What is the initial treatment approach for MALT (Mucosa-Associated Lymphoid Tissue) lymphoma?

From the Guidelines

The initial treatment approach for MALT lymphoma should be Helicobacter pylori eradication therapy for H. pylori-positive cases, as it can induce lymphoma regression and long-term clinical disease control in most patients 1. The treatment plan typically involves a combination of a proton-pump inhibitor (PPI) and antibiotics, such as clarithromycin-based triple therapy with either amoxicillin or metronidazole, for 10-14 days 1.

• Key considerations for H. pylori-positive cases include:
  • Eradication therapy should be given to all gastric MALT lymphomas, independently of stage 1
  • The outcome of the eradication therapy should be checked by a urea breath test (or by a monoclonal stool antigen test) at least 6 weeks after eradication therapy and at least 2 weeks after PPI withdrawal 1
• For H. pylori-negative cases, a regression of the lymphoma after antibiotic treatment is unlikely, and the immediate start of oncological treatments, such as radiation therapy, should be considered 1.
• Radiation therapy, typically moderate-dose involved-field radiotherapy (24-30 Gy radiation to the stomach and perigastric nodes given in 3-4 weeks), is often recommended for localized disease that does not respond to antibiotic therapy 1.
• Chemotherapy and/or immunotherapy, such as rituximab-based immunotherapy, may be considered for patients with MALT lymphoma of all stages, particularly those with symptomatic systemic disease or histological transformation 1.

From the Research

Initial Treatment Approach for MALT Lymphoma

The initial treatment approach for MALT (Mucosa-Associated Lymphoid Tissue) lymphoma depends on various factors, including the location and stage of the disease, as well as the presence of Helicobacter pylori infection.

• For patients with H. pylori-positive gastric MALT lymphoma, the standard therapy is eradication of H. pylori using a triple anti-H. pylori regimen approved by the US Food and Drug Administration 2.
• This approach can achieve a complete response in approximately 60% to 90% of patients with stage IE tumors, with better responses seen in patients with more superficial tumors 2.
• For patients with H. pylori-negative gastric MALT lymphoma, antibiotic therapy as sole management may be effective, with some studies showing durable remissions in a relevant percentage of patients 3.
• Radiation therapy or surgery with or without radiotherapy may be recommended for patients with tumors that are T4 node-positive or have adverse cytogenetics 2.
• Chemotherapy, such as CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone)-based chemotherapy, may be recommended for patients with tumors that have a significant high-grade component or large cell tumors with a minor low-grade MALT component 2.

Treatment Options for Gastric MALT Lymphoma

Treatment options for gastric MALT lymphoma include:

• Eradication of H. pylori using antibiotics, such as clarithromycin, amoxicillin, and metronidazole, plus a proton-pump inhibitor 4, 5.
• Radiation therapy, which can be effective for localized MALT lymphomas of the orbit, conjunctiva, salivary glands, and thyroid gland 2.
• Surgery, which may be considered for patients with large cell or bulky tumors, or for those with relapsed or refractory disease 2.
• Chemotherapy, which may be recommended for patients with disseminated MALT lymphomas or those with high-grade disease 2, 4.

Importance of H. pylori Eradication

H. pylori eradication is a crucial component of the treatment approach for gastric MALT lymphoma, as it can lead to complete remission in a significant percentage of patients 2, 4, 5.

• The recommended anti-Helicobacter triple drug therapy includes a proton pump inhibitor, clarithromycin, and amoxicillin (or metronidazole) 5.
• Alternative regimens, such as azithromycin, ofloxacin, bismuth, and omeprazole, may also be effective as second-line therapy for H. pylori eradication 6.