| Abstract|| |
Objectives: The aim of this study is to determine the clinico-pathological features of primary gastrointestinal non-Hodgkin's lymphoma (GI NHL) at King Abdulaziz University Hospital, Jeddah, and to compare our results to those reported in the literature. Materials and Methods: Twenty-three adult patients with primary GI NHL diagnosed over a 5-year period (2000 through 2005) were retrospectively studied clinically and histopathologically. They were classified using the REAL/WHO histopathologic classification. Results: Of the 23 patients with primary GI NHL, 14 (60.9%) were Saudis, with a male-to-female ratio of 1.3:1. The mean age of male patients was 61. 3 years, ranging from 42-83 years with an SD of ±13.09; while for females, the mean age was 64 years, ranging from 50-75 years with an SD of ±9.14. Abdominal pain was the most common presenting symptom (78.3%), and the most common primary site was the stomach (73.9%), followed by the small bowel (13%). The most frequent histologic subtype was the diffuse large B cell lymphoma, accounting for 60.9% of all cases, followed by the marginal-zone cell lymphoma (MALT type), which was Helicobacter pylori associated (39.1%). A large proportion of patients with primary GI NHL had early disease (Stage IE - 20%, Stage IIE - 58.6%). With regards to treatment, 15 patients (65.2%) had chemotherapy, while only 2 patients (8.7%) were treated by Helicobacter pylori eradication. The overall 5-year survival was 47.8%. Conclusion: The data demonstrated that primary GI NHL is more common among males, mainly in their sixth decade. Abdominal pain is the most common presenting symptom, with stomach being the most common involved site. Diffuse large B cell lymphoma is the most frequent histologic subtype, followed by extranodal marginal-zone B cell lymphoma (MALT type), which was Helicobacter-associated. A majority of cases have early disease (stage IE and IIE), mostly treated by combination chemotherapy.
Keywords: Epidemiology, histopathology, primary GI NHL
|How to cite this article:|
Al-Sayes FM. Gastrointestinal Non-Hodgkin's lymphoma: A clinico-pathological study. Saudi J Gastroenterol 2006;12:118-22
The gastrointestinal (GI) tract is the predominant site of extranodal non-Hodgkin's lymphoma (NHL). It accounts for about one-third of all primary extranodal NHLs but only 1 to 4% of malignancies arising in the GI.
The rarity of primary GI NHL (0.8 to 1.2 cases per 100,000 persons per year) lends itself feasibility mainly for retrospective studies reporting only small patient numbers or for studies that have been conducted over periods of up to two decades or more. Despite their rarity, primary NHLs of the GI tract are important since their epidemiologic features, staging, histologic classification and management are distinct from that of primary extranodal lymphomas. Primary GI NHL can be operationally defined as lymphoma in which the main bulk of the disease is confined to the GI tract, necessitating treatment directed towards that site. The mucosa-associated lymphoid tissue (MALT) published by Isaacson et al., revolutionized the concept of the pathogenesis of primary GI NHL and suggested that lymph node based classification system may not be fully applicable. MALT lymphomas tend to occur in order of frequency in the stomach, small bowel, ileocecal area, colon and the esophagus.
Epidemiologic studies support a strong association between MALT-type NHL and chronic Helicobacter pylori infection. The most dramatic evidence supporting a pathogenetic role for H. pylori in MALT-type NHL is remission of the tumor following eradication of H. pylori with antibiotic therapy.
The aim of the current study is to analyze the clinico-pathological features of primary GI NHL at King Abdulaziz University Hospital (KAUH), Jeddah. Our results will be compared to those reported in the literature.
| Materials and methods|| |
A total of 23 cases of adult patients with primary GI NHL diagnosed at KAUH over a 5-year period (2000 through 2005) were studied retrospectively. Medical records of all patients were reviewed, and clinical and pathological information was recorded in a structured questionnaire form. Primary GI NHLs were defined according to Lewin et al. The laboratory and radiological work-up included complete blood count, creatinine, liver enzymes, lactate dehydrogenase, uric acid, chest X-ray, computed tomography of chest and abdomen, bone marrow biopsy and endoscopic evaluation with multiple biopsies of the upper and lower GI tract.
Histology and immunohistochemistry
Tissue sections were obtained from formalin-fixed paraffin blocks and stained with hematoxylin and eosin. Special stains such as Periodic Acid-Schiff and reticulin stain were used in selected cases whenever indicated. Each biopsy was investigated immunohistochemically by staining for leukocyte common antigen, CD20, CD79, CD3 and CD45. Additionally, Helicobacter pylori were demonstrated using either fast cresyl violet or Giemsa stain.
Clinical staging and histopathologic classification
Patients were staged according to the Ann Arbor classification in its modification by Musshoff. Histopathologic classification was done using the current REAL/WHO classification.
Statistical analysis was done using SPSS version 10.
| Results|| |
From the year 2000 through 2005, 23 patients with primary GI NHL were accrued to the study; 14 (60.9%) were Saudis and 9 (39.1%) were non-Saudis. Thirteen patients were males (56.5%), while 10 were females (43.5%). The male-to-female ratio was 1.3:1. The mean age for males was 61.3 years, ranging from 42-83 years with an SD of ± 13.09; and for females, the mean age was 64 years, ranging from 50-75 years with an SD of ± 9.14.
Abdominal pain was the most common presenting symptom (78.3%), followed by abdominal mass (21.7%). The most common primary site was the stomach (73.9%), followed by the small bowel (13%). The third largest group was lymphoma originating in the colon (8.7%), followed by those of the mesentery (4.4%).
Characteristic features of patients with primary GI NHL are summarized in [Table - 1].
'B' symptoms occurred in 60.9% of the cases. Median time from onset of symptoms to diagnosis was 180 days. Lactate dehydrogenase level, which is an important prognostic factor at least in high-grade NHL, was elevated in approximately 17.4% of all patients. Normocytic normochromic anemia was seen in 56.5%. Other laboratory tests, including white blood cell, platelet count, uric acid level, creatinine and liver enzymes, were normal; majority of these patients also had positive 'B' symptoms (72.7%). The most frequent histologic subtype was the diffuse large B cell lymphoma, accounting for 60.9% of all cases; followed by MALT-type lymphoma (39.1%), which corresponds to the marginal-zone cell lymphoma in the REAL/WHO classification.
All marginal-zone cell lymphomas (MALT type) were of gastric origin. In two (8.7%) cases of the diffuse large B cell lymphoma, a simultaneous low-grade MALT-type component count is demonstrated. Helicobacter pylori bacilli ( H. pylori ) could be identified on histologic sections in all the nine cases (39.1%); the serologic test for H. pylori was available only for five cases, which was positive. GI endoscopy revealed that mass or filling defect was seen in 80% of cases, followed by ulcerated lesions and diffuse thickening of the mucosa in 15 and 5% of cases respectively. According to a modified staging classification, a larger proportion of patients with GI lymphoma had early disease (Stage IE - 20%, stage IIE - 58.6%), while stages IIIE and IVE accounted for 4 and 17.4% respectively.
With regards to treatment, five (21.7%) had gastrectomy followed by chemotherapy, and one (4.3%) received multimodality treatment in the form of gastrectomy and chemotherapy followed by radiotherapy. Fifteen patients (65.2%) had chemotherapy only, and the remaining patients two (8.7%) were treated with Helicobacter pylori eradication. The mean follow-up for all cases was 42.2 months. The overall 5-year survival was 47.8%. Outcome in patients with primary GI NHL in relation to histology is shown in [Table - 2].
| Discussion|| |
NHL constitutes a group of disorders originating from the malignant transformation of lymphocytes and involving either the lymph nodes or extranodal sites. Extranodal lymphomas may comprise 24-48% of NHL cases, and there appears to be an increasing incidence of these lymphomas during the past decades. Primary GI NHL is a heterogenous disease with regards to patients' characteristics, stage, histologic subtypes and treatment results. The results from the current study indicate that percentage of non-Saudi patients was 43.5%. Males were more than females with male-to-female ratio of 1.3:1. This figure is lower than what has been reported from Jordan and the West but is close to the ratio reported from Thailand and China.
The peak age of our patients was in the sixth decade, which is older than the age group of a previous study from the Kingdom of Saudi Arabia. The GI NHL diagnosis is rarely suspected because of the nonspecific presenting symptoms and signs. Abdominal pain tends to be the predominant symptom, occurring in up to 93% of patients. In our patients with GI NHL, abdominal pain was the most common symptom at presentation, followed by abdominal mass - in 78.3 and 21.7% respectively. The high incidence of gastrointestinal bleeding seen in GI NHL was not a manifesting complaint of our patient population.
Primary gastric lymphoma accounts for 3% of gastric neoplasms and 10% of lymphomas. The stomach is the most common extranodal site of lymphoma and is also the most common site of GI NHL. Gastric lymphoma can arise from mucosal areas, the so-called marginal-zone lymphoma of MALT type. Diffuse large B cell lymphoma may also arise within the stomach as a primary lesion (previously called 'high-grade' MALT lymphoma. In our patients, the sites of involvement were the stomach (73.9%), small bowel (13%), colon (8.7%), followed by the mesentery (4.4%). These results were similar to previous results from KSA, Bahrain, United Arab Emirates, Jordan, Thailand, China, Japan and the West. The situation is likely to be quite different in Mediterranean countries, where the problem of immunoproliferative small intestinal disease is common. The duration of symptoms is often long; in our series, median time from onset of symptoms to diagnosis was 180 days. This delay in presentation is because the diagnosis is rarely suspected, due to the nonspecific symptoms of GI NHL. Diffuse large B cell lymphoma is the commonest histologic subtype of GI NHL in most of the series.,,,,, It involves MALT sites. It is characterized by the presence of blast cells in excess of 20% or more. These patients tend to have more systemic symptoms and an advanced stage at diagnosis. In the current study of patients with diffuse large B cell lymphoma, interestingly 'B' symptoms occurred in 60.9% of the cases; 56.5% of these were among the diffuse large B cell lymphoma. Extranodal marginal-zone B cell lymphoma (MALT type) has been linked to clonal expansion of B cells that accompanies chronic gastritis in the presence of Helicobacter pylori infection. It accounts for about 40-50% of GI NHL. In our study, marginal-zone B cell lymphoma (MALT type) occurred in 39.1% of all cases; all of them were Helicobacter pylori positive on the histologic section. These findings are similar to previous studies.,, All the GI NHLs in this study were of B cell origin. One explanation for the high frequency of B cell lymphoma might be the fact that B cell undergoes clonal expansion during proliferation in the microenvironment of the germinal center. It appears that B cell lymphoma often needs stimulation that involves the antigen receptor or other receptors on the surface of the lymphoma cells. It could be that the stimulus is the same in the different sites of origin of B cell lymphoma. Upper and lower gastrointestinal endoscopy is very useful in the diagnosis of GI NHL. Our cases showed masses or filling defects in 80% of the cases, followed by ulcerated lesions (15%) and diffuse thickening of the mucosa (5%) - unlike a previous study from Saudi Arabia, where superficial and/or multicentric ulceration of the gastrointestinal mucosa was the most frequent endoscopic feature. At presentation (78.6%), our patients had Stage IE and IIE. Two authors reported 87, and 89%, which is comparable to our data.
Treatment strategies in GI NHL are debatable, particularly in gastric lymphoma. Surgery, radiotherapy and chemotherapy have been used alone or in various combinations. However, chemotherapy possesses the advantage of preserving gastric anatomy. Radiotherapy alone has been tried and showed good results. Stage IIIE, IVE disease treatment is solely by chemotherapy, and surgical resection has been a remote consideration. The association of marginal-zone B cell lymphoma (MALT type) with H. pylori has been dramatically demonstrated by regression of gastric MALT lymphoma following treatment aimed at eradicating H. pylori . Complete histologic regression has been demonstrated in 50 to 80% of carefully selected patients. For instance, patients with localized stage IE mucosal disease are candidates for anti- H. pylori therapy. It is estimated that less than 10% of patients with gastric lymphoma are in this category, as the majority have aggressive histology (i.e., diffuse large B cell lymphoma), extensive mural involvement or advanced stage (stage IIE to IV). In the current study, 8.7% only were treated by Helicobacter pylori eradication; in the two patients who were early Stage IE, remission was achieved and they are still under observation. Combination chemotherapy is usually reserved for patients failing or recurring after other less aggressive therapies, those with advanced stage disease (i.e., stages IIE-VI) and those with diffuse large B cell lymphoma. The original concern that chemotherapy in patients with involvement of the stomach might lead to gastric perforation and/or bleeding has not been confirmed in a number of comparative studies., In this series, 21.7% had gastrectomy before chemotherapy, and 4.3% received radiotherapy in addition to surgery and chemotherapy. Majority of our patients (65.2%) were treated by chemotherapy (anthracyclin-containing regimen). Since our study is retrospective and the number of patients is small, conclusion about treatment efficacy should be made with caution.
| Conclusion|| |
The current study showed that primary GI NHL is commoner among males than females, the peak age being in the sixth decade. Abdominal pain is the most common presenting symptom. Median time from onset of symptoms to diagnosis is 180 days. This delay in diagnosis is expected since the disease has very nonspecific complaints. Gastric NHL accounted for the majority. Diffuse large B cell lymphoma represents the most common histologic subtype, followed by extranodal marginal-zone B cell lymphoma (MALT type) and Helicobacter pylori associated lymphoma, in that order. At presentation, 78.6% of the cases had early stages. Anthracyclin-containing regimen is the frequently used treatment modality.
The data presented here is an approximate assessment of the epidemiological features of primary GI NHL. Further studies, together with national cancer registry data, will probably make attempts to identify epidemiology and risk factors for primary GI NHL, which are needed to undertake definite preventive and therapeutic measures. Moreover, it would be interesting to define the molecular background of this group of malignancy among our patients.
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Fatin M Al-Sayes
Department of Haematology, King Abdulaziz University Hospital, P.O. Box 80215, Jeddah - 21589
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2]