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Long-Term Outcomes of Surgical Treatment for Primary Lymphoma of Small and Large Intestine: Does Intestinal Perforation Matter?
Eon Chul Han*2, Seung-Bum Ryoo1, Ji Won Park1, Eun Kyung Choe3, Sang Hui Moon1, Seung-Yong Jeong1, Kyu Joo Park1
1Department of Surgery, Seoul National University College of Medicine, Seoul, Korea, Seoul, Korea (the Republic of); 2Department of Surgery, Dae Cheong Hospital, Seoul, Korea (the Republic of); 3Seoul National University Hospital Gangnam Center, Seoul, Korea (the Republic of)
Introduction
Lymphomas of small and large intestine represent about 15 to 20% of gastrointestinal (GI) lymphoma. Intestinal perforation in these patients is a serious complication, which can occur at diagnosis or during the course of treatment with chemotherapy, and surgical treatment should be performed. We aimed to analyze the characteristics and prognostic factors in the patients who had surgical treatment for small and large intestinal lymphoma, and the impact of intestinal perforation at operation on the overall survival.
Materials and methods
This study included 90 prospectively enrolled patients who underwent surgeries for small intestinal and colorectal lymphoma between 1998 and 2013. Patients were categorized into two groups: those with (perforation group, n=29) and without (non-perforation group, n=61) perforation at the time of operation.
Results
There were 60 males and 30 females with median age of 58.5 years (range, 20 - 81 years). Diffuse large B-cell lymphoma was the most common (perforation group: 79.3%, non-perforation group: 78.7%, p = 0.335). The small bowel (n=43) was the most common site of lymphoma, followed by colon (n=27) and ileocecal valve (n=20). There was a significantly higher proportion of initial treatment with chemotherapy (41.4% vs 21.3%, p=0.047) in perforation group. The perforation group had a poor Eastern Cooperative Oncology Group (ECOG) performance status (ECOG 2 -4) (p=0.040), elevated lactate dehydrogenase (LDH) (p=0.008), and advanced disease stage (III or IV) (p=0.024). Right hemicoloectomy was most commonly performed in 46 (51.1%) patients, followed by small bowel segmental resection (n=26, 28.9%). There was no significant difference for operation time (136.7 vs 123.6 minutes, p=0.616) and length of stay (14.6 vs. 11.1 days, p=0.142) between 2 groups. Postoperative complication rate was significantly higher in perforation group [41.4% (12/29) vs. 13.6% (8/61), p=0.004]. Wound complication was the most common frequent (12/20, 60.0%). The 30-day mortality occurred in 2 patients without perforation due to septic shock. However, there was no 30-day mortality in perforation group (p=0.324). After median follow-up of 31.6 months (range: 1 ~ 170 months), 5-year overall survival (OS) of perforation group was significantly worse (44.8% vs. 64.7%, p<0.001). On multivariable analysis, the following were found to be prognostic factors for OS: age over 70 years [hazard ratio (HR) = 3.39, p=0.004], elevated LDH level (HR = 2.99, p=0.016) and T-cell lymphoma (HR = 3.69, p=0.007).
Conclusion
Patients presented with intestinal perforation in lymphoma of small and large intestine have a poor OS after surgical treatment compared to without perforation. Thus, intestinal perforation should be minded cautiously in the course of treatment of small and large intestinal lymphoma.
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