Linfoma de células B de la zona marginal extranodal del tejido linfoide asociado a mucosas (malt) primario de esófago: Presentación de un caso

El tracto gastrointestinal es la localización mas frecuente de los linfomas no Hodgkin extranodales, sin embargo, el compromiso del esófago es extremadamente raro, con una incidencia menor del 1% de todos los pacientes con linfoma. Se ha descrito con mayor frecuencia afectación secundaria del esófago como parte de un compromiso extenso de un linfoma gástrico o mediastinal. Se presenta el caso de paciente femenina, de 59 años de edad, con síntomas dispépticos de 2 meses de evolución. En la Endoscopia Digestiva Superior (EDS) se evidencia en tercio distal de esófago, lesión elevada, de 1cm de diámetro, con características similares al resto de la mucosa, móvil. La biopsia Endoscópica revela la presencia de un linfoma MALT de bajo grado confirmado por inmunohistoquímica. Se indicó tratamiento de erradicación para H pylori, y los estudios de extensión fueron normales. Posteriormente se realizó resección mucosal endoscópica, donde se observaron grupos aislados de linfocitos neoplásicos, con bordes de resección libres. Paciente con seguimiento endoscópico normal. Pocos casos han sido reportados en la literatura acerca de linfomas MALT de esófago, por lo tanto las características clínicas y biológicas de estos linfomas no están claramente establecidas. Es necesario el estudio y seguimiento de estos casos, para determinar los posibles factores de riesgo y así aplicar las medidas preventivas.

The gastrointestinal tract is the most common extra nodal site involved in Non- Hodgkin's lymphoma. However, esophageal involvement is extremely rare, accounting for less than 1% of patients with lymphoma. It has been described that esophageal involvement in lymphoma is more often a result of contiguous spread from mediastinal lymph nodes or from an extended gastric lymphoma. A 59 year old female consulted for dyspeptic symptoms. Endoscopic examination revealed a small submucosal mass, that measured 1 cm located at the lower thoracic esophagus. The biopsy reported a Malt lymphoma that was confirmed by immunohistochemistry. She received therapy for H. pylori eradication. Endoscopic mucosal resection was performed, and isolated groups of atypical lymphocytes were found, with free resection margins. Endoscopic follow up has been normal. Few cases have been reported in literature, therefore biological and clinical characteristics of MALT lymphoma of the esophagus are currently unknown, further study is needed to establish risk factors in order to be able to take preventive measures.

Carcinoma gástrico precoz mucinoso: Reporte de un caso y revisión de la literatura

El carcinoma gástrico mucinoso (CGM) es infrecuente representa el 3% de todos los canceres gástricos (1). Detectado ocasionalmente en estadios precoces (2), con una relación avanzados/precoces de 2.1 - 2.3% y 0.3 - 1.0% respectivamente (1, 2). Correspondiendo el CGM en estadio precoz al 0.02 de todos los carcinomas gástricos. Se reporta este inusual caso de paciente femenina de 72 años de edad quien consultó por síntomas dispépticos, se hizo el diagnóstico histológico de ADC gástrico, por biopsia endoscópica, siendo sometida a gastrectomía subtotal, y cuyo reporte definitivo de la pieza quirúrgica fue CGM precoz, con compromiso submucoso, sin evidencia de ganglios metastáticos.

Mucinous gastric cancer (MGC) is very rare. The incidence of MGC is about 3% among all gastric cancers and only occasionally detected in early -stage with a relation between advanced and early gastric cancer around 2.3- 21% and 0.3- 1% respectively. Early-stage mucinous gastric cancer represents 0.02 of all gastric cancer types. We report an unusual case of a 72 years old female patient with histological diagnosis of gastric Adenocarcinoma. A total gastrectomy was performed. Final diagnosis was that of an early mucinous gastric cancer involving the submucosal layer without lymph node metastasis.

Linfoma no Hodgkin primario de esófago: Reporte de un caso

El Linfoma esofágico primario es un tumor muy raro, representa menos del 1% de los tumores esofágicos. Se reporta el caso un paciente con linfoma no Hodgkin localizado en esófago medio e inferior, que consulta por disfagia, siendo diagnosticado y tratado exitosamente con quimioterapia, con sobrevida de 12 meses, hasta la actualidad asintomático y sin evidencia de tumor.

SUMMARY Primary esophageal lymphoma is a very rare tumor; represents less than 1 % of all esophageal tumors. We report a case of a patient with no-Hodgkin lymphoma involving the medial and lower esophagus, presenting with dysphagia, he was treated successfully with chemotherapy, with an over all survival of 12 months. He is at the moment, asymptomatic and without evidence of tumor.

Astrocitoma pilocítico: ¿su comportamiento es siempre benigno?: a propósito de un caso / Pilocytic astrocytoma: its behavior is always benign?:a purpose of a case

Lactante mayor femenina de 15 meses de edad, con clínica de dificultad para la marcha, paresia de hemicuerpo derecho, desviación de la comisura labial hacia lado izquierdo, ptosis palpebral parcial ipsilateral. En la Resonancia Magnética Computarizada de cráneo con contraste reporta lesión ocupante de espacio intraxial temporo-parietal de aspecto quistico, con masa mural compatible con ASTROCITOMA PILOCITICO, corroborado con estudios histopatológico. En el presente trabajo se destaca que los astrocitomas pilocíticos aparecen con mayor frecuencia en la infancia y cuya ubicación predilectoria se encuentra a nivel del Cerebelo, sin embargo nuestro caso clínico presenta una ubicación a nivel supratentorial, siendo esta mas frecuente en los adultos que en los infantes, por lo que no se correlaciona con las estadísticas establecidas a nivel mundial y de diversos estudios realizados para los tumores primarios benignos, específicamente, el astrocitoma pilocítico, por tal motivo quisimos traer a colación el presente estudio.

Helicobacter pylori en Venezuela: un problema infeccioso multifactorial / Helicobacter pylori in Venezuela: a problem infectious multifactorial

Los objetivos del presente trabajo fueron: establecer la seroprevalencia de la infección por Helicobacter pylori en población venezolana y su asociación con trastornos gastroduodenales y evaluar la presencia del gen cagA mediante la reacción en cadena de la polimerasa y su asociación con trastornos gastroduodenales. Para el estudio de seroprevalencia se evaluaron un total de 1041 personas de distintos estados del país, 370 adultos sintomáticos, 406 asintomáticos, 27 niños sintomáticos y 238 asintomáticos. La determinación de anticuerpos IgG específicos se realizó mediante ELISA comercial. La presencia del gen CagA fue evaluada en 133 pacientes del área metropolitana y el Centro de Cáncer Gástrico de San Cristóbal. Las biopsias se analizaron por diferentes métodos de diagnóstico para H. pylori: cultivo, prueba de ureasa, reacción en cadena de la polimerasa. En la población infantil el porcentaje de niños con valores de anticuerpos IgG específicos anti-H. pylori varía de 30 por ciento a 60 por ciento. En adultos sintomáticos la seroprevalencia varía entre un 68 por ciento a 93 por ciento según el área geográfica estudiada. Una disminución de anticuerpos IgG anti- H. pylori se observó en pacientes con gastritis antral difusa asociada con metaplasia tipo II. En el grupo de pacientes de San Cristóbal se observaron títulos elevados en pacientes con gastritis antral difusa. Un 46 por ciento de las cepas de H. pylori aisladas de pacientes del Area Metropolitana presentaron el gen cagA a diferencia de grupo de San Cristóbal donde se observó una frecuencia menor (26,41 por ciento).

Lewis antigen alterations in a population at high risk of stomach cancer.

Anomalous Lewis(a) antigen and sulfomucin expression are considered as markers of progression in precursor lesions of gastric cancer. Additionally, Lewis antigen and secretor phenotype have been related to Helicobacter pylori infection and gastric epithelial damage. The two objectives of this study were to correlate Lewis antigen alterations with histochemical changes and to explore the relationship between Lewis and secretor phenotypes and gastric epithelial damage related to H. pylori infection. The study subjects were selected from a chemoprevention trial in Tachira State, Venezuela, an area with a high risk of gastric cancer. Anomalous Lewis(a) antigen expression in Lewis (a-b+) phenotype individuals was closely related to the severity of the histological lesions, especially to dysplasia and type III intestinal metaplasia lesions. A weak relationship was observed between nonsecretor individuals and more advanced lesions of IM, but this association was not statistically significant. There was no relationship between secretor phenotype and H. pylori status, atrophy, regenerative activity, erosion, or ulcer.

Histological diagnosis of precancerous lesions of the stomach: a reliability study.

BACKGROUND: Within the framework of a chemoprevention trial on stomach cancer, two substudies based on repeat measurement were undertaken to evaluate reliability of histological diagnoses of gastric precancerous lesions. METHODS: A subgroup of 45 subjects received two endoscopies separated by a period of one month. The two biopsies were reviewed by a single pathologist. A second subsample of 50 subjects had a single endoscopy and the biopsy results were reviewed by two pathologists. Agreement between the two diagnoses was assessed by Cohen's Kappa and by repeat frequency. RESULTS: When the same samples were reviewed by the pathologists involved in the trial, agreement was very high for advanced lesions (repeat frequency = 0.96 for intestinal metaplasia and 1.00 for dysplasia) but lower for less advanced lesions (repeat frequency = 0.73 for superficial gastritis and chronic gastritis, 0.65 for atrophic gastritis). When the same pathologist reviewed two sets of biopsies taken less than 2 months apart, the combination of random observer error and biopsy sampling error gave rise to quite low agreement, especially for early lesions, mainly attributable to biopsy sampling error. Comparison of diagnoses made at routine reading and at review by the same pathologist and by different pathologists showed substantial overall agreement with the exception of one pathologist for whom agreement was moderate. CONCLUSIONS: These results confirm that misclassification of histological diagnosis may be a relevant problem in chemoprevention trials of stomach cancer, more so when baseline diagnosis is taken into account in the analysis to estimate progression and regression rates of precancerous lesions. Further, the results suggest that misclassification is limited to early lesions, while diagnostic reliability of severe lesions is quite high.

Antioxidants, Helicobacter pylori and stomach cancer in Venezuela.

A randomized chemoprevention trial on precancerous lesions of the stomach is being conducted in Tachira State, Venezuela. The aims of the study are to evaluate the efficacy of vitamin supplementation in preventing the progression rate of precancerous lesions. Here we report on the pilot phase of the study in which two antioxidant preparations were evaluated on their ability to raise antioxidant levels in plasma and in gastric juice. The study aimed also to determine the antibiotic sensitivity profiles of Helicobacter pylori isolates prevalent in the area. Forty-three subjects with precancerous lesions (chronic gastritis, chronic atrophic gastritis, intestinal metaplasia and dysplasia) of the stomach were randomized to one of two antioxidant treatments. Treatment 1 (250 mg of standard vitamin C, 200 mg of vitamin E and 6 mg of beta-carotene three times a day) or treatment 2 (150 mg of standard vitamin C, 500 mg of slow release vitamin C, 75 mg of vitamin E and 15 mg of beta-carotene once a day) for 7 days. Blood levels of total vitamin C, beta-carotene and alpha-tocopherol and gastric juice levels of ascorbic acid and total vitamin C were measured before and after treatment on day 8. Both treatments increased the plasma levels of total vitamin C, beta-carotene and alpha-tocopherol/cholesterol but not those of ascorbic acid or total vitamin C in gastric juice. Treatment 1 was the best choice and resulted in a greater increase in the plasma levels of beta-carotene and alpha-tocopherol. H. pylori was cultured from 90% of the gastric biopsies; 35 isolates were identified which were highly resistant to metronidazole, a front-line antibiotic recommended against H. pylori in other settings.

Prevalence of precancerous lesions of the stomach in Venezuela.

Gastric biopsies from 1477 participants in a chemoprevention trial for precancerous lesions of the stomach in Venezuela were evaluated for the prevalence of precancerous lesions and Helicobacter pylori infection. These study subjects were selected from participants in an early detection program for gastric cancer using double-contrast X-ray. Overall, 94% had some type of chronic gastritis (CG) and were positive for H. pylori using Giemsa stain, 49% had atrophic gastritis, 34% had intestinal metaplasia (IM), and 6.5% had dysplasia. There were only three subjects (0.2%) with normal gastric mucosa, and 4% had only superficial gastritis. The prevalence of all of these precancerous lesions increased with age, but there was no clear difference by gender. The prevalence of the various lesions was higher in the antral mucosa than in the fundic mucosa. H. pylori infection was strikingly frequent in our study population, with prevalence rates ranging from 73% in subjects with superficial gastritis to 95% in those with atrophic gastritis and IM and 98% in those with CG. The prevalence of H. pylori was equally high in males and females, and it was significantly positively associated with the degree of infiltration of poly- and mononuclear cells and with that of active regeneration; it was inversely correlated with the degree of atrophy, IM, and dysplasia. Our findings support the precancerous nature of the various gastric lesions and the etiological role of H. pylori infection in CG.

[Early gastric cancer in the remnant stomach. Case report]. / Cancer gastrico precoz en la boca anastomotica. Presentacion de un caso.

Patients with partial gastrectomy are a High risk group to develop gastric cancer. Risk is higher in remnant estomach after partial gastrectomy by malignancy than benign disease. We present a case of a male patient, 64 years old, who was admitted in our Hospital with Hypovolaemia. We found during Endoscopic examination early gastric Cancer IIc + III type in the site of anastomosis. Partial gastrectomy was performed in this patient by Duodenal ulcer 11 years ago.

Determinants of plasma pepsinogen levels in a population at high risk for stomach cancer in Venezuela.

Determinants of plasma pepsinogens (PG) levels were studied in 1365 participants in a chemoprevention trial for gastric pre-cancerous lesions being conducted in Venezuela. Gastric biopsies, plasma samples and information on smoking and dietary habits were obtained at baseline examination. Both PG-I and PG-II levels increased progressively with the level of Helicobacter pylori infection in gastric biopsies, resulting in no clear trend in the I/II ratio. Instead, there was a progressive decrease in the I/II ratio with increasing degrees of infiltration of polynuclear cells and monocytes, atrophy, intestinal metaplasia and the stage of pre-cancerous lesions. The mean I/II ratios for atrophic gastritis or more advanced lesions were less than 4.0. When subjects with the I/II ratio 4 or higher were used as controls, severe reduction in the I/II ratio (< 2.0) was inversely associated with tobacco consumption. This may be due to a pharmacological effect of nicotine. The severe reduction of I/II ratio was also inversely associated with fresh fruit consumption. In addition, a decreased I/II ratio was positively associated with rice/pasta and arepas (tortilla made from corn) consumption and inversely associated with plantain consumption. Possible effects of vitamins and starchy food on the development of atrophic gastritis need to be studied further.

[Inflammatory response associated with Helicobacter pylori infection in gastric mucosa with intestinal metaplasia in a population in high risk for gastric cancer]. / Respuesta inflamatoria asociada con infeccíon por Helicobacter Pylori en mucosa gástrica con metaplasia intestinal en una población de alto riesgo para cancer gástrico.

Intestinal Metaplasia (IM) and Helicobacter Pylori (HP) infection had been related to gastric carcinogenesis. With the intention to know the relationship among HP infection, IM and inflammatory response of the mucosa in an area of high prevalence of gastric cancer, we studied 800 persons that attended the Gastric Cancer Mass Survey, ongoing in the State Tachira, Venezuela, since 1981. Out of these subjects, 259 had histology diagnosis of IM (32.4%) 52.1% were IM type Y, 19.3% type II and 22.8% type III (sulfomucin secretory). Histology demonstrated with Giemsa stain HP in 94.6% of the cases. Association between HP and inflammation response in gastric mucosa with IM, was statistically significant (p = 0.001). The are heavier bacteria overload in IM type I than in type III although it is not statistically significant. We ponder if gastric mucosa inflammation due to HP, conditions development of IM as a hostile way of the gastric environment to restrain bacterial growth. This phenomenon ally with other oncogeneous factors could induce to premalignant lesions and eventually gastric cancer.

[Macroscopic and histopathological aspects of atypical gastric epithelium]. / Aspectos macroscópicos e histopatológicos del epitelio atípico en estomago.

Atypical Epithelium is a localized lesion, which has histological and macroscopic findings similar to gastric cancer. In this paper we evaluated 44 cases of atypical epithelium studied and treated in our institute. We found 3 cases of atypical epithelium associated with early gastric cancer. That is 2.66% of the total of all cases. We established the relationship of these lesions and following variables: age, size, localization, macroscopic shape and intestinal metaplasia. We found atypical epithelium in patients older than 50 years old, most of then smaller than 2 cm., localized in antrum and body gastric, and macroscopically were slight elevated lesions. Histologically all of them had intestinal metaplasia.

Programa de pesquisa del cáncer gástrico en el Estado Táchira, Venezuela

Por la alta incidencia de cáncer gástrico, similar a la de otros estados andinos de Venezuela, se ha establecido, a partir de 1980, un Programa Piloto de Pesquisa del Cancer Gástrico en el Estado Táchira (PCG) y cuya secuencia ha consistido en planificación, motivación, radiología indirecta, segunda exploración (con fibrogastroscopia y radiología directa) histopatología, tratamiento y registro-seguimiento. Se presentan los resultados obtenidos en 429 casos avanzados y 129 precoces, observándose en los últimos años una moderada reducción en la mortalidad global.

Difficulty in eradicating Helicobacter pylori in a population at high risk for stomach cancer in Venezuela.

The bacterium Helicobacter pylori (HP) has been implicated in the etiology of precancerous lesions of the stomach and there is evidence suggesting that it may influence the efficacy of chemoprevention of gastric cancer with vitamin C. Eradication seldom has been attempted in populations from developing countries, with a high prevalence of HP frequently resistant to metronidazole. A randomized, double-blind, controlled trial to evaluate the efficacy of colloidal bismuth subcitrate (120 mg q.i.d.) and amoxycillin (500 mg q.i.d.) in eradicating HP was conducted in 220 subjects drawn from a population with a high prevalence of metronidazole-resistant HP in Tachira state, Venezuela. One month after completion of two weeks' treatment, eradication rates of 6.5 percent in the treatment group and two percent in the placebo group were estimated on the basis of HP diagnosis in biopsies, and of 13.9 percent compared with 3.9 percent on the basis of a 14C-urea breath test, although the negative predictive value of the breath test was very low compared with HP diagnosis in biopsies. In the treatment group, particularly among males, a significant decrease in bacterial load was detected. Reasons for failure of treatment in high HP-prevalence areas are discussed, and it is suggested that primary prevention of HP infection may be the optimal approach to reducing levels of stomach cancer in these high-risk groups.

[Gastric leiomyoblastoma. Histomorphologic and immunologic analysis of 3 cases]. / Leiomioblastoma gástrico. Análisis histomorfológico e inmunológico de tres casos.

We present three cases of Leiomioblastomas of stomach, diagnosed at the unit of Pathology of the Gastrointestinal Cancer Center "Dr Luis E. Anderson" -San Cristóbal-Táchira State Venezuela. The lesions are analyzed from the clinical, morphological and immunohistological points of view, utilizing Queratine and Vimentin techniques. This neoplasm is not frequent but it is interesting because its biologic behavior not always correspond to its histology-pattern.

[The use of urea carbon 14 in breath tests as diagnostic method for Helicobacter pylori infections]. / Uso del test úrea carbono14 en el aliento como método de diagnóstico de infección por Helicobacter pylori.

The Helicobacter Pylori has been indicated as a pathologic agent in the pathogenesis of antral gastritis, gastric and duodenal ulcers and probably in gastric cancer. Due to the high incidence of this infection in our place, we decided to look for a diagnostic method quick to perform, sensitive, reliable and no invasive. The breath test of 14C urea, based in the production of urea by the H. Pylori, represents this alternative. We have found, using does of 1 microCi, a high correlation with the diagnosis of H. Pylori by biopsies. We determined as negative less than 100 DPM, doubtful between 100 and 200 DPM and positive more than 200 DPM. The high pick of the curve keeps tight relation with the degree of infection. We checked this when we suppressed the H. Pylori with bismuth subsalicylate. The breath 14C Urea test showed high sensitivity (100%) and specificity (85.71%). We conclude that this breath test is an alternative way of diagnosing and follow up for H. Pylori infections. It is highly sensitive, reproducible and no invasive.

[Macroscopic aspect and depth in early gastric cancer]. / Aspecto macroscópico y profundidad en cáncer gástrico precoz.

Depth of invasion in Early Gastric Cancer (E.G.C.) is very important to be evaluated. We reviewed 78 cases of E.G.C., in patients of our program that were operated on. We established the relationship among three macroscopic variables (localization, size and macroscopic shape) and depth of invasion. We realized that the lesions located in the fundus, though diagnosed less frequently, has more tendency to invade the submucosa (50%), in relation to other localizations. We did not find a significant statistic relation chi 2 = 3.76 P: .58 df:5 between size and invasion. The macroscopic types IIa + IIc and the E.G.C. type III have tendency to further invasion (58.8 and 66.67%). The polypoid lesions Type I and IIa are mostly intramucosal, so they could be treated endoscopically in high risk and old patients.

[Endoscopic resection in early gastric cancer]. / Resección endoscópica en cáncer gástrico precoz.

Development of therapeutic endoscopy has permitted the treatment of early gastric cancer (EGC) in its different macroscopic forms. In this paper we present 9 cases of EGC treated endoscopically in our Institution. We describe the criteria we follow to perform this procedure. The patients selected were of advanced age and high surgical risk. Seven cases were macroscopically Type I and two were Type IIa. According to localization six were proximal tumors (body and fundus) and three were located in the antrum. Six of the nine patients are alive after resection, one more than 6 years and 3 more than 3 years. Three patients died of ailments no related to cancer.

[Histologic study of Helicobacter pylori in 265 consecutive gastric biopsies]. / Investigación histológica de Helicobacter pylori en 265 biopsias gástricas consecutivas.

We evaluated 265 consecutive endoscopic gastric biopsies of subjects attending the gastric cancer mass survey that is taken place in the State of Tachira, Venezuela. They were 152 males and 113 females between 18 and 70 years of age. We established the prevalence of Helicobacter pylori in relation with histologic diagnosis and location of the lesions in the stomach. We performed hematoxylin eosin, Giemsa and Gimenez stains. The bacteria was identified in chronic non atrophic gastritis in 81% of the cases, in 76% of erosive gastritis, in 72% of gastric ulcers, in 36% of chronic atrophic gastritis and in 16% of neoplastic tissues. Helicobacter pylori was found in 82% of antral biopsies, and in 9% of the body, 7% of the fundus and 2% of the cardiac biopsies. From the total of 265 biopsies HP was positive in 172. The prevalence of this bacteria was 69.9% in this investigation.