The importance of endoscopic ultrasonography in the management of low-grade gastric mucosa-associated lymphoid tissue lymphoma

Effectiveness of Helicobacter pylori eradication in the treatment of early-stage gastric mucosa-associated lymphoid tissue lymphoma: An up-to-date meta-analysis

BACKGROUND

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma (GML) is usually a low-grade B-cell neoplasia strongly associated with Helicobacter pylori (H. pylori)-induced chronic gastritis. Clinical practice guidelines currently recommend H. pylori eradication as the preferred initial treatment for early-stage GML. To determine the practical effect of bacterial eradication as the sole initial therapy for early-stage GML, an updated analysis and review of available evidence is imperative.

AIM

To perform a meta-analysis to assess the rate of complete remission (CR) of H. pylori-positive early-stage GML following bacterial eradication.

METHODS

We performed independent, computer-assisted literature searches using the PubMed/MEDLINE, Embase, and Cochrane Central databases through September 2022. Prospective and retrospective observational studies evaluating the CR of early-stage GML following bacterial eradication in H. pylori-positive patients. The risk of bias was assessed using Joanna Briggs Institute (JBI) Critical Appraisal Tools. The pooled estimate of the complete histopathological remission rate and respective confidence intervals (95%CI) were calculated following the random-effects model. Heterogeneity and inconsistency were assessed using Cochran's Q test and I2 statistic, and heterogeneity was defined as P < 0.01 and I² > 50%, respectively. Subgroup and meta-regression analyses were conducted to explore potential sources of heterogeneity.

RESULTS

The titles and abstracts of 1576 studies were screened; 96 articles were retrieved and selected for full-text reading. Finally, 61 studies were included in the proportional meta-analysis (P-MA). Forty-six were prospective and fifteen were retrospective uncontrolled, single-arm, observational studies. The overall risk of bias was low to moderate in all but a single report, with an average critical appraisal score across all studies of 79.02%. A total of 2936 H. pylori-positive early-stage GML patients, in whom H. pylori was successfully eradicated, were included in the analysis. The pooled CR of H. pylori-positive early-stage GML after bacterial eradication was 75.18% (95%CI: 70.45%-79.91%). P-MA indicated the substantial heterogeneity in CR reported across studies (I 2 = 92%; P < 0.01). Meta-regression analysis identified statistically significant effect modifiers, including the proportion of patients with t(11;18)(q21;q21)-positive GML and the risk of bias in each study.

CONCLUSION

Comprehensive synthesis of available evidence suggests that H. pylori eradication is effective as the sole initial therapy for early-stage GML. Although the substantial heterogeneity observed across studies limits the interpretation of the pooled overall CR, the present study is a relevant to informing clinical practice.

Value of staging information provided by linear-array endoscopic ultrasound for therapeutic response and prognosis prediction in gastric lymphoma

OBJECTIVES

Currently, positron emission tomography/computed tomography (PET/CT)-based Ann Arbor and Lugano staging systems are widely applied for gastric lymphoma, which majorly focused on the extent of systemic invasion, but there is insufficient assessment in extent of gastric wall invasion. Thus, we aimed to assess the value of linear-array EUS in therapeutic response and prognosis prediction, and provide an endoscopic ultrasound (EUS)-based staging system for gastric lymphoma.

METHODS

Between January 2012 and October 2019, 191 patients with histologically confirmed gastric lymphoma were included. We analyzed patients' clinicopathologic data, white-light appearance, EUS staging, tumor extension, and therapeutic regime to identify the predictors for complete remission (CR) and progression-free survival (PFS).

RESULTS

With a median follow-up period of 547 days, 136 patients achieved CR. Multivariate regression analysis identified EUS T stage three CR predictors, including T stage (T2-T4 vs. T1, OR = 0.271, 95% confidence interval (CI) = 0.108-0.683, P = 0.0085) was the independent predictor. The Ki67 index, lesion surface, EUS stage, tumor extension, and regime predicted PFS, but tumor extension was the only independent predictor (local vs. system, OR = 6.005, 95%CI = 2.365-15.236, P < 0.001). The concordance index (C-index) was higher for CR rate in the EUS-based staging [0.673; 95% CI = 0.628-0.718] than Lugano staging [0.663; 95% CI 0.616-0.710], and for PFS in the EUS-based staging [0.694; 95% CI 0.586-0.802] than Lugano staging [0.684; 95% CI 0.564-0.804].

CONCLUSIONS

An EUS-based staging system is suitable for CR and PFS prediction in gastric lymphoma, with highly informative assessment in extent of gastric wall invasion.

The value of EUS in combination with cytological, flow cytometry, and gene rearrangement in the diagnosis of gastrointestinal lymphoma

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) have a great value in clinical practice of gastrointestinal lymphoma (GIL). Auxiliary methods such as flow cytometry (FCM) and gene rearrangement provide additional information for the diagnosis. Current study aims to explore the diagnostic value of EUS-FNA combined with FCM and gene rearrangement for GIL in our single institution. Suspected GIL cases, which were referred to EUS, FNA, FCM, or gene rearrangement examination, were retrospectively reviewed from January 2011 to May 2014. Definitive final diagnosis was included based on the pathological and immunostaining evidence. The gene scan analysis was applied for fragment detection in gene rearrangement. The sensitivity, specificity, and accuracy were considered and calculated. Fifty-three EUS cases were identified, including 38 GIL, 10 inflammations, 4 linitis plastica, and one multiple myeloma. EUS-FNA was successfully conducted in 39 out of 53 cases. After combined with FCM, the sensitivity, specificity, and accuracy were increased from 60.7% to 76.9%, 90.9% to 100%, and from 69.2% to 81.8% respectively. Among 33 cases for FCM, 11 of them gained positive B or T non-Hodgkin lymphoma diagnosis, and 28 out of 53 specimens were delivered for gene rearrangement. The sensitivity, specificity, and accuracy of gene rearrangement were 68.2%, 100%, and 75% respectively. EUS-FNA is a possible technique for the diagnosis of GIL, With additional FCM examination may further improve the diagnostic efficiency and facilitate subclassification. Moreover, gene rearrangement assay by gene scan is also a considerable method in the specimens from GIL. Copyright © 2016 John Wiley & Sons, Ltd.

Radiological Features of Gastrointestinal Lymphoma

Gastrointestinal lymphomas represent 5–20% of extranodal lymphomas and mainly occur in the stomach and small intestine. Clinical findings are not specific, thus often determining a delay in the diagnosis. Imaging features at conventional and cross-sectional imaging must be known by the radiologist since he/she plays a pivotal role in the diagnosis and disease assessment, thus assisting in the choice of the optimal treatment to patients. This review focuses on the wide variety of imaging presentation of esophageal, gastric, and small and large bowel lymphoma presenting their main imaging appearances at conventional and cross-sectional imaging, mainly focusing on computed tomography and magnetic resonance, helping in the choice of the best imaging technique for the disease characterization and assessment and the recognition of potential complications.

Reoperative Heller Myotomy: More Pain, Less Gain

Heller myotomy provides durable and effective treatment of achalasia. Due to recurrence or persistence of symptoms, a small subset of patients seeks reoperation. This study was undertaken to determine if reoperative Heller myotomy provides salutary amelioration of symptoms. 609 patients undergoing laparoscopic Heller myotomy between 1992 to 2013 were prospectively followed; 38 underwent reoperative myotomy. Patients graded their symptom frequency and severity before and after myotomy on a Likert scale. Median data are reported. Patients undergoing reoperative myotomy, when compared to those undergoing their first myotomy, experienced a higher conversion rate to an “open” myotomy (8% vs 1%, P < 0.05) and a longer length of stay (3 vs 1 day, P < 0.05). Reoperative myotomy led to improvement in symptoms, but the magnitude of improvement in symptoms (e.g., dysphagia, choking, and coughing) was less than for patients undergoing their first myotomy (all P < 0.05). Patients undergoing reoperative Heller myotomy were less likely to report symptoms occurring once per month or less (83% vs 56%, P < 0.01). Patients undergoing reoperative myotomy note improvement in symptoms, although to a lesser extent than patients undergoing their first myotomy. Patients undergoing reoperative Heller myotomy can expect to experience less improvement of symptoms, denoting the importance of the first myotomy.

Helicobacter pylori infection in gastric mucosa-associated lymphoid tissue lymphoma

Gastrointestinal lymphoma is the most common type of extranodal lymphoma, and most commonly affects the stomach. Marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) and diffuse large B-cell lymphoma are the most common histologic types of gastric lymphoma. Despite its increasing incidence, diagnosis of gastric lymphoma is difficult at an earlier stage due to its nonspecific symptoms and endoscopic findings, and, thus, a high index of suspicion, and multiple, deep, repeated biopsies at abnormally and normally appearing sites in the stomach are needed. In addition, testing for Helicobacter pylori (H. pylori) infection and endoscopic ultrasonography to determine the depth of tumor invasion and involvement of regional lymph nodes is essential for predicting response to H. pylori eradication and for assessment of disease progression. In addition, H. pylori infection and MALT lymphoma development are associated, and complete regression of low-grade MALT lymphomas after H. pylori eradication has been demonstrated. Radiotherapy and/or chemotherapy can be used in cases that show poor response to H. pylori eradication, negativity for H. pylori infection, or high-grade lymphoma.

Prognostic assessment and treatment of primary gastric lymphomas: how endoscopic ultrasonography can help in tailoring patient management

Endoscopic ultrasonography (EUS) has recently gained a pivotal role in the management of gastric lymphomas, especially in the diagnostic workup. Its accuracy and reliability have overcome those of other imaging techniques, such that it represents an invaluable tool for the management of gastric lymphomas. Although this technique is operator dependent, its application in large series has proved its reliability. Thus, it has generally been considered a useful tool for providing information crucial in deciding the treatment program, especially for mucosa-associated lymphoid tissue (MALT) lymphomas, for which EUS can provide an accurate evaluation of disease extension and treatment response probability. Limited-stage disease, confined to the submucosa, has a greater probability to respond to sole Helicobacter pylori eradication. In contrast, the value of EUS in response assessment and follow-up monitoring is still debated, with discordant opinions about its reliability and clinical advantages, because normalization of the EUS findings occurs with a considerable delay compared to the histologic evaluation. In the follow-up setting, preliminary data have indicated that persistently positive EUS findings in low-grade gastric lymphoma could represent a warning for a possible relapse. However, in high-grade gastric lymphoma, such findings do not have any clinical implications.

Review of the molecular profile and modern prognostic markers for gastric lymphoma: how do they affect clinical practice?

Primary gastric lymphoma is a rare cancer of the stomach with an indeterminate prognosis. Recently, a series of molecular prognostic markers has been introduced to better describe this clinical entity. This review describes the clinical importance of several oncogenes, apoptotic genes and chromosomal mutations in the initiation and progress of primary non-Hodgkin gastric lymphoma and their effect on patient survival. We also outline the prognostic clinical importance of certain cellular adhesion molecules, such as ICAM and PECAM-1, in patients with gastric lymphoma, and we analyze the correlation of these molecules with apoptosis, angiogenesis, tumour growth and metastatic potential. We also focus on the host-immune response and the impact of Helicobacter pylori infection on gastric lymphoma development and progression. Finally, we explore the therapeutic methods currently available for gastric lymphoma, comparing the traditional invasive approach with more recent conservative options, and we stress the importance of the application of novel molecular markers in clinical practice.

Endoscopic ultrasonography in gastric lymphomas: appraisal on reliability in long-term follow-up

The reliability of endoscopic ultrasonography (EUS) in follow-up management of gastric lymphomas has not been clearly validated. We conducted a retrospective analysis on 23 patients, 12 affected by mucosa-associated lymphoid tissue (MALT) lymphoma, eight by diffuse large B-cell lymphoma, and three by high-grade lymphoma with low-grade component, all treated with a stomach-conservative approach. One hundred and twenty matched evaluations with both EUS and endoscopy with biopsy (E-Bx) were performed, according to validated guidelines and clinical judgment. At a median follow-up of 87 months ranged between 9.5 and 166 months, the analysis of progression-free survival and disease-free survival showed a strict relationship between the persistence of EUS abnormalities and the clinical outcome in patients with MALT lymphoma (p = 0.0079; p = 0.02) but not in patients with high-grade lymphoma. In conclusion, EUS evaluation does not seem reliable in follow-up management of high-grade lymphomas, although it could have a great clinical impact in the management of MALT lymphoma.

Effects of Helicobacter pylori eradication on early stage gastric mucosa-associated lymphoid tissue lymphoma

BACKGROUND & AIMS

Different remission rates of gastric low-grade, B-cell, mucosa-associated lymphoid tissue (MALT) lymphoma have been reported after Helicobacter pylori eradication. We assessed the long-term remission and relapse rates of early stage MALT lymphoma in patients treated only by H pylori eradication and identified factors that might predict outcome.

METHODS

This systematic review analyzed data from 32 studies, including 1408 patients.

RESULTS

The MALT lymphoma remission rate was 77.5% (95% confidence interval, 75.3-79.7), and was significantly higher in patients with stage I than stage II(1) lymphoma (78.4% vs 55.6%; P = .0003) and in Asian than in Western groups (84.1% vs 73.8%; P = .0001). Neoplasia confined to the submucosa regressed more frequently than that with deeper invasion (82.2% vs 54.5%; P = .0001); patients with lymphoma localized to the distal stomach experienced regression more frequently than those with lymphoma of the proximal stomach (91.8% vs 75.7%; P = .0037). The remission rate was higher among patients without the API2-MALT1 translocation than in those with this translocation (78% vs 22.2%; P = .0001). In an analysis of data from 994 patients, 7.2% experienced lymphoma relapse during 3253 patient-years of follow-up evaluation, with a yearly recurrence rate of 2.2%. Infection and lymphoma were cured by additional eradication therapy in all patients with H pylori recurrence (16.7%). Five (0.05%) of the patients initially cured of lymphoma developed high-grade lymphoma within 6 to 25 months of therapy.

CONCLUSIONS

H pylori eradication is effective in treating approximately 75% of patients with early stage gastric lymphoma. Long-term follow-up evaluation of these patients is needed to detect early lymphoma relapse or progression.

Staging role of EUS

Type of lymphoma and stage of disease are the two decisive prognostic factors and therapeutic determinants. For the locoregional staging, i.e. assessment of the gastric wall infiltration and perigastric lymphonodular involvement, endoscopic ultrasound (EUS) is highly useful. EUS has, therefore, to be integrated into the standard staging procedure of gastric lymphoma, although its impact on initial treatment decisions might be limited in the individual case. A benefit from the use of miniechoendoscopes, EUS elastography and EUS-guided biopsies has not yet been proven in gastric lymphoma. EUS also confers an important prognostic value regarding treatment responses to Helicobacter pylori eradication. On the contrary, EUS cannot be recommended as a regular part of follow-up investigations considering its limited value in predicting the response of the lymphoma to radiation or chemotherapy.

Eradication therapy for Helicobacter pylori in patients with gastric MALT lymphoma: a pooled data analysis

OBJECTIVES

Helicobacter pylori eradication is recognized as the initial therapy for gastric low-grade, B-cell, mucosa-associated lymphoid tissue (MALT) lymphoma. This study assesses (i) the H. pylori eradication rates for various first- and second-line and rescue therapies and (ii) the associated reinfection rates in patients.

METHODS

Pooled data analysis of systematic review of the literature was performed in this study.

RESULTS

Data from 34 studies with 1,271 treated patients were used. After first-line therapy, the infection was cured in 91% (95% confidence interval (CI)=89.4-92.5) of cases, the eradication rate being higher after dual therapy compared with the 7- or 14-day triple therapies (P=0.0525). After second-line therapy, the eradication rate was 80.8% (95% CI=82.7-95.1), being higher after triple rather than quadruple therapy. Further therapies (from three to five attempts) cured the infection in 75% of patients. H. pylori infection was ultimately cured in 1,250 patients, resulting in eradication rates of 98.3% (95% CI=97.6-99) and 99.8% (95% CI=99.6-100) at intention-to-treat and per-protocol analysis levels, respectively. Bacterial reinfection occurred in 18 (2.7%; 95% CI=1.4-3.9) of 676 patients who were followed-up (0.7% yearly). Overall, gastric lymphoma remission was achieved in 973 (77.8%) of 1,250 patients successfully cured of H. pylori infection.

CONCLUSIONS

This was the first comprehensive ( approximately 1,300 patients) analysis of the therapeutic management of H. pylori in gastric lymphoma patients. Data suggest that this infection is easily managed in these patients, being cured in nearly all cases.

Management and long-term follow-up of early stage H. pylori-associated gastric MALT-lymphoma in clinical practice: an Italian, multicentre study

BACKGROUND/AIM

Data on management and long-term follow-up of Helicobacter pylori-associated MALT-lymphoma in clinical practice are scanty. We evaluate the long-term efficacy of H. pylori eradication on low-grade MALT-lymphoma, and the efficacy of further therapies in refractory patients.

METHODS

This study enrolled patients with stages I-II(1) MALT-lymphoma and H. pylori infection. H. pylori eradication was attempted in all patients. Patients with lymphoma persistence or progression following H. pylori treatments received further lymphoma treatments. Both 5-year and disease-free survivals were calculated.

RESULTS

Sixty patients (stage I/II(1): 50/10) were followed up for a median time of 65 months (range 7-156). H. pylori infection was successfully eradicated in 53 (88.3%) patients following three consecutive therapeutic attempts, and lymphoma regressed in 42 (79.2%) of these patients. Sixteen patients received anti-neoplastic treatments due to either lymphoma persistence or progression, and lymphoma was cured in 14 (87.5%) cases. At follow-up, lymphoma relapsed in 13/42 (30.9%) patients within a median time of 19 months (range 3-41), and all but 1 patient were cured with further therapies. Overall, lymphoma regression was achieved in 56 patients (93.3%). The 5-year and disease-free survivals were 94.7% and 74.6%, respectively.

CONCLUSIONS

In clinical practice, a conservative approach with antibiotic eradication seems to be appropriate management for early-stage MALT-lymphoma, with oncologic therapy being reserved for those patients who fail to respond to H. pylori therapy.

Treatment of low-grade gastric MALT-lymphoma unresponsive to Helicobacter pylori therapy: a pooled-data analysis

The most favourable therapeutic strategy for gastric MALT-lymphoma not responding to Helicobacter pylori eradication still remains unclear, neither official guidelines nor randomised studies being available. We therefore performed a systematic review of the literature to evaluate the efficacy of different therapeutic approaches in these patients. Data regarding 315 patients were valuable, and lymphoma remission following the first therapeutic attempt was achieved in 90.1% cases. The most used therapy was radiotherapy (112 patients), followed by surgery (80 patients) and chemotherapy (68 patients), whilst a combination therapy was less frequent. Radiotherapy achieved a higher remission rate as compared to chemotherapy (97.3 vs. 85.3%; P = 0.007), being similar to surgery (97.3 vs. 92.5%; P = 0.2). No difference emerged when comparing lymphoma remission rate achieved by a single therapy with that of combined treatments (89.6 vs. 96.4%; P = 0.6). This is the first pooled-data analysis assessing the efficacy of different oncologic therapeutic approaches to treat gastric MALT-lymphoma unresponsive to H. pylori eradication. Radiotherapy seems to be the most suitable treatment in these patients.

Endoscopic diagnosis and staging of mucosa-associated lymphoid tissue lymphoma

PURPOSE OF REVIEW

The role of endoscopy, including endoscopic ultrasound, in the diagnosis and management of mucosa-associated lymphoid tissue lymphomas of the stomach has evolved steadily in the last two decades. The present review summarizes recent findings and puts them in context with studies on the diagnosis and management of mucosa-associated lymphoid tissue lymphoma published earlier.

RECENT FINDINGS

Several recent studies have emphasized the crucial role of endoscopic ultrasound in treatment planning in patients with gastric mucosa-associated lymphoid tissue lymphoma. This is important as early-stage gastric mucosa-associated lymphoid tissue lymphomas can be managed just by the eradication of Helicobacter pylori by appropriate antibiotic regimens. However, the more advanced lesions are treated with much more invasive treatment regimens involving radical gastrectomy, chemotherapy or radiation, or all.

SUMMARY

Endoscopic ultrasound staging is highly accurate in predicting response to Helicobacter pylori eradication in patients with gastric mucosa-associated lymphoid tissue lymphoma. Normalization of gastric wall thickness and architecture can be used to monitor tumor regression following treatment. Endoscopic ultrasound findings can also be used to identify treatment failures and relapses and can help identify patients who need more aggressive therapy.

The value of EUS in predicting the response of gastric mucosa-associated lymphoid tissue lymphoma to Helicobacter pylori eradication

BACKGROUND

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is associated with Helicobacter pylori infection, and regression of the tumor has been described after its eradication.

OBJECTIVE

To determine the value of EUS, in addition to other clinical/endoscopic features, in predicting the response of low-grade MALT lymphoma to H pylori eradication.

DESIGN

A retrospective, single-center study.

SETTING AND PATIENTS

Twenty-two patients with primary gastric MALT lymphoma were identified through a retrospective review of charts of patients seen at the American University of Beirut Medical Center. Only 19 patients with histopathologically confirmed gastric MALT lymphoma and H pylori infection who had EUS staging were included in the study.

MAIN OUTCOME MEASUREMENTS

Regression of the gastric MALT lymphoma as determined by follow-up endoscopy and mucosal biopsies.

RESULTS

Patients with disease restricted to the gastric mucosa had a significantly higher rate of complete remission after H pylori eradication compared with patients who had disease infiltrating into the gastric submucosa (77.8% vs 12.5%, P value .007). There was no statistical difference in terms of the mean follow-up time to achieve such response (P value .212). Age, sex, location of the tumor within the stomach, and endoscopic appearance did not correlate with the probability of complete remission of the MALT lymphoma.

LIMITATIONS

The limitations include a retrospective design and a relatively small sample population.

CONCLUSION

EUS determination of the invasion depth of gastric MALT lymphoma helps predict a complete response to H pylori eradication.

Primary gastric lymphoma pathogenesis and treatment: what has changed over the past 10 years?

Primary gastric (PG) lymphomas are generally non-Hodgkin lymphomas (NHL). They represent 5% of gastric malignancies and show an apparently increasing incidence worldwide. The most common histological subtypes are diffuse large B-cell and marginal zone B-cell NHL of the mucosa-associated lymphoid tissue (MALT)-type. Pathogenesis is often related to Helicobacter pylori infection (HPI). There is still no consensus on the optimal treatment for PG lymphoma. Nowadays surgery is limited to rare cases and radiotherapy--combined or not with chemotherapy--represents an effective therapeutic option ensuring long-term, organ-salvage benefits mainly in aggressive histological subtypes. Additionally, the description of MALT lymphomas has made the situation even more complex, because antibiotics alone can induce lasting remissions in those cases associated with HPI. Consequently, a global therapeutic approach to the cure of PG-NHL has completely changed over the last 10 years: innovative, conservative options to reduce treatment toxicity, thus preventing systemic relapses, have made their appearance and are on the rise.

Is endoscopic ultrasound clinically useful for follow-up of gastric lymphoma?

BACKGROUND

Endoscopic ultrasound (EUS) is considered the best technique for locoregional staging at diagnosis but its role in the follow-up of patients with gastric lymphoma after organ-conserving strategies has not been established.

DESIGN AND METHODS

We retrospectively evaluated 23 patients with primary gastric lymphoma treated with a stomach-conservative approach. Sixteen of them were affected by MALT lymphoma and seven by diffuse large-B-cell lymphoma (DLBCL). Five patients were treated with Helicobacter pylori (HP) eradication therapy alone (omeprazole + amoxicillin + clarithromycin); eight patients received a treatment including HP eradication and chemotherapy and the remaining 10 patients were treated with chemotherapy alone.

RESULTS

At the end of treatment, a complete remission was documented in 21 (91%) patients by endoscopy with biopsy (E-Bx) but in only seven (30%) patients by EUS. A total of 99 evaluations with both EUS and E-Bx were evaluated and we found concordance between the two methods in 33 occasions (33%) only. No significant difference on the percentage of concordance was recorded between MALT and DLBCL. After a median follow-up of 36.5 months we have not observed any relapse in 12 patients (six DLBCL and six MALT) with a persistent positive EUS but negative E-Bx.

CONCLUSIONS

Although the length of follow-up cannot exclude late relapse, we think that in restaging and follow-up of gastric lymphoma, EUS seems not to be a reliable tool if it is abnormal and E-Bx still remains the gold standard. Therefore, after conventional conservative treatment, persistence of EUS abnormality with a negative histology should not be considered as a clinically relevant persistence of disease and should not be a reason for further treatment.

Multicentre retrospective study on endoscopic ultrasound complications

BACKGROUND

Endoscopic ultrasonography, both conventional and interventional, has been used increasingly during the past 20 years and is deemed a safe technique. Its complication rate, however, has been studied to only a limited extent. This multicentre investigation sought to establish the complication rate for a large number of endoscopic ultrasonography procedures.

METHODS

By means of a questionnaire, we collected data from six centres on the number of endoscopic ultrasonography examinations performed and divided them into conventional and interventional examinations of the upper and lower gastrointestinal tract. Information was obtained on technical modalities such as instruments and sedation and, for interventional endoscopic ultrasonography, indications, pre-procedural exams and technical details (needle calibre, number of passes) had to be specified. Complications were classified as mild, moderate, severe or fatal and their onset as immediate, early or late. Variables that entered into the analysis of complication rate included type of endoscopic ultrasonography instrument used, type and site of lesion biopsied, number of needle passes and operator experience.

RESULTS

Eleven thousand five hundred thirty nine endoscopic ultrasonographic procedures were reported, of which 10,731 were conventional and 808 interventional. No deaths occurred; there were 14 (0.12%) complications, 5 (0.046%) of them following conventional endoscopic ultrasonography and 9 (1.11%) after interventional endoscopic ultrasonography. Seven complications were mild, four moderate and three severe.

CONCLUSIONS

Both conventional and interventional endoscopic ultrasonography were confirmed to be acceptably safe techniques.

Primary gastrointestinal lymphomas: A radiological-pathological review. Part 1: Stomach, oesophagus and colon

Primary gastrointestinal lymphomas are most common in the stomach, followed by small intestine and then colon. The most frequently used pathology classification of lymphomas is the Revised European and American Lymphoma /World Health Organization classification. The correlation of radiological morphology with histology is relatively poor, although characteristic subtypes will be discussed. In the stomach, the majority of primary lymphomas are of B-cell origin of mucosa-associated lymphoid tissue (MALT) type. Low-grade MALT lymphomas are associated with Helicobacter pylori infection and often respond to eradication of this organism. Radiological features include thickened folds, nodularity, depressed lesions, ulcers, prominent areae gastricae. High-grade (large B-cell) tumour patterns include infiltrative, polypoid, nodular, ulcerated or a combination. Endoscopy, endoscopic ultrasound and CT are important in diagnosis and staging, although appearances on barium studies should be recognized. Primary colonic lymphomas are rare. Most are of B-cell origin. Focal and diffuse forms are seen, the former producing polypoid or nodular or cavitating masses and the latter producing ulcerative or nodular (polyposis) patterns on imaging. Even when circumferential, lymphoma rarely causes obstruction. Small bowel lymphomas will be discussed in the forthcoming part 2 of this review.

EUS-guided FNA combined with flow cytometry in the diagnoses of suspected or recurrent intrathoracic or retroperitoneal lymphoma

BACKGROUND

Limited data exist on the combined use of EUS-guided FNA (EUS-FNA) and flow cytometry (FC) in the diagnosis of lymphoma. The aim of this study was to evaluate the accuracy of EUS-FNA combined with FC in the diagnosis of primary or recurrent lymphoma.

METHODS

This study was a retrospective analysis of a prospective collection of data over a 3-year period. Over 3 years, 29 patients with lesions (n=31) suspicious for lymphoma underwent EUS-FNA and FC.

RESULTS

Of the 29 patients, 10 patients had lymphoma and 17 patients had nonlymphoma lesions; for two patients, final diagnosis was indeterminate because of insufficient material for FC. The lymphoma cases included non-Hodgkin's lymphoma (n=6, including 3 recurrences), mucosa-associated lymphoid tissue (MALT) lymphoma (n=2), a non-GI lymphoma with mediastinal lymphadenopathy (n=1), and an uncharacterized lymphoma (n=1). Of the 31 lesions, 8 were true positive, 18 were true negative, and 3 were false negative; for two lesions, we could not determine the final diagnosis. No false-positive results were encountered. The sensitivity, the specificity, and the accuracy of EUS-FNA combined with FC for diagnosing lymphoma were 72.7%: 95% CI [43.3%, 90.3%], 100%: 95% CI [82.4%, 100.0%], and 89.7%: 95% CI [73.6%, 96.4%], respectively. Limitations to this study include a short duration of follow-up and a lack of a surgical criterion standard.

CONCLUSIONS

EUS-FNA in combination with FC allows the diagnosis of primary suspected or recurrent lymphoma. It also is an adjunct in staging MALT lymphoma and could direct clinicians toward further investigative procedures.

Mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach: results of a controlled clinical trial

Treatment of patients with early stage gastric mucosa-associated lymphoid tissue (MALT) remains undefined. We began a controlled clinical trial to evaluate efficacy and toxicity of the most common therapies. Two hundred and forty-one patients with gastric low-grade MALT lymphoma in early stage (IE and IIE) were randomized to surgery (80 cases), radiotherapy (78 cases), and chemotherapy (83 cases). With a median follow-up of 7.5 yr, actuarial curves at 10 yr showed that event-free survival was 52% in patients treated with surgery, 52% in radiotherapy arm, and 87% in the chemotherapy group (p < 0.01). However, overall survival did not showed any statistical differences: 80%, 75% and 87%, respectively (p = 0.4). Acute and late toxicities were mild. No death-related treatments were observed. No clear differences were observed between the most common therapies in patients with primary gastric MALT lymphoma in early stages, probably because this type of lymphoma has an high response rate to salvage treatment after failure to local treatment (surgery and radiotherapy). Thus considered, chemotherapy alone is an effective and safe therapeutic approach in this setting of patients. Surgery or radiotherapy will be reserved to patients that are not candidates for chemotherapy.

Mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach: results of a controlled clinical trial

Treatment of patients with early stage gastric mucosa-associated lymphoid tissue (MALT) remains undefined. We began a controlled clinical trial to evaluate efficacy and toxicity of the most common therapies. Two hundred and forty-one patients with gastric low-grade MALT lymphoma in early stage (IE and IIE) were randomized to surgery (80 cases), radiotherapy (78 cases), and chemotherapy (83 cases). With a median follow-up of 7.5 yr, actuarial curves at 10 yr showed that event-free survival was 52% in patients treated with surgery, 52% in radiotherapy arm, and 87% in the chemotherapy group (p < 0.01). However, overall survival did not showed any statistical differences: 80%, 75% and 87%, respectively (p = 0.4). Acute and late toxicities were mild. No death-related treatments were observed. No clear differences were observed between the most common therapies in patients with primary gastric MALT lymphoma in early stages, probably because this type of lymphoma has an high response rate to salvage treatment after failure to local treatment (surgery and radiotherapy). Thus considered, chemotherapy alone is an effective and safe therapeutic approach in this setting of patients. Surgery or radiotherapy will be reserved to patients that are not candidates for chemotherapy.

Mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach: results of a controlled clinical trial

Treatment of patients with early stage gastric mucosa-associated lymphoid tissue (MALT) remains undefined. We began a controlled clinical trial to evaluate efficacy and toxicity of the most common therapies. Two hundred and forty-one patients with gastric low-grade MALT lymphoma in early stage (IE and IIE) were randomized to surgery (80 cases), radiotherapy (78 cases), and chemotherapy (83 cases). With a median follow-up of 7.5 yr, actuarial curves at 10 yr showed that event-free survival was 52% in patients treated with surgery, 52% in radiotherapy arm, and 87% in the chemotherapy group (p < 0.01). However, overall survival did not showed any statistical differences: 80%, 75% and 87%, respectively (p = 0.4). Acute and late toxicities were mild. No death-related treatments were observed. No clear differences were observed between the most common therapies in patients with primary gastric MALT lymphoma in early stages, probably because this type of lymphoma has an high response rate to salvage treatment after failure to local treatment (surgery and radiotherapy). Thus considered, chemotherapy alone is an effective and safe therapeutic approach in this setting of patients. Surgery or radiotherapy will be reserved to patients that are not candidates for chemotherapy.

The emerging role of endoscopic ultrasonography in cancer staging

The management of solid organ cancers relies on accurate staging. Once distal metastasis has been excluded by conventional radiographic methods, local staging of the tumor and its nodal involvement is essential to determine the most optimal therapeutic approach. Many radiographic imaging modalities are unable to determine subtle tumor involvement. However, the emergence of endoscopic ultrasonography (EUS) has given promise to improved staging with its unique ability to examine tumors from within the gastrointestinal lumen with extremely close proximity. An additional advantage is the ability to perform fine-needle aspiration (FNA) biopsy to confirm or exclude tumor involvement. Many studies have shown superior accuracy in staging with EUS and EUS-FNA for tumors of the esophagus, stomach, pancreas, rectum, and mediastinum, including lung cancer. This review illustrates the principles of EUS and its role in staging of a variety of cancers and particularly its role alongside other imaging modalities.

Endoscopic ultrasound (EUS) in staging and follow-up of patients with malt lymphoma treated conservatively

Background: Endoscopic ultrasonography (EUS) is an important tool for diagnosis and pretreatment staging of primary gastric lymphoma. The aim of the study was to evaluate the diagnostic importance of endosonography (EUS)in gastric lymphoma; to assess the depth of tumoral infiltration in low-grade gastric lymphoma of mucosa-associated lymphoid tissue (MALT) and to assess EUS response to medical treatment (Cyclophosphamid/Mabtera and/or anti-Helicobacter pylori therapy). Methods: 26 patients with MALT gastric lymphoma were investigated by EUS. Six of them were evaluated after the eradication of Helicobacter pylori infection and 20 after and during the cyclophosphamide/Mabtera and anti H.pylori treatment. EUS staging was compared with histopathology. Tumors were staged according to the 2000 TNM and modified Ann Arbor classification. Results: Six patients were treated with anti - Helicobacter pylori eradication therapy. Full regression of lymphoma was observed in 2 of 6 (33.3%) patients, which was endoscopicaly and histologicaly proved. EUS correlated with histology in all (6/6). In 20 patients treated with cyclophosphamide/Mabtera therapy, EUS revealed regression of lymphoma in 14 cases. Positive correlation with histology was found in 11 patients (11/14; 78%). The initial EUS showed an increased wall thickness more than 5mm in 24 of 26 patients (92%). The thickening was predominantly of mucosa and submucosa and in 11 patients extended the muscularis propria. After the therapy, the gastric wall thickening returned to normal in 14 patients, however, 3 of them still had positive histology findings. In 2 cases, during the follow-up, the EUS showed remained thickening of gastric wall, whereas biopsies were negative. Six months later histology revealed progressive low-grade MALT lymphoma in this cases. Conclusion: EUS appears to be a sensitive procedure for initial staging and assessment of treatment response and long-term follow up in patients with gastric lymphoma. The importance of EUS lies in ability to detect relapse early, too.

Indolent lymphoma: the pathologist's viewpoint

Indolent lymphomas have recently been the object of numerous studies, which have focused on new aspects relevant both for the better comprehension of their histogenesis and the identification of new therapeutic strategies. As marginal-zone lymphoma (MZL) represents the category of indolent lymphomas that has obtained more benefit from such an approach, the authors focused on the most recent achievements and not yet solved controversies in this area. In spite of their postulated common derivation, the three categories of MZL of the WHO Classification appear dissimilar. In fact, they show significant molecular differences among them as well as a certain heterogeneity within each group. By no means, there is a cogent need of more refined tools to revise these neoplasms and to produce a more rational grouping. The recent identification of the IRTA gene family corresponding to IG-like receptors differentially expressed in B-cells might contribute to their better understanding.