Editing Gastric lymphoma


== '''Classification''' ==

* Described as primary gastric     lymphoma if the stomach is the exclusive or predominant site of disease
*

== '''Epidemiology''' ==

* Stomach is most common     extra-nodal site of lymphoma
* Overall accounts for 3% of     gastric cancers

== '''Risk factors''' ==

* Peak incidence 50-60yo
* Slight male predominance
* H. pylori infection
* Rheumatoid arthritis
* SLE
* Immunosuppression
* Coeliac disease

== '''Pathophysiology''' ==

* Diffuse large B cell lymphoma     - '''DLBCL''' (45-60%)
** Generally primary lesions,      but can also occur as progression from less aggressive lymphomas such      CLL, small lymphocytic lymphoma, follicular lymphoma, or MALT lymphoma
** Associated with      immunodeficiency and H. pylori infection
** Fairly high-grade
* Gastric Mucosa-Associated     Lymphoid Tissue ('''MALT''') lymphoma (40-50%)
** Lower grade than DLBCL
** B cell lineage
** Usually preceded by H.      pylori gastritis (in almost all cases). B cells are chronically activated      in stomach, forming a MALToma, which can transform into lymphoma.
** Characterised by      translocations at:
*** T(1;14)
*** T(3;14)
*** T(11;18)
*** T(14;18)
* Peripheral T cell lymphoma     (1-4%)
* Mantle cell lymphoma (<1%)
* Follicular lymphoma (<1%)
* Usually occurs in gastric     antrum, but can arise from anywhere

== '''Presentation''' ==

* Vague symptoms
** Epigastric pain
** Early satiety
** Fatigue
** B symptoms - only about 10%      of patients

== '''Workup''' ==

* Endoscopy
** Biopsy is indicated for all      patients
** Test for H. pylori (probably      need to also confirm with serologic testing)
** EUS can be used to determine      depth of invasion and evaluate for lymph node involvement
* Upper airway examination
** Look for distant disease -      Waldeyer tonsillar ring
* Bone marrow biopsy
* CT chest/abdo/pelvis
** Routine staging
* PET/CT (FDG)
** Dependent on subtype
** Usually done for DLBCL      staging

== '''Staging''' ==

== '''Treatment''' ==

* Chemotherapy
** Most commonly R-CHOP
** Associated with a 5% rate of      gastric perforation and GI bleeding
* Indications for surgery
** Symptomatic recurrence after      treatment failure
** Complications (bleeding,      gastric outlet obstruction, perforation)
* MALT
** Must evaluate for H. pylori      infection
** Early-stage MALT and active      H. pylori infection may be treated by eradication alone - successful      eradication results in remission for 75%, but need repeat endoscopy in 2      months and 6 monthly endoscopy for 3 years to document regression
** Predictors of failure from      eradication alone:
*** Trans-mural tumour       extension
*** Nodal involvement
*** Transformation into a large       cell phenotype
*** Nuclear BCL-10 expression
** MALT and H. pylori negative:
*** Consider radiotherapy if       all involved sites can be encompassed in a single field
*** Otherwise chemotherapy
** Risk factors for poor      prognosis:
*** Age >=70
*** Stage IV disease
*** Elevated LDH
*** 5 year survival of 98.7%       for no risk factors, 93.1% for one risk factor and 64.3% for two or       three risk factors

[[Category:UGIS]]