Surgery does not adversely affect survival in primary gastrointestinal lymphoma

Deep learning model for predicting the survival of patients with primary gastrointestinal lymphoma based on the SEER database and a multicentre external validation cohort

PURPOSE

Due to the rarity of primary gastrointestinal lymphoma (PGIL), the prognostic factors and optimal management of PGIL have not been clearly defined. We aimed to establish prognostic models using a deep learning algorithm for survival prediction.

METHODS

We collected 11,168 PGIL patients from the Surveillance, Epidemiology, and End Results (SEER) database to form the training and test cohorts. At the same time, we collected 82 PGIL patients from three medical centres to form the external validation cohort. We constructed a Cox proportional hazards (CoxPH) model, random survival forest (RSF) model, and neural multitask logistic regression (DeepSurv) model to predict PGIL patients' overall survival (OS).

RESULTS

The 1-, 3-, 5-, and 10-year OS rates of PGIL patients in the SEER database were 77.1%, 69.4%, 63.7%, and 50.3%, respectively. The RSF model based on all variables showed that the top three most important variables for predicting OS were age, histological type, and chemotherapy. The independent risk factors for PGIL patient prognosis included sex, age, race, primary site, Ann Arbor stage, histological type, symptom, radiotherapy, and chemotherapy, according to the Lasso regression analysis. Using these factors, we built the CoxPH and DeepSurv models. The DeepSurv model's C-index values were 0.760 in the training cohort, 0.742 in the test cohort, and 0.707 in the external validation cohort, which demonstrated that the DeepSurv model performed better compared to the RSF model (0.728) and the CoxPH model (0.724). The DeepSurv model accurately predicted 1-, 3-, 5- and 10-year OS. Both calibration curves and decision curve analysis curves demonstrated the superior performance of the DeepSurv model. We developed the DeepSurv model as an online web calculator for survival prediction, which can be accessed at http://124.222.228.112:8501/ .

CONCLUSIONS

This DeepSurv model with external validation is superior to previous studies in predicting short-term and long-term survival and can help us make better-individualized decisions for PGIL patients.

Iatrogenic Immunodeficiency Associated Lymphoproliferative Disorder in a Patient With Inflammatory Bowel Disease

Primary colorectal lymphoma is incredibly rare and cases of iatrogenic immunodeficiency associated lymphoproliferative disorder (IILPD) isolated to colorectal area are even more uncommon. Immunodeficiency associated lymphoproliferative disorders can occur in association with primary immune disorders such as inflammatory bowel diseases (IBDs) which are often treated with various immunomodulatory drugs. Of the immunomodulatory drugs, thiopurines, in particular, are known to have a significantly increased relative risk for development of IILPDs. Here we present the case of a 43-year-old Caucasian man with a 22-year history of IBD treated with longstanding immunomodulatory therapy who presented with severe rectal pain and drainage. He underwent an examination under anesthesia with rigid proctoscopy and biopsies were taken of a hard exophytic appearing tissue along the posterior wall of the rectosigmoid junction. Pathological investigation of the samples revealed IILPD. He underwent treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) and achieved complete remission. Literature demonstrates that the use of immunomodulators such as azathioprine has been shown to significantly improve the quality of life in patients with IBD. However, while the absolute risk of lymphoma for any given patient remains quite low, the relative risk of lymphoma in patients who are actively treated with thiopurines is moderate. Therefore, the decision to proceed with thiopurine treatment, especially in the setting of long-term therapy, requires extensive discussion and patient education of the risks/benefits along with closer monitoring of new or uncharacteristic symptoms.

Real-World clinical features and survival outcomes associated with primary gastrointestinal natural killer/T-cell lymphoma from 1999 to 2020

BACKGROUND

Primary gastrointestinal natural killer (NK)/T-cell lymphoma (PGINKTL) is a rare T-/NK-cell lymphoma subtype, and the clinical features and survival outcomes remain largely unknown.

METHODS

To summarize the clinical features and survival outcomes of PGINKTL, PGINKTL cases diagnosed at our hospital from May 1999 to December 2020 were reviewed; and the clinical data, information on treatment strategies, and survival were collected. Survival analysis was performed using the Kaplan-Meier method and multivariable Cox proportional hazards regression. We constructed a nomogram to visualize the survival prediction of PGINKTL. The discriminative ability and calibration of the nomogram for prediction were tested using the concordance index (C-index) and calibration plots.

RESULTS

The cohort included 81 cases, the median age was 36 years (range, 7-80 years), and the male-to-female ratio was 1.7:1. The most common clinical symptom at the time of diagnosis was abdominal pain (71.6%). The most common lesion site was the colon (59.3%). During a median follow-up period of 37.7 months, the median overall survival (OS) time of 81 patients was 4.0 months (95% confidence interval [CI], 3.1-4.9 months), and the 2-year OS rate was 30.7% (95% CI, 20.3%-40.1%). The multivariate analyses indicated that patients with an Eastern Cooperative Oncology Group (ECOG) performance status (PS) score ≥2, serum lactic dehydrogenase (LDH) level ≥ the upper limit normal (ULN), and perforation had worse OS. We used these data to establish a nomogram to predict survival for PGINKTL. The nomogram displayed good accuracy, with a C-index of 0.726.

CONCLUSION

The clinical features and poor outcomes of PGINKTL, which is a rare and fatal lymphoma type, are presented. The proposed nomogram provides an individualized estimate of survival for these patients. In the future, the study focused on exploring a better treatment strategy to improve survival is required in PGINKTL.

Surgical Management of Small Bowel Lymphoma

BACKGROUND

Primary small bowel non-Hodgkin's lymphoma is a rare disease representing 2% of small intestine malignancies. There is limited data delineating the optimal treatment for these heterogeneous tumors. We aim to examine relationships between different treatment modalities and surgical outcomes in patients with small bowel lymphoma.

MATERIALS AND METHODS

Patients diagnosed with stage I-III small bowel lymphoma in 2004-2015 who underwent surgery were identified in the National Cancer Database. Two cohorts were created based on systemic chemotherapy treatment status. The primary outcome was overall survival. An adjusted Cox proportional hazards model was used to evaluate the impact of treatment strategy on survival.

RESULTS

2283 patients met inclusion criteria Of these patients, 826 patients (36%) underwent surgical resection alone, and 1457 patients (64%) underwent resection with systemic chemotherapy. Chemotherapy was associated with improved overall survival in unadjusted (5-year overall survival, 55% versus 70%) and adjusted analysis (HR 0.54, 95% CI 0.47-0.63, p < 0.001).

DISCUSSION

Patients with small bowel lymphoma have a low five-year overall survival after surgery. Chemotherapy is associated with improved survival, although one third of patients do not receive this therapy. Several other clinical factors are identified that are also associated with overall survival, including histology subtype, margin status, age, and medical comorbidities. This information can help with prognostication and potentially aid in treatment decision-making.

Development and Validation of Prognostic Nomograms for Patients with Primary Gastrointestinal Non-Hodgkin Lymphomas

BACKGROUND AND AIMS

The objective of this study was to construct and authenticate nomograms to project overall survival (OS) and cancer-specific survival (CSS) in primary gastrointestinal non-Hodgkin lymphomas (PGINHL).

METHODS

Suitable patients were chosen from the Surveillance, Epidemiology and End Results database and Wannan Medical College Yijishan Hospital. The Cox regression model was used to acquire independent predictive factors to develop nomograms for projecting OS and CSS. The performance of the nomograms was validated using the Harrell's concordance index (C-index), calibration curves, and decision curve analysis (DCA) and was compared with that of the AJCC 7th staging system. Survival curves were obtained using the Kaplan-Meier method, while the log-rank test was used to compare the difference among the groups.

RESULTS

The C-index of the nomograms for OS and CSS was 0.735 (95% CI = 0.719-0.751) and 0.761 (95% CI = 0.739-0.783), respectively, signifying substantial predictive accuracy. These outcomes were reproducible when the nomograms were used for the internal and external validation cohorts. Moreover, assessments of the C-index, AUC, and DCA between the nomogram results and the AJCC 7th staging system showed that the former was better for evaluation and was more clinically useful.

CONCLUSIONS

We constructed the nomogram which could predict 1-, 3-, and 5-year OS and CSS of patients with PGINHL. Our nomogram showed good performance, suggesting that it can be used as an efficacious instrument for predictive assessment of patients with PGINHL.

Surgical Resection for Primary Rectal Lymphoma: Support for Local Excision?

BACKGROUND

Primary rectal lymphoma is an uncommon and heterogeneous malignancy. Because of its rarity, few data exist to guide treatment or counsel patients. We present the largest series to date of patients undergoing nonpalliative surgery for rectal lymphoma. We hypothesize that there will be no difference in overall survival between patients undergoing local resection (LR) or radical resection (RR).

MATERIALS AND METHODS

The National Cancer Data Base was queried for all cases of resected primary rectal lymphoma between years 2004 and 2014. Exclusion criteria included patients with stage IV disease and those operated on for palliation. Patients were categorized by resection approach-LR or RR. Approach along with demographic, histologic, and hospital-level factors were analyzed with a Cox proportional hazard analysis.

RESULTS

A total of 233 patients were identified. Mean age was 63 y (interquartile range 53-73), and 57% of the population was female. The most common histologic subtypes were marginal (44%), diffuse large B-cell (20%), and follicular lymphoma (17%). Eighty-seven percent underwent LR. There was no significant difference in R0 resection (LR: 38% versus RR: 58%; P = 0.07), adjuvant chemotherapy (LR: 18% versus RR: 29%; P = 0.22), or adjuvant radiation (LR: 21% versus RR: 16%; P = 0.63) between the groups. Five-year overall survival was 79%, and there was no significant difference in approach (LR: 81% versus RR: 56%, P = 0.06). Multivariable analysis did not identify an association between approach and overall survival.

CONCLUSIONS

Surgical resection of rectal lymphoma is rare. Our data support consideration of LR when possible, given the lack of convincing survival benefit of radical surgery or R0 resection.

Surgical management of primary colonic lymphoma: Big data for a rare problem

BACKGROUND AND OBJECTIVES

Primary colonic lymphoma (PCL) is rare, heterogeneous, and presents a therapeutic challenge for surgeons. Optimal treatment strategies are difficult to standardize, leading to variation in therapy. Our objective was to describe the patient characteristics, short-term outcomes, and five-year survival of patients undergoing nonpalliative surgery for PCL.

METHODS

We performed a retrospective cohort analysis in the National Cancer Database. Included patients underwent surgery for PCL between 2004 to 2014. Patients with metastases and palliative operations were excluded. Univariate predictors of overall survival were analyzed using multivariable Cox proportional hazard analysis.

RESULTS

We identified 2153 patients. Median patient age was 68. Diffuse large B-cell lymphoma accounted for 57% of tumors. 30- and 90-Day mortality were high (5.6% and 11.1%, respectively). Thirty-nine percent of patients received adjuvant chemotherapy. For patients surviving 90 days, 5-year survival was 71.8%. Chemotherapy improved survival (surgery+chemo, 75.4% vs surgery, 68.6%; P = .01). Adjuvant chemotherapy was associated with overall survival after controlling for age, comorbidity, and lymphoma subtype (HR 1.27; 95% CI, 1.07-1.51; P = .01).

CONCLUSIONS

Patients undergoing surgery for PCL have high rates of margin positivity and high short-term mortality. Chemotherapy improves survival, but <50% receive it. These data suggest the opportunity for improvement of care in patients with PCL.

The role of surgical intervention in primary colorectal lymphoma: A SEER population-based analysis

Background

Primary colorectal lymphoma (PCL) is a rare colorectal malignancy. The standard treatment and prognostic factors of PCL remain unexplored. Therefore, a large population-based study should be conducted to provide a detailed review of this disease.

Methods

We extracted the data of eligible patients with PCL registered in the SEER database from 1973 to 2011. All statistical analyses were performed using SPSS 19.0.

Results

A total of 2050 (61.3%) of the 3342 patients with PCL underwent surgical intervention, and 1292 (38.7%) patients received no surgical treatment. The median overall survival was 95 months, and patients receiving surgery exhibited significantly prolonged survival (adjusted HR =0.69, P <0.001). Young age, early tumor stage, and indolent lymphoma were independent predictors of improved survival. Further survival analyses demonstrated the potential benefit of surgery in patients with early tumor stage, right-sided lesions, or diffuse large B-cell PCL. Conversely, surgical intervention did not improve the survival of patients with advanced-stage, left-sided, or indolent PCL.

Conclusion

PCL is a rare tumor that can be effectively treated. Surgical intervention may play an important role in the treatment of PCL. Early tumor stage, a right-sided lesion, and diffuse large B-cell histological PCL seem to be the clinical characteristics of optimal surgical candidates.

Endoscopic management of duodeno-ileal fistula secondary to diffuse B-cell lymphoma

Lymphoma arising in the gastrointestinal tract is relatively common and can affect multiple sites. The development of a gastrointestinal fistula secondary to lymphoma is very rare and has not previously been reported between the duodenum and ileum. This is the first reported care where a fistula secondary to lymphoma has been treated by an endoscopic covered duodenal stent occluding the defect rather than surgical intervention. This strategy permitted early commencement of curative intent chemotherapy which led to tumour shrinkage and fistula closure.

The role of surgical management in primary small bowel lymphoma: A single-center experience

INTRODUCTION

Information on primary small intestinal lymphoma is more limited than for gastric lymphoma because most of the previous studies did not focus on the former. Few prognostic indicators in primary intestinal lymphoma have been reliably established because of limited patient numbers and variations in criteria for patient selection. In this study, we retrospectively reviewed the clinical and pathological characteristics of small intestinal lymphoma cases from our hospital, to determine prognostic factors and to clarify the effect of surgical resection on prognosis.

METHODS

Eighty-two patients were enrolled in this retrospective study between January 1997 and December 2012. Patients were divided into two groups based on whether or not they underwent surgical management. Gross resection was defined as complete removal of the primary lesion(s), as confirmed by the naked eye. Combined therapy refers to concurrent surgery and chemotherapy. The clinicopathological characteristics and long-term outcomes of patients were analyzed and compared between the two groups.

RESULTS

Most of the patients had abdominal pain (75.6%), and some had loss of body weight (29.3%) and bowel perforation (22.0%). Sixty-two patients (75.6%) underwent surgical management. Patients in the surgery group presented with fewer B symptoms (fever, night sweats, and weight loss; P = 0.035) but more bulky disease (P = 0.009). The ileocecal region was the most common site of solitary involvement (34.1%). The most common reason for surgery was for tumor-related complications (61.3%). Seven patients (11.3%) developed major complications of surgery, but these were not related to the indication, timing, or type of surgery. Only major surgical complications were statistically significant in relation to early mortality (P = 0.004). The estimated 5-year progression-free survival (PFS) was 35.1% and 5-year overall survival (OS) was 43.2%. Univariate analysis revealed that patients in the surgery group had improved 5-year PFS (P = 0.028). T-cell lymphoma, involvement of multiple gastrointestinal regions and extranodal involvement, higher scores for International Prognostic Index (IPI), more advanced Ann Arbor stage, lactate dehydrogenase (LDH) levels above 215 U/L, and management without combined therapy were prognostic for shorter PFS and OS in univariate analyses. Individuals who received R0 resection or gross resection had improved 5-year PFS and OS. Cox regression analysis demonstrated that primary T-cell lymphoma was an independent negative prognostic factor for both OS and PFS.

CONCLUSION

Combined therapy is an independent prognostic factor for long-term survival in small intestinal lymphoma. Gross resection is recommended in patients with small intestinal lymphoma and leads to improved PFS without significantly increasing the risk of complications. Emergency surgery does not lead to poor prognosis. However, caution is warranted in the management of all patients, because of the high risk of post-operative complications and potential for early mortality.

[Clinical features, diagnosis, treatment, and prognosis of 99 cases with primary intestinal lymphoma]

目的

探讨原发肠道恶性淋巴瘤（PIL）的临床特征、诊治方法和预后。

方法

回顾性分析1995年11月1日至2013年11月30日在北京大学肿瘤医院确诊的PIL患者病例资料。

结果

符合诊断条件的PIL患者99例，男65例，女34例，男女比为1.9∶1，中位年龄50（12~90）岁。胃肠道非特异性症状为主要临床表现，其中腹痛67例（67.68%），最为常见，26例（26.26%）患者发病时伴随有急腹症。回肠原发和回盲部原发均为21例，是最常见的发病部位。经消化内镜活检后诊断的PIL仅24例（24.24%），依靠手术诊断的患者为69例（69.70%）。Ⅰ~Ⅱ期71例（71.72%），Ⅳ期28例（28.28%）。所有病例均为非霍奇金淋巴瘤，B细胞来源77例（77.78%），T细胞来源22例（22.22%）。其中最常见为弥漫大B细胞淋巴瘤（DLBCL），共55例（55.56%）；国际预后指数（IPI）评分0~1分60例。本组患者中位总生存（OS）期为100.0个月，5年OS率为53.50%。多因素分析显示，T细胞来源者预后差（P<0.05）。74例患者进行了手术治疗，96例患者进行了全身化疗。手术联合化疗组和单纯化疗组的中位OS期分别为79.0个月和123.0个月，差异无统计学意义（P=0.616）。

结论

PIL好发于男性，腹痛是其最常见的临床表现，回肠及回盲部为最常见的发病部位，相对来说PIL发病比较局限，但内镜检查确诊率低下；最常见的病理类型是DLBCL，T细胞来源是PIL预后不良的独立影响因素。手术仍然是PIL常用的诊断及治疗手段，且手术并未增加PIL患者的生存风险。

Risk factors and patterns of lymph node involvement in primary gastric large B-cell lymphoma: implications for target definition

Background

The aim of this study was to identify the appropriate radiation volume for primary gastric diffuse large B-cell lymphoma (PG-DLBCL).

Methods

We retrospectively analyzed the clinical and pathological findings of 68 patients treated with total gastrectomy and D2 lymphadenectomy.

Results

There were 23, 14, and 29 patients with stage I, stage II, and stage IIE disease, respectively, and 30 patients had lymph node involvement. Primary tumor location, as well as the depth of invasion, was significantly associated with lymph node involvement. When the tumor was limited to the muscularis, the involved lymph nodes were found to be perigastric nodes. For tumors invading beyond the muscularis, regional lymph nodes were involved.

Conclusion

The optimal radiation volume for patients with PG-DLBCL is largely dependent on the primary location and depth of invasion. Larger series and longer follow-up are needed to further delineate the radiation volumes for PG-DLBCL.

Management of Primary Gastrointestinal Non-Hodgkin Lymphomas: a Population-Based Survival Analysis

INTRODUCTION

Primary gastrointestinal non-Hodgkin lymphomas (PGINHL) are a heterogeneous group of rare GI malignancies with limited data to guide management. This study describes management of PGINHL in a population-based registry and aims to determine the association between receipt of surgery and long-term survival.

METHODS

All adults diagnosed with PGINHL over 27 years in the Surveillance, Epidemiology, and End Results were identified (excluding mucosa-associated lymphoid tissue lymphomas). Demographic and clinical characteristics were assessed. Survival was compared using the log-rank method. Cox hazard modeling was used to determine independent prognostic factors.

RESULTS

We identified 16,129 patients. The majority were of gastric origin and had diffuse large B cell histology. Surgery was performed in 46.9 % of patients, not recommended in 41.8 % and recommended but not performed in 10.1 %. Overall 1-year and 5-year survival rates were 65.6 and 35.6 %, respectively. Patients undergoing surgery had a 5-year survival of 43.6 % compared to 34.8 % for whom surgery was recommended but not performed (p < .0001), (receipt of chemotherapy not available). Female gender, gastric location, follicular or mantle cell histology, and radiation therapy were associated with improved survival.

CONCLUSIONS

Nearly 50 % of PGINHL patients underwent surgery. Surgery was not associated with improved survival. More prospective, case-matched studies are needed to guide management.

Successful management of adult lymphoma-associated intussusception by laparoscopic reduction and appendectomy

Although primary gastrointestinal lymphoma is a rare malignancy, it can cause an intussusception in adults and can be a clinically challenging condition to manage. Intussusception could progress to life-threatening complications if left untreated or could delay chemotherapy if inappropriate surgical management is used. We report a 31-year-old man diagnosed with human immunodeficiency virus who was being treated with antiretroviral therapy. He presented with nausea, vomiting, poor appetite, and intermittent, cramping abdominal pain for over 1 wk. Abdominal computed tomography revealed a well-defined homogeneous mass in the mesenteric root region, together with a long segmental wall thickening in the ileum with ileocolic-type intussusception, which was suspected to be caused by a lymphoma. The intussusception was successfully laparoscopically reduced, and the tumor involvement of the appendix was confirmed by appendectomy with intraoperative frozen section. Systemic chemotherapy was immediately initiated after surgery without the need for bowel resection.

Primary Gastrointestinal Non-Hodgkin's Lymphoma of the Small and Large Intestines: a Systematic Review

BACKGROUND

Primary gastrointestinal non-Hodgkin's lymphoma (PGINHL) of small and large intestines is a group of heterogeneous, rare malignancies. Optimal treatment practices remain undefined.

METHODS

A systematic review (2003-2015) was performed to assess tumor characteristics, treatment practices, and treatment outcomes of PGINHL of small and large intestines.

RESULTS

Twenty-eight studies (1658 patients) were included; five focused on follicular lymphoma subtype. Of the non-follicular patients, 59.3% presented with abdominal pain, 37.2% were located in ileocecum, and 53.6% were diffuse large B cell lymphoma subtype. The majority of patients (60.7%) were treated with a combination of surgery and chemotherapy. Forty-three percent of studies concluded an overall survival benefit with surgery; none reported increased postoperative morbidity or mortality. Survival outcomes were not typically stratified by emergent versus elective surgery. Multivariate analysis within individual studies associated B cell lymphoma and ileocecum location with higher survival, while advanced stage and B symptoms were associated with poorer survival. Patients with asymptomatic follicular lymphoma had no progression with a watchful waiting approach.

CONCLUSIONS

The majority of patients with non-follicular small and large intestinal PGINHLs are treated with both chemotherapy and surgery. Although surgery appears to be an important part of the treatment algorithm, definitive statements regarding its survival benefit remain limited due to lack of patient stratification based on timing and indication for surgery.

Anatomic distribution, clinical features, and survival data of 87 cases primary gastrointestinal lymphoma

Background

The purpose of this study is to analyze the anatomic distribution, clinical features, therapeutic methods, and prognosis factors of primary gastrointestinal lymphoma (PGIL).

Methods

Clinical data of 87 cases PGIL in the First Affiliated Hospital of Dalian Medical University from January 1999 to December 2010 were collected. Follow-ups were made according to the clinical feature, pathological pattern, clinical stage, and therapeutic method. Kapan Meier method was used for the survival analysis. Log-rank test was used to perform univariate survival analysis. COX multivariate analysis was carried out to analyze factors of P < 0.05 in univariate survival analysis.

Results

The incidence of PGIL significantly increased in patients more than 40 years old (87.4 %). Clinical symptoms of PGIL were indistinguishable from other digestive system diseases, which included abdominal pain or discomfort (72.4 %), lack of appetite (16.3 %), gastrointestinal hemorrhage (14.9 %), and diarrhea (12.8 %). Some patients presented with systemic symptoms or complications, such as weight loss (35.6 %) and digestive tract obstruction (13.8 %). Primary gastric lymphoma (PGL) was the most common, followed by primary intestine lymphoma (PIL). The majority of PGIL were single lesion, which included 40 cases (87 %) PGL and 35 cases (94.5 %) PIL. The most frequent site of PGL was antrum of the stomach (43.5 %), as to PIL, the small intestine (90.2 %) was the most frequent site, especially within 100 cm far away from ileocecal valve. Most of PGIL were derived from B cell (93.1 %). The most common pathological type was mucosa-associated lymphoid tissue (MALT) (67.4 %) in the PGL group and diffuse large B cell lymphoma (DLBCL) (46.3 %) in the PIL group. Surgical treatment had been performed in most of PGIL, which included 32 cases in the PGL group and 38 cases in the PIL group. The 1-year overall survival (OS) and the 3-year OS were 82 and 77 %, respectively. Analysis of single factor affecting prognosis showed that lesion location, sources of cells, and clinical stage were associated with OS. PGL group had better OS than that of PIL group (1-year 89 vs 62 %, 3-year 84 vs 50 %, P = 0.03). B cell-originated group had better OS than that of T cell-originated group (1-year 89 vs 36 %, 3-year 85 vs 0 %, P = 0.008). Stage I + II group had better OS than that of stage III + IV group (1-year 89 vs 38 %, 3-year 87 vs 0 %, P = 0.007). Multivariate analysis showed that clinical stage and sources of cells were the significant independent prognostic factors.

Conclusions

It was more common to find location of PGIL in the stomach than that in the intestine. The most common pathological type was MALT in the PGL and DLBCL in the PIL. The treatment of PGL was focused on chemotherapy. It was noting that since PIL was not only difficult to make confirmed diagnosis but also likely to develop with complications, so it was usually needed surgical excision. Clinical stage and pathological pattern were related to prognosis of PGIL.

Mad2 overexpression is associated with high cell proliferation and reduced disease-free survival in primary gastrointestinal diffuse large B-cell lymphoma

OBJECTIVES

Primary gastrointestinal diffuse large B-cell lymphoma (PGI-DLBCL) is a rare hematological malignancy with limited results on carcinogenesis and clinical characteristics. The aims of the current study were to examine mitotic arrest deficiency protein 2 (Mad2) expressions in PGI-DLBCL, and assess its association with Ki-67 expression, Helicobacter pylori (H. pylori) infection, BCL-6 gene rearrangement, and clinicopathological variables.

METHODS

Cancer tissues from 38 PGI-DLBCL patients were examined for Mad2, Ki-67, and H. pylori expression by immunohistochemistry, using normal gastrointestinal tissues and nodal DLBCL as controls. BCL-6 gene translocation was analyzed by fluorescence in situ hybridization (FISH), and Mad2 expression status was evaluated along with clinicopathological characteristics.

RESULTS

Mad2 expression was increased in PGI-DLBCL patients when compared with controls. The expression of Mad2 was 51.55 ± 22.88% in PGI-DLBCL, which was higher than reactive lymph node (28.77 ± 10.89%) and lymphoid nodule in normal gastrointestinal tissue (26.41 ± 11.30%) (P = 0.002), while it was comparable to nodal DLBCL (57.23 ± 20.79%) (P = 0.358). Mad2 overexpression had a positive correlation with Ki-67 proliferation index (r = 0.55, P = 0.01) in PGI-DLBCL, and patients with BCL-6 gene rearrangement had lower Mad2 expression (P = 0.032) than patients with intact BCL-6, while no relation was found between Mad2 expression and H. pylori infection. PGI-DLBCL patients with higher Mad2 expression had lower estimated disease-free survival (DFS) (17.10% vs. 53.00%) (P = 0.049). However, no correlation was found between Mad2 expression levels and overall survival (OS) (P = 0.443).

CONCLUSIONS

Aberrant Mad2 expression was associated with cell proliferation and genetic instability, which may contribute to the carcinogenesis of PGI-DLBCL. Mad2 overexpression indicated a poor DFS and may be a potential biomarker for estimating prognosis for PGI-DLBCL patients.

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

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

The Role of Surgery in the Clinical Management of Primary Gastrointestinal Non-Hodgkin's Lymphoma

Primary gastrointestinal non-Hodgkin's lymphoma (PGINHL) is a heterogeneous family of tumors, with treatment modalities including chemotherapy, surgery, and radiotherapy. Because the role of surgery in PGINHL remains disputed, this study aims to assess the impact of operative resection on survival. We used a pathology database to identify all cases of PGINHL diagnosed at a single academic-affiliated medical center from 1988 to 2013. Demographic and clinical data were abstracted from the medical record. We summarized the clinical courses of patients with PGINHL and then performed a survival analysis to compare overall and disease-free survival, stratified by demographic and clinical variables. We identified 33 patients diagnosed with PGINHL during the study period. Of 29 who subsequently received treatment at the institution, 15 initially underwent chemotherapy, 10 underwent surgical resection, and 4 underwent surgery for other reasons such as diagnosis without resection or management of disease complications. Three patients suffered surgical complications and two of these patients died. We found no difference in overall survival between patients receiving surgical resection and patients managed initially with chemotherapy. This case series supports a continued role for surgical resection in the management of patients with PGINHL, though anticipated benefits should be weighed against the risk of complications.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Therapeutic comparison of Surgery combined with chemotherapy and chemotherapy alone for Primary Gastrointestinal Lymphoma: A single center study

Objectives There is still no consensus on the optimal treatment for primary gastrointestinal lymphoma (PGIL). The aim of this study was to compare surgery combined with chemotherapy and chemotherapy alone in PGIL. Methods We retrospectively reviewed and analyzed the treatment outcomes of 107 patients with primary gastrointestinal lymphoma diagnosed between March 1999 and December 2009 at Kosin University Gospel Hospital. Patients were divided into two groups: 35 patients who underwent surgery combined with chemotherapy (group A) and 72 patients who were treated with chemotherapy alone (group B). And we analyzed prognostic factors associated with short survival. Results The 5-year progression free survival rates (PFS) of group A and B were 86.7% and 66.1%, respectively (P = 0.037), while the 5-year overall survival rates (OS) were 86.8% and 68.4%, respectively (P = 0.129). In multivariate analysis, Both PFS and OS were not changed by treatment strategies (surgery combined with chemotherapy or chemotherapy only). The international prognostic index (IPI) was the only independent predictive factor for PFS. Conclusions In our study, surgery combined with chemotherapy and chemotherapy only make no difference of survival rate. And further randomized prospective studies are needed to confirm a treatment strategies at improving survival outcomes in PGIL patients.

Diffuse large B-cell lymphoma: sites of extranodal involvement are a stronger prognostic indicator than number of extranodal sites in the rituximab era

The National Comprehensive Cancer Network (NCCN) International Prognostic Index (IPI) is an enhanced prognostic tool that has identified some specific extranodal sites as a poor prognostic factor. We retrospectively analyzed 148 Taiwanese patients with newly diagnosed diffuse large B-cell lymphoma receiving rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP)-like regimens from January 2001 to December 2010 at the Tri-Service General Hospital. In univarate analysis, ≥ 2 extranodal involved sites had no significant prognostic relevance (p = 0.108), although extranodal involvement of the lung/pleura, liver, lower urinary tract or bone marrow was a statistically significant poor prognostic factor (p < 0.001). In multivariate analysis, specific extranodal sites had a stronger predictive value for poor prognosis (relative risk 3.654, 95% confidence interval 1.514-8.815, p = 0.004) compared with the number of extranodal sites involved. This finding suggests that specific extranodal involved sites have prognostic value in the R era.

A case of successful remission of extensive primary gastric diffuse large B cell lymphoma: radiologic, endoscopic and pathologic evidence

Though rare amongst stomach neoplasms, primary gastric diffuse large B cell lymphoma is one of the commonest extranodal non-Hodgkin lymphomas. If left untreated, it can have a devastating progression and life-threatening consequences. We present the case of a successfully treated large antral ulcer confirmed to be large B cell lymphoma as evidenced by radiologic, endoscopic and histopathologic findings. A brief discussion about the types of gastric lymphoma, their Helicobacter pylori relation and therapeutic modalities follows.

Malignant tumours of the small intestine

Adenocarcinoma, neuroendocrine tumours, sarcomas and lymphomas are the four most common malignant tumours arising in the small intestine, although over forty different histological subtypes are described. Collectively these account for only 2% of cancers of the digestive system. The incidence of small bowel cancer has increased in recent decades with a four-fold increase in carcinoid tumours. Risk factors for small bowel tumours include coeliac disease, inflammatory bowel disease and a number of genetic abnormalities. The non-specific nature of their symptoms and the difficulty in visualising these tumours with normal endoscopic techniques often results in late diagnosis. Furthermore the paucity of literature on this topic has made it difficult to standardise management. There has however been marked improvement in imaging methods resulting in earlier diagnosis in many cases. As expected, early detection of localised, well differentiated tumours followed by surgical resection with negative margins offers the best chance of long term survival. Better adjuvant treatment, notably for gastrointestinal stromal tumours, has improved 5-year survival rates significantly. Development of surveillance guidelines for at risk populations may be a valuable way of improving early diagnosis of this challenging group of conditions.

Increased expression of the spindle checkpoint protein BubR1 is associated with high cell proliferation in primary gastrointestinal diffuse large B cell lymphoma

Primary gastrointestinal diffuse large B cell lymphoma (PGI-DLBCL) is a relatively rare malignancy with limited results on clinical characteristics and carcinogenesis. Chromosome instability (CIN) is a hallmark of cancer cells, including lymphoma. As a key component of spindle assembly checkpoint (SAC), BubR1 plays a crucial role in maintaining genome stability. To elucidate the roles of BubR1 in the pathogenesis of PGI-DLBCL, and its relationship to cell proliferation, Helicobacter pylori infection, and BCL-6 gene translocation, we examined the possible alterations of BubR1 protein expression in PGI-DLBCL patients. Paraffin-embedded cancer tissues from 20 PGI-DLBCL patients were evaluated for BubR1 and H. pylori expression by immunohistochemistry, as well as cell proliferative activity measured by Ki-67 proliferation index (PI). BCL-6 gene rearrangement was assessed by fluorescence in situ hybridization (FISH) and BubR1 expression status was compared with clinicopathological parameters in PGI-DLBCL patients. Overexpression of BubR1 was observed in the majority of PGI-DLBCL patients. The mean expression level of BubR1 was 57.33 ± 23.27% in PGI-DLBCL, which was higher than normal gastrointestinal tissue (10.18 ± 5.65%) and reactive lymph node (26.74 ± 8.60%) (P < 0.01), while it was comparable to nodal lymphoma (54.32 ± 21.28%) (P > 0.05). BubR1 overexpression had a positive correlation with Ki-67 proliferation index (PI) (r = 0.51, P < 0.01) in PGI-DLBCL, but had no relationship to H. pylori infection and BCL-6 gene translocation. In addition, no correlation was found between BubR1 expression levels and overall survivals (P > 0.05). BubR1 overexpression was associated with cell proliferation and may play a role in the carcinogenesis of PGI-DLBCL. Aberrant BubR1 expression may potentially be a biomarker for estimating biologic characteristics of PGI-DLBCL.

The recognition and classification of lymphoproliferative disorders of the gut

Gastrointestinal lymphomas can be difficult to diagnose, particularly in small samples, when early in development, or when of unusual types. In this review, we describe lymphoid proliferations in the gastrointestinal tract in a location-based manner, including, mouth, esophagus, stomach, small intestine, and large bowel. For the purpose of differential diagnosis, benign mimics of lymphoma are also described. Lymphoma types that are specifically addressed include plasmablastic, extranodal natural killer/T-cell-nasal type, extranodal marginal zone lymphoma (eg, mucosa-associated lymphoid tissue lymphoma), diffuse large B cell, primary follicular of small intestine, enteropathy-associated T cell, and Burkitt and mantle cell. Immunohistochemical markers useful in the diagnostic approach are elaborated in detail.

Primary gastrointestinal non-Hodgkin's lymphoma: Analysis of 33 cases

AIM: To investigate the diagnosis and surgical treatment of primary gastrointestinal non-Hodgkin's lymphoma (PGINHL).

METHODS: The clinical data for 33 patients with PGINHL were retrospectively reviewed.

RESULTS: The tumor was mainly located in the stomach (n = 16), small intestine (n = 9), appendix (n = 1) or the colon (n = 7). All cases were pathologically confirmed to have non-Hodgkin's lymphoma. All the patients were treated surgically, containing radical excision in 26 cases, palliative resection in 4 cases, and intestinal short circuit anastomosis and biopsy in 3 cases. There were 2 deaths during the perioperative period. Twenty-two patients were followed and the 1-year survival rate was 85%.

CONCLUSION: The lack of specific clinical manifestations in PGINHL easily leads to misdiagnosis. When the diagnosis is not clear or the patient have surgical indications, surgery should be performed as soon as possible.

Primary gastrointestinal mantle lymphoma with massive bleeding: a case report and literature review

The incidence of primary gastrointestinal lymphomas (PGILs) has been increasing. The clinical presentation and treatment of PGIL are distinct from those of nodular lymphomas. Symptoms include abdominal pain, abdominal mass, changes in bowel habits, obstruction, and bleeding. Less life-threatening gastrointestinal bleeding occurs after chemotherapy and few reports have focused on the bleeding of PGILs. We report a case of severe gastrointestinal bleeding caused by low-dose chemotherapy, which was dramatically improved by rituximab monotherapy treatment. The prevention and treatment of gastrointestinal bleeding in PGIL should be given much attention.

The management of primary small bowel and colon lymphoma--a review

AIMS

The management of primary small bowel and colon lymphoma is controversial. A review of the literature was therefore undertaken to evaluate the evidence for the classification, staging, diagnosis, and treatment of primary small bowel and colon lymphoma and guide management.

METHODS

A literature search was performed utilising Embase, Medline, and Pubmed and papers were evaluated on an individual basis.

RESULTS

Consensus opinion favours the WHO classification scheme and the TNM staging systems for primary small bowel and colon lymphoma. CT enteroclysis and barium enterolysis are recommended for the diagnosis of primary small bowel lymphoma and capsule endoscopy and double-balloon enteroscopy maybe useful diagnostic tools. In terms of the diagnosis and staging of primary colonic lymphoma, the evidence is scarce and CT is to be recommended. The mainstay of treatment for primary GI lymphoma is surgery and/or chemotherapy. For primary small bowel and colonic lymphoma, there was no definitive evidence regarding the benefits of either strategy; however, chemotherapy seemed to give a survival benefit over surgery alone for primary small bowel lymphoma and colonic lymphoma was skewed towards surgery plus chemotherapy due to the large number of patients presenting as an emergency.

CONCLUSION

Published data regarding the management of primary small bowel and colon lymphoma is very limited. Classification and staging should be standardised to enable accurate evaluation of investigations and treatments and a large RCT undertaken to compare chemotherapy and surgery. Currently, we would recommend that management should involve chemotherapy with surgery reserved for those with clinical indication.

Gastric MALT lymphoma and grade II obesity: gastric bypass surgery as a therapeutic option

Mucosa-associated lymphoid tissue (MALT) is the most common extranodal lymphoma, with one third of the cases occurring in the stomach. Surgical treatment is a possible option. This case report describes an obese woman (body mass index 46 kg/m2) seeking bariatric surgery, with elevated serum cholesterol and uric acid, negative for Helicobacter pylori but with a positive biopsy for MALT (immunohistochemistry), stage IA. She was submitted to a Roux-en-Y gastric bypass and gastric resection. Two months later, she had lost 20 kg and the MALT lymphoma was in complete remission.

Does surgery or radiation therapy impact survival for patients with extrapulmonary small cell cancers?

BACKGROUND AND OBJECTIVES

Extrapulmonary small cell carcinomas (EPSCC) are rare tumors where therapy remains poorly defined. We sought to determine the impact of surgical extirpation and radiation therapy for outcomes of EPSCC.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with EPSCC which were further categorized by site and evaluated for survival by specific treatment strategy.

RESULTS

We identified 94,173 patients with small cell carcinoma of which 88,605 (94.1%) and 5,568 (5.9%) had pulmonary small cell carcinoma and EPSCC, respectively. EPSCC patients were subdivided by site with the following proportions: genitourinary (24.1%), gastrointestinal (22.1%), head and neck (7.1%), breast (4%), and miscellaneous (42.7%). Overall EPSSC and specifically gastrointestinal disease had significantly improved median, 5- and 10-year survival with surgery and/or radiation for all stages and sizes. For all EPSCCs multivariate analysis revealed age (>50), gender (female), stage (regional, distant), radiation, and surgery to be independent predictors of survival.

CONCLUSIONS

Although outcomes for EPSCC remains poor, both surgery and radiation is shown to significantly improve median, 5- and 10-year survival rates. EPSCC patients who are potential candidates for surgical resection or radiation therapy may benefit from these treatments.