Prognostic impact of the simplified hlama score and treatment-related complications in primary gastric diffuse large b-cell lymphoma: A retrospective study from a latin American center

Abstract Introduction Primary gastric lymphoma (PGL) is a common site of extranodal diffuse large B cell lymphoma (DLBCL) and represents the most frequent aggressive lymphoma affecting the stomach [1]. Historically, the International Prognostic Index (IPI) score has been used to identify prognosis risk in these patients, however due to its singular pathogenesis, treatment and potential complications, its usefulness has been questioned [2,3]. Furthermore, other series have showed that, unlike classical DLBCL, hypoalbuminemia and haemoglobin (Hb) levels have prognostic impact on survival and risk of adverse events [4]. In 2021, Zao et al published two novel prognostic models, HLAMA and simplified HLAMA (sHLAMA), which suggested superiority over IPI, especially identifying a high-risk group [5]. We present the results from PGL patients in the last 3 years, aiming to elucidate the association of sHLAMA and subsequent development of adverse events. Methods We conducted a retrospective observational study of adult patients diagnosed with PGL between January 2022 and December 2024 at a single tertiary referral center in Latin America. Inclusion criteria were age ≥18 years, histologically confirmed diagnosis of PGL, and complete clinical, laboratory, and imaging data at diagnosis. Clinical, pathological, and endoscopic characteristics were extracted from medical records. Risk stratification was performed using the sHLAMA score (Hb <10.5 g/dL, LDH ≥300 U/L, and age ≥75 years). Overall survival (OS) was estimated using the Kaplan-Meier method and compared across groups with the log-rank test. Adverse events, including gastric hemorrhage, perforation, and stenosis, were also recorded and correlated with survival outcomes and sHLAMA high-risk vs intermediate/low-risk groups. Results A total of 32 patients were included. The median age was 57.7 years, and 56.3% were female. At diagnosis, 65.6% had an ECOG performance status >2, and 15.6% had bulky disease. Endoscopic findings revealed gastric ulcers in 87.5% of patients. Based on Hans algorithm, the germinal center B-cell (GCB) subtype was predominant (53.1%). The median follow-up was 13 months (range 1–27 months). Median OS was not reached; 6- and 12-month OS rates were 78.1% and 61.7%, respectively. Adverse events during treatment included gastric hemorrhage (28.1%), perforation (21.9%), and stenosis (31.3%). When stratified by sHLAMA risk groups, 6- and 12-month OS rates were: Low-risk (n=12): 91.7% and 82.5%; Intermediate-risk (n=10): 90.0% and 70.0%; High-risk (n=10): 50.0% and 26.7%, respectively. Patients with gastric perforation had a median OS of 6 months, while those without perforation (n=25) had not reached median OS. Similarly, patients who experienced hemorrhage (n=9) had a median OS of 8 months, while those without hemorrhage (n=23) had higher OS (median OS not reached).In the analysis of gastrointestinal adverse events according to the sHLAMA score, a significant association was found between the high-risk category and the occurrence of gastric perforation (Chi² = 12.37, p < 0.001; Fisher's exact test = 0.001). Conclusion The simplified HLAMA score effectively stratified patients with PGL into distinct prognostic groups, with higher scores associated with significantly reduced OS and gastric perforation. Additionally, treatment-related complications—particularly gastric hemorrhage and perforation—were strongly associated with poorer survival outcomes. These findings support the use of the s HLAMA score as a practical prognostic tool in real-world settings and underline the need of future research anticipating and managing GI complications, specially gastric perforation, in this patient population. [1] Juárez-Salcedo,LM.,Sokol, L.,Chávez, JC.,et al.(2018)Primary gastric lymphoma, epidemiology, clinical diagnosis and treatment. Cancer control: Journal of the Moffitt Cancer Center, 25(1). [2] Lossos IS., Morgenztern D.(2006)Prognostic biomarkers in diffuse large B-cell lymphoma. J Clin Oncol. 2006;24(6):995 [3] Zhang S.,Wang L .,Yu D., et al.(2015)Localized primary gastrointestinal diffuse large B cell lymphoma received a surgical approach: An analysis of prognostic factors and comparison of staging systems in 101 patients from a single institution. World J Surg Oncol. 13:246 [4] Ibrahim EM ., Ezzat AA ., El-Weshi AN ., et al.(2001)Primary intestinal diffuse large B-cell non Hodgkin's lymphoma: clinical features, management, and prognosis of 66 patients. Annals of Oncology. 12:53-58.