A 58-year-old man with an 8-year history of untreated *Helicobacter pylori* infection presents with 6 months of epigastric discomfort, postprandial fullness, and microcytic anemia (Hb 11.2 g/dL). Upper endoscopy reveals striking abnormalities in the gastric antrum and lesser curvature. The structure marked **A** — the thickened, nodular, cobblestone-like mucosa with loss of normal rugal pattern — is biopsied and shows a dense lymphoid infiltrate with centrocyte-like B cells and lymphoepithelial lesions. Immunohistochemistry confirms CD20+, CD5−, CD10−, CD23− B-cell lymphoma. Cytogenetic studies show no t(11;18) translocation. Endoscopic ultrasound confirms stage I disease. What is the most appropriate FIRST-LINE management for this patient?

Question

Accepted Answer

A. H. pylori eradication therapy (triple or quadruple regimen). ## Why H. pylori eradication therapy is correct

The cobblestone nodular thickening marked **A** is the pathognomonic endoscopic feature of gastric MALT lymphoma. In H. pylori-positive, t(11;18)-negative, limited-stage (I) MALT lymphoma, H. pylori eradication with triple or quadruple therapy (e.g., bismuth quadruple) is the first-line treatment and achieves complete histologic remission in 70–80% of patients within 6–18 months. This patient has no adverse prognostic factors (negative t(11;18), stage I, no B-symptoms, no distant disease), making eradication therapy the standard of care per ESMO guidelines (Zucca 2023).

## Why each distractor is wrong

- **Involved-field radiotherapy**: Reserved for patients with persistent disease after H. pylori eradication failure, t(11;18)-positive disease, or higher-stage involvement. This patient has not yet received eradication therapy and has favorable prognostics.
- **Rituximab monotherapy**: Single-agent rituximab is used in eradication-resistant or t(11;18)-positive disease, not as first-line in eradication-naive, t(11;18)-negative patients.
- **Partial gastrectomy**: Surgical resection is not indicated for limited-stage MALT lymphoma and carries significant morbidity. Medical or radiotherapeutic approaches are preferred.

**High-Yield:** H. pylori-positive, t(11;18)-negative gastric MALT lymphoma = H. pylori eradication first; reserve radiotherapy/rituximab for eradication failure or adverse cytogenetics.

[cite: Zucca E. ESMO Clinical Practice Guideline: gastric MALT lymphoma 2023; Sugizaki K. Endoscopic features of MALT lymphoma 2022]

Answer

B. Rituximab monotherapy followed by observation

Answer

C. Partial gastrectomy with distal margin clearance

Answer

D. Involved-field radiotherapy (24–30 Gy) to the gastric antrum

Explanation

Why H. pylori eradication therapy is correct

Why each distractor is wrong

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