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ESSENTIALS OF DIAGNOSIS
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ESSENTIALS OF DIAGNOSIS
Symptoms of dyspepsia, weight loss, or anemia.
Distinguish primary gastric lymphoma with adjacent nodal spread from advanced systemic lymphoma with secondary gastric lymphoma involvement.
Upper GI series or endoscopy shows thickened folds, ulcer, mass, or infiltrating lesions; diagnosis established by endoscopic biopsy.
Abdominal CT and EUS required for staging.
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GENERAL CONSIDERATIONS
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Gastric lymphomas may be primary (arising from the gastric mucosa) or may represent a site of secondary involvement in patients with nodal lymphomas. Distinguishing advanced primary gastric lymphoma with adjacent nodal spread from secondary gastric lymphoma spread from advanced nodal lymphoma is essential because the prognosis and treatment of primary and secondary gastric lymphomas are different. Primary gastric lymphoma is the second most common gastric malignancy, accounting for 3–5% of gastric cancers. More than 95% of these are non-Hodgkin B-cell lymphomas mainly consisting of either (1) mucosa-associated lymphoid tissue (MALT)-type lymphoma; or (2) MALT)-type lymphoma; or diffuse large B-cell lymphoma; or, rarely, (3) gastric T-cell lymphoma. Over 90% of low-grade primary gastric MALT-type lymphomas are associated with H pylori infection. H pylori leads to chronic inflammation, producing lymphoid tissue in the stomach mucosa (MALT) that can lead to malignant transformation. Gastric T-cell lymphoma, which is associated with HTLV-1 infection makes up 7% of primary gastric lymphomas.
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CLINICAL FINDINGS & STAGING
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The clinical presentation and endoscopic appearance of gastric lymphoma are like those of adenocarcinoma. Most patients have abdominal pain, weight loss, or bleeding. Patients with diffuse large B-cell lymphoma are more likely to have systemic symptoms.
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At endoscopy, lymphoma may appear as an ulcer, mass, or diffusely infiltrating lesion. It tends to have horizontal infiltration as opposed to the vertical extension seen in adenocarcinoma. The diagnosis is established with endoscopic biopsy; FNA biopsy is not adequate. Since the disease can be multifocal, biopsies of both suspicious and normal-appearing areas are recommended. Biopsy specimens should be tested for H pylori and, if positive, for t(11;18) via PCR or FISH. EUS is the most sensitive test for determining the depth of invasion and presence of perigastric lymphadenopathy. All patients should undergo staging with CT scanning of chest, abdomen, and pelvis.
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For gastric MALT lymphomas, the Lugano staging system is most frequently used. Stage I is confined to the GI tract, stage II involves local or regional lymph nodes, stage IIE has invasion of adjacent organs or tissues, and stage IV has distant metastases. There is no stage III.
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Diffuse large B-cell lymphomas
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For patients with diffuse large B-cell lymphomas involving the stomach, combination PET-CT imaging, bone marrow biopsy with aspirate, tumor lysis laboratory tests, and hepatitis B and HIV serologies may be required for staging and treatment planning (see Chapter 13). Diffuse large B-cell lymphomas more likely present at ...