Reviewer's report
 Gastric adenocarcinoma in a patient re-infected with H. pylori after regression of MALT lymphoma Title:
with successful anti-H. pylori therapy
Authors:
Uday C Ghoshal (ghoshal@sgpgi.ac.in )
Debashish Guha (sanjayguha@vsnl.net )
Santu Bandyopadhyay (santu@cal2.vsnl.net.in )
Chiranjib Pal (santu@cal2.vsnl.net.in )
Srikanta Chakraborty (uday_ujjala@yahoo.com )
Ujjala Ghoshal (ujjala@sgpgi.ac.in )
Bhaskar B B Pal (pkb@123.india.com )
Prabir K K Banerjee (pkb@123.india.com )
 2  29 Oct 2001 Version: Date:
 Dr Shobna Bhatia Reviewer:
 A paper whose findings are important to those with closely related research interests Level of interest:
 Unable to decide on acceptance or rejection until I see revised version Advice on publication:
All comments are major 
1. The diagnosis of H. pylori in the case report rests on a single report of rapid urease test being 
positive in the biopsy obtained during the first endoscopy. No other test (even histology of the operated 
specimen) has subsequently demonstrated H. pylori infection in this patient. 
2. Regarding the RUT: The authors have not provided details on the sensitivity and specificity of their in-house RUT test; the timing of reading the test is also not available. It is known that the specificity of the test falls after 2 hours. 
3. Authors have also not mentioned the site of the biopsy which was studied using SEM; if biopsy is 
from the diseased area, the presence of H. pylori is unlikely. Findings of routine H&E staining are also not mentioned. 4. A positive ELISA could indicate past infection as well. Authors should mention the specificity, 
sensitivity and cut off values of the kit they used for the diagnosis of H. pylori. 
5. The operated specimen: The authors have not stated whether H. pylori was looked for in the normal area of the resection margin. 6. In none of the biopsy reports has there been mention about the presence of chronic gastritis or 
intestinal metaplasia. 
7. Post operatively, it is not clear whether endoscopy was repeated one month after surgery or after completion of H. pylori-eradication treatment. The authors found that H. pylori was negative. Only RUT 
was done for detection of H. pylori. Post-eradication testing for H. pylori status requires at least two 
negative tests; of these, RUT has the least sensitivity. 
8. Six months later, the biopsy was obtained from the edge of the ulcer at the gastrojejunostomy site, 
which is unlikely to yield H. pylori. Biopsy should have been obtained from the fundus and gastric corpus
because these sites may often harbour the infection even when the antrum is negative for H. pylori. 
9. After a course of lansoprazole, only RUT has been done to diagnose H. pylori infection. RUT can be 
false negative in such a situation, unless the PPI is stopped for at least a week. 
10. It is only at the time of final endoscopy that the diagnosis of H. pylori infection has been made 
convincingly. However, there is no mention of whether gastritis or intestinal metaplasia was present. 
11. Since the status of H. pylori infection prior to the final endoscopy is in doubt, it is unclear whether the carcinoma stomach was in any way related to the infection. Intestinal type of gastric carcinoma is also associated with metaplasia and atrophic gastritis. In patients with H. pylori infection, presence of 
severe gastric atrophy, corpus-predominant gastritis and intestinal metaplasia suggest an increased risk
for the development of carcinoma. None of these factors have been mentioned in the report. 
12. The authors' conclusion about H. pylori being related to gastric carcinoma in this patient is incorrect.The association of Helicobacter pylori and gastric carcinoma in India is not very strong and is only 
slightly more frequent than the occurrence of H pylori in the general population, as has been reported in
many studies. Possibly, the appearance of carcinoma after treatment for PGL is only a chance association. 
Competing interests:
None declared.
Reviewer's report
 Gastric adenocarcinoma in a patient re-infected with H. pylori after regression of MALT lymphoma Title:
with successful anti-H. pylori therapy
Authors:
Uday C Ghoshal (ghoshal@sgpgi.ac.in )
Debashish Guha (sanjayguha@vsnl.net )
Santu Bandyopadhyay (santu@cal2.vsnl.net.in )
Chiranjib Pal (santu@cal2.vsnl.net.in )
Srikanta Chakraborty (uday_ujjala@yahoo.com )
Ujjala Ghoshal (ujjala@sgpgi.ac.in )
Bhaskar B B Pal (pkb@123.india.com )
Prabir K K Banerjee (pkb@123.india.com )
 2  29 Oct 2001 Version: Date:
 Dr Shobna Bhatia Reviewer:
 A paper whose findings are important to those with closely related research interests Level of interest:
 Unable to decide on acceptance or rejection until I see revised version Advice on publication:
All comments are major 
1. The diagnosis of H. pylori in the case report rests on a single report of rapid urease test being 
positive in the biopsy obtained during the first endoscopy. No other test (even histology of the operated 
specimen) has subsequently demonstrated H. pylori infection in this patient. 
2. Regarding the RUT: The authors have not provided details on the sensitivity and specificity of their in-house RUT test; the timing of reading the test is also not available. It is known that the specificity of the test falls after 2 hours. 
3. Authors have also not mentioned the site of the biopsy which was studied using SEM; if biopsy is 
from the diseased area, the presence of H. pylori is unlikely. Findings of routine H&E staining are also not mentioned. 4. A positive ELISA could indicate past infection as well. Authors should mention the specificity, 
sensitivity and cut off values of the kit they used for the diagnosis of H. pylori. 
5. The operated specimen: The authors have not stated whether H. pylori was looked for in the normal area of the resection margin. 6. In none of the biopsy reports has there been mention about the presence of chronic gastritis or 
intestinal metaplasia. 
7. Post operatively, it is not clear whether endoscopy was repeated one month after surgery or after completion of H. pylori-eradication treatment. The authors found that H. pylori was negative. Only RUT 
was done for detection of H. pylori. Post-eradication testing for H. pylori status requires at least two 
negative tests; of these, RUT has the least sensitivity. 
8. Six months later, the biopsy was obtained from the edge of the ulcer at the gastrojejunostomy site, 
which is unlikely to yield H. pylori. Biopsy should have been obtained from the fundus and gastric corpus
because these sites may often harbour the infection even when the antrum is negative for H. pylori. 
9. After a course of lansoprazole, only RUT has been done to diagnose H. pylori infection. RUT can be 
false negative in such a situation, unless the PPI is stopped for at least a week. 
10. It is only at the time of final endoscopy that the diagnosis of H. pylori infection has been made 
convincingly. However, there is no mention of whether gastritis or intestinal metaplasia was present. 
11. Since the status of H. pylori infection prior to the final endoscopy is in doubt, it is unclear whether the carcinoma stomach was in any way related to the infection. Intestinal type of gastric carcinoma is also associated with metaplasia and atrophic gastritis. In patients with H. pylori infection, presence of 
severe gastric atrophy, corpus-predominant gastritis and intestinal metaplasia suggest an increased risk
for the development of carcinoma. None of these factors have been mentioned in the report. 
12. The authors' conclusion about H. pylori being related to gastric carcinoma in this patient is incorrect.The association of Helicobacter pylori and gastric carcinoma in India is not very strong and is only 
slightly more frequent than the occurrence of H pylori in the general population, as has been reported in
many studies. Possibly, the appearance of carcinoma after treatment for PGL is only a chance association. 
Competing interests:
None declared.
Please review this paper.
user
Reviewer's report
 Gastric adenocarcinoma in a patient re-infected with H. pylori after regression of MALT lymphoma Title:
with successful anti-H. pylori therapy
Authors:
Uday C Ghoshal (ghoshal@sgpgi.ac.in )
Debashish Guha (sanjayguha@vsnl.net )
Santu Bandyopadhyay (santu@cal2.vsnl.net.in )
Chiranjib Pal (santu@cal2.vsnl.net.in )
Srikanta Chakraborty (uday_ujjala@yahoo.com )
Ujjala Ghoshal (ujjala@sgpgi.ac.in )
Bhaskar B B Pal (pkb@123.india.com )
Prabir K K Banerjee (pkb@123.india.com )
 2  29 Oct 2001 Version: Date:
 Dr Shobna Bhatia Reviewer:
 A paper whose findings are important to those with closely related research interests Level of interest:
 Unable to decide on acceptance or rejection until I see revised version Advice on publication:
All comments are major 
1. The diagnosis of H. pylori in the case report rests on a single report of rapid urease test being 
positive in the biopsy obtained during the first endoscopy. No other test (even histology of the operated 
specimen) has subsequently demonstrated H. pylori infection in this patient. 
2. Regarding the RUT: The authors have not provided details on the sensitivity and specificity of their in-house RUT test; the timing of reading the test is also not available. It is known that the specificity of the test falls after 2 hours. 
3. Authors have also not mentioned the site of the biopsy which was studied using SEM; if biopsy is 
from the diseased area, the presence of H. pylori is unlikely. Findings of routine H&E staining are also not mentioned. 4. A positive ELISA could indicate past infection as well. Authors should mention the specificity, 
sensitivity and cut off values of the kit they used for the diagnosis of H. pylori. 
5. The operated specimen: The authors have not stated whether H. pylori was looked for in the normal area of the resection margin. 6. In none of the biopsy reports has there been mention about the presence of chronic gastritis or 
intestinal metaplasia. 
7. Post operatively, it is not clear whether endoscopy was repeated one month after surgery or after completion of H. pylori-eradication treatment. The authors found that H. pylori was negative. Only RUT 
was done for detection of H. pylori. Post-eradication testing for H. pylori status requires at least two 
negative tests; of these, RUT has the least sensitivity. 
8. Six months later, the biopsy was obtained from the edge of the ulcer at the gastrojejunostomy site, 
which is unlikely to yield H. pylori. Biopsy should have been obtained from the fundus and gastric corpus
because these sites may often harbour the infection even when the antrum is negative for H. pylori. 
9. After a course of lansoprazole, only RUT has been done to diagnose H. pylori infection. RUT can be 
false negative in such a situation, unless the PPI is stopped for at least a week. 
10. It is only at the time of final endoscopy that the diagnosis of H. pylori infection has been made 
convincingly. However, there is no mention of whether gastritis or intestinal metaplasia was present. 
11. Since the status of H. pylori infection prior to the final endoscopy is in doubt, it is unclear whether the carcinoma stomach was in any way related to the infection. Intestinal type of gastric carcinoma is also associated with metaplasia and atrophic gastritis. In patients with H. pylori infection, presence of 
severe gastric atrophy, corpus-predominant gastritis and intestinal metaplasia suggest an increased risk
for the development of carcinoma. None of these factors have been mentioned in the report. 
12. The authors' conclusion about H. pylori being related to gastric carcinoma in this patient is incorrect.The association of Helicobacter pylori and gastric carcinoma in India is not very strong and is only 
slightly more frequent than the occurrence of H pylori in the general population, as has been reported in
many studies. Possibly, the appearance of carcinoma after treatment for PGL is only a chance association. 
Competing interests:
None declared.
assistant