Surgical resection plus chemotherapy versus chemotherapy alone: comparison of two strategies to treat diffuse large B-cell gastric lymphoma

Primary diffuse large B-cell lymphoma of the stomach

The stomach is the extranodal site most commonly involved by non-Hodgkin lymphomas. Diffuse large B-cell lymphoma is the most common histotype category arising in this organ. This is an aggressive lymphoma usually presenting as limited disease, being associated or not to Helicobacter pylori infection and mucosa-associated lymphoid tissue-type areas. Histopathological characteristics are similar to those reported for other diffuse large B-cell lymphomas. It occurs more frequently in males with a median age ranging between 50 and 60 years. With an adequate therapeutic strategy, its prognosis is good, with a 5-year overall survival near to 90%. Conservative treatment with anthracycline-containing chemotherapy, followed or not by involved-field radiotherapy has replaced gastrectomy as standard approach against this malignancy. Several questions on the best treatment remain unanswered. Among others, the role of rituximab, consolidation radiotherapy as well as of more conservative approaches like H. pylori-eradicating antibiotic therapy should be better defined.

Primary gastrointestinal tract lymphoma: diagnosis and management of common neoplasms

Primary gastrointestinal lymphoma represents the most common location of extranodal lymphoma. With the bulk of disease manifesting within the gastrointestinal tract and contiguous lymph nodes, many of the lymphomas occurring in the peripheral lymph nodes can also present with primary gastrointestinal tract involvement. Molecular biology has recently enabled significant progress in the diagnosis and management of primary gastrointestinal lymphoma. Herein, we will discuss the major lymphomas affecting the bowel and highlight their key morphological, immunophenotypical and molecular diagnostic attributes. Similarly, in keeping with recent therapeutic advances, we will briefly discuss some important treatment considerations. Thus, this review is intended to offer clinicians and pathologists an overview of primary gastrointestinal lymphomas.

Gastric stump lymphoma after distal gastrectomy for benign peptic ulcer: Report of a case

We report a case of primary non-Hodgkin gastric stump lymphoma, found in a 78-year-old man 30 years after a distal gastrectomy for a benign peptic ulcer. The development of lymphoma in the gastric stump is rare. In fact, to our knowledge only 37 cases, including this one, have been documented. Although Helicobacter pylori is thought to be a predisposing factor, we found no histological evidence of this infection in our patient. Conversely, bile reflux and nitrite and N-nitrous compounds caused by abnormal bacterial growth in the gastric stump may play a role in inducing mucosa-associated lymphoid tissue lymphoma. The patient was treated by chemotherapy only, without surgery, which seems to be most appropriate for the early stages of this disease.

Primary gastrointestinal non-Hodgkin's lymphoma: a clinicopathologic study of 128 cases in Greece. A Hellenic Cooperative Oncology Group study (HeCOG)

The aim of this retrospective study was to illustrate the clinicopathologic data and the treatment results in patients with primary gastrointestinal tract non-Hodgkin's lymphoma (GI NHL). Among 810 patients with NHL, 128 cases (15.8%) were diagnosed as primary GI tract NHL. There were 79 males and 49 females with median age of 62 years. The most common primary site was the stomach (68%). Overall, 67.2% of the patients were in stages I - II, and 32.8% in stages III - IV. Simultaneous involvement of the GI tract and other extranodal sites was observed in 26 patients (20%). Extranodal marginal zone B-cell lymphoma (MZBL) (i.e., low-grade lymphoma of mucosa-associated lymphoid tissue type) accounted for 48.4% of lymphomas. Aggressive lymphomas (diffuse large B-cell lymphoma [DLBL]) accounted for 44.5%. Eighty-three patients (67.5%) achieved complete response (CR), either by surgery (43/43 patients, 17 with DLBL and 25 with MZBL) or by primary chemotherapy (40/64 patients, 22 with DLBL and 17 with MZBL). Sixty-two patients remain in CR; 33/43 after surgical resection (13/17 with DLBL and 20/25 patients with MZBL), and 29/40 after only chemotherapy (18/22 with DLBL and 10/17 with MZBL). The major prognostic factor for outcome in the present study was the stage of the disease. Patients with localized lymphoma (stage I and II) had significantly longer DFS and OS (DFS and OS at 3-year: 83% and 87%, respectively) than patients with extended disease (stage III and IV) (DFS and OS at 3-year: 46% and 60%, respectively) (P < 0.0001). The International Prognostic Index (IPI) for patients with aggressive lymphomas was prognostic only for DFS (79% for low-risk patients [IPI score 0 - 1] vs 49% for higher risk groups [IPI score >1] at 3-year, P = 0.0131).

CHOP followed by involved field radiotherapy for localized primary gastric diffuse large B-cell lymphoma: results of a multi center phase II study and quality of life evaluation

We aimed to define the role of cyclophosphamide, vincristine, doxorubicin, prednisone (CHOP) followed by involved field radiotherapy (IFRT) for treating localized primary gastric diffuse large B-cell lymphoma (DLBCL). Newly diagnosed patients with localized primary gastric DLBCL were to receive four cycles of CHOP followed by IFRT of 40.0 Gy. At 1 year after the completion of treatment, patients filled out the EORTC Quality of Life Questionnaire specified for stomach cancer (QLQ-C30-STO22). Fifty evaluable patients (25 men, 25 women) were included. The median age was 54.5 years (range, 21 - 73 years. The overall response rate to the CHOP was 94% (95% confidence interval [CI], 87 - 100) in the intent-to-treat population. Forty-one of the 50 patients (82%; 95% CI, 71 - 93) achieved complete remission (CR). After the completion of radiotherapy, five patients who were in PR following chemotherapy eventually attained CR. The overall complete response rate was thus 92% (95% confidence interval, 84 - 99). With a median follow-up period of 30 months, the 2-year progression-free and overall survival rate was 92% and 92%, respectively. The gastric function was well preserved with negligible stomach-related symptoms at 1 year after the completion of treatment. This organ-preserving combined treatment is highly effective and well tolerated for the patients with localized gastric DLBCL.

Quality of life after total or partial gastrectomy for primary gastric lymphoma

Up to 90% of patients with localized non-Hodgkin's lymphomas (NHL) in the gastrointestinal tract (GI) are cured and decreased use of radical surgery is favoured. Although quality of life (QOL) may impact treatment choice, little is known about QOL in gastric NHL survivors. The self-reported QOL (EORTC QLQ-C30 and a gastric module) and objective findings from upper GI endoscopy were evaluated in patients in complete remission after treatment for primary gastric NHL at the Norwegian Radium Hospital (NRH). Thirty-six (90%) patients completed the questionnaires, 33 (83%) met for endoscopy. Ten patients were treated with total gastrectomy, 17 with partial gastrectomy, while nine patients did not undergo surgery. Gastroscopy was normal in 55% of the non-gastrectomised patients, oesophagoscopy in 69%. Four patients had Barrett's metaplasia. QOL was not different from population values. Patients treated with total gastrectomy reported poorer emotional function, more diarrhoea and more food-related problems (p< or =0.05) compared with the others. Based on the higher level of digestive and food related problems after total gastrectomy, stomach-preserving surgery should be preferred whenever possible.

Vitamin D deficiency in patients operated on for gastric lymphoma

OBJECTIVE

To determine the nutritional status in patients treated for gastric non-Hodgkin's lymphoma (NHL).

MATERIAL AND METHODS

Patients treated during the period 1990-99 according to a protocol including primary gastric surgery for eligible patients were registered prospectively in successive patients. Those with aggressive lymphomas in stage IE-IIE underwent gastric surgery followed by CHOP-like chemotherapy. Patients with indolent lymphomas and localized disease did not receive any further treatment if the operation was considered radical; otherwise, they received local radiotherapy after surgery. Patients with advanced disease underwent gastric surgery only if there was a considerable risk of bleeding or perforation. Patients below the age of 80 years and in complete remission were offered a cross-sectional examination a median of 102 months later, including clinical examination with estimation of body mass index, upper endoscopy and blood tests (haemoglobin, ferritin, serum-Fe, total iron-binding capacity (TIBC), vitamin B(12), homocysteine, vitamin D status, parathyroid hormone (PTH), albumin and electrolytes).

RESULTS

Forty patients were identified, of whom 33 met for follow-up examination. Seventeen patients had a partial gastrectomy (PG), 9 a total gastrectomy (TG) and 7 patients were not operated on. The patients in the TG group had significant weight loss. Furthermore, the patients in the TG group had a lower storage iron content (s-ferritin and s-iron saturation), lower s-vitamin D, higher s-PTH and homocysteine than the other groups.

CONCLUSIONS

If surgery is necessary for gastric lymphomas, a PG should be performed when possible. The patients should receive dietary advice and be followed-up at least yearly for nutritional deficiencies. Regular intake of vitamin D and -B(12), calcium, folate and iron should be considered.

Primary pancreatic lymphoma--pancreatic tumours that are potentially curable without resection, a retrospective review of four cases

Background

Primary pancreatic lymphomas (PPL) are rare tumours of the pancreas. Symptoms, imaging and tumour markers can mimic pancreatic adenocarcinoma, but they are much more amenable to treatment. Treatment for PPL remains controversial, particularly the role of surgical resection.

Methods

Four cases of primary pancreatic lymphoma were identified at Prince of Wales Hospital, Sydney, Australia. A literature review of cases of PPL reported between 1985 and 2005 was conducted, and outcomes were contrasted.

Results

All four patients presented with upper abdominal symptoms associated with weight loss. One case was diagnosed without surgery. No patients underwent pancreatectomy. All patients were treated with chemotherapy and radiotherapy, and two of four patients received rituximab. One patient died at 32 months. Three patients are disease free at 15, 25 and 64 months, one after successful retreatment. Literature review identified a further 103 patients in 11 case series. Outcomes in our series and other series of chemotherapy and radiotherapy compared favourably to surgical series.

Conclusion

Biopsy of all pancreatic masses is essential, to exclude potentially curable conditions such as PPL, and can be performed without laparotomy. Combined multimodality treatment, utilising chemotherapy and radiotherapy, without surgical resection is advocated but a cooperative prospective study would lead to further improvement in treatment outcomes.

Clinical outcome of primary gastric lymphoma treated with chemotherapy alone or surgery followed by chemotherapy

BACKGROUND

The role of surgical resection in the treatment of primary gastric lymphoma (PGL) remains unclear. This retrospective study evaluated the clinical outcome of PGL treated with chemotherapy alone or surgery followed by chemotherapy.

METHODS

During 1986-2003, 59 patients with PGL (other than mucosa-associated lymphoid tissue type lymphoma) were identified from hospital files. The medical records, pathologic sections, radiographic images and treatment modalities of these patients were reviewed. Patients were categorized into localized (stage IE and IIE-1) and advanced (stage IIE-2 or beyond) stage groups. Survival was estimated by the Kaplan-Meier method.

RESULTS

The study included 55 patients who received treatment at the same institute. Among them, 32 had localized PGL (15 stage IE, 17 stage IIE-1) and 23 had advanced disease. The median survival of the localized stage group was not reached during a mean follow-up of 168.1 +/- 16.7 months (95% confidence interval [CI], 135.4-200.8 months), while that of the advanced stage group was 33.0 +/- 6.8 months (95% CI, 19.7-46.5; p < 0.001, log-rank test). Among patients with localized PGL, the 5-year overall survival rate of those receiving chemotherapy alone (n = 19) or combination therapy (surgery followed by chemotherapy, n = 13) was 73.4% and 87.5%, respectively (p = 0.229). The 5-year disease-free survival was 68.4% and 84.6%, respectively (p = 0.540). However, post-chemotherapy life-threatening hemorrhage occurred in five of the 32 patients (15.6%) in the localized stage group: four in the chemotherapy-alone group, and one in the combination therapy group, all of whom had failed to achieve complete response.

CONCLUSION

The clinical outcome of localized PGL treated by chemotherapy alone is similar to that treated by surgery followed by chemotherapy in terms of tumor response, disease-free survival and overall survival, suggesting that surgery be reserved for those with residual tumors after chemotherapy.

Treatment of gastric mucosa-associated lymphoid tissue lymphoma: Helicobacter pylori eradication and beyond

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is the paradigm of lymphomas developing in extranodal areas after antigen stimulation. In the stomach, Helicobacter pylori colonization induces the appearance of MALT and, eventually, MALT-derived lymphoma. This type of lymphoma is initially a localized form of disease, but may disseminate and transform into high-grade lymphoma, making full staging (as for nodal lymphomas) and endoscopic ultrasonography to evaluate the penetration of the lymphoma through the gastric wall mandatory. In localized gastric MALT lymphoma, the first step in treatment is eradication of H. pylori, which results in 60-90% regression. This response is maintained for years in most patients, with only 10-15% relapse, frequently precipitated by H. pylori reinfection. A component of high-grade lymphoma, penetration to gastric serosa or beyond and translocation t(11;18) are the main factors that make lymphoma resistant to eradication. Surgery or radiotherapy can cure localized lymphomas in 75-90% of patients. Chemotherapy with alkylating agents, combination chemotherapy and purine analogs, and anti-CD20 antibodies can also induce remission of localized lymphomas refractory to eradication, as well as locally advanced and disseminated lymphomas. The optimum chemotherapy treatment for advanced disease has not yet been established; however, combination therapy, including purine analogs with or without anti-CD20, may be a promising option. Despite histological responses and prolonged remissions, residual molecular disease can be demonstrated in most cases treated with H. pylori eradication, radiotherapy or alkylating agents, and even after more intense chemotherapy, although this does not seem to lead to late relapses. High-grade gastric MALT lymphoma should be treated with chemotherapy, with cyclophosphamide, doxorubicin, oncovin and prednisone being the best first-line option. All gastric MALT lymphomas associated with H. pylori should receive eradication treatment in addition to other required treatment.

Gastric Burkitt lymphoma is a distinct subtype that has superior outcomes to other types of Burkitt lymphoma/leukemia

Burkitt lymphoma/leukemia (BL) is a highly aggressive non-Hodgkin's lymphoma (NHL) often presenting in extranodal sites or as an acute leukemia. Because of the shared molecular and genetic features, the World Health Organization classification of lymphoid diseases recognizes the lymphomatous and leukemic phases of BL as a single entity: a mature B cell neoplasm, subtype Burkitt lymphoma/Burkitt cell leukemia. Because BL frequently appears in the stomach, we investigated the clinical presentation and outcome of gastric BL. We discovered 21 patients with gastric BL through a survey of our NHL registry, and retrospectively analyzed the distinct features of BL, including the St Jude/Murphy staging, other extranodal involvement, morphology and immunophenotype, response to treatment, and clinical outcome. The patients' median age was 48 years (range, 7-75), and the male-to-female ratio was 2.5. Stage 1 was found in five patients, stage 2 in five patients, and stage 4 in 11 patients. The stomach body and antrum were most frequently involved. All 21 patients were treated with systemic intensive chemotherapy, producing a 71% (15/21) rate of complete response (CR) to chemotherapy. Both the 2-year disease-free and overall survival rates were 55%. All ten patients in BL stages 1 and 2 showed outstanding outcomes, and nine of the ten patients exhibited CR and long-term survival. These data show that a high proportion of patients with gastric BL have a localized disease that is limited to stage 1 and 2, and that these localized BLs have outstanding outcomes. These findings suggest that these BLs could represent a distinct subtype that might have a different biology, which needs to be defined.

Routine application of the proton-pump inhibitor pantoprazole in patients with gastric lymphoma undergoing chemotherapy

OBJECTIVE

The stomach is the most common site of origin for extranodal lymphomas. While resection has played a major part in the management of such patients in the past, in recent years there has been a change towards organ-conserving therapies. However, the risk of perforation and bleeding in patients undergoing organ-conserving therapy has been used as an argument against primary application of chemotherapy. In this article, we present our experience with the prophylactic use of oral pantoprazole.

MATERIAL AND METHODS

All patients undergoing chemotherapy for gastric lymphoma at our institution were prophylactically given oral pantoprazole (2x40 mg) for the duration of chemotherapy. Compliance with intake of the proton-pump inhibitor (PPI) was assessed at every visit for application of chemotherapy and at routine blood counts taken 10-14 days after each cycle of treatment by direct questioning of the patient.

RESULTS

A total of 82 patients (median age 69 years, range 33-93) received chemotherapy for gastric lymphoma: 51 had diffuse large B-cell lymphoma (DLBCL), 24 had mucosa-associated lymphoid tissue (MALT) lymphoma and 7 had DLBCL+MALT lymphoma. Compliance with intake of the PPI was excellent, as only two patients reported irregular intake and only one patient refused regular medication with pantoprazople. All patients responded to chemotherapy, with 74 (90%) achieving complete remission and 8 (10%) partial remission. After a median follow-up time of 50 months (range: 9-84 months) only one of these 82 patients (1.22%), the patient who discontinued intake of pantoprazole, died from gastric perforation, while none of the other patients had gastrointestinal bleeding or perforation.

CONCLUSIONS

Judging from these data, continuous PPI intake is feasible and has a high rate of compliance. In the absence of randomized trials, routine application of oral pantoprazole in patients given chemotherapy for gastric lymphoma, especially DLBCL, appears to be a reasonable approach.

Japanese multicenter phase II study of CHOP followed by radiotherapy in stage I-II, diffuse large B-cell lymphoma of the stomach

CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) followed by radiotherapy is regarded as standard care for localized aggressive lymphoma; however, prospective confirmation of its applicability to localized primary gastric lymphoma is inadequate, and most patients in Japan have been initially treated with gastrectomy. We conducted a multicenter phase II study to evaluate the feasibility and efficacy of the non-surgical treatment. Eligibility criteria required primary gastric diffuse large B-cell lymphoma, stage I-II(1), age 20-75, performance status 0-1 and adequate organ function. Treatment consisted of three cycles of CHOP followed by radiotherapy 40.5 Gy. Fifty-five patients were enrolled between December 1999 and February 2003, and 52 eligible patients were analyzed. Patient characteristics were as follows: median age, 61 years; 28 men, 24 women; 36 with stage I, 16 with stage II(1); 47 with a low International Prognostic Index (IPI) and five with a low-intermediate IPI. All but one patient completed planned treatment. No serious complications including massive hemorrhage or perforation were observed. A complete response was achieved in 48 of the 52 patients (92%, 95% confidence interval: 82-98%) and progressive disease in three. Two patients underwent salvage gastrectomy due to disease persistence or recurrence. With a median follow-up period of 28 months, 2-year progression-free and overall survivals were 88 and 94%, respectively. CHOP followed by radiotherapy is safe and highly effective in localized gastric diffuse large B-cell lymphoma. This organ-preserving treatment should be considered as a very reasonable therapeutic option.

Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) for treatment of early-stage gastric diffuse large B-cell lymphoma

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) of the stomach is a relatively common disease. Recently, chemotherapy consisting of doxorubicin, cyclophosphamide, vincristine and prednisone (CHOP) has been reported as effective treatment for early-stage gastric DLBCL. Given the fact that the application of the CD20 antibody rituximab (R) in addition to CHOP has improved outcomes in nodal DLBCL, we have analysed our experience with application of R-CHOP in patients with early-stage gastric DLBCL.

PATIENTS AND METHODS

Patients with histologically verified early-stage gastric DLBCL undergoing treatment with R-CHOP for initial management were analysed.

RESULTS

Fifteen patients received a total of 79 cycles, with a median of six cycles per patient. All patients responded to therapy, 13 had a complete remission (CR) (87%) and two (13%) a partial remission. All patients in CR, except one who died unrelated to lymphoma, have remained so with a median follow-up of 15 months (range 4-42) after treatment. Subjective tolerance was moderate, and toxicities were mainly haematological, including leukocytopenia WHO grade 3 and 4 in 10 and five patients each. The addition of rituximab to the standard CHOP regimen did not appear to significantly increase toxicity.

CONCLUSIONS

Our data indicate that R-CHOP is an effective regimen for management of early-stage gastric DLBCL. However, given the excellent results with CHOP alone in such patients, the value of adding rituximab to standard CHOP remains to be determined in a randomised trial.

Helicobacter pylori and gastric malignancies

Clinical outcomes of Helicobacter pylori infection are diverse and caused by the variability of H. pylori virulence factors, host susceptibility, environmental factors and their interactions. Prospective epidemiological studies have clearly shown the relationship between H. pylori infection and gastric cancer. In addition, studies in animal models such as Mongolian gerbils with or without the addition of low-dose chemical carcinogens demonstrated that H. pylori infection can develop gastric carcinoma. Experimental studies have shown that virulence factors of H. pylori interact with gastric epithelial cell signaling related to carcinogenesis. While the effect of H. pylori eradication on prevention of such tumors in chronic H. pylori carriers is still controversial, progress has been made in therapy especially of gastric lymphoma with well tolerated chemotherapeutic regimen.