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Original Article
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
Kosin Medical Journal 2015;30(1):29-39.
DOI: https://doi.org/10.7180/kmj.2015.30.1.29
Published online: January 20, 2015

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: October 13, 2013   • Accepted: June 3, 2014

Copyright © 2015 Kosin University School of Medicine Proceedings

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.

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  • 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
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)
kmj-30-29f1.jpg
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)
kmj-30-29f2.jpg
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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        Therapeutic comparison of Surgery combined with chemotherapy and chemotherapy alone for Primary Gastrointestinal Lymphoma: A single center study
        Kosin Med J. 2015;30(1):29-39.   Published online January 20, 2015
        DOI: https://doi.org/10.7180/kmj.2015.30.1.29
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      Therapeutic comparison of Surgery combined with chemotherapy and chemotherapy alone for Primary Gastrointestinal Lymphoma: A single center study
      Image Image
      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)

      Figure 1.

      Figure 2.

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

      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

      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)

      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)  

      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

      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      
      Table 1. The classification of PGIL according to Ann-Arbor staging system

      Table 2 Patient characteristics (N=107)

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

      Table 3 Comparison of patients based on a treatment strategy

      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

      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

      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.

      Table 1.

      Table 2

      Table 3

      Table 4

      Table 5.

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