Early gastric lymphoma: a clinicopathologic study of ten patients, literature review, and comparison with early gastric adenocarcinoma

Primary Gastric Lymphoma, Epidemiology, Clinical Diagnosis, and Treatment

Primary gastric lymphoma (PGL) is the most common extranodal non-Hodgkin lymphoma and represents a wide spectrum of disease, ranging from indolent low-grade marginal zone lymphoma or mucosa-associated lymphoid tissue (MALT) lymphoma to aggressive diffuse large B-cell lymphoma. The PGL is a relatively rare cancer and easily misdiagnosed due to its unspecific symptoms of the digestive tract. The medical literature and ongoing clinical trials were reviewed on the clinical presentation, diagnosis, prognosis, prevention, and treatment of PGL. Primary gastric lymphoma is an event in the course of cancer with a variable clinical presentation and a wide differential diagnosis. Chronic gastritis secondary to Helicobacter pylori (H pylori) infection has been considered a major predisposing factor for MALT lymphoma. Magnetic resonance imaging and endoscopic ultrasonography have helped in staging of these cancers. The clinical course and prognosis of this disease are dependent on histopathological subtype and stage at the time of diagnosis. A global therapeutic approach to the cure of PGL has completely changed over the past 10 years, including innovative and conservative options to reduce treatment toxicity. Due to the rarity of PGL, many aspects of this neoplasm are still controversial. The incidence of this disease is increasing, making it necessary for clinicians to understand the clinical symptoms, workup, and treatment of these lymphomas.

[Gastric perforation caused by primary gastric diffuse large B cell lymphoma]

Spontaneous gastric perforation is a rare complication of gastric lymphoma that is potentially life threatening since it can progress to sepsis and multi-organ failure. Morbidity also increases due to prolonged hospitalization and delay in initiating chemotherapy. Therefore prompt diagnosis and appropriate treatment is critical to improve prognosis. A 64-year-old man presented to the emergency department with severe abdominal pain. Chest X-ray showed free air below the right diaphragm. Abdominal CT scan also demonstrated free air in the peritoneal cavity with large wall defect in the lesser curvature of gastric lower body. Therefore, the patient underwent emergency operation and primary closure was done. Pathologic specimen obtained during surgery was compatible to diffuse large B cell lymphoma. Fifteen days after primary closure, the patient received subtotal gastrectomy and chemotherapy was initiated after recovery. Patient is currently being followed-up at outpatient department without any particular complications. Herein, we report a rare case of gastric lymphoma that initially presented as peritonitis because of spontaneous gastric perforation.

Synchronous and metachronous occurrence of gastric adenocarcinoma and gastric lymphoma: A review of the literature

The occurrence of both primary gastric lymphoma and gastric adenocarcinoma in the same patient is a rare entity. The possible causative factors of synchronous or metachronous occurrence of both malignancies and varieties in the treatment modalities are reviewed according to published cases in English language medical literature.

Curative resection plus adjuvant chemotherapy for early stage primary gastric non-Hodgkin's lymphoma: a retrospective study with emphasis on prognostic factors and treatment outcome

BACKGROUND

There is controversy regarding the optimal therapy for primary non-Hodgkin gastric lymphoma with some authors defending surgical extirpation either alone or in association with radiotherapy and or chemotherapy, especially in relation to the earlier stages of the disease.

AIM

To analyze the clinical-pathological features and the results of management approaches for patients with primary early-stage non-Hodgkin's lymphoma of the stomach operated in Surgical Gastroenterology Department, "Hospital do Servidor Público Estadual", São Paulo, SP, Brazil. The literature is reviewed to highlight the aspects of diagnosis, prognostic factors and role of the various treatment regimens.

METHOD

Sixteen patients with primary early-stage gastric lymphoma underwent curative surgical treatment. The variables analyzed were age, sex, location, size, type of surgery, number of lesions, depth of invasion, histological type in accordance with Kiel's classification, involvement of lymph nodes, Ann Arbor stage classification modified by Musshoff and Schmidt-Vollmer, histological grade, margins, adjuvant therapy, clinical course and survival.

RESULTS

Ten patients (62.5%) underwent subtotal gastrectomy and six (37.5%) underwent total gastrectomy. The majority (9/56.2%) of the lesions were located in the antrum. Single lesions (10/62.5%) were more frequent than multiple lesions (6/37.5%). Thirteen patients (81.2%) were classified as stage IE and three (18.7%) as stage IIE1. Primary gastric lymphoma classified histologically as low or high grade was presented by 10 (62.5%) and 6 (37.5%) patients, respectively. The most frequent histological types were the lymphoplasmocytic cytoid (4/25.0%) and centroblastic (4/25.0%). Ten patients (62.5%) received adjuvant treatment (chemotherapy and/or radiotherapy). Nine patients (56.2%), all in stage IE, reached a survival greater than 5 years and of these eight (50.0.%) had received adjuvant therapy. Two (12.5%) patients with stage IIE1 presented peritoneal relapse and died 3.0 years and 3.5 years after their respective operations. The mean overall survival was 42.5 months.

CONCLUSIONS

Among the patients with primary early-stage gastric lymphoma (IE and IIE1), the gastric resection enabled an accurate clinicopathological staging, in addition to obtaining sufficient material for histopathological study and extirpation of the lesion. Furthermore, for patients with stage IE disease, the gastric resection combined with adjuvant therapy was associated with a greater than 5-year survival. Until prospective randomized studies are realized in order to evaluate the real efficacy of the different types of treatment for primary early-stage gastric lymphoma, management approaches should be individually tailored.

Clinical study of 31 patients with primary gastric mucosa-associated lymphoid tissue lymphoma

BACKGROUND

The purpose of the present paper was to investigate the clinical, endoscopic and histological features of 31 patients with gastric mucosa-associated lymphoid tissue (MALT) lymphoma to enable correct, early stage diagnosis.

METHODS

A retrospective study was undertaken of 31 patients with gastric MALT lymphoma. The cases were examined immunohistologically with anti-CD(20CY) and CD(45RO) antibodies for further diagnosis. Helicobacter pylori infection was also detected with modified Giemsa staining.

RESULTS

Patients with MALT lymphoma were aged between 22 and 73 years (mean, 45.0 years), and the male:female ratio was 11:20. The patients presented with non-specific symptoms, but chronic epigastric pain was the common symptom in a large proportion of the cases. The gastric smaller curvature was involved in 83.9% of cases (26/31) and in 13/31 cases (41.9%) it was confined the antrum. Under endoscopy, large and deep ulcers were similar to cancers in the majority of patients. Only 29.0% of patients were diagnosed by endoscopy on first examination. CD(20CY) were expressed in all cases and CD(45RO) expressed in only one case among 10 cases of indefinite diagnosis. Helicobacter pylori infection was found in 87.1% of patients.

CONCLUSIONS

These findings suggest that primary gastric MALT lymphoma has unique clinical, endoscopic and histological features. The diagnosis for primary gastric MALT lymphoma was delayed not only due to the non-specific symptoms but also due to lack of attention to its features. Endoscopy and submucosal multiple biopsy were the principal diagnostic tools in patients with gastric MALT lymphoma. CD(20CY) and CD(45RO) immunological staining are recommended, especially for patients with indefinite diagnosis of gastric MALT lymphoma.

Tratamento cirúrgico do linfoma gástrico primário

OBJETIVO: o objetivo deste estudo retrospectivo foi analisar os resultados de 25 doentes com linfoma gástrico primário operados com intenção curativa. MÉTODO: os dados foram obtidos pela revisão dos prontuários e contato com os doentes ou familiares. A doença foi estadiada pelo sistema Ann Arbor modificado por Musshoff e Schmidt-Vollmer e a classificação histológica utilizada foi o sistema de Kiel. O esquema de radioterapia utilizado foi o CHOP e a radioterapia aplicada foi de 2000 a 4000 cGy. RESULTADOS: os sintomas e sinais clínicos assemelhavam-se aos da doença péptica ulcerosa ou do carcinoma gástrico Obteve-se o diagnóstico pré-operatório pela biópsia endoscópica em três casos e a exploração cirúrgica foi necessária para o diagnóstico nos restantes. No pré-operatório, sete doentes (30,4%) foram submetidos ao mielograma, que foi normal. Todos os pacientes foram submetidos à ressecção (12 gastrectomias subtotais e 13 gastrectomias totais) com retirada dos linfonodos regionais. Dez doentes (40%) receberam tratamento complementar (quimioterapia e/ou radioterapia). O estadiamento foi significativamente mais avançado nas lesões fundocárdicas e nos mais idosos e a sobrevida média foi de 31,5 meses. CONCLUSÕES: nesta série, as variáveis que influenciaram significativamente os índices de sobrevida foram a idade e o estádio avançados, o tamanho da lesão maior que 6,0cm e a realização do tratamento adjuvante pós-operatório (p< 0,05). Estes resultados sugerem que a ressecção completa da lesão com linfonodos adjacentes, acompanhada de tratamento adjuvante, constitui a melhor abordagem do linfoma gástrico primário ressecável.

Gastrointestinal lymphoma: prevention and treatment of early lesions

Gastrointestinal lymphomas comprise a group of distinct clinicopathological entities. Differences in lifestyle and environmental factors between countries could account for the variety in the distribution of the main subtypes: low-grade B-cell lymphomas of the mucosa-associated lymphoid tissue type, alpha-chain disease and enteropathy (coeliac disease)-associated T-cell lymphoma (EATL). The possibility of preventing these lymphomas implies a knowledge of their natural history together with an identification of potential predisposing factors. The development of the lymphoid hyperplasia and subsequently low-grade lymphoma with the possibility of high-grade transformation is a multifactorial process involving both antigenic and host-related factors. The pathogenic role of Helicobacter pylori and gluten has been demonstrated in gastric lymphoma and enteropathy-associated T-cell lymphoma respectively, while environmental factors, especially non-specific bacterial ones, may play a major role in the pathogenesis of alpha-chain disease. The most difficult task in preventing these lymphomas is the recognition of early lesions likely to regress after the removal of the exogenous stimulus.

Low-grade gastric mucosa-associated lymphoid tissue lymphoma: correlation of radiographic and pathologic findings

PURPOSE

To describe upper gastrointestinal (Gl) examination findings of low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma and to correlate them with pathologic examination findings.

MATERIALS AND METHODS

A retrospective review of upper Gl examinations was performed in 25 patients with proved low-grade gastric MALT lymphomas. Upper Gl examinations were reviewed for common findings and most probable diagnosis, and these findings were correlated with pathologic findings in resected specimens in 15 patients.

RESULTS

The common findings at upper Gl examination included mucosal nodularity (n = 13), ulcer (n = 12), rugal thickening (n = 6), mass (n = 4), and enlarged areae gastricae (n = 2). The most probable diagnoses were early gastric carcinoma (n = 7), advanced gastric carcinoma (n = 6), gastritis (n = 9), and lymphoma (n = 3). Of 17 lesions found on resected specimens, six ulcers and two masses were not depicted at barium study. Disorganized convergent rugae projecting to multiple points and vague ulcer margins were present in four and seven lesions, respectively. Multiple ulcers were seen in two patients.

CONCLUSION

Although the common radiographic and pathologic findings observed in low-grade gastric MALT lymphomas were similar to those of gastric carcinomas or gastritis, disorganized convergent rugae, vague ulcer margins, and multiplicity of lesions may be helpful in differentiating them from gastric carcinomas or gastritis.

Clinicopathological features of primary gastric lymphoma

BACKGROUND AND OBJECTIVES

Surgery has been the mainstay of the treatment of primary gastric lymphoma, but the value of surgical treatment needs reevaluation.

METHODS

Thirty-two patients with primary non-Hodgkin B-cell lymphoma of the stomach were examined retrospectively to evaluate prognostic factors and their impact on survival. All patients had undergone abdominal exploration for radical surgery between 1979 and 1992. The prognostic factors in view of survival after treatment were determined with both univariate and multivariate analyses.

RESULTS

The resectability rate was 66% (21/32) and radical resections had been performed on 53% (17/32). The overall median survival was 65 months and the overall 5-year survival was 56%. The 5-year survival rates related to a modified Ann Arbor classification as follows: I 1E, 86%; I 2E, 100%; II 1E, 44%; II 2E, 37%; IIIE, 20%; and IVE, 0%. Univariate analysis using Kaplan-Meier estimates showed that radical surgery, Ann Arbor stage, patient's age, and lymph node involvement were significant prognostic factors. According to Cox proportional regression analysis, only Ann Arbor stage, radical surgery, and age were significant independent variables.

CONCLUSIONS

According to our experience, surgery is still needed for the treatment of primary gastric lymphomas, but the benefits of primary chemotherapy or adjuvant chemotherapy using cytotoxic drugs must be determined in large prospective controlled trials.

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.