Radiotherapy for 41 patients with stages I and II MALT lymphoma: a retrospective study

Reduced-dose radiotherapy for stage IE gastric mucosa-associated lymphoid tissue lymphoma: a multi-institutional prospective study (KROG 16-18)

PURPOSE

Definitive radiotherapy (RT) of 30 Gy or higher is commonly recommended to treat Helicobacter pylori-independent gastric mucosa-associated lymphoid tissue (MALT) lymphoma with an excellent disease control rate. However, the efficacy of reduced-dose RT has not yet been evaluated in a prospective cohort study. This multi-institutional study aimed to determine the role of reduced-dose RT in the treatment of stage IE gastric MALT lymphoma.

METHODS

Between March 2017 and June 2022, 62 patients with histologically confirmed stage IE gastric MALT lymphoma without evidence of H. pylori infection were enrolled. The patients were treated with reduced-dose RT at a total dose of 24-25.5 Gy to the entire stomach. The response to therapy was evaluated by endoscopy with a biopsy of suspicious lesions if necessary. The primary endpoints were 6-month complete remission (CR) and local failure-free survival (LFFS).

RESULTS

Among 62 patients, 32 (51.6%) were previously treated for H. pylori eradication. Radiotherapy was delivered using 3D-conformal (n=20, 32.3%) or intensity-modulated radiotherapy (n=42, 67.7%). The median follow-up duration was 34.5 months (range, 9.6-68.8 months). The 6-month CR rate was 96.7%. The 5-year LFFS and progression-free survival rates were 92.0% and 90.4%, respectively. None of the patients experienced grade 3 or worse acute toxicities, and grade 2 acute toxicities were reported in 17 patients (27.4%).

CONCLUSION

Reduced-dose RT exhibited excellent response rates in stage IE gastric MALT lymphoma, comparable to historical controls of standard dose (≥ 30 Gy) radiotherapy, with a minimal toxicity profile. Current prospective evidence strongly supports the use of definitive radiotherapy (24-25.5 Gy) for the treatment of H. pylori-independent stage IE gastric MALT lymphoma.

Radiation Therapy Dose for Limited-stage Extranodal Marginal Zone Lymphomas of the Mucosa-associated Lymphoid Tissues of the Stomach: A Meta-analysis

PURPOSE

To compare the outcomes of 2 standard radiation therapy (RT) doses for limited-stage gastric extranodal marginal zone lymphoma (EMZL) of the mucosa-associated lymphoid tissues.

METHODS AND MATERIALS

A database search was performed to identify articles published from database inception to August 31, 2023. Based on the current standard dose of 24.0 to 30.0 Gy, doses of approximately 30.0 Gy were classified as standard dose (SD), while those of approximately 24.0 Gy were classified as low dose (LD). Pooled estimates of the complete remission (CR) and local recurrence (LR) rates were calculated and compared.

RESULTS

Data from 1072 patients across 30 included studies were analyzed. SD was used in 28 studies (n = 987), while LD was used in 6 studies (n = 85), and both regimens were used in 4 studies. In all included studies, the CR rate was 0.96 (95% CI, 0.94-0.97), and the LR rate was 0.05 (95% CI, 0.04-0.06), showing no significant between-study heterogeneity (τ2 = 0 and I2 = 0% for both; P = .8447 and .9998, respectively). SD and LD resulted in no significant differences in the CR rates (0.96 [95% CI, 0.94-0.97] vs 0.96 [95% CI, 0.89-0.99]; P = .9174) or LR rates (0.05 [95% CI, 0.04-0.06] vs 0.03 [95% CI, 0.01-0.10]; P = .5495).

CONCLUSIONS

Both the SD and LD groups achieved excellent CR and LR rates. These results indicate that the RT dose for limited-stage gastric EMZL may be safely de-escalated without compromising local tumor control.

Definitive Radiotherapy for Stage I Gastric Mucosa-Associated Lymphoid Tissue Lymphoma: A Retrospective Cohort of Unique-Dose Administration of 30 Gy in 15 Fractions and Analysis of Remission Duration

Background

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma constitutes a significant proportion of primary stomach lymphomas. The optimal dosage for radiotherapy and standardized follow-up protocols are yet to be universally established. This study focuses on stage I gastric MALT lymphoma patients, presenting clinical outcomes of radiotherapy with a unique dose of 30 Gy in 15 fractions and analyzing remission time.

Methods

A retrospective cohort study, approved by the institutional review board, included consecutive stage I gastric MALT lymphoma patients undergoing curative radiotherapy between 2008 and 2022. Staging followed the Lugano Modification of the Ann Arbor Staging System. The prescribed dose was uniform dose of 30 Gy in 15 fractions.

Results

Fifty-three patients were eligible, with a median age of 63 years. All achieved complete remission (CR), with a median CR time of 3.9 months. At a median follow-up of 56.8 months, no deaths occurred, and three recurrences were noted. The 5-year overall survival, local control survival, and disease-free survival rates were 100%, 100%, and 97.7%, respectively. No severe acute adverse events were observed.

Conclusion

The study demonstrates sustained and favorable long-term disease control with a 30 Gy dose in 15 fractions for stage I gastric MALT lymphoma. Comparisons with existing literature highlight the efficacy and safety of radiotherapy in achieving durable remission. Ongoing efforts explore dose reduction and technological advancements to minimize toxicity. This study emphasizes the importance of awaiting clinical response confirmation to validate these outcomes in patients with gastric MALT lymphoma.

Low-grade malt lymphoma of the nasopharynx in young adults: Successful treatment of a rare diagnosis at a rare site by radiotherapy

INTRODUCTION

Mucosa Associated Lymphoid Tissue (MALT) lymphoma is the third most common subgroup of Non-Hodgkin's lymphoma and is the most common type of primary extranodal lymphoma. They are rarely found in the nasopharyngeal region and their mean age at presentation is the sixth decade of life.

MATERIALS AND METHODS

We present the clinical, pathological, treatment and 5-year follow-up data of 5 cases of nasopharyngeal MALT lymphoma treated with definitive radiotherapy at our hospital, between 2009 and 2011.

RESULTS

The average age of diagnosis was 27 years which is more than a decade earlier than what has been reported previously. Clinical symptoms included nasal obstruction, tinnitus and hearing loss. All five patients had locoregional disease. They were treated by definitive radiotherapy to a dose between 30 to 40 Gy. At 5 years of follow-up, 4 patients were in complete remission while one had disease relapse.

CONCLUSION

The younger age of presentation compared to older reports in this rare subsite was an interesting finding in our study. The authors speculate that rising levels of particulate air pollution may have played a part in the etiology in this younger population. Our series shows that despite the younger age, the disease displays an indolent course and responds well to radiotherapy alone as the primary treatment. Recurrence or disseminated disease is also highly treatable with systemic chemotherapy.

First-line antibiotic treatment in patients with localized extragastric mucosa-associated lymphoid tissue lymphoma

Between January 2010 and December 2015, we enrolled 28 patients with stage IEI/IIE1 extragastric mucosa-associated lymphoid tissue (MALT) lymphoma who received first-line antibiotic treatment, after informing them about the pros and cons of alternative therapies. In addition, during the same period, 64 patients with stage IE/IIE1 disease who received conventional treatment were selected as the control group. The most common primary sites were the ocular adnexal area (17 cases), followed by the salivary glands (four cases), pulmonary (three cases), and thyroid, trachea, larynx, and colon region (one case each). First-line antibiotic treatment resulted in an overall response rate of 57.1%: 12 patients achieved complete remission (CR), while four achieved partial remission (antibiotic-responsive tumors). Monoclonal gammopathy was significantly prevalent in antibiotic-unresponsive tumors than in antibiotic-responsive tumors (50.0% [6/12] vs. 12.5% [2/16], p = 0.044). After a median follow-up of 7 years, all patients with CR remained lymphoma-free, with 7-year event-free survival (EFS) and overall survival (OS) rates of 62.7% and 96.4%, respectively. The 7-year EFS and OS rates of patients who received conventional treatments were 73.1% and 91.1%, respectively. Compared with that noted in patients who received conventional treatment, antibiotic treatment was effective in some patients with localized extragastric MALT lymphoma.

Radiotherapy for gastric mucosa-associated lymphoid tissue lymphoma

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is a rare disease which is often associated with Helicobacter pylori (H. pylori) infection. First-line treatment of stage IE and IIE localized gastric MALT lymphoma is based on the eradication of H. pylori. The presence of H. pylori resistance factors such as translocation t (11;18), peri-gastric lymph node involvement and the degree of tumor infiltration of the gastric wall; or lack of response to antibiotic therapy are two main indications to treat with definitive radiotherapy (RT). RT is an effective treatment in localized gastric MALT lymphoma. A moderate dose of 30 Gy allows a high cure rate while being well tolerated. After treatment, regular gastric endoscopic follow-up is necessary to detect a potential occurrence of gastric adenocarcinoma.

A Case of Mucosa-Associated Lymphoid Tissue Lymphoma of the Bladder: An Extremely Rare Presentation

Extranodal mucosa-associated lymphoid tissue (MALT) is a type of non-Hodgkin’s lymphoma (NHL). It commonly involves the GI tract, but the involvement of the urinary bladder is very rare. It comprises less than 1% of bladder tumors and 0.2% of extranodal lymphomas. Fewer than a hundred cases are reported so far and limited literature is available on the management. Here we are presenting a gentleman with MALT lymphoma of the urinary bladder who presented with urinary frequency, an urgency which was initially managed as benign prosthetic hyperplasia. Initially, the treatment helped him with improvement in his symptoms. After a recurrence of his symptoms 11 years later, he underwent cystoscopy with biopsy that revealed MALT lymphoma of the bladder and underwent radiotherapy.

Radiotherapy in Early-stage Gastric MALT: Improved Survival Without Increased Cardiac Death

PURPOSE

Radiotherapy (RT) is an effective treatment for localized gastric mucosa-associated lymphoid tissue (MALT) lymphomas unresponsive to antibiotic therapy; however, irradiating the stomach can result in significant radiation to the heart, a risk factor for cardiac disease. We analyzed the Surveillance, Epidemiology, and End Results database to evaluate outcomes related to cardiac disease among patients treated with RT for stage I gastric MALT.

MATERIALS AND METHODS

We identified adult patients treated between 1993 and 2014. The relationship between treatment modality (RT, chemotherapy, combination, and no treatment) and overall survival (OS), mucosa-associated lymphoid tissue-specific survival (MSS), non-mucosa-associated lymphoid tissue-specific survival (non-MSS), and cardiac-specific survival (CSS) was assessed using the Kaplan-Meier estimator and Cox proportional hazards analyses.

RESULTS

A total of 2996 patients (median follow-up, 5.6 y) were analyzed: 27.5% had received RT alone, 12.1% chemotherapy alone, 3.9% chemoradiotherapy, and 56.5% no/unknown treatment (including antibiotic therapy). Compared with RT alone, patients who received chemotherapy alone exhibited worse OS (hazard ratio [HR]: 1.67; 95% confidence interval [CI]: 1.32-2.10; P<0.001) and MSS (HR: 2.10; 95% CI: 1.36-3.23; P=0.001). Although CSS appeared worse in patients who received chemotherapy (HR: 1.56; 95% CI: 0.92-2.66; P=0.10), it was not statistically significant. When comparing orbital and gastric MALT patients, there was no significant difference in CSS (HR: 0.80; 95% CI: 0.49-1.31; P=0.38).

CONCLUSIONS

RT improved survival among patients with stage I gastric MALT without increasing the risk of cardiac death. Those with gastric MALT exhibited similar CSS to those with orbital MALT. Although we cannot analyze nonfatal cardiac toxicity, these results suggest that, absent antibiotic therapy, RT should remain first-line treatment for early-stage gastric MALT.

Mucosa-Associated Lymphoid Tissue Lymphoma of the Thyroid Gland: A Systematic Review of the Literature

OBJECTIVE

Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type of the thyroid gland is a rare indolent malignant disease encountered in approximately 0.5% of patients with Hashimoto thyroiditis (HT). The purpose of the present systematic review was to accumulate the current evidence in the field.

STUDY DESIGN

We searched the Medline, Scopus, EMBASE, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials CENTRAL databases from inception to May 2018. Statistical analysis was performed with SPSS version 22.0.

RESULTS

Fourteen case series and 20 case reports were finally included in the present systematic review. Analysis of the patient data included in the published case reports suggested that the age at diagnosis of MALT lymphoma does no differ among males and females (64 [52.5-73] vs. 67 [60.5-72] years, p = 0.442). HT was detected in 60% of patients, whereas coexisting carcinoma was evident in 17% of cases. The incidence of HT and thyroid cancer was comparable among males and females (p = 0.474 and p > 0.999, respectively). Among all patients included in the present systematic review there were two disease relapses and two deaths attributed to the disease.

CONCLUSION

MALT lymphoma of the thyroid gland is a rare malignancy with an indolent course. The scarce data available in the literature preclude safe conclusions concerning the mode of treatment and follow-up of these patients. However, the combination of minimally invasive surgery and adjuvant therapy seems feasible. Moreover, an extended follow-up period is recommended.

[Results of a retrospective study on radiotherapy for gastric mucosa-associated lymphoid tissue lymphoma]

PURPOSE

We aimed to evaluate therapeutic results of radiotherapy for gastric mucosa-associated lymphoid tissue (MALT) lymphomas.

PATIENTS AND METHODS

We reviewed retrospectively the records of 11 patients presenting with gastric MALT lymphoma treated between 1993 and 2014. Patients with low-grade lymphoma in failure after helicobacter eradication had exclusive gastric external radiotherapy. Chemotherapy followed by radiotherapy were indicated in case of high grade lymphoma. Radiotherapy doses range between 30 and 40Gy (2Gy per fraction, five fractions per week).

RESULTS

All tumours were IE stage. Seven patients with low-grade lymphoma had radiotherapy. Four patients with high-grade lymphoma received chemotherapy then radiotherapy. Ten patients are in complete remission after treatment achievement. Five and 10 years disease-free survival are 100%. No severe toxicity was seen.

CONCLUSION

Eradication of Helicobacter pylori is the mainstay of treatment of gastric MALT. External irradiation is an effective and well-tolerated treatment modality in case of resistance to helicobacter eradication.

Radiotherapy for mucosa-associated lymphoid tissue (MALT) lymphoma of the rectum: a case report

Extra-nodal mucosa-associated lymphoid tissue (MALT) lymphoma is frequently involved with the upper gastrointestinal tract, but rarely involved with the rectum. We report a case of rectal MALT lymphoma treated by radiotherapy (RT) alone. A 74-year-old woman with lower abdominal pain was diagnosed with MALT lymphoma by endoscopic mucosal resection (EMR). She was diagnosed as stage IE (Ann Arbor) MALT lymphoma by diagnostic work-up and review of EMR specimens. Definitive RT was performed with curative intent, totaling 30 Gy in 15 fractions. Complete response was confirmed by colonoscopy after RT with no progression observed at 5 years. Definitive RT is effective for rectal MALT lymphoma.

Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma of the Colon: A Case Report and a Literature Review

Patient: Female, 56

Final Diagnosis: Colonic MALT lymphoma

Symptoms: Epigastric pain

Medication: —

Clinical Procedure: Colonoscopy and biopsy

Specialty: Gastroenterology and Hepatology

Mucosa-associated lymphoid tissue (MALT) variant of primary rectal lymphoma: a review of the English literature

PURPOSE

Primary rectal lymphoma (PRL) is the third most common cause of rectal cancer following adenocarcinoma (90-95 %) and carcinoid (5 %). The most common variant of PRL is the mucosa-associated lymphoid tissue (MALT) type. To date, no study has been able to recommend an optimal treatment algorithm for this rare disease. The aim of our study was to review the English literature on primary rectal MALT lymphoma.

METHODS

A review of the English literature was conducted to identify articles describing the MALT variant of PRL.

RESULTS

Fifty-one cases were identified. A complete response was achieved in 12 of 19 cases treated with Helicobacter pylori eradication therapy, 5 of 6 with radiation, 2 of 4 cases with chemotherapy, 2 of 4 with endoscopic resection, 6 of 8 cases with surgical resection, and all 8 with combination therapies. Cases failing initial therapies were responsive to various second-line treatments. Two cases spontaneously regressed with observation alone.

CONCLUSION

Complete regression of primary rectal MALT lymphoma was achieved using various therapeutic strategies, although the numbers of different treatment modalities are too small to draw definitive conclusions.

Early, Isolated Duodenal Mucosa-Associated Lymphoid Tissue Lymphoma Presenting without Symptoms or Grossly Apparent Endoscopic Lesions and Diagnosed by Random Duodenal Biopsies

Clinical data regarding mucosa-associated lymphoid tissue lymphoma (MALToma) solely involving the duodenum are sparse because of the relative rarity of the disease. A comprehensive literature review revealed only 17 cases reported until 2004, and only a moderate number of cases have been reported since. MALToma can be asymptomatic in its very early stages but frequently produces localized or nonspecific symptoms, including early satiety, abdominal pain, vomiting, and involuntary weight loss in later stages. While gastric MALToma is strongly associated with gastric Helicobactor pylori infection, duodenal MALToma is often unassociated with H. pylori infection. A 74-year-old female presented with only dysphagia (without symptoms referable to a duodenal lesion), without systemic 'B' symptoms, and with no evident duodenal lesions at esophagogastroduodenoscopy; however, she was diagnosed with duodenal MALToma by pathologic examination of random duodenal biopsies performed to exclude celiac disease. An important clinical feature of this case is that duodenal MALToma was diagnosed by pathologic analysis of duodenal biopsies despite (1) no endoscopically apparent duodenal lesions; (2) duodenal involvement without gastric involvement; (3) lack of symptoms attributable to duodenal MALToma, and (4) absence of evident H. pylori infection. This work shows that early duodenal MALToma can be difficult to diagnose because of absent symptoms, absence of gastric involvement, absence of endoscopic abnormalities, and absence of H. pylori infection; it may require random duodenal biopsies for diagnosis.

Recurrence patterns of mucose-associated lymphoid tissue lymphoma after definitive radiation treatment: A single center experience

OBJECTIVES

To evaluate the treatment outcomes in non-gastric and non-nodal mucose-associated lymphoid tissue (MALT) lymphoma patients treated by definitive radiation therapy (RT).

METHODS

A total of 134 patients were analyzed. The RT dose was 30.6 or 36 Gy.

RESULTS

The median follow-up duration for all patients was 51.1 months (range, 3.0-132.4 months). Among the 88 orbital MALT lymphoma patients, 12 had disease recurrence. There were 23 head and neck tumor patients. Two patients experienced relapse, all at out-of-field locations. Gastrointestinal MALT lymphoma was diagnosed in 13 patients, and three showed local (n = 1), distant (n = 1), or local/distant (n = 1) relapse.

CONCLUSION

RT alone is highly effective in achieving local control and long-term survival in localized MALT lymphoma. In orbital MALT, excellent local control is achieved, and relapse is predominantly observed in the contralateral eye. Other head and neck lymphomas are also well controlled.

Mucosa-associated lymphoid tissue lymphoma of the larynx: a case report and literature review

The clinicopathological characteristics and rational treatment of primary laryngeal mucosa-associated lymphoid tissue (MALT) lymphoma are still unclear and need to be further defined due to the paucity of this separate lymphoma.Herein, a supraglottic primary MALT lymphoma was described with detailed clinical course, intervention, and follow-up. To date, research of laryngeal MALT lymphoma has seldom been initiated. Our experience in this case will help to expand our understanding of this unique disease. A 58-year-old female presented with a history of progressive hoarseness for about 10 months. Multiple laryngoscopy examinations revealed severe hypertrophy of left ventricular band. She was admitted to our department with residual MALT lymphoma of supraglottic region after partial resection by laser. After systemic evaluation, she was staged as IEA, International Prognostic Index score 0. Irradiation of intensity modulated radiotherapy technique with a dose of 30.6 Gy/17f to the tumor and 25.5 Gy/17f to the related lymphatic drainage area achieved a complete remission. The disease-free survival has reached to 4 years. The irradiation related acute and late side effects were mild.Radiotherapy is the first option for limited-stage primary laryngeal MALT lymphoma because of excellent treatment outcome.

Electron dose distributions caused by the contact-type metallic eye shield: Studies using Monte Carlo and pencil beam algorithms

A metallic contact eye shield has sometimes been used for eyelid treatment, but dose distribution has never been reported for a patient case. This study aimed to show the shield-incorporated CT-based dose distribution using the Pinnacle system and Monte Carlo (MC) calculation for 3 patient cases. For the artifact-free CT scan, an acrylic shield machined as the same size as that of the tungsten shield was used. For the MC calculation, BEAMnrc and DOSXYZnrc were used for the 6-MeV electron beam of the Varian 21EX, in which information for the tungsten, stainless steel, and aluminum material for the eye shield was used. The same plan was generated on the Pinnacle system and both were compared. The use of the acrylic shield produced clear CT images, enabling delineation of the regions of interest, and yielded CT-based dose calculation for the metallic shield. Both the MC and the Pinnacle systems showed a similar dose distribution downstream of the eye shield, reflecting the blocking effect of the metallic eye shield. The major difference between the MC and the Pinnacle results was the target eyelid dose upstream of the shield such that the Pinnacle system underestimated the dose by 19 to 28% and 11 to 18% for the maximum and the mean doses, respectively. The pattern of dose difference between the MC and the Pinnacle systems was similar to that in the previous phantom study. In conclusion, the metallic eye shield was successfully incorporated into the CT-based planning, and the accurate dose calculation requires MC simulation.

A retrospective study of 5-year outcomes of radiotherapy for gastric mucosa-associated lymphoid tissue lymphoma refractory to Helicobacter pylori eradication therapy

BACKGROUND

The favorable response rate of radiotherapy for localized gastric mucosa-associated lymphoid tissue lymphoma refractory to Helicobacter pylori eradication has been demonstrated. However, there are limited data available on the long-term outcomes. The aim of this retrospective study was to evaluate the long-term outcomes of radiotherapy for localized gastric mucosa-associated lymphoid tissue lymphoma refractory to Helicobacter pylori eradication.

METHODS

Thirty-four consecutive patients with localized gastric mucosa-associated lymphoid tissue lymphoma that were refractory to eradication were treated with radiotherapy (a total dose of 30 Gy). The response and adverse events of radiotherapy were retrospectively analyzed as short-term outcomes, and recurrence-free, overall and disease-specific survival rates were calculated as long-term outcomes.

RESULTS

Thirty-three (97.1%) patients achieved complete remission and radiotherapy was well tolerated. One patient underwent emergency gastrectomy due to severe hematemesis. Of the 34 patients during the median follow-up period of 7.5 (1.2-13.0) years, one patient had local recurrence after 8.8 years, one patient underwent surgery for bowel obstruction secondary to small bowel metastasis after 5.1 years and one patient had pulmonary metastasis after 10.9 years. Pathologically, all three recurrences revealed mucosa-associated lymphoid tissue lymphoma without any transformation to high-grade lymphoma. None died of gastric mucosa-associated lymphoid tissue lymphoma. The 5-year recurrence-free survival rate was 97.0%. The 5-year overall survival rates and disease-specific survival rates were 97.0 and 100%, respectively.

CONCLUSIONS

Radiotherapy in patients with localized gastric mucosa-associated lymphoid tissue lymphoma refractory to Helicobacter pylori eradication can achieve excellent overall survival. However, long-term surveillance is necessary to identify late recurrences.

Treatment of gastric MALT lymphoma with a focus on Helicobacter pylori eradication

Mucosa-associated lymphoid tissue (MALT) lymphoma is an indolent disease with a prolonged clinical course that most often involves the stomach. Clinically, for Helicobacter pylori-positive low-grade MALT lymphoma, antibiotics have been used as the first-line treatment. The recommended anti-Helicobacter triple drug therapy includes a proton pump inhibitor (or ranitidine bismuth citrate), clarithromycin, and amoxicillin (or metronidazole). Considering the difficulty involved with confirming histological remission and the lack of systemic endoscopic follow-up, much work remains to be done in this area. This review describes MALT lymphoma treatment methods and their efficacy, highlights results of the newest studies, and proposes avenues toward future developments in this field.

18F-fluorodeoxyglucose positron emission tomography/computed tomography findings in mucosa-associated lymphoid tissue lymphoma of the larynx: a case report and literature review

Laryngeal mucosa-associated lymphoid tissue (MALT) lymphoma is rare, with only 25 cases reported in the literature. This report presents a case of laryngeal MALT lymphoma in a 35-year-old female with a 6-year history of progressively worsening hoarseness. MALT lymphoma was diagnosed based on biopsy and immunohistochemical analysis. The patient received two cycles of cyclophosphamide + epirubicin + vincristine + prednisone (CHOP) chemo therapy, which was ineffective. (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT) showed (18)F-FDG accumulation in the larynx only and identified stage IE lymphoma. CHOP chemotherapy was terminated and the patient was treated with radiotherapy. After 3 months (total radiation dose 27 Gy), (18)F-FDG PET/CT scan showed that the laryngeal lesion was in complete remission. A review of the literature on the MEDLINE(®)/PubMed(®) databases regarding laryngeal MALT lymphoma and the use of PET/CT found that radiotherapy is the first-line treatment for stage I and II MALT lymphoma.

Radiotherapy in marginal zone lymphoma

Purpose

To evaluate the efficacy of radiotherapy (RT) for early-stage nodal and extranodal marginal zone lymphoma (MZL).

Materials and methods

Patients with stage I (n = 22) and stage II (n = 8) MZL, who were treated with RT were reviewed. The primary tumor localisation was in the orbita (n = 12), stomach (n = 8), head and neck other than the orbita (n = 8), breast (n = 1) and one case of marginal zone lymphoma of the skin (n = 1). The median radiotherapy dose was 40 Gy (5 to 45 Gy).

Results

The median follow-up time was 103 months. The 5-year overall survival and event-free survival rates were 85 ± 7% and 71 ± 9%, respectively. There was no infield recurrence. Recurrence occurred outside of the radiation field in six patients. The relapses were treated with salvage RT and had excellent local control (100%) at five years after salvage RT.

Conclusions

Localized extranodal MZL have an excellent prognosis following moderate-dose RT. RT is also an effective salvage therapy in cases of localized recurrence. Further clinical studies should evaluate the optimal dose for MZL.

Application of a dummy eye shield for electron treatment planning

Metallic eye shields have been widely used for near-eye treatments to protect critical regions, but have never been incorporated into treatment plans because of the unwanted appearance of the metal artifacts on CT images. The purpose of this work was to test the use of an acrylic dummy eye shield as a substitute for a metallic eye shield during CT scans. An acrylic dummy shield of the same size as the tungsten eye shield was machined and CT scanned. The BEAMnrc and the DOSXYZnrc were used for the Monte Carlo (MC) simulation, with the appropriate material information and density for the aluminum cover, steel knob and tungsten body of the eye shield. The Pinnacle adopting the Hogstrom electron pencil-beam algorithm was used for the one-port 6-MeV beam plan after delineation and density override of the metallic parts. The results were confirmed with the metal oxide semiconductor field effect transistor (MOSFET) detectors and the Gafchromic EBT2 film measurements. For both the maximum eyelid dose over the shield and the maximum dose under the shield, the MC results agreed with the EBT2 measurements within 1.7%. For the Pinnacle plan, the maximum dose under the shield agreed with the MC within 0.3%; however, the eyelid dose differed by -19.3%. The adoption of the acrylic dummy eye shield was successful for the treatment plan. However, the Pinnacle pencil-beam algorithm was not sufficient to predict the eyelid dose on the tungsten shield, and more accurate algorithms like MC should be considered for a treatment plan.

Helicobacter pylori-Negative Primary Rectal MALT Lymphoma: Complete Remission after Radiotherapy

Rectal mucosa-associated lymphoid tissue (MALT) lymphoma is a rare condition. Although the majority of patients undergo surgical resection, a definitive treatment for rectal MALT lymphoma has not yet been established. In the present study, we report the outcome of radiotherapy in 3 patients with rectal MALT lymphoma. Our cohort ranged from 56 to 65 years of age. The male/female ratio was 1:2, and all patients were in stage I (Lugano classification) of the disease. Endoscopic findings revealed elevated lesions resembling submucosal tumors in 2 patients, and a sessile elevated lesion with a nodular surface in 1 patient. One of the 3 patients underwent magnifying endoscopy with crystal violet staining that demonstrated a type I pit pattern (Kudo's classification) lesion with a broad intervening area caused by the upthrust of the tumor from the submucosa. All patients tolerated radiotherapy at doses of 30 Gy without major complications and achieved complete remission. Follow-up ranged from 13 to 75 months (mean 51.0 months), revealing no recurrence of MALT lymphoma. As such, we propose radiotherapy to be a safe and effective means for treating rectal MALT lymphoma.

F-18 FDG PET/CT evaluation of radiotherapy response in rare case of mucosa-associated lymphoid tissue lymphoma

We experienced two cases of mucosa-associated lymphoid tissue (MALT) lymphoma arising at unusual locations and used F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) to evaluate their response to radiation therapy (RT). A 62-year-old male with proven prostatic MALT lymphoma and a 43-year-old woman with proven duodenal MALT lymphoma had diffuse FDG uptake in the lesion. Both cases were treated with RT; following FDG, PET/CT showed decreased FDG uptake in each lesion. Neither patient had evidence of recurrence at more than 18 months after RT. FDG PET/CT is useful for indicating the treatment site in MALT lymphoma and in evaluation of therapeutic response following RT.

Radiotherapy for mucosa-associated lymphoid tissue (MALT) lymphoma of the esophagus: a case report with a diagnostic and therapeutic discussion

Mucosa-associated lymphoid tissue (MALT) lymphoma is increasing common in various sites; however, MALT lymphoma in the esophagus is still rare, so its diagnostic features have not yet been well recognized and optimal treatment has not been properly discussed. Though radiotherapy is widely preferred for gastric and orbital MALT lymphoma, surgery has been the most frequently reported treatment for esophageal MALT lymphoma. This raises the question: why not radiotherapy for esophageal MALT lymphoma instead of surgery? The only reported case of definitive radiotherapy for esophageal MALT lymphoma lacks follow-up data. Three years ago (2007), we treated a 59-year-old male patient with a large esophageal submucosal tumor, diagnosed as MALT lymphoma, with 36 Gy of solo external beam radiotherapy. The tumor was 15 cm in craniocaudal length, homogeneously weakly contrast-enhanced on X-ray computed tomography (CT), homogeneously hypoechoic and clearly demarcated from the surrounding adventitia, and had a concave pattern between the folds. During and after radiotherapy, no treatment-related complications occurred except for transient Grade 2 leukocytopenia. The tumor showed remarkable reduction and histological negativity in the next month. Over the follow-up period, no recurrence was observed in semiannual PET/CT/MRI studies. Taking the current observation with the well known effectiveness of radiotherapy for MALT lymphoma in various other sites, we recommend considering radiotherapy as a reasonable less-invasive treatment for this rare entity.

Long-term outcome in localized extranodal mucosa-associated lymphoid tissue lymphomas treated with radiotherapy

BACKGROUND

This study was conducted to evaluate the long-term outcomes in patients with stage IE and IIE mucosa-associated lymphoid tissue (MALT) lymphomas treated with involved field radiotherapy (RT).

METHODS

Between 1989 and 2004, 192 patients with stage I and II MALT lymphomas were treated. The report focuses on 167 patients who received RT. The median age of patients was 58 years with a female predominance (2:1). Presenting sites were as follows: orbital adnexa in 71 patients, salivary glands in 28 patients, stomach in 25 patients, thyroid in 21 patients, and other sites in 22 patients. The median dose to nonorbital sites was 30 grays (Gy) (range, 17.5-35 Gy) and was 25 Gy for the orbit (range, 25-35 Gy). The median follow-up was 7.4 years (range, 0.67-16.20 years).

RESULTS

Complete response and complete response, unconfirmed (CR/CRu) was noted in 166 (99%) patients. The 10-year recurrence-free rate (RFR) was 76%, the disease-free survival (DFS) rate was 68%, the overall survival (OS) rate was 87%, and the cause-specific survival rate was 98%. According to presenting site, the 10-year RFR was 95% for thyroid, 92% for stomach, 68% for salivary glands, and 67% for orbit. Patients with thyroid and gastric MALTs had better outcome compared with patients with MALTs diagnosed at other sites (P=.004). Among those patients who achieved CR, 19% developed disease recurrence (n=31), chiefly in distant sites or untreated contralateral-paired organs. At the time of disease recurrence, 7 patients (23%) had transformed to diffuse large B-cell lymphoma, 2 of whom died of lymphoma. The 5-year OS rate after treatment failure was 83%.

CONCLUSIONS

Patients with localized MALT lymphomas are reported to have excellent clinical outcome after moderate-dose RT, and some are likely cured. In the current study, thyroid and gastric MALTs were found to have significantly less risk of distant recurrence. Despite disease recurrence, the overall survival remains excellent in these patients.

Role of radiotherapy in the treatment of lymphomas of the gastrointestinal tract

In patients with gastrointestinal lymphoma the most frequently involved site is the stomach (60%-75% of cases), followed by the small bowel, ileum, cecum, colon and rectum. The most common histological subtypes are extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) and diffuse large B-cell lymphoma (DLBCL). The role of radiotherapy is most definite in early stage gastric lymphoma. The therapeutic approach for patients with gastric Non Hodgkin lymphoma (NHL) has changed significantly over the last decades. The primary treatment of limited gastric MALT lymphoma consists of Helicobacter pylori eradication. In case of insufficient response to H. pylori eradication or in case H. pylori is absent, irradiation of the stomach and perigastric lymph nodes to a dose of 30-40Gy in 15-20 fractions is indicated. In patients with gastric DLBCL conservative treatment with anthracycline-based chemotherapy alone or in combination with involved-field radiotherapy has become the therapy of choice.

Favorable outcomes of radiotherapy for early-stage mucosa-associated lymphoid tissue lymphoma

PURPOSE

The aim of this study was to evaluate the efficacy of radiation therapy (RT) for early-stage mucosa-associated lymphoid tissue (MALT) lymphoma.

MATERIALS AND METHODS

Patients with stage IotaE (n=48) and stage capital PE, CyrillicE (n=2) MALT lymphoma treated with RT were reviewed. The primary tumor originated in the stomach in 20 patients, in the orbit in 9 patients, in the conjunctiva or eyelid and the parotid glands in 6 patients each, and 9 patients in the others. The median total RT dose was 32Gy (range, 25.6-50Gy). The median follow-up time was 50 months.

RESULTS

Although disease did not recur in the RT field in any patient regardless of the total dose, disease recurred outside the RT field in the seven patients. As all recurrences were localized, salvage RT was performed for each recurrence and achieved complete response without recurrence in the field. The 5-year overall survival, local control, and progression-free survival rates were 96.6%, 100%, and 82.2%, respectively.

CONCLUSIONS

A total dose of 25-30Gy is appropriate for local control of MALT lymphoma. RT is also an effective salvage therapy in cases of localized recurrence.