Primary mucosa-associated lymphoid tissue (MALT) lymphoma occurring in the rectum: a case report and review of the literature.

Abstract: The primary extranodal B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) is a distinct clinical pathologic entity that develops in diverse anatomic locations such as the stomach, salivary gland, thyroid, lung, and breast; however, colorectal involvement is rare.

To the best of our knowledge, only 30 cases of primary rectal MALT lymphoma have been published in the English language literature, mostly from Japan. A single case has been reported from the US before this report. The most common symptoms ranged from asymptomatic to occult or gross gastrointestinal bleeding. Simultaneous involvement of the cecum or colon was seen in 20% of the patients. Ninety percent of the patients were classified as low grade, Stage 1 at the time of diagnosis. Polypoid lesions were 10-fold more common than ulcerative lesions. Seven patients were reported to have H pylori in the stomach. The majority of the patients underwent surgical or endoscopic resection as a cure; however, controversy exists with regards to antibiotic treatment or observation alone because of unknown etiopathogenesis. Infection with microorganisms other than H pylori has been postulated in the development of rectal MALT lymphoma; however, this hypothesis remains unproven. The overall prognosis of rectal MALT lymphoma appears favorable; however, long-term follow-up data is lacking. Therefore, periodic clinical monitoring should be done in these patients.

Key Words: mucosa-associated lymphoid tissue (MALT), lymphoma, rectum

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The primary extranodal B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) is a distinct clinical pathologic entity. (1) MALT lymphoma is characterized histologically by the diffuse infiltration of small lymphoid cells (centrocyte-like or monocytoid-looking cells), infiltration of lymphoma cells around the epithelium (lymphoepithelial lesions) and the proliferation of plasma cells in the lamina propria of the mucosa. The clinical behavior of MALT lymphomas has been reported as favorable. (2)

The MALT lymphoma develops in diverse anatomic locations such as the stomach, salivary gland, thyroid, lung, and breast (3); however, colorectal involvement is extremely rare. (4,5) To our knowledge, only 30 cases of primary rectal MALT lymphoma have been reported in the English language literature and a single case has been reported from the United States. In the present paper, we describe a patient with MALT lymphoma arising in the rectum and review the literature.

Case Report

A 69-year-old Hispanic man was referred for colonoscopy because of rectal polyps that were seen on a screening sigmoidoscopy. Three sessile polyps ranging in size from 5 to 6 mm were seen in the rectum and a 6 mm sessile polyp was present in the cecum (Fig. 1). All polyps were removed with cold snare. Histologic sections of the biopsies taken showed typical features of low grade MALT lymphoma: atypical lymphoid hyperplasia with reactive follicles surrounded by hyperplastic mantle and/or marginal zones and scattered epithelioid histiocytes (Fig. 2). Scattered lymphoepithelial lesions were also present. By immunohistochemistry on both blocks, the majority of cells in the expanded mantle zones or marginal zones were positive for CD 20 and BCL-2, negative for CD5, cyclin D1, CD10, CD3 and CD43. Kappa and lambda showed scattered polyclonal plasma cells. Polymerase chain reaction analysis done on both rectal and cecal biopsy specimens showed identical monoclonal heavy chain gene rearrangement in both specimens, confirming the diagnosis of MALT lymphoma on the rectal and cecal biopsy. No extraintestinal involvement was found on staging evaluation, which included computed tomography (CT) of the abdomen, chest, pelvis and a bone marrow biopsy. His upper endoscopy was negative for H pylori. He did not have a family history of similar tumors.

Follow-up upper endoscopy and colonoscopy after 8 months showed a 5 mm sessile polyp in the gastric body, diminutive polyp in the ascending colon and a 10 mm sessile polyp in the rectum near the dentate. In addition, a submucosal nodule approximately 5 to 6 mm in size was also seen in the rectum near the dentate line (Fig. 3). Biopsies from gastric, colon and rectal polyps revealed reactive lymphoid aggregates. On rectal endoscopic ultrasound (EUS), the rectal submucosal nodule appeared hypoechoic and was limited to the mucosa and submucosa. The muscularis propria was intact and no local lymph node was noted. The patient was referred to the colorectal surgeon for excision of the rectal submucosal nodule because of close proximity to the dentate line; however, the patient was then lost to follow-up.

Discussion

Isaacson and Wright introduced the concept of lymphoma of the MALT type in 1983. (1) MALT-type lymphomas usually arise in organs originally devoid of lymphoid tissue, which is acquired by persistent antigenic stimulation triggered by infectious or autoimmune processes. (6) Most MALT-type lymphomas arise from gastrointestinal organs as well as from extragastrointestinal organs such as the salivary gland, thyroid gland, lung, bladder, and skin. (3) The stomach is the most common site of gastrointestinal involvement by MALT lymphoma and constitutes approximately 70% of all cases. (3) Primary colorectal involvement by MALT lymphoma is very rare. (4,5)

[FIGURE 1 OMITTED]

We searched the MEDLINE for English language articles from 1966 to 2003 using the terms "MALT," "colon" and "rectum." Only 30 published cases of primary rectal MALT lymphoma were found. These are summarized in the Table.

Most of the reported cases of primary rectal MALT lymphoma are from Japan (Table) and one is reported from the United States before this report. In these 30 patients and our present patient, the ages ranged from 33 to 83 years (mean 59.8 yr) and the male to female ratio was approximately 1:1. The most common presenting symptoms ranged from asymptomatic to occult or gross gastrointestinal bleeding. Simultaneous involvement of the cecum was seen in 6 patients. Ninety percent of patients (27 of 30) were low grade and in stage I at the time of diagnosis. Two patients each were in stage II and IV. Only 7 patients out of 30 were reported to be H pylori positive on biopsy from the gastric mucosa or by serology. Macroscopically, polypoid lesions were 10-fold more common than ulcerative lesions. Differences in gross appearance of gastric and rectal MALT lymphoma may be related to H pylori infection of the stomach. In gastric lymphoma, H pylori-negative cases tend to form submucosal tumor-like lesions. (30)

[FIGURE 2 OMITTED]

MALT lymphoma is characterized by infiltrate of centrocyte-like cells, which may show plasma cell differentiation, lymphoepithelial lesions, and reactive lymphoid follicles. Colonization of the follicles may be seen, which can cause confusion with follicular lymphoma. Another differential diagnosis includes mantle cell lymphoma that presents as lymphomatous polyposis in the gastrointestinal tract and is composed of small to medium-sized lymphocytes with irregular nuclei arranged in a nodular or mixed nodular pattern. There is no epithelial invasion and the cells are positive for CD5 and cyclin D1, which are negative in MALT lymphoma. Also, low-grade MALT lymphoma is distinguished from reactive conditions by showing light chain restriction.

Reported forms of treatment for rectal MALT lymphoma include surgical resection in 9 patients (30%), surgical resection followed by chemotherapy in 3 patients (10%), radiation and chemotherapy in 7 patients (23%), endoscopic resection in 5 patients (17%), endoscopic resection followed by antibiotic treatment in 3 patients (10%), antibiotic treatment alone in 6 patients (20%), and observation alone in 2 patients (6%). Thus, the majority of patients have undergone surgical or endoscopic resection as a cure. However, controversy exists with regards to antibiotic treatment or observation because of unknown etiopathogenesis of primary rectal MALT lymphoma. In contrast, gastric MALT lymphoma is often associated with infection by H pylori. Eradication of H pylori has been investigated as the first line of treatment for patients with MALT-type lymphoma of the stomach, and has been found to be highly effective in patients with localized low-grade disease. (31) Patients with more disseminated disease, t(11:18) or t(l:19) chromosomal translocations or those with high-grade malignancy are generally not thought to be responsive to antibiotic treatment alone. MALT lymphoma of other sites have been associated with infections. For example, cutaneous MALT lymphoma has been associated with Borrelia burgdorferi infections (32) and orbital adnexal MALT lymphoma with Chlamydia psittaci infections. (33) In both types, there have been reports of lymphoma regression with successful treatment of the infection.

[FIGURE 3 OMITTED]

Regression of low-grade MALT lymphoma after H pylori eradication therapy has been reported in extragastric sites of the gastrointestinal tract. (8,34-36) Nakase et al (20) reported three H pylori-negative cases of rectal MALT lymphoma which regressed after antibiotic treatment. Regression of rectal MALT lymphoma after administration of quinolones has also been reported. (26,27) These reports suggest involvement of microorganisms other than H pylori in the development of rectal MALT lymphoma; however, this hypothesis remains unproven. Spontaneous regression of rectal MALT lymphoma has also been reported in 2 patients (15,16); however, the follow-up in each patient was very limited. Neither our patient nor any of the reported cases had a family history of similar tumors, suggesting an unlikely genetic predisposition. We treated our patient with local excision alone, without H pylori eradication treatment, given the negative biopsy.

Our patient's follow up after 9 months showed no recurrence of MALT lymphoma; however, the exact etiology of his rectal submucosal nodule was unclear in the absence of excision biopsy or further endoscopic follow-up and therefore, recurrence of MALT lymphoma could not be ruled out. The follow-up of reported cases ranged from 0.2 to 10 years (mean 2 yr). The prognosis appears favorable and none of the patients died due to rectal MALT lymphoma. However, close follow-up examination is important since the long-term follow-up data is lacking in these patients.

References

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2. Isaacson PG. The malignant lymphoma concept updated. Ann Oncol 1995;6:319-320.

3. Zucca E, Roggera E, Bertoni F, et al. Primary eztra-nodal non-Hodgkin's lymphomas. Part 1: gastrointestinal, cutaneous and genitourinary lymphomas. Ann Oncol 1997;8:727-737.

4. Schmid C, Vazquez JJ, Diss TC, et al. Primary B-cell mucosa-associated lymphoid tissue lymphoma presenting as a solitary colorectal polyp. Histopathology 1994;24:357-362.

5. Onishi Y, Fujisawa T, Maeda M, et al. Large mucosa-associated lymphoid tissue lymphoma simulating multiple polypoid lesions at the cecum and rectum. Digestive endoscopy 2001;13:225-229.

6. Greiner A, Marx A, Heesemann J, et al. Idiotype identity in a MALT-lymphoma and B-cells in Helicobacter pylori associated chronic gastritis. Lab Invest 1994;70.

7. Bschorer R, Lingenfeiser T E K, et al. Malignant lymphoma of the mucosa-associated lymphoid tissue (MALT)--consecutive unusual manifestation in the rectum and gingiva. J Oral Pathol Med 1993;22:190-192.

8. Matsumoto T, Lida M M S. Regression mucosa-associated lymphoid-tissue lymphoma of rectum after eradication of Helicobacter pylori. Lancet 1997;350:115-116.

9. Yatabe Y. Nakamura S, Nakamura T, et al. Multiple polypoid lesions of primary mucosa-associated lymphoid-tissue lymphoma of colon. Histapathology 1998;32:116-125.

10. Gianni L, Tassinari D, Sartori S, et al. Gastric, duodenal and rectal multifocal MALT lymphoma: the possible co-existence of two different eel] populations. Eur J Cancer 1998;34:1640-1641.

11. Matsumoto T, Shirnizu M, lida M, et al. Primary low-grade, B-cell, mucosa-associated lymphoid tissue lymphoma of the colorectum: clinical and colonoscopie features in six cases. Gastrointest Endosc 1998;48:501-508.

12. Orita M, Yamashita K, Okino M, et al. A case of MALT (Mucosa-Associated Lymphoid Tissue) lymphoma occurring in the rectum. Hepato-Gastroenterology 1999;46:2352-2354.

13. Inoue F, T C. Regression of MALT lymphoma of the rectum after anti-H. Pylori therapy in a patient negative for H. pylori. Gastroenterology 1999;117:514-515.

14. Hosaka S, Akamatsu T, Nakamura S, et al. Mucosa-associated lymphoid tissue (MALT) lymphoma of the rectum with chromosomal translocation of the t(11;18)(q21;q21) and an additional aberration of trisomy 3. Am J Gastroenterol 1999;94:1951-1954.

15. Takenaka R, Tomoda J, Sakata T, et al. Mucosa associated lymphoid tissue lymphoma of the rectum that regressed spontaneously. J of Gastroenterology & Hepatology 2000;15:331-335.

16. Okamura S, Katsuhiko H T S. Regression of rectal mucosa-associated lymphoid tissue lymphoma unrelated to Helicobacter pylori. Annals of Internal Medicine 2000;132:247.

17. Gavioli M, Bagni A, Santacroce G, et al. Endorectal sono graphic appearances of rectal MALT lymphoma, its response to therapy, and local recurrence. J Clin Ultrasound 2001;29:401-405.

18. Tsang RW, Gospodarowicz MK, Pintilie M, et al. Stage I and II MALT lymphoma: results of treatment with radiotherapy, Int J Radial Oncol Eiol Phys 2001;50:1258-1264.

19. Tanimoto A, Hamada T, Yamamoto T, et al. MALT lymphoma with extreme plasma cell differentiation of the rectum. Am J Gastroenterol 2002;97:1860-1862.

20. Nakase H, Ohana M, Ikeda K, et al. The possible involvement of microorganisms other than Helicobacter pylori in the development of rectal MALT lymphoma in H. pylori-negative patients. Endoscopy 2002;34: 343-346.

21. Hisabe T, Imamura K, Furukawa K, et al. Regression of CD5-positive and Helicobacter pylori--negative mucosa associated lymphoid tissue lymphoma of the rectum after administration of antibiotics. Dis Colon Rectum 2002;45: (7) 1267-1270.

22. Rey J, Coso D, Ramuz O, et al. Low-grade rectal malt lymphoma occurring in a patient with chronic lymphocytic leukaemia, Br J Haematol 2002;119:1137-1138.

23. Tanaka S, Ohta T, Kaji E, et al. EMR of mucosa-associated lymphoid tissue lymphoma of the rectum. Gastrointest Endosc 2003;57:956-959.

24. Navarra G, Adani GL, Bardella E, et al. Primary rectal lymphoma as a cause of bowel obstruction. Report of a case. Tumori 2003;89:88-90.

25. Chim CS, Shek TW, Chung LP, et al. Unusual abdominal tumors: case 3. Multiple lymphomatous polyposis in lymphoma of colon. J Clin Oncol 2003;21:953-955.

26. Dohden K, Kaizaki Y, Hosokawa O, et al. Regression of rectal mucosa-associated iymphoid tissue Jymphoma but persistence of Helicobacter pylori infection of gastric mucosa after administration of levofloxacin: report of a case. Dis Colon Rectum 2004;47:1544-1546.

27. Hori K, Suguro M, Koizuka H, et al. Disappearance of rectal mucosa-associated lymphoid tissue lymphoma following antibiotic therapy. Dig Dis Sci 2004;49:413-416.

28. Lee YG, Lee S, Han SW, et al. A case of multiple mucosa-associated lymphoid tissue (MALT) lymphoma of the colon identified as simple mucosal discoloration. J Korean Med Sci 2005;20:325-328.

29. Ahlawat S, Haddad N, Kanber Y. et al. Primary mucosa-associated lymphoid tissue lymphoma occurring in the rectum. Gastrointest En dosc 2005;62:443-444; discussion 444.

30. Yokoi T, Nakamura T, Nagashima S, et al. [Differential diagnosis of gastric MALT lymphomas]. Ito Cho [Stomach Inttestine] 2000;36:13-20 (in Japanese with an English abstract).

31. Thiede C, Morgner A, Alpen B, et al. What role does Helicobacter pylori eradication play in gastric MALT and gastric MALT lymphoma. Gastroenterology 1997;113 (Suppl 6):S61-S64.

32. Roggero E, Zucca E, Mainetti C, et al. Eradication of Borrelia burgdorferi infection in primary marginal zone B-cell lymphoma of the skin. Hum Pathol 2000;31:263-268.

33. Ferreri AJ, Guidoboni M M P. Evidence of an association between chlamydia psittaci and ocular adnexal lymphoma. J Natl Cancer Inst. 2004;96:571-573.

34. Nagashima R, Takeda H. Maeda K, et al. Regression of duodenal mucosa-associated lymphoid-tissue lymphoma after eradication of Helicobacter pylori. Gastroenterology 1996;111:1674-1678.

35. Fischbach W, Tacke W, Greiner A, et al. Regression of immunoproliferative small intestinal disease after eradication of Helicobacter pylori. Lancet 1997;349:31-32.

36. Raderer M, Pfeffel F, Pohl G, et al. Regression of colonic low grade B cell lymphoma of the mucosa-associated lymphoid tissue type after eradication of Helicobacter pylori. Gut 2000;46:133-135.

Sushil Ahlawat, MD, Yonca Kanber, MD, Aline Charabaty-Pishvaian, MD, Metin Ozdemirli, MD, PhD, Philip Cohen, MD, Stanley Benjamin, MD, and Nadim Haddad, MD

From the Division of Gastroenterology, Department of Pathology, and Division of Hematology and Oncology. Georgetown University Hospital, Washington DC.

Reprint requests to Nadim Haddad, M.D., Division of Gastroenterology, Department of Medicine, 3800 Reservoir Road, NW, Washington DC 20007. Email: [e-mail]

Accepted January 17, 2006.

RELATED ARTICLE: Key Points

* Mucosa-associated lymphoid tissue (MALT) lymphoma accounts for approximately one-third of colorectal lymphomas.

* It is unclear if colorectal MALT lymphoma is related to Helicobacter pylori infection, and there are reports of colorectal MALT lymphoma regressing after treatment for H. pylori even if such infection is absent, suggesting that microorganisms other than H. pylori may play a role in the pathogenesis of nongastric MALT lymphomas.

* Local therapy, as in the present case, is reasonable because colorectal MALT lymphoma is slow to spread.

Table. Summary of primary rectal mucosa-associated lymphoid tissue
lymphoma cases reported in the English language literature

First author
(reference)     Year  Country    Age  Sex  Symptoms

Bschorer (7)    1993  Germany    56   M    Weight loss, anorexia,
                                             painful defecation
Matsumoto (8)   1997  Japan      72   F    Rectal bleeding
Yatabe (9)      1997  Japan      75   M    None
                                 38   F    Ileus
Gianni (10)     1998  Italy      56   M    NA
Matsumoto (11)  1998  Japan      71   F    Hematochezia
                                 72   F    None
                                 62   F    Hematochezia
                                 72   M    Diarrhea
                                 60   M    Hematochezia
Orita (12)      1999  Japan      64   M    Stool occult blood positive
Inoue (13)      1999  Japan      62   F    Hematochezia
Hosaka (14)     1999  Japan      56   M    Stool occult blood positive
Takenaka (15)   2000  Japan      76   M    Stool occult blood positive
Okamura (16)    2000  Japan      54   M    NA
Onishi (5)      2001  Japan      76   M    Hematochezia
Gavioli (17)    2001  Italy      45   M    Rectal bleeding
Tsang (18)+     2001  Canada     NA   NA   NA
Tanimoto (19)   2002  Japan      75   F    Rectal bleeding
Nakase (20)     2002  Japan      66   M    Hematochezia
                                 33   F    Hematochezia & fever
Hisabe (21)     2002  Japan      70   F    NA
Rey (22)        2002  France     42   F    Abdominal pain, rectal
                                             bleeding
Tanaka (23)     2003  Japan      62   M    Screening
Navarra (24)    2003  Italy      54   F    Abdominal pain
Chim (25)       2003  Hong Kong  43   F    Rectal bleeding
Dohden (26)     2004  Japan      60   F    Hematochezia
Hori (27)       2004  Japan      83   F    Anal swelling
Lee (28)        2005  Korea      47   M    Tenesmus, mucoid stool
Ahlawat (29)    2005  USA        57   F    None
Present case    2005  USA        69   M    Screening

                                                    Ann
First author                                        Arbor  Helicobacter
(reference)     Endoscopic findings                 stage  pylori status

Bschorer (7)    Ulcerated polypoid lesion in the    IBE    NA
                  rectum (5 X 7.5 cm)
Matsumoto (8)   Broad-based protrusion in the       IAE    Positive
                  rectum
Yatabe (9)      3 nodular lesions in the rectum     I      NA
                7 nodular lesions in the colon and  I      NA
                  rectum
Gianni (10)     Multifocal involving the stomach,   NA     Positive
                  duodenum and rectum
Matsumoto (11)  Whitish, solitary protrusion in     IE     Positive
                  the rectum
                Reddish solitary protrusion in the  IE     Positive
                  rectum
                Reddish solitary protrusion in the  IE     NA
                  rectum
                Multiple whitish protrusion and     IE     NA
                  erosion in the sigmoid colon and
                  rectum
                Multiple whitish to reddish         IE     Positive
                  protrusions and erosions in the
                  ascending, transverse, sigmoid
                  colon and rectum
Orita (12)      Oval-shaped tumor in the rectum     IAE    NA
                  (3.5 X 4.8 cm)
Inoue (13)      Broad-based protrusion in the              Negative
                  rectum
Hosaka (14)     Multiple, red, nodular lesion in    IE
                  the rectum
Takenaka (15)   Slightly yellowish protruding       IE     Negative
                  lesion with grooved depression
                  in the lower rectum (2 cm) and
                  2 flat, slightly yellowish
                  elevations in the upper rectum
Okamura (16)    Small, nodular elevations in the    IE     Negative
                  rectum
Onishi (5)      Elevated lesion (8 X 7 cm) in the   IIE    Negative
                  rectum & cecum (4 X 3.5)
Gavioli (17)    Circumferential polypoid            IV     NA
                  thickening with an irregular
                  friable surface
Tsang (18)+     NA                                  IV     NA
Tanimoto (19)   Submucosal tumor with a central     NA     NA
                  area of ulcerated mucosa
                  (2 X 1 cm)
Nakase (20)     Reddish, flat, elevated lesion in   IE     Negative
                  the descending & sigmoid colon
                  with a protruding lesion in the
                  rectum
                Small, whitish lesion at the        NA     Negative
                  rectum
Hisabe (21)     Hemispheric protrusion 1.5 cm in    IE     Negative
                  size
Rey (22)        Tumoral and infiltrated aspect of   IE     Negative
                  the rectal mucosa with
                  hemorrhagic suffusions
Tanaka (23)     Flat, yellowish, elevated lesion    IAE    Negative
                  (2 cm)
Navarra (24)    Bulky, smooth, ulcerated, 5 cm      IIE    NA
                  mass occupying 70% of rectal
                  circumference
Chim (25)       Multiple polypoid lesions in the    IE     NA
                  rectum and descending colon
Dohden (26)     3.5 cm submucosal tumor near the    IE     Positive
                  dentate line
Hori (27)       Diffuse, protruding lesion 5 cm in  IE     Positive
                  length in the lower rectum
Lee (28)        Granular and reddish mucosal        IE     Negative
                  thickening just above rectum,
                  reddish inflammatory mucosa at
                  appendiceal orifice
Ahlawat (29)    Sessile, 1.5 X 2 cm nodular rectal  IE     Negative
                  mass
Present case    Three sessile polyps (5-6 mm) in    IAE    Negative
                  the rectum and a 5 mm sessile
                  polyp in the cecum

First author                                          Follow-up
(reference)     Treatment              Outcome        in years

Bschorer (7)    Chemo + RT             Complete        4
                                         remission
Matsumoto (8)   HPE                    Cured (a)       1
Yatabe (9)      Surgery                NED             2
                Surgery                NED             2
Gianni (10)     Chemo + HPE            Relapse after  NA
                                         7 months
Matsumoto (11)  Local resection        NED             2.6
                Partial endoscopic     NED             0.6
                  resection + HPE
                Local resection        NED            10
                Partial endoscopic     NA              3.5
                  resection,
                  proctosigmoidectomy
                Partial endoscopic     NED             0.75
                  resection
Orita (12)      APR                    Cured (a)       2
Inoue (13)      HPE                    Cured (a)       1
Hosaka (14)     Surgical resection +   Cured (a)
                  adjuvant chemo
Takenaka (15)   Observation            Cured (a)       1.6
Okamura (16)    Observation            Spontaneous    NA
                                         regression.
                                         biopsy
                                         proven
Onishi (5)      Ileocecectomy, APR +   Cured (a)       1
                  adjuvant chemo
Gavioli (17)    Chemo                  NED             2
Tsang (18)+     RT                     NED             4.2 (median)
Tanimoto (19)   APR                    Cured (a)       0.9
Nakase (20)     HPE                    Cured (a)       1.5
                HPE                    Cured (a)       0.8
Hisabe (21)     HPE                    Cured (a)       1.6
Rey (22)        Chemo                  Cured          NA
Tanaka (23)     EMR                    Cured (a)       3
Navarra (24)    Chemo, Low APR         Cured           3
Chim (25)       Chemo                  NED             1.5
Dohden (26)     Antibiotics            Cured           0.4
Hori (27)       Antibiotics, HPE       Cured           0.5
Lee (28)        Chemo + RT             NED             0.25
Ahlawat (29)    EMR + HPE              NED             1
Present case    Snare polypectomy      Likely cure     0.8

(a) Documented by endoscopy and histology.
EMR, endoscopic mucosal resection; HPE, Helicobacter pylori eradication;
APR, abdominoperineal resection; F, female; M, male; NED, no evidence of
disease; RT, radiotherapy.