Stage-modified international prognostic index effectively predicts clinical outcome of localized primary gastric diffuse large B-cell lymphoma. International Extranodal Lymphoma Study Group (IELSG)

Primary extranodal diffuse large B-cell lymphoma in the rituximab era: a single center, retrospective analysis

OBJECTIVES

To analyse the clinical characteristics and therapeutic response of Chinese patients with primary extranodal diffuse large B-cell lymphoma DLBCL (PE-DLBCL).

METHODS

We analysed the clinical features and outcomes of 197 patients who were newly diagnosed with PE-DLBCL between January 2015 and December 2020.

RESULTS

The gastrointestinal tract showed the highest rate of involvement (34%), followed by the central nervous system (CNS) and intraocular system (31.5%). The 3-year overall survival (OS) rate was 81% for the entire group and 79% for those with CNS and vitreoretinal involvement. Ann Arbour stage, lactate dehydrogenase level, International Prognostic Index > 2, and complete remission (CR) were significantly related to the survival of patients with PE-DLBCL. The lack of CR was the only independent adverse prognostic factor for OS.

CONCLUSION

The clinical outcomes of patients with PE-DLBCL at our centre were encouraging, especially for patients with CNS and vitreoretinal involvement.

Pattern of failure and optimal treatment strategy for primary gastric diffuse large B-cell lymphoma treated with R-CHOP chemotherapy

PURPOSE

The optimal treatment for primary gastric diffuse large B-cell lymphoma (PG-DLBCL) is still unknown. We evaluated unfavorable prognostic factors and pattern of failure in PG-DLBCL to determine the optimal treatment strategy.

METHODS

Between April 2001 and November 2018, 120 patients with complete remission following rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) chemotherapy were retrospectively reviewed. According to the Lugano staging system, 80 patients (66.7%) had localized disease and 40 patients (33.3%) had advanced disease. A total of 93 (77.5%) patients had single gastric lesion and 27 (22.5%) patients had multiple gastric lesions. Ninety patients (75%) were treated with R-CHOP chemotherapy alone and 30 patients (25%) received R-CHOP chemotherapy with additional local treatment for gastric lesions.

RESULTS

The 5-year locoregional failure-free survival (LRFS), progression-free survival (PFS), and overall survival (OS) rates in patients treated with R-CHOP chemotherapy with local treatment were 100%, 100%, and 100%, respectively, whereas the LRFS, PFS, and OS rates in patients treated with R-CHOP chemotherapy alone were 86.3%, 78.2%, and 87.4%, respectively (p = 0.031, p = 0.095, and p = 0.025, respectively). During the follow-up period, 17 patients (14.2%) had disease recurrence. Only 3 of the 17 patients had relapse in a completely new site without relapse in the initial involved site. All, except 2, cases of local recurrence included gastric failure. In the multivariate analysis, performance status and number of gastric lesions were independent prognostic factors for treatment outcome.

CONCLUSIONS

Patients with complete remission following R-CHOP chemotherapy showed a good prognosis. The main pattern of failure in patients with PG-DLBCL was local recurrence, especially in the stomach. Patients who received local treatment for gastric lesions showed improved gastric control. Therefore, in patients with unfavorable prognostic factors, we recommend R-CHOP chemotherapy with additional local treatment for gastric lesions.

Novel treatment of refractory / recurrent pulmonary hepatoblastoma

BACKGROUND

There is no consensus about how to manage pulmonary metastasis in patients with hepatoblastoma. We reviewed a treatment with a combination of oxaliplatin, vincristine, and topotecan (OVT) paired with radiofrequency ablation (RFA) of 12 patients with multiple refractory / recurrent pulmonary hepatoblastoma.

METHODS

The medical records from patients with ≤21 years of age presenting with multiple deposits (≥2) of refractory / recurrent pulmonary hepatoblastoma were reviewed. The following data were extracted from each patient: age, gender, histological subtyping, cycles of OVT, tumor size, biomarkers, chemotherapy regimen and dosage, RFA details, treatment response, follow up, and patient outcomes. The primary outcome measure was the complete response (CR) of pulmonary diseases, and secondary outcomes were event-free survival rate and overall survival rate.

RESULTS

Of 12 assessable patients, three (25%) (95% CI, 46.3-104) patients achieved PR (partial resopnse) after they finished OVT. After RFA, five (41.7%) (95% CI, 8.95-74.4) patients achieved CR (complete response). The 2 year event-free survival rate was 33% (95% CI, 20.5-64.6). The 2 year overall survival for the study group was 41.7% (95% CI, 8.9-74.4). All toxicity events were handled satisfactorily and no toxic related deaths were observed.

CONCLUSIONS

Our review report shows that OVT combined with RFA can be a successful treatment modality for previously heavily treated refractory / recurrent pulmonary metastatic lesions from hepatoblastoma.

Primary cardiac lymphoma with central nervous system relapse

Primary cardiac lymphoma (PCL), a rare disease, often presents with symptoms resembling other cardiac diseases. The correct diagnosis is crucial, as cardiac lymphoma can be cured with immuno‐chemotherapy. PCL has a high risk of central nervous system recurrence (CNS); therefore, screening for CNS involvement and even prophylaxis may be necessary.

Histological transformation from gastric mucosa-associated lymphoid tissue lymphoma to gastric diffuse large B-cell lymphoma

This study evaluated the clinical features, treatment and prognosis in Chinese patients with histological transformation (HT) from gastric mucosa-associated lymphoid tissue lymphoma to gastric diffuse large B-cell lymphoma. We reviewed the medical records of 71 patients diagnosed with HT between 2001 and 2013, retrospectively. Patients had a median age of 56 years. The ratio of sex (male:female) was 1.3:1. The clinical course was often insidious, lacking specific clinical presentation. Macroscopically, the antrum was the most commonly involved site. Thirty-one patients (45%) presented at stage I, and 25 (35%) presented with local (18/71, 25%) or distant (7/71, 10%) nodal involvement. There were also stage IIE (9/71, 12%) and stage IV (6/71, 8%) patients with advanced stages. For all 71 patients, the 5-year progression-free survival (PFS) and overall survival (OS) estimates were 50 and 56%, respectively. There was no statistical difference in 5-year PFS and OS estimates between patients receiving Helicobacter pylori (H. pylori) containing eradication (HPE) (p=0.189) and those receiving non-HPE (p=0.359). Upon the Cox regression model, advanced stages were the only independent prognostic factors associated with shorter PFS, and m-IPI was independently associated with shorter PFS and OS. There was no specific clinical manifestation for patients with HT. HPE is thus a promising therapeutic approach for such patients. Moreover, advanced stages and m-IPI significantly influenced patient outcome.

Retrospective analysis of primary gastric diffuse largeB-cell lymphoma: a single center study from Turkey

BACKGROUND/AIM

Diffuse large B-cell primary gastric lymphomas (DLBC-PGLs) are treated with different therapies. Their optimal treatment is not well documented.

MATERIALS AND METHODS

We retrospectively analyzed the data of 51 patients diagnosed with DLBC-PGL in the previous 10 years. All patients were treated with R-CHOP as first line. Radiotherapy was added to chemotherapy in 8 patients. Surgery was performed in 5 patients.

RESULTS

The median follow-up time of the 51 patients was 45.5 (range 5-144) months and the complete response (CR) rate was 90.2%. CR was achieved in 34 (89.4%) of 38 patients treated with single chemotherapy, in all (100%) 5 patients treated with chemotherapy plus surgery, and in 7 (87.5%) of 8 patients treated with chemotherapy plus radiotherapy. The 5-year overall survival (OS) and event-free survival (EFS) rates were 85.8% and 89.6%, respectively. The 5-year OS and EFS rates were not significantly different between patients treated with single chemotherapy or chemotherapy plus radiotherapy/surgery (P > 0.05).

CONCLUSION

R-CHOP chemotherapy is as effective as R-CHOP plus radiotherapy/surgery in the treatment of DLBC-PGL patients. Prospective randomized large cohort studies are needed to generate guidelines for the treatment of DLBC-PGL.

Clinical characteristics and prognostic factors of primary gastric lymphoma: A retrospective study with 165 cases

Primary gastric lymphoma (PGL) is the most common extranodal non-Hodgkin lymphoma. This retrospective study aimed to analyze the clinical characteristics, prognostic factors, and roles of different treatment modalities in patients with PGL.From January 2003 to November 2014, 165 patients who were diagnosed with PGL at West China Hospital were enrolled in this study. The clinical features, treatment, and follow-up information were analyzed.In this study, diffuse large B-cell lymphoma (DLBCL) (108, 65.5%) and mucosa-associated lymphoid tissue (MALT) lymphoma (52, 31.5%) were two predominant histological subtypes. One-year and 5-year overall survival (OS) rates of all patients were 95.2% and 79.5%, respectively; in whom 110 (66.7%) underwent surgery, 110 (66.7%) received chemotherapy, 12 (7.3%) received radiotherapy, and 10 (6.1%) received Helicobacter pylori eradication. And 75 patients (45.5%) were treated with at least 2 different types of therapies. Elevated lactic dehydrogenase (LDH) levels, poor performance status (PS), advanced stage, International Prognostic Index (IPI) score ≥3, conservative treatment, and high-grade histological subtype were associated with worse prognosis in univariate analysis. Cox regression analysis showed that LDH levels, PS, staging, and histological subtype were independent predictors of survival outcomes. In the DLBCL type, 5-year OS was significantly better in the surgically treated group (80.1%) than that of patients conservatively treated (49.8%) (P = 0.001). Surgical treatment had almost no impact on OS in the MALT type than conservative treatment (P = 0.597). The proportion of patients received conservative treatment increased from 4.5% in period 1 to 51.7% in period 4.High LDH levels, poor PS, advanced staging, and malignant pathological type at diagnosis are significantly associated with poor OS. Our data suggest that surgery is superior in prognosis over conservative treatment in the DLBCL type, but not in the MALT type. Recently, conservative treatment is becoming more preferred approach in patients with PGL.

Evaluation of the clinical characteristics, management, and prognosis of 103 patients with gastric mucosa-associated lymphoid tissue lymphoma

The diagnosis of gastric mucosa-associated lymphoid tissue (MALT) lymphoma is difficult owing to its non-specific symptoms and various endoscopic findings. Treatments such as radiotherapy (RT) for localized and chemotherapy (CT) for advanced stages of the disease are employed. The aim of the present study was to examine the clinical characteristics and prognostic factors of Helicobacter pylori (H. pylori) eradication (HPE) in patients with gastric MALT lymphoma. The medical records of 103 patients with gastric MALT lymphoma for the period 2001–2013, were analyzed. The 103 median age of the patients was 53 years and the male to female ratio was 1:1. Serum lactate dehydrogenase and β2-microglobulin were within normal range. Macroscopically, the most commonly involved site was the antrum, followed by the corpus and fundus. A total of 97 patients (94%) tested positive for H. pylori. Forty patients (39%) had stage I, 35 patients (35%) had local or distant nodal involvement, 20 of 103 patients had stage IIIE (19%) and 8 of 103 patients had stage IV (7%) disease. Complete remission, after HPE, was achieved in 54 of the 69 patients (78%) that were H. pylori-positive and in 2 of the 4 patients (50%) that were H. pylori-negative. HPE had a superior trend in the H. pylori-positive patients although no significant difference was identified in the two groups (p=0.194). In patients with advanced disease, the 5-year progression-free survival (PFS) and overall survival (OS) estimates were significantly improoved for patients receiving HPE with CT or RT than those receiving CT or RT (p=0.046 and 0.035, respectively). The multivariate analysis revealed that, the advanced stages were independently associated with shorter PFS, and the modified-International Prognostic Index (m-IPI) (≥2) was associated with shorter OS. In conclusion, gastric MALT lymphoma had a favorable outcome with a high OS rate. HPE was an effective treatment for gastric MALT lymphoma. The patients with advanced stages and m-IPI (≥2) had a much worse prognosis.

Prognostic significance of serum beta-2 microglobulin in patients with non-Hodgkin lymphoma

BACKGROUND AND OBJECTIVE

Elevated serum beta-2 microglobulin (β2-M) has previously been reported in non-Hodgkin lymphoma (NHL) patients. This study examined the association between serum β2-M and the prognosis of NHL and analyzed its predictive value.

METHOD

A total of 287 NHL patients from Taiyuan, Shanxi, China, participated in a prospective cohort study between 2008 and 2011. Overall survival (OS) was compared between NHL patients with high and normal β2-M levels using the log-rank test. Three standard Cox regression models including the International Prognostic Index (IPI) score, β2-M or IPI score+β2-M as independent variables were constructed. The time-dependent receiver operating characteristic curves method and C index were used to examine the tendency of the models' predictive accuracy over time.

RESULTS

NHL patients with elevated β2-M values had worse OS (p<0.001) and higher mortality risk (HR=1.93, 95% CI 1.37-2.77, p<0.001) than patients with normal β2-M values. There were statistically significant differences between the C indexes for the models with IPI+β2-M, IPI or β2-M alone (p<0.001).

CONCLUSION

Our results demonstrated an association between serum β2-M and NHL prognosis. Combining β2-M with IPI may help to improve the prognostic accuracy of NHL.

A retrospective analysis of primary gastric diffuse large B-cell lymphoma with or without concomitant mucosa-associated lymphoid tissue (MALT) lymphoma components

Primary gastric diffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease entity that includes patients with (DLBCL/MALT) and without detectable mucosa-associated lymphoid tissue (MALT) lymphoma components (de novo DLBCL). We sought to evaluate the clinical characteristics and outcome of this disease in a large number of cases. Patients with primary gastric DLBCL (n=162) seen on 2001-2011 at the Tianjin Medical University Cancer Institute and Hospital and the First affiliated Hospital of Chinese PLA General Hospital were retrospectively reviewed. The distribution of sex, age, Lugano staging, and other main clinical characteristics was similar between the de novo DLBCL and DLBCL/MALT groups (p>0.05). However, the proportion of patients with a stage-modified international prognostic index (m-IPI) ≥ 2 was higher in the de novo DLBCL (34 %) than the DLBCL/MALT group (17 %) (p=0.026). In addition, the Helicobacter pylori infection rates were higher in the DLBCL/MALT (75 %) than the de novo DLBCL group (36 %) (p<0.001). Five-year progression-free survival (PFS) and overall survival (OS) estimates were similar for patients in the de novo DLBCL (p=0.705) and DLBCL/MALT groups (p=0.846). Surgical treatment did not offer survival benefits when compared with chemotherapy for 5-year PFS (p=0.607) and OS estimates (p=0.554). There were no significant differences in 5-year PFS and OS estimates for patients treated with rituximab-chemotherapy (p=0.261) or conventional chemotherapy (p=0.227). Non-GCB subtype and m-IPI ≥ 2 were independently associated with shorter OS, and advanced stages of lymphoma were independently associated with shorter PFS.

A case of primary biliary cirrhosis that progressed rapidly after treatment involving rituximab

Primary biliary cirrhosis (PBC) is a progressive liver disease for which limited therapies are recommended. Rituximab, an anti-CD20 monoclonal antibody, is expected to be a useful therapeutic regimen for PBC. Previous studies indicated biochemical and immunological improvement in PBC after rituximab treatment. Although rituximab shows therapeutic potential for PBC, few cases have been reported and histological improvement and long-term outcome remain uncertain. Here, we report a case of PBC in a 66-year-old Japanese female patient who presented with a gastric lymphoma and who had been treated with a regimen containing rituximab for incidental malignant lymphoma. She showed biochemical and immunological improvements, and liver histology before and after rituximab treatment confirmed a decrease in liver inflammation. However, she developed liver cirrhosis a short time after rituximab treatment without biochemical or immunological worsening. Rituximab treatment for PBC might be considered and careful observation is required after treatment.

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

Gastrointestinal diffuse large B cell lymphoma (DLBCL) is a common subtype of extranodal lymphoma. There has been uncertainty about the clinical efficacy of combination therapy (surgery and chemotherapy) for gastrointestinal DLBCL. We retrospectively analyzed 114 patients with newly diagnosed gastrointestinal DLBCL from six medical centers. We evaluated four groups based on whether they were treated with or without surgery as the initial treatment for DLBCL, followed by either a regimen with cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP) or CHOP with rituximab (R-CHOP). For all patients, treatment with R-CHOP resulted in significantly greater overall survival (OS; 93.2 vs. 74.5%, p = 0.008) and progression-free survival (89.8% vs. 72.7, p = 0.029). Tumor resection did not improve OS (84.0 vs. 85.0%, for surgery and chemotherapy alone, respectively, p = 0.980). However, for younger patients, overall survival was greater (p = 0.005) for patients treated with surgery plus chemotherapy (83.9%) than for patients treated with chemotherapy alone (40.0%). Elevated serum lactate dehydrogenase level (p = 0.004) and performance status (Eastern Cooperative Oncology Group; p = 0.003) were independent predictors of survival in patients with gastrointestinal DLBCL. Stage-modified IPI was recognized as the best prognostic tool. There were significant differences among patients with low-risk, intermediate-risk, and high-risk groups in 50-month OS (94.2 vs. 84.0 vs. 66.7%, p = 0.008). The results of this large-scale study suggest that R-CHOP regimen is the first-line treatment for gastrointestinal DLBCL. The benefit of surgery for these patients remains controversial. Further prospective analyses are warranted.

High response rate and improvement of long-term survival with combined treatment modalities in patients with poor-risk primary thyroid diffuse large B-cell lymphoma: an International Extranodal Lymphoma Study Group and Intergruppo Italiano Linfomi study

The impact of different treatment modalities and prognostic factors on the clinical course of primary thyroid diffuse large B-cell lymphoma (PTDLBCL) is still the subject of research. This study was conducted to clarify these clinical aspects of this disorder. The clinical parameters of 48 patients with PTDLBCL at time of diagnosis were comparable to those of previous studies. Patients underwent either radiotherapy (RT)  ±  surgery (SX), chemotherapy (CHT) alone or in combination with local treatments (RT or SX), or SX followed by CHT and RT. A 90% complete remission (CR) rate was observed among patients who underwent combined treatment modalities (CTM), compared to 76% among the others. The 5-year progression-free survival differed significantly between both groups (p = 0.028). Poor performance status and advanced age correlated with decreased survival. PTDLBCL is a curable disease prevalent in elderly patients. Combined treatment modalities were able to induce an elevated rate of CR, improving long-term survival in younger patients. However, the outcome in elderly patients still remains unsatisfactory.

Primary cardiac lymphoma: an analysis of presentation, treatment, and outcome patterns

BACKGROUND

Primary cardiac lymphoma (PCL) represents a rare subset of non-Hodgkin lymphoma, characterized by poor outcomes. The authors aimed to construct a framework of known clinical presentations, diagnostic features, disease complications, treatment, and outcomes to improve prognostication.

METHODS

Individual patient data were obtained from defined cases of PCL (1949-2009) and systematically analyzed.

RESULTS

The authors report results of a review of 197 cases of PCL, with half of all cases reported since 1995. Survival was affected by 4 factors: immune status, left ventricular involvement, presence of extra-cardiac disease, and arrhythmia. Median overall survival (OS) for immunocompromised and immunocompetent was 3.5 months (m) and not reached, respectively (HR 0.29, 95% CI, 0.13-0.68; P = .004). LV involvement was uncommon (26%) and associated with an OS of only 1 m, whereas patients free of LV involvement had a median OS of 22 m (HR 0.28, 95% CI, 0.12-0.64; P = .002). Patients with extracardiac disease had shorter median OS compared with those without (6 m vs 22 m, HR 0.49, 95% CI, 0.26-0.91; P = .02). Those patients with an arrhythmia of any type had a median OS that was not reached (n = 55), whereas those without rhythm disturbances (n = 41) had median OS of 6 m (HR 0.51, 95% CI, 0.29-0.91; P = .024). Overall response rate to therapy was 84%, with long-term OS over 40%.

CONCLUSIONS

The current study presents the largest analysis of PCL to date. The data demonstrate that PCL is now more frequently diagnosed premortem and appears to have reasonable response rates. Lack of LV involvement and the presence of arrhythmias are associated with improved survival.

Primary gastric non-Hodgkin's lymphoma in Chinese patients: clinical characteristics and prognostic factors

Background

Optimal management and outcome of primary gastric lymphoma (PGL) have not been well defined in the rituximab era. This study aimed to analyze the clinical characteristics, prognostic factors, and roles of different treatment modalities in Chinese patients with PGL.

Methods

The clinicopathological features of 83 Chinese patients with PGL were retrospectively reviewed. Staging was performed according to the Lugano staging system for gastrointestinal non-Hodgkin's lymphoma.

Results

The predominant pathologic subtype among Chinese patients with PGL in our study was diffuse large B cell lymphoma (DLBCL), followed by mucosa-associated lymphoid tissue (MALT) lymphoma. Among the 57 patients with gastric DLBCL, 20 patients (35.1%) were classified as the germinal center B cell-like (GCB) subtype and 37 patients (64.9%) as the non-GCB subtype. The 83 patients had a five-year overall survival (OS) and event-free survival (EFS) of 52% and 59%, respectively. Cox regression analysis showed that stage-modified international prognostic index (IPI) and performance status (PS) were independent predictors of survival. In the 67 B-cell lymphoma patients who received chemotherapy, 36 patients treated with rituximab (at least 3 cycles) had a mean OS of 72 months (95% CI 62-81) versus 62 months (95% CI 47-76) for patients without rituximab treatment (P = 0.021).

Conclusion

The proportion of Chinese gastric DLBCL cases with non-GCB subtype was higher than the GCB subtype. Stage-modified IPI and PS were effective prognostic factors in Chinese patients with PGL. Our data suggested that primary gastric B-cell lymphoma might have an improved outcome with rituximab in addition to chemotherapy. More studies are necessary, preferentially large prospective randomized clinical trials to obtain more information on the impact of the rituximab in the primary gastric B-cell lymphoma.

Primary diffuse large B-cell lymphoma of the stomach

The stomach is the extranodal site most commonly involved by non-Hodgkin lymphomas. Diffuse large B-cell lymphoma is the most common histotype category arising in this organ. This is an aggressive lymphoma usually presenting as limited disease, being associated or not to Helicobacter pylori infection and mucosa-associated lymphoid tissue-type areas. Histopathological characteristics are similar to those reported for other diffuse large B-cell lymphomas. It occurs more frequently in males with a median age ranging between 50 and 60 years. With an adequate therapeutic strategy, its prognosis is good, with a 5-year overall survival near to 90%. Conservative treatment with anthracycline-containing chemotherapy, followed or not by involved-field radiotherapy has replaced gastrectomy as standard approach against this malignancy. Several questions on the best treatment remain unanswered. Among others, the role of rituximab, consolidation radiotherapy as well as of more conservative approaches like H. pylori-eradicating antibiotic therapy should be better defined.

Primary gastric lymphoma of T-cell origin: clinicopathologic features and treatment outcome

We conducted a retrospective analysis to investigate the natural history and the clinical outcome after treatment of primary gastric lymphoma of T-cell origin. Seventeen cases of T-cell origin among 444 primary gastric lymphoma patients were analyzed. The median age of the 14 male and 3 female patients was 49 years (range 22-76 years). The median progression-free survival (PFS) and overall survival (OS) were only 10 months (95% CI; 0-20 months), and 12 months (95% CI; 4-21 months), respectively. This study showed that the incidence of this subtype of T-cell gastric lymphoma was very rare, and had poor prognosis.

Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) for treatment of early-stage gastric diffuse large B-cell lymphoma

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) of the stomach is a relatively common disease. Recently, chemotherapy consisting of doxorubicin, cyclophosphamide, vincristine and prednisone (CHOP) has been reported as effective treatment for early-stage gastric DLBCL. Given the fact that the application of the CD20 antibody rituximab (R) in addition to CHOP has improved outcomes in nodal DLBCL, we have analysed our experience with application of R-CHOP in patients with early-stage gastric DLBCL.

PATIENTS AND METHODS

Patients with histologically verified early-stage gastric DLBCL undergoing treatment with R-CHOP for initial management were analysed.

RESULTS

Fifteen patients received a total of 79 cycles, with a median of six cycles per patient. All patients responded to therapy, 13 had a complete remission (CR) (87%) and two (13%) a partial remission. All patients in CR, except one who died unrelated to lymphoma, have remained so with a median follow-up of 15 months (range 4-42) after treatment. Subjective tolerance was moderate, and toxicities were mainly haematological, including leukocytopenia WHO grade 3 and 4 in 10 and five patients each. The addition of rituximab to the standard CHOP regimen did not appear to significantly increase toxicity.

CONCLUSIONS

Our data indicate that R-CHOP is an effective regimen for management of early-stage gastric DLBCL. However, given the excellent results with CHOP alone in such patients, the value of adding rituximab to standard CHOP remains to be determined in a randomised trial.

Monoclonal gammopathy in extranodal marginal zone lymphoma (ENMZL) correlates with advanced disease and bone marrow involvement

Monoclonal gammopathy is a well-recognized occurrence in splenic marginal zone lymphoma (MZL); however, its prevalence has never been reported in extranodal MZL (ENMZL). We present results of a retrospective analysis of 26 patients with newly diagnosed as well as previously treated ENMZL. Monoclonal gammopathy was detected in 7 out of 26 (27%) patients. All patients with a monoclonal gammopathy had stage IV disease, and most of them had involvement of lymph nodes and/or bone marrow (n = 6). Only 1 out of 7 patients with a monoclonal spike had stage IV disease diagnosed based on multifocal mucosal involvement. There was also a strong correlation between the involvement of bone marrow and the presence of a monoclonal spike (Fisher's exact test, P = 0.0007). Prevalence of monoclonal gammopathy is higher than previously recognized and indicates advanced disease. However, the prognostic significance of the presence of monoclonal gammopathy in this population is unknown.

Radiation therapy versus chemotherapy as initial treatment for localized nasal natural killer (NK)/T-cell lymphoma: a single institute survey in Taiwan

BACKGROUND

To clarify the role of intention to treat for patients with localized nasal natural killer (NK)/T-cell lymphoma, and to determine the prognostic factors for these patients.

PATIENTS AND METHODS

We conducted a retrospective review of 46 patients with localized nasal NK/T-cell lymphomas treated at a single institute between January 1988 and July 2002.

RESULTS

The type of intended treatment was a significant factor for overall survival (OS) (5-year OS: RT versus CT = 83.3% versus 28.6%, P = 0.0269) or failure-free survival (FFS) (5-year FFS: RT versus CT = 83.3% versus 27.1%, P = 0.0247). In the intended chemotherapy group, salvage with radiotherapy was superior to chemotherapy alone for OS (5-year OS: 42.2% versus 20.0%, P = 0.0252) or FFS (5-year FFS: 41.0% versus 20.0%, P = 0.0352). On multivariate analysis, both N stage and serum lactate dehydrogenase level were independent factors for OS and FFS. No radiotherapy was an independent adverse factor for OS; advanced T stage and more than one extranodal involvement were independent adverse factors for FFS.

CONCLUSIONS

Patients with localized nasal NK/T-cell lymphomas were better managed with radiotherapy as front-line therapy. The advantage of radiotherapy persisted even as palliative therapy after chemotherapy.

The role of surgery in primary gastric lymphoma: results of a controlled clinical trial

OBJECTIVE

We began a controlled clinical trial to assess efficacy and toxicity of surgery (S), surgery + radiotherapy (SRT), surgery + chemotherapy (SCT), and chemotherapy (CT) in the treatment of primary gastric diffuse large cell lymphoma in early stages: IE and II1.

SUMMARY BACKGROUND DATA

Management of primary gastric lymphoma remains controversial. No controlled clinical trials have evaluated the different therapeutic schedules, and prognostic factors have not been identified in a uniform population.

PATIENTS AND METHODS

Five hundred eighty-nine patients were randomized to be treated with S (148 patients), SR (138 patients), SCT (153 patients), and CT (150 patients). Radiotherapy was delivered at doses of 40 Gy; chemotherapy was CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) at standard doses. International Prognostic Index (IPI) and modified IPI (MIPI) were assessed to determine outcome.

RESULTS

Complete response rates were similar in the 4 arms. Actuarial curves at 10 years of event-free survival (EFS) were as follows: S: 28% (95% confidence interval [CI], 22% to 41%); SRT: 23% (95% CI, 16% to 29%); that were statistically significant when compared with SCT: 82% (95% CI, 73% to 89%); and CT: 92% (95% CI, 84% to 99%) (P < 0.001). Actuarial curves at 10 years showed that overall survivals (OS) were as follows: S: 54% (95% CI, 46% to 64%); SRT: 53% (95% CI, 45% to 68%); that were statistically significant to SCT: 91% (95% CI, 85% to 99%); CT: 96% (95% CI, 90% to 103%)(P < 0.001). Late toxicity was more frequent and severe in patients who undergoing surgery. IPI and MIPI were not useful in determining outcome and multivariate analysis failed to identify other prognostic factors.

CONCLUSION

In patients with primary gastric diffuse large cell lymphoma and aggressive histology, diffuse large cell lymphoma in early stage SCT achieved good results, but surgery was associated with some cases of lethal complications. Thus it appears that CT should be considered the treatment of choice in this patient setting. Current clinical classifications of risk are not useful in defining treatment.

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 nasal natural killer cell lymphoma: long-term treatment outcome and relationship with the International Prognostic Index

Nasal natural killer (NK) cell lymphoma is rare, so that its optimal therapy, long-term outcome, and prognostic factors are unclear. Data on 52 men and 15 women with well-characterized nasal NK cell lymphomas were analyzed retrospectively to define the impact of primary therapy on remission and long-term outcome and the validity of the International Prognostic Index (IPI). Most (84%) had stage I/II disease with an IPI score of 1 or less (52%). Seven patients received radiotherapy only; 47 patients received anthracycline-containing chemotherapy plus consolidation radiotherapy; and 12 patients received nonanthracycline-containing chemotherapy plus radiotherapy. The overall complete remission (CR) rate was 64.2%; the 20-year overall survival (OS) and disease-free survival (DFS) rates were 37.1% and 33.5%, respectively. Front-line radiotherapy was apparently better than chemotherapy for CR (100% versus 59%, P =.04) and OS (83.3% versus 32.0%, P =.03). Relapses occurred in 4 radiotherapy-treated (all local) and 14 chemotherapy-treated patients (9 local, 4 systemic). Among these, 5 late relapses (4 local, 1 systemic) occurred at 170 months (range, 92-348 months) from CR. The IPI score was of prognostic significance for the whole group (IPI <or= 1 superior to IPI >or= 2 for 20-year OS: 57.4% versus 27.6%, P = 0.012), as well as for patients treated with chemotherapy/radiotherapy (IPI <or= 1 superior to IPI >or= 2 for CR: 76.7% versus 35.7%, P =.017; and 10-year OS: 63.8% versus 26.8%, P =.003).

Gastrointestinal lymphoma

The ability to make treatment recommendations for patients with gastrointestinal lymphoma is hampered by a lack of prospective trials and by a lack of uniformity in classification and staging. Patients with gastric diffuse large B-cell lymphoma have traditionally been treated with surgery and many physicians continue to recommend this approach. However, recent data suggest that these patients can be treated with combination chemotherapy regimens in the same manner as patients with nodal presentations of diffuse large B-cell lymphoma. There is evidence to suggest that adjuvant radiotherapy may improve the outcome for these patients. The recognition that extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue is a distinct clinicopathologic entity and the elucidation of the pathogenic role of Helicobacter pylori has revolutionized the treatment of these gastric lymphomas. Patients with localized disease should be managed with antibiotic therapy initially. Radiation therapy is extremely effective for these patients, but it should probably be reserved for patients who fail anti-H. pylori treatment.

Treatment of extranodal lymphomas

At least one-quarter of the non-Hodgkin's lymphomas arise primarily at extranodal sites. The rising incidence of non-Hodgkin's lymphomas, observed over recent decades, have mainly affected the primary extranodal entities. Survival rates vary among the specific sites of primary extranodal lymphomas. This is due partly to differences in natural history, related mainly to the histological type but also to differences in management strategy which are related to organ-specific problems. Few controlled studies facilitate therapeutic decisions in this setting. This chapter represents a general overview of the available data.

The modified International Prognostic Index can predict the outcome of localized primary intestinal lymphoma of both extranodal marginal zone B-cell and diffuse large B-cell histologies

We have previously reported on the efficacy of a modified International Prognostic Index (MIPI) in predicting the outcome of patients with primary gastric lymphoma. This prompted the retrospective analysis of a large series of patients with primary intestinal lymphoma (PIL) of both diffuse large B-cell (DLCL) and low-grade (extranodal marginal zone B-cell lymphoma, MZL) histology. Clinical records of 122 patients with localized primary intestinal lymphoma of MZL (n=35) and DLCL (n=87) histology, confirmed by an ad hoc expert panel of pathologists, were reviewed. Forty-nine patients were treated with single therapy, while 72 received combined-modality treatment, which included surgery followed by a short-term chemotherapy. MIPI was included in a multivariate prognostic analysis for overall survival (OS) and event-free survival (EFS). Sixty-five patients (75%) with DLCL and 22 with MZL(65%) achieved complete remission. After a median follow-up of 42 months (range 6-163 months), 5-year estimates of OS and EFS were 68% and 50% for DLCL and 65% and 26% for MZL. OS varied according to MIPI, from, respectively, 86% and 87% for DLCL and MZL patients with 0-1 risk factor to 50% and 32% for patients with > 1 risk factor (P=0.01 and P=0.02). Similar results were obtained for EFS. Cox regression analysis showed an unfavourable MIPI to be the only independent predictor of shorter EFS. This retrospective study shows that stage-MIPI can be a reliable prognostic indicator for PIL of both low-grade MZL and diffuse large B-cell histology, enabling the early identification of patients at higher risk of failure.

Chemotherapy for management of localised high-grade gastric B-cell lymphoma: how much is necessary?

BACKGROUND

Recent data suggest that chemotherapy with the cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) regimen is a highly effective treatment for localised primary gastric lymphoma of diffuse large B-cell histology (DLBCL). We have reported that the large majority of patients achieve complete remission (CR) following three cycles of treatment, and now provide an updated series with special emphasis on patients receiving only short-term chemotherapy.

PATIENTS AND METHODS

All patients with a histologically verified diagnosis of gastric DLBCL in stages EI and EII(1) undergoing chemotherapy with the CHOP regimen were evaluated. Data analysed included clinical stage, histology [presence of an additional mucosa-associated lymphoid tissue (MALT) component], evidence of Helicobacter pylori infection, H. pylori eradication, time to CR, survival and regular restaging (i.e. after three and six cycles, respectively).

RESULTS

A total of 37 patients with DLBCL of the stomach with localised disease were identified, five of whom also had a MALT component. Twenty-two patients presented with stage EI and 15 with stage EII(1) disease. All patients were given chemotherapy as sole management of their lymphoma; 36 patients received CHOP, while one patient was given CHOP along with rituximab. Thirty-two (86%) achieved a CR after a maximum of three cycles, while only four patients had to be given six cycles for CR. In total, nine of 37 patients (24%) discontinued therapy earlier than scheduled: one patient received one cycle, two received two, six received three and one patient received four cycles. Two of these patients stopped treatment due to toxicity, i.e. protracted thrombocytopenia or chemotherapy extravasation. One additional patient died after one cycle of treatment; autopsy disclosed no signs of remaining lymphoma. Three patients have died after a median follow-up of 39 months (including the one patient who discontinued therapy after one cycle of treatment), while the remaining 34 patients are alive without evidence of disease. Twenty-four out of 37 patients (65%) had also undergone H. pylori eradication (including six of nine patients receiving only short-term treatment).

CONCLUSIONS

DLBCL of the stomach appears to be a highly chemosensitive disease. Our data question the need for full-term CHOP treatment in patients achieving CR upon first follow-up. However, recent data suggest that additional H. pylori eradication might have contributed to the excellent results achieved in our series.

Primary gastrointestinal non-Hodgkin's lymphoma: I. Anatomic and histologic distribution, clinical features, and survival data of 371 patients registered in the German Multicenter Study GIT NHL 01/92

PURPOSE

The study was initiated to obtain epidemiologic data and information on anatomic and histologic distribution, clinical features, and treatment results in patients with primary gastrointestinal non-Hodgkin's lymphomas (PGI NHL).

PATIENTS AND METHODS

Between October 1992 and November 1996, 371 PGI NHL patients were eligible to evaluate clinical features. Radiotherapy and chemotherapy were stratified according to histologic grading, stage, and whether surgery had been carried out or not.

RESULTS

A total of 74.8% patients had gastric NHL (PGL). Within the intestine, the small bowel and the ileocecal region were involved in 8.6% and 7.0% of the cases, respectively. Multiple GI involvement (MGI) was 6.5%. Approximately 90% of the GI NHL were in stages IE/IIE. Aggressive NHL accounted for the majority, with a distinguishable pattern in several sites. Forty percent of PGL were of low-grade mucosa-associated lymphatic tissue type. One third of large-cell lymphomas had low-grade components. Most intestinal NHL were germinal-center lymphomas. The site of origin was prognostic. In gastric and ileocecal lymphoma, event-free (EFS) and overall survival (OS) were significantly higher as compared with the small intestine or MGI (median time of observation, 51 months). In PGL, localized disease was prognostic for EFS and OS. Histologic grade influenced only EFS significantly. Numbers in intestinal lymphomas were too small for subanalyses.

CONCLUSION

PGI NHL are heterogeneous diseases. The number of localized PGL allowed for detailed analyses. Larger studies are needed for stages III and IV and for intestinal NHL. A uniform reporting system for PGI NHL, in terms of definitions and histologic and staging classifications, is needed to facilitate comparison of treatment results.

Primary gastrointestinal non-Hodgkin's lymphoma: II. Combined surgical and conservative or conservative management only in localized gastric lymphoma--results of the prospective German Multicenter Study GIT NHL 01/92

PURPOSE

The aim of the study was to obtain data on anatomic and histologic distribution, clinical features, and treatment results of patients with primary gastrointestinal non-Hodgkin's lymphomas, particularly combined surgical and conservative treatment (CSCT) versus conservative treatment (CT) alone for primary gastric lymphoma (PGL) in localized stages.

PATIENTS AND METHODS

Whether the treatment included surgery was left to the discretion of each participating center. Radiotherapy (Rx) and chemotherapy were stratified according to histologic grading, stage, and the inclusion or omission of surgery as follows: patients with low-grade PGL were treated with extended-field (EF) Rx (30 Gy). In case of residual tumor after surgery or in case of CT only (in stage IIE after six cycles of cyclophosphamide, vincristine, and prednisone), an additional boost of 10 Gy was given. All patients with high-grade PGL were treated with four (stage IE) or six (stage IIE) cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone followed by EF Rx (stage IE) or involved-field (IF) Rx (stage IIE). Rx dosage corresponded to low-grade NHL.

RESULTS

Between October 1992 and November 1996, 106 patients had CT only. The survival rate (SR) after 5 years was 84.4% and was influenced neither by patients' characteristics nor by stage or histologic grade. Seventy-nine patients had CSCT. Their SR was 82.0%. Complete resection of the tumor (R0) was prognostic for the overall survival (P =.0165) as compared with incomplete resection.

CONCLUSION

Although the study was not randomized, a stomach-conserving approach may be favored.

Localized non-Hodgkin's lymphoma of Waldeyer's ring: clinical features, management, and prognosis of 130 adult patients

BACKGROUND

Waldeyer's ring (WR) is the primary site of non-Hodgkin's lymphoma (NHL) involvement in approximately 5% to 10% of all lymphoma patients, and it accounts for more than half of all primary extranodal lymphomas of the head and neck. Materials and Methods A retrospective review was performed of 130 adult patients with localized (stages I and II) WR-NHL seen at a single institution over 18 years.

RESULTS

Patients had a median age of 55 years, and the male-female ratio was 1:5:1. Seventy five (58%), 46 (35%), and 9 (7%) patients had primary tonsillar, nasopharyngeal, and base of the tongue lymphoma, respectively. Forty-five (35%) and 85 (65%) had stage I and stage II disease, respectively. Most patients (109 patients, 84%) had diffuse large B-cell NHL (DLC). Chemotherapy (CT) was given to 58 (45%) patients, whereas 26 (20%) received radiation therapy (RTX), and 46 (35%) were managed with a combination of chemotherapy and radiotherapy (CMT). One hundred nine (84%), 16 (12%), and 5 (4%) patients attained complete remission (CR), partial remission (PR), and treatment failure, respectively, with no difference in CR rates between the three therapeutic modalities. Of those patients with DLC, 90 (83%), 15 (14%), and 4 (3%) demonstrated CR, PR, and treatment failure, respectively. In a multivariate analysis, the modified International Prognostic Index (IPI) was found to predict the attainment of CR. Over a median follow-up of 49 months; 76 (58%) of the patients were alive and disease-free, 5 (4%) were alive with evidence of disease, and the remaining 49 (38%) were dead. Most distant relapses were in nongastrointestinal extranodal sites. The median overall survival (OS) has not been reached; however, the projected 5-year OS was 58%. No OS difference was noted between patients with stage I and stage II. Cox proportional hazards model identified primary tonsillar site and a low-risk group as defined by the modified IPI were associated with favorable OS. The median event-free survival was 82.3 months, with the primary tonsillar site, and low-risk modified IPI group were associated with favorable EFS in a multivariate analysis. Probably because of the high frequency of patients with DLC, the outcome and the prognostic factors in those patients were not distinctive from those for the whole group. The CMT was not associated with a superior OS compared with either of the single modality treatments; however, it was associated with more favorable EFS.

CONCLUSIONS

This series characterized the clinicopathologic features and outcome of adult patients with early stage WR-NHLs. No survival difference was noted between stage I and stage II, and the outcome was favorable. Primary tonsillar site and the low-risk group of the modified IPI predicted favorable OS and EFS. CMT is probably superior to single modality treatment; however, prospective studies are warranted.