Recent evidence suggests that a significant proportion of primary gastrointestinal
lymphomas are driven by exogenous agents/
antigens. In the stomach, Helicobacter pylori appears to be responsible for most cases of
low-grade lymphomas (MALToma), whereas an infectious etiology is suspected in immunoproliferative small intestine disease (
IPSID). Similarly,
enteropathy-associated T-cell lymphomas appear to result from a disordered response to
gluten, although this profile remains controversial. Accordingly, although traditional
antineoplastic treatments, such as surgery and radiation, are still important for the treatment of primary GI
lymphomas,
antibiotics may be the first line of
therapy for low-grade gastric MALToma, and they are often used alone or in combination with
chemotherapy for
IPSID. In patients with
celiac sprue, a
gluten-free diet appears to markedly reduce the risk for
lymphoma. An important caveat for the treatment of gastric
lymphomas is that only low-grade gastric MALTomas have consistently responded to
antibiotics. Treatment of high-grade
gastric lymphoma is evolving. Although surgery was once considered central to diagnosis, staging, and treatment of
gastric lymphoma, most patients can now have a diagnosis established by endoscopic biopsy and are candidates for
chemotherapy and adjuvant radiation. The risks of fatal
hemorrhage and perforation have probably been vastly overestimated and appear to be equal or less than the mortality associated with surgery. In addition, the long-term effects of gastric resection on quality of life have been almost completely ignored. Systemic
lymphomas involve the GI tract far more often than is clinically apparent. In most cases, treatment should not be affected.