Int J Biol Med Res.

2012; 3(5): 1419-1422

Int J Biol Med Res [Link]
Volume 2, Issue 4, Jan 2012

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Original Article
Clinicopathologic characteristics and therapeutic outcome of primary
gastrointestinal lymphoma in cuddalore district in india.
Rajesh Kumar N*
Assistant professor, Department of pathology, Annapoorna medical college and hospitals, NH47, Sankari road, Seeragapadi, Salem. India.

ARTICLE INFO ABSTRACT

Keywords: Objectives: The aim of the study is to determine the clinico-pathological features and
Primary gastrointestinal lymphoma therapeutic out come of primary gastrointestinal lymphoma [PGIL] aat a tertiary care hospital
Lymphoma
Gastrointestinal malignancy at Cuddalore district, India. Materials and methods: 36 patients with primary
Gastrointestinal lymphoma[PGIL] diagnosed over a 6 year period from 2003 to 2008 were
retrospectively and prospectively studied clinically and histopathologically and a followup was
done for minimum of three years till 2010 they were classified using the REAL/WHO
histopathologic classification and follow up was done for a minimum period of 3 years. Results:
36 patient (38.7%) were PGIL arising out of 93 total lymphomas diagnosed. Out of 980
primary gastrointestinal malignancies, 36(3.6%) were PGIL, with a male to female ratio of 1.5 :
1. All the patient were non vegetarians and majority of males were alcoholics and smokers. The
mean age of the male patients was 61.3 years with age varying from 42 – 83 years with an SD of
±13.09: while for females, the mean age was 64 years, ranging from 50-75 years with an SD of
±9.14. Abdomen pain was the most common presenting syphtom (70%), and the most
common primary site was stomach (72.2%), followed by small bowl (16%), the important
histological type was Non Hodgkins lymphoma (100%), no Hodgkins lymphoma was
diagnosed. The predominant subtype was diffuse large B cell lymphoma accounting for 72.5 %
of the csases. followed by the marginal marginal zone cell lymphoma (25%) which was
hecicopylori associated (55%). A large proportion of patient with primary GIL had early
disease( stage I E – 20 % and stage IIE 60%) . 17 (47.2%) Patient had chemotheraphy,
11(30.5%) patients underwent gastrectomy followed by chemotheraphy and only one patient
was treated by HPylori eradication. The overall 3 survival rate was 58%. Conclusion: primary
gastrointestinal lymphomas constitute about 3.6 % of all gastric malignancies and Hodgkins
lymphoma was nil and Non Hodgkins lymphoma constituted all the PGIL. Abdomen pain was
the common presenting symptom and stomach being the commonly involved site and majority
of cases presenting as exophyitc mass. Diffuse large B cell lymphoma is the most common
histological subtype, followed by extra nodal marginal zone B cell lymphoma(MALT) The
majority of the cases have early disease( stage 1 and IIE), mostly treated by combination
chemotheraphy.
c Copyright 2010 BioMedSciDirect Publications IJBMR -ISSN: 0976:6685. All rights reserved.

1. Introduction

GI Tract is the most common extranodal site involved by lymphomas, followed by the small intestine 20 -30% [4,5,6,7] the
lymphoma accounting for 5 – 20% of all cases [1, 2, 3]. PGIL colon and the rectum 10 – 20%. .90percent of the PGIL are of B cell
lymphoma are rare constituting only about 1% - 4% of all GI lineage with very few T-cell lymphomas and Hodgkin lymphoma.
malignancies. The stomach is the most common location of GI Certain histological subtypes have been noted to have a relative
predilection site as MALT lymphoma in stomach, mantle cell
* Corresponding Author : Dr .[Link] kumar M.D.,
lymphoma in terminal ileum, jejunum and colon, as well as
Assistant professor,
Department of pathology, enteropathy- associated T cell lymphoma in jejunum, and follicular
Annapoorna medical college and hospitals, lymphoma in duodenum [8].
NH47, Sankari road, Seeragapadi, Salem. India.
E-mail: rajeshprnatesan @[Link].
The esophagus is a rarely involved site, accounting for < 1% of
c Copyright 2010 BioMedSciDirect Publications. All rights reserved. all gastrointestinal lymphomas. Primary esophageal lymphoma is
 Rajesh Kumar N / Int J Biol Med Res. 2012; 2(4):1419-1422 1420

extremely rare, with less than 30 cases reported in the Symptoms such as fever, night sweats, weight loss occurred in
literature[9,10,11]. Primary gastric lymphomas[PGL] is the most 42% of cases. The mean time from onset of symptoms to diagnosis
common extranodal lymphoma, representing 30-40% of all was 100 days.
extranodal lymphoma and about 60 – 75% of all gastro intestinal
Lactate dehydrogenase level was elevated in approximately
lymphomas [12,13,14]. PGL constitute less than 15 percent of
45% of patients, other laboratory tests including white blood cell,
gastric malignancies and about 2 percent of all lymphomas [16]. In
platelet count, uric acid level, creatinine and liver enzymes, were
PGL >90% cases are diffuse large B cell lymphoma ( DLBCL) and
normal.
marginal zone B-cell lymphoma of the Mucosa- associated
lymphoid tissue tumor. [17,18] Small intestinal lymphomas The most frequent histologic subtype was the diffuse large Bcell
constitute 20 to 30 percent of all PGIL [ 19,20] and 11.8 percent of lymphoma, accounting for 72.2% of all the cases; followed by
small intestinal tumors [ 19 ]. The lymphomas of colorectal MALT type lymphoma (25%)which corresponds to the marginal –
represents 0.2 – 0.4 % of all colorectal tumors [25,22] and 20 to 30 zone cell lymphoma in the REAL/ WHO classification.
percent of all colorectal lymphomas. Cecum followed by rectum
are more frequently involved sites and predominantly of diffuse Most of the marginal zone lymphoma cell lymphomas (MALT
large cell lymphoma 40 percent and Burkitts lymphoma 60 type) were of gastric origin. Helicobacter pylori could be identified
percent [41] on histological sections in all the four cases; the serological test for
H. Pylori was available only for three cases, which was positive . GI
2. Material and Methods endoscopy revealed exophytic mass in 50 % of cases, and ucerative
A total of 36 patients with PGIL diagnosed at a tertiary care lesion in 25% of cases and the rest as flat lesions.
hospital at cuddalore district, India over a period of 6
years were studied prospectively and retrospectively(2003 According to the modified staging classification, a larger
through 2008) and a followup was done for minimum three years proportion of patients with GI lymphoma had early disease ( stage
till 2010. Medical records of all the patients were reviewed and 1E - 20%, stage 11 E – 60 %), while stages 111 E and 1VE
clinical and pathological information was recored in a structured accounted for 4 and 18 % respectively.
questunnaire form. the laboratory and radiological work- up With regards to treatment, eleven patient (30.5%) had
included complete blood count, creatinine, liver enzymes, lactate gastrectomy followed by chemotheraphy, and six (16.6 %)
dehydrogenase, uric acid, chest x ray, computed tomography of received multimodality treatment in the form of gastrectomy and
chest and abdomen, bone marrow biopsy and endoscopic chemotherapy followed by radiotheraphy, seventeen patients
evaluation with multiple biopsied of upper and lower GI tract. (47.2%) of patients had chemotheraphy only, and the remaining
[Link] and immunohistochemistry patients were treated with Helicopylori pylori eradication. The
mean follow up of was three years. The overall 3 year survival was
Tissue sections were obtained from formalin fixed paraffin
58%.
blocks and stained with Hematoxylin and eosin. Special stains such
as Periodic Acid –Schiff and reticulin stains were used in seclected The out come in patients with primary GI Lymphoma in relation
cases whenever indicated. Each biopsy was investigated to histology is shown in table.
immunohistochemically by staining for leukocyte common
Outcome of primary GI lymphoma in relation to different
antigen, CD 20, CD 43, CD 138, and CD 45. Additionally
histological subtypes.
Helicobacterpylori were demonstrated using either fast cresyl
violet or giemsa stain.
Marginal zone lymphoma Diffuse large B cell lymphoma
3. Results Patients(n) % Patients(n) %
From the year 2003 through 2008, 36 patients with primary GI
Cured 9 25 7 19.4
lymphoma were accrued to the study. Out of 980 gastrointestinal
Remission 2 5 2 5
malignancies 36 were found to be lymphomas comprising about
3.6% of all GI malignancies. Twenty one patients were males and Relapse 2 2 5
fifteen were females. The male to female ratio was 1.4:1. The mean Died - 5 2 5
age for male was 61.3 years ranging from 42 to 83, With a SD of ± Lost to follow up 2 5 7 19.4
13.09 and for females the mean age was 64 years, ranging from 50
to 75 years with an SD of ± 9.14. 4. Discussion
Gastrointestinal lymphomas constitues 1% to 4 % of all
Abdominal pain was the most common presenting symptom( gastrointestinal malignanices and it is common extranodal site of
70%), followed by abdominal mass(20%). lymphoma and hodgkins lymphoma is rare in gastrointestinal
lymphomas comprising and non Hodgkings lymphoma constitutes
Almost all the patient were non vegetarians and majority of the majority of all GI lymphomas. PGL is the most common
them are mutton eater. In male patients majority are alcoholic and extranodal lymphoma, representing 30-40% of all extranodal
smoker were as females were non alcoholics and non smokers. The lymphoma and about 60 – 75% of all gastric malignancies
most common site was stomach 72.2%, followed by the small bowl [12,13,14,15]
16%.. The third largest group of lymphoma originating in the colon
13.8%.
1421 Rajesh Kumar N / Int J Biol Med Res. 2012; 2(4):1419-1422

Males were affected more than females in our study 1.5:1 which However, it is still thought that the prognosis of intestinal
is lower than what has been reported from Jordan [24] and the lymphomas is to surgery, therefore, it seens appropriate and
West [42] but it is close to the ratio reported from Thilland [26] cautious to resect intestinal lymphoma whenever possible.
and china [27]. [37,38]. Those with limited stage disease may enjoy prolonged
survival when treated with aggressive chemotheraphy. [4].
The peak age of our patients was in the sixth decade, which is
Radiotheraphy is beneficial for incomplete resection or
older than the age group of a previos study from the kingdom of
nonresectable [Link] region and cecum were the most
Saudi Arabia [28]. PGIL is rarely suspected because of the
frequent sites of invobement [76%] , most patients had bulky
nonspecific presenting symptoms and signs [29]. Abdominal pain
disease. Diffuse large cell lymphoma was seen in 11 patients and
is the predominant occurring upto 93% of patients [30] ib iur
peripheral T cell lymphoma in one patient. Three patients had
study abdominal pain was the most commom symptom at
mantle cell lymphoma and two had indolent lymphomas.[ MALT -1
presentation followed by abdominal mass in 70% and 20%
and small lymphocytic -1]. Eleven patients underwent
respectively. These results were similar to the previous results
hemicolectomy Right side in nine left side in two, five diffuse large
from KSA [28], Bahrain 21, united arab emirates, Jordan, Thailand,
B cell lymphoma patients required emergency surgery for
chinal, japan and west
intestinal perforation. Due to the rarity of oesophageal lymphoma,
no standard approaches to its management have been formulated,
Primary GI lymphoma is a heterogenous disease with regards to
external beam radiation at the dose of 40Gy can be used [ 39]. The
patients characteristics, stage, histological subtypes and
patient were treated with initial radiotheraphy followed by
treatments results.[31].
surgery an chemotheraphy in few cases and surgery along with
chemotheraphy in some patient. Radiotheraphy along with
The duration of symptoms is often long [30]in our series,
surgery and chemotheraphy prove better results than only with
median time from onset of symptoms to diagnosis is 100 days. This
surgery and chemotheraphy.
delay in presentation is because the diagnsosis is rarely suspected
due to he nonspecific symptoms of GI Lymphoma.
The most widely recommended stratery for the management of
early stage [Link] positige MALT type of gastric lymphoma is to
Diffuse large cell B cell lymphoma is the commonest histolgoic
eradiacte [Link] with antibiotics and proton pump inhibitors.
subtype of GI [Link] most of the series [24,26,27,28,30,32].
Although surgery has been used as its initial treatment, recent
It involes the MALTsites. In the current study diffuse large B cell
studies showed that radiotheraphy alone can achieve a completer
lymphoma is the most commonest followed by extranodal
remission with a 5 year disease free period [40-43]. In present
marginal – zone B cell lymphoma which accompanies chronic
study majority of patients with gastric lymphoma were treated
gastritis in the presence of Helicobacter pylori infection. It
with chemoimmunotherapy with 4 cycles of R- CHIO( Rituximab,
accounts for it accounts for about 40 50% of GI NHL[32] . In the
cyclophosphamide, doxorubicin, vincristine and prednisone
current study accounts for about 42% and all of them were
followed by radiotheraphy. A complete remission was obtained
Helicobacter pylori positive on histological sections.
and it was better than chemotheraphy alone.

Our cases showed mass or filling defects in 80% of cases, 5. Conculsion

followed by ulcerated lesion [ 15%] and diffuse thickening of the The current study showed that PGIL is commoner among males
mucosa[5%]unlike a previous study from Saudi Arabia, were than females, the peak age being in the sixth decade. Abdomen pain
superficial and multicentric ulceration of mucsoa was the most is the common spresenting symptom. The median time to the onset
frequent endoscopic feature [ 33]. of symptoms to diagnosis is 100 days. The majority of patient were
non vegetarians and most of them were mutton takers. Most of the
At presentation 79%, our patients had stage IE and II E . two male patients were alcoholics and smokers and female patients
authors reported 87[ 30,34] and 89%which is comparable to our were non alcoholic and non smokers. The disease showed non
data. specific symptoms which lead to a delay in the time of diagnosis.
Hodgkins lymphoma was nil in our study and the majority of
Combined modality of approach that includes surgical lymphoma was gastric origin. Diffuse large B cell lymphoma
debulking and systemic chemotherapy is the preferred represents the most common histological type, followed by
treatment.[35]. Different therapeutic approaches were used in two extranodal marginal- zone B cell lymphoma and helicobacter
subsets: radical tumor resection( hemicolectomy) plus multiagent pylori associated lymphoma. Most of the lymphomas were
chemotheraphy in advanced age patients.[4,5,36]. Poly detected at an early stage of the disease. The data presented here is
chemotheraphy includes CHOPC[cyclophosphamide, doxorubicin, an approximate assessment of the epidemiological features of
vincristin, and prednisolone] or CHOP like combination primary GIL which are needed to undertake definite preventive
chemotherapy or MACOP-B like regimens [4,5].surgery can be and therapeutic measures.
considered as an adequate treatment for patients with low – grade
NHL disease that has not infiltrated beyond mucosa.[25]
 Rajesh Kumar N / Int J Biol Med Res. 2012; 2(4):1419-1422 1422

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