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472 Part IV Stomach and Duodenum
exposure of the celiac, splenic, and hepatic arteries and their
associated nodal beds. When a D2 node dissection is to be
performed, these nodal beds are cleared of lymphatic tissue.
Ideally, dissection of these nodes is delayed until the duodenum has been divided in order to facilitate exposure.
e gastroduodenal junction is palpated and evaluated for
distal tumor involvement. If the area appears free of malignancy, the duodenum is divided 1–2 cm distal to the pylorus
(Fig. 22-6). If tumor is palpable at the pylorus or proximal
duodenal bulb, the duodenum is divided 1–2 cm distal to
that point to obtain a microscopically negative resection
margin. In this situation, however, care must be taken not to
injure the retroduodenal portion of the common bile duct,
the minor papilla, or the ampulla of Vater. e gastroduodenal artery serves as a useful landmark as it passes behind the
duodenal bulb. e retroduodenal common bile duct usually
lies within 1 cm to the right of this vessel. We generally complete the division of the duodenum with a GIA stapler. Others prefer to transect the duodenum between bowel clamps
and close the duodenal stump with a running 3-0 absorbable monolament suture such as PDS. ere are no data to
support the superiority of one method over the other. Some
surgeons invaginate the duodenal staple/suture line with
interrupted sutures in a standard Lembert fashion (Fig. 22-7).
If a D2 node dissection is performed, division of the
duodenum provides improved exposure to the nodal bearing tissue adjacent to the hepatic, celiac, and splenic arteries
located along the superior border of the pancreas. is tissue should be dissected and cleared from the region of the
gastroduodenal artery to the basin adjacent to the proximal
splenic artery. Care must be taken not to injure the pancreatic
parenchyma or the celiac plexus.
Dissection of the lesser omentum is completed along
thelesser curvature of the stomach from the inferior edge of the
A
FIGURE 22-6 e duodenum is divided 1–2 cm distal to the pylorus.
B
FIGURE 22-7 A. and B. e duodenal staple/suture line is invaginated
with interrupted Lembert sutures.
hepatoduodenal ligament to the right crus of the diaphragm.
e retroperitoneal incision created along the lateral border of
the second portion of the duodenum is extended superiorly
to the conuence with the hepatoduodenal ligament at the
inferior aspect of the foramen of Winslow. Next, the left lobe
of the liver is retracted superiorly and to the right to expose
the region of the diaphragmatic hiatus. e hepatogastric ligament is then incised from the diaphragmatic crus anterior to
the gastroesophageal junction and along the hepatic border to
the level of the porta hepatis at its conuence with the hepatoduodenal ligament (Fig. 22-8). e incision is then carried
Chapter 22 Gastric Adenocarcinoma and Other Gastric Neoplasms (Except Gastrointestinal Stromal Tumors) 473
FIGURE 22-8 e hepatogastric ligament is incised from the dia-
phragmatic crus anterior to the gastroesophageal junction and along the
hepatic border from the porta hepatis to the hepatoduodenal ligament.
FIGURE 22-9 e left gastric artery and vein are exposed and ligated.
e retroperitoneal dissection is carried to the left and inferiorly to
join the retroperitoneal resection margin along the superior border of
the pancreas.
inferiorly along the left border of the left hepatic artery to just
above the junction with the duodenum, then medically to join
with the retroperitoneal incision created previously. e hepatoduodenal ligament is then incised superiorly at the level of
the cystic duct, and then reected medially, exposing the structures of the porta hepatis inferiorly. e superior and inferior
resection margins of the hepatoduodenal ligament are carried
posteriorly behind the portal vein. e right gastric artery and
vein are identied, ligated, and transected. e hepatoduodenal ligament that had been freed circumferentially from the
porta hepatis can now be taken along with the nodal bearing
connective tissue medial to the portal triad. e retroperitoneal
dissection is then continued to the right of the aorta superiorly
to the median arcuate ligament. e left gastric artery and vein
are then exposed and ligated at their origins. If a D2 dissection
is to be completed, dissection and clearance of the nodal bearing tissue around the left gastric artery should be performed at
this point. e retroperitoneal dissection is then carried to the
left and inferiorly to join the retroperitoneal resection margin
along the superior border of the pancreas (Fig. 22-9).
e point of proximal gastric resection must be determined
based on the location of the lesion. is requires resection of
the entire lesion with a minimum 5-cm margin free of cancer.
For a distal gastrectomy, the proximal resection plane is created from approximately 2 cm distal to the esophagogastric
junction along the lesser curvature to a point along the greater
curvature that will allow for a 5-cm resection margin. Division of the remaining greater omentum is performed to the
level of the greater curvature resection point either by dividing
between clamps and suture ligating the short gastric vessels or
with an appropriate surgical energy source. Care should be
exercised to avoid injury to the short gastric vessels located in
the unresected greater omentum. With the proximal resection
line delineated, the stomach is transected either between
clamps or with a surgical stapler (Fig. 22-10). e en bloc
specimen should be marked to orient the pathologist to the
appropriate margins and sent for frozen pathological analysis to ensure an adequate resection margin free of cancer has
been obtained. Failure to obtain a cancer-free resection margin
necessitates one or more attempted proximal gastric resections
until appropriate margins are obtained if anatomically feasible.
Once the resection is complete, the decision as to which
reconstructive technique will be used must be made. We
FIGURE 22-10 With the proximal resection line delineated, the
stomach is transected either between clamps or with a surgical stapler.
474 Part IV Stomach and Duodenum
generally perform a Billroth II reconstruction. For details on
reconstructive options and surgical techniques, please review
the section on operative reconstruction options below.
Total Gastrectomy
e surgical approach for a proximal gastric lesion is very
similar to that outlined previously for a distal gastric lesion.
e only major variation is completion of the proximal dissection at the gastroesophageal junction and diaphragmatic
crura with en bloc removal of the gastric pericardial and
paraesophageal lymph nodes (Fig. 22-11). e dissection
of the omentum along the greater curvature must also be
completed, taking care to divide the remaining short gastric
vessels close to the spleen. Once the preceding dissection is
completed, the proximal transaction margin is identied on
the esophagus, just proximal to the gastroesophageal junction. Esophageal division can be completed with an intestinal stapling device or an angled bowel clamp can be placed
proximal to the planned transaction margin using a scalpel
to divide the esophagus (Fig. 22-12). As with the distal gastrectomy, frozen-section analysis of the proximal margin
must be completed in order to ensure a curative resection. If
a cancer-free margin cannot be obtained, the surgeon must
determine whether the patient is a candidate for a curative
esophagogastrectomy. Once the en bloc resection is complete and frozen-section pathological analysis has conrmed
adequate operative margins, the intestinal reconstruction
must be completed through the use of a Roux-en-Y esophagojejunostomy. e surgical approach to this reconstructive
method is described in detail in the following text.
FIGURE 22-12 Esophageal division is completed with an intestinal
stapling device or an angled bowel clamp.
GASTROINTESTINAL
RECONSTRUCTIVE TECHNIQUES
When determining the appropriate reconstructive method
to restore intestinal continuity after gastric resection, it is
important to choose a technique that will minimize longterm postoperative nutritional deciencies.
common of these complications include marked weight loss
77–79
and dumping syndrome.
Some authors have asserted that
this is best accomplished by restoring gastroduodenal integrity through construction of a jejunal interposition graft after
80–82
total or subtotal gastrectomy.
Although numerous case
reports and case series have been published on various jejunal interposition techniques, there is currently no convincing
evidence to support their use or a consensus on a standardized
or optimal technique. Given the lack of adequate scientic
evidence to support the merits of jejunal interposition grafts,
we do not currently recommend their use. What does seem
clear from published studies is that the most important concepts of reconstruction are to choose a technique that restores
gastrointestinal continuity while reducing the incidence of
bile reux and anastomotic strictures.
77,78
e most
FIGURE 22-11 Proximal dissection at the gastroesophageal
junction and diaphragmatic crura with en bloc removal of the gastric
pericardial and paraesophageal lymph nodes.
Intestinal Reconstruction After
Distal Gastrectomy
BILLROTH II RECONSTRUCTION
Given its technical ease, reasonable long-term patency rate,
and good functional outcome, we generally recommend the
Chapter 22 Gastric Adenocarcinoma and Other Gastric Neoplasms (Except Gastrointestinal Stromal Tumors) 475
use of a Billroth II reconstruction after distal gastrectomy. is
is achieved by identifying the jejunal origin at the ligament
of Treitz, by tracing the Billroth II reconstruction distally to
identify the shortest amount of jejunum necessary to create a
tension-free anastomosis, roughly 15 cm from the ligament of
Treitz. A shorter limb is thought to reduce the incidence of
aerent limb syndrome. Once this point has been identied, it
is marked with a suture to facilitate ease of future identication.
Next, it must be decided whether to bring the jejunal limb to
the proximal gastric remnant through a retrocolic or antecolic
approach. Although there are advocates of both approaches,
neither has been shown to have a true functional advantage
over the other. We prefer the antecolic approach when the jejunal limb can easily reach in this manner, as it does not carry the
attendant risk of retrocolic internal herniation. If limb length
is an issue, the retrocolic approach may shorten the distance
involved for a tension-free anastomosis. In this setting, we prefer to bring the gastric remnant down through the mesocolic
defect so that the anastomosis is completely inframesocolic.
is may reduce the incidence of aerent limb obstruction.
e gastrojejunal anastomosis is then created by placing
the segment of the jejunal limb previously marked with suture
adjacent to and in parallel with the proximal gastric remnant
along its posterior-inferior margin. Once the location of the
gastrojejunal anastomosis has been determined, a posterior
row of Lembert-type sutures is placed to join the jejunum to
the gastric wall. is is accomplished using either 3-0 Vicryl
or silk-interrupted sutures along the entire posterior aspect
FIGURE 22-13 For a Billroth II anastomosis, a gastrojejunal anasto-
mosis is performed with a running absorbable monolament sutures.
of the anastomosis. Electrocautery is then used to create a
full-thickness defect in the gastric wall anterior to the row of
the posterior Lembert sutures that is long enough to facilitate
a 5-cm anastomotic opening. A similar full-thickness defect
is made in the adjacent segment of jejunum. An anastomosis
is created using 3-0 or 4-0 PDS beginning at the posteriormiddle segment. Two 3-0 PDS sutures are placed immediately next to each other and run in opposite directions until
they meet in the anterior aspect of the anastomosis. e two
PDS sutures are then tied together to complete the anastomosis. Next, an anterior row of Lembert-type sutures are
placed using either 3-0 Vicryl or silk suture (Fig. 22-13). If
a retrocolic approach was used, the defect in the transverse
mesocolon must be closed by sutures between the mesocolon
and the stomach to avoid internal herniation.
ROUX-EN-Y RECONSTRUCTION
An acceptable alternative reconstruction method is Roux-enY gastrojejunostomy. e Roux technique has the advantage
of eliminating bile reux into the gastric remnant but has the
disadvantages of two anastomoses and the possibility of Rouxstasis syndrome. e Roux technique is approached by identifying the origin of the jejunum at the ligament of Treitz. e
jejunum is traced distally to approximately 10–15cm. A defect
is created in the jejunal mesentery just below the mesenteric
border of the jejunum. e jejunum is then divided either
between bowel clamps, or, as we prefer, with a gastrointestinal stapler (Fig. 22-14). e mesentery is divided enough to
FIGURE 22-14 For Roux-en-Y reconstruction, the jejunum is
divided 10–15 cm distal to the ligament of Treitz.
476 Part IV Stomach and Duodenum
permit the limb to reach to the gastric remnant while avoiding
bowel devascularization. is usually includes division of the
rst anastomotic arcade of the jejunum. Care should be taken
with transillumination of the mesentery to understand the
vascular anatomy and preserve blood supply to both limbs of
the jejunum. e distal segment of the transected jejunum is
brought to lie along the posterior-inferior aspect of the gastric
margin as with the Billroth II reconstruction above. A posterior row of Lembert-type sutures is place to attach the jejunum
to the gastric wall. is is accomplished using either 3-0 Vicryl
or silk-interrupted sutures along the entire posterior aspect of
the anastomosis. Electrocautery is then used to create a fullthickness defect in the gastric wall anterior to the row of the
posterior Lembert sutures that is long enough to facilitate a
5-cm anastomotic opening. A similar full-thickness defect is
made in the adjacent segment of jejunum. An anastomosis
is created using 3-0 or 4-0 PDS beginning at the posteriormiddle segment. Two 3-0 PDS sutures are placed immediately
next to each other and run in opposite directions until they
meet in the anterior aspect of the anastomosis. e two PDS
sutures are then tied together to complete the anastomosis.
Next, an anterior row of Lembert-type sutures are placed
using either 3-0 Vicryl or silk suture (Fig. 22-15).
Attention is then turned to creation of the jejunojejunostomy. e proximal jejunal staple line is anastomosed to
the distal jejunal segment approximately 45–50 cm distal
to the gastrojejunostomy. is distance has previously been
shown to be the optimal length of the Roux limb needed
to reduce the incidence of bile reux, while also reducing
excessive limb length, which may contribute to stasis and
malnutrition. e two segments of jejunum to be anastomosed are aligned parallel to each other in order to create a
5-cm antimesenteric anastomosis. e anastomosis may be
A
B
FIGURE 22-15 A. e distal segment of the transected jejunum is brought to lie along the posterior-inferior aspect of the gastric margin, and
a posterior row of Lembert type sutures is place to attach the jejunum to the gastric wall. B. Two 3-0 PDS sutures are placed immediately next to
each other and run in opposite directions until they meet in the anterior aspect of the anastomosis. C. An anterior row of interrupted reinforcing
Lembert suture is placed to complete the superior anastomosis.
C
Chapter 22 Gastric Adenocarcinoma and Other Gastric Neoplasms (Except Gastrointestinal Stromal Tumors) 477
reconstruction after distal gastrectomy with one notable variation. Instead of creating a proximal gastrojejunostomy, the
proximal anastomosis will be an end-to-end or end-to-side
esophagojejunostomy. is may be performed as a hand-sewn
anastomosis as described previously for a gastrojejunostomy
or may be performed as a stapled technique using an appropriately sized EEA stapler.
As described previously, the hand-sewn technique entails
performing a circumferential reinforcing row of Lembert-type
sutures using 3-0 Vicryl or silk. e posterior row is placed
after aligning the anastomotic segments, ensuring the jejunal
limb is not twisted. e anastomosis is then performed with
two full-thickness 3-0 or 4-0 PDS sutures placed immediately next to each other in the posterior segment of the anastomosis. e two sutures are then run circumferentially in
opposite directions until they meet in the anterior midline.
e sutures are then tied, completing the anastomosis. When
feasible, an anterior row of interrupted reinforcing Lembert
sutures are placed in the same manner as was completed in
the posterior row (Fig. 22-17).
FIGURE 22-16 e two segments of jejunum to be anastomosed are
aligned parallel to each other, and a 5-cm antimesenteric anastomosis
is created.
If a stapled technique is used, the anastomosis is created
between the transected end of the esophagus and the antimesenteric border of the proximal Roux limb near the staple line.
e anastomosis is performed in and end-to-side fashion.
e EEA sizers are placed in the esophageal lumen, choosing an anvil size that will allow the largest possible diameter
created with the use of a gastrointestinal stapler or may be
hand-sewn in the same manner a described for the gastrojejunostomy above (Fig. 22-16). Care must be taken to close
all mesenteric defects with either 3-0 Vicryl or silk to prevent
the development of an internal hernia.
anastomotic lumen without causing undue tension on the
esophageal or jejunal wall, preferably a 25- to 28-mm stapler.
A purse-string suture is placed circumferentially at the distal
end of the esophagus, just superior to the transection border
using a 3-0 monolament suture. e anvil is placed in to the
esophageal lumen, and the purse-string suture is tightened
and tied snugly around the anvil rod. e stapled end of the
Roux limb is opened, and the EEA stapler is placed through
Intestinal Reconstruction After
Total Gastrectomy
the lumen in such a manner as to allow the staple pin to be
punctured through the antimesenteric jejunal border several
centimeters distally. e EEA anvil is then mated to the sta-
Total gastrectomy is associated with worse postoperative weight
loss and increased dumping symptoms when compared to distal gastrectomy. is is thought to be due to lack of a gastric
reservoir. is has resulted in an ongoing debate of whether to
create a jejunal pouch either with or without a jejunal interposition technique in order to simulate the gastric reservoir function. e literature in this area has generally been inconclusive
due to the lack of appropriate controls, standardized outcomes
80–82
measures, and poor study design.
A recent meta-analysis
and systematic review of the literature has provided level IA
evidence to support the use of an inverted J pouch or S pouch
in conjunction with a Roux-en-Y reconstruction as a means
of improving postgastrectomy-associated dumping, long-term
78
weight loss, loss, and patient quality of life.
is study did
not nd evidence to support the benet of a pouch with a
jejunal interposition in order to maintain duodenal passage of
enteric contents.
In most patients, a standard Roux-en-Y reconstruction
will be the preferred technique to restore intestinal continuity.
e procedure will be conducted as described previously for
pling device and closed, ensuring that the Roux limb is not
twisted and no extraneous tissue is present between the anvil
and stapler surface. Once stapling is completed, the device
and anvil are removed through the jejunum and the stapler
is inspected to ensure that the presence of two completed
donuts of tissue are present (Fig. 22-18). e esophageal
donut should be marked as “proximal esophageal margin”
and sent to pathology for permanent section. e proximal
end of the Roux limb must then be closed either with a surgical stapler or hand-sewn technique.
Once the esophagojejunostomy has been performed,
attention is turned to creation of the jejunojejunostomy as
described for the Roux-en-Y technique for distal gastrectomy
previously (Fig. 22-19).
For select patients who are thought to have a good longterm prognosis, use of a jejunal pouch should be considered in an attempt to reduce postoperative weight loss and
dumping syndrome. e jejunal S pouch or inverted J
pouch are both reasonable choices, although no data exit to
prove the benets of one over the other. e reconstruction
A
B
C
FIGURE 22-17 A–C. Roux-en-Y reconstruction with hand-sewn anastomosis after total gastrectomy.
478
Chapter 22 Gastric Adenocarcinoma and Other Gastric Neoplasms (Except Gastrointestinal Stromal Tumors) 479
A B
C
D
FIGURE 22-18 A–D. Roux-en-Y reconstruction with stapled anastomosis after total gastrectomy.
480 Part IV Stomach and Duodenum
FIGURE 22-19 Completed Roux-en-Y reconstruction after total
gastrectomy.
is performed just as a standard Roux-en-Y technique with
the exception that the pouch is created at the proximal Roux
limb prior to creating the esophagojejunostomy. e pouch
is created by aligning the proximal jejunum in an inverted J
or an S conguration, then by creating a common channel
between the overlapping jejunal segments with a GIA stapler
(Fig. 22-20). Once the pouch has been formed, a standard
Roux-en-Y with esophagojejunostomy is performed as was
described previously.
PRIMARY GASTRIC LYMPHOMA
Epidemiology
Gastric lymphoma is the second most common primary
malignancy of the stomach, accounting for approximately 5%
of gastric cancers.
a nearly 80% increase in the incidence of lymphoma in the
United States.
83
Over the past four decades, there has been
84
is marked increase in lymphoma incidence
A
FIGURE 22-20 A. Creation of a jejunal S pouch. B. Creation of
a jejunal J pouch.
B
has been especially notable for extranodal lymphomas, where
up to 40% of cases present as primary gastrointestinal tract
85–87
lesions.
Gastric lymphoma accounts for the majority of
these cases, representing approximately 50–75 % of primary
83,88,89
gastrointestinal lymphomas.
Primary gastric lymphoma
is typically an extranodal form of a non-Hodgkin’s lymphoma
(NHL), whereas, Hodgkin’s lymphomas, are rarely found to
involve the stomach.
83,90
Lymphomas represent a diverse and heterogeneous group
of neoplasms and, as a result, have been very dicult to
classify. Currently, the World Health Organization (WHO)
lymphoma classication system is the accepted standard
91
used by most medical professionals worldwide.
is classication system categorizes lymphomas based on their cell of
origin and specic molecular, phenotypic, and genetic characteristics. Its most recent revision also takes into account
clinical features such as patient age, site of involvement, and
92
associated etiologic conditions.
Although the WHO classication system has facilitated treatment approaches and
standardization of research protocols, it remains a very complex diagnostic schematic due to the intrinsic heterogeneity
of lymphoproliferative disorders. e revised 2008 WHO
lymphoma classication system recognizes more than 25
main categories of lymphoma derived from a mature B-cell
origin and more than 20 derived from a T cell or NK cell
of origin.
92,93
Chapter 22 Gastric Adenocarcinoma and Other Gastric Neoplasms (Except Gastrointestinal Stromal Tumors) 481
Histology
Histologically, up to 98% of primary gastric lymphomas
are derived from a B-cell origin.
classi ed as di use large B-cell lymphomas (DLBCL) and
approximately 38% are marginal zone B-cell lymphomas
of the mucosa-associated lymphoid tissue (MALT) ( Table
94
22-4 ).
Both DLBCL and MALT-associated B-cell lym-
phomas are thought to be associated with chronic H. Pylori
infection. is linkage is better established for MALTassociated B-cell lymphomas, where as many as 90% of
cases are thought to be the result of H. pylori infection and
where H. pylori eradication therapy usually leads to a dura-
95–98
ble remission.
e association between H. pylori infec-
tion and DLBCL is more controversial. Approximately 35%
of patients with DLBCL are found to be H. pylori posi-
tive, with the majority of these patients showing concurrent
MALT areas on endoscopic evaluation. Despite these data,
up to 63% of patients with DLBCL have a durable treatment response to H. Pylori eradication therapy alone.
Di use large B-cell lymphomas are aggressive high-grade
lymphomas that may be derived from MALT-associated B-cell
87,
lymphomas.
88 Di use large B-cell lymphomas frequently
express high levels of Bcl-6, an oncogene found on chromo-
83
some 3.
ere are two recognized subcategories of DLBCL
that can be immunohistochemically di erentiated: those that
resemble germinal center (GC)–type B cells (CD10+, Bcl-6–,
and BCL2+/–) and those that are not GC-like (CD10–, Bcl-
83
6+, and BCL2–).
GC-type B cells are thought to be derived
de novo from mature B lymphocytes, while non–GC-type
DLBCL is thought to arise from MALT-associated B-cell
lymphomas.
MALT-associated B-cell lymphomas are typically
multifocal lesions. ey arise from gastric mucosal lymphatic
tissue, which is thought to occur as a result of chronic H. pylori
infection, in most cases. MALT-associated B-cell lymphomas
express the CD20 cell surface antigen, generally produce IgG
light-chain antibodies, and may express CD43. ree genetic
translocations have been identi ed for MALT- associated
TABLE 22-4: DISTRIBUTION OF LYMPHOMA
HISTOLOGICAL SUBTYPE IN 398 PATIENTS
WITH PRIMARY GASTRIC LYMPHOMA
(REAL CLASSIFICATION) 94
Lymphoma Histological Distribution Frequency (%)
Di use large B-cell lymphoma 59
Without MALT component 14
With MALT component 45
Malt lymphoma of the marginal zone 38
Peripheral T-cell lymphoma 1.5
Mantle lymphoma 1
Follicular lymphoma 0.5
MALT, mucosa-associated lymphoid; REAL, Revised European-American
Lymphoma.
93
Nearly 60% of these are
98
B-cell lymphomas that, when combined, may be present
in up to 65% of cases. ese characteristic translocations
include t(11;18)(q21;q21), t(1;14)(p22;q32), and t(14;18)
83,
(q32;q21).
98 Although each of these translocations produces
a di erent direct upstream impact on cellular regulation, they
all result in activation of the nuclear factor-kB cell activation
99
pathway.
Sings and Symptoms
e clinical presentation of patients with primary gastric
lymphoma is similar to patients with gastric adenocarcinoma.
e signs and symptoms tend to be nonspeci c, with dyspepsia, abdominal pain, nausea, vomiting, anorexia, and change
83,
91,
98,
100
in bowel habits being the most common.
Gastroin-
testinal bleeding may also occur and is the initial presentation
88
in up to 30% of patients.
With the exception of weight loss,
B symptoms (weight loss, fevers, and night sweats) are rarely
83
present in primary gastric lymphomas.
A complete history
and physical examination must be performed with particular
emphasis paid to examination of all accessible nodal beds,
including Waldeyer’s ring. A detailed abdominal examination
should be performed to evaluate for an abdominal masses or
organomegaly. e patient’s presenting history provides the
most important diagnostic clues, as the physical examination
will fail to reveal any diagnostic ndings up to 60% of the
83
time.
Diagnostic Workup and Staging
Patients with presenting histories or objective ndings on
clinical examination concerning for gastric malignancy must
be undergo immediate upper endoscopic evaluation. Comprehensive upper endoscopy with biopsy of concerning
lesions will make the diagnosis of gastric lymphoma in more
than 95% of cases.
has been pathologically con rmed, the patient must undergo
staging of their disease to ensure initiation of the appropriate
treatment algorithm and provide the patient with prognostic information. Although nearly universal acceptance of the
2008 WHO lymphoma classi cation system has helped to
standardize the lymphoma staging workup, some variations
still exist depending on the histological subtype.
All patients should undergo laboratory testing to include
H. Pylori serology, a CBC with di erential, liver function tests,
serum chemistry panel with lactate dehydrogenase (LDH)
microglobulin, and serum electrophoresis to evaluate
and B
2
for M proteins. Additionally, although the bone marrow is
rarely involved in primary gastric lymphoma, a bone marrow
aspirate and biopsy should be completed. A spiral CT scan of
the neck, chest, abdomen, and pelvis is performed to evaluate
for addition lesions.
by pathological analysis, a PET scan has been demonstrated
to increase staging accuracy above that of CT scan alone with
a sensitivity of more than 80% and a speci city of more than
91
Once the diagnosis of gastric lymphoma
91,
99 When DLBCL has been conformed