Treatment of gastrointestinal diffuse large B cell lymphoma in China: a 10-year retrospective study of 114 cases

Advances in diagnosis, treatment and prognostic factors of gastrointestinal DLBCL

Gastrointestinal diffuse large B-cell lymphoma (GI-DLBCL) is an extremely aggressive form of B-cell non-Hodgkin lymphoma (BNHL) which has complex histological characteristics and manifests a high degree of heterogeneity in terms of clinical, morphological, immunological, and genetic features. GI-DLBCL mainly spreads by infiltrating neighboring lymph nodes, and common gastrointestinal complications (GICS) such as obstruction, perforation, or bleeding, frequently arise during the progression of the disease, posing significant challenges in both diagnosing and treating the condition. Meanwhile, the incidence of GI-DLBCL has been gradually increasing in recent years, and its strong invasiveness makes it prone to being misdiagnosed or completely missed. In clinical practice, over half of the patients diagnosed with the disease are in stage III or stage IV. What makes it worse is that certain patients may not exhibit a favorable response to chemotherapy. All these lead to intricacies in management of this disease. Unfortunately, there is currently no large prospective study or evidence-based medical evidence to provide clear guidance on treatment decisions for this specific type of lymphoma. Neither do physicians have a consensus regarding the optimal approach to address this condition. Recent studies have identified the presence of various prognostic factors that significantly impact survival in GI-DLBCL, which demonstrates the unique particularity of GI-DLBCL, and could help optimize the clinical decision.

Extranodal Diffuse Large B-Cell Lymphoma of the Small Bowel in Female Patient Causing Intestinal Obstruction: A Case Report

Diffuse large B cell lymphoma is the most common extranodal non-Hodgkin lymphoma of the small intestine accounting for more than 50% of cases. Forty percent of these cases initially present with small bowel obstruction. Therefore, the diagnosis is usually established after surgery for bowel obstruction. The treatment is then continued with a certain chemotherapy regimens. We present a case of a 46-years-old female patient with signs of small bowel obstruction due to previously undiagnosed diffuse large B-cell lymphoma. Postoperatively, the patient was treated with 7 cycles of R-CHOP protocol and complete response was achieved in the short follow-up period.

Primary gastrointestinal diffuse large B-cell lymphoma: A prospective study from South India

Background

Gastrointestinal tract (GIT) is the most common extranodal site for non-Hodgkin's lymphoma (NHL) and constitutes about 10%-15% of all NHL. This was a prospective study to evaluate the epidemiological, clinicopathological characteristics, and treatment outcome of primary GIT diffuse large B-cell lymphoma (PGIL).

Materials and Methods

Newly diagnosed patients of PGIL with DLBCL histology were eligible. Lugano staging system was used. All patients were treated with prephase treatment (1 mg vincristine and 100 mg prednisolone) followed by CHOP-based chemotherapy (with or without rituximab) as definitive treatment.

Results

A total of 21 patients of PGIL were diagnosed. The median age was 46 years (range: 27-69 years) with male:female ratio of 2:1. Dull aching abdominal pain was the most common presenting complaint. Stomach was the most common site involved (52.4%, n = 11) followed by the colon (23.8%, n = 5). The estimated median survival in patients with Stage IV disease was significantly lower as compared to patients with localized disease (Stage I and II) (6.23 months vs. 23.4 months; P = 0.04). Patients, who did not achieve complete response (CR), had 15.5 times higher risk of death, as compared to those who achieved CR (P = 0.01).

Conclusions

Stomach was the most common site for PGIL. Localized disease and CR after first-line chemotherapy were associated with better survival. A higher cost of rituximab was the prohibitive factor for cure in these patients.

Nomogram for Predicting the Overall Survival of Adult Patients With Primary Gastrointestinal Diffuse Large B Cell Lymphoma: A SEER- Based Study

Background: The aim of this study was to establish a precise prognostic model, based on significant clinical parameters, for predicting the overall survival (OS) of adult patients with primary gastrointestinal diffuse large B cell lymphoma (GI DLBCL).

Materials and Methods: The data of 7,121 GI DLBCL patients, diagnosed between 1997 and 2015, were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. These patients were randomly divided into two sequential cohorts: training (n = 5,697) set and validation (n = 1,424) set. ROC methodology and calibration curves were explicitly used to evaluate the predictive performance of nomogram.

Results: The median OS in the training cohort was 76 months (1–239 months), and 3, 5, and 10-year OS rates were 60.3, 53.9, and 39.5%, respectively. Age at diagnosis, Ann Arbor stage, and marital status were important clinical predictors of OS. These characteristics were used to build a nomogram. The AUC of the nomogram for predicting 3, 5, and 10-year OS were 0.669, 0.692, and 0.740, respectively. All RUC and calibration curves revealed good accuracy in predicting prognosis of GI DLBCL.

Conclusion: In summary, the established nomogram was validated to predict OS for adult patients with GI DLBCL. This predictive model could help clinicians identify high-risk patients to improve their prognosis.

Prognostic impact of PD-L1 expression in primary gastric and intestinal diffuse large B-cell lymphoma

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease and the most common gastrointestinal lymphoma. The prognostic/predictive indicators among patients with gastric and intestinal DLBCL (giDLBCL) are controversial beyond their anatomical sites. We compared giDLBCL cases and investigated the clinical utility of newly emerging indicators with an emphasis on programmed cell death ligand 1 (PD-L1) expression.

METHODS

This retrospective study included 174 patients with primary gastric (n = 129) or intestinal (n = 45) DLBCL treated with rituximab-containing chemotherapy between 1995 and 2018.

RESULTS

Compared with gastric DLBCL (gDLBCL) cases, patients with intestinal DLBCL (iDLBCL) had a significantly higher rate of advanced Lugano stage (71% vs 37%, P < 0.001), perforation (13% vs. 0.8%, P = 0.001), PD-L1 expression on microenvironment immune cells (miPD-L1, 70% vs 46%, P = 0.008), CD10 positivity (47% vs 28%, P = 0.027), and CD5 positivity (9% vs 1.6%, P = 0.040). The iDLBCL patients showed significantly worse progression-free survival (PFS) and overall survival (OS) than gDLBCL cases (P = 0.0338 and P = 0.0077, respectively). PD-L1 expression on tumor cells was detected in only 3 (2%) of 174 cases with early relapse and/or an aggressive clinical course; whereas, miPD-L1-positive cases had significantly better OS than the miPD-L1-negative gDLBCL and iDLBCL cases (P = 0.0281 and P = 0.0061, respectively). Multivariate analysis revealed that miPD-L1 negativity (P = 0.030) was an independent adverse prognostic factor for OS in giDLBCL.

CONCLUSIONS

The anatomical site of disease did not influence outcome in giDLBCL cases treated with rituximab-containing chemotherapy; while, miPD-L1 expression had a favorable impact on the outcome.

Evaluation of 22 Primary Gastrointestinal Lymphoma Patients

Objective

Primary gastrointestinal non-hodgkin lymphomas (PGI-NHL) are uncommon diseases with treatment modalities including chemotherapy, surgery, and radiotherapy. Our aim is to analyze the demographic and clinical features and treatment results of PGI-NHL.

Materials and Methods

286 patients diagnosed with lymphoma who referred to Ataturk University Medical Faculty Hospital between July 2001 and April 2014 were surveyed retrospectively and 22 (7.6%) PGI-NHL cases whose primary lesions were in gastrointestinal system were included.

Results

Mean age was 47 (min.25-max.77) and 14 (63.6%) of them were men. The origin was determined as small intestines (50%), stomach (31.8%) and colon (18.2%), respectively. The most common complaint and pathologic subtype were abdominal pain (68.2%) and diffuse large B cell lymphoma (86.4%), respectively. The Lugano Classification was as follows: stage 1 (18.2%), stage 2 (59.1%), and stage 4 (22.7%). Surgery and chemotherapy were administered to 40.9% of patients. Complete and partial response and disease progression were established in 72.1%, 4.5% and 13.6% of the patients, respectively. Mean survival time was 99.6±16 months. Mean overall survival time was determined significantly longer in small bowel group than gastric group (119±15 vs. 50±24 months) (p=0.039). Age, gender, Eastern Cooperative Oncology Group performance status, International Prognostic Index, stage, histological type, tumor size, LDH level, albumin level, Hemoglobin level and treatment options were not associated with survival.

Conclusion

Demographic and clinical characteristics of our series were similar with Middle Eastern and African countries. Optimal treatment options or prognostic factors for PGI-NHL are not clear. There is a need for randomized prospective studies including large number of patients and long follow-up period.

Primary extra-nodal diffuse large B-cell lymphoma: A prognostic analysis of 141 patients

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of lymphoma. Approximately 40% of DBLCL originates from extra-nodal sites, but the diversity of clinical presentations and the genetic and molecular alterations indicate that extra-nodal DLBCLs may be distinct disease entities. The aim of the present study was to highlight the various aspects of primary extra-nodal DLBCL (PE-DLBCL) based on a single center cohort. The data from 141 patients with PE-DLBCL treated at Peking Union Medical College Hospital were retrospectively evaluated. The primary extra-nodal sites involved were the gastrointestinal tract (n=42), central nervous system (CNS; n=38), breast (n=19), adrenal gland (n=15), female genital system (FGS; n=12), thyroid (n=8) and bone (n=7). The median overall survival rate was 28 months (range, 1–116). Multivariate analysis demonstrated that an International Prognostic Index (IPI) ≤2 (P=0.049), complete remission (CR) achieved following first-line therapy (P=0.001) and chemotherapy combined with rituximab (P<0.001) were positive prognostic factors. Patients with DLBCL with primary adrenal gland or female genital system (FGS) involvement exhibited a significantly higher risk of CNS recurrence (P<0.05). Rituximab treatment may have reduced the likelihood of CNS recurrence (P=0.005), whereas prophylaxis with intrathecal injection alone was not sufficient for prevention (P>0.05). In conclusion, IPI >2 and the lack of a CR following first-line therapy were independent prognostic risk factors for PE-DLBCL. Patients with primary adrenal gland or FGS involvement exhibited a higher risk of CNS relapse. Rituximab had a positive impact on the survival of patients with PE-DLBCL, also reducing the likelihood of CNS relapse.

Transcatheter Arterial Embolization for Gastrointestinal Bleeding Secondary to Gastrointestinal Lymphoma

PURPOSE

To evaluate the effectiveness of transcatheter arterial embolization (TAE) for gastrointestinal (GI) bleeding caused by GI lymphoma.

MATERIALS AND METHODS

The medical records of 11 patients who underwent TAE for GI bleeding caused by GI lymphoma between 2001 and 2015 were reviewed retrospectively.

RESULTS

A total of 20 TAE procedures were performed. On angiography, contrast extravasation, and both contrast extravasation and tumor staining were seen in 95 % (19/20) and 5 % (1/20) of the procedures, respectively. The most frequently embolized arteries were jejunal (n = 13) and ileal (n = 5) branches. Technical and clinical success rates were 100 % (20/20) and 27 % (3/11), respectively. The causes of clinical failure in eight patients were rebleeding at new sites. In four patients who underwent repeat angiography, the bleeding focus was new each time. Three patients underwent small bowel resection due to rebleeding after one (n = 2) or four (n = 1) times of TAEs. Another two patients underwent small bowel resection due to small bowel ischemia/perforation after three or four times of TAEs. The 30-day mortality rate was 18 % due to hypovolemic shock (n = 1) and multiorgan failure (n = 1).

CONCLUSION

Angiogram with TAE shows limited therapeutic efficacy to manage GI lymphoma-related bleeding due to high rebleeding at new sites. Although TAE can be an initial hemostatic measure, surgery should be considered for rebleeding due to possible bowel ischemic complication after repeated TAE procedures.

Primary Gastrointestinal Lymphoma: A Retrospective Multicenter Clinical Study of 415 Cases in Chinese Province of Guangdong and a Systematic Review Containing 5075 Chinese Patients

Primary gastrointestinal lymphoma (PGIL) is a rare malignant tumor without standard diagnosis and treatment methods. This study is aimed to systematically analyze its clinical characteristics and draw out an appropriate flow chart of diagnosis and treatment process for PGIL in China.This study retrospectively analyzed the clinicopathological characteristics, diagnostic approaches, prognostic factors, and therapeutic modalities in 415 cases of PGIL in Chinese province of Guangdong. A systematic review was conducted in 118 studies containing 5075 patients to further identify clinical manifestations and mortalities of therapeutic modalities.The most common clinical presentations were abdominal pain and bloody stools. Endoscopic biopsy was an important diagnostic means, and usually more than once to make a definite diagnosis. Retrospective multicenter clinical study showed that younger onset age (<60 years), female, one region involved, one lesion, early stage, International Prognostic Index (IPI ≤1), normal lactate dehydrogenase (LDH), normal albumin, and nonemergency operation were significant prognostic factors for B-cell lymphoma; non-B symptom, tumor restricted to gastric or ileocecal region, one lesion, performance status (PS ≤1), normal LDH, and nonsurgery alone were significant prognostic factors for T-cell lymphoma. Site of origin and IPI were independent prognostic factors for B-cell lymphoma; PS was the independent prognostic factor for T-cell lymphoma. And T-cell lymphoma had worse overall survival (OS) and progression-free survival (PFS) than B-cell lymphoma. Among different therapeutic modalities, chemotherapy alone or combined with surgery showed better OS and PFS than surgery alone for diffuse large B-cell lymphoma (DLBCL) of stage I/II E and T-cell lymphoma. For DLBCL of stage III E/IV and mucosa-associated lymphoid tissue lymphoma, OS and PFS did not differ among different therapeutic groups. In meta-analysis, surgery plus chemotherapy showed lowest mortality.Chemotherapy alone or combined with surgery may be the first-line treatment for DLBCL of stage I/II E and T-cell lymphoma. A flow chart of diagnosis and treatment process for PGIL was approximately drew out.

Localized primary gastrointestinal diffuse large B cell lymphoma received a surgical approach: an analysis of prognostic factors and comparison of staging systems in 101 patients from a single institution

Background

Diffuse large B cell lymphoma (DLBCL) represents the most common histological subtype of primary gastrointestinal lymphoma and is a heterogeneous group of disease. Prognostic characterization of individual patients is an essential prerequisite for a proper risk-based therapeutic choice.

Methods

Clinical and pathological prognostic factors were identified, and predictive value of four previously described prognostic systems were assessed in 101 primary gastrointestinal DLBCL (PG-DLBCL) patients with localized disease, including Ann Arbor staging with Musshoff modification, International Prognostic Index (IPI), Lugano classification, and Paris staging system.

Results

Univariate factors correlated with inferior survival time were clinical parameters [age >60 years old, multiple extranodal/gastrointestinal involvement, elevated serum lactate dehydrogenase and β2-microglobulin, and decreased serum albumin], as well as pathological parameters (invasion depth beyond serosa, involvement of regional lymph node or adjacent tissue, Ki-67 index, and Bcl-2 expression). Major independent variables of adverse outcome indicated by multivariate analysis were multiple gastrointestinal involvement. In patients unfit for Rituximab but received surgery, radical surgery significantly prolonged the survival time, comparing with alleviative surgery. Addition of Rituximab could overcome the negative prognostic effect of alleviative surgery. Among the four prognostic systems, IPI and Lugano classification clearly separated patients into different risk groups. IPI was able to further stratify the early-stage patients of Lugano classification into groups with distinct prognosis.

Conclusions

Radical surgery might be proposed for the patients unfit for Rituximab treatment, and a combination of clinical and pathological staging systems was more helpful to predict the disease outcome of PG-DLBCL patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-015-0668-5) contains supplementary material, which is available to authorized users.

Overexpression of DNA methyltransferase 1 as a negative independent prognostic factor in primary gastrointestinal diffuse large B-cell lymphoma treated with CHOP-like regimen and rituximab

The aims of the present study were to elucidate the transcript levels of DNA methyltransferase (DNMT)1, DNMT3a and DNMT3b by quantitative polymerase chain reaction in patients with primary gastrointestinal diffuse large B-cell lymphoma (PGI-DLBCL), and determine the association of their expression with the clinical parameters and prognostic values of the disease. The results revealed that the expression of DNMT1 in patients with PGI-DLBCL was significantly higher than that in healthy controls (P=0.04), while the expression of DNMT3a and DNMT3b were significantly lower (P<0.001 and P=0.001, respectively). The increased expression of DNMT1 was significantly correlated with shorter overall survival and progression-free survival rates (P=0.018 and P=0.008, respectively). The multivariate analysis demonstrated that the level of DNMT1 was an independent prognostic factor. In conclusion, DNMT1 was identified to be an independent prognostic factor for predicting the survival of patients with PGI-DLBCL; this suggests that it could be used as a marker to indicate the prognosis of PGI-DLBCL.