Management of gastrointestinal lymphoma

Primary Hodgkin's Disease of the Stomach. A Case Report

Primary gastric Hodgkin's disease is rare and has been reported in only 2 % of patients with primary gastric lymphomas. Its existence is quite controversial, and new immunohistochemical techniques and flow cytometry have reduced the frequency of diagnosis of this pathology. The authors describe a case of primary gastric Hodgkin's disease in a 61-year-old woman.

Primary non-Hodgkin lymphoma of the small bowel

PURPOSE

To clarify the natural history of primary lymphoma of the small bowel and identify preferred treatments for it.

MATERIALS AND METHODS

A retrospective analysis of 61 patients with primary lymphoma of the small bowel was performed. The Ann Arbor stages were I in 20 patients, II in 28, and IV in 13. After resection or biopsy, 15 patients were treated with radiation therapy, 26 with chemotherapy, and 16 with combined-modality therapy. Four patients underwent no adjuvant treatment after resection.

RESULTS

The actuarial 10-year overall survival and relapse-free survival for the patients with intermediate- and high-grade lymphoma were 47% and 53%, respectively. For the patients with low-grade lymphoma, these rates were 81% and 62%. For patients who underwent radiation therapy, combined-modality therapy, or chemotherapy, the recurrence rates inside the abdomen or pelvis were one of 12, two of 15, and five of 20, respectively, and those outside the abdomen or pelvis were four of 12, one of 15, and zero of 20, respectively. Four of the five abdominopelvic recurrences of disease in the chemotherapy group were among the nine patients who had Ann Arbor stage II disease.

CONCLUSION

Chemotherapy lowered the recurrence rate outside the abdomen or pelvis. Patients with stage II disease may benefit most from radiation therapy.

[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%.

Primary gastrointestinal non-Hodgkin's lymphoma. A population based study in central Finland in 1975-1993

Gastrointestinal lymphomas have been uncommon, but the frequency of their predisposing conditions is increasing. The objective of the present study is to determine the frequency of gastrointestinal lymphomas in the area of central Finland as well as the influence of clinical features and therapeutical approaches on the survival of these patients. All samples of gastrointestinal non-Hodgkin's lymphomas diagnosed of patients living in the province of central Finland in 1975-1993 were re-examined. In central Finland the mean annual frequency of new gastrointestinal lymphomas was 10/1000000 in 1975-1984 and 16.0/1000000 in 1985-1993. The total incidence of gastrointestinal lymphomas in Finland adjusted for age to the world standard population was 12.5/1000000 in 1992. Two patients with peripheric T-cell lymphoma had a coeliac disease. Other predisposing conditions were not found. The stage of distribution of the lymphoma (p < 0.01) and radicality of the surgery (p < 0.01) were the most influencing factors on the survival of these patients. In conclusion the early distinction of gastrointestinal lymphomas is vital because of an increasing frequency of predisposing factors and a better prognosis due to new combination therapies.

Primary gastrointestinal lymphoma: 30-year experience at the Cancer Institute, Madras, India

A retrospective study was conducted of 49 patients with primary gastrointestinal lymphoma to analyze clinicopathological features, prognostic factors, and results of treatment. Intestinal lymphomas (63%) were more common than gastric lymphomas (29%). Endoscopic biopsy was diagnostic in 64% of gastric lymphomas, while 97% of intestinal lymphomas required laparotomy for diagnosis. Lymphoblastic (35%) and diffuse large cell (33%) lymphomas were the most frequent histologic types. Complete remission (CR) was achieved in 61% of patients, with a 5-year survival of 72% in those who achieved CR. The overall 5-year survival and disease-free survival were 47% and 40%, respectively. All disease-related mortality occurred within 2 years of diagnosis, with 79% occurring in the first year. There was no overall significant difference in survival between the different treatment groups. Stage, extent of surgical resection, response to treatment, serosal involvement, multimodality treatment, and performance status were significant prognostic factors. Achievement of complete remission and complete surgical resection were the most favorable independent prognostic factors on multivariate analyses.

Primary gastric non-Hodgkin's lymphoma: a clinicopathological study of 41 patients

Pathological findings in 41 patients (male/female ratio: 1.3/1) with primary localized gastric non-Hodgkin's lymphoma (NHL) were retrospectively studied and correlated with survival. The median observation period after diagnosis was 32 (0-189) months. Nineteen patients were low-grade NHL, all but one B-cell lymphomas of the mucosa-associated lymphoid tissue (MALT) type. Twenty-two patients had primary (n = 7) or secondary (n = 15) high-grade lymphomas; Musshoff stage IE was found in 29 and IIE in 12 cases. The median age at diagnosis was 61 years (range, 26-88 years), and proliferation, measured by the number of mitosis and Ki-67 antigen positivity (MIB-1), was high or moderately high in 24 cases and low in 17 cases. Follicular lymphatic hyperplasia could be found in 25 of 34 evaluable cases, more often in low-grade than in high-grade NHL. Most of the patients were treated by resective surgery and additional ratio- or chemotherapy. Thirteen patients (31%) died (median survival: 10 months), 5 of them within 3 months after surgery owing to postoperative complications. Survival was superior, though not statistically significant, in low-grade lymphomas. Our retrospective analysis of heterogeneously treated gastric lymphomas reveals that gastric lymphomas, especially of the low-grade MALT type, often remain a localized disease with a good long-term prognosis. Our study confirms previous reports indicating that lymphomas of the MALT type represent a specific clinicopathological entity.

Combined surgery and chemotherapy in primary gastric non-Hodgkin's lymphoma: a retrospective study in sixty-six patients

Sixty-six consecutive patients with primary gastric non-Hodgkin's lymphoma are reported. All patients underwent surgery which consisted of radical resection in 23 patients (36%) and partial or palliative excision in the remaining 43 cases (36 and 7 respectively). Three patients died before starting chemotherapy, two refused the treatment and 61 completed the postoperative chemotherapeutic programme. We analysed this group of patients in order to assess the efficacy of chemotherapy following surgery. Chemotherapy included either CVP or the original protocols from our institution. Excluding patients who underwent radical resection, postoperative chemotherapy induced complete remission in 87% of the remaining 39 patients. After a median follow-up of 84 months (range 6-216), the 10-year cause-specific survival was 90% with a stable curve plateau after about 25 months. The survival was only influenced by response to therapy (p < 0.0001). The disease-free survival for patients who were not radically resected was 93%. We encountered only two relapses after 15 and 32 months. One of these was local and the other systemic. Our results indicate that chemotherapy following surgery induces long-term remission and survival in primary gastric lymphoma and in particular improves remission and survival, in stage II. In our opinion, surgery may also be fundamental for the treatment of gastric lymphoma in the majority of cases.

Report on a workshop convened to discuss the pathological and staging classifications of gastrointestinal tract lymphoma

It was considered timely to review the pathological and staging classifications of GI tract lymphoma. This meeting specifically did not address the question of treatment; the management of GI tract lymphoma could perhaps form the basis for a further workshop. The following recommendations were made: to adopt the Isaacson histological classification, that all patients with GI tract lymphoma be investigated uniformly, to record the prognostic factors described above, to use the staging classification shown above. It is hoped that these recommendations will be taken into account in the design of future clinical trials of therapy for GI tract lymphoma.

Primary colorectal non-Hodgkin's lymphoma

BACKGROUND

The gastrointestinal tract is the most common site of extranodal involvement in non-Hodgkin's lymphoma (NHL). Primary colorectal NHL comprises 13-18% of all gastrointestinal NHL but is not commonly reported as a separate entity.

METHODS

This was a retrospective review of the medical records of 19 patients over a 16-year period to evaluate the clinical features and behavior of colorectal NHL.

RESULTS

A pediatric group of seven male patients presented at an early stage with acute symptomatology. The primary tumor was located in the ileocecum in all cases and intussusception was common. An adult group of 12 patients presented at a later stage with chronic symptomatology. Staging study results were positive by bone marrow biopsy in four of 16 patients (25%), by lymph-angiography in six of 11 patients (54.5%), and by gallium scan in eight of 10 patients (80%). Seven patients relapsed a median of 8 months after treatment. Three other patients died during treatment, one died of other causes, and one died without receiving treatment. The remaining seven patients are alive from 41 to 231 months without evidence of disease. Five of these patients are in the pediatric group, where the median survival was > 72 months. The overall median survival was 45 months.

CONCLUSION

Colorectal NHL is a disease that affects both the pediatric and adult population. Although pediatric patients have an excellent prognosis with anticipated long-term survival after treatment, long-term survival can be expected in approximately 50% of adult patients. In both groups of patients, multimodality therapy with surgery, chemotherapy, and radiation is the treatment of choice.

Gastrointestinal lymphoma in adults: clinical features and management of 300 cases

BACKGROUND/AIMS

Gastrointestinal lymphoma is a rare disease. A study was conducted to assess its prevalence and clinical features in adult patients with lymphoma.

METHODS

Retrospective analysis of 1352 patients with adult non-Hodgkin's lymphoma showed 300 (22%) cases with gastrointestinal involvement at initial presentation.

RESULTS

Of the 185 patients with primary gastrointestinal lymphoma, 94 (51%) had gastric primary lymphoma and the rest (49%) had a lymphoma of intestinal origin. Patients with intestinal lymphoma were considerably younger (median age, 35.0 years), frequently had multifocal disease (14%), and had a 10-year survival rate of 48%. Cases with gastric primary lymphoma had a median age of 54.5 years (P < 0.001) and rarely had multifocal disease (1%; P < 0.001) but had an equal 10-year survival rate of 53% (P = 0.431). For both groups, the combined surgical resection followed by chemotherapy led to better 10-year survival (45%) compared with either modality used alone (0% and 35%, respectively; P < 0.05). Better survival was also noted in ambulatory patients, younger patients, those with localized disease, and those without intestinal perforation. Another 115 patients had gastrointestinal involvement secondary to disseminated disease with frequent high-grade histology (29%) and a poor 10-year survival rate of 22%.

CONCLUSIONS

Gastrointestinal involvement is relatively common in patients with adult lymphoma. Multimodality treatment appeared superior to therapy with either surgery or chemotherapy used alone.

Primary digestive tract lymphoma: a prospective multicentric study of 91 patients. Groupe d'Etude des Lymphomes Digestifs

BACKGROUND

The optimal management of primary gastrointestinal lymphoma including the use of surgery remains unsettled. This prospective study aimed to determine the prognostic factors of primary gastrointestinal lymphoma and to evaluate a therapeutic strategy based on surgical tumor reduction, followed by chemotherapy adapted to the histological type of tumor and tumor removal or nonremoval.

METHODS

Ninety-one patients were included (mean age, 50.4 years) with mainly gastric (61%) or several digestive tract organ (18%) involved sites in clinical stages IE (43%), IIE (27%), and IV (30%). Three therapeutic groups were defined: group I, patients with low-grade lymphoma (n = 28); group II, patients with high-grade lymphoma who had complete tumor removal (n = 24); and group III, patients with high-grade lymphoma who had only partial or no tumor removal (n = 39). Each group underwent adapted chemotherapy.

RESULTS

The respective overall 5-year survival rates for groups I, II, and III were 81% +/- 6%, 100%, and 56% +/- 8%, respectively (P < 0.0001). By Cox multivariate analysis, the prognostic factors of survival were age under 65 (P < 0.05), gastric localization (P < 0.05), stage IE (P < 0.001), and radical or incomplete surgery (P < 0.01).

CONCLUSIONS

Combined radical surgery and chemotherapy according to histological grading is associated with prolonged remission in patients with primary digestive tract lymphoma. Moreover, compared with chemotherapy alone, incomplete resection of tumor is associated with increased survival of high-grade lymphomas.

Role of surgery in patients with primary non-Hodgkin's lymphoma of the stomach: an old problem revisited

The literature after 1980 dealing with the treatment of primary gastric non-Hodgkin's lymphoma (stages I and II) is reviewed. Gastrectomy is recommended for patients with acute symptoms at presentation or with complications of chemotherapy or radiotherapy. In elective cases, patients with stage I disease may be candidates for gastrectomy as a single therapy, provided that tumour-free resection margins are achieved. There is no evidence of substantial benefit from adding postoperative chemotherapy or radiotherapy after an apparently radical resection. In stage II disease, the best results are achieved with ablative surgery plus adjuvant therapy. The resection volume should be limited to macroscopically involved structures, in principle avoiding total gastrectomy and extensive lymph node dissection, since residual disease may be optimally controlled with radiotherapy or chemotherapy. Primary chemotherapy, with or without radiotherapy, represents an experimental approach; the advantages of sparing the stomach must be balanced against the toxicity of an aggressive chemotherapy regimen and the risk of emergency operation for iatrogenic complications.

Primary gastrointestinal non-Hodgkin's lymphoma: a review of 175 British National Lymphoma Investigation cases

A retrospective analysis was performed upon 175 patients with Non-Hodgkin's Lymphoma involving the gastrointestinal tract and entered into BNLI trials and studies between 1974-1988. Malignant histiocytosis of the intestine (MHI), which was present in 16 patients, was associated with a survival of less than 25% at 18 months, and probably accounted for the poor survival of patients with jejunal involvement. Histopathological evidence of tumour origin from mucosa-associated lymphoid tissue (MALT) was found in 50% of patients with gastric involvement and in 27% of those with intestinal involvement. The overall survival of the series as a whole was 44% at 10 years. Multivariate analysis identified evidence of tumour origin from MALT as the only factor to attain prognostic significance in patients with gastric involvement, and clinical stage and the presence of MHI as the only factors to attain prognostic significance in patients with intestinal involvement. It is suggested that there is a need for a large multicentre prospective study of GIT lymphoma.

HTLV-I associated and non-associated primary T-cell lymphoma of gastrointestinal tract

The gastrointestinal (GI) tract is the common extranodal site for non-Hodgkin's lymphoma (NHL), and primary lymphoma of GI tract are mostly of B-cell origin. We have treated 16 patients with primary lymphoma of GI tract between 1981 and 1991, of whom 10 (62%) were of B-cell origin, while 6 (38%) were of T-cell origin. The incidence of T-cell phenotype in our hospital was considered to be much higher than that of previous reports and these 6 patients with primary T-cell lymphoma of GI tract were carefully studied. The primary sites were stomach in 4, ileocecum in 1, and duodenum in 1 case. Their T-cell nature was confirmed by immunohistochemical methods. All were peripheral T-cell lymphomas; one was CD 3+ 4- 8- and the other 5 were CD 3+ 4+ 8-. The antibody against human T-cell leukemia virus type I (HTLV-I) was positive in 3 cases (HTLV-I associated), but negative in 3 (HTLV-I non-associated). The integration of HTLV-I proviral DNA in HTLV-I associated patients was demonstrated by Southern blot analysis after DNA amplification by means of polymerase chain reaction (PCR). The clinical features of the HTLV-I associated and HTLV-I non-associated primary T-cell lymphoma of the GI tract were quite different. HTLV-I associated patients showed leukemic manifestations and tumor involvement of the skin at a later stage of the disease. These observations indicated that HTLV-I can play an important role in the occurrence of primary T-cell lymphoma of GI tract.

Malignant lymphoma of the stomach associated with systemic sarcoidosis

The case of a patient with gastric malignant lymphoma associated with systemic sarcoidosis is reported. The patient's sarcoidosis was identified by the findings of bilateral hilar lymphadenopathy and secondary glaucoma. Biopsy of a cervical lymph node showed epithelioid cell granuloma; the sarcoidosis was diagnosed 15 years previously. She had been treated with prednisolone for 5 years until 1979. Proximal gastrectomy, splenectomy, and lymph node dissection were done in 1989. The tumor was diagnosed as malignant lymphoma of the diffuse large cell type according to the Working Formulation. There was no infiltration of lymphoma cell in the 45 dissected lymph nodes, but sarcoid nodules were observed in all nodes. Only three cases of gastric malignant lymphoma complicating sarcoidosis have been reported to the authors' knowledge. Further study should be done in support of the concept of a sarcoidosis-lymphoma syndrome.

Gastric lymphoma treatment. Medical versus surgical

The treatment of gastric lymphoma is an area of ongoing controversy. Surgical resection has been the standard therapy. Recent advances, however, have been developed in other treatment modalities. A comparison of treatment options is presented.

Primary gastric non-Hodgkin's lymphoma. A retrospective clinico-pathological study

Prognostic factors and treatment results were analysed in 72 consecutive patients with primary gastric lymphoma treated between 1970 and 1985. There were 37 patients in stage IE, 17 in IIE, 3 in IIES and 15 in stage IV. Histopathological re-evaluation and classification according to the TNM system were performed. We found that disseminated disease (stage IV), serosal penetration (T3), involvement of adjacent organs (T4) and extensive abdominal lymph node involvement (N3) were poor prognostic factors. Neither histological malignancy grading, nor the appearance of lympho-epithelial lesions were significantly associated with relapse-free survival. Forty-six patients with 'limited localized' disease (stage IE, IIE, N3 excluded) received potentially curative treatment (surgery, radiotherapy, chemotherapy or combinations thereof), of whom 85% remained relapse-free. Thirty-four patients did only get local treatment (surgery and/or radiotherapy) with curative potential, the relapse-free survival rate was 85%. We conclude that primary gastric lymphoma stage IE and IIE (N3 excluded) is often a truly localized disease that can be cured with local therapy.

Clinicopathological features of primary gastrointestinal lymphomas: a study of 42 cases

The clinicopathological features of 42 patients with gastrointestinal lymphoma during the period 1982-88 are described. Ten cases (23.8%) were seen in the stomach, 23 cases (54.8%) in the small intestine and 9 cases (21.4%) in the large intestine. In 4 cases multiple sites were involved. The tumours occurred most frequently in the 2nd to 4th decade. Histologically, using the working formulation for non-Hodgkin's lymphoma, all were found to be diffuse and mostly of the high grade type (45%). Seven lymphomas were seen in children. Three were of the Burkitt's type. Patients presented quite late in a large number of cases (43%). Compared with most other published series small intestinal involvement was common. There was a high incidence in males. Predominant small intestinal involvement did not result in malabsorption syndrome and primary lymphomas constituted 3.5% of all malignancies of the gastrointestinal tract.

Primary non-Hodgkin's lymphoma of the stomach: endoscopic diagnosis and the role of surgery

Primary non-Hodgkin's lymphoma of the stomach represents a minority of 1-7% of all gastric malignancies. Symptoms are non-specific. At endoscopy three main patterns can be recognized: ulceration, diffuse infiltration, or a polypoid mass. Endoscopic biopsy results may be false-negative (up to 8%) owing to submucosal localization. The new technique of endoscopic ultrasonography is accurate in measuring depth of infiltration and regional lymph nodes. Preoperative diagnosis altered the indication for surgery. Without resection an excellent local tumour control (stage I, 85%, and stage II, 69%) can be achieved, leading to a fair prognosis: 5-year relapse free survival in stage I, 83%, and in stage II, 58%. Intra-abdominal recurrences were scarce (2%), and severe complications such as perforation and life-threatening haemorrhage were seldom present (4%). Thus, resection is not necessary, but early recognition is highly significant. Favourable results can be achieved by irradiation or chemotherapy with irradiation.

Gastrointestinal lymphoma

Primary GI lymphoma is a rare clinical entity. A primary nodal tumor should be ruled out. Symptoms may not be localizing and B symptoms are less common. A tissue diagnosis, preferably by transmural biopsy for small intestinal involvement, often reveals a high-grade morphology. The staging work-up should include a bone marrow examination, although formal staging laparatomy is not always required. Patients with Mushoff stage IE or IIE1 disease do better than those with extraregional nodal disease or distant metastatic involvement. Surgical resection with clear margins is required in order to maximize the changes for cure. Chemotherapy or radiotherapy may give a survival advantage when used as adjuvant treatment for selected stage IE and IIE disease. Chemotherapy should be used after surgical debulking in more advanced disease in order to minimize the chance for bleeding or performation. Future randomized, multi-institutional trials will give more direction as to the best modes of management.

Primary gastric non-Hodgkin's lymphoma in Finland, 1972-1977. Clinical presentation and results of treatment

During the period 1972-1977, 66 patients were treated for primary gastric non-Hodgkin's lymphoma in various hospitals in Finland. Most frequently, the disease occurred in middle-aged or old patients and had a male predominance. Clinical symptoms were non-specific. An abdominal mass was felt in 21% of the patients. Roentgenologic findings were mostly non-specific but suggested a malignant tumour. A definitive diagnosis was difficult to confirm by endoscopic examination. Forty-four patients had surgical resection, 30 patients curative resection, and 14 palliative resection, and 16 patients had only explorative laparotomy. Eighty-five per cent of the patients who had curative resection survived 5 years, compared with 15% of those who underwent palliative resection. Curative resection gave the best survival of 5 years. The stage of the disease was a very important prognostic factor: the 5-year survival was 85% for patients with stage-I disease but only 3% for those with stage-IV disease.

Primary gastric lymphoma: a prospective analysis of 12 cases and review of the literature

The clinicopathological features of 12 cases of primary lymphoma of the stomach are reviewed, and the efficacy of various treatment modalities is evaluated. The presenting symptomatology and the radiological signs were found to be similar to those of gastric carcinoma. Gastroscopy and computed tomography (CT) proved to be effective diagnostic and staging tools. There were two patients of stage I, seven patients of stage II, and three patients of stage IV. Multimodal therapy involving judiciously combined surgery, radiation therapy, and chemotherapy produced early complete remission in all the nine patients with localized disease, and all of them are disease-free at a minimum follow-up period of 12 months. These results are irrespective of whether surgery formed part of the treatment regimen. The relevant literature is reviewed, and the present status of the efficacy of nonsurgical therapy is evaluated.

Primary ileocecal lymphoma. A study of 22 patients

Twenty-two patients with primary ileocecal non-Hodgkin's lymphoma were reviewed. Abdominal pain (67%), altered bowel habits (50%), and weight loss (50%) were the most common presenting symptoms and an abdominal mass was palpable in 50%. Sixteen (73%) had histologic evidence of local lymph node involvement at diagnosis and another two (9%) had nonhistologic evidence of nodal involvement. An abdominal computed tomography (CT) scan was the most helpful staging investigation. Twenty-one (95.5%) patients underwent surgical resection of their disease. Subsequent chemotherapy, with or without radio-therapy, appeared to prolong survival (median, 34 months versus 14 months). There were three treatment-related deaths. Neither the age of the patient nor the stage of disease at presentation (Ann Arbor) appeared to influence survival. Adequate initial surgery combined with chemotherapy may provide optimum therapy in patients with primary ileocecal lymphoma.

Gastric lymphomas: chemotherapy as a primary treatment

Twenty-one of 65 patients with gastric lymphoma have been treated with combination chemotherapy; 17 patients had chemotherapy as primary treatment, and 4 had it for residual disease after incomplete surgical resection. Three of these patients were in stage III and 18 were in stage IV of the disease, according to the TNM Staging Classification. CHOP-Bleo or CHOP combination was given to 17 patients, and the COPP-Bleo regimen to three; the last one was treated with COP. Sixteen of the 18 stage IV patients entered into complete remission after 6 to 10 courses of CHOP or COPP-Bleo; there was one partial response and one failure. Six complete responders had a surgical restaging performed and none of them had gross evidence of residual disease; all of them had partial gastrectomy and in five cases there was no microscopical evidence of disease; in one of the resected stomachs, a focus of residual disease was discovered involving the submucosa but without compromise of the serosa. Fourteen (77.7%) of these patients are alive with no evidence of disease 1-10 (X = 3.8 years); one patient died with recurrent disease at 30 months; another patient died of other causes after 3 years; one patient is alive with disease at 18+ months. All the remaining 16 stage IV patients who were not given chemotherapy have died, median survival time being 5 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary rectal lymphoma and malignant lymphomatous polyposis. Two cases illustrating current methods in diagnosis and management

Two cases of colorectal lymphoma are presented. Preoperative histologic diagnosis is difficult and examination of the fresh specimen using immunocytochemical and gene rearrangement techniques are necessary to establish the precise nature of the lesion. Surgical excision is the mainstay of treatment for localized lymphoma of the colorectum and chemotherapy for malignant lymphomatous polyposis.

Prognostic factors in primary gastrointestinal non-Hodgkin's lymphoma. A multivariate analysis, report of 106 cases, and review of the literature

The authors have reviewed 106 cases of primary gastrointestinal non-Hodgkin's lymphoma (GI-NHL) treated at the Institut Gustave-Roussy (IGR), France, between 1975 and 1986. The occurrence was 55 in the stomach, 26 in the small intestine, ten ileocecal, seven in the large intestine, and eight patients had multiple involvement. Patients were clinically staged according to the Ann Arbor staging system using the modification of Musshoff for Stage IIE. All histologic material of the 106 patients were reviewed and graded according to the Working Formulation (WF) and the Kiel classifications. Most patients received combination chemotherapy as part or all of their primary treatment program (95 patients, 90%). Seventy five patients (71%) had a multimodality treatment. The overall 5-year survival rate was 60%. Sixteen variables were tested by univariate analyses for prognostic influence on survival. Of these, only clinical stage (P less than 0.001), the achievement of initial complete remission (CR) (P less than 0.001), erythrocyte sedimentation rate (ESR) (P = 0.01), mesenteric involvement (P = 0.03), and serosal infiltration (P = 0.05) were significant prognostic factors. Important variables were tested by a multivariate analysis using the Cox model taking into account different treatment modalities. Only three variables entered the regression analysis at a significant level: clinical stage (P = 0.02), surgical resection (P = 0.03), and histologic grade (Kiel) (P = 0.04). When the achievement of initial CR was introduced into the model, it was the most significant variable (P less than 0.001) whereas all other variables became nonsignificant except for the histologic grade (Kiel) (P = 0.004). Based on results of the multivariate analyses we propose two prognostic classifications of patients: one at the initial evaluation depending on clinical stage, surgical resectability, and histologic grade (Kiel); the other at the end of primary treatment depending on the achievement or not of CR and the histologic grade.

Combined surgery and chemotherapy for the treatment of primary gastrointestinal intermediate- or high-grade non-Hodgkin's lymphomas

Fifty-five consecutive patients with primary gastrointestinal intermediate or high grade non-Hodgkin's lymphoma were analysed to assess the efficacy of chemotherapy following surgical tumour resection. Histological subtypes were high grade (n = 18), intermediate grade (n = 36) and unclassified (n = 1). The majority of patients had gastric presentation (71%) and localised disease (84%). Surgery consisted of radical resection in 25 patients (45%) and partial or palliative excision in the remaining cases (22 and 8 respectively). Four subjects died within 3 months of surgery, two patients refused adjuvant chemotherapy and 49 completed the postoperative chemotherapeutic programme. Chemotherapy included either Fi2/74 (adriamycin + vincristine + bleomycin + cyclophosphamide + prednisone) or Fi3/74 (adriamycin + VM26 + bleomycin + cyclophosphamide + prednisone). Excluding the group who underwent radical tumour resection, postoperative chemotherapy induced complete remission in 81% of the remaining 30 patients. The 10-year cause-specific survival for the 53 treated patients was 76% (median follow-up 58 months) with a stable curve plateau after 80 months. Proportional-hazard multivariate statistics showed that survival was influenced by type of surgical resection (P less than 0.05) and stage (P less than 0.05), whereas age, sex and histological subtype were not influential. Our data indicate that chemotherapy following surgical resection of gastrointestinal lesion induces long-term remission in primary gastrointestinal lymphomas.

Primary non-Hodgkin's lymphoma of the stomach: changing aspects and therapeutic choices

Eighty-five consecutive patients, seen between 1970 and 1987, with primary gastric non-Hodgkin's lymphoma were studied to evaluate diagnostic findings and treatment results. At endoscopy three main patterns were recognized: ulceration (n = 21), diffuse infiltration (n = 16) and a polypoid mass (n = 26). Recently, the new technique of endoscopic ultrasonography was used to measure depth of infiltration and regional lymph nodes. Preoperative diagnosis altered the indication of surgery. Since 1978 surgical staging was performed in only 29% of the patients compared to 90% in the earlier period. In the later period stage II was more systematically treated with a combination of chemotherapy and radiotherapy. Over the whole period patients in stage I (n = 52) had a 5 year disease-free survival of 63%. In stage II 38% had a 5 year disease-free survival. Complications were one perforation and one haemorrhage after radiotherapy and two cases of haemorrhage after radiotherapy combined with chemotherapy. Intraabdominal recurrences were found in two cases. Recognition of endoscopic features may lead to early detection and ultimately improved survival.

Primary malignant lymphoma of the colon and rectum. A histopathological and immunohistochemical analysis of 45 cases with clinicopathological correlations

Primary colorectal lymphoma accounts for only about 0.2% of large intestinal malignancies. Management difficulties are compounded by a lack of consistent pathological reporting and by the use of numerous different classifications. Forty-five cases of primary colorectal lymphoma are included in this study. The presenting features are indistinguishable from those of colorectal cancer. Seven patients had a history of chronic ulcerative colitis but no other predisposing factors were identified. Immunohistochemical studies showed that all tumours were of B-cell phenotype. Most tumours were difficult to characterize using standard pathological classifications such as Kiel, except for the 11 cases of malignant (multiple) lymphomatous polyposis, which were morphologically diffuse centrocytic lymphomas. Twenty-nine lymphomas showed the morphological and immunohistochemical features associated with tumours arising in mucosa-associated lymphoid tissue. These tumours showed variable but often marked polymorphism and we have used the term polymorphic B-cell lymphoma to describe them. Consistency was achieved between three observers as to whether these tumours were low or high grade, and grade was found to be prognostically important. A modified Dukes staging system was adopted and there was a trend for early stage to give prognostic advantage. This study supports the view that surgery should be the primary treatment for localized lymphoma of the gastrointestinal tract with radiotherapy and/or chemotherapy for advanced cases and for malignant lymphomatous polyposis.

Primary gastrointestinal non-Hodgkin lymphoma. A review of 36 cases

A retrospective study was made of 36 patients with primary gastrointestinal (GI) non-Hodgkin lymphoma (NHL), of which 16 occurred in stomach, 14 in small intestine, 3 in ileocecal region and 3 in large intestine. The mean age was 57 years. According to the 'Working Formulation' large cell lymphomas were most common. All patients were surgically explored, 27 undergoing resection and 9 laparotomy with biopsy. Radiotherapy was given to 14 patients and 27 received chemotherapy. Patients with stomach as the primary site had a slightly better outlook than patients with intestinal tumors. In patients with stage I and II disease the group which had been resected and received both radiation treatment and chemotherapy had the best prognosis with a 3-year survival of 76%. The material also indicates that radiotherapy is of value for GI-NHL in stage I or II.

Gastrointestinal non-Hodgkin's lymphoma

Seventy-two patients with gastrointestinal non-Hodgkin's lymphoma treated between 1952 and 1980 are reviewed. The small intestine was involved in 49% of cases and the stomach in 29%. Surgical resection of the tumour was performed whenever feasible. Radiotherapy was used either adjuvantly or for incompletely excised tumours and chemotherapy was more often reserved for advanced, unresected disease. The overall 5 year survival was 36% and the 5 year relapse free survival was 22%. Forty-one (57%) patients relapsed of whom 33 (80%) subsequently died of non-Hodgkin's lymphoma. The histology in each case was reviewed using the British National Lymphoma Investigation criteria and 94% of cases were reclassified as Grade 2 non-Hodgkin's lymphoma.

A prospective study of the treatment of high-grade histology non-Hodgkin's lymphoma involving the gastrointestinal tract

Thirty-six patients presenting with stage II-IV primary gastrointestinal non-Hodgkin's lymphoma of high-grade pathology were treated in a prospective study from 1975 to 1983 with combined modality therapy. A complete response rate of 56% was obtained and the overall 5-yr survival rate was 36%. The 5-yr relapse-free survival rate of the complete remitters was 79%. Multivariate analysis revealed that the remission achieved (P less than 0.001) and the completeness of primary surgery (P = 0.018) would reliably predict the duration of overall survival. The finding of diffuse histiocytic histology (Rappaport) predicted longer relapse-free survival. The majority of deaths were related to intra-abdominal complications and not to disseminated lymphoma. Gastrointestinal tract non-Hodgkin's lymphoma of high-grade pathology of all stages is curable with a combination of chemotherapy and radiotherapy following surgery to remove as much macroscopic disease as is possible.