Franco Cavalli

Eradication of Helicobacter pylori Infection in Primary Low-Grade Gastric Lymphoma of Mucosa-Associated Lymphoid Tissue

Low-grade gastric lymphoma of mucosa-associated lymphoid tissue (MALT) is an uncommon tumor with an indolent natural history and prolonged confinement to the site of origin. Its morphologic appearance is characterized by prominent and often multifocal lymphoepithelial lesions showing dense, diffuse infiltrates of centrocyte-like cells within the lamina propria [1]. B-cell monoclonality can often be shown by either immunocytochemical or molecular methods [2]. A close association has been suggested between gastric MALT lymphoma and the presence of certain strains of Helicobacter pylori, which are found in more than 90% of patients with gastric MALT lymphoma [3]. Regression of this lymphoma after eradication of H. pylori was reported in 5 of 6 patients who received antibiotic therapy [2]. We analyzed the effects of antibiotic therapy for H. pylori infection in 26 patients with low-grade gastric MALT lymphoma. Our patients were from a geographic area (southern Switzerland and northern Italy) where the incidence of gastric tumors appears to be uncommonly high [4, 5]. Many patients with primary gastric lymphoma reside in northeastern Italy [6], a region geographically close and environmentally similar to the area in which our patients reside. Reasons for these disease clusters are not known. Methods Twenty-six patients (14 women, 12 men; median age, 60 years [range, 21 to 76 years]) with histologic diagnoses of localized (stage IE), primary, B-cell, low-grade gastric MALT lymphoma and H. pylori infection (diagnosed using endoscopic biopsy specimens) were entered into our study. Almost all patients had a prolonged history (as long as 4 years) of gastric symptoms before diagnosis of H. pylori infection, and most of them had already been given antacid medication, motility stimulant agents, or both. Before patients received treatment for H. pylori infection, the following staging procedures were done: physical examination, routine laboratory tests, chest radiographs, abdominal ultrasound or computed tomographic scans, endoscopic gastric biopsy specimens, and bone marrow biopsy specimens. Patients were treated for H. pylori infection for 2 weeks with amoxicillin (500 mg three times daily) plus metronidazole (400 mg three times daily) and colloidal bismuth (120 mg four times daily; 13 patients) or omeprazole (20 mg twice daily; 13 patients). Twenty patients were treated immediately after diagnosis of H. pylori infection, and 6 were treated after an observation period of several months (median, 5 months; range, 3 to 36 months) without endoscopic and histologic changes of the MALT lymphoma. One patient had a brief response to first-line combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP regimen), but the patient later had a local relapse. This patient still had histologic characteristics of low-grade gastric MALT lymphoma when treatment for H. pylori infection was given. To reevaluate the condition of the patients after treatment for H. pylori infection, biopsy specimens were obtained from any abnormal area in the stomach and randomly obtained from the rest of the stomach. These multiple (range, 8 to 20 specimens), random biopsy specimens of the gastric mucosa were obtained within 6 months of treatment (3 months for 19 patients, 4 months for 4 patients, and 6 months for the remaining 3 patients); patients were reevaluated every 3 to 6 months thereafter. The patients with persistent H. pylori infection had additional treatment for 2 weeks with a different regimen: omeprazole (20 mg twice daily), metronidazole (400 mg three times daily), and azithromycin (500 mg daily for 3 consecutive days every week). Restaging with chest radiographs and abdominal ultrasound was done again after 1 year. In 9 patients, a bone marrow biopsy specimen was obtained again after 6 months. Histologic responses were graded according to the histologic scoring system recently proposed for the diagnosis of gastric MALT lymphoma [2]. We considered a post-treatment score of 2 or less to be evidence of lymphoma regression. Binomial exact 95% CIs were calculated for outcome percentages. Results Complete eradication of H. pylori was initially achieved in 21 patients (81%; 95% CI, 61% to 93%); in the remaining 4 patients, second-line antibiotic treatment was needed to eradicate the microorganism. The overall eradication rate was therefore 96% (25 of 26 patients; 95% CI, 80% to 99%). After treatment for H. pylori infection, the median follow-up was 12 months (range, 3 to 36 months). One patient, treated after an observation period of 36 months without clinical or histologic change, showed persistent gastric infection and unchanged lymphoma features on biopsy specimens obtained 3 months after treatment. The patient received additional antibiotic treatment but has not been reevaluated with endoscopy. All but one of the patients were symptomatic at presentation; the main symptoms were pain (60% of patients), dyspepsia (30% of patients), and nausea and vomiting (7% of patients). One patient presented with gastrointestinal hemorrhage. Symptoms disappeared in 77% of patients or markedly diminished after antibiotic treatment. At the endoscopic evaluation done before treatment, 11 patients had gastric ulcers, 9 had endoscopic evidence of gastritis, and the remaining 6 had abnormal, congestive (hyperemic) gastric mucosa. In all patients, these endoscopic features improved after eradication of H. pylori infection and all of the ulcers healed, but only one patient had a complete recovery of the gastric mucosa. Histologic regression of the MALT lymphoma (Table 1) was observed in 15 patients (60%; CI, 39% to 79%) after H. pylori eradication, including the 1 patient who relapsed after chemotherapy. Five patients had complete disappearance of any histologic evidence of lymphoma (histologic score, 0 to 1), and 10 patients had residual lymphoid follicles but no longer had lymphoepithelial lesions (histologic score, 2). Three patients showed persistent suspicious, probably reactive, lymphoid infiltrate in the lamina propria (histologic score, 3) and were considered to have not responded to treatment. The other patients showed no change or only partial improvement in the lymphoma histologic pattern in repeat gastric biopsy specimens. Table 1. Effects of Helicobacter pylori Eradication on Gastric Mucosa-Associated Lymphoid Tissue Lymphoma Our study suggests that regression of the lymphoma may require a prolonged period. Only 8 patients showed histologic regression on the first biopsy specimen after antibiotic treatment, but when endoscopic specimens were obtained again 3 or more months later, regression was clearly evident in 7 additional patients. At a median follow-up of 12 months, all patients were alive and 14 of 15 responders, including the 1 patient who relapsed after chemotherapy, were free of lymphoma. A bone marrow specimen from 1 patient showed evidence of relapse shortly thereafter, with a response duration of only 4 months; however, no evidence of MALT lymphoma was found in repeat gastric biopsy specimens (histologic score, 2). Discussion A strong causal relation between H. pylori infection and gastritis, duodenal ulcer, or both has been shown; moreover, increasing epidemiologic and histopathologic evidence indicates a link between H. pylori infection and gastric tumors, both carcinomas [7] and lymphomas [3, 8]. Further, the ability of H. pylori to stimulate cellular proliferation in low-grade gastric MALT lymphoma has been reported [9], and eradication of H. pylori may inhibit the growth of the lymphoma [2]. The rarity of extra-abdominal spread low-grade gastric MALT lymphoma may also be partially explained by the role of H. pylori in the pathogenetic process [9]. Our data confirm, in a larger series of patients, the recent observations that eradication of H. pylori can lead to a regression of the lymphoma [2, 10] and further support the concept of a causal correlation between H. pylori infection and gastric lymphoma. The case of low-grade gastric MALT lymphomas is not the only one in which a bacterial infection has been implicated in the pathogenesis of a lymphoma. Antibacterial therapy has already been reported to be useful in the treatment of -chain disease (a small-intestinal lymphoma) [11], providing indirect evidence that bacteria may have a pathogenetic role in lymphomas. Only careful, prolonged follow-up will ascertain whether treatment for H. pylori can definitely cure gastric MALT lymphoma. Currently, this represents one of the many questions in the treatment of gastric lymphoma (others include those about the necessity for surgery and role of chemotherapy) [12]. Our data show that for low-grade MALT gastric lymphoma, an antibiotic treatment designed to eradicate H. pylori appears to be mandatory before further therapeutic options are considered. An international randomized trial will soon investigate whether it is beneficial to add cytotoxic chemotherapy to such an antibiotic treatment.

Report of an International Workshop to Standardize Baseline Evaluation and Response Criteria for Primary CNS Lymphoma

Standardized guidelines for the baseline evaluation and response assessment of primary CNS lymphoma (PCNSL) are critical to ensure comparability among clinical trials for newly diagnosed patients. The relative rarity of this tumor precludes rapid completion of large-scale phase III trials and, therefore, our reliance on the results of well-designed phase II trials is critical. To formulate this recommendation, an international group of experts representing hematologic oncology, medical oncology, neuro-oncology, neurology, radiation oncology, neurosurgery, and ophthalmology met to review current standards of reporting and to formulate a consensus opinion regarding minimum baseline evaluation and common standards for assessing response to therapy. The response guidelines were based on the results of neuroimaging, corticosteroid use, ophthalmologic examination, and CSF cytology. A critical issue that requires additional study is the optimal method to assess the neurocognitive impact of therapy and address the quality of life of PCNSL survivors. We hope that these guidelines will improve communication among investigators and comparability among clinical trials in a way that will allow us to develop better therapies for patients.

Clinical Features, Treatment and Outcome in a Series of 93 Patients with Low-Grade Gastric MALT Lymphoma

The purpose of this paper is to report the clinical characteristics and treatment outcome following different therapeutic approaches in a large series of patients with primary low-grade MALT lymphoma of the stomach. A total of ninety-three patients (median age 63 years) were reviewed. The patients were treated by different modalities (local treatment alone, combined treatment, chemotherapy, antibiotics alone); seven patients refused any treatment. The antibiotic-treated group of patients was prospectively followed with regular endoscopic biopsies, and their responses were histologically evaluated. The 5-years projected overall survival is 82% (95% C.I.; 67%-91%) in the series as a whole. Second tumors were observed in 21.5% of the patients in this series (95% CI 14%v to 31%). There was no apparent difference in overall survival and event-free survival between patients who received different treatments. In the antibiotic-treated group histologic regression of MALT lymphoma was documented in 67% of patients (95% CI 51% to 80%). In conclusion the indolent nature of the disease justifies a conservative approach. The use of antibiotics as first-line therapy may avert or at least postpone the indication for surgical resection in the majority of patients.

Primary extranodal non-Hodgkin's lymphomas. Part 2: Head and neck, central nervous system and other less common sites

The first part of this Review, which included a general introduction and the discussion of gastro-intestinal, cutaneous and genito-urinary non-Hodgkins lymphomas, was published in a previous issue of this journal (Zucca E, Roggero E, Bertoni F, Cavalli F. Primary extranodal non-Hodgkins lymphomas. Part 1: Gastrointestinal, cutaneous and genitourinary lymphomas. Annals of Oncology 1997; 8(8): 727-37). We do not discuss again here the general problems posed by the extranodal presentation of non-Hodgkins lymphomas. However, it is important to remember that the fundamental contribution of the R.E.A.L. Classification [4] in recognising different lymphoma entities can be the basis to improve our knowledge in extranodal lymphomas as well as in the nodal ones. However, at least thus far, treatment approaches are more influenced by the histologic type than the presenting site, thus emphasising how essential is a precise pathologic diagnosis. The above mentioned Part 1 also contained the first part of the bibliography (References 1-101) and the first six tables.

Immunoglobulin heavy chain Diversity genes rearrangement pattern indicates that MALT-type gastric lymphoma B cells have undergone an antigen selection process

Gastric MALT lymphoma usually develops from chronic gastritis, the vast majority of which (>90%) is associated with Helicobacter pylori infection. We sequenced the third complementarity determining region (CDR3) of immunoglobulin heavy chain genes in 19 gastric MALT lymphoma clones to determine the pattern of variable (V), diversity (D) and joining (J) gene utilization during immunoglobulin gene rearrangement.

Treatment and Prognosis of Centrocytic (Mantle Cell) Lymphoma: A Retrospective Analysis of Twenty-six Patients Treated in One Institution

We retrospectively attempted to analyse prognostic factors in a group of 26 patients with centrocytic lymphomas (CCL) treated from 1979 to 1991 (representing 7% of all cases of NHL diagnosed in our institution during that period). Ten of the patients were females and 16 males, and their median age at diagnosis was 69 years (range 38-85). The majority of patients (77%) had advanced disease (Ann Arbor stage III-IV) at presentation. Twenty-two patients (85%) had good performance status (0-1 ECOG). B-symptoms were present in 10 cases. Most patients (87%) presented with generalized adenopathies. Bone marrow involvement was observed in 12 patients (46%) and Waldeyers ring involvement in 5 (4 of them with stage I-II). In 5 cases the liver was involved and 3 pts had gastrointestinal localizations; 15 patients had more than 2 sites of disease: LDH elevation was observed in 8/24 pts. Fourteen patients (54%) received single-agent chlorambucil (3 pts) or CVP (11 pts). Eleven patients were treated with ADM-containing regimens (7 with CHOP or M-ACOD and 4 with 3rd generation regimens). One patient had radiotherapy alone. The complete response (CR) rate was 50% (13/26); 8 patients relapsed with a median time to progression of 19 months, and only 3 responded to salvage treatment. The median overall survival was 33 months, with fewer than 40% of patients surviving longer than 3 years. At univariate analysis the use of ADM-containing regimens seems significantly correlated with the CR rate (p = 0.047), the failure-free survival (p = 0.023), and the overall survival (p = 0.004).(ABSTRACT TRUNCATED AT 250 WORDS)

A NOVEL FLOW CYTOMETRIC METHOD FOR THE QUANTIFICATION OF P53 GENE EXPRESSION

We describe a rapid and simple flow cytometry technique for the detection and quantification of p53 in several human cell lines, including an adenocarcinoma cell line (SW 626) having a mutant (m) p53, and a pre-B leukemia cell line (NALM-6) having wild-type (wt) p53. By introducing a second antibody coupled to RPE-fluorescence, the discrimination between control and specific peaks was improved over that achieved with methods used previously. To quantify the content of p53 molecules in the cells, we used a series of beads with the capability to bind mouse monoclonal IgG antibodies. p53 cell content, expressed as antibody binding capacity (ABC), was directly quantified from logarithmic scattergrams; the results were reproducible in all cell lines tested. Flow cytometric results were compared with those of a standard immunocytochemistry method routinely used for the detection of p53 in cells, and found to be in correlation. Furthermore, cytometric data also reflect ELISA determinations. In summary, we showed for the first time that (i) p53 can be clearly detected by flow cytometry in various cell lines, (ii) p53 can be quantitated in terms of number of molecules per cell, and (iii) it can be easily monitored as a function of time after stimulation.

Cardiac involvement in HIV-related non-Hodgkin's lymphoma: a case report and short review of the literature

Abstract We report a case of secondary heart involvement in AIDS-related primary lymphoma of the liver. A worsening dyspnea led to the diagnosis of pericardial effusion, and transesophageal echocardiography revealed the presence of large endocardial ventricular masses. Clinical suspicion of a lymphomatous origin was confirmed at the autopsy, which showed an extranodal dissemination pattern (heart, liver, intestine, and lung). In AIDS patients, both primary and secondary lymphomatous heart involvement are increasing in incidence. Clinical symptoms and signs are vague. Since the hematogenous route is the most common pattern of involvement, even extrathoracic lymphomas can present heart dissemination. Thus, it should be suspected in lymphoma patients who present with even mild aspecific heart symptoms. Appropriate imaging procedures include transesophageal echocardiography and, if possible, ECG-gated MRI. A negative transthoracic echocardiograph does not exclude the presence of myocardial tumor. Chemotherapy is only occasionally beneficial, and the prognosis remains poor.

Estimation of the haematological toxicity of minor groove alkylators using tests on human cord blood cells.

We evaluated the myelotoxicity and the anti-tumor potential of tallimustine, three of its analogues and carzelesin, with melphalan as reference substance. Tallimustine was tested by clonogenic assays on both human bone marrow (BM) and cord blood (hCB) cells, the other compounds on hCB only. The degree of inhibition of the haemopoietic progenitors GM-CFC, CFC-E and BFU-E was evaluated after exposure to different concentrations. The same schedules were tested on five tumour cell lines. We found that the dose-response curves for tallimustine on BM and hCB cells were similar. Carzelesin was shown to be the most potent of the substances tested and to be the one with the best in vitro therapeutic index; of the distamycin analogues, the one bearing an alpha-bromoacrylic group (FCE 25450) had the best index. For melphalan, tallimustine and carzelesin, the concentration inhibiting the growth of 70% of progenitor cells in vitro (ID70) was similar to the concentrations found in the serum of patients treated at the maximum tolerated dose (MTD). We conclude that hCB cells may be used instead of BM cells for in vitro myelotoxicity tests. Therapeutic indexes can be extrapolated from this model and could help in selecting the most promising analogue for further clinical development. The in vitro-active concentrations are similar to myelotoxic concentrations in patients, suggesting a predictive value for the assay.

Detection of chromosome 11 alterations in blood and bone marrow by interphase cytogenetics in mantle cell lymphoma

The t(11;14)(q13;q32) translocation is a consistent chromosome change in mantle cell lymphomas. This study investigates the application of fluorescent in situ hybridization (FISH) with chromosome painting probes for interphase cytogenetic analysis in patients with mantle cell lymphomas. Chromosome 11 paints have been able to show splitting of the chromosome signal consistent with the t(11; 14) translocation in interphase cells from bone marrow and blood of patients with mantle cell lymphomas. These include some in clinical remission. The chromosome probes conjugated with fluorescent molecules are hybridized with patients DNA allowing the easy detection of chromosome 11 abnormalities with fluorescent‐light microscopes. Interphase FISH has a higher sensitivity and is quicker than standard metaphase cytogenetics. This may be beneficial in rapid detection of chromosome 11 abnormalities, assisting in the diagnosis of mantle cell lymphomas. In addition, detection of a clonal population of cells is possible.