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Dr. CC Chan Kwong Wah Hospital

Role of Surgeon in Management of Gastric Lymphoma. Dr. CC Chan Kwong Wah Hospital. Introduction. Primary gastric lymphoma Uncommon disease 5% of all gastric malignancy 10% of all malignant lymphoma S tomach is by far the most common site of extra-nodal non-Hodgkin lymphoma (NHL)

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Dr. CC Chan Kwong Wah Hospital

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  1. Role of Surgeon in Management of Gastric Lymphoma Dr. CC Chan Kwong Wah Hospital

  2. 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

  3. Revised European-American Lymphoma (REAL) (WHO 1993) • B-cell lymphoma • Diffuse Large B-cell • Marginal-zone (Extranodal, Nodal, splenic) • Lymphoblastic • Small lymphocytic • Lymphoplasmacytoid • Mantle-cell • Follicular center (follicular, diffuse, small) • T cell lymphoma • Lymphoblastic • Mycosis fungoides/ sezary syndrome • Peripheral T-cell • Burkitt’s / Burkitt-like

  4. Classification by Histology • Two histological subtypes accounted for over 90% of cases: • Diffuse large B-cell (DLBC) Lymphoma • Marginal zone B-cell lymphoma

  5. Classification by Grading • 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

  6. Presentation of Gastric Lymphoma • 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

  7. Historically, laparotomy and biopsy is required for diagnosis and accurate staging of the disease

  8. Diagnosis of Gastric Lymphoma • Upper endoscopy • Three main patterns: ulcerative, diffuse infiltrative, polypoid mass • Multiple biopsies from macroscopic lesions • Antrum biopsy • Assess for H. pyloriinfection • Achieved 90% efficacy in diagnosing gastric lymphoma Gastroenterology Research • 2009;2(5):253-258

  9. Staging of Gastric Lymphoma • Musshoffs modification of Ann Arbor system

  10. Staging of Gastric Lymphoma • 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

  11. Treatment of Low Grade MALToma • 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.

  12. Treatment of Low Grade MALToma • 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

  13. Treatment of Advanced Disease • 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

  14. Controversies in Treatment of Gastric Lymphoma • 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

  15. Optimal Treatment for Early Stage High Grade Gastric Lymphoma • 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

  16. Optimal Treatment for Early Stage High Grade Gastric Lymphoma • 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 1991 GermanMulticenter Study Group by Koch et al in 2001

  17. Chemotherapy in Managing Gastric Lymphoma • 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.

  18. 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. Annals of Oncology, Vol. 14, No. 12, 2003, pp. 1751-1757. American Journal of Medicine, Vol. 90, No. 1, 1991, pp. 77-84.

  19. 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

  20. Radicality of Gastrectomy • 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 J Surg Oncol 1997;64(3):237-241, J Clin Oncol 2001;19(18):3874-3883. Rev Esp Enferm Dig 2006; 98(3): 180-188 Gastroenterology Research 2009;2(5):253-258

  21. Management of Complication • 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

  22. Summary • 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

  23. Thank you

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