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Treatment of Localized Primary Gastric Lymphoma

Division of Bone Marrow Transplantation, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria

Marlene Troch, Markus Raderer

Division of Oncology, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria

To the Editor:

The article "Treatment Results in Localized Primary Gastric Lymphoma: Data of Patients Registered Within the German Multicenter Study (GIT NHL 02/96)" by Koch et al,¹ although being performed in a nonrandomized fashion, again impressively demonstrates that surgery should not have a part in the management of primary gastric lymphoma (PGL) except for emergencies. In addition, the authors set out to reduce treatment intensity to improve quality of life for the patients without compromising the results achieved so far in their analysis. Although—to put it in military terms—the quantity of patients and data have a quality of their own, we think that still some highly intriguing questions for treatment of PGL remain.

Firstly, the approach of using reduced doses of chemotherapy and radiation apparently would result in improved quality of life. However, this is hard to demonstrate on formal grounds in the absence of standardized assessment using suitable questionnaires or analyzing adverse effects of the different treatment modalities.

Secondly, the authors stated that they wanted to reduce toxicity by using antibiotic treatment of Helicobacter pylori for qualified patients (marginal zone cell lymphoma stage I patients, positive proof of H pylori). This would imply that they have not used antibiotic treatment in patients with H pylori infection and diffuse large B-cell lymphoma (DLBCL). Because it was recently shown that patients with DLBCL of the stomach also respond to H pylori eradication,^2,3 it would be reasonable to eradicate H pylori in all patients with PGL. In view of this, more details about patients treated with antibiotic therapy and the criteria used to determine initiation of chemotherapy and/or radiotherapy would be extremely useful.

Finally, the authors cited two studies by Aviles et al^4,5 that also show that surgery is not necessary for management of PGL. In addition, however, both of these trials suggest in a randomized fashion that the outcome of patients not receiving radiation therapy is not worse than for those undergoing combined-modality treatment. In addition to phase II studies with chemotherapy as sole management for DLBCL of the stomach,^6-8 which have resulted in excellent outcome, these highly important data raise the provocative question whether radiation therapy is indeed necessary for patients with gastric lymphoma, especially DLBCL achieving complete response with chemotherapy alone. Although no detailed results of adverse effects resulting from radiation are given in the analysis by Koch et al,¹ one might speculate that omission of radiation might greatly improve quality of life in patients with gastric lymphoma, should future trials confirm noninferiority of chemotherapy alone over chemotherapy plus radiation. Therefore, trials including H pylori eradication also for gastric DLBCL are warranted, as are further studies to define the role of radiation (or probably its absence) in PGL in a randomized fashion.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Koch P, Probst A, Berdel WE, et al: Treatment results in localized primary gastric lymphoma: Data of patients registered within the German multicenter study (GIT NHL 02/96). J Clin Oncol 23:7050-7059, 2005[Abstract/Free Full Text]

2. Chen LT, Lin JT, Shyu RY, et al: Prospective study of Helicobacter pylori eradication therapy in stage I(E) high-grade mucosa-associated lymphoid tissue lymphoma of the stomach. J Clin Oncol 19:4245-4251, 2001[Abstract/Free Full Text]

3. Morgner A, Miehlke S, Fischbach W, et al: Complete remission of primary high-grade B-cell gastric lymphoma after cure of Helicobacter pylori infection. J Clin Oncol 19:2041-2048, 2001[Abstract/Free Full Text]

4. Aviles A, Nambo MJ, Neri N, et al: The role of surgery in primary gastric lymphoma: Results of a controlled clinical trial. Ann Surg 240:44-50, 2004[CrossRef][Medline]

5. Aviles A, Nambo MJ, Neri N, et al: Mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach: Results of a controlled clinical trial. Med Oncol 22:57-62, 2005[CrossRef][Medline]

6. Raderer M, Valencak J, Osterreicher C, et al: Chemotherapy for the treatment of patients with primary high grade gastric B-cell lymphoma of modified Ann Arbor Stages IE and IIE. Cancer 88:1979-1985, 2000[CrossRef][Medline]

7. Binn M, Ruskone-Fourmestraux A, Lepage E, et al: Surgical resection plus chemotherapy versus chemotherapy alone: Comparison of two strategies to treat diffuse large B-cell gastric lymphoma. Ann Oncol 14:1751-1757, 2003[Abstract/Free Full Text]

8. Wohrer S, Puspok A, Drach J, et al: Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) for treatment of early-stage gastric diffuse large B-cell lymphoma. Ann Oncol 15:1086-1090, 2004[Abstract/Free Full Text]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Wöhrer, S. Articles by Raderer, M. Search for Related Content PubMed PubMed Citation Articles by Wöhrer, S. Articles by Raderer, M. Social Bookmarking                            What's this?