Gastric MALT

[Mandelin Rain]

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85 yo with small focus on EGD.

H. pylori negative in specimen.

H. pylori IgG Antibody positive.

Stool antigen negative.

Translocation pending.



What do you do? It looks like NCCN recommends triple therapy on the basis of the antibody positivity, but I'd like to see either the path or stool positive as well. Would the translocation change anything for anyone?

 

[BobbyHeenan]

Given H. pylori negative in specimen and stool antigen negative - if t(11:18) also present, I'd probably prep the patient with the fact that <5% of patients with the translocation will show a tumor response. So I'd probably let him/her have a "trial" of antibiotics first, but see him back in 6 weeks and if still symptomatic then just move forward with XRT (no re-scope). Let him/her know that if they feel like they're getting worse at any point over the next 6 weeks just call and I'd sim. If he/she becomes asymptomatic after antibiotics I would send for re-scope.

If the patient was 65 I'd probably just treat, but with a small focus and elderly I suppose it's worth a trial of conservative therapy first, even though I share your concerns about the H. pylori testing results suggesting H. pylori may not be the causative agent.

Whatever you do, make sure med onc doesn't start rituximab in the interim 🙂

 

[Burt Radnolds]

Is he symptomatic? (I would guess he might be, based on the fact he got an EGD to start). Did they run an H. Pylori IgA? Do you have a urease breath test available (probably not)? I wouldn't be chomping at the bit to treat this guy with radiation. I think antibiotic therapy is very reasonable to start with given that a positive antibody in someone who hasn't been intentionally treated for H.Pylori is usually considered a reason to treat for eradication. If the translocation is positive, that seems like a reasonable indication to treat with radiation, especially if he has symptoms.

 

[Mandelin Rain]

Thanks for the thoughts. Minimally symptomatic (some reflux). No bleeding or anything. No previous H. pylori rx. I'll probably just see how it goes on triple therapy.