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Dr. CC ChanKwong Wah Hospital
Role of Surgeon in Management of Gastric
Lymphoma
Introduction Primary gastric lymphoma
◦ Uncommon disease◦ 5% of all gastric malignancy◦ 10% of all malignant lymphoma
Stomach is by far the most common site of extra-nodal non-Hodgkin lymphoma (NHL)◦ Accounting for 60% of cases
Revised European-American Lymphoma (REAL) (WHO 1993)• B-cell lymphoma– Diffuse Large B-cell– Marginal-zone
(Extranodal, Nodal, splenic)
– Lymphoblastic – Small lymphocytic – Lymphoplasmacytoi
d – Mantle-cell – Follicular center
(follicular, diffuse, small)
• T cell lymphoma– Lymphoblastic–Mycosis
fungoides/ sezary syndrome
– Peripheral T-cell• Burkitt’s /
Burkitt-like
Two histological subtypes accounted for over 90% of cases:◦ Diffuse large B-cell (DLBC) Lymphoma◦ Marginal zone B-cell lymphoma
Low-grade (Indolent NHL)◦ Derived from Mucosa Associated lymphoid tissue
(MALT)◦ Remained localized for extended period of time
High-grade (Aggressive NHL)◦ One third contained low-grade component
Progress from low grade lesion◦ Includes diffuse large B cell lymphoma (DLBCL)◦ Disseminate more rapidly
Presenting symptoms are non-specific◦ Abdominal pain (80%)◦ Weight loss (40%)◦ Gastrointestinal bleeding (36%)◦ Vomiting (32%)
Delay in diagnosis◦ Median time from onset of symptoms to diagnosis
is about 3 months
Historically, laparotomy and biopsy is required for diagnosis and accurate staging of the disease
Upper endoscopy ◦ Three main patterns: ulcerative, diffuse infiltrative,
polypoid mass◦ Multiple biopsies from macroscopic lesions ◦ Antrum biopsy
Assess for H. pylori infection◦ Achieved 90% efficacy in diagnosing gastric
lymphoma
Gastroenterology Research • 2009;2(5):253-258
Musshoffs modification of Ann Arbor system
Stage Definition
IE Lymphoma limited to the stomach
IIE₁ Involvement of stomach and contiguous LN
IIE₂ Involvement of stomach and non-contiguous sub-diaphragmatic LN
III Involvement of stomach and LN on both sides of diaphragm
IV Hematogenous spread (stomach and one or more extra-lymphatic organs or
tissues)
Endoscopic ultrasound◦ Determine depth of tumor invasion◦ Detect any enlarged peri-gastric lymph nodes◦ Sensitivity
T staging: 80–92% N staging: 77–90%
Ann Oncol 1993;4(10):839-846., Endoscopy 1993;25(8):531-533
Look for distant spread of disease◦ Bone marrow biopsy◦ CT scan of thorax, abdomen and pelvis◦ Positron emission tomography (PET) scan
Diagnostic value only for DLBCLs but controversial for MALT lymphomas
Low-grade MALT lymphoma◦ Presented as stage I or II disease with slow
progression◦ Helicobacter pylori identified in 90% of cases
Systematic review in 2010 of 32 studies including 1408 patients◦ Remission rate after HP eradication up to 77.5%
Prognosis◦ 10-year survival 80-90%
Gastroenterol Hepatol 2010;8:105e10.
Complete remission◦ Within 6 to12 months from eradication
Follow-up (EGILS consensus report 2011)◦ First endoscopy 3-6 months after triple therapy
Check for H pylori status◦ Subsequent follow-up endoscopy every 4-6
months until complete remission
Stage III & IV disease◦ Primary treatment with chemotherapy and
monoclonal antibody (R-CHOP)
Surgery indicated in:◦ Patient with localized residual disease in stomach
alone after chemoRT◦ To Palliate symptoms of bleeding and obstruction
that do not resolve with non-operative therapies
Ann Surg 2004;240: 28–37
Optimal Treatment for Early Stage High Grade Gastric Lymphoma
Radicality of Gastrectomy
Management of Complications◦ Bleeding & Perforation during Chemotherapy◦ Obstruction
Journal of Cancer Therapy, 2013, 4, 145-152
Brands et al reviewed 100 papers analyzing over 3000 patients of gastric lymphoma treated from 1974 to 1995
For early stage disease◦ 80% of studies recommended treatment with
surgery
Eur J Surg. 1997;163:803–813
Results of combined modality (Surgery + chemotherapy) and chemotherapy compared◦ No significant difference in survival rate in both groups
5 year survival rate ranged from 75% to 84%
Aviles et al in 1991German Multicenter Study Group by Koch et al in 2001
Aveiles et al in Ann Surg 2004 Prospective Randomized Control Study 589 patients of Stage I & II Diffuse Large B cell
Lymphoma Four groups:
◦ Surgery alone◦ Surgery + Radiotherapy ◦ Surgery + Chemotherapy ◦ Chemotherapy (CHOP: Cyclophamide, vincristine,
doxorubicin, prednisolone)
Ann Surg 2004;240:44–50.
Overall Survival Rate at 10 years◦ Surgery alone: 52% [46% to 64%]◦ Surgery + Radiotherapy: 53% [45% to 65%]◦ Surgery + Chemotherapy: 91% [85% to 99%] ◦ Chemotherapy: 96% [90% to 100%]
No difference observed between chemotherapy alone & Surgery + Chemotherapy
Surgical resection before chemotherapy◦ Not affect complete response rate, survival rate and
disease free survival
Ann Surg 2004;240:44–50.
American Journal of Medicine, Vol. 90, No. 1, 1991, pp. 77-84.
Annals of Oncology, Vol. 14, No. 12, 2003, pp. 1751-1757.
Risk of Gastrectomy◦ Mortality: 5%◦ Complication Rate: 30%
Better Quality of Life in patient with gastric preservation◦ Dumping syndrome◦ Nutrition malabsorption
Chemotherapy recommended as first line treatment for early stage high grade gastric lymphoma
Better outcome in radical resection compared with incomplete resection or biopsy alone
More recent studies◦ Positive margin has no impact on outcome◦ ? Related to lower tumor burden which allow
complete resection
Role of Chemotherapy
Rev Esp Enferm Dig 2006; 98(3): 180-188Gastroenterology Research 2009;2(5):253-258
J Surg Oncol 1997;64(3):237-241, J Clin Oncol 2001;19(18):3874-3883.
Risk of perforation◦ Low: 1.7% without surgery
Risk of bleeding◦ 2.1% (without surgery) vs 2.2% (with surgery)◦ Not significant different
Obstruction◦ High dose steroid◦ Non-responder: Surgical resection
Ann Surg 2004;240: 28–37
Management of primary gastric lymphoma should involve a multidisciplinary approach
Treatment for primary gastric lymphoma◦ For low-grade MALToma: HP eradication therapy ◦ Chemotherapy for early stage high grade lymphoma
and advanced disease Controversy still exists in the radicality of surgery Risk of bleeding and perforation during chemotherapy
is extremely low Surgeons still play a role in diagnosing and accurate
staging of gastric lymphoma as well as management of complication
Thank you