Gastric Lymphoma

                                                                                   

                                                                                 MALT Lymphoma

 

                                                         Treatment of MALT lymphoma

 

  1. Disease limited to the mucosa and submucosa
  • – H.pylori eradication
  • F-Up endoscopy: 3-6 months after completion of therapy to document clearance of infection and to assess disease regression
  • If H.pylori is still present : Treat with second-line antibiotic
  • Predictors of subsequent response to therapy on histologic findings
  •         – Small foci of lymphoma: Predictive of subsequent complete response
  •         – Diffuse persistent disease: Low likelihood of subsequent complete response

       After that

Endoscopy: 6 monthly for 2 year then yearly

  • – 75% patients will achieve complete remission if disease is confined to mucosa and submucosa
  • – Median time of remission: 5 months
  • – 90% patients will remain in remission who had a complete clinical remission
  • – Relapse may occur but can be cured by Hp eradication
  • – Lack of response to Hp eradication is seen in
  •                                    • Hp negative lymphoma
  •                                    • Patients with LN involvement
  • Management options in disease unresponsive to Hp eradication
  •                  • Surgical resection
  •                  • Chemotherapy
  •                  • Radiation
  • – Hp negative cases should also be treated by anti Hp due to the possibility of false negative result of Hp
  1. Locally advanced MALT (Involvement of muscularis propria or serosa)
  • – Hp eradication plus
  • – Radiation therapy (involved field radiation to the stomach and perigastric LN)
  •                     • This is well tolerated and preserve gastric function
  • – Other indications of radiation therapy
  •                      • Advanced stage local disease
  •                      • Hp negative lymphoma
  •                      • Persistent lymphoma despite Hp treatment
  1. Advanced disease
  • – This is low grade lymphoma that has spread to distal LN or extra nodal sites
  • – Treatment options:
  •                   • Chemotherapy with Rituximab
  • – This disease is usually not considered curable but is generally indolent with transient response to chemotherapy

 

 

 

                                                                  Diffuse Large B Cell Lymphoma (DLBCL)

 

  • – 50% gastric lymphoma are DLBCL
  • – DLBCL + MALToma consists 90% of primary gastric lymphoma
  • – Median age: 60 years, slight male excess

 

Pathogenesis of DLBCL:

                  – Many large cell tumors (25-40%) have low grade MALT tissue component and assumed to have evolved through transformation of low  grade lesion

-If large cell lesions arise from progression of low grade lesion, then Hp may have a role in initial pathogenesis

-Somatic mutation of immunoglobulin heavy chain variable gene is other mechanism responsible for DLBCL

 

Pathology of DLBCL

  • – DLBCL typically invades muscularis propria or more deeply
  • Gross appearance:
  •                 – Large ulcer
  •                – Protruded tumor
  •                – Multiple shallow ulcer
  • Most common site of involvement
  •               – Body and antrum of the stomach
  • Immunophenotypes:
  •               – B-cell antigen markers: CD19, CD22,CD79a, CD 45

 

                                                    Treatment of DLBCL

  • – Most patients with DLBCL of the stomach have more advanced disease and antibiotics alone are inadequate treatment
  • – Standard management of DLBCL parallels management of nodal large B cell lymphoma
  • Treatment of localized diseae: (stage I, II)
  •          – 3-6 cycles of combination chemotherapy typically CHOP with or without consolidation radiotherapy
  • Treatment of stage IV disease:
  •          – 6-8 cycle of CHOP plus Rituximab with or without radiotherapy

 


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