Annals of Oncology 15:841-842, 2004
© 2004 European Society for Medical Oncology
Comments on "Surgical resection plus chemotherapy versus chemotherapy alone: comparison of two strategies to treat diffuse large B-cell gastric lymphoma" by M. Binn, A. Ruskoné-Fourmestraux, E. Lepage et al. (Ann Oncol 2003; 14: 1751–1757)
1 Ankara Numune Egitim ve Arastirma Hastanesi, 2 Hacettepe University Faculty of Medicine, Medical Oncology, Ankara, Turkey
*E-mail: habali1970@yahoo.com
We have read the article on the management of gastric lymphomas with interest [1]. The authors compared the survival of 44 patients from the Groupe d’Étude des Lymphomes de l’Adulte (GELA) who had been treated without surgery and 40 included in the protocol of the Groupe d’Étude des Lymphomes Digestifs (GELD) who had undergone surgical resection followed by chemotherapy. All the patients analyzed for survival were reported as having a low International Prognostic Index (IPI 0–1). We think that results from this study must be evaluated cautiously for the following reasons.
First, lactate dehydrogenase (LDH), one of the main elements of IPI score calculation, was found to be higher in 28% of GELA patients compared with 2.4% in the GELD group. The exact timing of LDH determination in the GELD group in reference to surgery was not reported. Serum LDH levels, hence the IPI score, may change depending on whether it was determined before or after surgery, since removal of tumor bulk would certainly decrease LDH level. On the other hand, if it was tested immediately following surgery, it may be elevated. Thus, IPI scores prior to surgery are more informative.
Secondly, the authors defined the point of randomization as the start time for overall and event-free survival. The word ‘randomization’ probably only applies to those patients from GELA where patients had been randomized to LNH-87 and LNH-93 studies, since there is no actual randomization for the current study. In other words, the starting point for survival in GELD patients was not clearly defined.
Thirdly, response criteria were not clearly defined for GELD patients. The authors stated that all patients had achieved complete response, 95% with complete resection of the tumor and an additional 5% following chemotherapy. It is debatable whether complete resection could be an appropriate substitute for complete response according to the criteria defined by Cheson et al. [2]. Moreover, response to chemotherapy is an innate good prognostic feature of the tumor itself. In the article by Binn et al., persistence of radiological abnormalities at sites of previous bulky disease were considered as complete response if tumoral reduction was >75% [1]. However, it must be classified as ‘complete response/unconfirmed’ according to the criteria of Cheson et al. [2].
Fourthly, neither the chemotherapeutic nor the surgical strategy was homogeneous in the study population. Treatment was more aggressive (chemotherapy with or without transplantation) in the GELA group.
In the Discussion, the authors emphasize that their results conflict with several studies suggesting that complete or incomplete surgical resection is a favorable prognostic factor for survival. Unfortunately, some of the prior studies that contradict the present work also belong to the same authors [3, 4]. Indeed much remains to be learned regarding the biology and clinical course of gastric lymphomas. Some investigators are trying to modify the IPI so that it correlates better with the course of gastric lymphomas [5, 6], while others are working on molecular prognostic factors, such as DNA content and proliferative activity in this entity [7, 8]. Hopefully, all these studies will provide new insight into the management of gastric diffuse large B-cell lymphomas.
REFERENCES
1. Binn M, Ruskoné-Fourmestraux A, Lepage E et al. Surgical resection plus chemotherapy versus chemotherapy alone: comparison of two strategies to treat diffuse large B-cell gastric lymphoma. Ann Oncol 2003; 14: 1751–1757.
2. Cheson BD, Horning SJ, Coiffier B et al. Report of an international workshop to standardize response criteria for non-Hodgkin’s lymphomas. J Clin Oncol 1999; 17: 1244–1253.
3. Ruskoné-Fourmestraux A, Aegerter P, Delmer A et al. Primary digestive tract lymphoma: a prospective multicentric study of 91 patients. Groupe d’Étude des Lymphomes Digestifs. Gastroenterology 1993; 105: 1662–1671.[Web of Science][Medline]
4. Vaillant JC, Ruskoné-Fourmestraux A, Aegerter P et al. Management and long-term results of surgery for localized gastric lymphomas. Am J Surg 2000; 179: 216–222.[CrossRef][Web of Science][Medline]
5. Castrillo JM, Montalban C, Abraira V et al. Evaluation of the international index in the prognosis of high grade gastric malt lymphoma. Leuk Lymphoma 1996; 24: 159–163.[Web of Science][Medline]
6. Cortelazzo S, Rossi A, Roggero F et al. Stage-modified international prognostic index effectively predicts clinical outcome of localized primary gastric diffuse large B-cell lymphoma. International Extranodal Lymphoma Study Group (IELSG). Ann Oncol 1999; 10: 1433–1440.
7. Aydin ZD, Barista I, Canpinar H et al. Gastric lymphomas in Turkey. Analysis of prognostic factors with special emphasis on flow cytometric DNA content. Cancer 2000; 89: 12–20.[CrossRef][Web of Science][Medline]
8. Bellesi CJ, Parasi AS, Manioudaki HS et al. Prognostic impact of DNA ploidy pattern, S-phase fraction (SPF), and proliferating cell nuclear antigen (PCNA) in patients with primary gastric lymphoma. J Surg Oncol 2003; 82: 247–255.[CrossRef][Web of Science][Medline]
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