Prognostic factors in primary gastrointestinal non-Hodgkin's lymphoma. A multivariate analysis, report of 106 cases, and review of the literature

Non-surgical treatment with primary chemotherapy, with or without radiation therapy, of stage I-II high-grade gastric lymphoma

Morbidity, mortality and discomfort related to gastrectomy has led some investigators to treat patients with stage I-II primary gastric high-grade lymphoma (PGL) with a conservative strategy. Here we report a retrospective series of 21 patients with PGL treated with primary chemotherapy alone or followed by radiation therapy and analyze previously reported series, focusing on therapeutic results, treatment-related morbidity and stomach preservation rate. All 21 patients with stage I-II PGL received an initial anthracycline-containing chemotherapy, which was followed by involved field-radiation therapy in 8 cases. Data regarding toxicity, response and relapse rates and survival of this patient group and 14 previously published series, involving 316 patients treated with conservative modality, were also analyzed. In the present series two patients did not complete the planned treatment, while the remaining 19 achieved a complete remission (response rate: 90%). Three patients relapsed, all of whom had been treated with chemotherapy alone. Two patients died of lymphoma, one of sepsis and the other of lung cancer while still relapse-free. The survival rate at 50 months is 81%, and the 5-year actuarial cause-specific survival is 82%. The stomach preservation rate is 100%. Previously reported series showed a response rate ranged between 76% and 100%. Gastrointestinal bleeding was observed in only 3% of cases, while no cases of gastric perforation were reported. Treatment mortality rate was 2.5%. 5-year actuarial survival ranged between 73% and 90% and stomach preservation rate was 97%. Short-term chemotherapy obtained similar results to more prolonged treatment. In conclusion, conservative treatment with primary chemotherapy followed by involved field-radiation therapy should be used for the first-line treatment of patients with stage I/II PGL considering that it is associated with a high response and survival rates, and with an insignificant risk of bleeding or perforation, high stomach preservation rate and good quality of life.

Primary non-Hodgkin lymphoma of the small bowel

PURPOSE

To clarify the natural history of primary lymphoma of the small bowel and identify preferred treatments for it.

MATERIALS AND METHODS

A retrospective analysis of 61 patients with primary lymphoma of the small bowel was performed. The Ann Arbor stages were I in 20 patients, II in 28, and IV in 13. After resection or biopsy, 15 patients were treated with radiation therapy, 26 with chemotherapy, and 16 with combined-modality therapy. Four patients underwent no adjuvant treatment after resection.

RESULTS

The actuarial 10-year overall survival and relapse-free survival for the patients with intermediate- and high-grade lymphoma were 47% and 53%, respectively. For the patients with low-grade lymphoma, these rates were 81% and 62%. For patients who underwent radiation therapy, combined-modality therapy, or chemotherapy, the recurrence rates inside the abdomen or pelvis were one of 12, two of 15, and five of 20, respectively, and those outside the abdomen or pelvis were four of 12, one of 15, and zero of 20, respectively. Four of the five abdominopelvic recurrences of disease in the chemotherapy group were among the nine patients who had Ann Arbor stage II disease.

CONCLUSION

Chemotherapy lowered the recurrence rate outside the abdomen or pelvis. Patients with stage II disease may benefit most from radiation therapy.

Malignant lymphoma of the gastrointestinal tract

AIMS

The gastrointestinal tract (GIT) is the most common site of extra-nodal lymphoma. Most of these lymphomas arise from mucosa associated lymphoid tissue (MALT). We attempt in this study to define the natural history and treatment outcome of this type of lymphoma.

METHODS

We carried out a retrospective study of patients presenting at our centre with histopathological diagnosis of primary GIT lymphoma between 1990 and 1994.

RESULTS

Equal numbers of cases of stomach and small bowel lymphoma were found. Vomiting and feeling of fullness were the two most common presenting symptoms. Large cell type and high grade tumours were found to be the commonest histological types. All the patients were treated with surgery followed by chemotherapy. A 5-year disease-free survival (DFS) rate of 73%) was observed with a confidence interval of 0.65-1.35. Survival in stomach cancer was 73.5% (95% CI 0.26-1.74) while it was 76.4% in small bowel tumours (95% CI 0.54-1.46). The difference in survival was not statistically significant.

CONCLUSIONS

Although there is no consensus regarding treatment of primary GI lymphoma, surgery and adjuvant chemotherapy yield good survival.

Results and prognostic factors in stage I(E)-II(E) primary gastric lymphoma after gastrectomy

BACKGROUND

Infrequency of gastric lymphomas and lack of homogeneity of studies dealing with them preclude accurate management schemes. Helicobacter pylori (HP) and Isaacson's classification are new factors to consider. Our aim was to analyze these and other prognostic factors in a homogeneous series.

STUDY DESIGN

Fifty-four patients (mean age 62.4 years) treated by gastrectomy for primary gastric non-Hodgkin's lymphoma in stages IE or IIE were retrospectively reviewed. Twenty-seven patients received postoperative chemotherapy. HP and histologic features were studied using new slides from the paraffin-embedded gastrectomy specimens.

RESULTS

Postoperative morbidity and mortality rates were 19% and 5.6%, respectively. Five-year survival was 83%. Classification showed low-grade tumors in 59% and high-grade tumors in 41%. HP was positive in 64% of the patients. A poorer survival was associated with high-grade tumors (p = 0.02) and serosa involvement (p = 0.02). We did not find any significant difference between patients treated either by partial or total gastrectomy (p = 0.2), or receiving chemotherapy or not (p = 0.9). Nor did we appreciate any differences concerning margin involvement (p = 0.9).

CONCLUSIONS

Most primary gastric lymphoma patients have gastric HP. Serosa involvement and high-grade tumors adversely influence survival but gastrectomy type, resection margin invasion, and postoperative chemotherapy did not appear to have any influence.

[Radiotherapy for gastrointestinal lymphomas: indications and techniques]

Gastrointestinal lymphomas are almost exclusively of a non-Hodgkin's type. The Western form is characterized by a higher incidence of stomach location (50%), a MALT type (mucosa associated lymphoid tissue) (40%), a B-cell type (90%), and a high grade (55%). Chronic infection with Helicobacter pylori is an important risk factor. Mediterranean lymphomas form a particular clinical and pathological entity with diffuse involvement of the small bowel and are frequently being associated with a chronic malabsorption disorder. Eradication of Helicobacter pylori in early gastric lymphomas, and the use of tetracyclines in early Mediterranean lymphomas, have been shown to induce durable remissions. For more advanced gastric lymphomas, treatment usually consists of anthracyclin-based chemotherapy followed by involved field radiotherapy. Surgery is usually reserved for complications such as perforation or bleeding, or in some selected cases for salvage after failure of non-surgical therapy. For intestinal lymphomas, surgical resection whenever feasible, followed by anthracyclin-based chemotherapy is the most common treatment. Radiotherapy is usually reserved for consolidation in some clinical situations. The most commonly found prognostic factors are stage, grade, and tumor bulk. Treatment results vary with the presence of adverse prognostic factors and the used treatment combination. In general, patients with favorable disease receiving combined therapy have a 5-year relapse free survival (RFS) approaching 90%, whereas those with unfavorable disease have a RFS of 40-50%.

Differences in endoscopic and clinicopathological features of primary and secondary gastric non-Hodgkin's lymphoma. German Gastrointestinal Lymphoma Study Group

BACKGROUND

Lymphomatous neoplasia of the stomach is initially seen either as primary gastric B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) or as nodal non-Hodgkin s lymphoma (NHL) secondarily involving the GI tract. One hundred seventy-six patients with primary gastric NHL (low grade, n = 65; high grade, n = 111) and 29 with secondary gastric NHL (low grade, n = 19; high grade, n = 10) were studied to evaluate whether differences in pathogenesis are associated with distinct clinical and endoscopic features.

METHODS

Clinical features, tumor size, localization, and growth pattern were analyzed by means of esophagogastroduodenoscopy; grading was determined with histologic examination.

RESULTS

The analysis of various clinical symptoms and endoscopic findings revealed a relationship between the occurrence of abdominal pain, vomiting, and unifocal growth pattern with an affiliation to the group with primary gastric NHL (p < 0.001), whereas tumor localization in the gastric fundus was predominantly found in secondary gastric NHL (p < 0.001). An equation has been generated that may help to predict affiliation to primary or secondary gastric NHL with an accuracy of 96%.

CONCLUSIONS

Our results indicate that careful pretreatment analysis of clinical and endoscopic findings may be helpful in the diagnosis of primary or secondary gastric involvement by NHL, although reliable discrimination still requires histologic verification.

Primary gastrointestinal non-Hodgkin's lymphoma in adults: a population-based clinical and histopathologic study

OBJECTIVES

To analyse the clinical course and the histopathology of primary gastrointestinal non-Hodgkin's lymphoma (GI-NHL) in adult patients and to investigate a possible impact of Helicobacter pylori.

DESIGN/SETTING

Retrospective study of all adult patients in Copenhagen county diagnosed during a 6-year period with NHL.

SUBJECTS

A total of 55 patients with GI-NHL diagnosed during the period from 1985 to the end of 1990.

RESULTS

Twenty-eight patients had primary lymphoma in the stomach, 14 in the small intestine, 11 in the large intestine and two patients had multifocal involvement. The dominant presenting symptoms were abdominal pain, weight loss, diarrhoea, constipation and fatigue. Acute emergency problems such as severe haemorrhage or perforation at initial presentation were unusual. According to the revised European-American lymphoma (REAL) classification, diffuse large B-cell lymphoma was the most frequent histologic subtype comprising 53% of the cases. Helicobacter pylori infection was documented in 15 of 25 evaluable patients (60%) with gastric lymphomas and was not associated with any specific histological subtype. Endoscopic procedures and barium X-rays were the diagnostic approaches with highest sensitivity. In total, 30 patients (58%) achieved complete remission, 10 (19%) achieved partial remission, and 12 (23%) did not respond to treatment. The overall 5 year survival rate was 0.36 without statistically significant difference between the histological subtypes. Likewise the presence of Helicobacter pylori did not affect survival.

CONCLUSION

Primary GI-NHL is a heterogeneous disease entity with considerable therapeutic controversies. No specific clinical or histological phenotype was associated with the presence of Helicobacter pylori.

Primary lymphoma of the stomach: three-year results of a prospective multicenter study. The German Multicenter Study Group on GI-NHL

BACKGROUND

In October 1992, an ongoing prospective study on primary gastrointestinal (GI) lymphoma was initiated to evaluate histological features, sites of involvement, and management.

PATIENTS AND METHODS

Until May 1996, 352 patients were enrolled, with 279 being evaluable for clinical features (208 patients presented with primary gastric lymphoma). Standardized diagnostic workup included central histologic review and endoscopic and radiologic evaluation of the complete GI tract. Primary surgery or conservative management depended on the physician's decision, followed by radiotherapy with or without chemotherapy. Treatment outcome is evaluable in 122 patients with gastric lymphoma.

RESULTS

In 279 evaluable patients, the distribution of NHL was as follows: stomach 74.6%, small bowel 8.6%, ileocoecal region 6.5%, multilocal GI involvement 6.8%. In gastric lymphoma, low-grade NHLs accounted for 39%. Of the remaining high-grade NHLs, 36.1% showed simultaneous low-grade components, thus being also of MALT origin. Of 208 patients with gastric NHL, 71.1% were classified as stage I and II1. CCR rate in stomach lymphoma is significantly higher compared to those of the small bowel, whereas involvement of multiple GI organs has the worst prognosis. So far only 7 patients with gastric NHL in stages I and II presented with progressive disease or relapse. Over all stages there seems to be no difference in therapeutic outcome in surgically or conservatively treated patients. Even after R0-resection in limited stages patients appear to have no better outcome.

CONCLUSION

The value of surgery in treatment of primary gastric lymphoma--as favored by most authors--should be reexamined.

Primary Gastric Lymphoma

BACKGROUND: Gastric lymphoma is a common presentation of non-Hodgkin's lymphoma. Controversy reigns about many aspects of its classification and management, especially regarding roles for surgical resection. METHODS: The authors review the clinical features, staging, pathology, prognosis, and management issues with an emphasis on the role of surgical resection. RESULTS: Staging usually can be completed using noninvasive techniques. Those with a low-grade B-cell MALT type lymphoma with Helicobacter pylori infection may be treated with antibiotics and close follow-up. Patients with stage I or II disease may be treated with chemotherapy and radiation. Surgery is indicated for those with perforation or uncontrolled bleeding. CONCLUSIONS: Gastric lymphoma, primarily a B-cell tumor, can be diagnosed and managed effectively with various approaches. Few prospective, randomized trials of alternative approaches have been performed.

Primary non-Hodgkin's lymphoma of the stomach: three radical modalities of treatment in 75 patients

BACKGROUND

Non-Hodgkin's lymphoma (NHL) remains a rare form of gastric malignancy, with a rising incidence. Approaches to treatment vary from surgery alone to conservative management.

METHODS

To determine the optimal scheme of treatment, a randomized clinical trial was undertaken. Seventy-five patients were randomized into three groups: A-surgery alone (25), B-surgery followed by chemotherapy (29), and C-radiation therapy followed by surgery and chemotherapy (21). Forty-nine patients had stage IE and 26 had stage IIE disease. Chemotherapy (COP and COPP) consisted of 6 courses during a 1-year period, with the courses being 6 weeks apart.

RESULTS

Subtotal gastrectomy was performed in 26 patients. Forty-nine patients underwent total gastrectomy. Postoperative complications occurred in 6 (8%) patients: 3 (12%) in group A, 2 (6.9%) in group B, and 1 (4.7%) in group C. Postoperative mortality occurred in 2 (8%) patients in group A (2.7% of all patients). An increase in hospital admissions number per year and decrease of mean age of patients with NHL of the stomach after the Chernobyl accident on April 26, 1986 was noted.

CONCLUSIONS

Improved survival in gastric NHL was achieved by a combination of preoperative radiation with surgery and postoperative chemotherapy, presumptively through the management of local and systemic disease.

Surgical therapy of gastrointestinal non-Hodgkin's lymphomas

Within a period of 13 years 39 patients underwent surgery for primary gastrointestinal non-Hodgkin's lymphoma. The stomach was the most frequent site of involvement (26 cases) followed by the small intestine (10 cases) and the large bowel (three cases). Operative procedures included: total gastrectomy (n = 19), subtotal gastrectomy (n = 5), partial gastrectomy (n = 2), small bowel resection (n = 7), right hemicolectomy (n = 5) and sigmoid resection (n = 1). According to Musshoff's modification of the Ann Arbor system, we found stage I in nine, stage II in 12, stage III in two and stage IV in 16 patients. Histological typing according to the Kiel classification showed low-grade malignancy in 11 cases and high-grade in 28. Twenty-eight patients received chemotherapy and/or radiation in accordance with the tumour staging and type of malignancy. The follow-up data were analysed by the method of Kaplan and Meier. Including five patients who died post-operatively from perforated or bleeding lymphomas, the overall 5-year survival rate was 53.8%.

Role of surgery in the management of primary lymphoma of the gastrointestinal tract

The role of surgery in the management of primary gastrointestinal lymphoma remains controversial. We retrospectively reviewed the management and outcome of 107 patients with the diagnosis of gastrointestinal lymphoma treated at the UCLA Medical Center during the period 1956-1990. Sixty-four patients underwent surgical exploration at the UCLA Medical Center; 35 of these underwent resection for cure. Sixteen of these 35 patients received no postoperative adjuvant therapy. Twenty-nine patients underwent palliative or "noncurative" resection. There were five postoperative deaths (mortality rate 8%). The overall morbidity rate was 48% There were 3 perforations in a total of 53 patients receiving multiagent chemotherapy. Five-year actuarial survival was as follows: 59% for curative resection alone, 51% for curative resection plus adjuvant therapy, and 28% for "noncurative" resection (P<0.05). Multivariate analysis revealed that stage of disease (P<0.01) and resection for cure (P<0.05) were independent predictors of survival. These results suggest that patients undergoing resection for cure have improved survival. The apparent low risk of perforation during chemotherapy, along with the considerable risk of morbidity and mortality associated with operation, suggests that a policy of debulking large tumors prior to chemotherapy is unwarranted.

A clinicopathologic study of 233 cases with special reference to evaluation with the MIB-1 index

BACKGROUND

Few articles have analyzed the prognostic data from a large series of primary gastric lymphoma classified according to the concept of mucosa-associated lymphoid tissue (MALT).

METHODS

The resected specimens from 233 patients with primary gastric lymphoma were investigated retrospectively, including immunostaining with MIB-1 (Ki-67).

RESULTS

Histologically, 70 (30%) of the cases were low grade B-cell lymphoma of MALT, 27 (12%) low grade B-cell lymphoma of MALT with a focal high grade component, 100 (43%) high grade B-cell lymphoma of MALT, 15 (6%) other B-cell lymphomas, 14 (6%) T-cell lymphomas, and 7 (3%) undetermined. Macroscopically, 96 (41%) were superficial-spreading type, 100 (43%) mass-forming, 14 (6%) diffuse-infiltrating, and 23 (10%) unclassified. The MIB-1 index correlated with phenotype, histologic grade, stage, depth of invasion, and macroscopic type. A significantly better survival was noted for young patients, and those with tumors of a B-cell phenotype, histologic low grade, macroscopic superficial-spreading type, low stage, low depth of invasion, and low MIB-1 index. No significantly different survival rates were found between the patients who underwent gastric resection alone and those who also received additional chemotherapy. By Cox multivariate analysis, independent prognosticators included B-cell phenotype, low stage, and macroscopic superficial-spreading type.

CONCLUSIONS

In addition to stage, phenotype and macroscopic type are also important prognostic indicators of primary gastric lymphoma. Immunostaining with MIB-1 had limited independent value for predicting prognosis.

Primary gastrointestinal lymphoma: 30-year experience at the Cancer Institute, Madras, India

A retrospective study was conducted of 49 patients with primary gastrointestinal lymphoma to analyze clinicopathological features, prognostic factors, and results of treatment. Intestinal lymphomas (63%) were more common than gastric lymphomas (29%). Endoscopic biopsy was diagnostic in 64% of gastric lymphomas, while 97% of intestinal lymphomas required laparotomy for diagnosis. Lymphoblastic (35%) and diffuse large cell (33%) lymphomas were the most frequent histologic types. Complete remission (CR) was achieved in 61% of patients, with a 5-year survival of 72% in those who achieved CR. The overall 5-year survival and disease-free survival were 47% and 40%, respectively. All disease-related mortality occurred within 2 years of diagnosis, with 79% occurring in the first year. There was no overall significant difference in survival between the different treatment groups. Stage, extent of surgical resection, response to treatment, serosal involvement, multimodality treatment, and performance status were significant prognostic factors. Achievement of complete remission and complete surgical resection were the most favorable independent prognostic factors on multivariate analyses.

A retrospective analysis of treatment outcome in 106 cases of localized gastric non-Hodgkin lymphomas. Danish Lymphoma Study Group, LYFO

197 cases of gastric lymphoma were reported to a population-based Danish registry of non-Hodgkin's lymphomas. 106 of these cases were localized, representing stages IE and II1E, and were analyzed retrospectively, using Cox regression analysis. 67 had surgical resection, 51 chemotherapy, and 55 radiotherapy, or combinations thereof. No type of treatment showed any superiority as regards survival (p = 0.13). Overall 5-year survival was 67%. The pretherapeutic presence of fever or S-LDH-elevation had a far more significant influence on survival than histology or any of the treatments or treatment combinations. Surgical resection was associated with a significantly higher risk of late complications than radiotherapy, suggesting that radiotherapy may be preferable to surgery as the primary treatment in localized gastric lymphoma. It could not be determined from the available data whether the addition of chemotherapy to the primary treatment provides any survival benefit.

Intermediate and high-grade gastric non-Hodgkin's lymphoma: a prospective study of non-surgical treatment with primary chemotherapy, with or without radiotherapy

The role of surgery as initial treatment in gastric lymphoma remains controversial. We have prospectively evaluated a stomach conservation strategy in histologically aggressive gastric lymphoma, using primary adriamycin-containing chemotherapy, followed by involved-field radiotherapy in patients with limited disease. Twenty-six patients (median age 69 years) were entered in this study; 15 had stage I disease, 7 had stage II disease and 4 had stage IV disease. The chemotherapy combinations were CHOP (18 patients) and ProMACE/MOPP (8 patients). Radiotherapy was given to 11 patients. Of the 24 patients evaluated for response, 18 (75%) achieved endoscopically-confirmed complete response and 4 (17%) partial response. During follow-up (median 22 months), none of the complete responders developed recurrent lymphoma. Gastric resection was performed in 1/26 patients who did not respond to primary chemotherapy. There were no cases of perforation, but three patients (12%) developed acute gastro-intestinal bleeding a few days after the onset of chemotherapy, one of whom required a surgical devascularization procedure. There was no treatment-related mortality. These data further support the non-surgical approach in histologically aggressive gastric lymphoma, using primary chemotherapy with or without radiation therapy.

Primary gastric non-Hodgkin's lymphoma: a clinicopathological study of 41 patients

Pathological findings in 41 patients (male/female ratio: 1.3/1) with primary localized gastric non-Hodgkin's lymphoma (NHL) were retrospectively studied and correlated with survival. The median observation period after diagnosis was 32 (0-189) months. Nineteen patients were low-grade NHL, all but one B-cell lymphomas of the mucosa-associated lymphoid tissue (MALT) type. Twenty-two patients had primary (n = 7) or secondary (n = 15) high-grade lymphomas; Musshoff stage IE was found in 29 and IIE in 12 cases. The median age at diagnosis was 61 years (range, 26-88 years), and proliferation, measured by the number of mitosis and Ki-67 antigen positivity (MIB-1), was high or moderately high in 24 cases and low in 17 cases. Follicular lymphatic hyperplasia could be found in 25 of 34 evaluable cases, more often in low-grade than in high-grade NHL. Most of the patients were treated by resective surgery and additional ratio- or chemotherapy. Thirteen patients (31%) died (median survival: 10 months), 5 of them within 3 months after surgery owing to postoperative complications. Survival was superior, though not statistically significant, in low-grade lymphomas. Our retrospective analysis of heterogeneously treated gastric lymphomas reveals that gastric lymphomas, especially of the low-grade MALT type, often remain a localized disease with a good long-term prognosis. Our study confirms previous reports indicating that lymphomas of the MALT type represent a specific clinicopathological entity.

Treatment of early-stage gastric lymphoma

The treatment of early-stage gastric lymphoma is controversial. This retrospective analysis reports on the outcome of 24 patients treated in our institution during the past 25 years. Fourteen patients had stage IEA, one patient had IEB, six patients IIEA1, and three patients had stage IIEA2 non-Hodgkin's lymphoma (NHL). Diffuse large cell intermediate-grade NHL was diagnosed in 17 patients, diffuse small cleaved cell in three patients, and diffuse mixed large and small cell lymphosarcoma, low-grade B-cell lymphoma, and unclassified lymphoma in one patient each. Fourteen patients underwent surgery, 21 had radiation therapy (XRT), and 10 patients received chemotherapy. Surgery + XRT were given to 7 patients, surgery + XRT + chemo and XRT alone were delivered to five patients each, and XRT + chemotherapy were employed in four patients. Surgery alone was the initial treatment in two patients and chemotherapy alone was given to one patient. Following treatment 22/24 achieved a complete response. During a mean follow-up period of 77.6 months (range 1-285), five patients relapsed. At 10 years, the actuarial survival of the 15 patients with stage I disease was 57.4% and for stage II it was 51.9% (Gehan P-value 0.33). Freedom from relapse (FFR) was 60.7% and 58.3%, respectively (P-value 0.56). No significant statistical differences in terms of survival and FFR were noted in patients treated with surgery, chemotherapy, or XRT. The outcome of patients treated with triple-modality therapy was similar to those treated with double-modality therapy and to patients treated with XRT alone. Gender, age, presenting symptoms, depth of tumor through the gastric wall, and stage were not statistically significant for prediction of either survival or FFR. Both surgery + XRT and chemotherapy + XRT are effective in the treatment of early-stage gastric disease. XRT alone is equally effective as two or three modality treatments in the subset of patients with early-stage gastric lymphoma. However, the low number of patients treated with various approaches over a long period precludes a firm conclusion. Until prospective randomized studies are initiated, management programs should be individually tailored.

Role of Postoperative Radiation Therapy in the Management of Early Stage Primary Gastric Non-Hodgkin's Lymphomas: A Retrospective Analysis

Background

Clinical approaches to early primary gastric non-Hodgkin's lymphomas have not yet been clearly defined, and the role of postoperative radiotherapy remains a matter of discussion.

Methods

Twenty-seven patients with early primary gastric non-Hodgkin's lymphoma were observed from December 1978 to December 1990 at our Institution. They were staged according to Musshoff and Schmidt-Volmer (19) as I E (n = 16), II E 1 (n = 7) and II E 2 (n = 4). All of them underwent local combined treatment, consisting of surgery and postoperative radiotherapy; chemotherapy was also administered to 10 patients, mainly with the CHOP regimen, for 4-6 cycles before radiotherapy. Irradiation was delivered using 10 MV photons from a linear accelerator. Large abdominal fields were employed in 21 cases with daily fractions of 1.5-2 Gy up to a median total dose of 30 Gy (range: 27-36 Gy). Six patients were irradiated only on the surgical bed up to 40.5 Gy (range: 39-40.5 Gy).

Results

The 5-year overall and disease-free survivals were respectively 92.4% and 89.8%. The main known prognostic indicators, stage of disease, type of surgery as well as age and sex, were not found to be statistically significant in our series. No clear difference emerged between patients sequentially treated with the combination surgery-chemotherapy-radiotherapy and those who did not receive adjuvant chemotherapy. Two patients recurred at distant sites, but no local failure was seen during the follow-up.

Conclusions

Although no firm conclusion can be drawn, our experience, in agreement with recent published reports, points out that the use of postoperative radiotherapy is associated not only to favorable results in terms of local control and survival, but also, and moreover, to a negligible incidence of side effects and sequelae. However, in the absence of multi-institutional prospective randomized studies, whose activation is nowadays strongly warranted, the exact role of adjuvant therapies remains a matter of discussion, and the optimal treatment of early primary gastric non-Hodgkin's lymphoma still depends on individual experience and the physician's philosophy.

Gastrointestinal tumors in children: an analysis of 39 cases

BACKGROUND

Gastrointestinal tumors are relatively uncommon in infants and children, and the histologic diagnoses differ from those seen in an adult practice. Furthermore, the clinical presentation of such tumors is quite variable.

METHODS

We reviewed the records of 39 pediatric patients who had been treated for tumors of the alimentary tract at our hospital over the past 20 years. The symptoms, physical findings, treatments, and outcomes are tabulated and discussed.

RESULTS

Non-Hodgkin's lymphoma was the predominant diagnosis. It was found in 22 children, and the survival rate was 60%. Other malignant tumors found in this pediatric series included colorectal carcinoma in four patients and gastric leiomyosarcoma in one. The outcomes of these patients were poor; four of the children have died, and one girl remains alive with extensive disease. Benign lesions included neurogenic tumors (n = 5), inflammatory pseudotumors (n = 3), hemangiomas (n = 2), teratoma and carcinoid (n = 1 each). These tumors were ultimately cured, with one exception, after surgical resection.

CONCLUSIONS

Gastrointestinal tumors in children cover a broad spectrum of benign and malignant varieties and stem from conditions that differ significantly from those observed in adults. While treatment varies according to diagnosis, most patients respond best to complete resection of the primary tumor.

A proposed staging system for primary gastric lymphoma

BACKGROUND

Although primary gastric lymphoma is the most common extranodal lymphoma, no specific staging system exists.

METHODS

The authors reviewed 98 cases histologically classified according to the Working Formulation, including low grade B-cell lymphoma of mucosa-associated lymphoid tissue type. Survival rates were calculated by the Kaplan-Meier method according to T, N, and M of the general rules of the International Union Against Cancer TNM system. The definitions of these categories are as follows: T1, tumor invades the lamina propria or submucosa; T2, the muscularis propria; T3, the subserosa; T4, the serosa without invasion of adjacent structures; T5, adjacent structures; N0, no regional lymph node metastasis; N1, perigastric lymph nodes within 3 cm of the edge of the primary tumor; N2, perigastric lymph nodes more than 3 cm from the edge of the primary tumor or in lymph nodes along the left gastric, common hepatic, splenic, or celiac arteries; N3, paraaortic and hepatoduodenal lymph nodes and/or other intraabdominal lymph nodes; N4, beyond N3; M0, no distant metastasis; and M1, positive.

RESULTS

The overall 5-year survival rate was 83.5%; it was 100% in T1, 82.4% in T2, 84.2% in T3, 52.9% in T4, and 33.3% in T5; 93.9% in N0, 90.5% in N1, 66.2% in N2, and 44.4% in N3/N4; and 86.0% in M0 and 25.0% in M1. Based on these results, the authors proposed a new staging system as follows: Stage I, T1/N0, N1/M0; Stage II, T1/N2/M0, T2,T3/N0,N1,N2/M0; Stage III, T4,T5/any N/M0, any T/N3, N4/M0; and Stage IV, any T/any N/M1. According to this system, the 5-year survival rate significantly decreased as the stage progressed: 100% in Stage I, 88.9% in Stage II, 52.1% in Stage III, and 25.0% in Stage IV. In Stages I and II, survival rates were not significantly different whether chemotherapy was done or not, whereas in Stage III all patients treated with surgery alone died.

CONCLUSIONS

This staging system is useful for assessing prognosis of and deciding a therapeutic plan for primary gastric lymphoma.

Gastrointestinal lymphoma in adults: clinical features and management of 300 cases

BACKGROUND/AIMS

Gastrointestinal lymphoma is a rare disease. A study was conducted to assess its prevalence and clinical features in adult patients with lymphoma.

METHODS

Retrospective analysis of 1352 patients with adult non-Hodgkin's lymphoma showed 300 (22%) cases with gastrointestinal involvement at initial presentation.

RESULTS

Of the 185 patients with primary gastrointestinal lymphoma, 94 (51%) had gastric primary lymphoma and the rest (49%) had a lymphoma of intestinal origin. Patients with intestinal lymphoma were considerably younger (median age, 35.0 years), frequently had multifocal disease (14%), and had a 10-year survival rate of 48%. Cases with gastric primary lymphoma had a median age of 54.5 years (P < 0.001) and rarely had multifocal disease (1%; P < 0.001) but had an equal 10-year survival rate of 53% (P = 0.431). For both groups, the combined surgical resection followed by chemotherapy led to better 10-year survival (45%) compared with either modality used alone (0% and 35%, respectively; P < 0.05). Better survival was also noted in ambulatory patients, younger patients, those with localized disease, and those without intestinal perforation. Another 115 patients had gastrointestinal involvement secondary to disseminated disease with frequent high-grade histology (29%) and a poor 10-year survival rate of 22%.

CONCLUSIONS

Gastrointestinal involvement is relatively common in patients with adult lymphoma. Multimodality treatment appeared superior to therapy with either surgery or chemotherapy used alone.

Non-Hodgkin's lymphoma in Saskatchewan. A review of 10 years' experience

BACKGROUND

The incidence and treatment of non-Hodgkin's lymphoma (NHL) have changed in recent years. This study was intended to compare current features with a previous study (1966-1975) and assess the impact of these changes in our jurisdiction.

METHODS

Clinical features and treatment of 547 patients with NHL registered at our center from January 1980 through December 1989 were reviewed, including reassessment of histologic type in each patient. Multivariate analysis of potential pretreatment prognostic factors was performed using the Cox proportional hazards model, and survival was analyzed in relation to treatment outcome.

RESULTS

This review includes virtually all incident cases of NHL in a defined geographic area, representing an average annual incidence of 11.3/100,000 population. The male-to-female ratio was 1.1:1, median age was 65 years (range, 4-92 years). Median survival time (MST) of 482 patients with disease diagnosed antemortem was 4.8 years (95% confidence interval [CI], 3.7-6.1 years), 52% of whom have died. Thirty-nine percent of patients with disease classified by the International Working Formulation (IWF) had low-grade disease (MST, 103 months); 27% had intermediate disease (MST, 62 months), and 30% had high-grade disease (MST, 35 months). Sixteen percent of patients had associated neoplasms: 4 acute leukemias, 35 skin cancers, and 37 miscellaneous solid tumors. Results of radiation therapy (RT), chemotherapy (CT), and combined CT/RT were analyzed. Survival correlated strongly with responsiveness to treatment. Considering all patients treated with CT, anthracycline-containing CT was associated with the highest response rate, and survival time (more than 48 months) may have been affected by the addition of this agent. A survival advantage for patients with bulky Stage I and II disease treated with consolidative RT after CT is suggested, but not for more advanced stage disease. The proportional hazards model identified histologic type, disease stage, patient age, hemoglobin level, lactate dehydrogenase (LDH) level, bulky abdominal disease, and systemic "B" symptoms as significant independent prognostic factors influencing survival.

CONCLUSIONS

The incidence of NHL has increased, and the survival of patients with high-grade disease has improved significantly since the previous study. A high incidence of other associated malignancies was demonstrated in this group of patients with NHL. Recognition of prognostic factors should permit a rational application of innovative treatments for patients in unfavorable prognostic categories.

Postoperative chemotherapy increases the disease-free survival rate in primary gastric lymphomas stage IE and IIE

We describe 53 patients with primary gastric non-Hodgkin's lymphoma (38 stage IE,15 stage IIE) treated with surgery as a primary procedure. According to the Working Formulation, 13 cases had low, 21 had intermediate and 19 had high grade malignancy. 34 patients considered at high risk received postoperative polychemotherapy. The overall 10-year disease-related survival is 91%. Median follow-up is 52 months. 7 patients relapsed (13%). The 10-year disease-free survival rate of the 19 patients initially treated with surgery is 60%, as compared with 92% in the patients who also received chemotherapy (P = 0.004). However, overall survival did not differ between the two groups, since two-thirds of the patients who relapsed after surgery alone were rescued with chemotherapy. Stage, age, sex and histology did not correlate with survival. In our experience, surgery was an adequate first step procedure; the addition of chemotherapy significantly reduced relapses and increased the disease-free survival rate in patients with unfavourable prognostic factors.

Primary digestive tract lymphoma: a prospective multicentric study of 91 patients. Groupe d'Etude des Lymphomes Digestifs

BACKGROUND

The optimal management of primary gastrointestinal lymphoma including the use of surgery remains unsettled. This prospective study aimed to determine the prognostic factors of primary gastrointestinal lymphoma and to evaluate a therapeutic strategy based on surgical tumor reduction, followed by chemotherapy adapted to the histological type of tumor and tumor removal or nonremoval.

METHODS

Ninety-one patients were included (mean age, 50.4 years) with mainly gastric (61%) or several digestive tract organ (18%) involved sites in clinical stages IE (43%), IIE (27%), and IV (30%). Three therapeutic groups were defined: group I, patients with low-grade lymphoma (n = 28); group II, patients with high-grade lymphoma who had complete tumor removal (n = 24); and group III, patients with high-grade lymphoma who had only partial or no tumor removal (n = 39). Each group underwent adapted chemotherapy.

RESULTS

The respective overall 5-year survival rates for groups I, II, and III were 81% +/- 6%, 100%, and 56% +/- 8%, respectively (P < 0.0001). By Cox multivariate analysis, the prognostic factors of survival were age under 65 (P < 0.05), gastric localization (P < 0.05), stage IE (P < 0.001), and radical or incomplete surgery (P < 0.01).

CONCLUSIONS

Combined radical surgery and chemotherapy according to histological grading is associated with prolonged remission in patients with primary digestive tract lymphoma. Moreover, compared with chemotherapy alone, incomplete resection of tumor is associated with increased survival of high-grade lymphomas.

Analysis of prognostic factors in localized gastric lymphoma: the importance of bulk of disease

PURPOSE

To identify prognostic factors in localized gastric lymphoma patients for optimal therapy selection.

METHODS AND MATERIALS

From 1974 to 1990, 77 patients with localized gastric lymphoma (38 Stage IE and 39 Stage IIE) were treated with radiation therapy, chemotherapy, surgery, or a combination. Univariate and multivariate local control and survival analyses were performed on possible prognostic factors, such as patient age, gender, histologic subtype, stage, tumor size, depth of penetration, multicentricity, and treatment modality.

RESULTS

At 5 years, the relapse-free survival was 52%; 74% of the relapses occurred at local sites. Smaller tumor size was most strongly associated with local control (p = .001) and relapse-free survival (p < .001). Patients with tumor sizes < or = 5 cm had relapse-free survival of 87%, compared with 41% and 15% for those with tumor sizes of 5.1 cm to 10 cm and > 10 cm, respectively. The 47 patients who received combined-modality therapy had a relapse-free survival of 65%, compared with 24% for the 30 who received single-modality therapy (p < .01). Although patient age, stage, depth of penetration, and resective surgery affected the above endpoints, these factors were not independent predictors of outcome. Analysis of treatment subgroups showed that surgical resection combined with postoperative irradiation was associated with highest local control (p = .002) and the best relapse-free survival (p = .004), when compared with other treatment modalities. In 27 patients with tumor sizes < or = 5 cm, comparison of the 15 patients who had surgery with the 12 who did not failed to reveal a local control benefit from the addition of surgery.

CONCLUSION

These data demonstrate that tumor bulk is an important prognostic determinant of local control and relapse-free survival in localized gastric lymphoma patients. Stage IE and IIE lymphoma of the stomach can be selectively treated with primary radiation, but surgical resection may be necessary for large tumors (> 5 cm), followed by adjuvant radiation.

Role of surgery in patients with primary non-Hodgkin's lymphoma of the stomach: an old problem revisited

The literature after 1980 dealing with the treatment of primary gastric non-Hodgkin's lymphoma (stages I and II) is reviewed. Gastrectomy is recommended for patients with acute symptoms at presentation or with complications of chemotherapy or radiotherapy. In elective cases, patients with stage I disease may be candidates for gastrectomy as a single therapy, provided that tumour-free resection margins are achieved. There is no evidence of substantial benefit from adding postoperative chemotherapy or radiotherapy after an apparently radical resection. In stage II disease, the best results are achieved with ablative surgery plus adjuvant therapy. The resection volume should be limited to macroscopically involved structures, in principle avoiding total gastrectomy and extensive lymph node dissection, since residual disease may be optimally controlled with radiotherapy or chemotherapy. Primary chemotherapy, with or without radiotherapy, represents an experimental approach; the advantages of sparing the stomach must be balanced against the toxicity of an aggressive chemotherapy regimen and the risk of emergency operation for iatrogenic complications.

Familial primary gastric lymphoma

Familial lymphoma is uncommon and is usually associated with various forms of hereditary immunodeficiencies. Primary gastric lymphomas that occurred in three adults from the same family, who had no overt immunodeficiency or cancer of non-lymphomatous origin, are reported. Two sisters presented with a low grade lymphoma of the mucosa associated lymphoid tissue type. Their father presented with a high grade form of later onset. All lymphomas have been phenotypically characterised as being of B cell origin. Epstein-Bar virus DNA was detected by polymerase chain reaction in the biopsy specimen of the high grade lymphoma but bcl-2/JH protooncogene rearrangement, t (14:18), was not identified in either the low or high grade lymphoma specimens tested.

Gastrointestinal malignant lymphomas of the mucosa-associated lymphoid tissue: factors relevant to prognosis

Three hundred seven cases (244 gastric, 63 intestinal) of primary gastrointestinal non-Hodgkin's lymphoma (NHL) in stages EI and EII, according to a modified Ann Arbor system, were examined retrospectively. The histological classification for mucosa-associated lymphoid tissue-derived lymphomas was applied. Gastric NHLs (male-female ratio, 0.97; mean age, 64.5 years) were stage EI in 51% and stage EII in 49% of cases. Histological grade of malignancy was low in 41% and high in 59% of cases; all NHLs were B-cell type. Tumors were radically resected in 87%, and overall 2-, 5-, and 10-year survival rates were 61%, 55%, and 46%, respectively. Early lymphomas (substage EI1) had best prognosis (5- and 10-year survival rates, 90% and 70%, respectively). Intestinal NHLs (male-female ratio, 1.1; mean age, 54.4 years) were stage EI in 30% and stage EII in 70% of cases. Histology was low grade in 21% and high grade in 79%, and all but 11 cases were B-cell type. In 58% of cases, radical tumor resection resulted in overall 2- and 5-year survival rates of 44% and 24%, respectively. Major prognosticators for survival in gastric location were low-grade histology, low depth of infiltration, and low stage and radical resectability of lymphoma; all factors were strictly intercorrelated. In intestinal site, radical tumor resectability was highly significant for survival. Cumulative proportion of relapses after 5 years was higher in intestinal than in gastric sites (44% vs. 22%). In conclusion, primary gastrointestinal tract NHLs may represent an entity with respect to characteristic histological features, focal tumor growth, and potential cure by radical resection. Because of late relapses, clinical follow-up is needed.

Gastric lymphoma treatment. Medical versus surgical

The treatment of gastric lymphoma is an area of ongoing controversy. Surgical resection has been the standard therapy. Recent advances, however, have been developed in other treatment modalities. A comparison of treatment options is presented.

Primary gastric non-Hodgkin's lymphoma. A retrospective clinico-pathological study

Prognostic factors and treatment results were analysed in 72 consecutive patients with primary gastric lymphoma treated between 1970 and 1985. There were 37 patients in stage IE, 17 in IIE, 3 in IIES and 15 in stage IV. Histopathological re-evaluation and classification according to the TNM system were performed. We found that disseminated disease (stage IV), serosal penetration (T3), involvement of adjacent organs (T4) and extensive abdominal lymph node involvement (N3) were poor prognostic factors. Neither histological malignancy grading, nor the appearance of lympho-epithelial lesions were significantly associated with relapse-free survival. Forty-six patients with 'limited localized' disease (stage IE, IIE, N3 excluded) received potentially curative treatment (surgery, radiotherapy, chemotherapy or combinations thereof), of whom 85% remained relapse-free. Thirty-four patients did only get local treatment (surgery and/or radiotherapy) with curative potential, the relapse-free survival rate was 85%. We conclude that primary gastric lymphoma stage IE and IIE (N3 excluded) is often a truly localized disease that can be cured with local therapy.

Role of surgery in multimodality therapy for gastrointestinal lymphoma

Between 1973 and 1989, 49 patients with gastrointestinal lymphomas were treated at the Virginia Mason Medical Center, Seattle, Washington, and followed in the tumor registry. The purpose of this review was to determine the influence of treatment on long-term survival of these patients. The mean age was 63 years (range: 38 to 83 years). There were 33 men and 16 women. The primary tumor sites were gastric 33 (67%), small bowel 11 (22%), and colon 5 (10%). Common signs and/or symptoms at presentation were pain (n = 38), bleeding (n = 11), and weight loss (n = 14). The diagnostic sensitivities of contrast radiography, computed tomography, and endoscopic biopsy were 76%, 89%, and 79%, respectively. Forty-eight patients were treated, and one received supportive care only. Thirty-one patients had surgical resections, 33 patients had chemotherapy, and 16 patients had radiotherapy. Most (n = 30) had multimodality treatment. Statistically significant variables affecting survival rates in patients with gastric lymphomas were lower tumor stage, younger patient age, and surgical resection.

Primary non-Hodgkin's lymphoma of the stomach: endoscopic diagnosis and the role of surgery

Primary non-Hodgkin's lymphoma of the stomach represents a minority of 1-7% of all gastric malignancies. Symptoms are non-specific. At endoscopy three main patterns can be recognized: ulceration, diffuse infiltration, or a polypoid mass. Endoscopic biopsy results may be false-negative (up to 8%) owing to submucosal localization. The new technique of endoscopic ultrasonography is accurate in measuring depth of infiltration and regional lymph nodes. Preoperative diagnosis altered the indication for surgery. Without resection an excellent local tumour control (stage I, 85%, and stage II, 69%) can be achieved, leading to a fair prognosis: 5-year relapse free survival in stage I, 83%, and in stage II, 58%. Intra-abdominal recurrences were scarce (2%), and severe complications such as perforation and life-threatening haemorrhage were seldom present (4%). Thus, resection is not necessary, but early recognition is highly significant. Favourable results can be achieved by irradiation or chemotherapy with irradiation.

Gastrointestinal lymphoma

Primary GI lymphoma is a rare clinical entity. A primary nodal tumor should be ruled out. Symptoms may not be localizing and B symptoms are less common. A tissue diagnosis, preferably by transmural biopsy for small intestinal involvement, often reveals a high-grade morphology. The staging work-up should include a bone marrow examination, although formal staging laparatomy is not always required. Patients with Mushoff stage IE or IIE1 disease do better than those with extraregional nodal disease or distant metastatic involvement. Surgical resection with clear margins is required in order to maximize the changes for cure. Chemotherapy or radiotherapy may give a survival advantage when used as adjuvant treatment for selected stage IE and IIE disease. Chemotherapy should be used after surgical debulking in more advanced disease in order to minimize the chance for bleeding or performation. Future randomized, multi-institutional trials will give more direction as to the best modes of management.