Guidelines on Diagnosis and Treatment of Malignant Lymphomas
Guidelines on Diagnosis and Treatment of Malignant Lymphomas
Guidelines on Diagnosis and Treatment of Malignant Lymphomas
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Recommended Investigati<strong>on</strong>s<br />
As for other indolent B-cell lymphomas. Additi<strong>on</strong>al investigati<strong>on</strong>s<br />
recommended for patients with Gastric MALT lymphomas are:<br />
■<br />
■<br />
Biopsy with H pylori stain <strong>and</strong> culture<br />
(H pylori serology may be useful if infecti<strong>on</strong> is not<br />
c<strong>on</strong>firmed histologically)<br />
Urea breath test<br />
Endoscopic Ultrasound may be useful but is not universally<br />
available. The t(11;18) status should be established.<br />
Prognostic Factors / Index<br />
The clinical course is typically indolent, <strong>and</strong> these lymphomas<br />
are slow to disseminate. Involvement <strong>of</strong> multiple extranodal<br />
sites <strong>and</strong> b<strong>on</strong>e marrow involvement do not appear to c<strong>on</strong>fer a<br />
worse prognosis.<br />
Adverse prognostic factors identified for Gastric MALT<br />
lymphomas include:<br />
■<br />
H.pylori negative<br />
■<br />
■<br />
Failure to distinguish from other c<strong>on</strong>diti<strong>on</strong>s. The differential<br />
diagnosis includes reactive processes (Helicobacter pylori<br />
gastritis, lymphoepithelial sialadenitis, Hashimoto’s thyroiditis),<br />
<strong>and</strong> other small B-cell lymphomas (follicular lymphoma,<br />
mantle-cell lymphoma, small lymphocytic lymphoma).<br />
Ann Arbour staging is misleading – for example, involvement<br />
<strong>of</strong> multiple extranodal sites, especially within the same organ<br />
(e.g., salivary gl<strong>and</strong>, skin, GI tract) does not indicate<br />
disseminated disease.<br />
<strong>Treatment</strong><br />
Gastric MALT Lymphoma:<br />
Limited disease:<br />
For disease c<strong>on</strong>fined to the mucosa or submucosa, H. Pylori<br />
eradicati<strong>on</strong> produces complete remissi<strong>on</strong> rates <strong>of</strong> approximately<br />
70%. There is no clinical trial evidence to support the use <strong>of</strong><br />
c<strong>on</strong>solidati<strong>on</strong> Chlorambucil therapy for patients with successful<br />
H.pylori eradicati<strong>on</strong><br />
■<br />
■<br />
■<br />
■<br />
Tumour invasi<strong>on</strong> bey<strong>on</strong>d the submucosa<br />
t(1;14)(p22;q21)<br />
t(11;18)(q21;q21) - this translocati<strong>on</strong> does not<br />
resp<strong>on</strong>d to H pylori eradicati<strong>on</strong><br />
Bcl-10 nuclear expressi<strong>on</strong><br />
Various effective regimens for H Pylori Eradicati<strong>on</strong> are available.<br />
One is:<br />
■<br />
■<br />
■<br />
Omeprazole 20mg po bid x 1 week<br />
Amoxycillin 1g po bid x 7 days<br />
Clarithromycin 500mg po bid x 7 days<br />
Potential Pitfalls<br />
■ Failure to properly identify diffuse large B cell lymphoma<br />
in the presence <strong>of</strong> an accompanying MALT lymphoma<br />
or to distinguish from de novo gastric diffuse large<br />
B Cell lymphoma.<br />
■<br />
Metr<strong>on</strong>idazole 400 mg po bid x 7 days<br />
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