Gastrointestinal lymphoma and sarcoma. A case for aggressive search and destroy

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.

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.

Role of surgery in multimodality therapy for gastrointestinal lymphoma

Between 1973 and 1989, 49 patients with gastrointestinal lymphomas were treated at the Virginia Mason Medical Center, Seattle, Washington, and followed in the tumor registry. The purpose of this review was to determine the influence of treatment on long-term survival of these patients. The mean age was 63 years (range: 38 to 83 years). There were 33 men and 16 women. The primary tumor sites were gastric 33 (67%), small bowel 11 (22%), and colon 5 (10%). Common signs and/or symptoms at presentation were pain (n = 38), bleeding (n = 11), and weight loss (n = 14). The diagnostic sensitivities of contrast radiography, computed tomography, and endoscopic biopsy were 76%, 89%, and 79%, respectively. Forty-eight patients were treated, and one received supportive care only. Thirty-one patients had surgical resections, 33 patients had chemotherapy, and 16 patients had radiotherapy. Most (n = 30) had multimodality treatment. Statistically significant variables affecting survival rates in patients with gastric lymphomas were lower tumor stage, younger patient age, and surgical resection.

Prognostic value of serum beta 2 microglobulin in primary gastric lymphoma

Sixty-eight previously untreated patients with primary gastric non-Hodgkin's lymphoma (NHL) available for analysis, were entered in a study in which the prognostic significance of serum beta 2 microglobulin levels were evaluated. The serum beta 2 microglobulin was the most significant prognostic factor. Patients with high levels (greater than 3.5 micrograms/mL) had a relapse-free survival (RFS) of 36 months, while the median RFS has not been reached in patients with normal levels (p less than 0.001). The 5-year survival was 80 per cent for patients with normal levels, statistically significant when compared to patients with high levels: 38 per cent (p less than 0.001). Serum beta 2 microglobulin should be included in the initial staging of patients with primary extranodal NHL and patients with high levels should be treated more aggressively.

[Primary non-Hodgkin's lymphoma of the stomach]

Between 1980 and 1987 a total of 17 patients were operated upon in curative intention of the Non-Hodgkin-Lymphoma of the stomach at our surgical department. Ten of these patients were within Ann-Arbor-Stage I, four within stage II/1 and the other three within stage II/2. In six cases we found low-malignant and in the other 11 cases high-malignant tumors. One patient died postoperatively after a myocardial infarction, one female died four months postoperatively in spite of chemotherapy of the disease. 15 patients (94%) are still alive today without any new symptoms of the disease, within a median average observation time of 40.6 months.

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.

Has the incidence of primary gastric lymphoma increased?

Various reports from the surgical and gastroenterologic literature have stated that the incidence of primary gastric lymphoma has increased. Other reports have claimed that this is a relative increase or represents referral center bias. The current study was designed to determine if the incidence of primary gastric lymphoma has increased in the community hospital setting. A total of 147 cases of gastric neoplasms were reviewed over a 10-year study period. The cases were divided into two 5-year periods, i.e., 1978-82 and 1983-87. There were two new cases (2.8%) of primary gastric lymphoma in the period 1978-82 and 11 new cases (19%) in the period 1983-87. The difference in proportion of primary gastric lymphoma between these two time periods was statistically significant (P = 0.01 by chi-square analysis). This increased incidence of primary gastric lymphoma is difficult to explain, but it must be recognized by surgeons and endoscopists.

Primary gastric lymphoma in Auckland, New Zealand

The case-notes of 30 patients presenting with primary gastric lymphoma in the Auckland area during 1969-87 have been reviewed. The mean age of the study group was 62 years, and 16 were female and 14 were male. There were 22 European, one Maori and seven Polynesian patients. The most common presenting symptom was abdominal pain and five patients presented acutely with gastrointestinal haemorrhage. The lesions occurred more frequently in the distal stomach and half were polypoid and half were ulcerating. They tended to be of substantial size at presentation, with seven being greater than 10 cm in diameter. Nine lesions were confined to the stomach, 12 involved the surrounding lymph nodes and eight were invading adjacent organs. Twenty-three patients underwent partial or total gastrectomy. Four of these received postoperative radiotherapy, and adjuvant chemotherapy was administered to 13. Chemotherapy, or combination chemo- and radiotherapy were used as the primary treatment in seven patients. Following surgical treatment, 18 patients remained alive and well. Five of the seven patients treated nonsurgically were dead of disease at the time of study and the other two remained alive with persisting disease. The following factors were found to affect prognosis adversely: weight loss of greater than 5 kg, tumour invasion of adjacent organs, and non-surgical primary treatment. Involvement of the lymph nodes draining the stomach did not appear to worsen the outlook, and there was little correlation between lesion size and prognosis.