Gastric lymphoma

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mazia Fatima, MBBS [2]

Overview

Primary gastric lymphoma is cancer derived from lymphocytes (a type of white blood cell) that originates in the stomach. Most common cause of primary gastric lymphoma is mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBCL) of the stomach. Primary gastric lymphoma may be classified according to histology into MALT lymphoma and DLBCL. MALT lymphoma can be further divided into H. pylori positive MALT lymphoma and H. pylori negative MALT lymphoma. DLBCL can be divided into 3 subgroups germinal-center B-cell-like, activated B-cell-like, primary mediastinal DLBCL. The exact pathogenesis of primary gastric lymphoma is not fully understood. Common symptoms of primary gastric lymphoma include epigastric discomfort, anorexia, weight loss, nausea associated with or without vomiting, occult gastrointestinal bleeding, early satiety. Less common symptoms include ever and night sweats. Patients with primary gastric lymphoma usually appear normal. Vital signs are within normal limits unless there is complication. Physical examination of patients with primary gastric lymphoma is usually remarkable for palpable mass and peripheral lymphadenopathy. Gastric lymphoma must be differentiated from conditions with similar presentation like acute gastritis, chronic gastritis, atrophic gastritis, Crohn's disease, gastroesophageal reflux disease, peptic ulcer disease, gastrinoma and gastric adenocarcinoma. Primary gastric lymphoma commonly affects elderly patients in the fifth or sixth decade of life. Primary gastric lymphoma is more prevalent in men than in women. Risk factors for gastric lymphoma include Helicobacter pylori, long-term immunosuppressant drug therapy, HIV infection. The majority of patients with primary gastric lymphoma present with nonspecific symptoms in the 5th decade of life. Early clinical features include epigastric pain, nausea, and vomiting. If left untreated, patients with gastric lymphoma may progress to develop anorexia, weight loss, and early satiety. Common complications of gastric lymphoma include perforation, hemorrhage, and obstruction. Prognosis is generally good, and complete remission can be achieved after 6-8 rounds of chemotherapy or following surgery. Upper gastrointestinal endoscopy with biopsy is the gold standard test for the diagnosis of gastric lymphoma. Laparotomy and laparoscopy should be performed when the patient presents with complications such as perforation or obstruction. An endoscopic ultrasound (EUS) will help assess the depth of lymphoma invasion and involvement of perigastric nodes. MALT lymphoma presents as superficial spreading or diffuse infiltrating lesion whereas diffuse large B cell lymphoma has a typical mass forming lesion appearance on endoscopic ultrasound. Imaging investigations including CT scans or endoscopic ultrasound are useful to stage disease. Hematological parameters are usually checked to assist with staging and to exclude concomitant leukemia. An elevated LDH level may be suggestive of lymphoma. There are no established measures for the primary and secondary prevention of gastric lymphoma.

Classification

Primary gastric lymphoma may be classified according to histology into the following subtypes:

Pathophysiology

In case of DLBCL, antibiotic eradication therapy for H.pylori has shown to result in complete remission of lymphoma highlighting the role of H.pylori in the pathogenesis.

  • HBV plays a role in the pathogenesis of B-cell NHL, evidenced by an increased risk of developing NHL in HBsAg positive patients.

Histopathology

Most of the gastric lymphomas are predominantly non-Hodgkin’s lymphoma of B-cell origin. Primary gastric lymphoma can vary from being well-differentiated, low-grade lymphomas to high grade or large cell lymphomas.[5]

Symptoms

Common Symptoms

Common symptoms of primary gastric lymphoma include:[6][7]

Less Common Symptoms

Less common symptoms include:

Physical Examination

Appearance of the Patient

  • Patients with primary gastric lymphoma usually appear normal.[7]

Vital signs

Vital signs are within normal limits unless there is complication.

Abdominal Examination

Differential Diagnosis

Gastric lymphoma must be differentiated from conditions with similar presentation like acute gastritis, chronic gastritis, atrophic gastritis, Crohn's disease, gastroesophageal reflux disease, peptic ulcer disease, gastrinoma and gastric adenocarcinoma :[8][9][10][11][12][13][14][15][16]

Disease Cause Symptoms Diagnosis Other findings
Pain Nausea

&

Vomiting

Heartburn Belching or

Bloating

Weight loss Loss of

Appetite

Stools Endoscopy findings
Location Aggravating Factors Alleviating Factors
Primary gastric lymphoma - - - - - +/- - - Useful in collecting the tissue for biopsy Other symptoms
Acute gastritis Food Antacids +/- +/- +/- - +/- Black stools -
Chronic gastritis Food Antacids +/- +/- +/- +/- +/- - H. pylori gastritis

Lymphocytic gastritis

  • Enlarged folds
  • Aphthoid erosions
-
Atrophic gastritis Epigastric pain - - +/- - +/- +/- +/- - H. pylori

Autoimmune

Autoimmune gastritis diagnosis include:

Crohn's disease - - - - - +/- +/-
  • Mucosal nodularity with cobblestoning
  • Multiple aphthous ulcers
  • Linier or serpiginous ulcerations
  • Thickened antral folds
  • Antral narrowing
  • Hypoperistalsis
  • Duodenal strictures
GERD
  • Lower esophageal sphincter abnormalities
  • Spicy food
  • Tight fitting clothing
+/-

(Suspect delayed gastric emptying)

+/- - - - - Other symptoms:

Complications

Peptic ulcer disease Duodenal ulcer
  • Pain aggravates with empty stomach

Gastric ulcer

  • Pain aggravates with food
  • Pain alleviates with food
+/- +/- - - - Gastric ulcers
  • Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base
  • Most ulcers are at the junction of fundus and antrum
  • 0.5-2.5cm

Duodenal ulcers

Other diagnostic tests
Gastrinoma - - +/-

(suspect gastric outlet obstruction)

+/- - - - Useful in collecting the tissue for biopsy

Diagnostic tests

Gastric Adenocarcinoma - - +/- +/- +/- +/- +/- Esophagogastroduodenoscopy
  • Multiple biopsies are taken to establish the diagnosis
Other symptoms

Demographics

Risk Factors

Risk factors for gastric lymphoma include the following:[18]

Natural History, Complications and Prognosis

Natural History

Complications

Prognosis

Diagnosis


By Samir at the English language Wikipedia, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=4647530

MRI

Findings of Gastric lymphoma on MRI includes:

  • Irregularly thickened mucosal folds
  • Irregular submucosal infiltration
  • Annular constricting lesion
  • Exophytic tumor growth
  • Retroperitoneal lymphadenopathy.

Treatment

Prevention

Primary Prevention

Proper treatment of Helicobacter pylori, can prevent MALT lymphoma.

Secondary Prevention

There are no established measures for the secondary prevention of gastric lymphoma.

References

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  2. Engels EA, Cho ER, Jee SH (2010). "Hepatitis B virus infection and risk of non-Hodgkin lymphoma in South Korea: a cohort study". Lancet Oncol. 11 (9): 827–34. PMC 2933963Freely accessible. PMID 20688564. doi:10.1016/S1470-2045(10)70167-4. 
  3. Dawson IMP, Cornes JS, Morrison BC. Primary malignant lymphoid tumours of the intestinal tract. Br J Surg. 1961;49:80-89.
  4. Aisenberg AC. Coherent view of non-Hodgkin's lymphoma. J Clin Oncol. 1995;13:2656-2675.
  5. 5.0 5.1 Wang T, Gui W, Shen Q (2010). "Primary gastrointestinal non-Hodgkin's lymphoma: clinicopathological and prognostic analysis". Med. Oncol. 27 (3): 661–6. PMID 19565363. doi:10.1007/s12032-009-9265-1. 
  6. Freeman C, Berg JW, Cutler SJ (1972). "Occurrence and prognosis of extranodal lymphomas". Cancer. 29 (1): 252–60. PMID 5007387. 
  7. 7.0 7.1 Koch P, del Valle F, Berdel WE, Willich NA, Reers B, Hiddemann W, Grothaus-Pinke B, Reinartz G, Brockmann J, Temmesfeld A, Schmitz R, Rübe C, Probst A, Jaenke G, Bodenstein H, Junker A, Pott C, Schultze J, Heinecke A, Parwaresch R, Tiemann M (2001). "Primary gastrointestinal non-Hodgkin's lymphoma: I. Anatomic and histologic distribution, clinical features, and survival data of 371 patients registered in the German Multicenter Study GIT NHL 01/92". J. Clin. Oncol. 19 (18): 3861–73. PMID 11559724. doi:10.1200/JCO.2001.19.18.3861. 
  8. Sugimachi K, Inokuchi K, Kuwano H, Ooiwa T (1984). "Acute gastritis clinically classified in accordance with data from both upper GI series and endoscopy.". Scand J Gastroenterol. 19 (1): 31–7. PMID 6710074. 
  9. Sipponen P, Maaroos HI (2015). "Chronic gastritis.". Scand J Gastroenterol. 50 (6): 657–67. PMC 4673514Freely accessible. PMID 25901896. doi:10.3109/00365521.2015.1019918. 
  10. Sartor RB (2006). "Mechanisms of disease: pathogenesis of Crohn's disease and ulcerative colitis.". Nat Clin Pract Gastroenterol Hepatol. 3 (7): 390–407. PMID 16819502. doi:10.1038/ncpgasthep0528. 
  11. Sipponen P (1989). "Atrophic gastritis as a premalignant condition.". Ann Med. 21 (4): 287–90. PMID 2789799. 
  12. Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease.". World J Gastrointest Pharmacol Ther. 5 (3): 105–12. PMC 4133436Freely accessible. PMID 25133039. doi:10.4292/wjgpt.v5.i3.105. 
  13. Ramakrishnan K, Salinas RC (2007). "Peptic ulcer disease.". Am Fam Physician. 76 (7): 1005–12. PMID 17956071. 
  14. Banasch M, Schmitz F (2007). "Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors.". Wien Klin Wochenschr. 119 (19-20): 573–8. PMID 17985090. doi:10.1007/s00508-007-0884-2. 
  15. Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM (2005). "Gastric adenocarcinoma: review and considerations for future directions.". Ann Surg. 241 (1): 27–39. PMC 1356843Freely accessible. PMID 15621988. 
  16. Ghimire P, Wu GY, Zhu L (2011). "Primary gastrointestinal lymphoma.". World J Gastroenterol. 17 (6): 697–707. PMC 3042647Freely accessible. PMID 21390139. doi:10.3748/wjg.v17.i6.697. 
  17. Thirlby RC. Gastrointestinal lymphoma: a surgical perspective. Oncology (Huntingt). 1993;7:29-32.
  18. NEJM article
  19. Cogliatti SB, Schmid U, Schumacher U, Eckert F, Hansmann ML, Hedderich J, Takahashi H, Lennert K (1991). "Primary B-cell gastric lymphoma: a clinicopathological study of 145 patients". Gastroenterology. 101 (5): 1159–70. PMID 1936785. 
  20. Muller AF, Maloney A, Jenkins D, Dowling F, Smith P, Bessell EM, Toghill PJ (1995). "Primary gastric lymphoma in clinical practice 1973-1992". Gut. 36 (5): 679–83. PMC 1382669Freely accessible. PMID 7797116. 
  21. Hauptrock B, Hess G (2008). "Rituximab in the treatment of non-Hodgkin's lymphoma". Biologics. 2 (4): 619–33. PMC 2727901Freely accessible. PMID 19707443. 
  22. Morgner A, Schmelz R, Thiede C, Stolte M, Miehlke S (2007). "Therapy of gastric mucosa associated lymphoid tissue lymphoma". World J. Gastroenterol. 13 (26): 3554–66. PMC 4146794Freely accessible. PMID 17659705. 



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