Role and Extent of Surgery in Multimodality Treatment

Doubtless, the knowledge about the pathogenesis of primary gastric lymphoma could be improved during the last decade. This knowledge is based, above all on histomorphological, experimental and epidemiological investigations which demonstrated that Helicobacter pylori infection plays the important role in developing gastric MALT lymphoma [1]. Nevertheless, the management of this disease remains confusing despite the many studies published over the last years [2]. The optimal treatment is still unproven, and the role and extent of surgery in multimodality therapy are discussed controversely. Advocates for primary chemoand/or radiotherapy believe that equal success, i.e. survival rates, can be achieved without the traditional surgical resection demonstrated by the data of the clinical studies [3–5]. On the contrary, some authors suggest that surgery alone appears adequate in special subsets of patients or must be an important part in multimodality treatment [2, 6–9]. Independent of this ‘old’ discussion of new ways of treatment in superficial low-grade malignant lymphomas, some potential roles for the importance of surgical resection of primary gastric lymphoma still exist – at least as long as clear-cut data of prospective multicenter studies are available: – Only in few patients operative procedures are needed to relieve clinical symptoms or emergency situations, i. e., obstruction of gastric outlet or acute bleeding [3, 7]. – Despite improved diagnostic tools including endosonography etc., surgery is still important for tumor diagnosis and staging. Even in an actual study, exact diagnoses of gastric lymphoma could be confirmed in 16% of cases only after surgical resection. Furthermore, if primary conservative treatment is favored, an exact prediction of the depth of infiltration or the type of malignancy is an important requirement. Although numerous endoscopic biopsies are taken during clinical examination, a discrepancy in the grade of malignancy was obtained in 26% of cases comparing pathohistological reports of the biopsies or resected specimens. The correct prediction of the endosonography with regard to depth of infiltration and N category was 78 and 75%, respectively, in comparison to the gold standard, i.e., surgical exploration and resection followed by pathohistological examination [1]. – Nowadays the role of surgery to prevent bleeding or perforation of the tumor induced by chemoor radiotherapy can be qualified despite the fact that different retrospective data available. If the tumor does not involve the entire stomach wall, the risk of this complication is less than 3% and similar to the risk of dying from postoperative complications [3, 7]. Letters to the Editors · Briefe an die Herausgeber