Difference between revisions of "Gastric lymphoma"

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==Overview==
 
==Overview==

Revision as of 21:08, 3 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Mazia Fatima, MBBS [2]

Overview

Primary gastric lymphoma (lymphoma that originates in the stomach itself)[1] is an uncommon condition, accounting for less than 15% of gastric malignancies and about 2% of all lymphomas. However, the stomach is a very common extranodal site for lymphomas (lymphomas originating somewhere else with metastasis to stomach)[2]; it is also the most common source of lymphomas in the gastrointestinal tract[3]

Primary Gastric Lymphoma

Endoscopic image of gastric MALT lymphoma taken in body of stomach in patient who presented with upper GI hemorrhage. Appearance is similar to gastric ulcer with adherent clot.

Clinical presentation

Primary gastric lymphoma usually affects the elderly (with peak incidence in the sixth decade of life)[4] and presenting symptoms include epigastric pain, early satiety, fatigue and weight loss.

Diagnosis

These lymphomas are often difficult to differentiate from gastric adenocarcinoma. The lesions are usually ulcers with a ragged, thickened mucosal pattern on contrast radiographs.

The diagnosis is typically made by biopsy at the time of endoscopy. Several endoscopic findings have been reported, including solitary ulcers, thickened gastric folds, mass lesions and nodules. As there may be infiltration of the submucosa, larger biopsy forceps, endoscopic ultrasound guided biopsy, endoscopic submucosal resection, or laparotomy may be required to obtain tissue.

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.

Histopathology

The majority of gastric lymphomas are non-Hodgkin's lymphoma of B-cell origin. These tumors may range from well-differentiated, superficial involvements (MALT) to high-grade, large-cell lymphomas.

Other lymphomas involving the stomach include mantle cell lymphoma and T-cell lymphomas which may be associated with enteropathy; the latter usually occur in the small bowel but have been reported in the stomach.

Risk Factors

Risk factors for gastric lymphoma include the following:

Differential Diagnosis

Gastric lymphoma must be differentiated from:[6][7][8][9][10][11][12][13][14]

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
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
Primary gastric lymphoma - - - - - ? - - Useful in collecting the tissue for biopsy Other symptoms


Treatment

Diffuse large B-cell lymphomas of the stomach are primarily treated with chemotherapy with CHOP with or without rituximab being a usual first choice.

Antibiotic treatment to eradicate H. pylori is indicated as first line therapy for MALT lymphomas. About 60% of MALT lymphomas completely regress with eradication therapy [15]. Second line therapy for MALT lymphomas is usually chemotherapy with a single agent, and complete response rates of greater than 70% have gain been reported [16].

Subtotal gastrectomy, with post-operative chemotherapy is undertaken in refractory cases, or in the setting of complications, including gastric outlet obstruction.

References

  • Fauci, et al. Harrison's Principles of Internal Medicine,16th Ed.

Notes

  1. Dawson IMP, Cornes JS, Morrison BC. Primary malignant lymphoid tumours of the intestinal tract. Br J Surg. 1961;49:80-89.
  2. Aisenberg AC. Coherent view of non-Hodgkin's lymphoma. J Clin Oncol. 1995;13:2656-2675.
  3. Koch P et al. 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 2001 Sep 15;19(18):3861-73.
  4. Thirlby RC. Gastrointestinal lymphoma: a surgical perspective. Oncology (Huntingt). 1993;7:29-32.
  5. NEJM article
  6. 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. 
  7. 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. 
  8. 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. 
  9. Sipponen P (1989). "Atrophic gastritis as a premalignant condition.". Ann Med. 21 (4): 287–90. PMID 2789799. 
  10. 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. 
  11. Ramakrishnan K, Salinas RC (2007). "Peptic ulcer disease.". Am Fam Physician. 76 (7): 1005–12. PMID 17956071. 
  12. 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. 
  13. 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. 
  14. 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. 
  15. Bayerdorffer E et al., Regression of primary gastric lymphoma of mucosa-associated lymphoid tissue type after cure of Helicobacter pylori infection. MALT Lymphoma Study Group, Lancet 1995 Jun 24;345(8965):1591-4.
  16. Hammel P et al. Efficacy of single-agent chemotherapy in low-grade B-cell mucosa-associated lymphoid tissue lymphoma with prominent gastric expression. J Clin Oncol 1995 Oct;13(10):2524-9.



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