Two Atypical Cases of Nodular Gastritis: A Poorly Differentiated Gastric Adenocarcinoma and a Pseudo-Low Grade Gastric MALT Lymphoma

Abstract

Nodular gastritis is a Helicobacter pylori-related gastritis with endoscopically proven gooseflesh skin-like nodularity in the gastric antrum. Although an association between nodular gastritis and gastric malignancies has been suggested, there is neither a treatment strategy nor a treatment guideline for this condition because of its relative rarity. We have recently experienced two cases of diffuse-type nodular gastritis invading both the antrum and corpus of the stomach with atypical findings that required specific treatments in two young females. The first patient was diagnosed with a suspicious low grade gastric mucosa associated lymphoid tissue (MALT) lymphoma lesion on a diffuse-type nodular gastritis, and was cured by H. pylori eradication. The second patient was diagnosed with a signet cell type gastric cancer on a diffuse-type nodular gastritis, and was cured by surgical resection. When considering the nature and significance of these gastric lesions, a link between nodular gastritis and gastric malignancy should be considered, especially in young women who have diffuse-type nodular gastritis involving both the antrum and corpus of the stomach.

Keywords: Gastric cancer; Gastric mucosa associated lymphoid tumor; Helicobacter pylori; Nodular gastritis.

Figure 1

Endoscopic findings of the proximal antrum in the first patient (a 39 years old woman). (A) Initial findings showed micronodules measuring 2-5 mm in diameter with a smooth surface. The findings are observed from the antrum to the low corpus of the stomach, indicating a diffuse-type nodular gastritis. (B) There were no remarkable changes in nodular elevation on chromoendoscopic findings 1 month after H. pylori eradication, even after applying 0.2% indigo carmine spray. There was also no change in diffuse-type nodular gastritis since the previous examination. (C) Indigo carmine (0.2%) chromoendoscopy conducted 3 months after successful H. pylori eradication revealed, diminished nodular elevations.

Figure 2

Histologic findings of biopsied specimens from the anterior aspect of the antrum in the first patient. (A) On microscopic findings at a low magnification, the nodular mucosa is expanded by a marked lymphoplasma cell infiltration with the presence of a prominent germinal center (H&E stain, x100). (B) On microscopic findings at a higher magnification, diffuse lymphoplasma cell infiltration is noted in the lamina propria, and a few lymphocytes are infiltrating the epithelium. Low grade gastric MALT lymphoma is suspected, but no definite lymphoepithelial lesion is found (H&E stain, x400).

Figure 3

Gross findings of endoscopy and surgical specimens in the second patient (a 30 years old woman). (A) Chromoendoscopic findings with application of 0.2% indigo carmine showed diffuse mucosal nodularity evident on the antrum and lower corpus of the stomach, leading to a diagnosis of diffuse-type nodular gastritis. A round, elevated lesion with central ulceration can be seen on the anterior aspect of the proximal antrum. The edge and base of the ulcer are irregular and uneven, suggesting a cancerous change. (B) A 3.2 x 2.0 x 1.0 cm Borrmann type III gastric cancer was completely resected surgically by subtotal gastrectomy, with negative resection margins.

Figure 4

Histological findings of the resected gastric cancer in the second patient. (A) On microscopic findings at a low magnification, mononuclear cell infiltration with germinal centers is noted in the mucosa and submucosa around the gastric cancer (H&E stain, x40). (B) On microscopic findings at a higher magnification, a poorly differentiated tubular adenocarcinoma is evident near the lymphoid follicle in the mucosa (H&E stain, x400).

Figure 5

Schema of the progression of nodular gastritis to gastric neoplasms. In contrast to the case in children, novel H. pylori infection may lead to nodular gastritis in some adults, and some may progress to a diffuse-type nodular gastritis that invades both the antrum and body. A few cases of diffuse-type nodular gastritis may progress further to gastric neoplasm, especially in young women, due to fewer atrophic changes.