Gastric Lymphoma

The approach to the management of gastric lymphoma must begin with a precise pathologic diagnosis based on histologic examination and immunophenotyping, at a minimum. This should be followed by detailed staging procedures that include endoscopic ultrasonography (EUS). Most primary gastric lymphomas are low-grade Mucosa-Associated Lymphoid Tissue (MALT) or large-cell (high-grade) types. The treatments for these differ. For low-grade MALT lymphomas confined to the stomach, an attempt at eradication of Helicobater pylori is the first choice. If the patient does not have H. pylori, if eradication is unsuccessful, or if the disease stage is II1(E), radiation therapy is the next approach. Chemotherapy is the best option for disease that is stage II2(E) or higher and for disease that does not respond to antibiotics and radiation. Surgery should be reserved for patients with localized disease who do not respond to these other therapies. In patients with clinical stage I(E) large-cell lymphomas, there are valid arguments for and against the use of both surgery and stomach-sparing therapy. Surgery alone (if disease is pathologic stage I(E)) or surgery followed by chemotherapy (for disease that is pathologic stage II or higher) has more data defining expected outcomes. Recently published experience indicates that chemotherapy plus radiation therapy may be an acceptable alternative to surgery. The entire clinical picture and the patient's preferences must play a role in this difficult management decision. Chemotherapy is the clear first option in patients with disease that is stage II or higher. Local radiation therapy should be added in selected cases with residual local disease or bulky tumor.