1. Gastrointestinal Lymphomas

13. Pathogenesis H pylori Infection Chronic gastritis due to bacterial products like NH 3 Polyclonal multiplication of B cells in face of antigenic stimulation. Acquisition of EARLY t(11:18 ) Monoclonal proliferation in face of continuous antigenic stimulation Independence from continued H. pylori infection and low risk of other abnormalities. Lymphomatous transformation

28. RT Results ** In 2001 Koch et al treated all patients by WAR. (+ 6 cycles CHOP in stage IIE patients) * In 2005 field borders were shrunk to lower border of L5 in stage I N.B. Little clinical data exists for treatment of stage III /IV gastric MALT lymphoma perhaps owing to the relative rarity of the disease. EFRT ** 52 mo 30 Gy + 10 Gy boost I /II 52 Koch et al 3 (2001) IFRT 27 mo 30 Gy (28.5-43.5) I / II 17 Schechter et al 4 (1998) IFRT 59 mo 25 Gy ( 20–30) I / II 13 Tsang et al 2 (2003) 42 mo FU I / II Stage EFRT * Technique 30 Gy + 10 Gy boost 144 Koch et al 1 (2005) Dose (Gy) N Series

29. RT results

30. RT Failure * Combined figures for DLBCL & low grade lymphoma Noteworthy point is that 5 out of 6 relapses in the German 02/96 study were seen in stage IIE (Blackledge stage) patient perhaps indicating a need for a combined modality approach in these patients. 0 0 0 Schechter et al (1998) 7 ( 13.4%) * Not specified Not specified Koch et al (2001) 0 0 0 Tsang et al (2003) 6 (4.1%) Not specified Not specified Koch et al (2005) Total Out field failure In field failure Series

34. Results 75% 80% OS 52% 52% 10 yr EFS 78 80 N Aviles et al (2005) 1 RT Surgery Series 87.2% 90.6% 5 yr OS 82.2% 87.6% 5 yr EFS 32 52 N RT Koch et al (2001) Surgery Series RT Surgery Series 92% 90% 5 yr OS 88% 83% 5 yr EFS 23 34 N Sonnen et al (1994) RT Surgery Series 87% 88% 5 yr OS 56 27 N Norman et al (2000)

38. Gastric MALT: Approach 1 * NCCN advocates observation in patients who have advanced stage IV but asymptomatic disease. Gastric MALT Stage IE Others H pylori positive H pylori (-)ve or t (11:18) +ve H pylori eradication Recurrence / Failure Local Radiotherapy Complications e.g. Bleeding/ perforation/ Bulky disease Uncomplicated * Surgery ? Radiation + CCT *

40. Approach Stage I & II Non Bulky Disease Bulky Disease CCT with CHOP x 6 cycles ± Rituximab (CD 20 +ve) IFRT 30 – 35 Gy in 4 – 5 weeks ≥ 2 risk factors No risk factors CCT with CHOP x 3-4 cycles ± Rituximab (CD 20 +ve)

44. Results: CMT Early stage NA 94% 2 yr OS NA 88% 2 yr EFS NA 52 N Satoshi et al (2005) 77.9% 86.0% 5 yr EFS 77.8% 21 91.6% 91.1% 44 CCT + Sx 72.6% 5 yr OS 38 N Liu et al (2000) 85.9% 5 yr EFS 90.5% 5 yr OS 40 N Binn et al (2003) CCT ± RT Series 76.6% 69.6% 2 yr EFS 78.9% 77.9% 2 yr OS 47 54 N Koch et al (2001) 85.4% 88.4% 5 yr EFS 87.5% 49 62% 67% 13 CCT + Sx 88.5% 5 yr OS 188 N Koch et al (2005) 85% 5 yr EFS 60% 5 yr OS 24 N Popescu et al (2003) CCT ± RT Series

47. Histology Intestinal Lymphomas B Cell Lymphoma (60% - 70%) T cell lymphoma ( 20% - 30%) High Grade B cell (70% -80%) Low – intermediate grade (20% - 30%) MALT Others (mainly MCL) Mediterranean lymphoma Or Immunoproliferative small intestinal disease

53. Results Survival Relapse 65% (5 yr) 35 (87) 71.3% Sx + CCT ± RT All Cortelazzo et al 5 45% (4 yr) NA NA Sx + CCT All Otter et al 4 (population based registry study) 47% (10 yr) 13 (52) 85.2% Sx + CCT ± RT (WAR) All 94% (2yr) 8 (19) Chul et al 3 95% Sx + CCT (CHOP) I & II 59% (5yr) 1 (2) Duam et al 2 4 (22) 20% 100% CR CCT (MACOP - B) only III & IV SX + CCT (CHOP / MACOP B) I & II Zinzani et al 1 Modality Stage