approximately 40% of all non - hodgkin lymphomas ( nhls ) occur in extranodal locations .
primary nhls of the gastrointestinal tract are rare , accounting for only 14% of malignancies arising in that area .
primary gastric lymphoma ( pgl ) accounted for 6875% of patients with primary gastrointestinal tract nhl [ 4 , 5 ] .
there was a slight predominance of males with pgl ( male : and female , 1.1  :  1 ) .
pgl diagnoses reached their peak incidence in individuals between the ages of 50 to 60 years .
the most common presenting symptoms included epigastric pain , epigastric discomfort , anorexia , weight loss , nausea , vomiting , and gastrointestinal bleeding .
systemic b symptoms occurred in 12% of pgl patients [ 4 , 5 ] .   
extranodal marginal zone b - cell lymphoma of the mucosa associated lymphoid tissue ( malt ) type accounted for 4048% of pgl cases [ 4 , 5 ] . according to pathological classification ,
currently , high - grade stage i / ii pgl can be treated with chemotherapy followed by radiotherapy , and advanced stage pgl is usually treated with chemotherapy only [ 6 , 7 ] .
low - grade stage i / ii helicobacter pylori ( + ) malt lymphomas can be treated with antibiotic therapy .
treatment failure with h. pylori eradication can be managed with radiation therapy .   in this study
, we aimed to determine the clinical characteristics of patients with pgl who were referred to our clinic over the last 12 years .
we also aimed to evaluate patient survival and prognostic factors affecting survival and the effect of combined surgical and conservative treatment .
we retrospectively reviewed and analyzed the data of patients treated for pgl in our clinic ( istanbul university , cerrahpasa medical faculty , department of internal medicine , division of medical oncology ) from 1998 through 2010 .
all patients with malt lymphoma who did not respond to antibiotic therapy for h. pylori eradication or who demonstrated relapse during followup were included in the study .
approval from the local ethics committee and informed consent of the patients or their next of kin were obtained prior to the study .
the following characteristics or results were recorded for each patient : medical history , physical examination , biochemistry , computed tomography ( ct ) of the thorax and abdomen , multiple gastroscopic biopsies of the upper and lower gastrointestinal tract , examination of waldeyer 's ring , and bone marrow biopsy .
poor performance status was defined using the karnofsky scale ( < 80 ) . a blood lactate dehydrogenase ( ldh ) level of 240 
mg / dl was accepted as high ( normal range , 0240  mg / dl ) .
conservative ( e.g. , chemotherapy , radiotherapy ) or surgical treatments applied to each patient were recorded .
overall and disease - free survival ( os and dfs ) were the primary endpoints .
dfs was defined as the time until disease recurrence , progression , or death from disease or chemotherapy related toxicity , whichever occurred first .
the effects of age , sex , ldh level , tumor stage and pathological subtype , performance status , presenting symptoms , and tumor treatment modality on os and dfs were evaluated .  
categorical and continuous variables were summarized using descriptive statistics ( e.g. , median , range , frequency , and percentage ) and compared with chi - square and mann - whitney u tests , respectively .
the effects of clinical variables on dfs and os were assessed with a univariate analysis .
a cox proportional hazards model was used to assess independent prognostic factors for dfs and os .
the corpus and antrum of the stomach were the predominant sites of pgl . abdominal pain and dyspepsia were the main symptoms of presentation in 70% of patients , followed by weight loss , fever , or night sweats ( b symptoms ) in 53% and nausea and vomiting in 10% of patients ( table 1 ) .  
the median age at presentation was 57 years ( range , 1885 years ) and 37 patients ( 47% ) were male .
of the 79 patients , 63 ( 79% ) were classified as having non - malt and 16 ( 21% ) as having malt lymphoma .
eleven patients had a poor performance status , according to the karnofsky scale ( < 80 ) .
of the 79 total patients , 57 ( 81% ) had stage i / ii or iie disease and 22 ( 19% ) had stage iv disease .
the clinical characteristics of the patients with respect to malt status are shown in table 2 .  
the treatment modalities applied to patients with respect to malt status and stage of disease are shown in table 3 .
thirty patients ( 38% ) underwent surgery , 74 ( 92% ) received chemotherapy , and 18 ( 23% ) received radiotherapy .
the most common type of surgical treatment procedure was total gastrectomy and lymph node dissection either as combined or single treatment modalities .
the most common chemotherapy regimen was cyclophoshamide , doxorubicine , vincristine , and prednisolone ( chop ) ( 70% of patients ) .
fifty percent of patients were administered six cycles of chemotherapy , 25% were administered three cycles , and 25% were administered four or five cycles .
patients who received radiotherapy were treated with extended - field irradiation to the upper and middle parts of the abdomen with 3045  gy .
the five - year os and dfs , which were estimated by using the kaplan - meier method , were 83.1% and 78.6% , respectively ( figures 1 and 2 ) . in patients with stage
i / ii or iie presentation , the five - year os and dfs rates were 91.2% and 83.9% , respectively . the five - year os and dfs in patients with stage
both os and dfs were significantly lower in those with advanced stage disease ( p = 0.002 and p = 0.02 , resp . ) . for malt lymphoma patients , the five - year os and dfs rates were 91.2% and 81.3% , respectively .
os and dfs were not different between malt and non - malt groups ( p = 0.38 and p = 0.57 , resp . ) .
poor performance status was significantly associated with lower dfs and os rates ( p = 0.002 for both ) .
the effects of clinical variables on five - year os and dfs are given in table 4 .  
based on the results from the univariate analyses , we performed multivariate analyses using a cox proportional hazard model ( table 5 ) .
poor karnofsky performance status , advanced stage , and high level of ldh were significant prognostic factors for dfs in the cox model .
advanced stage , poor karnofsky index , and age > 60 years were significant prognostic factors for os in multivariate analyses .
pgls represent more than half of all primary gastrointestinal lymphomas , accounting for 5% of all malignant tumors of the stomach [ 912 ] . according to histological type
, pgls are divided into low - grade and high - grade . in this retrospective study ,
the rate of malt lymphomas ( 21% ) was lower than previously shown [ 4 , 5 ] .
about 40% of pgls are low - grade lesions thought to arise in the mucosa from the defined malt lymphoma , and 60% are histologically considered high - grade [ 4 , 6 , 10 ] .  
epigastric pain , epigastric discomfort , anorexia , weight loss , nausea , vomiting , and gastrointestinal bleeding were the most common symptoms in the present study , as reported in other series [ 4 , 1315 ] . in the current report
, there was a slight male predominance [ 4 , 13 , 14 , 16 ] , while other studies reported female prominence among cases of pgl [ 14 , 16 ] . in pgl , there are multiple factors that affect survival . in previous studies , advanced stage , poor performance status , age > 60 years , and elevated ldh at presentation of the disease were associated with poor outcome ; female sex , low - grade histology , good performance status , and surgical resection for local disease have been reported to be associated with high os and dfs rates [ 4 , 1719 ] . in our study , the five - year os and dfs rates were 83.1% and 78.6% , respectively . in patients with stage
i / ii or iie disease at presentation , the five - year os and dfs rates were 91.2% and 83.9% , respectively .
the five - year os and dfs rates of those with stage iv disease at presentation were 70.6% and 65.5% , respectively .
in prior studies , the survival rate of patients with pgl was 7892% , according to stage and treatment modality [ 6 , 1922 ] .
based on our results , variables associated with poor dfs were advance stage , high ldh level , and poor performance status . in a multivariate analysis ,
variables associated with poor dfs were also advanced stage , high ldh level , and poor performance status .
regarding os , a univariate analysis revealed that advanced stage , age > 60 years , and poor performance status were associated with a poor prognosis . in the multivariate analysis , advanced stage , poor performance status , and age
there are no standard therapeutic guidelines for patients in whom antibiotic therapy has failed . in two retrospective studies of patients with malt lymphoma ,
no significant differences in survival were found between different treatment modalities [ 23 , 24 ] . in our study , patients with malt lymphoma were those in whom antibiotic therapy failed .
no significant differences in dfs or os were demonstrated among pgl patients who had nonsurgical or surgical treatment of the local disease ( stage i / ii or iie ) of malt or non - malt lymphoma .
controversy remains over the optimal treatment for early stages of pgl , particularly regarding the role of surgery .
recently , it has become evident that there is no difference in survival rates for those who were treated with surgery compared to a conservative modality .
surgery is no longer accepted as the cornerstone treatment of pgl and is reserved for when nonsurgical treatment is not possible .
surgery should be considered following nonsurgical treatment and when disease complications , such as hemorrhage , obstruction , or perforation , have occurred .
however , it is well known that surgical approaches have a number of potential disadvantages .
additionally , significant morbidity is associated with gastrectomy , as follows : 17% of patients developed malabsorption syndromes , 38% reported weight loss , and 13% developed dumping syndrome . on the other hand , of the patients who received chemotherapy
, only 5% developed acute complications , such as gastric perforation and gastrointestinal hemorrhage [ 20 , 2730 ] . in the present study
, there was no difference between conservative and surgical treatment approaches with regard to dfs and os .
the main limitations of this study were its retrospective design and the lack of data on patient quality of life and toxicities in patients treated with a conservative approach or surgery . in conclusion ,
poor performance status , advanced stage of disease , high ldh level , and advanced age were bad prognostic factors for patients with pgl .
surgery provides no advantage for survival over conservative treatment ; thus , conservative treatment modalities should be preferred initially at early stages of pgl .
further prospective , large - scale , controlled studies are needed to determine the impact of different treatment modalities on the outcome of patients with pgl .
 
 objectives . the aim of this study was to evaluate clinical characteristics , prognostic factors , survival rates , and treatment modalities in patients with primary gastric lymphoma ( pgl ) . methods . 
 we retrospectively reviewed and analyzed data from patients treated for pgl in our clinic from 1998 through 2010 . 
 staging was performed using the lugano staging system . 
 overall and disease - free survival ( os and dfs ) were calculated from the date of diagnosis . 
 results . 
 we identified 79 patients . 
 thirty - seven patients ( 47% ) were male . 
 the median age at presentation was 57 ( 1885 ) years . 
 the median follow - up time was 41 ( 952 ) months . 
 thirty patients ( 38% ) underwent surgery , 74 ( 92% ) received chemotherapy , and 18 ( 23% ) received radiotherapy . 
 the five - year os and dfs rates were 91.2% and 83.9% , respectively , in patients with stage i / ii or iie disease and 70.6% and 65.5% , respectively , in patients with stage iv disease ( p = 0.02 for both rates ) . 
 treatment modality ( surgical or conservative ) had no impact on os or dfs in early stages . in a multivariate analysis , 
 poor performance status , advanced stage , and high ldh levels were significant bad prognostic factors for dfs , while advanced stage , poor performance status , and age >  60 years were significant bad prognostic factors for os . 
 conclusion . 
 surgery provides no advantage for survival over conservative treatment ; thus , conservative treatment modalities should be preferred initially at early stages of pgl . 
1. Introduction
2. Materials and Methods
3. Results
4. Discussion