Revised 29 October 2012
The gastrointestinal (GI) tract is a frequent site of involvement with lymphoma which usually involves the stomach, less frequently the small intestine and rarely the colon or esophagus. As with other sites, management is dependent on type, stage and age but with several additional special requirements as outlined below. Previously the Lymphoma Tumour Group recommended resection of GI lymphoma to prevent hemorrhage or perforation, however, earlier diagnosis and current management techniques seem to have reduced this risk. Thus, resection of GI lymphoma is no longer recommended, unless necessary to establish a definite diagnosis or to control the complications of hemorrhage or perforation.
- All patients with GI lymphoma should have a careful ENT examination because of the 20% risk of associated involvement at that site.
Helicobacter pylori and gastric lymphoma
There is a strong association between H. pylori and gastric lymphoma of the MALT (mucosa associated lymphoid tissue) type. This, combined with the general frequency of H. pylori infection, makes it prudent to give a course of antibiotics to eradicate H. pylori to all patients with gastric lymphoma, either as the primary treatment (see section on MALT lymphoma below) or after completion of planned chemotherapy and/or irradiation whether or not H. pylori has been actually proven to be present.
Standard Treatment of GI Lymphoma
Indolent grade lymphoma, other than MALT (see below)|
|Advanced||As appropriate for age|
Aggressive grade lymphoma|
R-CHOP x 3 followed by PET-based algorithm for limited stage aggressive lymphoma, Table 3.1. In addition to PET scan, patients should be considered for repeat endoscopy after cycle 3 of R-CHOP (as the PET scan can miss low volume gastric involvement). If the PET scan and endoscopy are negative, complete treatment with a final cycle of R-CHOP (total 4 cycles), otherwise, complete with IFRT.
|Advanced||Chemotherapy appropriate for age (see management for advanced stage aggressive lymphoma, Table 3.1)|
MALT Lymphoma of Stomach
Gastric mucosa associated lymphoid tissue (MALT) lymphoma almost always arises in association with Helicobacter pylori. When the MALT lymphoma is low grade and confined to the stomach eradication of the H. pylori may induce prolonged remission of the lymphoma. Low grade MALT lymphoma of the stomach should be treated as follows:
- Standard staging for lymphoma. If diagnosis is made via gastroscopy, multiple large, deep biopsies should be taken and processed for lymphoma and stained for H. pylori.
Stage II AE or greater should be managed as advanced low grade lymphoma (see table 3.3.2) plus eradication of H. pylori with antibiotics.
- Stage I AE should be treated with oral omeprazole 20 mg bid, clarithromycin 500 mg bid and either metronidazole 500 mg bid or amoxicillin 1000 mg bid for one week (Soll, JAMA, 1996; 275:622) or an equivalently effective regimen.
- After treatment with antibiotics patients should undergo repeat gastroscopy every six months for two years then annually for three years. Each time biopsies should be taken to examine for lymphoma and H. pylori. If H. pylori persists one re-treatment should be tried. If lymphoma persists or recurs more than six months after eradication of H. pylori the patient should be treated with upper abdominal irradiation or oral chlorambucil.