Review for 10.1186/s12876-024-03476-5 (2024)

Title: Endoscopic Morphology of Gastric MALT Lymphoma Correlate with API2/MALT1
Fusion and Predict Treatment Response After Helicobacter pylori Eradication
Version: 2 Date: 05 Sep 2024
Reviewer's report:
This article focus on the association of endoscopic findings of gastric MALT lymphoma and
API2/MALT1 fusion as predictor of lymphoma response to H. pylori eradication. The authors
conclude that endoscopy has the potential to predict the result of eradication therapy. However,
this conclusion has no real impact on the management of gastric MALT lymphoma at present.
Nowadays H. pylori eradication therapy is the well accepted first-line therapy worldwide in
all patients with gastric lymphoma as expressed in international guidelines (EGILs, ref. 4;
Zucca, ref. 6; Fischbach, Z Gastroenterol 2024: Update S2k-Guideline Helicobacter pylori and
gastroduodenal disease of the German Society of Gastroenterology, to be cited; Malfertheiner,
Maastricht VI/Florence Consensus report, Gut 2022, to be cited).
This has to be clearly stated in the paper and be part of the conclusion.
The patient flow chart of the study (figure 4) is totally confusing! Several aspects need to be
clarified:
n=193 were included in the analysis. N=153 were found to have H. pylori infection as
documented by UBT (127) or histology (26). All 153 patients were diagnosed to have gastric
MALT lymphoma, obviously on histology. If histology is present, why H. pylori status could
not be analysed histologically in all cases?
API2-MALT1 was tested in 114 cases: of which cohort? (n=348; n=193; ??).
95 cases revealed superficial lesions (text), however n=73 in figure 4?
Besides these major criticism there are several other aspects which should be addressed when
revising the manuscript.
A first analysis of the endoscopic appearance of gastric MALT lymphoma was reported in 1999:
Kolve M et al, Gastrointest Endosc 1999;49:307-315. In this analysis it was found that also
normal appearing mucosa can be infiltrated by MALT lymphoma. This is of practical importance
as it lead to the recommendation of a gastric mapping biopsy protocol (ref. 4). This has to be
addressed.
What eradication protocol was used? No data on that in the article.
If the authors speculate on a possible therapeutic approach based on endoscopic findings with
regard to lymphoma regression after H. pylori eradication therapy another aspect needs to be
discussed. We do know from large series that patients revealing histological residuals of MALT
lymphoma after successful eradication therapy can be safely managed by a watch-and-wait
strategy (Fischbach et al, Lancet 2002;360:547; Fischbach et al, Gut 2007;565:1685). In most
cases, there is no need for any oncological therapy. A watch-and-wait strategy can also be
applied to patients with persisting endoscopic changes after eradication therapy (Z Gastroenterol
2019;57:1-7).
Some minor points:
Wording in the abstract section: 2nd line: predicts; mixed type; results: instead of “Hp was
infected in 153 cases” better: H. pylori infection was present in 153 cases; RAC: abbreviation
should not be used in the abstract; results last sentence: verb is missiong.
Background: “ … coexists with H. pylori”: misleadingly expressed! Better: Hp is present in
70-90% of patients with gastric MALT lymphoma, or similar.
In summary: there is a need for major revision of the manuscript addressing the above mentioned
aspects and especially describing the patient flow chart in a understandable and clear way.