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Department of Medicine –Hematology and Oncology, Westfälische-Wilhelms-Universität, Münster, Germany

Normann A. Willich, Gabriele Reinartz

Radiation Oncology, Westfälische-Wilhelms-Universität, Münster, Germany

Wolfgang E. Berdel

Department of Medicine –Hematology and Oncology, Westfälische-Wilhelms-Universität, Münster, Germany

Wöhrer et al address two important questions: (1) is there a standard for treatment of primary gastric lymphomas (PGL), and (2) what are the options to reach such a standard?

In two consecutive prospective studies, we have documented that surgery, in contrast to proposals by others,^1,2 should no longer be standard in the treatment strategy for PGL.^3,4 This was further supported by randomized studies.^5,6

We have also addressed the question of how to improve treatment, particularly in indolent lymphomas, by decreasing the volume of radiation. This proved to be feasible as reported in a first interim analysis at last year's Lugano meeting.⁷ Wöhrer et al suggested to assess quality of life by using questionnaires, which we did not, but we have analyzed acute and late toxicity according to standard procedures, which documented less measurable adverse effects along with reduction of treatment intensity.⁸ Consequently a further reduction in radiation volume was introduced in our ongoing third study. This might lead to a standard in treating indolent PGL, though others advise lower doses for radiation published in small series.^9,10

Whereas antibiotic treatment of Helicobacter pylori, which was carried out in our study, is considered a standard in stage I marginal zone B-cell lymphoma (MZZL), Wöhrer et al address the question of this treatment in aggressive H pylori–positive PGL. Although in the articles cited complete remissions were reported, the number of patients was small and the time of observation short. Therefore, this kind of treatment needs further evaluation. However, we agree that in case of H pylori infection, antibiotic therapy should be part of the treatment strategies as in our ongoing study.

Further, Wöhrer et al questioned our concept using combined chemo-/radiotherapy for aggressive PGL. The rationale for this approach is the simultaneous occurrence of low-grade components in diffuse large B-cell PGL, which occurred in up to one third of patients in our series,¹¹ and which is highly dependent on the number of biopsies taken. We observed that these components were still seen after CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) therapy, whereas the large blastic cells had disappeared. Only after additional radiotherapy could a complete remission be diagnosed. Aviles et al have excluded this type of lymphoma from evaluation; therefore, their study does not contradict with our view. For these reasons our study group recommends combined chemo-/radiotherapy for aggressive PGL.

We agree with Wöhrer et al that further studies testing other approaches are required before a standard can be defined. In our current study, for indolent lymphoma we aim for reducing radiation toxicity, and for aggressive PGL for reducing CHOP chemotherapy from six to four cycles in combination with rituximab followed by radiation.

Authors' Disclosures of Potential Conflicts of Interest

Although all authors completed the disclosure declaration, the following authors or their immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

Authors Employment Leadership Consultant Stock Honoraria Research Funds Testimony Other Wolfgang E. Berdel Amgen Inc (B); Merck & Co (B); Astra Zeneca (A) Amgen Inc (B); Merck & Co (B); Astra Zenaca (A) Amgen Inc (B) Astra Zeneca (A)

Dollar Amount Codes (A) < $10,000 (B) $10,000-99,999 (C) $100,000 (N/R) Not Required

ACKNOWLEDGMENTS

Supported in part by Amgen and Hoffmann-LaRoche AG, Germany.

REFERENCES

1. Brands F, Mönig SP, Raab M: Treatment and prognosis of gastric lymphoma. Eur J Surg 163:803-813, 1997[Medline]

2. Fischbach W, Dragosics B, Kolve Gobeler ME, et al: Primary gastric B-cell-lymphoma: Results of a prospective multicenter study. Gastroenterology 119:1191-1202, 2000[CrossRef][Medline]

3. Koch P, del Valle F, Berdel WE, et al: Primary gastrointestinal non-Hodgkin's lymphoma II: Combined surgical and conservative or conservative management only in localized gastric lymphoma—Results of the prospective German multicenter study (GIT NHL 01/92). J Clin Oncol 19:3874-3883, 2001[Abstract/Free Full Text]

4. 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 28:7050-7059, 2005[CrossRef]

5. 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]

6. 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]

7. Liersch R, Berdel W, Willich N, et al: Reduction of treatment in localized indolent primary gastric lymphoma (PGL): Results of two prospective studies GIT NHL 01/92 + 02/96. Ann Oncol 16:93, 2005 (suppl 5; abstr 1193)

8. Reinartz G, Willich N, Koch P: Radiotherapy in patients with primary gastrointestinal lymphomas [in German]. Chir Gastroenterol 18:53-59, 2002[CrossRef]

9. Schechter NR, Portlock CS, Yahalom J: Treatment of mucosa-associated lymphoid tissue lymphoma of the stomach with radiation alone. J Clin Oncol 16:1916-1921, 1998[Abstract]

10. Tsang RW, Gospodarowicz M, Pintilie M, et al: Stage I and II MALT lymphoma: Results of treatment with radiotherapy. Int J Radiat Oncol Biol Phys 50:1958-1964, 2001

11. Koch P, del Valle F, Berdel WE, et al: Primary gastrointestinal non-Hodgkin's lymphoma I: Anatomical and histological distribution, clinical features, and survival data of 371 patients registered in the German Multicenter Study (GIT NHL 01/92). J Clin Oncol 19:3861-3873, 2001[Abstract/Free Full Text]

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