Primary Gastric Lymphoma for Stage I/II1 E: Operative and Conservative Management in Retrospective Data from 71 Cases

The standard management of primary gastric lymphoma (PGL) has not been established despite the use of various treatment modalities [1]. In fact, in patients with PGL both surgery and combined modality including radio and chemotherapy have been widely performed. However, in the last decade a trend toward a conservative approach is emerging although it is not supported by randomised studies [2]. Our aim was to retrospectively analyse the survival of patients with PGL according to the treatment type. From November 1980 to February 1999 different treatments were used in 71 consecutive (37 Females, 34 Males) patients with PGL limited stage I/II1 E, according to the Lugano staging system for gastro-intestinal lymphomas [3]: surgery and chemotherapy combined treatment (CMT), only surgery, only chemotherapy or only Helicobacter pylori eradication therapy [4]. The procedures of staging included gastroscopy with several biopsies with a middle number of six specimens (range 3– 12), small bowel radiograph with contrast, colonscopy, chest–abdomen or total body TC or bone marrow biopsy and otorhinolaryngologist evaluation. Table I shows the main clinical features of our patients. Median age was 58 years (range: 22–81 years) with 25% of patients older than 65 years, median performance status (WHO) was 1; the stage of disease was I E in 38 patients and II1E in 33. At onset, patients experienced more frequently epigastric pain, weight loss more than 5 kg, nausea, vomiting, rare episodes of light hematemesis and gastric bleeding without anaemia; only 7 patients had levels of hemoglobin , 10 g/dl and 1 patient, with levels of hemoglobin 7.4 g/dl, had recurrent episodes of gastric bleeding needing packed red cell transfusions. Histologic evaluation according to WHO criteria gave the following results: 48 patients had an aggressive lymphoma and 23 patients had an indolent lymphoma; 15 (21%) patients were found to have MALT lymphoma [5]. All patients had B-cell phenotype and were diagnosed by gastric biopsy or gastric surgery. Total or partial gastrectomy was performed in 41 (58%) patients and 30 of them subsequently received 4–6 courses of chemotherapy. In contrast, 24 patients were treated only with chemotherapy, while 6 patients received antibiotic therapy with metronidazole (2 £ 550 mg/d), clarythromicin (2 £ 500 mg/d) and omeprazole (2 £ 20 mg/d) by oral therapy for 10 days for their HPrelated low-grade MALT lymphoma [6]. The treatment with an inhibitor of the protonic pump was extended for the whole duration of chemotherapy in order to reduce the risk of bleeding. Chemotherapy given either as primary treatment or following surgery consisted of CVP regimen (intravenous cyclophosphamide 400 mg/m 1–5 days, vincristine 1.4 mg/m 1 day and prednisone 100 mg/m 1–5 days) for patients with indolent histology or older than 65 years, or of anthracycline-containing regimen (CHOP/CHOP-like and ProMECE Cyta-BOM) for those younger or with aggressive histology patients. In our experience we have not submitted any patient to radiotherapic treatment [7]. The antiemetic prophylaxis with antagonists of the receptor 5-HT3 was routinely administered. Including criteria to start therapy were left ventricular ejection fraction .50%, white blood cell count .3500/ml, platelet count .100,000/ml, and normal parameters of liver and renal function as well. After 4 cycles of therapy a response evaluation was done by gastroscopy and biopsies, TAC scan of chest and abdomen and ETG abdomen. Response to treatment was classified on the basis of the standard WHO criteria.