EUS in MALT lymphoma

Effect of Helicobacter pylori eradication therapy on the response of MALT-Gastric lymphoma

INTRODUCTION

The link between gastric mucosa-associated lymphoid tissue lymphoma (LG-MALT) and chronic Helicobacter Pylori (HP) infection had led to a real revolution in the management of the disease.

AIMS

To study the results of the HP eradication therapy and to clarify its place in the tumor response.

METHODS

A descriptive retrospective bicentric study, between January 2007 and December 2016, including patients with LG-MALT treated in the gastroenterology departments of Sahloul hospital in Sousse and Habib Bougtafa hospital in Bizerte, and having received treatment for eradication of HP.

RESULTS

Sixty-three patients were included. The male/female sex ratio was 1.42. The average age was 58 years. The symptomatology was dominated by epigastric pain (96.8%). On digestive endoscopy, the most frequent location and appearance were gastric antrum (39.6%) and ulcerations (89%). The lymphoma was classified as stage IE and IIE1 in 81% and 19% of cases, respectively. The HP status was positive in all patients. The HP eradication rate was 82.5% after three anti-HP treatment courses. Complete remission of lymphoma was obtained in 81% of patients at 18 months. Non-response to HP eradication therapy was observed in 19% of patients. Non-responder patients had a longer diagnostic delay (p=0.02), more diffuse endoscopic involvement (p=0.001) and a more frequent appearance of large gastric folds (p=0.001).

CONCLUSION

The course of LG-MALT is determined by the treatment for the eradication of HP. Its success promotes remission of lymphoma.

Endoscopic ultrasound in oncology: An update of clinical applications in the gastrointestinal tract

An accurate staging is necessary to select the best treatment and evaluate prognosis in oncology. Staging usually begins with noninvasive imaging such as computed tomography, magnetic resonance imaging or positron emission tomography. In the absence of distant metastases, endoscopic ultrasound plays an important role in the diagnosis and staging of gastrointestinal tumors, being the most accurate modality for local-regional staging. Its use for tumor and nodal involvement in pre-surgical evaluation has proven to reduce unnecessary surgeries. The aim of this article is to review the current role of endoscopic ultrasound in the diagnosis and staging of esophageal, gastric and colorectal cancer.

Duodenal mucosa-associated lymphoid tissue lymphomas: two cases and the evaluation of endoscopic ultrasonography

Mucosa-associated lymphoid tissue lymphoma mainly arises in the stomach, with fewer than 30% arising in the small intestine. We describe here two cases of primary duodenal mucosa-associated lymphoid tissue lymphoma which were evaluated by endoscopic ultrasonography. A 52-year-old man underwent endoscopy due to abdominal pain, which demonstrated a depressed lesion on duodenal bulb. Endoscopic ultrasonographic finding was hypoechoic lesion invading the submucosa. The other case was a previously healthy 51-year-old man. Endoscopy showed a whitish granular lesion on duodenum third portion. Endoscopic ultrasonography image was similar to the first case, whereas abdominal computed tomography revealed enlargement of multiple lymph nodes. The first case was treated with eradication of Helicobacter pylori, after which the mucosal change and endoscopic ultrasound finding were normalized in 7 months. The second case was treated with cyclophosphamide, vincristine, prednisolone, and rituximab every 3 weeks. After 6 courses of chemotherapy, the patient achieved complete remission.

Gastric oncology: an update

PURPOSE OF REVIEW

As the field of endoscopy progresses, new tools and techniques continue to be developed for gastroenterology in general and gastrointestinal oncology in particular. Some of these include enhancements in diagnostic optics such as chromoendoscopy, magnification endoscopy, and confocal laser endomicroscopy. Others include advanced therapeutics such as endoscopic mucosal resection and endoscopic submucosal dissection. In this review, we will update the reader on these latest of technologies, their benefits and risks, as well as their role in evaluating, staging, and treating gastric neoplasms, especially gastric adenocarcinoma, gastrointestinal stromal tumors, and primary gastric lymphoma.

RECENT FINDINGS

Noteworthy studies in this review indicate that in properly selected patients with gastric adenocarcinoma, endoscopic submucosal dissection is a viable alternative to gastric resection with 100% 5-year survival rates; in patients with metastatic gastrointestinal stromal tumors, imatinib can provide effective treatment with reasonable outcome; and in patients with low grade mucosa-associated lymphoid tissue lymphoma, eradication therapy with antibiotics is curative with a very low recurrence rate.

SUMMARY

The advances discussed in this review have significantly improved the care we can offer our patients in gastric oncology. With continued advancement in the field, it will be crucial to continue to study outcomes and safety of these techniques and to develop structured training for those looking to perform these procedures.

Endoscopic ultrasound of the upper gastrointestinal tract and mediastinum: diagnosis and therapy

Endoscopic ultrasound (EUS) has developed significantly over the last two decades and has had a considerable impact on the imaging and staging of mass lesions within or in close proximity to the gastrointestinal (GI) tract. In conjunction with conventional imaging such as helical computed tomography and magnetic resonance imaging, the indications for EUS include (1) differentiating between benign and malignant lesions of the mediastinum and upper GI tract, (2) staging malignant tumors of the lung, esophagus, stomach, and pancreas prior to surgery or oncological treatment, (3) excluding common bile duct stones before laparoscopic cholecystectomy, thereby avoiding the need for endoscopic retrograde cholangiopancreatography (ERCP) in some patients, and (4) assessing suspected lesions that are either equivocal or not seen on conventional imaging. In recent years, EUS has charted a course similar to that taken by ERCP, evolving from a purely diagnostic modality to one that is interventional and therapeutic. These indications include (5) obtaining a tissue diagnosis by EUS-guided fine-needle aspiration or trucut-type needle biopsy and (6) providing therapy such as coeliac plexus neurolysis and pancreatic pseudocyst drainage--in many cases, more accurately and safely than conventional techniques. Emerging investigational techniques include EUS-guided enteric anastomosis formation and fine-needle injection therapy for malignant disease.

Radiotherapy for low-grade gastric marginal zone lymphoma: a retrospective study

BACKGROUND

We evaluated the efficacy and toxicity of radiotherapy (RT) in patients with low-grade gastric marginal zone lymphoma.

METHODS

A retrospective review of consecutive cases of gastric marginal zone lymphoma treated by radical RT at the Peter MacCallum Cancer Centre and Radiation Oncology Victoria between January 1980 and September 2003 was carried out.

RESULTS

Eighteen patients (11 men and 7 women) were identified. The median age at commencement of RT was 65 years (range 42-84 years). Prior treatment included Helicobacter pylori eradication in 12 patients, chemotherapy in 7 and surgery in 2, whereas 2 patients had no prior therapy. The median time to progression after commencement of last treatment before RT was 4.8 months (range 0-129.4 months). The radiation fields included the stomach plus perigastric and coeliac nodes in 15 patients (83%), stomach plus spleen in 2 patients (11%) and stomach plus para-aortic nodes in 1 patient (6%). The median RT dose was 30 Gy (range 30-36 Gy) in a median 20 fractions (range 17-24 fractions). One patient required treatment interruption for acute toxicity. A complete response on post-RT biopsies was achieved in 17 of 18 patients (94%). With a median follow up of 4.5 years after RT, 3 of these 17 patients (18%) have had a recurrence. At the last follow up, 11 patients were alive in continuous complete histological remission. No late renal toxicity was identified.

CONCLUSION

Radiotherapy is an effective, well-tolerated treatment for patients with low-grade gastric marginal zone lymphoma, including those who have had prior therapy.

Endoscopic ultrasonography (EUS) in the staging of malignancy

Since first introduced over 20 years ago, endoscopic ultrasonography (EUS) has become established as an important tool in the staging of gastrointestinal malignancies and potentially resectable non-small cell lung cancer. This review describes the current roles of EUS in staging these tumours, highlighting interventional roles, current problem areas and future developments.