From the Guidelines
Relapse is an indication for a watch-and-wait policy or immunochemotherapy in gastric marginal zone lymphoma (MZL), depending on the presence of H. pylori infection and disease extent. For patients who experience relapse after initial treatment, a watch-and-wait policy appears to be safe in cases of persistent but stable residual disease or histological relapse without distant dissemination and/or gross endoscopic tumor 1. However, in cases where H. pylori eradication therapy or radiation therapy has failed, or in patients with more aggressive disease features at relapse, immunochemotherapy regimens such as R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) or R-bendamustine (rituximab plus bendamustine) may be considered 1.
Key Considerations
- The choice between a watch-and-wait policy and immunochemotherapy depends on patient factors, including age, comorbidities, and previous treatments.
- Before initiating treatment, patients should undergo restaging with endoscopy, imaging (CT or PET-CT), and possibly bone marrow biopsy to assess disease extent.
- Immunochemotherapy is particularly effective for relapsed gastric MZL because it combines the targeted approach of anti-CD20 therapy (rituximab) with conventional chemotherapy, addressing both the B-cell component of the lymphoma and rapidly dividing cells.
- Treatment response should be assessed after completion with repeat endoscopy and imaging to determine efficacy.
Disease Management
- Helicobacter pylori eradication therapy should be given to all gastric MALT lymphomas, independently of stage 1.
- In H. pylori-negative cases, a regression of the lymphoma after antibiotic treatment is unlikely, and the immediate start of oncological treatments should be considered.
- Radiotherapy might be the preferred option for localized stage, with excellent disease control using radiation therapy alone reported by several institutions.
- Chemotherapy and/or immunotherapy are effective in patients with MALT lymphoma of all stages, with chemoimmunotherapy preferred in case of histological transformation, contraindications to radiotherapy, and vice versa.
From the Research
Relapse and Immunochemotherapy for Gastric MALT Lymphoma
- Relapse in gastric MALT lymphoma may require alternative treatment approaches, including immunochemotherapy 2, 3.
- The effectiveness of immunochemotherapy, such as rituximab and chlorambucil, has been demonstrated in patients with t(11;18)-positive gastric MALT lymphoma, with high response rates and durable remissions 2.
- In patients with translocation (11;18)-negative gastric MALT lymphoma, rituximab alone or in combination with chlorambucil may be effective, with combination therapy potentially offering improved progression-free survival 3.
- Other treatment options, such as reduced-dose intensity-modulated radiation therapy, may also be considered for patients with gastric MALT lymphoma, particularly those with localized disease 4.
- The role of immunochemotherapy in the management of relapsed gastric MALT lymphoma is not well established, but it may be considered in patients who have failed other treatments, such as eradication of H. pylori or radiation therapy 5, 6.
Treatment Approaches for Gastric MALT Lymphoma
- Eradication of H. pylori is the primary treatment approach for gastric MALT lymphoma, with immunochemotherapy and radiation therapy reserved for patients who do not respond to eradication therapy or have more advanced disease 5.
- Immunochemotherapy, including rituximab and chlorambucil, may be effective in patients with gastric MALT lymphoma, particularly those with t(11;18)-positive disease 2, 3.
- Radiation therapy, including reduced-dose intensity-modulated radiation therapy, may also be considered for patients with localized gastric MALT lymphoma 4.
- Anti-angiogenic strategies, such as VEGF receptor antibodies and celecoxib, may be potential new treatment approaches for gastric MALT lymphoma, particularly in patients who have failed other treatments 6.