Biological Behaviour And Surgical Treatment Of Primary Gastric Lymphoma

Objective: The incidence of primary gastric lymphoma( PGL) is merely inferior to gastric carcinoma in the gastric malignancies.Because of its low incidence, it is of great difficulty to do a large scale and multicentre of clinical researches on PGL. Therefore,there is no unitive aggrements on the treatment of PGL at present .This thesis is to study the clinical features,diagnosis and treatment of PGL ,hope to prove the diagnosis and propose the best choice of therapeutic regiment.Methods:We collected data of 37 patients diagnosed as PGL and treated by surgery in 4th hospital of HeBei Medical University from October 1996 to November 2009.We studied ages,gender,clinical manifestation(vague pain in epigastrium, nausea and vomiting, return sour and heartbum, emaciation and melena, tenderness in superior belly or xiphoid process, goiter in abdominal part), auxiliary examinations(imaging examination, endoscopy examination, pathology and immunohistochemical examination), clinical pathological feature (tumor region, morphous manifestation ,infiltrating depth,size of the tumor,lymph node metastasis, involved surrounding organs,AnnArbor clinical stages),surgical treatment and so on. Clinical data was showed by constituent ratio or percentage and statistics description analyses were made to each observation index.Results:1 The general condition of PGL patients:there were 23 males and 14 females.Ratio of male and female was 1.64:1.Age rang of 37 PGL patients were from 27 years to 70 years.And meso-age was 57 years.The course of disease(from fall to ill to visit the doctor)was 3 days to 365 days.2 The clinical manifestation(cardinal symptoms and physical signs):37 patients with vague pain in middle and epigastrium(100%),9 patients with nausea and vomitting(24.3%),8 patients with return sour and heartbum (21.6%),7 patients with belching(18.9%),7 patients with indigestion or poor appetite(18.9%),7 patients with melena and hematochezia(18.9%),1 patient with general systems such as fever(2.7%),but no one with anaemia(0%).Vague pain in epigastrium was most common,then there were nausea and vomiting, return sour and heartbum, belching, melena.19 patients can be touched with tenderness in superior belly or xiphoid process(51.4%).3 patients can be touched with goiter in abdominal part(8.1%).15 patients were without the masccline sign(40.5%).3 Auxiliary examination:37 cases accepted at least once,and obtained biopsy for pathology test.34 among those were tested in our hospital.9 cases were misdiagnosed gastric adenocarcinoma(26.5%).9 cases were misdiagnosed chronic inflammation in mucous membrane(26.5%).16 cases were diagnosed PGL correctly(47.1%).The rate to make a definite diagnosis by gastroscope in our hospital was 47.1%(16/34).3 cases were misdiagnosed gastric adenocarcinoma in local hospital.18 of 37 patients had done multi-row spiral CT examination.16 of 18 show that gastric wall was uneven thickening(88.9%).2 of 18 showed celiac lymphadenectasis(11.1%).4 of 18 showed liver metastasis (22.2%).5 of 18 showed gastric lymphadenectasis (27.8%).2 of 18 showed without abnormality(11.1%).4 Clinical pathological feature:35 of 37 were origined of B-cell(94.6%).2 of 37 were origined of T-cell(5.4%). Tumor region:15 in sinus ventricul(40.5%), 10 in body of stomach(27.0%),3 in fundus of stomach(8.1%), 9 involved at least 2 parts at the same time(24.3%) which include 6 in body of stomach and sinus ventricul(16.2%),1 in fundus of stomach and body of stomach(2.7%),1 in fundus of stomach, body of stomach and fundus of stomach(2.7%),1 in sinus ventricul and duodenum(2.7%). Morphous manifestation: 26 with ulcer type(70.3%), 7 with tumor type/protrude type(18.9%),4 with infiltrating type (10.8%). Ulcer type was most common.Infiltrating depth:3 localized in mucous membrane and submucosa(8.1%),13 localized in muscular layer(35.1%),6 loclized in placenta percreta(16.2%),15 invaded surrounding soft tissue(40.5%).Size of tumor:15 with the diameter<5cm(40.5%),17 with the diameter between 5cm and 10cm(45.9%),5 with the diameter>10cm(13.5%).Lymph node metastasis:9 with lymph node metastasis (24.3%),28 without lymph node metastasis(75.7%).8 were involved surrounding organs:2 invaded transverse colon(5.4%),1 invaded head of pancreas(2.7%), 5 invaded body and tail of pancreas (13.5%). AnnArbor clinical stages:25 wasâ… E(67.6%),6 wasâ…¡E(16.2%),2 wasâ…¢E (5.4%),4 wasâ…£E(10.8%).5 Surgery treatment:37 patients were performed operation.3 with proximate subtotal gastrectomy(8.1%),26 with distant subtotal gastrectomy (70.3%),7 with total gastrectomy(18.9%),and 1 with gastric wedge excision (2.7%).There wss no intraoperative death.34 with radical excision(91.9%),3 of 34 with proximate subtotal gastrectomy (8.1%),25 of 34 with distant subtotal gastrectomy(67.6%),6 of 34 with total gastrectomy(16.2%).3 with palliative resection(8.1%),1 of 3 with palliative distant subtotal gastrectomy(2.7%) which was found head of pancreas involved,1 of 3 with palliative total gastrectomy(2.7%),1 of 3 with gastric wedge excision(2.7%).Conclusion:1 PGL is prone to middle-aged men and senium.There is no specificity in clinical manifestation.Gas pains or unwell in abdomen,nausea and vomiting, anorexia, alimentary tract hemorrhage often occurs. Masccline signs are mainly tenderness in superior belly or xiphoid process and goiter in abdominal part.2 If considered PGL ,it is better to get biopsy tissues with multi-site and deep part ( reach to submucosa is necessary).Many times and multiple punch biopsy and using trap biopsy with bulk gastric mucosa including submucosa can increase the diagnosis rate of gastroscope.3 PGL in CT mainly shows irregular gastric wall thickening.However, imaging examination is considered not having specific diagnosis significance.But CT examination is helpful to clinical stages before surgery and options of modus operandi can be based on.4 Predilection site of PGL are sinus ventricul and body of stomach.PGL can be solitary tumor and frequently-occurring tumors.There are ulcer type, tumor type(infiltrating type) and infiltrating type of PGL in general. And ulcer type is most common.5 PGL are mainly origined of B-cell and rarely are origined of T-cell.6 Nowadays,surgery is considered to be a principal way to treat PGL in China.It includes radical subtotal gastrectomy(radical proximate subtotal gastrectomy and radical distant subtotal gastrectomy), radical total gastrectomy, radical partial gastrectomy, palliative subtotal gastrectomy (palliative proximate subtotal gastrectomy and palliative distant subtotal gastrectomy), palliative total gastrectomy, palliative partial gastrectomy, combined with surrounding devisceration, and so on.Proportionate radiotherapy and chemotherapy after surgery can improve therapeutic efficacy and prognosis of PGL.