Primary gastric non-Hodgkin's lymphoma stage IE and IIE

GPX3 methylation is associated with hematologic improvement in low-risk myelodysplastic syndrome patients treated with Pai-Neng-Da

Objective

The aim of this prospective randomized controlled clinical trial was to explore the relationship between GPX3 methylation and Pai-Neng-Da (PND) in the treatment of patients with low-risk myelodysplastic syndrome (MDS).

Methods

There were 82 low-risk MDS patients who were randomly divided into the following two groups: androl, thalidomide, and PND capsule (ATP group, n = 41); or androl and thalidomide (AT group, n = 41). Hemoglobin and neutrophil and platelet counts and changes in GPX3 methylation level were assessed.

Results

The plasma hemoglobin level increased in both groups after treatment. However, the platelet count increased only in the ATP group. Patients in the ATP group had a better platelet response than the AT group, and GPX3 methylation markedly decreased after treatment with ATP but not after treatment with AT. Moreover, male patients had a significantly lower GPX3 methylation level than female patients, while platelet counts from male patients increased dramatically after the ATP regimens compared with female patients. GPX3 methylation changes were negatively correlated with platelet changes in ATP group.

Conclusion

PND can improve hematological parameters and decrease the GPX3 methylation level. Decreasing GPX3 methylation is associated with the hematologic response that includes platelet in GPX3 methylation.

China Clinical Trial Bureau (ChiCTR;http://www.chictr.org.cn/) registration number: ChiCTR-IOR-15006635.

Safety and efficacy of low-dose pre-phase before conventional-dose chemotherapy for ulcerative gastric diffuse large B-cell lymphoma

Potentially fatal chemotherapy (CT)-related gastrorrhagia and gastric perforation in patients with gastric lymphoma present difficult problems to doctors. We retrospectively analyzed 54 patients with ulcerative gastric diffuse large B-cell lymphoma (G-DLBCL) to compare the safety and efficacy of low-dose pre-phase CT before 4-6 cycles of conventional-dose CT (n = 28) with 4-6 cycles of conventional-dose CT (n = 26) between October 2005 and August 2014. Patients who received low-dose pre-phase before conventional-dose CT showed a lower gastrorrhagia or gastric perforation rate (0% vs. 15.4%, p = 0.047) and higher complete response (CR) rate (78.6% vs. 46.2%, p = 0.023) and 5-year progression-free survival (PFS) rate (63% vs. 31%, p = 0.021) than patients who received conventional-dose CT alone. Our study suggests that low-dose pre-phase therapy before conventional-dose CT provides a safe and effective method for ulcerative G-DLBCL.

Efficient palliative involved-field radiotherapy on highly progressive diffuse large B-cell primary gastric lymphoma with liver cirrhosis

We report the case of a 73-year-old woman having diffuse large B-cell primary gastric lymphoma with a cirrhotic liver caused by hepatitis C virus infection. She visited our hospital with symptoms of nausea and vomiting, which appeared to be caused by stenosis due to the tumor. Metastatic tumors were seen in the gastric and jugular lymph nodes. The clinical stage was IVB with a high risk of poor prognosis according to the international index. Because of poor hepatic reserve function, standard chemotherapy could not be administered. To maintain her quality of life, palliative involved-field radiotherapy was performed. The symptoms and tumor markers significantly improved, and computed tomography and endoscopy indicated the disappearance of the primary gastric tumor. Two months after radiotherapy and her return home, she died of pneumonia. Autopsy showed neither lymphoma cells nor stenosis of gastric lesion. The significant anti-tumor effect on primary tumor in our case suggests that the involved-field radiotherapy, although palliative, can be a therapeutic option for primary gastric lymphoma patients with various complications.

Rapid progression of Epstein-Barr-virus-positive gastric diffuse large B-cell lymphoma during chemoradiotherapy: a case report

A 61-year-old woman was referred to our hospital with epigastralgia and appetite loss. Barium examination and upper gastrointestinal endoscopy revealed uneven erythematous mucosa with multiple elevated lesions from the gastric fornix to the upper corpus. Abdominal computed tomography showed thickening of the wall of the fornix and swelling of perigastric lymph nodes, but whole-body gallium scintigraphy and bone marrow examination did not indicate further involvement. Biopsy specimens showed diffuse infiltration of large atypical lymphoid cells in which Epstein-Barr virus (EBV) was detected by in situ hybridization. Diffuse large B-cell lymphoma (DLBCL), stage II1, was diagnosed. Combination chemotherapy [cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP)], was given, and this was followed by radiotherapy. Partial remission was achieved by chemotherapy, but the disease progressed rapidly during radiotherapy. Because the reported prognosis of EBV-positive DLBCL is unfavorable, the therapeutic strategy for EBV-positive gastric DLBCL should be considered carefully.

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.

Incidence of gastric B-cell lymphomas: a population-based study in Germany

BACKGROUND

While the clinical and experimental knowledge concerning gastric lymphomas is increasing, there is a scarcity of epidemiological data.

PATIENTS AND METHODS

A population-based sample of patients in Franconia and Saarland in Germany was collected from a clinical trial, hospital archives and a cancer registry.

RESULTS

Over a period of 3 years, 94 patients with primary gastric lymphoma were recorded out of a total population of 3.5 million. The standardised incidence rates in Saarland and Franconia were 0.7 and 0.8 cases per 100 000, respectively. Patients were predominantly from higher age groups (mean age 62.1 years) and the incidence in men was slightly more than in women (P <0.03). The distribution of histological subtypes in Franconia was as follows: marginal zone B-cell lymphomas (MZBL), 58%; diffuse large-cell B-cell lymphoma (DLBL), 33%; and mixed forms, 9%. Helicobacter pylori could be detected histologically in 84% of all cases, 95% of MZBL cases and 68% of DLBL cases.

CONCLUSIONS

Incidence rates of gastric lymphoma in Germany were similar to that in other European countries, except England, where rates are lower. The subtype-specific differences of H. pylori infection rates could be due to differences in carcinogenesis or to secondary changes during malignant transformation.

A clinicopathological study of 152 surgically treated primary gastric lymphomas with survival analysis of 109 high grade tumours

AIMS

To describe the clinicopathological features of a large number of surgically treated and followed up primary gastric lymphomas and thereby gain a better understanding of their biology, with particular reference to the prognostic factors of high grade tumours.

METHODS

A retrospective study of 152 patients.

RESULTS

High grade gastric lymphomas, both pure and with a residual low grade component, differed from low grade mucosa associated lymphoid tissue (MALT)-type lymphomas in that they were more frequently large, ulcerated, at an advanced stage, and highly proliferating. In addition, patients were older and had a worse outcome. The prognosis of high grade lymphomas was influenced by patient age, tumour stage, depth of infiltration in the gastric wall, and the invasion of adjacent organs. Adjuvant postsurgical treatment prolonged survival only in patients with advanced stage and deep neoplastic infiltration.

CONCLUSIONS

There is a sharp distinction between low grade MALT-type lymphomas and tumours with a high grade component, justifying their different treatment approach. The postsurgical management of high grade lymphomas should be based on the accurate evaluation of the neoplastic extension.

Epidemiological and prognostic aspects of gastric MALT-lymphoma

Since mucosa-associated lymphoid tissue (MALT) lymphoma was defined in the mid-1980s as a clinicopathologic entity, many sets of data on pathological, biological and clinical aspects have been generated. In particular, the finding that this process was responding well to antibiotic treatment fueled interest in it and has led to several clinical trials. This overview deals with epidemiological and prognostic aspects and identifies important questions which need to be answered before data from different sources can be compared. Incidence figures of gastric MALT lymphoma vary between countries and parallel the numbers of all non-Hodgkin's lymphoma. The incidence does not parallel the occurrence data of Helicobacter pylori infection. Incidence figures are highly dependent on the definition used for MALT-type primary gastric lymphomas. Several studies show that some prognostic factors are relevant, for instance stage and grade, whereas other factors such as the International Prognostic Index or treatment are not. These studies do not include the recently introduced antibiotic therapy. The inclusion of recent insights in biology and the treatment of gastric MALT lymphomas in prospective clinical studies will soon answer some of the main questions posed.

Primary gastric non-Hodgkin's lymphoma: clinical features, management, and prognosis of 185 patients with diffuse large B-cell lymphoma

BACKGROUND

Primary gastric non-Hodgkin's lymphoma (PG-NHL) is common in Saudi Arabia. This has prompted the analysis of a large series of patients with PG-NHL having high-grade diffuse large B-cell lymphoma (DLCL) in order to define the clinical features and outcome of this disease.

PATIENTS AND METHODS

The data of all adult patients in the series with PG-NHL having DLCL histology were retrospectively reviewed. Patients were eligible if they had biopsy-confirmed diagnoses obtained by endoscopy or following laparotomy.

RESULTS

Over a 16-year period, 185 patients with DLCL PG-NHL were identified and their data were reviewed. Patients had a median age of 54 years. In 53% of them only one initial therapeutic modality was given, while 47% were managed by a multi-modality approach. One hundred forty patients (76%), 19 (10%), and 26 (14%) attained complete remission (CR), partial remission, and no response/progressive disease, respectively. Multivariate analysis showed that poor performance status and advanced stage were negatively associated with the likelihood of attaining CR. Over a median follow-up of 54 months, 118 (64%) of the patients were alive and disease-free, 17 (9%) were alive with evidence of disease, and the remaining 50 (27%) were dead. The projected 5-year and 10-year overall survivals (OS) (+/- SD) were 68% (+/- 4%) and 61% (+/- 6%), respectively. The Cox proportional hazards model identified the same variables of response as adverse prognostic factors of survival. Using the influence of performance status, and stage, a prognostic index was constructed to recognize three prognostically distinctive risk categories with overall survival proportions of 87%, 61%, and 45%, respectively. The unadjusted International Prognostic Index, however, failed to classify patients into prognostically meaningful risk strata. Of the 140 patients who achieved CR, the median disease-free survival (DFS) was not reached, but the predicted 5- and 10-year DFS were 82% and 75%, respectively. A multivariate analysis identified poor performance status as the only independent prognostic covariate that adversely influenced DFS. Our analysis showed that compared with single-modality management, multi-modality strategy attained significantly higher CR, and advantageous OS and DFS.

CONCLUSIONS

This large series characterized the clinico-pathologic features and outcome of patients with DLCL PG-NHL. Performance status, and stage significantly influenced patient outcome. A prognostic index was developed and it identified three prognostically distinctive risk groups; however, prospective validation is warranted.

Non-surgical treatment with primary chemotherapy, with or without radiation therapy, of stage I-II high-grade gastric lymphoma

Morbidity, mortality and discomfort related to gastrectomy has led some investigators to treat patients with stage I-II primary gastric high-grade lymphoma (PGL) with a conservative strategy. Here we report a retrospective series of 21 patients with PGL treated with primary chemotherapy alone or followed by radiation therapy and analyze previously reported series, focusing on therapeutic results, treatment-related morbidity and stomach preservation rate. All 21 patients with stage I-II PGL received an initial anthracycline-containing chemotherapy, which was followed by involved field-radiation therapy in 8 cases. Data regarding toxicity, response and relapse rates and survival of this patient group and 14 previously published series, involving 316 patients treated with conservative modality, were also analyzed. In the present series two patients did not complete the planned treatment, while the remaining 19 achieved a complete remission (response rate: 90%). Three patients relapsed, all of whom had been treated with chemotherapy alone. Two patients died of lymphoma, one of sepsis and the other of lung cancer while still relapse-free. The survival rate at 50 months is 81%, and the 5-year actuarial cause-specific survival is 82%. The stomach preservation rate is 100%. Previously reported series showed a response rate ranged between 76% and 100%. Gastrointestinal bleeding was observed in only 3% of cases, while no cases of gastric perforation were reported. Treatment mortality rate was 2.5%. 5-year actuarial survival ranged between 73% and 90% and stomach preservation rate was 97%. Short-term chemotherapy obtained similar results to more prolonged treatment. In conclusion, conservative treatment with primary chemotherapy followed by involved field-radiation therapy should be used for the first-line treatment of patients with stage I/II PGL considering that it is associated with a high response and survival rates, and with an insignificant risk of bleeding or perforation, high stomach preservation rate and good quality of life.

[Radiotherapy for gastrointestinal lymphomas: indications and techniques]

Gastrointestinal lymphomas are almost exclusively of a non-Hodgkin's type. The Western form is characterized by a higher incidence of stomach location (50%), a MALT type (mucosa associated lymphoid tissue) (40%), a B-cell type (90%), and a high grade (55%). Chronic infection with Helicobacter pylori is an important risk factor. Mediterranean lymphomas form a particular clinical and pathological entity with diffuse involvement of the small bowel and are frequently being associated with a chronic malabsorption disorder. Eradication of Helicobacter pylori in early gastric lymphomas, and the use of tetracyclines in early Mediterranean lymphomas, have been shown to induce durable remissions. For more advanced gastric lymphomas, treatment usually consists of anthracyclin-based chemotherapy followed by involved field radiotherapy. Surgery is usually reserved for complications such as perforation or bleeding, or in some selected cases for salvage after failure of non-surgical therapy. For intestinal lymphomas, surgical resection whenever feasible, followed by anthracyclin-based chemotherapy is the most common treatment. Radiotherapy is usually reserved for consolidation in some clinical situations. The most commonly found prognostic factors are stage, grade, and tumor bulk. Treatment results vary with the presence of adverse prognostic factors and the used treatment combination. In general, patients with favorable disease receiving combined therapy have a 5-year relapse free survival (RFS) approaching 90%, whereas those with unfavorable disease have a RFS of 40-50%.

Clinicopathological features of primary gastric lymphoma

BACKGROUND AND OBJECTIVES

Surgery has been the mainstay of the treatment of primary gastric lymphoma, but the value of surgical treatment needs reevaluation.

METHODS

Thirty-two patients with primary non-Hodgkin B-cell lymphoma of the stomach were examined retrospectively to evaluate prognostic factors and their impact on survival. All patients had undergone abdominal exploration for radical surgery between 1979 and 1992. The prognostic factors in view of survival after treatment were determined with both univariate and multivariate analyses.

RESULTS

The resectability rate was 66% (21/32) and radical resections had been performed on 53% (17/32). The overall median survival was 65 months and the overall 5-year survival was 56%. The 5-year survival rates related to a modified Ann Arbor classification as follows: I 1E, 86%; I 2E, 100%; II 1E, 44%; II 2E, 37%; IIIE, 20%; and IVE, 0%. Univariate analysis using Kaplan-Meier estimates showed that radical surgery, Ann Arbor stage, patient's age, and lymph node involvement were significant prognostic factors. According to Cox proportional regression analysis, only Ann Arbor stage, radical surgery, and age were significant independent variables.

CONCLUSIONS

According to our experience, surgery is still needed for the treatment of primary gastric lymphomas, but the benefits of primary chemotherapy or adjuvant chemotherapy using cytotoxic drugs must be determined in large prospective controlled trials.