Extranodal non-Hodgkin's lymphomas of the gastrointestinal tract represent 30%-40% of all extranodal lymphomas. Gastric lymphomas are increasingly described in the literature due to the development of diagnostic techniques and the increased incidence, together with the reduced incidence of gastric solid neoplasms. Significant diagnostic difficulties are determined by the non-specificity of the symptoms, which are mostly chronic, characterised by a slow progression. Localisation in the small intestine often appears as surgical urgency, due to the development of an intestinal obstruction or enterorrhagia. We present two cases of extranodal diffuse large B-cell lymphoma localisation, presented as a secondary lesion localised in the first one in the stomach, and in the second one in the first duodenal portion.

Gastric non-Hodgkin lymphoma is a rare tumour that represents approximately 7% of all stomach cancers and 2% of all lymphomas. The most frequent location of gastric MALT (mucosa associated lymphoid tissue) lymphomas is in the antrum in 41% of the cases, and 33% can be multifocal. The risk of spontaneous perforation of a gastric MALT lymphoma is 4-10%.

24 year old male patient carrying the Human Immunodeficiency Virus, who began with signs and symptoms of acute abdomen and fever 72 hours before arriving in the emergency room. A computed tomography was performed that showed free fluid in the cavity, and gastric wall thickening. The patient underwent a laparotomy, finding absence of the anterior wall of the stomach, sealed with the left lobe of the liver, colon and omentum. Total gastrectomy, with oesophagosty and jejunostomy tube, was performed.

Gastric perforation secondary to a MALT lymphoma is rare, with high mortality. There is limited information reported of this complication and should be highly suspected in order to provide appropriate treatment for a complication of this type.

Non-Hodgkin lymphomas (NHLs) are a diverse group of blood cancers derived from lymphocytes that vary significantly in their severity. Surgery is not often used as a treatment because of the efficacy of chemotherapy, biological therapy, radiotherapy and hematopoietic stem cell transplantation. We reviewed the natural history and possible role of surgery for NHL. Surgery may be useful in confirming or refuting an equivocal radiological diagnosis through biopsy, removing symptomatic limited disease from an affected organ and in splenectomy for primary splenic lymphoma. Emergency abdominal surgery for acute complications of NHL provides palliation and diagnosis. There is as yet no consensus as to the optimum treatment for symptomatic limited disease affecting an organ and timing of chemotherapy perioperatively. Prospective randomized trials are required.

Female, 91 FINAL DIAGNOSIS: Low-grade gastric MALT lymphoma Symptoms: Recurrent epigastric and right upper quadrant dyscomfort Medication: Rituximab Clinical Procedure: esophagogastroduodenoscopy • gastric biopsy Specialty: Gastroenterology.

Unusual or unexpected effect of treatment.

Mucosa associated lymphoid tissue (MALT) lymphoma can occur in any extranodal organ or tissue, stomach being the common site. Most of the gastric MALT lymphomas are related to chronic H. pylori infection. H. pylori negative gastric MALT lymphoma is relatively uncommon and usually treated with a short course of chemotherapy, radiotherapy or surgery.

Herein, we present a case of an elderly female with H. pylori negative, low-grade gastric MALT lymphoma that was successfully treated with a short course of rituximab.

This case report emphasizes that rituximab monotherapy can be an effective treatment for H. pylori negative low grade gastric MALT lymphoma especially in an elderly patient where surgery or radiotherapy may not be appropriate.

To assess the clinical and endoscopic presentation of primary gastric lymphoma.

Remission rate and long-term survival in patients with gastric lymphoma mainly depend on disease stage at diagnosis. Series reporting clinical and endoscopic presentation of gastric lymphoma are generally small and heterogeneous.

Systematic review with pooled-data analysis assessing clinical and endoscopic presentation of primary gastric lymphoma.

Data regarding 2000 patients were collected. Overall, males were slightly more prevalent, alarm symptoms were absent in near half of the patients, lymphoma was diagnosed in a stage >I in one-third of the patients, and Helicobacter pylori infection was present in 88.8% of considered patients. At endoscopy, the ulcerative type was the most frequent presentation, although low-grade lymphoma was diagnosed on normal/hyperemic gastric mucosa in 9% of cases. Patients with high-grade lymphoma presented alarm symptoms (anemia and/or melena and/or hemorrhage, persistent vomiting, weight loss), an exophytic or ulcerative lesion, a stage III-IV, and a H. pylori negative status more frequently than low-grade lymphoma cases.

Our pooled-data analysis showed that gastric lymphoma is still disappointingly diagnosed in an advanced stage in a large number of patients. This is probably due to presence of nonspecific symptoms at initial clinical presentation and/or a normal appearing mucosa at endoscopic observation in the early stages.

Nowadays the management strategy for primary gastric lymphoma is undergoing change due to the effectiveness of chemotherapy and immunotherapy. While earlier surgical resection was the primary treatment and chemotherapy was only a follow-on procedure, at the present time this arrangement seems to have been reversed. Early stage low-grade MALT lymphoma can be treated with Helicobacter pylori eradication. Total or subtotal gastrectomy with D2 lymphadenectomy and with adjuvant chemotherapy in R1 situation is proposed up to stage II.1. The strategy is similar in the case of high-grade gastric lymphoma, but resection is useful only in those cases when one can be assured the result will be an R0 situation. With the exception of these cases, the only indication for resection is chemo-resistance. There is no reason for operating in advanced stages of the disease. The only purpose can be to manage complications. Unfortunately, the exact diagnosis is difficult. The diagnosis of lymphoma can often only be made after the operation. In the 6-year period between 1st January 2000 and 31st December 2005 we treated 38 patients for primary gastric lymphoma. Altogether 9 patients were operated on. Resection was performed in 6 cases. The diagnosis of lymphoma was known preoperatively only in one case. Nowadays surgery seems to be only secondary to chemotherapy and immuno-chemotherapy in the treatment of primary gastric MALT lymphoma. Our own cases also mirror this change.