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

Management of stage one and two-E gastric large B-cell lymphoma: chemotherapy alone or surgery followed by chemotherapy?

Management of localized primary gastric B lymphoma (PGL) remains controversial. The aim of this study is to compare two treatments: chemotherapy alone and surgery plus chemotherapy.

Combination therapy with rituximab and intravenous or oral fludarabine in the first-line, systemic treatment of patients with extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue type

BACKGROUND

Currently, there are no consensus guidelines regarding the best therapeutic option for patients with extranodal marginal zone lymphomas of the mucosa-associated lymphoid tissue (MALT) type.

METHODS

Patients with systemically untreated or de novo extranodal MALT lymphoma received rituximab 375 mg/m(2) intravenously on Day 1 and fludarabine 25 mg/m(2) intravenously on Days 1 through 5 (Days 1-3 in patients aged >70 years) every 4 weeks, for 4 to 6 cycles. After the first cycle, oral fludarabine could be given orally at 40 mg/m(2) on the same schedule. After 3 cycles, a workup was done. Patients who achieved a complete remission (CR) received an additional cycle, and patients who achieved a partial remission (PR) received a total of 6 cycles.

RESULTS

Twenty-two patients were studied, including 12 patients with gastric lymphoma and 10 patients with extragastric MALT lymphoma. Six patients (27%) had stage IV disease. In total, 101 cycles were administered (median, 4 cycles per patients). After the third cycle, 13 patients (62%) achieved a CR, and 8 patients (38%) achieved a PR. Primary extragastric disease was an adverse factor to achieve CR after 3 cycles of chemotherapy (hazard ratio, 23.3; 95% confidence interval, 2.0-273.3). At the end of treatment, the overall response rate was 100%, and 90% of patients achieved a CR. The progression-free survival rate at 2 years in patients with gastric and extragastric MALT lymphoma was 100% and 89%, respectively. Toxicities were mild and mainly were hematologic.

CONCLUSIONS

Combination therapy with rituximab and fludarabine is a very active treatment with favorable safety profile as first-line systemic treatment for patients with extranodal MALT lymphoma.

Early stage gastric diffuse large B-cell lymphomas: results of a randomized trial comparing chemotherapy alone versus chemotherapy + involved field radiotherapy. (IELSG 4). [corrected]

Here, we present the results of a randomised clinical trial carried out between 1998 and 2004, evaluating the possible role of radiotherapy (RT) as consolidation treatment after induction chemotherapy (CT) in diffuse large B-cell (DLBC) gastric lymphoma. Fifty-four patients were enrolled and all received anthracycline containing regimens as induction CT. Patients were evaluated after four to six cycles and those in complete remission (CR) were randomised to receive gastric involved field (IF) RT or two addition cycles of the same CT. Forty-five patients (83%) were randomised after the induction CT. Clinical results of patients allocated to the RT arm showed a significant reduction in incidence of local relapse versus patients who received CT alone. However, overall survival was not different between the two arms. Our results confirm that CT could be considered as first line therapy for newly diagnosed gastric DLBC lymphoma; IF RT delivered in those patients achieving CR after induction CT is able to prevent local relapse.

The Evolution in the Management of Gastric Lymphoma

The management of gastric lymphoma is a rapidly changing field. The classification and staging of lymphomas have been revised in the past two decades, reflecting diagnostic advances that include the use of immunohistochemical stains and cell-surface markers. Furthermore, the use of CT scanning and endoscopic ultrasound has revolutionized the non-operative diagnostic modalities available. Despite these advances, the future of gastric lymphoma research lies in the development of therapeutic regimens.

Management of gastric lymphoma with chemotherapy alone

PURPOSE

The optimal therapy for gastric lymphoma except MALToma has not yet been established. This study was undertaken to investigate whether gastric lymphoma can be managed effectively and safely with chemotherapy alone.

PATIENTS AND METHODS

A total of 58 patients (median age 56 years) with newly diagnosed gastric lymphoma between 1989--2001 at Seoul National University Hospital and who were initially managed with chemotherapy alone were evaluated. MALToma was excluded from the pathologic review.

RESULTS

All patients received initially anthracycline-containing chemotherapy. ECOG performance scale 0--1 was 88% and B symptoms were present in 41.4%. Diffuse large B cell type was the most common (74.1%). Stage IE, II1E accounted for 51.7% and II2E, IIIE, IV for 48.3%. The international prognostic index (IPI) of risk was low in 39.7%, low-intermediate in 22.4%, high-intermediate in 15.5% and high in 22.4%. The complete response rate after first-line chemotherapy was 71.4% and the partial response rate was 12.2%. (overall response rate: 83.6%). Among patients who did not reach the complete response, a further complete response was achieved by second-line chemotherapy including etoposide-based regimen. Ultimately, the maximum complete response rate by chemotherapy was 83.7% (92% in stage IE, II1E, 75% in stage II2E, IIIE, IV). Median overall survival was 47.4 months (84.7 months in stage IE, II1E, 32.5 months in stage II2E, IIIE, IV) and the 5-year survival rate was 46%. Bleeding as a complication occurred in 3 of 58 patients (5.6%) and these cases were controlled by embolization or conservative management. No perforation episode occurred and surgical intervention due to complication was not necessary. Organ preservation was possible in 57 of 58 patients (98%). The one gastrectomy was performed due to a partial clinical response to chemotherapy but the specimen showed pathologic CR. Multivariate analysis revealed that only IPI had a significant influence on survival.

CONCLUSIONS

Gastric lymphoma except MALToma can be managed effectively and safely with chemotherapy alone.

Surgery does not adversely affect survival in primary gastrointestinal lymphoma

OBJECTIVE

To evaluate the impact of surgery on gastrointestinal lymphoma.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried from 1973 to 2005.

RESULTS

A total of 17,222 cases of PGIL were identified. The overall incidence of PGIL was approximately 1.505 cases per 100,000. A significantly increasing incidence for PGIL was observed (APC = +4.67, P < 0.05). In the cases for which treatment data was available, resection occurred in roughly half of the patients. In univariate analysis, surgical extirpation did not improve survival (47 months vs. 76 months, P < 0.001), while radiation treatment improved median survival (77 months vs. 59 months, P < 0.001). Multivariate analysis revealed increasing age and male gender as independent predictors of decreased overall survival. Tumor location also was a significant predictor of outcome. Large B-cell lymphoma type PGIL had a poorer prognosis than marginal zone B-cell lymphoma. By multivariate analysis, surgery was not found to increase the risk of death (HR = 0.99).

CONCLUSIONS

No associated survival benefit for surgery in the treatment in gastrointestinal lymphoma was observed. Determination of lymphoma should preclude surgical resection. Nonetheless, inadvertent extirpative surgery or in association with perforation does not appear to increase mortality.

Non-Hodgkin's lymphoma of mucosa-associated lymphoid tissue

The concept of mucosa-associated lymphoid tissue (MALT) lymphomas was introduced by Isaacson and Wright [Cancer 1983; 52:1410-1416] in 1983. After more than 20 years of clinical research MALT lymphomas are now recognized as a distinct subtype of non-Hodgkin's lymphoma (NHL) with unique pathogenic, histological, and clinical features. Although this subtype of NHL occurs frequently, optimal management remains elusive. This manuscript reviews features of the clinical presentation, diagnosis, pathology, molecular characteristics, and management of both gastric and non-gastric MALT lymphoma.

Epstein-Barr virus involvement is a predictive factor for the resistance to chemoradiotherapy of gastric diffuse large B-cell lymphoma

Primary gastric diffuse large B-cell lymphomas are generally well controlled by non-surgical treatment with combination chemotherapy followed by radiotherapy. We have previously reported that over 90% of patients achieved complete response (CR) with this therapeutic strategy: three cycles of cyclophosphamide, adriamycin, vincristine and prednisone followed by radiotherapy (40.5 Gy). Although the CR rate was very high, some patients still showed resistance to this combination therapy. In order to clarify the factors related to therapy resistance, we examined the relationship between Epstein-Barr virus (EBV), which was examined using an in situ hybridization technique, and the patients' clinical courses. Out of the 50 patients, four were EBV positive; over half of lymphoma cells were positive for EBV by in situ hybridization. Of the three EBV-positive patients, two showed progressive disease and one achieved partial response (PR). Two of the patients died of disease progression. The other patient achieved CR, but the lymphoma recurred with distant metastasis in the cerebellum 3 months after remission. In the present study, eight patients did not achieve CR or they relapsed, four patients showed progressive disease, one patient achieved PR, and three patients achieved CR with recurrence. Therefore, half of these unfavorable patients were EBV positive. This finding strongly indicated that EBV-associated gastric diffuse large B-cell lymphomas frequently show resistance to standard chemoradiotherapy, although some other adverse factors remain unclear.

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.

Conservative management of gastric lymphoma: the treatment option of choice

The study was initiated to assess the safety and effectiveness of primary chemotherapy (CHT) followed by radiotherapy (RT) compared to surgery prior to CHT and/or RT in the management of localized gastric lymphoma. Ninety-two patients treated between 1985 and 2000 were included in a retrospective analysis. Sixty patients received primary CHT followed by extended field or involved field RT. Thirty-two patients had undergone primary surgery prior to referral and were treated with curative or consolidative CHT and/or RT. CHT was carried out according to the CHOP or COP-Blam protocol. Median age was 60 years (29-85). Forty patients had tumor stage IE, 36 II1E and 16 II2E (Musshoff classification). MALT histology was present in 25, diffuse large-cell in 62, lymphoplasmocytic in 4 cases and follicular histology in 1 case. Five-year disease-specific survival was 93% both after primary CHT and after primary surgery (P = 0.8). Five-year relapse-free survival was 91% and 93%, respectively (P = 0.7). No patient experienced gastric perforation or bleeding during CHT. Primary CHT of localized gastric lymphoma is associated with a low risk of treatment-related complications. Survival was similar compared to patients initially treated with surgery. To avoid long-term sequelae after gastric resection, primary CHT is recommended as standard initial treatment in localized gastric lymphoma.

Rationale for radiotherapy as a treatment modality in gastric mucosa-associated lymphoid tissue lymphoma

PURPOSE

To provide a rationale for the use of local radiotherapy (RT) for the treatment of low-grade mucosa-associated lymphoid tissue lymphoma of the stomach (MLS). In addition, the clinicopathologic characteristics were analyzed.

METHODS AND MATERIALS

The data of 72 patients with MLS, who underwent radical surgery between 1991 and 2001, were retrospectively reviewed. The depth of invasion into the gastric wall and the pattern of lymph node spread according to pathologic grade were analyzed.

RESULTS

The patient age range was 24-77 years (median, 51 years). Of the 72 patients, 45 (62.5%) had low-grade and 27 (37.5%) had high-grade MLS; 44 (61%) had Stage I and 28 (39%) Stage II. The tumors were confined to the mucosa or submucosa in 43 patients (58.9%). Sixty-seven percent of low-grade tumors and 48% of high-grade tumors were confined to the mucosa and submucosa. Lymph node involvement was identified in 24.4% of the low-grade MLS patients and 63.0% of the high-grade MLS patients. In the low-grade group, lymph node involvement was limited to the perigastric lymph nodes in all cases except for one. One patient with tumor infiltration beyond the serosa had extensive lymph node involvement into the paraaortic and omental lymph nodes.

CONCLUSION

Local RT to the stomach and regional lymphatics can be applied preferably instead of gastrectomy in patients with low-grade MLS who are negative for Helicobacter pylori or are refractory to anti-H. pylori therapy. The timing of RT and the exclusion criteria for RT should be determined in the future.

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

BACKGROUND

The usefulness of chemotherapy to treat gastric diffuse large B-cell lymphomas (DLBCL) is well known. Whether or not chemotherapy should be performed as the only treatment or after surgical resection is debated. The aim of this study was to compare two strategies: surgical resection plus chemotherapy versus chemotherapy alone.

PATIENTS AND METHODS

Between January 1988 and December 1996, 58 patients included in the trials promoted by the Groupe d'Etude des Lymphomes de l'Adulte (GELA) (LNH-87 and LNH-93) received chemotherapy and 48 included in the protocol of the Groupe d'Etude des Lymphomes Digestifs (GELD) underwent surgical resection followed by chemotherapy. They all presented with localized DLBCL (stage IE and IIE according to the Ann Arbor classification). From the GELA group, seven patients received additional radiotherapy. Gastrectomy was total in 27 of the 48 patients in the GELD group. In both groups chemotherapy included anthracyclin and alkylating agents. Chemotherapy was more intensive in the GELA group than in the GELD group.

RESULTS

In the GELA and the GELD groups, distribution according to sex ratio, age (>60 or < or = 60 years), ECOG performance status (> or = 2 or <2) and staging (IE or IIE) was similar. Univariate analysis comparing prognostic factors in both groups showed significant differences: serum lactate dehydrogenase level above normal (28.6% versus 2.4%, P = 0.001), tumor size >10 cm (28.6% versus 12.5%, P = 0.04), patients with International Prognostic Index (IPI) >1 (21.4% versus 11.1%, P = 0.168) and 5-year survival (79% versus 90%, P = 0.03). Multivariate analysis of prognostic factors with a Cox model showed that IPI was the only independent prognostic factor (odds ratio 3, P = 0.03). Consequently, patients with IPI 0-1 were selected for comparison between the GELA group (44 patients) and the GELD group (40 patients). There was no significant difference between the two groups. Median follow-up was 59 months (range 3-128). Estimates of 5-year survival rates and event-free survival rates were 90.5% versus 91.1% (P = 0.303) and 85.9% versus 91.6% (P = 0.187), respectively. In the GELA group, seven of 44 patients died: five from a lymphoma-unrelated cause and two from tumor progression. In the GELD group, four of 40 patients died: two of unrelated causes and two from tumor progression.

CONCLUSIONS

This study shows that in localized gastric DLBCL with IPI 0-1, a similar 5-year survival rate (>90%) is to be expected with either surgery plus chemotherapy or chemotherapy alone.

Primary gastrointestinal non-Hodgkin's lymphoma: treatment outcome

Primary gastrointestinal lymphoma is the most common extranodal presentation of non-Hodgkin's lymphoma. In this retrospective study, all cases of primary gastrointestinal lymphoma registered at Kuwait Cancer Control Center between January 1992 and December 2001 were reviewed. Patients were diagnosed through an endoscopic biopsy or exploratory laparotomy. Staging procedures included computed axial tomography scan, bone marrow biopsy, barium and follow-through study, as well as routine chemistry (including lactate dehydrogenase) and hemography. There were 46 patients (30 men and 16 women); ages ranged from 16 to 82 years (median age, 43.6 years). The most common site of involvement was the stomach (70%), and the most common histology was large B cell. At least 50% of cases underwent primary radical surgery, and the majority of patients received subsequent chemotherapy and/or local radiation therapy. Chemotherapy consisted of the CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) regimen for large B-cell histology and CVP (cyclophosphamide/vincristine/prednisone) or oral alkylating agents for low-grade histology. Of this cohort, only 12 cases (26%) have had local or distant relapse. Disease-free survival rates for low-grade and high-grade non-Hodgkin's lymphoma were 64% and 81%, respectively. Primary gastrointestinal lymphoma is a potentially curable malignancy.

External beam radiation therapy in the treatment of patients with extranodal stage IA non-Hodgkin's lymphoma

The purpose of this report was to study the results of external beam radiotherapy for patients with extranodal stage IA non-Hodgkin's lymphoma (NHL). A retrospective review was carried out on 27 patients seen between 1984 and 1998 with stage IA NHL of extranodal sites, and followed up for a minimum of 1 year. Sites involved included eye/orbit (seven), parotid (five), breast (four), Waldeyer ring (four), thyroid (three), other head and neck (two), stomach (one), and prostate (one). All patients had biopsy-proven disease and underwent staging workup to rule out other sites of disease. Histologic analysis revealed 16 patients with low-grade NHL, 9 with intermediate-grade, and 2 with high-grade. Ten patients received chemotherapy before radiation therapy, and eight of them had a complete response. The remaining 17 patients were treated with external beam radiation therapy alone. Radiation was directed to the involved field at 1.8 Gy to 2.0 Gy per fraction to a median dose of 40 Gy (range: 20-50.4 Gy). The median patient age was 71 years (range: 39-85 years); 55% were female, and 45% were male. A complete response was attained in all 27 patients after radiation therapy. There were five failures (all in uninvolved distant sites), and two deaths during the follow-up. Median disease free survival (DFS) and overall survival (OS) have not been reached. The 5-year DFS and OS are 85% and 94%, respectively. Older age at presentation showed a trend toward worse outcome (p = 0.07), but because of the relatively few events, other factors (radiation dose, grade of disease, sex, or the use of chemotherapy) showed no statistical differences among the patients. External beam radiation therapy is a highly effective treatment for stage IA NHL found in extranodal sites.

Primary Malignant Large Bowel Lymphoma

Primary gastrointestinal (GI) lymphomas constitute about 5.6 per cent of total gut neoplasms. The involvement of large bowel as primary site is all the more rare. We carried out this study to evaluate the prevalence and clinicopathological features of large bowel lymphoma at Gujarat Cancer and Research Institute and to compare our findings with published literature. We carried out a retrospective analysis of the records of histologically diagnosed cases of large bowel lymphoma over a 5 year period. A total of eight cases of large bowel lymphoma were identified compared with 57 cases of primary GI lymphoma of other sites, constituting about 12.3 per cent (eight of 65) of all GI lymphomas. Peak incidence was observed in the second decade of life with a mean age at presentation of 30.6 years (range 4–70 years). A male-to-female ratio of one to two was observed. The most commonly presenting feature was altered bowel habits and diarrhea in more than 50 per cent of the patients. One patient presented with acute intestinal obstruction. Diagnosis was made by colonoscopic biopsies in all but one case. All of the patients were treated with surgery and adjuvant chemotherapy. A 4-year disease-free survival of 66.7 per cent was observed (95% confidence interval 0.05–1.28). There was no significant difference in survival in patients with high-grade versus low-grade tumors (50% vs 66.7%; P = 0.88) and stage of disease (75% vs 50%; P = 0.45) in stage II and III respectively. We conclude that large bowel lymphoma is a curable disease if treated aggressively. We suggest that all patients should be treated by primary surgery and should receive adjuvant chemotherapy.

Primary gastrointestinal B-cell lymphoma. A clincopathological and immunohistochemical study of 61 cases with an evaluation of prognostic parameters

We hereby present a retrospective clinicopathological and immunohistochemical study of surgically resected primary gastrointestinal (GI) lymphoma with an analysis of parameters of potential prognostic relevance. From a larger series of 144 cases of primary GI lymphomas, we chose 61 cases with sufficient clinical follow-up (mean 60, range 1-219 months), classified either as extranodal marginal zone B-cell lymphoma of MALT type (MALT lymphoma) or diffuse large B-cell lymphoma (DLBCL), after having excluded other subtypes. In addition to conventional clinical and morphological parameters, the expression levels of Ki-67 (MIB-1), bcl-2 and p53 were evaluated for prognostic significance. Twenty-one (34.4%) cases were classified as pure low grade marginal zone B-cell lymphoma of MALT type, 12 (19.7%) cases as low grade MALT lymphoma with a high grade component (mixed type), and 28 (45.9%) cases as primary extranodal DLBCL. Most of the lymphomas (53/61; 86.9%) were localized in the stomach, 3 (4.9%) in the small bowel, 3 (4.9%) multifocal in both stomach and small intestine and 2 (3.3%) in the large bowel. MIB-1 expression in more than 30% of tumor cells was detected in 42 (68.6%), bcl-2 expression in 20 (32.8%) and p53 accumulation in more than 10% of neoplastic cells in 16 (26.2%) lymphomas. Both high Ki-67 expression and p53 accumulation were more prevalent in the DLBCL. 30 (49%) patients showed lymph node involvement at surgery, 14 (23%) patients suffered tumor recurrence, and 24 (38.5%) died during the follow-up period. Tumor recurrence occurred primarily in patients who had presented lymph node involvement (9/14, 64.3%). The 5-year survival rate was 66.1% for all patients. Important prognostic factors for overall survival were tumor stage (p < .004) and p53 accumulation (p < .05) in univariate analysis, and tumor stage in multivariate analysis (p < .001). Although p53 accumulation did not reach statistical significance in our small study group, it may be both important in the transformation of low grade MALT lymphoma and an indicator for aggressive behavior in high grade tumors.

Chemotherapy alone versus surgery followed by chemotherapy for stage I/IIE large-cell lymphoma of the stomach

The optimal treatment of localized large-cell lymphoma of the stomach remains controversial. In particular, the role of surgical resection of the primary tumor needs to be clearly defined. We have reviewed all patients with a diagnosis of gastric lymphoma and treated in our institutions between 1988 and 1998. Patients fulfilling the following criteria were included in this study: (1) histologically proven large-cell lymphoma of the stomach; (2) adequate pathological materials and complete clinical information for analysis; (3) clinical stage I/II disease according to the Musshoff modification of Ann Arbor system; and (4) received primary chemotherapy alone with anthracycline- or anthracenedione-containing regimens (group A) or curative surgery followed by adjuvant chemotherapy (group B). There were 38 and 21 patients in group A and group B, respectively. All pertinent clinicopathologic features were similar between the two groups of patients, except that patients of group A had significantly more stage II-2 disease (P = 0.004). Of group A, among 36 patients who could be evaluated for response to chemotherapy, there were 29 complete and 1 partial responses, with an overall response rate of 83.3% (95% CI, 71.1-95.5%). The projected 5-year relapse-free survival (RFS) and overall survival (OS) were 86.0% (95% CI, 73.3-98.7%) and 72.6% (95% CI, 57.0-88.2%), respectively. On the other hand, the projected 5-year RFS and OS of group B were 77.9% (95% CI, 58.0-97.8%) and 77.8% (95% CI, 57.9-97. 7%), respectively, not significantly different from that of group A. Our data suggest that systemic chemotherapy alone may be a reasonable alternative treatment for stage I/II large-cell lymphoma of the stomach. Resection of the primary tumor before systemic chemotherapy does not appear to improve the cure rate of this group of patients.

Chemotherapy alone versus surgery followed by chemotherapy for stage I/IIE large-cell lymphoma of the stomach

The optimal treatment of localized large-cell lymphoma of the stomach remains controversial. In particular, the role of surgical resection of the primary tumor needs to be clearly defined. We have reviewed all patients with a diagnosis of gastric lymphoma and treated in our institutions between 1988 and 1998. Patients fulfilling the following criteria were included in this study: (1) histologically proven large-cell lymphoma of the stomach; (2) adequate pathological materials and complete clinical information for analysis; (3) clinical stage I/II disease according to the Musshoff modification of Ann Arbor system; and (4) received primary chemotherapy alone with anthracycline- or anthracenedione-containing regimens (group A) or curative surgery followed by adjuvant chemotherapy (group B). There were 38 and 21 patients in group A and group B, respectively. All pertinent clinicopathologic features were similar between the two groups of patients, except that patients of group A had significantly more stage II-2 disease (P = 0.004). Of group A, among 36 patients who could be evaluated for response to chemotherapy, there were 29 complete and 1 partial responses, with an overall response rate of 83.3% (95% CI, 71.1-95.5%). The projected 5-year relapse-free survival (RFS) and overall survival (OS) were 86.0% (95% CI, 73.3-98.7%) and 72.6% (95% CI, 57.0-88.2%), respectively. On the other hand, the projected 5-year RFS and OS of group B were 77.9% (95% CI, 58.0-97.8%) and 77.8% (95% CI, 57.9-97. 7%), respectively, not significantly different from that of group A. Our data suggest that systemic chemotherapy alone may be a reasonable alternative treatment for stage I/II large-cell lymphoma of the stomach. Resection of the primary tumor before systemic chemotherapy does not appear to improve the cure rate of this group of patients.

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.

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.

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.

Mucosa-associated lymphoid tissue lymphoma of the stomach: long term outcome after local treatment

BACKGROUND

Although antibiotic therapy is emerging as effective initial treatment for patients with gastric lymphoma of mucosa-associated lymphoid tissue (MALT), there is a subset of patients for whom antibiotics are ineffective or inappropriate. Surgical resection can be curative, but total gastrectomy may be required for the eradication of all disease. To identify the optimal nonantibiotic therapy for early stage gastric MALT lymphoma, the authors retrospectively evaluated the Massachusetts General Hospital experience with gastric MALT lymphoma.

METHODS

Disease patterns and treatment outcomes were retrospectively analyzed in data from 21 consecutive patients with gastric MALT lymphoma who were treated between 1978 and 1995 at the Massachusetts General Hospital.

RESULTS

Sixteen patients were Stage IE, and 5 were in higher stages. Treatment consisted of resection with or without radiation or chemotherapy (14 patients), radiation alone (4 patients), or radiation plus chemotherapy (2 patients). Thirteen Stage IE patients received local therapy only. The 10-year actuarial relapse free survival rate for Stage IE patients was 93%, with 1 relapse among 15 treated patients. Because the patient who relapsed was treated successfully with chemotherapy, the 10-year cancer free survival was 100%. Overall survival for Stage IE patients was 93% at 5 years and 58% at 10 years, with no deaths from lymphoma.

CONCLUSIONS

These data indicate that a high probability of long term remission can be achieved with only local treatment of patients with Stage I gastric MALT lymphoma. Preliminary results suggest that radiation therapy is well tolerated and effective and may well be the optimal nonantibiotic treatment for patients with localized gastric MALT lymphoma.

The role of radical gastrectomy with systematic lymphadenectomy for the diagnosis and treatment of primary gastric lymphoma

OBJECTIVE

We evaluated the therapeutic efficacy of radical gastrectomy for primary B-cell lymphoma of the stomach and attempted to identify patients who could be adequately treated with surgery alone.

SUMMARY BACKGROUND DATA

Several recent gastric lymphoma reports have discussed the therapeutic benefits of various treatment strategies for stage IE and IIE lymphoma. However, few studies have been based on patients accurately staged by systematic lymphadenectomy with subsequent pathologic examination.

METHODS

A retrospective study was performed to evaluate the survival and biologic behavior of lesions in 60 patients with gastric lymphoma who were treated by radical gastrectomy alone. Tumors were classified according to the histopathologic concept of mucosa-associated lymphoid tissue (MALT)-derived lymphoma.

RESULTS

A low histopathologic grade was associated with a significantly lower incidence of nodal metastasis (p = 0.07) and less extensive infiltration of the gastric wall (p < 0.005) despite larger tumor size. A 5-year survival rate of >95% was attained with surgery alone for MALT lymphoma and for true stage IE lymphoma diagnosed by pathologic examination of up to N2 lymph nodes routinely performed after radical gastrectomy.

CONCLUSIONS

Surgery alone is adequate treatment for stage IE or pure MALT lymphoma, provided that the staging is performed after radical gastrectomy.

Total gastrectomy for primary gastric lymphoma at stages IE and IIE: a prospective study of fifty cases

BACKGROUND

Treatment of primary gastric lymphoma at Ann Arbor stage IE or IIE is controversial. Randomized trials to compare various modalities are not feasible because of the rarity of this disease. We have prospectively treated patients by means of primary surgery to achieve complete local control and accurate staging.

METHODS

Between 1987 and 1995, 50 patients with stage IE or IIE gastric lymphoma were prospectively treated by total gastrectomy with systematic lymphadenectomy. When nodal metastases were histologically confirmed or the resection was noncurative, chemotherapy was added. Intragastric tumor spread, lymph node metastasis, and treatment results were examined.

RESULTS

Resection was potentially curative in 48 cases. There were no operative deaths. Histologically, the middle third of the stomach was most frequently involved. Either the proximal two thirds or the entire stomach was involved in 62% of all patients. Lymph node metastasis was demonstrated in 25 patients. The deeper the tumor invasion in the gastric wall, the more frequent and distant the nodal involvement. The 5-year survival rate was 85.6%, excluding one death caused by heart disease.

CONCLUSIONS

Primary surgery followed by chemotherapy in selected cases is an appropriate strategy for primary gastric lymphoma in patients in whom this regimen can be safely carried out.

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 gastrointestinal non-Hodgkin's lymphoma. A population based study in central Finland in 1975-1993

Gastrointestinal lymphomas have been uncommon, but the frequency of their predisposing conditions is increasing. The objective of the present study is to determine the frequency of gastrointestinal lymphomas in the area of central Finland as well as the influence of clinical features and therapeutical approaches on the survival of these patients. All samples of gastrointestinal non-Hodgkin's lymphomas diagnosed of patients living in the province of central Finland in 1975-1993 were re-examined. In central Finland the mean annual frequency of new gastrointestinal lymphomas was 10/1000000 in 1975-1984 and 16.0/1000000 in 1985-1993. The total incidence of gastrointestinal lymphomas in Finland adjusted for age to the world standard population was 12.5/1000000 in 1992. Two patients with peripheric T-cell lymphoma had a coeliac disease. Other predisposing conditions were not found. The stage of distribution of the lymphoma (p < 0.01) and radicality of the surgery (p < 0.01) were the most influencing factors on the survival of these patients. In conclusion the early distinction of gastrointestinal lymphomas is vital because of an increasing frequency of predisposing factors and a better prognosis due to new combination therapies.

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.

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.