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Management and long-term follow-up of early stage H. pylori-associated gastric MALT-lymphoma in clinical practice: An Italian, multicentre study

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Abstract

Background/Aim

Data on management and long-term follow-up of Helicobacter pylori-associated MALT-lymphoma in clinical practice are scanty. We evaluate the long-term efficacy of H. pylori eradication on low-grade MALT-lymphoma, and the efficacy of further therapies in refractory patients.

Methods

This study enrolled patients with stages I–II1 MALT-lymphoma and H. pylori infection. H. pylori eradication was attempted in all patients. Patients with lymphoma persistence or progression following H. pylori treatments received further lymphoma treatments. Both 5-year and disease-free survivals were calculated.

Results

Sixty patients (stage I/II1: 50/10) were followed up for a median time of 65 months (range 7–156). H. pylori infection was successfully eradicated in 53 (88.3%) patients following three consecutive therapeutic attempts, and lymphoma regressed in 42 (79.2%) of these patients. Sixteen patients received anti-neoplastic treatments due to either lymphoma persistence or progression, and lymphoma was cured in 14 (87.5%) cases. At follow-up, lymphoma relapsed in 13/42 (30.9%) patients within a median time of 19 months (range 3–41), and all but 1 patient were cured with further therapies. Overall, lymphoma regression was achieved in 56 patients (93.3%). The 5-year and disease-free survivals were 94.7% and 74.6%, respectively.

Conclusions

In clinical practice, a conservative approach with antibiotic eradication seems to be appropriate management for early-stage MALT-lymphoma, with oncologic therapy being reserved for those patients who fail to respond to H. pylori therapy.

Introduction

The gastrointestinal tract is the most frequent site of primary extranodal non-Hodgkin's lymphomas, and the stomach is the most common location accounting for more than 75% of such tumours [1], [2], [3]. Although primary gastric lymphoma remains a rare disease, its frequency has been rising in recent decades [4]. In particular, an incidence as high as 13.2 cases per 100,000 per year has been estimated in Northern Italy [5]. It is widely accepted that H. pylori infection is the main pathogenic factor for development of low-grade, marginal-zone-B-cell-lymphoma of MALT (MALT-lymphoma) of the stomach [6], [7]. Indeed, several studies have documented total regression of this lymphoma following H. pylori eradication in large series in which early stage neoplasia was diagnosed [8], [9], [10]. However, long-term follow-up data are still scanty in the literature, particularly regarding the efficacy of bacterial eradication in inducing prolonged remission and in preventing recurrence [8]. Different treatment approaches – chemotherapy, radiotherapy, immunotherapy, and surgery – are indicated as possible therapies in those patients who do not respond to H. pylori eradication, but no treatment guidelines are currently available.

The present study was designed to evaluate: (1) the efficacy of H. pylori eradication in inducing remission of low-grade MALT-lymphoma in stages I–II1 at prolonged follow-up and (2) the efficacy of further treatments in refractory or relapsing cases.

Section snippets

Study design

This was a retrospective, multicentre, Italian study involving 4 centres (1 Northern, 1 Central, and 2 Southern Italian locations). Only patients followed for at least 6 months post lymphoma diagnosis were considered.

Patients

Data for all consecutive patients with primary gastric MALT-lymphoma observed in the participating Centres between January 1993 and December 2006 were retrieved. Inclusion criteria were: (1) Age >18 years; (2) presence of low-grade, MALT-lymphoma of the stomach according to the

Study population

During the study period, 64 H. pylori infected patients with stage I/II1 gastric lymphoma were identified. Four patients were excluded due to a short follow-up (<6 months) and/or incomplete data availability. Sixty patients (males: 33, mean age: 60 years, range 23–80) were therefore enrolled. Stage I gastric lymphoma was diagnosed in 50 (83.3%) patients, and stage II1 disease in the remaining 10 (16.7%) cases. Follow-up time ranged from 7 to 156 months with a median of 65 months.

Lymphoma outcome following H. pylori eradication therapy

All patients

Discussion

The role of H. pylori infection in the pathogenesis of gastric MALT-lymphoma is widely recognised. Indeed, different guidelines suggest that bacterial eradication should be the first-line treatment for this neoplastic disease [14], [15], [16]. A review of 24 studies comprising 780 patients found that complete lymphoma regression following H. pylori eradication is achieved in 35–100% of patients [6]. Moreover, it has been observed that the regression rate inversely correlates with the neoplastic

Conflict of interest statement

None declared.

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