Long-term Outcomes for Anti-Helicobacter Treatment of Localized Gastric MALT Lymphoma
Long-term Outcomes for Anti-Helicobacter Treatment of Localized Gastric MALT Lymphoma
Abstract & Commentary
By William B. Ershler, MD
Synopsis: In a retrospective review of 105 patients treated exclusively with anti-Helicobacter therapy for locally confined gastric MALT lymphoma initial complete responses were achieved in 75% of cases and at a median follow-up of 6.3 years, disease relapse had occurred in only 13.
Source: Stathis A, et al. Long-term outcome following Helicobacter pylori eradication in a retrospective study of 105 patients with localized gastric marginal zone B-cell lymphoma of MALT type. Ann Oncol. 2009;20:1086-1093.
Although gastric lymphomas are relatively uncommon, marginal zone B-cell of the mucosa associated lymphoid tissue (MALT) lymphoma, which account for approximately 50% of the cases,1 is particularly important to recognize because of its association with Helicobacter pylori infection and clinical response to antibiotic therapy.2 Treatment aimed at eradicating Helicobacter pylori infection results in lymphoma remission in most cases. However, it remains to be established how often this approach results in long-term disease control.
To address this, Stathis et al from Switzerland and Italy reviewed the experience of 156 patients with localized gastric MALT lymphoma who had been referred for treatment to their respective institutions. Of these, 105 cases received anti-Helicobacter as exclusive first-line treatment; the outcomes for these patients were analyzed for this report. Of the 156, 105 patients with localized gastric MALT lymphoma were initially treated only with H. pylori eradication regimens. Lymphoma responses were graded using the Wotherspoon score.3
A notable feature of this series was the presence of autoimmune or inflammatory disease in 17% of cases before the diagnosis of MALT lymphoma. Six had thyroiditis, three had rheumatoid arthritis, one had fibromyalgia, one had celiac disease, one had scleroderma, one had temporal arteritis, one had psoriasis, one had sarcoidosis, and one had Raynaud's syndrome. Also, one or more additional tumors were observed in 21 patients (22%), for a total of 26 tumors (13 diagnosed before and 13 after the gastric MALT lymphoma). Twenty-three were solid tumors (seven basal cell and one squamous cell cutaneous carcinomas, three breast, three prostate, three endometrium, one bladder, one non small-cell lung cancer, one renal, one rectal, one melanoma, and one gastric) and three were hematological neoplasms (one Hodgkin's lymphoma, one mantle cell lymphoma, and one follicular lymphoma).
All patients received, as first-line therapy, a combination of antibiotics (amoxicillin and claritromicin in 36%, metronidazole and claritromicin in 24%, amoxicillin and metronidazole in 15%, and others in 16%) and proton pump inhibitors (mostly omeprazole, less commonly pantoprazole or lansoprazole). A second-line antibiotic treatment was given for patients who failed to eradicate the microorganism.
Helicobacter pylori, detected by histology in 81% of cases, was eradicated in all positive patients. Histological regression of the lymphoma was achieved in 78 of 102 assessable patients (76%, 95% confidence interval [CI]: 67% to 84%), with complete remission in 66 and partial remission in 12. At a median follow-up of 6.3 years, histological remission was consistently confirmed in 33 of 74 assessable patients; 13 presented with lymphoma relapse. Only one patient had a distant progression. Transformation to a large-cell lymphoma was seen in two cases. The 5- and 10-year overall survival was 92% (95% CI: 84% to 96%) and 83% (95% CI: 70% to 91%), respectively. Only one patient died of lymphoma after transformation to a high-grade lymphoma.
Commentary
The association of gastric MALT lymphomas with Helicobacter pylori infection has been appreciated for well over a decade, and the supposition that the infection was associated with the pathogenesis of the lymphoma was supported by early observations of regression with antibiotics alone (i.e., without surgery, radiation or cytotoxic chemotherapy). In fact, from prior retrospective series, it is apparent that antibiotics alone resulted in survival figures comparable to the more aggressive approaches.4,5
In the current series, Helicobacter pylori eradication resulted in complete lymphoma remission in the majority of cases and, for the majority, the responses were durable. The relatively long observation period for this study (median follow-up of 6.3 years) provides reassurance that the less aggressive anti-Helicobacter approach was sufficient for disease control and supports this as a standard for initial treatment for those with disease localized to the gastric wall. Furthermore, a watch-and-wait policy appears to be safe in patients with minimal residual disease or histological-only local relapse.
Gastric MALT lymphomas also present an intriguing and important opportunity to examine the pathogenesis of lymphoma, particularly in association with infection. The observation in this series of an association with other chronic inflammatory or autoimmune diseases, and the high incidence of second malignancies, provide significant leads for the exploration of the importance of inflammation and/or immune function on the pathogenesis of lymphoma and other malignancies.
References
1. Koch P, 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. 2005;23:7050-7059.
2. Du MQ, Isaccson PG. Gastric MALT lymphoma: from aetiology to treatment. Lancet Oncol. 2002;3:97-104.
3. Wotherspoon AC, et al. Regression of primary low-grade B-cell gastric lymphoma of mucosa-associated lymphoid tissue type after eradication of Helicobacter pylori. Lancet. 1993;342:575-577.
4. Pinotti G, et al. Clinical features, treatment and outcome in a series of 93 patients with low-grade gastric MALT lymphoma. Leuk Lymphoma. 1997;26:527-537.
5. Thieblemont C, et al. Outcome in relation to treatment modalities in 48 patients with localized gastric MALT lymphoma: a retrospective study of patients treated during 1976-2001. Leuk Lymphoma. 2003;44:257-262.
In a retrospective review of 105 patients treated exclusively with anti-Helicobacter therapy for locally confined gastric MALT lymphoma initial complete responses were achieved in 75% of cases and at a median follow-up of 6.3 years, disease relapse had occurred in only 13.Subscribe Now for Access
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