MALT LYMPHOMA. Silvia Montoto, St Bartholomew s Hospital, London, UK ESMO Preceptorship on Lymphoma

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1 MALT LYMPHOMA Silvia Montoto, St Bartholomew s Hospital, London, UK ESMO Preceptorship on Lymphoma Lugano, 3-4 November 2017

2 Disclosures: Roche: honoraria Gilead: travel grant ESMO Preceptorship on Lymphoma Lugano, 3-4 November 2017

3 Marginal zone B-cell lymphomas SMZL, NMZL, MALT The NHL Classification Project, Blood 1997

4 The Mucosa Associated Lymphoid Tissue concept Native MALT normally present in certain extra-nodal sites (e.g. Peyer s patches) Acquired MALT where lymphoid tissue is not a natural component (e.g. Sjögren, Hashimoto, H. pylori-gastritis) MALT Lymphoma 1st described in the stomach by Isaacson and Wright in 1983; it can arise from a wide variety of extra-nodal tissues (usually at acquired MALT sites)

5 MALT lymphoma: clinical characteristics Median age: 60 years BM involvement: 15-20% Most common: gastric (1/3) Other sites of involvement: Small bowel/colon Lung Ocular Skin Thyroid Salivary glands

6 Gastric MALT 50% of primary gastric lymphomas Associated with HP infection (2/3) Molecular characteristics: t(11;18)(q21;q21) Potential histological transformation to a highgrade lymphoma

7 H. pylori and MALT lymphoma B B B B B B B B B H. pylori-dependent MALT lymphoma neutrophils activation with release of genotoxic free radicals H. pylori-independent MALT lymphoma genetic alterations B B B B B B additional genetic damages B B-cell proliferation H. pylori chronic gastritis contact-dependent B-cell stimulation antigen selection autoimmunity T T T T T mucosal T-cell proliferation diffuse large B-cell lymphoma

8 Diagnosis and staging of gastric MALT OGD + biopsies nonspecific gastritis peptic ulcer rarely mass lesions often multifocal (even if macroscopically normal) FISH Echo-endoscopy H pylori detection CAP CT BM aspirate and biopsy

9 Detection of Helicobacter pylori Test Sensitivity Specificity Advantages Disadvantages Histology: H/E, IHC Histology: urease test (Clo-test) Histology: culture 95% 99% Information re gastric histo Interobserver variability; affected by PPI/ATB use 90% 93% Rapid results Affected by PPI/ATB use 58% 100% ATB sensitivity Trained staff; expensive Serology 76-84% 79-90% Widely available; inexpensive Urea breath test >95% >95% Useful before/after treatment Stool Ag test 96% 97% Useful before/after treatment +ve might reflect past infection; not useful after treatment False ve if PPI/ATB; personnel/resources Stool collection; false ve if PPI/ATB;

10 Gastric MALT-Staging Zucca et al, Annals of Oncol, 2013

11 Gastric MALT lymphoma: OS according to treatment Treatment n CR rate 5-year OS Antibiotics 45 67% 94% Local treatment a % 91% Chemotherapy 8 50% 75% Combined modality b 5 100% 80% Total 72 74% 89% a surgery ± RT, b surgery + adjuvant chemotherapy Pinotti et al, 1997

12 Surgery for gastric MALT Surgery +/- additional treatment (chemo, RT): 5-year OS: 85%-95% If surgery is considered total gastrectomy (as MALT lymphoma is often multifocal)

13 Radiotherapy for gastric MALT Author n RT dose (Gy) FFP Schechter, % at 2 yr Tsang, % at 5 yr Yahalom, % at 4 yr Hitchcock, % (100% local)

14 Chemotherapy for MALT Single Agent ORR CR Reference alkylating 100% 75% Hummel, JCO 1995 cladribine 100% 84% Jager, JCO 2002 oxalyplatin 93% 56% Raderer, JCO 2005 Combination CVP 100% 100% Zinzani, Cancer 2004 FM 100% 100% Zinzani, Cancer 2004 MCP 100% 53% Wohrer, Ann Oncol 2003

15 Response to antibiotics Reference n staging CR rate time to CR relapses procedure (%) (mos.) (n) Savio, CT Pinotti, CT Neubauer, CT±EUS Nobre Leitao, CT+EUS Steinbach, CT±EUS Montalban, CT±EUS Ruskone-Formestraux, CT+EUS LY03 interim analysis, CT

16 Predictive factors for lack of response to antibiotics Deep infiltration of gastric wall Lymph node involvement Increased number of large cells t(11;18)

17 ESMO guidelines: localised stage

18 Assessment of response Histology & assessment of HP eradication Persistence of residual lymphoma on Bx can last 12 months PCR for B-cell clonality remains +ve in 50% of histological CR

19 ESMO guidelines: advanced stage

20 IELSG 19 study

21 IELSG 19 study Zucca et al, J Clin Oncol, 2013

22 Follow-up EGILS 2011 guidelines follow-up gastroscopies with biopsies seem advisable ESMO 2013 guidelines a long-term careful endoscopic and systemic follow-up is recommended for all patients

23 Histological transformation in MZL patients with MZL HT Bx-proven Median follow-up: 5 yrs 2-yr OS postht: 57% At 5 yrs: 5% Conconi et al, Annals Oncol, 2015

24 Non-gastric MALT

25 Non-gastric MALT Chlamydia psittaci v Sjögren syndrome Borrelia burgdorferi Hashimoto thyroiditis

26 Non-gastric MALT: outcome according to primary site Zucca et al, Blood, 2003

27 MALT of the salivary glands: IELSG patients with MALT Median follow-up: 55 months Jackson et al, The Oncol, 2015

28 OAL and Chlamydia: IELSG 27 48% eradication RR: 65% Ferreri et al, J Clin Oncol, 2012

29 Summary Antigen-driven processes treatment of initiating event Disseminated disease, limited to mucosal sites, not associated with poor outcome Excellent prognosis (OS) regardless of treatment

30 Thank you!