pylori infection
Cheat Sheet for Exams
Infection-Associated Malignancies
Viruses
- EBV → Hodgkin lymphoma, Burkitt lymphoma, nasopharyngeal carcinoma
- HTLV-1 → Adult T-cell leukaemia/lymphoma
- HIV → High-grade B-cell lymphoma
Bacteria
- Helicobacter pylori → Gastric MALT lymphoma
Parasites
- Malaria (Plasmodium falciparum) → Burkitt lymphoma (cofactor with EBV)
- Schistosoma haematobium → Bladder cancer
Key Points on Gastric MALT Lymphoma
- Arises commonly in antrum
- Strongly linked to chronic H. pylori infection
- Symptoms: dyspepsia, constitutional symptoms (fever, weight loss, sweats)
- Treatment: H. pylori eradication → remission in majority
- Transformation to high-grade lymphoma can occur if untreated
Flashcards (20)
- Q: Main cause of gastric MALT lymphoma?
A: Chronic H. pylori infection. - Q: Where in the stomach does MALT lymphoma commonly arise?
A: The antrum. - Q: What type of lymphoma is MALT?
A: Low-grade B-cell lymphoma. - Q: What symptom pattern suggests lymphoma?
A: B symptoms (fever, night sweats, weight loss). - Q: What happens to many MALT lymphomas after H. pylori eradication?
A: They regress. - Q: Which virus causes nasopharyngeal carcinoma?
A: Epstein–Barr virus (EBV). - Q: Which cancer is linked to S. haematobium?
A: Bladder cancer. - Q: Coeliac disease predisposes to which lymphoma?
A: Enteropathy-associated T-cell lymphoma. - Q: HTLV-1 is associated with?
A: Adult T-cell leukaemia/lymphoma. - Q: HIV predisposes to which malignancy?
A: High-grade B-cell lymphoma. - Q: Which infection is linked with Burkitt lymphoma?
A: EBV (+ malaria cofactor). - Q: What is first-line therapy for gastric MALT lymphoma?
A: Triple/quadruple therapy for H. pylori. - Q: Does MALT lymphoma cause ulcers?
A: Yes, can mimic peptic ulcer disease. - Q: Is stomach normally rich in lymphoid tissue?
A: No—MALT appears after chronic inflammation. - Q: Can MALT lymphoma transform?
A: Yes, to diffuse large B-cell lymphoma. - Q: Which lymphoma presents in small intestine with coeliac disease?
A: EATL. - Q: Is EBV linked to gastric lymphoma?
A: Rarely; not typical for MALT. - Q: Does travel history affect MALT lymphoma risk?
A: No. - Q: Best diagnostic test for gastric lymphoma?
A: Endoscopic biopsy. - Q: Typical age group for MALT lymphoma?
A: Middle-aged to older adults.
MCQsÂ
1. A 60-year-old woman with chronic dyspepsia is diagnosed with gastric MALT lymphoma. What is the most appropriate initial treatment?
A. CHOP chemotherapy
B. Gastrectomy
C. H. pylori eradication therapy
D. Radiotherapy
Answer: C
2. Which infection is most strongly associated with adult T-cell leukaemia/lymphoma?
A. EBV
B. HTLV-1
C. HIV
D. H. pylori
Answer: B
3. Which malignancy is most strongly linked to Schistosoma haematobium?
A. Colorectal cancer
B. Bladder carcinoma
C. Gastric lymphoma
D. Kaposi sarcoma
Answer: B
4. A patient with coeliac disease develops severe abdominal pain and weight loss. Which cancer is most likely?
A. MALT lymphoma
B. Enteropathy-associated T-cell lymphoma
C. Follicular lymphoma
D. Hodgkin lymphoma
Answer: B
5. Burkitt lymphoma usually involves which infectious cofactor?
A. EBV
B. HTLV-1
C. Hepatitis C
D. CMV
Answer: A
Quick-Revision SummaryÂ
Gastric MALT lymphoma is most commonly caused by chronic Helicobacter pylori infection, which induces persistent gastric inflammation. This leads to the development of mucosa-associated lymphoid tissue in the stomach, a site that normally contains little lymphoid tissue. Continuous antigenic stimulation can drive clonal B-cell proliferation and ultimately lymphoma. MALT lymphomas often present with dyspepsia, systemic symptoms like fever and night sweats, and weight loss. Endoscopy typically shows an antral mass or ulcerating lesion. Many MALT lymphomas regress completely after H. pylori eradication therapy, making this the first-line treatment. Other infections associated with haematological malignancy include EBV (Hodgkin, Burkitt, nasopharyngeal carcinoma), HTLV-1 (adult T-cell leukaemia/lymphoma), HIV (high-grade B-cell lymphoma), and malaria acting with EBV in endemic Burkitt lymphoma. Coeliac disease predisposes to enteropathy-associated T-cell lymphoma, not gastric lymphoma. Schistosoma haematobium causes bladder cancer, while S. japonicum is associated with colorectal cancer. Gastric MALT lymphoma usually affects middle-aged or older adults. Transformation to high-grade lymphoma can occur if infection is untreated. Early recognition and eradication of H. pylori significantly improve outcome.