Therapeutic comparison of Surgery combined with chemotherapy and chemotherapy alone for Primary Gastrointestinal Lymphoma: A single center study

Je Hun Kim; Ho Sup Lee; Jun Seop Lee; Jin Young Lee; Su Young Kim; Cheol Su Kim; Joung Wook Yang; Ga In You

doi:10.7180/kmj.2015.30.1.29

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Kim, Lee, Lee, Lee, Kim, Kim, Yang, and You: Therapeutic comparison of Surgery combined with chemotherapy and chemotherapy alone for Primary Gastrointestinal Lymphoma: A single center study

Original Article

Kosin Medical Journal 2015;30(1):29-39.

Published online: 20 January 2015

DOI: https://doi.org/10.7180/kmj.2015.30.1.29

Therapeutic comparison of Surgery combined with chemotherapy and chemotherapy alone for Primary Gastrointestinal Lymphoma: A single center study

Je Hun Kim, Ho Sup Lee, Jun Seop Lee, Jin Young Lee, Su Young Kim, Cheol Su Kim, Joung Wook Yang, Ga In You

Department of Internal Medicine, College of Medicine, Kosin University, Gospel Hospital, Busan, Korea

Corresponding Author：Ho Sup Lee, Department of Internal Medicine, College of Medicine, Kosin University, Gospel Hospital, 262, Gamcheon-ro, Seo-gu, Busan, Korea TEX: +82-51-990-5820 FAX: +82-51-990-5821 E-mail: hs3667@hanmail.net

Received 13 October 201319 March 2014 Accepted 3 June 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objectives

There is still no consensus on the optimal treatment for primary gastrointestinal lymphoma (PGIL). The aim of this study was to compare surgery combined with chemotherapy and chemotherapy alone in PGIL.

Methods

We retrospectively reviewed and analyzed the treatment outcomes of 107 patients with primary gastrointestinal lymphoma diagnosed between March 1999 and December 2009 at Kosin University Gospel Hospital. Patients were divided into two groups: 35 patients who underwent surgery combined with chemotherapy (group A) and 72 patients who were treated with chemotherapy alone (group B). And we analyzed prognostic factors associated with short survival.

Results

The 5-year progression free survival rates (PFS) of group A and B were 86.7% and 66.1%, respectively (P = 0.037), while the 5-year overall survival rates (OS) were 86.8% and 68.4%, respectively (P = 0.129). In multivariate analysis, Both PFS and OS were not changed by treatment strategies (surgery combined with chemotherapy or chemotherapy only). The international prognostic index (IPI) was the only independent predictive factor for PFS.

Conclusions

In our study, surgery combined with chemotherapy and chemotherapy only make no difference of survival rate. And further randomized prospective studies are needed to confirm a treatment strategies at improving survival outcomes in PGIL patients.

Keywords: Chemotherapy, Primary gastrointestinal lymphoma, Surgery

References

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Figure 1.

Progression free survival rates compared in patients according to the treatment strategy. Patients treated with surgery combined with chemotherapy were shown had superior 5-year progression free survival rates than chemotherapy only in patients with primary gastrointestinal lymphoma. (P = 0.037)

Figure 2.

Overall survival rates compared in patients according to the treatment strategy. There was no significant difference in 5-year overall survival rates between patients with primary gastrointestinal lymphoma treated with surgery combined with chemotherapy and chemotherapy only in patients with primary gastrointestinal lymphoma. (P = 0.129)

Table 1.

The classification of PGIL according to Ann-Arbor staging system

I	Involvement of a single lymph node region (I) or a single extralymphatic organ or site (IE)
II	Involvement of two or more lymph node regions on the same side of the diaphragm (II) or of an extralymphatic organ and its adjoining lymph node site (IIE)
III	Involvement of lymph node sites o both sides of the diaphragm (III) or localized involvement of an extralymphatic site (IIIE), spleen (IIIS), or both (IIISE)
IV	Diffuse or disseminated involvement of one or more extralymphatic organs with or without associated lymph node involvement

Table 2

Patient characteristics (N=107)

Characteristics/Category	Number(%)
Age, years
Median (range)	56 (21–79)
Sex
Male	53 (49.5)
Female	54 (50.5)
Histologic type
Diffuse large B cell lymphoma	69 (64.5)
Marginal zone B cell lymphoma	28 (26.2)
Peripheral T cell lymphoma	6 (5.6)
Other B cell lymphoma	4 (3.7)
Gastrointestinal tract involved site
Stomach	68 (63.6)
Small intestine	26 (24.3)
Colon	13 (12.1)
Ann Arbor Stage
IE	29 (27.1)
IIE	33 (30.8)
IIIE	25 (23.4)
IV	20 (18.7)
Bone marrow involvement
Present	5 (4.7)
No	102 (95.3)
LDH
< 450 IU/L	74 (69.2)
≥ 450 IU/L	33 (30.8)
ECOG performance status
0–1	67 (62.6)
≥2	40 (37.4)
IPI risk,
Low	48 (44.9)
Low intermediate	20 (18.7)
High intermediate	12 (11.2)
High	27 (25.2)
Treatment
Surgery+ Chemotherapy group	35 (32.7)
Chemotherapy group	72 (67.3)
Rituximab
Yes	33 (30.8)
No	74 (69.2)

ECOG, Eastern Cooperative Oncology Group; IPI, international prognostic index; and LDH, Lactate dehydrogenase

Table 3

Comparison of patients based on a treatment strategy

	Surgery+ Chemotherapy group (n=35)	Chemotherapy group (n= 72)	P-value
Age, years < 60	23 (65.7)	45 (62.5)	0.746
≥ 60	12 (34.3)	27 (37.5)
Sex Male	16 (45.7)	37 (51.4)	0.582
Female	19 (54.3)	35 (48.6)
Histology
DLBCL	23 (65.7)	46 (63.9)	0.790
MZL	8 (22.9)	20 (27.8)
Others	4 (11.4)	6 (8.3)
Gastrointestinal tract involved site
Stomach	14 (40.0)	54 (75.0)	0.685
Small intestine	16 (45.7)	10 (13.9)
Colon	5 (14.3)	8 (11.1)
Ann Arbor Stage
IE	11 (31.4)	18 (25.0)	0.001
IIE	18 (51.4)	15 (20.8)
IIIE	5 (14.3)	20 (27.8)
IV	1 (2.9)	19 (26.4)
Tumor size
< 10 cm	19 (79.2)	37 (80.4)	0.900
≥ 10 cm	5 (20.8)	9 (19.6)
Bone marrow involvement
Present	0 (0.0)	5 (6.9)	0.110
No	35 (100.0)	67 (93.1)
LDH
< 450 IU/L	26 (74.3)	48 (66.7)	0.423
≥ 450 IU/L	9 (25.7)	24 (33.3)
ECOG performance status
0–1	22 (62.9)	45 (62.5)	0.971
≥2	13 (37.1)	27 (37.5)
IPI risk
Low	19 (54.3)	29 (40.3)	0.432
Low intermediate	7 (20.0)	13 (18.1)
High intermediate	3 (8.6)	9 (12.5)
High	6 (17.1)	21 (29.2)
Rituximab
Yes	8 (22.9)	25 (34.7)	0.212
No	27 (77.1)	47 (65.3)

DLBCL, diffuse large B cell lymphoma; ECOG, Eastern Cooperative Oncology Group; IPI, international prognostic index; LDH, lactate dehydrogenase; and MZL, marginal zone B cell lymphoma.

Table 4

Univariate analysis of prognostic factors

	5-year PFS (%)	p-value	5-year OS (%)	p-value
Age, years				0.205
< 60	79.7	0.54	79.7
≥ 60	58.7		63.8
Sex				0.879
Male	72.8	0.677	76.1
Female	73.7		73.7
Histology				0.011
DLBCL	78.8	0.094	78.8
MZL	71.9		78.0
Others	44.4		44.4
GI involve site Stomach Small intestine Colon	69.5 57.0 71.6	0.167	74.5 58.0 67.7	0.096
Ann Arbor Stage				0.026
IE and IIE	83.3	0.002	83.3
IIIE and IV	56.5		60.3
Tumor size				0.155
< 10 cm	73.5	0.161	77.1
≥ 10 cm	55.5		55.0
Bone marrow involvement				0.408
Present	53.3	0.522	53.3
No	74.3		75.8
LDH				< 0.001
< 450 IU/L	80.7	0.016	82.6
≥ 450 IU/L	52.6		52.1
ECOG performance status				0.158
0–1	78.9	0.016	79.0
≥2	62.7		67.0
IPI risk				< 0.001
Low and Low intermediate	84.3	< 0.001	84.4
High intermediate and High	50.3		54.6
Treatment				0.129
Surgery + Chemotherapy group	86.7	0.037	86.8
Chemotherapy group	66.1		68.4
Rituximab				0.475
Yes	81.2	0.118	76.7
No	62.9		68.8

BM, bone marrow; DLBCL, diffuse large B cell lymphoma; ECOG, Eastern Cooperative Oncology Group; GI, gastrointestinal; IPI, international prognostic index; LDH, lactate dehydrogenase; MZL, marginal zone B cell lymphoma; OS, Overall survival; and PFS, progression free survival

Table 5.

Multivariate analysis of prognostic factors

	PFS			OS
	RR	95% C.I.	p-value	RR	95% C.I.	p-value
Histology DLBCL MZL Others				0.516	0.140–1.907	0.321
Ann Arbor Stage (%) IE and IIE IIIE and IV	0.918	0.321–2.631	0.874	0.576	0.214–1.549	0.274
LDH < 450 IU/L ≥ 450 IU/L	0.828	0.364–1.881	0.652	0.447	0.181–1.104	0.081
ECOG performance status 0–1 ≥2	1.339	0.519–3.449	0.546
IPI risk Low and Low intermediate High intermediate and High	0.184	0.058–0.583	0.004	0.503	0.168–1.504	0.219
Treatment Surgery + Chemotherapy group Chemotherapy group	0.446	0.149–1.332	0.148

ECOG, Eastern Cooperative Oncology Group; IPI, international prognostic index; LDH, lactate dehydrogenase; OS, overall survival; PFS, progression free survival; RR, relative risk; and 95% C.I., 95% confidence interval.

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