Non-Hodgkin's lymphoma of the stomach: a prospective pilot study of surgery plus chemotherapy in early and advanced disease

Using the primary site as a prognostic tool for nodal mantle cell lymphoma: a SEER-based study

Background: Nodal mantle cell lymphoma (NMCL) has a worse survival than extra-nodal mantle cell lymphoma. Materials & methods: A cohort study was conducted to evaluate the primary site role as a mortality predictor using data from 1983 to 2011 from the Surveillance, Epidemiology, and End Results (SEER) database. Results: Most patients had NMCL in multiple regions (71.9%). There was a significantly increased incidence of NMCL cases over years with 83.2% of them occurred between 1998 and 2011. The mean survival was 52.9 months with overall survival/cancer-specific survival rate of 29.2/42.9%, respectively. Lymph nodes of intrathoracic and multiple regions had a worse overall survival while the head, face and neck, intra-abdominal, pelvic, inguinal region and leg as well as multiple regions had worse cancer-specific survival. Conclusion: NMCL primary site can serve as a prognostic factor. We encourage adding it to MCL International Prognostic Index.

Cardiovascular mortality trends in non-Hodgkin's lymphoma: a population-based cohort study

BACKGROUND

Non-Hodgkin's lymphoma (NHL) survivors are at a higher risk of cardiovascular diseases (CVDs).

METHODS

A population-based study was conducted to investigate the cardiovascular mortality trends to identify NHL survivors at the highest risk.

RESULTS

The CVDs mortality was the second most common cause of death (13.07%) after NHL. There were more patients ≥ 60 years old in the cardiovascular group (87.2%), P < 0.001. Patients who died from CVDs had the best survival while patients who died from NHL had a significantly lower mean survival. The overall survival rate was 92.4%. Consistently, older age, unmarried, male patients, not recently diagnosed with NHL and not receiving radiation and/or surgery were associated with a worse survival across all models. The black race and stage IV only had a worse cardiovascular specific survival (CVSS).

CONCLUSIONS

Although the CVSS improved over time, the mortality from the CVDs is still the second most common cause of death after NHL. Older age, not married, black, male patients, not recently diagnosed with NHL, with an advanced stage and not receiving radiation and/or surgery were associated with a worse survival. Risk factor modification along with CVDs screening should be intensified in NHL patients with these mortality predictors.

Clinical outcome of primary gastric lymphoma treated with chemotherapy alone or surgery followed by chemotherapy

BACKGROUND

The role of surgical resection in the treatment of primary gastric lymphoma (PGL) remains unclear. This retrospective study evaluated the clinical outcome of PGL treated with chemotherapy alone or surgery followed by chemotherapy.

METHODS

During 1986-2003, 59 patients with PGL (other than mucosa-associated lymphoid tissue type lymphoma) were identified from hospital files. The medical records, pathologic sections, radiographic images and treatment modalities of these patients were reviewed. Patients were categorized into localized (stage IE and IIE-1) and advanced (stage IIE-2 or beyond) stage groups. Survival was estimated by the Kaplan-Meier method.

RESULTS

The study included 55 patients who received treatment at the same institute. Among them, 32 had localized PGL (15 stage IE, 17 stage IIE-1) and 23 had advanced disease. The median survival of the localized stage group was not reached during a mean follow-up of 168.1 +/- 16.7 months (95% confidence interval [CI], 135.4-200.8 months), while that of the advanced stage group was 33.0 +/- 6.8 months (95% CI, 19.7-46.5; p < 0.001, log-rank test). Among patients with localized PGL, the 5-year overall survival rate of those receiving chemotherapy alone (n = 19) or combination therapy (surgery followed by chemotherapy, n = 13) was 73.4% and 87.5%, respectively (p = 0.229). The 5-year disease-free survival was 68.4% and 84.6%, respectively (p = 0.540). However, post-chemotherapy life-threatening hemorrhage occurred in five of the 32 patients (15.6%) in the localized stage group: four in the chemotherapy-alone group, and one in the combination therapy group, all of whom had failed to achieve complete response.

CONCLUSION

The clinical outcome of localized PGL treated by chemotherapy alone is similar to that treated by surgery followed by chemotherapy in terms of tumor response, disease-free survival and overall survival, suggesting that surgery be reserved for those with residual tumors after chemotherapy.

Primary Malignant Large Bowel Lymphoma

Primary gastrointestinal (GI) lymphomas constitute about 5.6 per cent of total gut neoplasms. The involvement of large bowel as primary site is all the more rare. We carried out this study to evaluate the prevalence and clinicopathological features of large bowel lymphoma at Gujarat Cancer and Research Institute and to compare our findings with published literature. We carried out a retrospective analysis of the records of histologically diagnosed cases of large bowel lymphoma over a 5 year period. A total of eight cases of large bowel lymphoma were identified compared with 57 cases of primary GI lymphoma of other sites, constituting about 12.3 per cent (eight of 65) of all GI lymphomas. Peak incidence was observed in the second decade of life with a mean age at presentation of 30.6 years (range 4–70 years). A male-to-female ratio of one to two was observed. The most commonly presenting feature was altered bowel habits and diarrhea in more than 50 per cent of the patients. One patient presented with acute intestinal obstruction. Diagnosis was made by colonoscopic biopsies in all but one case. All of the patients were treated with surgery and adjuvant chemotherapy. A 4-year disease-free survival of 66.7 per cent was observed (95% confidence interval 0.05–1.28). There was no significant difference in survival in patients with high-grade versus low-grade tumors (50% vs 66.7%; P = 0.88) and stage of disease (75% vs 50%; P = 0.45) in stage II and III respectively. We conclude that large bowel lymphoma is a curable disease if treated aggressively. We suggest that all patients should be treated by primary surgery and should receive adjuvant chemotherapy.

Primary gastric B-cell lymphoma: results of a prospective multicenter study. The German-Austrian Gastrointestinal Lymphoma Study Group

BACKGROUND & AIMS

Appropriate management of primary gastric lymphoma is controversial. This prospective, multicenter study aimed to evaluate the accuracy of endoscopic biopsy diagnosis and clinical staging procedures and assess a treatment strategy based on Helicobacter pylori status and tumor stage and grade.

METHODS

Of 266 patients with primary gastric B-cell lymphoma, 236 with stages EI (n = 151) or EII (n = 85) were included in an intention-to-treat analysis. Patients with H. pylori-positive stage EI low-grade lymphoma underwent eradication therapy. Nonresponders and patients with stage EII low-grade lymphoma underwent gastric surgery. Depending on the residual tumor status and predefined risk factors, patients received either radiotherapy or no further treatment. Patients with high-grade lymphoma underwent surgery and chemotherapy at stages EI/EII, complemented by radiation in case of incomplete resection.

RESULTS

Endoscopic-bioptic typing and grading and clinical staging were accurate to 73% and 70%, respectively, based on the histopathology of resected specimens. The overall 2-year survival rates for low-grade lymphoma did not differ in the risk-adjusted treatment groups, ranging from 89% to 96%. In high-grade lymphoma, patients with complete resection or microscopic tumor residuals had significantly better survival rates (88% for EI and 83% for EII) than those with macroscopic tumor residues (53%; P < 0.001).

CONCLUSIONS

There is a considerable need for improvement in clinical diagnostic and staging procedures, especially with a view toward nonsurgical treatment. With the exception of eradication therapy in H. pylori-positive low-grade lymphoma of stage EI and the subgroup of locally advanced high-grade lymphoma, resection remains the treatment of choice. However, because there is an increasing trend toward stomach-conserving therapy, a randomized trial comparing cure of disease and quality of life with surgical and conservative treatment is needed.

Stage-modified international prognostic index effectively predicts clinical outcome of localized primary gastric diffuse large B-cell lymphoma. International Extranodal Lymphoma Study Group (IELSG)

BACKGROUND

The definition of prognostic parameters in early stages of gastric lymphoma is still controversial. The aim of this retrospective analysis was to assess the value of the stage-modified international prognostic index (IPI) in predicting the outcome of a large, consecutive series of patients with PGL of diffuse large B-cell histology (DLCL).

PATIENTS AND METHODS

Three hundred twelve consecutive, newly-diagnosed, patients with localized PGL (stages I-IIE according to the 'Lugano staging system for GI lymphomas') referred from April 1972 to December 1997 to eight Italian and one Swiss centers were reviewed and their outcomes updated to June 1998. One hundred three patients were treated with single-modality therapy, while two hundred four received combined-modality treatment, most of which included surgery and short-term chemotherapy.

RESULTS

After a median follow-up of 66 months (range 0.6-300 months), 195 (64%) were alive in first continuous complete remission (CCR). The five-year estimates of overall survival (OS) and event-free survival (EFS) were 75% and 67%, respectively. OS and EFS varied according to IPI, from, respectively, 90% and 82% for patients with 0-1 risk factors, to 40% and 35% for patients with > or = 3 risk factors (P = 0.00001). Cox regression analysis showed that IPI was the strongest predictor of survival.

CONCLUSIONS

This study shows that stage-modified IPI is an effective predictive model in patients with primary DLCL of the stomach, enabling identification of patients with significantly different outcomes.

Surgery plus chemotherapy or chemotherapy alone for primary intermediate- and high-grade gastric non-Hodgkin's lymphoma: the Royal Marsden Hospital experience

Primary gastric lymphomas (PGL) have traditionally been treated with surgery followed by chemotherapy or radiotherapy. Surgery was thought to improve staging, optimise local disease control and reduce risk of perforation or bleeding, but recent studies question its role. In this study, patients with intermediate- or high-grade PGL who received chemotherapy from 1985 to 1996 at the Royal Marsden Hospital were identified using a prospectively accrued database. A total of 37 patients (6 with low-grade mucosa-associated lymphoid tissue lymphoma (MALT-L), 9 with high-grade MALT-L, 20 with diffuse large B-cell (DLBC) lymphoma and 2 other histologies), 17 of whom had localised disease, were treated with either surgery plus chemotherapy or chemotherapy alone. 5-year overall survival for localised and advanced PGL was 94 and 50%, respectively, with no differences between the two treatments over a 53 months median follow-up. No perforations or serious bleeding occurred. Surgery is associated with important morbidity and we detected no benefit of surgery prior to chemotherapy in this limited series of patients.

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.

Results and prognostic factors in stage I(E)-II(E) primary gastric lymphoma after gastrectomy

BACKGROUND

Infrequency of gastric lymphomas and lack of homogeneity of studies dealing with them preclude accurate management schemes. Helicobacter pylori (HP) and Isaacson's classification are new factors to consider. Our aim was to analyze these and other prognostic factors in a homogeneous series.

STUDY DESIGN

Fifty-four patients (mean age 62.4 years) treated by gastrectomy for primary gastric non-Hodgkin's lymphoma in stages IE or IIE were retrospectively reviewed. Twenty-seven patients received postoperative chemotherapy. HP and histologic features were studied using new slides from the paraffin-embedded gastrectomy specimens.

RESULTS

Postoperative morbidity and mortality rates were 19% and 5.6%, respectively. Five-year survival was 83%. Classification showed low-grade tumors in 59% and high-grade tumors in 41%. HP was positive in 64% of the patients. A poorer survival was associated with high-grade tumors (p = 0.02) and serosa involvement (p = 0.02). We did not find any significant difference between patients treated either by partial or total gastrectomy (p = 0.2), or receiving chemotherapy or not (p = 0.9). Nor did we appreciate any differences concerning margin involvement (p = 0.9).

CONCLUSIONS

Most primary gastric lymphoma patients have gastric HP. Serosa involvement and high-grade tumors adversely influence survival but gastrectomy type, resection margin invasion, and postoperative chemotherapy did not appear to have any influence.

Primary gastrointestinal non-Hodgkin's lymphoma in adults: a population-based clinical and histopathologic study

OBJECTIVES

To analyse the clinical course and the histopathology of primary gastrointestinal non-Hodgkin's lymphoma (GI-NHL) in adult patients and to investigate a possible impact of Helicobacter pylori.

DESIGN/SETTING

Retrospective study of all adult patients in Copenhagen county diagnosed during a 6-year period with NHL.

SUBJECTS

A total of 55 patients with GI-NHL diagnosed during the period from 1985 to the end of 1990.

RESULTS

Twenty-eight patients had primary lymphoma in the stomach, 14 in the small intestine, 11 in the large intestine and two patients had multifocal involvement. The dominant presenting symptoms were abdominal pain, weight loss, diarrhoea, constipation and fatigue. Acute emergency problems such as severe haemorrhage or perforation at initial presentation were unusual. According to the revised European-American lymphoma (REAL) classification, diffuse large B-cell lymphoma was the most frequent histologic subtype comprising 53% of the cases. Helicobacter pylori infection was documented in 15 of 25 evaluable patients (60%) with gastric lymphomas and was not associated with any specific histological subtype. Endoscopic procedures and barium X-rays were the diagnostic approaches with highest sensitivity. In total, 30 patients (58%) achieved complete remission, 10 (19%) achieved partial remission, and 12 (23%) did not respond to treatment. The overall 5 year survival rate was 0.36 without statistically significant difference between the histological subtypes. Likewise the presence of Helicobacter pylori did not affect survival.

CONCLUSION

Primary GI-NHL is a heterogeneous disease entity with considerable therapeutic controversies. No specific clinical or histological phenotype was associated with the presence of Helicobacter pylori.

The role of radical gastrectomy with systematic lymphadenectomy for the diagnosis and treatment of primary gastric lymphoma

OBJECTIVE

We evaluated the therapeutic efficacy of radical gastrectomy for primary B-cell lymphoma of the stomach and attempted to identify patients who could be adequately treated with surgery alone.

SUMMARY BACKGROUND DATA

Several recent gastric lymphoma reports have discussed the therapeutic benefits of various treatment strategies for stage IE and IIE lymphoma. However, few studies have been based on patients accurately staged by systematic lymphadenectomy with subsequent pathologic examination.

METHODS

A retrospective study was performed to evaluate the survival and biologic behavior of lesions in 60 patients with gastric lymphoma who were treated by radical gastrectomy alone. Tumors were classified according to the histopathologic concept of mucosa-associated lymphoid tissue (MALT)-derived lymphoma.

RESULTS

A low histopathologic grade was associated with a significantly lower incidence of nodal metastasis (p = 0.07) and less extensive infiltration of the gastric wall (p < 0.005) despite larger tumor size. A 5-year survival rate of >95% was attained with surgery alone for MALT lymphoma and for true stage IE lymphoma diagnosed by pathologic examination of up to N2 lymph nodes routinely performed after radical gastrectomy.

CONCLUSIONS

Surgery alone is adequate treatment for stage IE or pure MALT lymphoma, provided that the staging is performed after radical gastrectomy.

Primary Gastric Lymphoma

BACKGROUND: Gastric lymphoma is a common presentation of non-Hodgkin's lymphoma. Controversy reigns about many aspects of its classification and management, especially regarding roles for surgical resection. METHODS: The authors review the clinical features, staging, pathology, prognosis, and management issues with an emphasis on the role of surgical resection. RESULTS: Staging usually can be completed using noninvasive techniques. Those with a low-grade B-cell MALT type lymphoma with Helicobacter pylori infection may be treated with antibiotics and close follow-up. Patients with stage I or II disease may be treated with chemotherapy and radiation. Surgery is indicated for those with perforation or uncontrolled bleeding. CONCLUSIONS: Gastric lymphoma, primarily a B-cell tumor, can be diagnosed and managed effectively with various approaches. Few prospective, randomized trials of alternative approaches have been performed.

Advantage of surgery and adjuvant chemotherapy in the treatment of primary gastrointestinal lymphoma

BACKGROUND

Surgery has been the mainstay of treatment for gastrointestinal (GI) lymphoma. The role of adjuvant chemotherapy to surgery has not been clearly elucidated.

METHODS

The review covered 100 patients who were diagnosed with primary GI lymphoma and treated from 1980 to 1993 at Providence Hospital (Southfield, MI), and Hartford and St. Francis Hospitals (Hartford, CT) with a median follow-up of 5 years. Forty-two patients were treated with surgery alone; 31 patients with surgery and adjuvant chemotherapy; 23 patients with primary chemotherapy, and 4 patients received no treatment.

RESULTS

The 5-year actuarial survival based on the above treatments calculated by life-table analysis were 57%, 76%, 58%, and 0%, respectively. This series showed that surgery with adjuvant chemotherapy significantly improved the 5-year actuarial survival of patients with primary GI Lymphoma and that primary chemotherapy showed comparable survival to surgery alone. There was no difference in prognosis when comparing patients with different stage, grade, or location of disease in the GI tract.

CONCLUSIONS

We recommend surgery when feasible with adjuvant chemotherapy as the mainstay of treatment for primary GI lymphoma. However, if a patient presents with comorbid factors, primary chemotherapy offers an effective alternative.

A prospective study of surgery and adjuvant chemotherapy for primary gastric lymphoma stage II

The standard management of primary gastric lymphoma (PGL) (stage II) has not been established despite the use of various treatment modalities. The present prospective trial of combined surgery and chemotherapy for the treatment of PGL (stage II) included 25 consecutive patients treated between July 1978 and December 1993. Twenty-one patients were treated with total gastrectomy and four with partial gastrectomy; this was followed by post-operative chemotherapy with m-VEPA (vincristine, cyclophosphamide, prednisolone and doxorubicin), followed by consolidation chemotherapy with VEMP (vindesine, cyclophosphamide, methotrexate and prednisolone) or VQEP (vindesine, carbazilquinone, cyclophosphamide and prednisolone). Twenty-one of the 25 patients who completed post-operative chemotherapy were free of relapse 26-203 (median 94) months after the gastrectomy. Of the four patients who did not complete the projected chemotherapy, two relapsed and died of lymphoma. Another patient with recurrent lymphoma died in an accident, and the fourth patient was in remission at 54 months after surgery. The post-operative overall and disease-free survival rates at 10 years for the 25 evaluable patients were 81.6% and 92.0% respectively. Major surgical complications and treatment-related death after chemotherapy were not observed. PGL (stage II) appears to be curable when treated with gastrectomy and adjuvant chemotherapy.

Primary non-Hodgkin's lymphoma of the stomach: three radical modalities of treatment in 75 patients

BACKGROUND

Non-Hodgkin's lymphoma (NHL) remains a rare form of gastric malignancy, with a rising incidence. Approaches to treatment vary from surgery alone to conservative management.

METHODS

To determine the optimal scheme of treatment, a randomized clinical trial was undertaken. Seventy-five patients were randomized into three groups: A-surgery alone (25), B-surgery followed by chemotherapy (29), and C-radiation therapy followed by surgery and chemotherapy (21). Forty-nine patients had stage IE and 26 had stage IIE disease. Chemotherapy (COP and COPP) consisted of 6 courses during a 1-year period, with the courses being 6 weeks apart.

RESULTS

Subtotal gastrectomy was performed in 26 patients. Forty-nine patients underwent total gastrectomy. Postoperative complications occurred in 6 (8%) patients: 3 (12%) in group A, 2 (6.9%) in group B, and 1 (4.7%) in group C. Postoperative mortality occurred in 2 (8%) patients in group A (2.7% of all patients). An increase in hospital admissions number per year and decrease of mean age of patients with NHL of the stomach after the Chernobyl accident on April 26, 1986 was noted.

CONCLUSIONS

Improved survival in gastric NHL was achieved by a combination of preoperative radiation with surgery and postoperative chemotherapy, presumptively through the management of local and systemic disease.

Role of surgery in the management of primary lymphoma of the gastrointestinal tract

The role of surgery in the management of primary gastrointestinal lymphoma remains controversial. We retrospectively reviewed the management and outcome of 107 patients with the diagnosis of gastrointestinal lymphoma treated at the UCLA Medical Center during the period 1956-1990. Sixty-four patients underwent surgical exploration at the UCLA Medical Center; 35 of these underwent resection for cure. Sixteen of these 35 patients received no postoperative adjuvant therapy. Twenty-nine patients underwent palliative or "noncurative" resection. There were five postoperative deaths (mortality rate 8%). The overall morbidity rate was 48% There were 3 perforations in a total of 53 patients receiving multiagent chemotherapy. Five-year actuarial survival was as follows: 59% for curative resection alone, 51% for curative resection plus adjuvant therapy, and 28% for "noncurative" resection (P<0.05). Multivariate analysis revealed that stage of disease (P<0.01) and resection for cure (P<0.05) were independent predictors of survival. These results suggest that patients undergoing resection for cure have improved survival. The apparent low risk of perforation during chemotherapy, along with the considerable risk of morbidity and mortality associated with operation, suggests that a policy of debulking large tumors prior to chemotherapy is unwarranted.

Long-term follow-up after curative surgery for early gastric lymphoma

OBJECTIVE

This study was designed to examine the long-term survival of a homogenous group of patients with stage IE or IIE-1 gastric lymphoma after complete surgical resection.

SUMMARY BACKGROUND DATA

The management of gastric lymphoma remains controversial. Enthusiasm for multimodality approaches for gastric lymphoma has lead to the current trend of using chemotherapy as primary treatment, thus avoiding gastric resection. Surgery, however, may result in improved long-term survival rates.

METHODS

The records of all patients with the diagnosis of gastric lymphoma from 1980 to 1991 were reviewed retrospectively. Of 106 patients examined, 34 underwent curative resection and regional lymphadenectomy for pathologically staged IE or IIE-1 (pN1) gastric lymphoma. Fifteen patients underwent surgery alone, whereas 19 also received postoperative adjuvant therapy.

RESULTS

The median follow-up time was 74 months. The 10-year actuarial disease-free survival was 91% for stage IE disease (n = 23) and 82% for stage IIE-1 disease (n = 11). There were no operative deaths and a 26% morbidity rate. No difference in survival was found for those treated with adjuvant therapy.

CONCLUSIONS

The results compare favorably to those reported with the use of primary chemotherapy and radiation therapy and suggest that surgery remains the best frontline therapy for early gastric lymphoma.

Primary gastric lymphoma: a clinical and therapeutic evaluation of 82 patients

Eighty-two patients with primary gastric (IE, II1E, and II2E) non-Hodgkin's lymphoma according to the Musshoff's staging system were treated with combined modality including surgery with/without radiotherapy between January 1985 and December 1991. According to the Updated Kiel classification 54 had high-grade histologic subtypes and 28 low-grade. The strategy throughout the study was to resect primary tumor: all patients underwent gastrectomy, 40 subtotal and 42 total gastrectomy. The resection permitted complete surgical staging utilizing three pathologic features: disease confined within or beyond the serosa, negative/positive regional lymph nodes, and negative/positive surgical margins. If there was no evidence of these pathologic factors, the patients who underwent surgery alone received no further radiotherapy. On the other hand, all patients who presented at least one of three pathologic factors were treated with adjuvant radiotherapy after the resection. All except 14 patients presented at least one of the pathologic features and 50 (61%) patients had involvement of the whole gastric wall. Radiotherapy included the gastric bed and para-aortic lymph nodes and, for the patients, who had positive regional lymph nodes in combination with the complete involvement of the gastric wall, the irradiation included the whole abdominal approach. The complete response rate was 97% and the 9-year disease-free survival was 93%. All but one of the 5 relapses occurred within 18 months stressing the need for more specific staging. Gastric resection with/without radiotherapy may still represent the primary therapeutic procedure in early stage gastric non-Hodgkin's lymphoma.

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.

Intermediate and high-grade gastric non-Hodgkin's lymphoma: a prospective study of non-surgical treatment with primary chemotherapy, with or without radiotherapy

The role of surgery as initial treatment in gastric lymphoma remains controversial. We have prospectively evaluated a stomach conservation strategy in histologically aggressive gastric lymphoma, using primary adriamycin-containing chemotherapy, followed by involved-field radiotherapy in patients with limited disease. Twenty-six patients (median age 69 years) were entered in this study; 15 had stage I disease, 7 had stage II disease and 4 had stage IV disease. The chemotherapy combinations were CHOP (18 patients) and ProMACE/MOPP (8 patients). Radiotherapy was given to 11 patients. Of the 24 patients evaluated for response, 18 (75%) achieved endoscopically-confirmed complete response and 4 (17%) partial response. During follow-up (median 22 months), none of the complete responders developed recurrent lymphoma. Gastric resection was performed in 1/26 patients who did not respond to primary chemotherapy. There were no cases of perforation, but three patients (12%) developed acute gastro-intestinal bleeding a few days after the onset of chemotherapy, one of whom required a surgical devascularization procedure. There was no treatment-related mortality. These data further support the non-surgical approach in histologically aggressive gastric lymphoma, using primary chemotherapy with or without radiation therapy.

Early stage gastric lymphoma: is operation essential?

To assess the efficacy of primary chemotherapy for treatment of early stage patients with gastric lymphoma, multiple agent chemotherapy was given to patients prior to surgery. Five patients with stages IE and IIE of primary gastric lymphoma (54-65 years of age; three men, two women) were treated with multiple agent chemotherapy prior to gastric resection. In all patients the diagnosis was established by endoscopic biopsy. Two patients had stage IE disease, and three had stage IIE. Histopathologically, there was one diffuse large cell lesion and four diffuse medium cell lesions. All patients received two cycles of VEPA every 4 weeks. On the 16th to 44th day after completion of chemotherapy, total gastrectomy, systematic dissection of regional lymph nodes with resection of the caudal pancreas, and splenectomy were performed. Swelling of the regional lymph nodes was noted in four cases. In all five cases, histologic findings revealed no residual cells of malignant lymphoma in the resected specimen. None of the patients had no evidence of recurrence at 12 to 40 months after surgery. Primary chemotherapy alone thus resulted in the disappearance of malignant cells in stage IE/IIE gastric lymphoma. Our results suggest that surgery may not be an essential procedure for treatment of early stage gastric lymphoma.

Treatment of early-stage gastric lymphoma

The treatment of early-stage gastric lymphoma is controversial. This retrospective analysis reports on the outcome of 24 patients treated in our institution during the past 25 years. Fourteen patients had stage IEA, one patient had IEB, six patients IIEA1, and three patients had stage IIEA2 non-Hodgkin's lymphoma (NHL). Diffuse large cell intermediate-grade NHL was diagnosed in 17 patients, diffuse small cleaved cell in three patients, and diffuse mixed large and small cell lymphosarcoma, low-grade B-cell lymphoma, and unclassified lymphoma in one patient each. Fourteen patients underwent surgery, 21 had radiation therapy (XRT), and 10 patients received chemotherapy. Surgery + XRT were given to 7 patients, surgery + XRT + chemo and XRT alone were delivered to five patients each, and XRT + chemotherapy were employed in four patients. Surgery alone was the initial treatment in two patients and chemotherapy alone was given to one patient. Following treatment 22/24 achieved a complete response. During a mean follow-up period of 77.6 months (range 1-285), five patients relapsed. At 10 years, the actuarial survival of the 15 patients with stage I disease was 57.4% and for stage II it was 51.9% (Gehan P-value 0.33). Freedom from relapse (FFR) was 60.7% and 58.3%, respectively (P-value 0.56). No significant statistical differences in terms of survival and FFR were noted in patients treated with surgery, chemotherapy, or XRT. The outcome of patients treated with triple-modality therapy was similar to those treated with double-modality therapy and to patients treated with XRT alone. Gender, age, presenting symptoms, depth of tumor through the gastric wall, and stage were not statistically significant for prediction of either survival or FFR. Both surgery + XRT and chemotherapy + XRT are effective in the treatment of early-stage gastric disease. XRT alone is equally effective as two or three modality treatments in the subset of patients with early-stage gastric lymphoma. However, the low number of patients treated with various approaches over a long period precludes a firm conclusion. Until prospective randomized studies are initiated, management programs should be individually tailored.

Role of Postoperative Radiation Therapy in the Management of Early Stage Primary Gastric Non-Hodgkin's Lymphomas: A Retrospective Analysis

Background

Clinical approaches to early primary gastric non-Hodgkin's lymphomas have not yet been clearly defined, and the role of postoperative radiotherapy remains a matter of discussion.

Methods

Twenty-seven patients with early primary gastric non-Hodgkin's lymphoma were observed from December 1978 to December 1990 at our Institution. They were staged according to Musshoff and Schmidt-Volmer (19) as I E (n = 16), II E 1 (n = 7) and II E 2 (n = 4). All of them underwent local combined treatment, consisting of surgery and postoperative radiotherapy; chemotherapy was also administered to 10 patients, mainly with the CHOP regimen, for 4-6 cycles before radiotherapy. Irradiation was delivered using 10 MV photons from a linear accelerator. Large abdominal fields were employed in 21 cases with daily fractions of 1.5-2 Gy up to a median total dose of 30 Gy (range: 27-36 Gy). Six patients were irradiated only on the surgical bed up to 40.5 Gy (range: 39-40.5 Gy).

Results

The 5-year overall and disease-free survivals were respectively 92.4% and 89.8%. The main known prognostic indicators, stage of disease, type of surgery as well as age and sex, were not found to be statistically significant in our series. No clear difference emerged between patients sequentially treated with the combination surgery-chemotherapy-radiotherapy and those who did not receive adjuvant chemotherapy. Two patients recurred at distant sites, but no local failure was seen during the follow-up.

Conclusions

Although no firm conclusion can be drawn, our experience, in agreement with recent published reports, points out that the use of postoperative radiotherapy is associated not only to favorable results in terms of local control and survival, but also, and moreover, to a negligible incidence of side effects and sequelae. However, in the absence of multi-institutional prospective randomized studies, whose activation is nowadays strongly warranted, the exact role of adjuvant therapies remains a matter of discussion, and the optimal treatment of early primary gastric non-Hodgkin's lymphoma still depends on individual experience and the physician's philosophy.

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.

Primary gastric lymphomas: a clinicopathologic study with literature review

Prognostic factors and treatment results were analysed in 28 consecutive patients with primary gastric lymphoma (PGL) diagnosed and treated, all by surgery and in many cases with additional chemotherapy (CT) and/or radiotherapy (RT), between 1977 and 1988. There were 13 patients in stage IE, 5 in IIE, and 10 in stage IV. The resection rate was 96.4% (27/28). Sixteen patients underwent an extended total and 11 a subtotal gastrectomy. Seventeen out of 25 cases (68%) were diagnosed by endoscopic biopsies. In 10 endoscopically diagnosed PGL cases the clinical staging and separation between stages IE and IIE from stage IV, due to ultrasonographic scan, computed tomography and bone marrow biopsy, was correct and the same with the surgical-pathological staging information. According to the Kiel-classification 18 patients had a low-grade and 9 patients a high-grade lymphoma. One patient could not be classified. All patients were completely followed-up, in an average time of 52 months. The probability of overall 5-year survival was 92% in stage IE, 75% in stage IIE, 88% in stages IE+IIE together, and 35% in stage IV. Extent of surgery (total vs. subtotal gastrectomy), Kiel-classification (low-grade vs. high-grade malignant histologic subtypes) and adjuvant CT in patients with stage IE (all 11 patients without CT remain in complete remission after an average of 45 months) did not significantly influence survival. The sole prognostic factor with proven impact on survival was the stage of disease (IE+IIE vs. IV: P = 0.001). For the Kiel-classification in particular there was no significant difference between low-grade and high-grade lymphomas with regard to the sex, symptomatic, extent of surgery, and stage at operation. These findings, together with data from the literature, suggest that gastric resection seems to be the optimal primary treatment in clinically assessed stages IE or IIE. In patients with stage IE disease, surgical resection can result in a cure, with no need for further therapy. The CT and/or RT can be effective in unresected and even bulky cases. Because of the difference in primary treatment, a preoperative clinical staging and separation between early stages from stage IV is always indicated.

Postoperative chemotherapy increases the disease-free survival rate in primary gastric lymphomas stage IE and IIE

We describe 53 patients with primary gastric non-Hodgkin's lymphoma (38 stage IE,15 stage IIE) treated with surgery as a primary procedure. According to the Working Formulation, 13 cases had low, 21 had intermediate and 19 had high grade malignancy. 34 patients considered at high risk received postoperative polychemotherapy. The overall 10-year disease-related survival is 91%. Median follow-up is 52 months. 7 patients relapsed (13%). The 10-year disease-free survival rate of the 19 patients initially treated with surgery is 60%, as compared with 92% in the patients who also received chemotherapy (P = 0.004). However, overall survival did not differ between the two groups, since two-thirds of the patients who relapsed after surgery alone were rescued with chemotherapy. Stage, age, sex and histology did not correlate with survival. In our experience, surgery was an adequate first step procedure; the addition of chemotherapy significantly reduced relapses and increased the disease-free survival rate in patients with unfavourable prognostic factors.

The clinical spectrum and treatment of primary non-Hodgkin's lymphoma of the stomach

BACKGROUND

Primary non-Hodgkin's lymphoma (NHL) of the stomach is a rare disease; diagnosis may be difficult and the method of treatment is at debate, especially the role of surgery. We therefore evaluated clinical findings, in particular endoscopic diagnosis and long-term results of various treatment strategies, especially the effect of the stomach-saving procedure with radiotherapy alone, in patients with stage I and II NHL of the stomach over a 20 year period (1970-91).

PATIENTS AND METHODS

A series of 119 consecutive patients (71m + 48f, median age 62 years) were studied: 80 patients in stage I and 39 in stage II. Treatment schedules were: group A: standard radiotherapy alone, after clinical staging (n = 46); group B: gastric resection followed by standard radiotherapy (n = 28); group C: various combinations of resection, radiotherapy plus or minus chemotherapy (n = 45). Since 1978 surgery was no longer advocated: our resection rate dropped from 83% to 38%.

RESULTS

Symptoms and signs were non-specific: epigastric pain (81%), nausea (33%), vomiting (24%) and weight loss (66%). Haemorrhage or perforation at presentation were unusual, in 14 (12%) and 5 (4%) cases, respectively. At endoscopy 3 main patterns were recognized: ulceration (34%); diffuse infiltration (18%) and a polypoid mass (37%). Endoscopic biopsies were diagnostic in 92%, including 11% after repeated endoscopy. Treatment results were excellent for stage I: local control in 93%, 5-year survival 70%; in stage II the results were less favorable: 57% and 37%, respectively. Recurrences were only seen in 17 cases, among which 10 cases were extra-abdominal. According to treatment schedule, results were similar in group A (n = 46), with radiotherapy alone, and group B (n = 28), with resection plus radiotherapy, leading to a 5-year overall survival of 71% and 82%, respectively (no significant difference). Severe complications of treatment were infrequent: one perforation, another with a fatal haemorrhage in group A. In group C (n = 45) various individualized schemes were applied, usually palliative either due to large tumour extent or patients of old age and poor condition, leading to a 5-year survival of only 31%.

CONCLUSIONS

Clear patterns were recognized at endoscopy, and diagnosis on endoscopic biopsies was possible in the vast majority (92%); in clinical stage I radiotherapy alone is effective, safe and well tolerated.

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.

Analysis of prognostic factors in localized gastric lymphoma: the importance of bulk of disease

PURPOSE

To identify prognostic factors in localized gastric lymphoma patients for optimal therapy selection.

METHODS AND MATERIALS

From 1974 to 1990, 77 patients with localized gastric lymphoma (38 Stage IE and 39 Stage IIE) were treated with radiation therapy, chemotherapy, surgery, or a combination. Univariate and multivariate local control and survival analyses were performed on possible prognostic factors, such as patient age, gender, histologic subtype, stage, tumor size, depth of penetration, multicentricity, and treatment modality.

RESULTS

At 5 years, the relapse-free survival was 52%; 74% of the relapses occurred at local sites. Smaller tumor size was most strongly associated with local control (p = .001) and relapse-free survival (p < .001). Patients with tumor sizes < or = 5 cm had relapse-free survival of 87%, compared with 41% and 15% for those with tumor sizes of 5.1 cm to 10 cm and > 10 cm, respectively. The 47 patients who received combined-modality therapy had a relapse-free survival of 65%, compared with 24% for the 30 who received single-modality therapy (p < .01). Although patient age, stage, depth of penetration, and resective surgery affected the above endpoints, these factors were not independent predictors of outcome. Analysis of treatment subgroups showed that surgical resection combined with postoperative irradiation was associated with highest local control (p = .002) and the best relapse-free survival (p = .004), when compared with other treatment modalities. In 27 patients with tumor sizes < or = 5 cm, comparison of the 15 patients who had surgery with the 12 who did not failed to reveal a local control benefit from the addition of surgery.

CONCLUSION

These data demonstrate that tumor bulk is an important prognostic determinant of local control and relapse-free survival in localized gastric lymphoma patients. Stage IE and IIE lymphoma of the stomach can be selectively treated with primary radiation, but surgical resection may be necessary for large tumors (> 5 cm), followed by adjuvant radiation.

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.

Cancer in the elderly

This article reviews geriatric oncology and assesses options for treatment and care of the elderly patient with cancer. The size of the population over 65 years old is defined, with particular reference to the continuing growth of this subsection of the community. The high incidence of many cancers and their associated mortality rates in the elderly are identified and the epidemiology of such diseases in the geriatric population is addressed. Given the discrepancies in incidence and survival rates between patients younger and older than 65 years, the association between tumorigenesis and the aging process is explored. Specific aspects of tumor growth in the elderly are considered. General considerations of therapy for elderly patients with cancer are discussed, including the pharmacokinetics and pharmacodynamics of chemotherapy in those over 65 years old, surgical options, the use of radiotherapy, and overall patient assessment. Next, treatment options for individual cancer states are reviewed, with particular emphasis on newer treatment options designed specifically for the elderly. Sections on cancer screening and supportive care are also included, the latter dealing with aspects of symptom control, quality of life assessment, and the physical and psychologic rehabilitation of the elderly patient with cancer who is undergoing treatment. Conclusions are then drawn as to the extent of the oncological process in those over 65 years old, with particular emphasis on the underdiagnosis and undertreatment of many malignancies in the past. The challenge created by the growing elderly population is underscored and necessary plans of action for oncologists in the future are defined. Such proposals are necessary if inroads are to be made into the unacceptable morbidity and mortality rates borne by our elderly patients with cancer.

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.

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.

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.

Surgical debulking is associated with improved survival in stage I-II diffuse large cell lymphoma

Tumor burden is an important predictor of survival in patients with diffuse large cell lymphoma (DLCL). The authors reviewed the charts of 147 patients with early stage presentation (Stage I-IE and II-IIE) seen from 1974 through 1984. The 10-year survival for the 85 patients with bulky disease was 54% compared with 76% for those who did not have bulky disease. Of the 62 with nonbulky disease, 14 had been rendered so by removal of greater than 80% of the initial tumor mass (surgical debulking). The authors compared these 14 patients with a matched control group of 14 patients selected from the 85 with bulky disease who had equivalent stage, therapy, site, size of initial mass, performance status, and sex and age. All had received similar therapy with cyclophosphamide, Adriamycin (doxorubicin), vincristine, prednisone, bleomycin, and radiotherapy to the involved field. At a 7-year follow-up, the 14 debulked patients had a better survival when compared with the matched controls (93% versus 35%, P = 0.003). The authors also analyzed the initial serum lactate dehydrogenase (LDH) levels. Preoperative LDH values were available in six of 14 debulked patients. In the three with elevated LDH levels at presentation, surgical debulking was associated with subsequent decreased LDH levels, which is known to be associated with better prognosis. The other three presented with normal values that remained normal after surgery. These data suggest a potentially important role for surgery as front-line therapy in patients with Stage I-IE and II-IIE bulky DLCL whose disease is deemed resectable. More studies are needed in order to better define this role as well as to determine how frequently and safely surgical debulking can be performed.

The role of surgery in the multimodal treatment of primary gastric non-Hodgkin's lymphomas. A report of 76 cases and review of the literature

Seventy-six patients with primary gastric non-Hodgkin's lymphomas (PGL) were diagnosed, and 75 were treated between 1975 and 1985. According to the Working Formulation 22 patients had low-grade malignant histologic subtypes, 27 intermediate-grade, and 27 high-grade. Twenty-four cases were diagnosed by endoscopic biopsies, 52 through laparotomy biopsies. Forty-five underwent subtotal or total gastric resection; seven were considered unresectable at laparotomy; 23 did not undergo surgery because of the high operative risk, mainly due to advanced age and coexisting diseases; and one died of myocardial infarction a few days after admission, before starting therapy. All patients who did not undergo laparotomy were staged with bipedal lymphangiography or abdominal ultrasonography and/or computed tomography. Stage, evaluated according to the criteria of Musshoff, was I or II1 in 16 cases, II2 in five, and IV in the remaining 55. Treatment modalities included surgery (S), chemotherapy (CT), radiotherapy (RT), and combinations thereof in the following proportions: only S in ten cases, S + CT in 32 cases, S + RT in one case, S + CT + RT in two cases, CT only in 25 cases, CT + RT in five cases. No substantial differences in response to therapy and in survival were found in relation to the different treatments. Ten-year survival was 43% in Stage I or II and 20% in Stage IV. Of the 45 resected patients, five postoperative deaths were recorded (11%). No bleeding or perforations were observed in the 30 unresected patients, and survival of such cases compared with that of the resected ones. These findings, together with data from the literature, suggest that some of the advantages claimed for surgery in PGL (debulking and abatement of the risk of perforation or hemorrhage during CT or RT) have been overestimated in relation to the intrinsic surgical risk and to the possibility of anticancer therapy. Gastric resection may still be unavoidable as a diagnostic procedure in a minority of cases and may represent the primary therapeutic procedure in clinically assessed early-stage and low-risk patients, but it cannot be considered mandatory whenever possible merely for debulking purposes or to obviate possible perforation or hemorrhage. The CT and/or RT can be effective in unresected and even bulky cases, providing minimal risk of severe hemorrhage or perforation.

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.

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 gastrointestinal non-Hodgkin's lymphoma in a population-based registry

In a population-based registry of 580 patients with non-Hodgkin's lymphoma (NHL) 54 patients had a primary gastric lymphoma, 42 an intestinal, 113 a primary extranodal lymphoma localised elsewhere than in the gastrointestinal tract and 371 a primary nodal NHL. Histological specimens were reviewed by a panel of pathologists and classified according to the Kiel classification and the International Working Formulation. The 4-year survival rates for primary gastric, intestinal, other extranodal and nodal NHL ranged from 50 to 60%; the 4-year recurrence-free survival rates were 50%, 35%, 19% and 19%, respectively. Among patients with localised intermediate-grade disease survival for those with gastric NHL was better than for those with intestinal lymphoma. Because it is population-based, our study cohort was not subjected to exclusion due to age, performance scale, etc. and therefore provides a more realistic picture of the occurrence and presentation of as well as prognosis for lymphoma in the population.

[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.