A Clinicopathological Analysis Of Primary Gastric Lymphoma

Introduction:
Primary gastrointestinal lymphoma represents the most common location of extranodal lymphoma (1).The stomach represents 50-75% of the gastrointestinal tract localizations (2). Primary gastric lymphomas are divided into indolent (low grade) and aggressive (high grade) types. They are mainly the disease of middle age, with a male predominance reported by most of the studies (3). Controversy remains regarding the best treatment for early stages of the disease. Chemotherapy, Surgery and combination have been studied and shared almost comparable results with survival rate of 70-90%. However, chemotherapy possesses the advantage of preserving gastric anatomy (4). Recent years have seen a dramatic paradigm shift in the treatment approach to the most common gastrointestinal lymphomas, i.e. DLBCL and MALT lymphoma of the stomach. While surgery had been the main stay of treatment for decades, it has now virtually been abolished due to the absence of a beneficial effect as compared to conservative therapy (5). The discovery of an association between Helicobacter pylori (HP) and gastric MALT lymphoma and the subsequent reports of lymphoma regression following HP-eradication have revolutionized treatment options for such patients. HP-eradication is currently considered standard first-line therapy in patients with gastric MALT lymphoma and evidence of HP-infection, with complete responses being obtained in roughly 75% of selected patients [My paper] (6). Also combined modality treatment by chemo-radiation for localized gastric lymphoma is associated with a low risk of treatment related complications, with avoidance of long term sequelae after gastric resection (7). In DLBCL of the stomach, the association with HP-infection is less pronounced than in MALT lymphoma at roughly 50% of patients. While gastric DLBCL had also been subjected to surgery in order to prevent bleeding and perforation during subsequent chemotherapy and radiation, it has been demonstrated that such prophylactic surgery is not necessary with the consequent application of a high dose proton pump inhibitors for the whole duration of therapy. In addition, the relapse rate and survival are not beneficially influenced by additional surgery, while quality of life may be severely impaired. Most large studies have been performed combining anthracycline - based chemotherapy and radiation therapy (5). The response rate after Chemotherapy was 90%, while after radiotherapy it was 100%, only 10% of patients had relapse after ending treatment. Only one case died during the follow up Table 2.
Grade I nausea and vomiting was the most frequent complication of chemotherapy among studied patients
* Oncology Department of Ain Shams University.
** Oncology Department of Ahmed Maher Teaching Hospital
followed by Grade I myelosuppression where only 25% of patients complained from it Fig 2
Grade I anorexia was the most common complication of radiotherapy among studied patients followed by Grade I nausea and vomiting where 40% of patients complained from it Fig 3.
The mean overall survival time was 21 months, from the survival curve; the survival rate was estimated at 24 months to be 94.7%. The mean disease free survival time was 19.97 months, from the survival curve; the disease free survival rate was estimated at 12 and 24 months to be 98.7% and 94.2% respectively. There was no significant difference between male and females, high and low grade type, different tumor stage, H.Pylori infection, increased LDH level, fungating or ulcerating mass as regarding the mean survival time and mean disease free survival time. Significant association between B2 microglobulin increase and relapse of patients, as 50% of relapsed patients had an increase in B2 microglobulin. Highly significant association between LDH increase during follow up and occurrence of relapse as 100% of relapsed patients showed increases LDH levels during follow up, on the other hand none of the non-relapsed patients had elevated LDH.