IE Lymphoma Research Articles

114 Stage IE and IIE extranodal non-hodgkin lymphomas: Results of treatment with radiotherapy

114 Stage IE and IIE extranodal non-hodgkin lymphomas: Results of treatment with radiotherapy

Primary Laryngeal Lymphoma: Case Report

Extranodal laryngeal lymphoma is extremely rare. We report a case of primary laryngeal lymphoma in a 76-year-old man who had presented with a 7-week history of progressive hoarseness. Laryngoscopy revealed asymmetry of the right false vocal fold. Pathology of a deep biopsy specimen identified a malignant, diffuse, CD20-positive, B-cell lymphoma. The stage IE lymphoma completely resolved after treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) and rituximab. Despite its relative rarity, the consequences of a missed diagnosis warrant vigilance for this type of laryngeal tumor.

A Mid-Treatment FDG-Positron Emission Tomography (PET) Scan Is Highly Predictive of Subsequent Treatment Failure in Patients with Diffuse Large B-Cell Lymphoma (DLBCL).

AIMS Computerised Tomography (CT) scanning is the primary modality for assessment of therapeutic response in DLBCL. We evaluated whether functional imaging utilising FDG-PET may provide additional prognostic information in response assessment prior to completion of chemotherapy for patients with DLBCL.METHODS We performed a retrospective, single-centre study of patients with DLBCL who received anthracycline-based chemotherapy +/− radiotherapy (RT) and had PET prior to completion of therapy.RESULTS From 1996–2004 there were 45 eligible patients. Median age was 59 years (range 26–82) with disease stage I–II (n=25) or III–IV (n=20). Median IPI was 2[IPI 0–2(n=27), IPI 3–4(n=13)] in 40 evaluable patients. Therapy included full-course CHOP/CHOP-like therapy (n=26); HyperCVAD (n=6) and limited (3–4 cycles) CHOP/CHOP-like chemotherapy with RT (n=13). Rituximab was used concurrently in 18 patients. Planned RT was administered in 23 patients. 13 (29%) patients were PET positive after a median of 3 chemotherapy cycles (range 1–5). Of these, 7 (54%) progressed a median of 7.2 months following completion of therapy. Of the 6 progression-free, 4 demonstrated residual low-grade activity at sites of prior bone involvement (median follow-up 50.8 months), while 2 patients (stage I and IV disease) had limited follow-up (<8 months). Of 32 patients who were PET-negative, only 3 have progressed (median 7.7 months follow-up); 2 with stage IV (IPI 1 and 2 respectively) and 1 with stage I disease. Overall the Positive predictive value (PPV) of a positive-interim PET was 58.3% [Hazard Ratio of 6.67 (95% C.I. 2.6 – 46.3)] and Negative PV(NPV) was 90.9% (see figure 1). Excluding patients with Stage IE bone lymphoma (see Figure 2), the PPV of positive-interim PET was 88%(77–98%) and NPV was 91%(82–100%). The median number of chemotherapy cycles after which PET was performed was equivalent according to interim PET status (3 cycles) as was median baseline IPI [IPI 2(PET-positive), IPI 1.5(PET-negative); p=0.17].CONCLUSIONS Patients with DLBCL receiving chemotherapy who have persisting PET-positivity during their therapy have a greatly increased risk of treatment failure and should be considered for treatment intensification. Bone lymphoma may represent a distinct entity with a good prognosis despite some minor persisting PET-positivity prior to completion of therapy. [Display omitted] [Display omitted]

A case of primary rectal mucosa-associated lymphoid tissue lymphoma treated by endoscopic mucosal resection

A 53-year-old man underwent surveillance colonoscopy that revealed a submucosal tumor-like polypoid lesion on the Rb area of the rectum. Histological examination of biopsy specimens showed chronic inflammation. Endoscopic mucosal resection was performed after obtained informed consent for the purpose of obtaining accurate diagnosis and for curative treatment. Pathological findings of the resected specimen showed low-grade B-cell lymphoma of mucosa-associated lymphoid tissue type (MALT lymphoma). Gallium-scintigraphy, abdominal CT, small bowel series and endoscopic examination of the upper gastrointestinal tract revealed no abnormalities. Based on the findings, a diagnosis of stage IE lymphoma was made. However it was suspected that the vertical cut-end of the resected specimen had residue of lymphoma cells. Additional transanal resection of the rectum was therefore performed, but no lymphoma cells were found in the specimen. Eradication of Helicobacter pylori was also performed. Although a standard therapeutic strategy for colonic MALT lymphoma has not been established, endoscopic mucosal resection might be a good therapeutic choice.

Translocation t(11;18)(q21;q21) Is Not Predictive of Response to Chemotherapy with 2CdA in Patients with Gastric MALT Lymphoma

Background: t(11;18)(q21;q21) resulting in the API2-MALT1 fusion transcript is an exclusive finding in extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). While it has recently been demonstrated as a negative predictor for gastric MALT lymphoma undergoing eradication of Helicobacter pylori, nothing is known about the relation between t(11;18)(q21;q21) status and response to chemotherapy. We have therefore performed a retrospective analysis of t(11;18)(q21;q21) in patients undergoing chemotherapy with the nucleoside analogue cladribine (2CdA) for gastric MALT lymphoma. Patients and Methods: Eighteen cases of gastric MALT lymphoma treated with 2CdA were reviewed, and 17 could be investigated for t(11;18)(q21;q21) by reverse-transcription polymerase chain reaction and fluorescence in situ hybridization. t(11;18)(q21;q21) was correlated with response to chemotherapy. Results: Of the 17 patients with gastric MALT lymphoma treated with 2CdA, 9 were at stage IE, 2 at stage IIE and 6 at stage IV. Eight cases with stage IE lymphoma were first treated with H. pylori eradication, but none of them showed histological regression during a minimum follow-up of 12 months, and they were subsequently treated with primary chemotherapy. One patient received chemotherapy due to absence of H. pylori infection. Another patient initially rated as stage IE whose gastric lymphoma did not respond developed spread to the lung during follow-up after eradication. All the remaining 13 cases were treated by chemotherapy at the time of diagnosis. Out of these 17, 8 patients (47%) were found to carry t(11;18)(q21;q21). One patient, who was negative for t(11;18)(q21;q21), progressed during chemotherapy and died 5 months after initiation of treatment. One patient each with and without t(11;18)(q21; q21) had a partial response lasting for 14 and >18 months, respectively. One t(11;18)(q21;q21)-positive patient had stable disease for >16 months. The remaining patients achieved a complete remission (CR) following treatment; 6 were positive for t(11;18)(q21;q21), while the remaining 6 were negative. Two patients [1 positive and 1 negative for t(11;18)(q21;q21), respectively] have developed a local relapse following CR and were salvaged by radiotherapy. Conclusion: Our findings suggest that the presence of the API2-MALT1 fusion transcript resulting from t(11;18)(q21;q21) does not adversely affect the response of gastric MALT lymphoma to chemotherapy with 2CdA. 2CdA appears to be an attractive agent for treatment of gastric MALT lymphoma unresponsive to H. pylori eradication, including those positive for t(11;18)(q21;q21).

Outcome analysis for stage IE and IIE thyroid lymphoma.

Previous reports have revealed modest results in the management of thyroid lymphoma with radiotherapy alone. This retrospective report evaluates the outcome of patients treated for thyroid lymphoma with radiotherapy alone and with combined modality therapy (chemotherapy and radiotherapy) at a single institution. Twenty-seven patients with stages IE and IIE non-Hodgkin's lymphoma of the thyroid gland were treated between 1960 and 1998 at Barnes-Jewish Hospital, of which 14 patients were stage IE and 13 patients were stage IIE. The median age at diagnosis was 67 years, and there were 21 females and 6 males evaluated. The median follow-up time was 38 months (range: 3-279 months). All patients had histologically proven non-Hodgkin's lymphoma, of which 22 patients (81%) were intermediate grade. Treatment consisted of radiotherapy alone in 19 patients and a combined modality therapy in 8 patients. The median radiation dose to the thyroid bed was 44 Gy, and most patients received a doxorubicin-containing regimen administered prior to radiotherapy. Patient, tumor, and treatment-related characteristics were evaluated using Cox regression analysis. Local-regional tumor control, disease-free survival (DFS), and overall survival (OS) were calculated using the Kaplan-Meier method. Four patients had local relapse in this series, with a crude local tumor control rate of 85%. No factor was determined to be significant for local tumor control. The actuarial 5-year DFS and OS for the entire cohort were 57%, and 56%, respectively. In terms of DFS, both age and stage were statistically significant. The 5-year actuarial DFS for patients less than age 65 years was 83% versus 37% for those more than this age (p = 0.024). Furthermore, the 5-year actuarial DFS for patients with stage I and II disease was 69% and 45%, respectively (p = 0.022). In multivariate analysis, age continued to be significant for DFS (p = 0.049). Overall survival analysis revealed age, local tumor control, and stage to be significant in univariate analysis. Multivariate analysis was further carried out using Cox proportional hazard model, and it revealed age (p = 0.006) and local tumor control (p = 0.007) to be significant. Primary thyroid gland lymphomas have a favorable outcome with appropriate therapy, but prognosis depends on both clinical stage and age at presentation. Because of the risk of both local-regional and distant failure, combined modality approaches that use chemotherapy with radiotherapy are warranted for intermediate- and high grade thyroid lymphoma.

Stage IE Primary NonHodgkin???s Lymphoma of Bone

The results of treatment of 28 patients with Stage IE primary lymphoma of bone were evaluated. Nine patients were treated with curative intent with irradiation alone and 19 patients received radiotherapy combined with adjuvant chemotherapy. Local control was 100%. The 10-year freedom-from-relapse rate was 53%; all relapses were distant metastases, and the median time to failure was 1 year. All patients with relapses succumbed to their disease. The 10-year cause-specific survival rate was 48%. The 10-year survival rate was 53%. Multivariate analysis of survival suggested that pathologic fracture before treatment, age greater than 60 years, no aggressive chemotherapy, and lesions that were not in long bones may influence these end points. Two patients (7%) sustained moderate or severe late toxicity. Although the likelihood of local control after treatment of Stage IE primary lymphoma of bone is very high with radiotherapy, more effective systemic regimens are needed. A significant proportion of patients with this disease die of distant metastases, despite the use of what are considered standard doxorubicin-based chemotherapy regimens.

Diffuse large B-cell lymphoma of the stomach: assessment of microsatellite instability, allelic imbalance, and trisomy of chromosomes 3, 12, and 18.

Several types of genetic aberrations including microsatellite instability (MSI), allelic imbalance (AI), and chromosomal trisomies have been reported in low-grade (LG) mucosa-associated lymphoid tissue (MALT)-type gastric lymphomas. Presence of such genetic alterations could be a discriminator between de novo large cell lymphoma and high-grade (HG) MALT-type lymphoma. We investigated 17 primary gastric large B-cell lymphomas with and without features of MALT-type lymphoma for MSI, AI, and presence of trisomy of chromosomes 3, 12, and 18. We studied resection specimens from 17 primary gastric extranodal diffuse large B-cell lymphomas. Cases classified as HG MALT-type lymphoma, based on either the presence of LG MALT-type lymphoma component in the background (L/H MALT) or large cell lymphoepithelial lesions (HG MALT), and diffuse large B-cell lymphoma (DLBCL-NOS) when no features of MALT were present. MSI was analyzed using fluorescently labeled polymerase chain reaction primers (D3S11, D6S262, D3S1261, D3S1262, D3S1265). Paired tumor and normal DNA samples were amplified, and PCR products were analyzed on a DNA sequencer (ABI PRISM 373XL) with GeneScan (Applied Biosystems, Foster City, CA). MSI was defined as a gain of a novel-length allele compared with the corresponding normal tissue. AI was assessed at locus 3q27 (D3S1262 and D3S1265). The cases were analyzed for the presence of trisomy of chromosomes 3, 12, and 18 using interphase fluorescence in situ hybridization. MSI was detected in 4 out of 15 (27%) cases from which DNA was amplifiable with all primers and all MALT-type lymphomas. In two cases (13%), MSI was present at two loci sufficient to be classified as high-frequency MSI (MSI-H); this was seen exclusively in HG MALT lymphomas (P = 0.04). In the remaining two cases, MSI was detected at a single locus (low-frequency MSI). Allelic imbalance at the locus D3S1262 was detected in 4 out of 17 (24%) cases. It occurred more commonly in stage IE lymphomas when compared with higher stages (P = 0.03), regardless of lymphoma subtype. Trisomy 12 was detected in 3 out of 17 cases (18%) exclusively in stage IE lymphomas (P = 0.08). MSI was uncommon and was found exclusively in MALT-type lymphomas. MSI-H was even less common but occurred in HG MALT lymphomas only. Allelic imbalance at 3q27 (D3S1262) and trisomy 12 were found more commonly in low-stage disease. The latter two findings are in concordance with the recent suggestion that the published variation in gain of chromosomal material in high-grade gastric lymphomas may be related to stage rather than to the subtype of lymphoma. Because of the relatively low frequency of MSI in the high-grade B-cell lymphomas of the stomach, this feature cannot be used to reliably discriminate between the histologic types of extranodal diffuse large B-cell lymphoma.

Gastric MALT lymphomas: the value of an endoscopic follow-up evaluation.

Findings have demonstrated the close association between primary gastric B-cell lymphomas originating from mucosa-associated lymphoid tissue (MALT) and Helicobacter pylori (HP) infection, with their regression after an HP eradication therapy in up to 70% of the cases. Endoscopic-biopsy diagnosis and endoscopic ultrasound are of major importance as decisive prognostic factors and therapeutic determinants. We report 3 years of experience and follow-up evaluation in the management of MALT lymphomas. We also describe the guidelines strategy therapy used in our institution. Since July 1996, nine patients with a histologic diagnosis of low-grade, HP-positive MALT gastric lymphomas, have been followed up. All patients had stage IE lymphomas (according to Musshoff classification). Eradication of HP was performed with triple therapy amoxycillin, clarithromycin, and omeprazole using over a 14-day period. The patients were seen for endoscopic follow-up assessment after 3, 6, 9, and 15 months, then twice a year. The actual median follow-up time was 30.4 months (range, 16-38 months). All the patients are now free of disease and asymptomatic. We have registered two cases of HP relapse (both after 1-year follow-up evaluation), positively treated with the same triple therapy, and three cases of disease relapse treated with single-dose chemotherapy (plus radiotherapy in one patient). In our experience the eradication of HP appears to be effective, and we consider it the first therapeutic option in patients with stage IE gastric low-grade MALT lymphoma, although long-term results are still needed. Prolonged follow-up evaluation (particularly by endoscopy) is necessary (and feasible in our experience) to determine whether these remissions are long-lasting. We recommend that HP be eradicated in these lymphomas before referral to other standard treatment.

Testicular lymphoma is associated with a high risk of extranodal recurrence

In their interesting report on testicular lymphoma, Fonseca et al.1 found that stage IE patients had an adverse prognosis with a high risk of central nervous system (CNS) and testicular lymphoma relapse. However, since only 48 of 62 and 43 of 62 reported patients, respectively, had bone marrow examination and abdominal computed tomography (CT) performed, some of them may have been understaged. In a similar retrospective analysis of our admittedly fewer Stage IE patients with testicular lymphoma, we did not observe relapses in the CNS or the testicle. During the years 1980–1996, a total of 1377 patients (median age, 64 years) were seen at the Norwegian Radium Hospital. These patients had histologically confirmed high grade non-Hodgkin lymphoma (H-NHL) according to the Kiel classification2 and were clinically staged following the Ann Arbor staging classification,3 including abdominal CT and bilateral bone marrow aspirate and biopsy. Eleven patients (0.8% of all H-NHL and 4.4% of Stage I H-NHL) had Stage IE testicular lymphoma, and their median age was 71 years (range, 53–80 years). Histologic diagnosis was centroblastic (n = 7), immunoblastic (n = 2), or large cell (n = 2) lymphoma. Serum lactate dehydrogenase was within normal limits in all 11 patients. Treatment consisted of orchiectomy followed by no further treatment (n = 2), radiotherapy (n = 1), or either COP (cyclophosphamide, vincristine, and prednisone) (n = 3) or CHOP (COP with hydroxydaunomycin) (n = 5) chemotherapy. One patient received intrathecal methotrexate. The median duration of follow-up was 30 months (range, 11–207 months). A Kaplan–Meier plot of overall survival calculated from the date of histologic diagnosis (Fig. 1). showed that the overall prognosis for patients with testicular Stage IE H-NHL was no worse than for other Stage I H-NHL patients in the same age group. Relapse in the CNS or the contralateral testicle was not observed. Three patients relapsed with H-NHL, one died of a second cancer, and two patients died of other causes. Overall survival of 11 patients with Stage IE testicular lymphoma. Age at presentation, histology, and overall survival of our 11 patients were comparable to those of the 31 Stage IE patients reported by Fonseca et al. in their article.1 However, Stage IE testicular lymphoma may carry less risk of CNS or testicular relapse following chemotherapy than testicular involvement in patients with more advanced stages. Deaths from causes unrelated to lymphoma and the inherently worse prognosis of elderly lymphoma patients4, 5 no doubt considerably contribute to the reported adverse prognosis associated with Stage IE testicular lymphoma. Chemoradiotherapy as proposed by Connors et al.6 has generally proved effective in Stage I lymphoma7 and probably is also optimal therapy for patients with Stage IE testicular lymphoma. Knut Lote M.D., Ph.D.*, Harald Holte M.D., Ph.D.*, Stein Kvaløy M.D., Ph.D.*, * Department of Oncology, Norwegian Radium Hospital, Oslo, Norway

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

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

Lymphoma presenting as an intramuscular mass

Resection of an intramuscular mass without tissue diagnosis can lead to unnecessary surgery. During a 4.5-year period 19 previously healthy patients referred with an undiagnosed soft tissue tumour were found to have intramuscular non-Hodgkin's lymphoma. In seven patients this was the only focus of disease (Stage IE). Patients were treated with chemotherapy or radiotherapy alone or in combination. After mean follow-up of 43 months all of the patients with stage IE lymphoma are alive and disease free. Primary intramuscular non-Hodgkin's lymphoma has a good prognosis. The importance of a tissue diagnosis by needle core biopsy is emphasized.

Clinical stage IE primary lymphoma of the nasal cavity: radiation therapy and chemotherapy.

To determine the appropriate radiation therapy and chemotherapy for primary lymphoma of the nasal cavity to improve the local control and survival rates. Of the 25 adult patients with stage IE nasal lymphoma, nine underwent local radiation therapy alone and 16 underwent radiation therapy and chemotherapy (intravenous infusion). Radiation doses to the involved area were 22-54 Gy (median dose, 49 Gy). The 5- and 10-year cause-specific survival rates were 91% and 73%, respectively. The 5- and 10-year disease-free survival rates were 83% and 59%, respectively. Eight patients developed recurrent disease: six at the local site, one in the cervical nodes, and one in the small intestine. Five of the six patients with local recurrence received less than 50 Gy. Four of the six patients developed recurrent disease in the treated area; the other two patients developed marginal recurrences. Prognostic factors such as age, sex, maximum tumor size, and lactate dehydrogenase level were of limited value. The most common recurrence site was the local site. To improve the local control rate, the involved area should be treated with high-dose radiation therapy. The clinical results did not demonstrate the usefulness of combination chemotherapy for stage IE nasal lymphoma.

Total gastrectomy for primary gastric lymphoma at stages IE and IIE: A prospective study of fifty cases

Background. Treatment of primary gastric lymphoma at Ann Arbor stage IE or IIE is controversial. Randomized trials to compare various modalities are not feasible because of the rarity of this disease. We have prospectively treated patients by means of primary surgery to achieve complete local control and accurate staging. Methods. Between 1987 and 1995, 50 patients with stage IE or IIE gastric lymphoma were prospectively treated by total gastrectomy with systematic lymphadenectomy. When nodal metastases were histologically confirmed or the resection was noncurative, chemotherapy was added. Intragastric tumor spread, lymph node metastasis, and treatment results were examined. Results. Resection was potentially curative in 48 cases. There were no operative deaths. Histologically, the middle third of the stomach was most frequently involved. Either the proximal two thirds or the entire stomach was involved in 62% of all patients. Lymph node metastasis was demonstrated in 25 patients. The deeper the tumor invasion in the gastric wall, the more frequent and distant the nodal involvement. The 5-year survival rate was 85.6%, excluding one death caused by heart disease. Conclusions. Primary surgery followed by chemotherapy in selected cases is an appropriate strategy for primary gastric lymphoma in patients in whom this regimen can be safely carried out.

Stage I Non-Hodgkin's Lymphoma Treated with Doxorubicin-containing Chemotherapy with or without Radiotherapy

Seventy-six patients with stage 1 or IE intermediate-grade or immunoblastic non-Hodgkin's lymphoma were treated with a short course of doxorubicin-containing chemotherapy with (n = 58) or without (n = 18) involved field radiotherapy. Chemotherapy consisted of 3 or 4 cycles of M-BACOD or (bleo-)CHOP. Seventy-two (97%) of the 74 evaluable patients achieved a complete response. The 3-year overall survival was 89%, recurrence-free survival 94%, and lymphoma-specific survival 93%. Patients older than 60 years also had a 3-year lymphoma-specific survival rate of as high as 92%. The International Prognostic Index was associated with overall survival (p = 0.04), but not with lymphoma-specific survival (p = 0.18). We conclude that stages I and IE intermediate-grade or immunoblastic non-Hodgkin's Hodgkin's lymphoma is highly curable if treated with short doxorubicin-containing chemotherapy and involved field radiotherapy.

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

The aim of this study was to evaluate retrospectively the different treatment approaches and outcome of patients with stage IE and IIE gastric non-Hodgkin's lymphoma in a cancer registry. Between 1982 and 1992, the Comprehensive Cancer Centre South (CCCS), Eastern Section, The Netherlands, registered, in a population of 1 million people, a total of 81 cases of gastric lymphoma stage IE and IIE (43 men and 38 women). Median age was 69.7 years (range 30.4-88.1). According to the Working Formulation, the malignancy grade was: 9 low, 55 intermediate and 14 high. According to the MALT classification, the malignancy grade was: 38 low and 40 high. Grade was unknown in 3 patients. Patients received the following treatment modalities: surgery alone (n = 22), locoregional radiotherapy without (n = 12) or with (n = 13) surgery; or systemic chemotherapy alone (n = 10) or with radiotherapy and/or surgery (n = 18). No treatment was given or recorded in 6 patients. For stage IE, 5-year actuarial survival and relapse-free survival rates were, respectively, 76 and 64% in 18 patients who received only surgery; 70 and 67% in 17 patients given locoregional treatment (radiotherapy with or without surgery), and 76 and 62% in 13 patients given systemic treatment (chemotherapy alone or with radiotherapy and/or surgery). Radiotherapy as sole treatment seemed to be as effective as other treatment modalities in achieving local and abdominal control. For stage IIE, none of the 4 patients who were treated with surgery alone survived 5 years. The 5-year actuarial survival and relapse-free survival rates of 8 patients who received radiotherapy with or without surgery were, respectively, 25 and 17% and 49 and 33%, for 14 patients given systemic therapy (chemotherapy alone and/or radiotherapy/surgery). In stage IIE, local, abdominal as well as distant relapse were more common, irrespective of treatment modality. In the multivariate analyses, stage (P = 0.002), grade (P = 0.02), age (P = 0.04) and gender (P = 0.04) were significant prognostic factors. This report on a limited number of patients shows that the outcome of patients with stage IIE gastric lymphoma is much worse than for patients with stage IE. Grade, age, gender and particularly stage are much stronger indicators for survival than different modes of treatment. Systemic therapy might improve outcome for stage IIE, but not for stage IE, for which radiotherapy alone seems a good option.

Long-Term Follow-Up After Curative Surgery for Early Gastric Lymphoma

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. 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. 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. 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. 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.

Management of stage IE primary gastric lymphoma.

From 1975 to 1991, stage IE gastric lymphoma was diagnosed or treated in 40 patients at our institution. Thirty-five evaluable patients were the subject of this analysis (median age, 63 years). All histologic specimens were reviewed and classified according to the working formulation. Immunohistochemical stains were performed in 33 of 35 cases. The following histologic subtypes were identified: 26 patients had diffuse large cell, 2 had diffuse mixed cell, and 7 had mucosa-associated lymphocytic lymphoma (small lymphocytic lymphoma with features of MALT lymphoma). Of the 35 patients, 30 (86%) underwent laparotomy, with subtotal or total gastrectomy performed in 29. After gastrectomy, 17 patients had radiation therapy, 3 had chemotherapy, 2 had radiation plus chemotherapy, and 7 had no further treatment. Five patients were diagnosed with endoscopic biopsy and had radiation therapy, chemotherapy, or both without further surgical treatment. The median follow-up period was 69.2 months. The commonest presenting symptom was pain. The 5-year disease-free survival was 90% for the entire group and 88% for the 28 patients with working formulation intermediate histology. For patients with MALT lymphoma, the 5-year disease-free survival was 100%. The prognosis for patients with stage IE working formulation intermediate-histology gastric lymphoma is good and for those with stage IE MALT lymphoma, excellent.

Gastrocolic Fistula Secondary to Primary Gastric Lymphoma

Gastrocolic fistula in primary non-Hodgkin's lymphoma (NHL) of the stomach is rare; in a review of the literature we found only four cases, all in association with disseminated (stage IV) disease. We describe the first case of a gastrocolic fistula in a patient with stage IE lymphoma. The diagnosis was suggested by feculent vomiting, and the fistula was located using barium enema and CT scan. Therapy consisted of local resection followed by combination chemotherapy.

Thyroid lymphoma. The case for combined modality therapy.

Radiation therapy with or without surgery is generally considered standard treatment for lymphoma of the thyroid. Because of the small number of cases, the role of chemotherapy or combined modality treatment is difficult to determine. The published literature was analyzed, supplemented by a series from Yale, for the incidence of local and distant relapse after radiation therapy, chemotherapy, or combined modality treatment for Stage I-II thyroid lymphoma. Patients with advanced disease or in whom radiation was probably inadequate were excluded. Only patients receiving an anthracyline-based regimen were considered in the group with chemotherapy. Patients receiving single agents or non-anthracycline-based regimens were excluded from analysis or, if they also received radiation, were included in the group that received radiation only. Including a series from Yale, a total of 211 patients with Stage IE and IIE thyroid lymphoma were identified. Distant and overall relapse rate were significantly lower in the group that received combined modality treatment. Local relapse was also less, but the difference was not statistically significant. In a small number of patients with disease confined to the neck, the results with radiation were similar to combined modality treatment if the mediastinum was included in the treatment port. Although mucosa-associated lymphoma tissue lymphomas are thought to have a low distant recurrence rate and are therefore often treated with local therapy alone, a review of the published literature suggests that 30% of thyroid lymphomas with clinically localized disease will have a distant relapse. The addition of chemotherapy to radiation significantly lowered distant and overall recurrence.