Page 183 - Medicine and Surgery

P1: KOA
BLUK007-04 BLUK007-Kendall May 25, 2005 7:57 Char Count= 0

Chapter 4: Gastrointestinal oncology 179

Clinical features Aetiology/pathophysiology
Patients tend to present late with non-specific weight Gastric lymphoma is a non-Hodgkin B cell lymphoma.
loss, anorexia and anaemia. There may be dyspepsia or Tumours arising in the mucosa associated lymphoid tis-
haematemesis. In early stages there may be occult blood sue (MALT) result from H. pylori infection in over 90%
in faeces. Examination reveals epigastric tenderness and of cases.
often a mass. Dermatomyositis and acanthosis nigricans
may be manifestations of an underlying gastric malig- Clinical features
nancy. Patients present similarly to gastric adenocarcinoma
with non-specific weight loss, anaemia and malaise and
Microscopy associated epigastric tenderness. Symptoms may be mild
Histologically gastric adenocarcinomas may have an in- despite a large tumour mass.
testinal pattern with gland like spaces or they may be
diffuse infiltrative carcinoma with sheets of anaplastic Microscopy
cellswhich have a mucin containing vacuole. Lymphoma cells range from small cells to large im-
munoblastic cells.
Investigations
Diagnostic testing usually involves an endoscopy and Investigations
biopsy,whichmaybeprecededbyabariummeal.Ifthere Endoscopy and biopsy is diagnostic.
isanassociatedascitesdiagnostictappingandcytological
examination may be useful. Anaemia is a non-specific Management
finding and liver metastases may cause a rise in liver Lymphoma often responds to H. pylori eradication ther-
function tests. A CT scan is used for staging and surgical apy. As there is potential for recurrence frequent up-
planning. pergastrointestinal endoscopy and multiple biopsies are
recommendedforallpatientsfollowingeradicationther-
Management apy. Patients who do not respond to, or who relapse fol-
Treatment of choice is surgical resection wherever pos- lowing eradication therapy are treated with single agent
sible. At laparotomy if there is no evidence of local in- chemotherapy(e.g.cyclophosphamideorchlorambucil)
vasion or spread beyond local nodes, a partial gastrec- or radiation therapy. Patients with advanced or aggres-
tomy is performed for distal carcinoma (Bilroth II with sive disease and those who fail to respond or recur after
anastomosis to the jejunum and closure of the duodenal single agent chemotherapy are treated with multiagent
stump) or in proximal carcinomas a total gastrectomy is chemotherapy, such as CHOP (cyclophosphamide, dox-
performed. Lymph node clearance is performed of re- orubicin, vincristine and prednisone). Surgery is now
gional nodes. Palliative resections may be performed for rarely indicated.
blood loss or obstruction. Combination chemotherapy
Prognosis
may be used in disease not amenable to surgery.
Postoperative 5-year survival of 80–90%.
Prognosis
In Japan early disease cure rates are up to 90%. Overall Small intestine lymphoma
5-year survival in the United Kingdom is around 10%
Definition
due to late presentation.
Anon-Hodgkin lymphoma which occurs within the
small bowel particularly in the ileum.
Gastric lymphoma
Aetiology/pathophysiology
Definition Non-Hodgkin B cell lymphoma arises in the mucosal
Aprimary lymphoma of the stomach which accounts for associated lymphoid tissue (MALT) and occurs within
3% of malignant gastric tumours. the distal ileum.