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: 20 Sep 2024
Reviewer's report:
1. The authors state in the Abstract, “This study aimed to assess the correlation between
endoscopic morphology of MALT lymphoma and API2/MALT1 fusion and the predictive
value for the treatment response to Hp eradication.” However, the results and conclusions
corresponding to this objective are not clearly stated in the Abstract. The characteristic
endoscopic features of API2/MALT1 fusion-positive MALT lymphoma, as well as the
predictive value (or should it be “predictive factor”?) for the response to Hp eradication,
should be explicitly mentioned. The Abstract should be structured so that it can be understood
independently by the reader.
2. The authors state, “Recently, the Kyoto Gastritis Consensus indicated that endoscopic
appearance could predict Hp-negative status, leading to the hypothesis that if MALT lymphoma
emerges in a background of Hp-negative gastric mucosa, it might suggest the existence of API2/
MALT1 fusion, even predicting the response to Hp eradication [7]. However, there is a lack
of literature exploring this hypothesis. Therefore, this study aims to explore the correlation
between endoscopic features of MALT lymphomas and the status of API2/MALT1 fusion.” This
reasoning is flawed. The Kyoto Gastritis Consensus discusses the background gastric mucosa,
whereas the authors intend to analyze the presence or absence of RAC (a single feature of the
background gastric mucosa) and MALT lymphoma lesions, which are unrelated statements.
3. In Figure 1, “Absence of Hp infection” should be revised to “Absence of Hp infection status.”
4. The statement “193 patients were finally included in the analysis” is not appropriate.
According to the authors, the primary aim is “to explore the correlation between endoscopic
features of MALT lymphomas and the status of API2/MALT1 fusion, and to analyze the
prognosis of MALT lymphomas with different endoscopic morphologies after anti-Hp therapy.”
Therefore, only cases with a known API2/MALT1 fusion status should be analyzed, and all
other cases should be excluded. Moreover, the secondary objective is “to analyze the prognosis
of MALT lymphomas with different endoscopic morphologies after anti-Hp therapy,” so only
cases that have undergone Hp eradication therapy should be included. As a result, the data on
193 cases presented in Table 1 are meaningless. The study design should be reconsidered, and
the entire “Clinicopathologic Features of MALT” section should be deleted.
5. The primary objective of the authors is “to explore the correlation between endoscopic
features of MALT lymphomas and the status of API2/MALT1 fusion.” Would it not be better to
divide the cases into API2/MALT1 fusion-positive and API2/MALT1 fusion-negative groups
for comparison and analysis?
6. The section “Predictive Factors for API2-MALT1 fusion: A binary logistic regression analysis
was conducted on 73 cases of superficial subtypes to predict the API2-MALT1 fusion based on
factors such as clinical staging of MALT lymphoma, endoscopic features, and the effectiveness
of anti-Hp therapy. The analysis identified the non-responder of anti-Hp treatment (OR=5.04,
95% CI 1.16-21.87, p=0.031) and the localized superficial morphology (OR=4.04, 95% CI
1.37-11.92, p=0.011) as independent predictors of the API2-MALT1 fusion (Table 6)” is
redundant. Reason 1: The primary aim of the authors is to explore the correlation between
endoscopic features of MALT lymphomas and the status of API2/MALT1 fusion; response to
anti-Hp treatment is not an endoscopic feature. Reason 2: Even if the presence of non-response
to anti-Hp treatment and localized superficial morphology predict API2-MALT1 fusion, what
is the clinical utility of this information? I recommend deleting the section titled ‘Predictive
Factors for API2-MALT1 Fusion.
7. In the conclusion, the authors state, “This study found that localized superficial gastric
MALT lymphoma has low Hp infection rates, a higher rate of RAC sign, and is associated with
API2/MALT1 fusion, suggesting that endoscopic morphology has potential application value in
predicting the response of gastric MALT lymphoma to eradication therapy.” However, 71.1% of
localized superficial gastric MALT lymphoma cases were H. pylori positive, which contradicts
the claim of “low Hp infection rates.” This statement needs revision.
8. Additionally, the authors claim in the conclusion, “The localized lesion had a remission rate of
34.3% (12 cases) after anti-Hp therapy,” indicating that one-third of patients achieved remission.
If the remission rate of localized superficial gastric MALT lymphoma is low, how should this
be applied in clinical practice? It is unlikely that H. pylori eradication would be omitted as the
initial treatment for patients with localized superficial gastric MALT lymphoma.